2017年-世界发展银行全球_Ghana_National_Health_Insurance_Scheme___Improving_Financial_Sustainability_Based_on_Expenditure_Review_71页_1mb

Summary of the Ghana National Health Insurance Scheme: Improving Financial Sustainability Based on Expenditure Review

Core Content

The Ghana National Health Insurance Scheme (NHIS), established in 2003, has made significant progress toward universal health coverage. As of 2014, it covered 40% of the population, or 10.5 million people, and the number of inpatient and outpatient visits to health facilities increased from just under 0.5 per capita in 2005 to almost 3 per capita in 2014. However, financial sustainability remains a critical challenge, with the NHIS experiencing a growing annual deficit that reached GH¢300 million by 2014.

The Ghana National Health Insurance Authority (NHIA) has been working to improve the NHIS's financial health by strengthening its technical capacities in actuarial sciences, financial management, and insurance mechanisms. A clinical audit division was established in 2009 to reduce fraud and ensure the authenticity of claims. The NHIA also introduced a capitation payment system for primary outpatient care in the Ashanti region in 2012, which is being rolled out to other regions.

The Volta region was selected for an in-depth expenditure analysis due to its relatively representative characteristics in terms of demographics and health service delivery. The study used a combination of quantitative analysis and desk review, drawing on national and regional data, including NHIS financial statements, demographic surveys, and health facility inventories.

Main Views and Key Information

1. Financial Sustainability Challenges

• Total NHIS claims payments rose from GH¢7.6 million in 2005 to over GH¢1.07 billion in 2014.
• The NHIS's annual deficit reached GH¢300 million in 2014, prompting a government-led review.
• The study emphasizes the importance of efficient spending to address the deficit, especially in the current macro-fiscal context where raising additional revenue is difficult.

2. NHIS Overview

• The NHIS is a public health financing mechanism that aims to provide affordable and equitable access to health services.
• It includes a benefits package, enrollment system, claims management process, and provider payment system.
• The NHIS shifted inpatient payments from a fee-for-service (FFS) model to Ghana Diagnosis-Related Groups (GDRG) to promote cost containment.
• Capitation payments for primary outpatient care were introduced in 2012 and are being expanded.

3. Expenditure Trends and Distribution

• Trends in NHIS claims expenditures showed a steady increase over time.
• Claims expenditures in the Volta region were analyzed in detail, revealing variations by service type, facility type, and ownership.
• Per-claim expenditures varied significantly depending on the facility type and ownership.
• Member characteristics such as age, number of outpatient visits, and membership category influenced expenditure patterns.
• Equity in health outcomes was assessed, showing disparities between income groups, particularly in access to health services.

4. Factors Affecting Expenditure Levels and Efficiency

• Service provider behaviors and member utilization patterns were found to significantly impact expenditure levels.
• NHIA internal management plays a key role in ensuring the accuracy and efficiency of claims processing.
• Incomplete claims data was identified as a major issue, particularly in private facilities, which can lead to inefficiencies and potential fraud.

5. Policy Recommendations

• The study recommends customized policies for efficient spending in the NHIS.
• Strengthening the claims administration system is crucial to reducing inefficiencies and improving financial sustainability.
• Further analytical work is needed to better understand the dynamics between the NHIS, service providers, and members.
• Capitation in the Volta region is an area of focus for future policy design and evaluation.

Key Findings

• The Volta region serves as a representative case for analyzing NHIS expenditure patterns.
• Public health workers and private sector participation vary across regions, affecting the distribution of health service utilization and expenditure.
• The NHIS has made progress in expanding coverage, but disparities in access and utilization persist, particularly among lower-income groups.
• Data quality is a major concern, with incomplete or inaccurate information in claims records affecting the efficiency of the system.
• The Ghanaian economy has grown, but health indicators have not kept pace, indicating a need for improved health financing mechanisms.

Structure of the Report

The report is organized into six chapters:

1. Introduction – Background, objective, methodology, and organization of the book.
2. Country Context and Health Sector Features – Overview of Ghana’s population, economic context, and health outcomes.
3. NHIS Overview – Description of the NHIS, its structure, and key features.
4. NHIS Claims-Expenditure Review – Analysis of expenditure trends, regional distribution, and variations by service type and member characteristics.
5. Factors Affecting Expenditure Levels and Efficiency – Examination of provider and member behaviors, as well as internal NHIA management.
6. Designing Policies for Efficient Spending – Recommendations and areas for further research.

Conclusion

This study provides quantitative evidence on the NHIS's expenditure patterns, highlighting the need for efficient spending and policy reforms to ensure long-term financial sustainability. It underscores the importance of data quality, provider behavior, and internal management in improving the efficiency and equity of the NHIS. The findings serve as a baseline for future policy development and evaluation, particularly in regions implementing capitation models.