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1.  Something old or something new? Social health insurance in Ghana 
There is considerable interest at present in exploring the potential of social health insurance to increase access to and affordability of health care in Africa. A number of countries are currently experimenting with different approaches. Ghana's National Health Insurance Scheme (NHIS) was passed into law in 2003 but fully implemented from late 2005. It has already reached impressive coverage levels. This article aims to provide a preliminary assessment of the NHIS to date. This can inform the development of the NHIS itself but also other innovations in the region.
This article is based on analysis of routine data, on secondary literature and on key informant interviews conducted by the authors with stakeholders at national, regional and district levels over the period of 2005 to 2009.
In relation to its financing sources, the NHIS is heavily reliant on tax funding for 70–75% of its revenue. This has permitted quick expansion of coverage, partly through the inclusion of large exempted population groups. Card holders increased from 7% of the population in 2005 to 45% in 2008. However, only around a third of these are contributing to the scheme financially. This presents a sustainability problem, in that revenue is de-coupled from the growing membership. In addition, the NHIS offers a broad benefits package, with no co-payments and limited gate-keeping, and also faces cost escalation related to its new payment system and the growing utilisation of members. These features contributed to a growth in distressed schemes and failure to pay outstanding facility claims in 2008.
The NHIS has had a considerable impact on the health system as a whole, taking on a growing role in funding curative care. In 2009, it is expected to contribute 41% of the overall resource envelope. However there is evidence that this funding is not additional but has been switched from other funding channels. There are some equity concerns about this, as the new funding source (a VAT-based tax) may be more regressive. In addition, membership of the NHIS at present has a pro-rich bias, and a pro-urban bias in relation to renewals. Only a very small proportion is registered as indigent, and there is some evidence of 'squeezing out' of non-members from health care utilisation. Finally, considerable challenges remain in relation to strengthening the purchasing role of the NHIS, and also settling debates about its structure and accountability.
Some trade-offs will be necessary between the existing wide benefits package of the NHIS and the laudable desire to reach universal coverage. The overall resource envelope for health is likely to be stable rather than increasing over the medium-term. In the longer term, the investment costs in the NHIS will only be justified if it is able to increase the cost-effectiveness of purchasing and the responsiveness of the system as a whole.
PMCID: PMC2739838  PMID: 19715583
2.  Players and processes behind the national health insurance scheme: a case study of Uganda 
Uganda is the last East African country to adopt a National Health Insurance Scheme (NHIS). To lessen the inequitable burden of healthcare spending, health financing reform has focused on the establishment of national health insurance. The objective of this research is to depict how stakeholders and their power and interests have shaped the process of agenda setting and policy formulation for Uganda’s proposed NHIS. The study provides a contextual analysis of the development of NHIS policy within the context of national policies and processes.
The methodology is a single case study of agenda setting and policy formulation related to the proposed NHIS in Uganda. It involves an analysis of the real-life context, the content of proposals, the process, and a retrospective stakeholder analysis in terms of policy development. Data collection comprised a literature review of published documents, technical reports, policy briefs, and memos obtained from Uganda’s Ministry of Health and other unpublished sources. Formal discussions were held with ministry staff involved in the design of the scheme and some members of the task force to obtain clarification, verify events, and gain additional information.
The process of developing the NHIS has been an incremental one, characterised by small-scale, gradual changes and repeated adjustments through various stakeholder engagements during the three phases of development: from 1995 to 1999; 2000 to 2005; and 2006 to 2011. Despite political will in the government, progress with the NHIS has been slow, and it has yet to be implemented. Stakeholders, notably the private sector, played an important role in influencing the pace of the development process and the currently proposed design of the scheme.
This study underscores the importance of stakeholder analysis in major health reforms. Early use of stakeholder analysis combined with an ongoing review and revision of NHIS policy proposals during stakeholder discussions would be an effective strategy for avoiding potential pitfalls and obstacles in policy implementation. Given the private sector’s influence on negotiations over health insurance design in Uganda, this paper also reviews the experience of two countries with similar stakeholder dynamics.
PMCID: PMC3849368  PMID: 24053551
Health insurance; Stakeholder analysis; Context analysis; Policy reform; Health financing; Case study; Uganda
3.  Assessing equity in health care through the national health insurance schemes of Nigeria and Ghana: a review-based comparative analysis 
Nigeria and Ghana have recently introduced a National Health Insurance Scheme (NHIS) with the aim of moving towards universal health care using more equitable financing mechanisms. This study compares health and economic indicators, describes the structure of each country’s NHIS within the wider healthcare system, and analyses impacts on equity in financing and access to health care.
The World Bank and other sources were used to provide comparative health and economic data. Pubmed, Embase and EconLit were searched to locate studies providing descriptions of each NHIS and empirical evidence regarding equity in financing and access to health care. A diagrammatical representation of revenue-raising, pooling, purchasing and provision was produced in order to analyse the two countries’ systems.
Over the period 2000–2010, Ghana maintained a marked advantage in life expectancy, infant mortality, under-5 year mortality, and has a lower burden of major diseases. Health care expenditure is about 5% of GDP in both countries but public expenditure in 2010 was 38% of total expenditure in Nigeria and 60% in Ghana. Financing and access are less equitable in Nigeria as, inter alia, private out-of-pocket expenditure has fallen from 80% to 66% of total spending in Ghana since the introduction of its NHIS but has remained at over 90% in Nigeria; NHIS membership in Nigeria and Ghana is approximately 3.5% and 65%, respectively; Nigeria offers a variable benefits package depending on membership category while Ghana has uniform benefits across all beneficiaries. Both countries exhibit improvements in equity but there is a pro-rich and pro-urban bias in membership.
Major health indicators are more favourable in Ghana and overall equity in financing and access are weaker in Nigeria. Nigeria is taking steps to expand NHIS membership and has potential to expand its public spending to achieve greater equity. However, heavy burdens of poverty, disease and remote settings make this a substantial challenge. Ghana’s relative success has to be tempered by the high number of exemptions through taxation and the threat of moral hazard. The results and methods are anticipated to be informative for policy makers and researchers in both countries and other developing countries more widely.
PMCID: PMC3626627  PMID: 23339606
Healthcare systems; Health economics; Health care expenditure; Access; Equity; Social health insurance; National Health Insurance Scheme; NHIS; Sub-Saharan Africa; Nigeria; Ghana
4.  Refusal to enrol in Ghana’s National Health Insurance Scheme: is affordability the problem? 
Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources.
The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified.
Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS.
Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.
PMCID: PMC4300159  PMID: 25595036
Voluntary health insurance; Universal coverage; Enrolment; Premium; Affordability; Ghana
5.  Historical account of the national health insurance formulation in Kenya: experiences from the past decade 
Many Low-and-Middle-Income countries are considering reviewing their health financing systems to meet the principles of Universal Health Coverage (UHC). One financing mechanism, which has dominated UHC reforms, is the development of health insurance schemes. We trace the historical development of the National Health Insurance (NHI) policy, illuminate stakeholders’ perceptions on the design to inform future development of health financing policies in Kenya.
We conducted a retrospective policy analysis of the development of a NHI policy in Kenya using data from document reviews and seven in depth interviews with key stakeholders involved in the NHI design. Analysis was conducted using a thematic framework.
The design of a NHI scheme was marked by complex interaction of the actor’s understanding of the design, proposed implementation strategies and the covert opposition of the reform due to several reasons. First, actor’s perception of the cost of the NHI design and its implication to the economy generated opposition. This was due to inadequate communication strategies to articulate the policy, leading to a vacuum of factual information flow to various players. Secondly, perceived fear of implications of the changes among private sector players threatened support and success gained. Thirdly, underlying mistrust associated with perceived lack of government’s commitment towards transparency and good governance affected active engagement of all key players dampening the spirit of collective bargain breeding opposition. Finally, some international actors perceived a clash of their role and that of international programs based on vertical approaches that were inherent in the health system.
The thrust towards UHC using NHI schemes should not only focus on the design of a viable NHI package but should also involve stakeholder engagements, devise ways of improving the health care system, enhance transparency and develop adequate governance structures to institutions mandated to provide leadership in the reform process to overcome covert opposition.
PMCID: PMC4332452
Health insurance; Universal health care coverage; Policy Analysis
6.  Ghana’s National Health Insurance Scheme: a national level investigation of members’ perceptions of service provision 
Ghana’s National Health Insurance Scheme (NHIS), established into law in 2003 and implemented in 2005 as a ‘pro-poor’ method of health financing, has made great progress in enrolling members of the general population. While many studies have focused on predictors of enrolment this study offers a novel analysis of NHIS members’ perceptions of service provision at the national level.
Using data from the 2008 Ghana Demographic Health Survey we analyzed the perceptions of service provision as indicated by members enrolled in the NHIS at the time of the survey (n = 3468; m = 1422; f = 2046). Ordinal Logistic Regression was applied to examine the relationship between perceptions of service provision and theoretically relevant socioeconomic and demographic variables.
Results demonstrate that wealth, gender and ethnicity all play a role in influencing members’ perceptions of NHIS service provision, distinctive from its influence on enrolment. Notably, although wealth predicted enrolment in other studies, our study found that compared to the poorest men and uneducated women, wealthy men and educated women were less likely to perceive their service provision as better/same (more likely to report it was worse). Wealth was not an important factor for women, suggesting that household gender dynamics supersede household wealth status in influencing perceptions. As well, when compared to Akan women, women from all other ethnic groups were about half as likely to perceive the service provision to be better/same.
Findings of this study suggest there is an important difference between originally enrolling in the NHIS because one believes it is potentially beneficial, and using the NHIS and perceiving it to be of benefit. We conclude that understanding the nature of this relationship is essential for Ghana’s NHIS to ensure its longevity and meet its pro-poor mandate. As national health insurance systems are a relatively new phenomenon in sub-Saharan Africa little is known about their long term viability; understanding user perceptions of service provision is an important piece of that puzzle.
PMCID: PMC3765400  PMID: 23968385
Health care; Ghana; Health insurance; National health insurance scheme; Perceptions; Service
7.  Community-based health insurance programmes and the national health insurance scheme of Nigeria: challenges to uptake and integration 
Nigeria has included a regulated community-based health insurance (CBHI) model within its National Health Insurance Scheme (NHIS). Uptake to date has been disappointing, however. The aim of this study is to review the present status of CBHI in SSA in general to highlight the issues that affect its successful integration within the NHIS of Nigeria and more widely in developing countries.
A literature survey using PubMed and EconLit was carried out to identify and review studies that report factors affecting implementation of CBHI in SSA with a focus on Nigeria.
CBHI schemes with a variety of designs have been introduced across SSA but with generally disappointing results so far. Two exceptions are Ghana and Rwanda, both of which have introduced schemes with effective government control and support coupled with intensive implementation programmes. Poor support for CBHI is repeatedly linked elsewhere with failure to engage and account for the ‘real world’ needs of beneficiaries, lack of clear legislative and regulatory frameworks, inadequate financial support, and unrealistic enrolment requirements. Nigeria’s CBHI-type schemes for the informal sectors of its NHIS have been set up under an appropriate legislative framework, but work is needed to eliminate regressive financing, to involve scheme members in the setting up and management of programmes, to inform and educate more effectively, to eliminate lack of confidence in the schemes, and to address inequity in provision. Targeted subsidies should also be considered.
Disappointing uptake of CBHI-type NHIS elements in Nigeria can be addressed through closer integration of informal and formal programmes under the NHIS umbrella, with increasing involvement of beneficiaries in scheme design and management, improved communication and education, and targeted financial assistance.
PMCID: PMC3941795  PMID: 24559409
Community-Based Health Insurance; CBHI; Healthcare; National Health Insurance Scheme; NHIS; Sub-Saharan Africa; Nigeria
8.  Achieving universal health care coverage: Current debates in Ghana on covering those outside the formal sector 
Globally, extending financial protection and equitable access to health services to those outside the formal sector employment is a major challenge for achieving universal coverage. While some favour contributory schemes, others have embraced tax-funded health service cover for those outside the formal sector. This paper critically examines the issue of how to cover those outside the formal sector through the lens of stakeholder views on the proposed one-time premium payment (OTPP) policy in Ghana.
Ghana in 2004 implemented a National Health Insurance Scheme, based on a contributory model where service benefits are restricted to those who contribute (with some groups exempted from contributing), as the policy direction for moving towards universal coverage. In 2008, the OTPP system was proposed as an alternative way of ensuring coverage for those outside formal sector employment. There are divergent stakeholder views with regard to the meaning of the one-time premium and how it will be financed and sustained. Our stakeholder interviews indicate that the underlying issue being debated is whether the current contributory NHIS model for those outside the formal employment sector should be maintained or whether services for this group should be tax funded. However, the advantages and disadvantages of these alternatives are not being explored in an explicit or systematic way and are obscured by the considerable confusion about the likely design of the OTPP policy. We attempt to contribute to the broader debate about how best to fund coverage for those outside the formal sector by unpacking some of these issues and pointing to the empirical evidence needed to shed even further light on appropriate funding mechanisms for universal health systems.
The Ghanaian debate on OTPP is related to one of the most important challenges facing low- and middle-income countries seeking to achieve a universal health care system. It is critical that there is more extensive debate on the advantages and disadvantages of alternative funding mechanisms, supported by a solid evidence base, and with the policy objective of universal coverage providing the guiding light.
PMCID: PMC3532243  PMID: 23102454
Universal health care coverage; National health insurance; Policy objective; Policy options; Those outside formal sector employment; Tax funding; One-time premium payment; Ghana
9.  Risk management assessment of Health Maintenance Organisations participating in the National Health Insurance Scheme 
The National Health Insurance Scheme (NHIS), operated majorly in Nigeria by health maintenance organisations (HMOs), took off formally in June 2005. In view of the inherent risks in the operation of any social health insurance, it is necessary to efficiently manage these risks for sustainability of the scheme. Consequently the risk-management strategies deployed by HMOs need regular assessment. This study assessed the risk management in the Nigeria social health insurance scheme among HMOs.
Materials and Methods:
Cross-sectional survey of 33 HMOs participating in the NHIS.
Utilisation of standard risk-management strategies by the HMOs was 11 (52.6%). The other risk-management strategies not utilised in the NHIS 10 (47.4%) were risk equalisation and reinsurance. As high as 11 (52.4%) of participating HMOs had a weak enrollee base (less than 30,000 and poor monthly premium and these impacted negatively on the HMOs such that a large percentage 12 (54.1%) were unable to meet up with their financial obligations. Most of the HMOs 15 (71.4%) participated in the Millennium development goal (MDG) maternal and child health insurance programme.
Weak enrollee base and poor monthly premium predisposed the HMOs to financial risk which impacted negatively on the overall performance in service delivery in the NHIS, further worsened by the non-utilisation of risk equalisation and reinsurance as risk-management strategies in the NHIS. There is need to make the scheme compulsory and introduce risk equalisation and reinsurance.
PMCID: PMC4178337  PMID: 25298605
Health maintenance organisations; National Health Insurance Scheme; risk equalisation; risk management
10.  Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya 
Health insurance is currently being considered as a mechanism for promoting progress to universal health coverage (UHC) in many African countries. The concept of health insurance is relatively new in Africa, it is hardly well understood and remains unclear how it will function in countries where the majority of the population work outside the formal sector. Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. Progress has been slow, but commitment to achieve UHC through a NHIS remains. This study contributes to this process by exploring communities’ understanding and perceptions of health insurance and their preferred designs features. Communities are the major beneficiaries of UHC reforms. Kenyans should understand the implications of health financing reforms and their preferred design features considered to ensure acceptability and sustainability.
Data presented in this paper are part of a study that explored feasibility of health insurance in Kenya. Data collection methods included a cross-sectional household survey (n = 594 households) and focus group discussions (n = 16).
About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance schemes but limited knowledge of how health insurance functions as well as understanding of key concepts related to income and risk cross-subsidization. Wide dissatisfaction with the public health system was reported. However, the government was the most preferred and trusted agency for collecting revenue as part of a NHIS. People preferred a comprehensive benefit package that included inpatient and outpatient care with no co-payments. Affordability of premiums, timing of contributions and the extent to which population needs would be met under a contributory scheme were major issues of concern for a NHIS design. Possibilities of funding health care through tax instead of NHIS were raised and preferred by the majority.
This study provides important information on community understanding and perceptions of health insurance. As Kenya continues to prepare for UHC, it is important that communities are educated and engaged to ensure that the NHIS is acceptable to the population it serves.
PMCID: PMC3842821  PMID: 24219335
11.  The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana 
Prepayments and risk pooling through social health insurance has been advocated by international development organizations. Social health insurance is seen as a mechanism that helps mobilize resources for health, pool risk, and provide more access to health care services for the poor. Hence Ghana implemented the National Health Insurance Scheme (NHIS) to help promote access to health care services for Ghanaians. The study examined the influence of the NHIS on the behavior of health care providers in their treatment of insured and uninsured clients.
The study took place in Bolgatanga (urban) and Builsa (rural) districts in Ghana. Data was collected through exit survey with 200 insured and uninsured clients, 15 in-depth interviews with health care providers and health insurance managers, and 8 focus group discussions with insured and uninsured community members.
The NHIS promoted access for insured and mobilized revenue for health care providers. Both insured and uninsured were satisfied with care (survey finding). However, increased utilization of health care services by the insured leading to increased workloads for providers influenced their behavior towards the insured. Most of the insured perceived and experienced long waiting times, verbal abuse, not being physically examined and discrimination in favor of the affluent and uninsured. The insured attributed their experience to the fact that they were not making immediate payments for services. A core challenge of the NHIS was a delay in reimbursement which affected the operations of health facilities and hence influenced providers’ behavior as well. Providers preferred clients who would make instant payments for health care services. Few of the uninsured were utilizing health facilities and visit only in critical conditions. This is due to the increased cost of health care services under the NHIS.
The perceived opportunistic behavior of the insured by providers was responsible for the difference in the behavior of providers favoring the uninsured. Besides, the delay in reimbursement also accounted for providers’ negative attitude towards the insured. There is urgent need to address these issues in order to promote confidence in the NHIS, as well as its sustainability for the achievement of universal coverage.
PMCID: PMC3505458  PMID: 22828034
National health insurance; Social health insurance; Universal health coverage; Perceptions; Experiences; Health care providers’ behavior; Insured; Uninsured; Ghana
12.  Who pays for health care in Ghana? 
Financial protection against the cost of unforeseen ill health has become a global concern as expressed in the 2005 World Health Assembly resolution (WHA58.33), which urges its member states to "plan the transition to universal coverage of their citizens". An important element of financial risk protection is to distribute health care financing fairly in relation to ability to pay. The distribution of health care financing burden across socio-economic groups has been estimated for European countries, the USA and Asia. Until recently there was no such analysis in Africa and this paper seeks to contribute to filling this gap. It presents the first comprehensive analysis of the distribution of health care financing in relation to ability to pay in Ghana.
Secondary data from the Ghana Living Standard Survey (GLSS) 2005/2006 were used. This was triangulated with data from the Ministry of Finance and other relevant sources, and further complemented with primary household data collected in six districts. We implored standard methodologies (including Kakwani index and test for dominance) for assessing progressivity in health care financing in this paper.
Ghana's health care financing system is generally progressive. The progressivity of health financing is driven largely by the overall progressivity of taxes, which account for close to 50% of health care funding. The national health insurance (NHI) levy (part of VAT) is mildly progressive and formal sector NHI payroll deductions are also progressive. However, informal sector NHI contributions were found to be regressive. Out-of-pocket payments, which account for 45% of funding, are regressive form of health payment to households.
For Ghana to attain adequate financial risk protection and ultimately achieve universal coverage, it needs to extend pre-payment cover to all in the informal sector, possibly through funding their contributions entirely from tax, and address other issues affecting the expansion of the National Health Insurance. Furthermore, the pre-payment funding pool for health care needs to grow so budgetary allocation to the health sector can be enhanced.
PMCID: PMC3142212  PMID: 21708026
13.  An exploratory study of the policy process and early implementation of the free NHIS coverage for pregnant women in Ghana 
Pregnant women were offered free access to health care through National Health Insurance (NHIS) membership in Ghana in 2008, in the latest phase of policy reforms to ensure universal access to maternal health care. During the same year, free membership was made available to all children (under-18). This article presents an exploratory qualitative analysis of how the policy of free maternal membership was developed and how it is being implemented.
The study was based on a review of existing literature – grey and published – and on a key informant interviews (n = 13) carried out in March-June 2012. The key informants included representatives of the key stakeholders in the health system and public administration, largely at national level but also including two districts.
The introduction of the new policy for pregnant women was seen as primarily a political initiative, with limited stakeholder consultation. No costing was done prior to introduction, and no additional funds provided to the NHIS to support the policy after the first year. Guidelines had been issued but beyond collecting numbers of women registered, no additional monitoring and evaluation have yet been put in place to monitor its implementation. Awareness of the under-18 s policy amongst informants was so low that this component had to be removed from the final study. Initial barriers to access, such as pregnancy tests, were cited, but many appear to have been resolved now. Providers are concerned about the workload related to services and claims management but have benefited from increased financial resources. Users still face informal charges, and are reported to have responded differentially, with rises in antenatal care and in urban areas highlighted. Policy sustainability is linked to the survival of the NHIS as a whole.
Ghana has to be congratulated for its persistence in trying to address financial barriers. However, many themes from previous evaluations of exemptions policies in Ghana have recurred in this study – particularly, the difficulties of getting timely reimbursement to facilities, of controlling charging of patients, and of reaching the poorest. This suggests that providing free care through a national health insurance system has not solved systemic weaknesses. The wider concerns about raising the quality of care, and ensuring that all supply-side and demand-side elements are in place to make the policy effective will also take a longer term and bigger commitment.
PMCID: PMC3599129  PMID: 23446355
Maternal health; Exemptions; Ghana; Health insurance; Policy process; Implementation
14.  Challenges in Provider Payment Under the Ghana National Health Insurance Scheme: A Case Study of Claims Management in Two Districts 
Ghana Medical Journal  2012;46(4):189-199.
In 2004, Ghana started implementing a National Health Insurance Scheme (NHIS) to remove cost as a barrier to quality healthcare. Providers were initially paid by fee - for - service. In May 2008, this changed to paying providers by a combination of Ghana - Diagnostic Related Groupings (G-DRGs) for services and fee - for - service for medicines through the claims process.
The study evaluated the claims management processes for two District MHIS in the Upper East Region of Ghana.
Retrospective review of secondary claims data (2008) and a prospective observation of claims management (2009) were undertaken. Qualitative and quantitative approaches were used for primary data collection using interview guides and checklists. The reimbursements rates and value of rejected claims were calculated and compared for both districts using the z test. The null hypothesis was that no differences existed in parameters measured.
Claims processes in both districts were similar and predominantly manual. There were administrative capacity, technical, human resource and working environment challenges contributing to delays in claims submission by providers and vetting and payment by schemes. Both Schemes rejected less than 1% of all claims submitted. Significant differences were observed between the Total Reimbursement Rates (TRR) and the Total Timely Reimbursement Rates (TTRR) for both schemes. For TRR, 89% and 86% were recorded for Kassena Nankana and Builsa Schemes respectively while for TTRR, 45% and 28% were recorded respectively.
Ghana's NHIS needs to reform its provider payment and claims submission and processing systems to ensure simpler and faster processes. Computerization and investment to improve the capacity to administer for both purchasers and providers will be key in any reform.
PMCID: PMC3645172  PMID: 23661837
claims management; claims process; claims rejection; health insurance
15.  Identifying Children with Special Health Care Needs in the National Health Interview Survey: A New Resource for Policy Analysis 
Health Services Research  2004;39(1):53-72.
To test the feasibility of using the National Health Interview Survey (NHIS) to identify children with chronic illness through a noncategorical approach, as exemplified by the Children with Special Health Care Needs (CSHCN) screener. The ability to use the NHIS to identify CSHCN will permit analyses of the effects of welfare reform and public insurance eligibility expansions during the late 1990s on CSHCN.
Data Sources
The NHIS from 1997, 1999, and 2000. The NHIS is an ongoing household survey representative of the civilian, noninstitutionalized population of the United States.
Study Design
Survey items were selected from the NHIS and thresholds designated to replicate the content and logic of the CSHCN screener. The screener asks explicit questions concerning an elevated need for, or use of health care services, and about limitations in activity, both caused by a chronic health condition. The algorithm created was applied to the pooled 1999–2000 NHIS to generate national prevalence estimates. Multivariate logistic regression was estimated to determine the effect of having particular demographic characteristics on the likelihood of being identified as CSHCN. Log odds ratios were compared to those from earlier NHIS-based estimates and from a pretest of the CSHCN screener.
Principal Findings
An estimated 12 percent of noninstitutionalized children aged 0 through 17 have a chronic condition that results in elevated service use or limitations in normal activity. This estimate is sensitive to inclusion of children with a broader array of less serious or shorter-term conditions. The estimated effects of child characteristics on the likelihood of being identified as having special health needs are similar but not identical to other algorithms that have been used to identify CSHCN.
It is feasible to use existing questions in the NHIS to identify a population of CSHCN that is substantially similar to children identified through other algorithms or through use of a screening instrument imbedded in a household survey. The availability of this algorithm will permit use of the NHIS for important analyses of the effects of welfare reform and public insurance expansions on children with special health care needs.
PMCID: PMC1360994  PMID: 14965077
Children; chronic illness; measurement; CSHCN screener
16.  Impact of the healthcare payment system on patient access to oral anticancer drugs: an illustration from the French and United States contexts 
Oral anticancer drugs (OADs) allow treating a growing range of cancers. Despite their convenience, their acceptance by healthcare professionals and patients may be affected by medical, economical and organizational factors. The way the healthcare payment system (HPS) reimburses OADs or finances hospital activities may impact patients’ access to such drugs. We discuss how the HPS in France and USA may generate disincentives to the use of OADs in certain circumstances.
French public and private hospitals are financed by National Health Insurance (NHI) according to the nature and volume of medical services provided annually. Patients receiving intravenous anticancer drugs (IADs) in a hospital setting generate services, while those receiving OADs shift a part of service provision from the hospital to the community. In 2013, two million outpatient IADs sessions were performed, representing a cost of €815 million to the NHI, but positive contribution margin of €86 million to hospitals. Substitution of IADs by OADs mechanically induces a shortfall in hospital income related to hospitalizations. Such economic constraints may partially contribute to making physicians reluctant to prescribe OADs. In the US healthcare system, coverage for OADs is less favorable than coverage for injectable anticancer drugs. In 2006, a Cancer Drug Coverage Parity Act was adopted by several states in order to provide patients with better coverage for OADs. Nonetheless, the complexity of reimbursement systems and multiple reimbursement channels from private insurance represent real economic barriers which may prevent patients with low income being treated with OADs. From an organizational perspective, in both countries the use of OADs generates additional activities related to physician consultations, therapeutic education and healthcare coordination between hospitals and community settings, which are not considered in the funding of hospitals activities so far.
Funding of healthcare services is a critical factor influencing in part the choice of cancer treatments and this is expected to become increasingly important as economic constraints grow. Drug reimbursement systems and hospital financing changes, coupled with other accompanying measures, should contribute to improve equal and safe patient access to appropriate anticancer drugs and improve the management and care pathway of cancer patients.
PMCID: PMC4082413  PMID: 24950778
Oral; Chemotherapy; Targeted therapy; Healthcare payment system; Reimbursement; Hospital funding; Medicare Part D; Cancer
17.  Ordering Social Objectives: National Health Service and National Health Insurance as Policy Options in Organizing the Medical Care System 
For many years, a sharp distinction was made between NHS and NHI on the basis of payment and program focus. First, NHS was defined as a program essentially based on Congressional appropriations (general revenues); while NHI would be based on premiums largely derived from the insured. Second, NHS guaranteed service while NHI guaranteed only payment for services rendered.
The distinctions were later extended from these definitions to include differences in response to resource needs, changing task descriptions and personnel assignments, more equitable redistribution of manpower, centralized administration and consumer participation.
In general, if the goal were equity, NHS seemed more responsive than NHI.
However, in recent years, the approach to NHI has been modified in response to criticism as well as increasing recognition of changed needs, and proposals for NHI like the Kennedy-Corman bill have become more like proposals for a NHS. In short, the difference today is largely one of immediate as against eventual transformation of the medical care system into a social instrument aiming to achieve equity. The major disagreement is whether the present medical care system lends itself to modification so as to achieve that end.
PMCID: PMC2595663  PMID: 685298
18.  What are the emerging features of community health insurance schemes in East Africa? 
The three East African countries of Uganda, Tanzania, and Kenya are characterized by high poverty levels, population growth rates, prevalence of HIV/AIDS, under-funding of the health sector, poor access to quality health care, and small health insurance coverage. Tanzania and Kenya have user-fees whereas Uganda abolished user-fees in public-owned health units.
To provide comparative description of community health insurance (CHI) schemes in three East African countries of Uganda, Tanzania, and Kenya and thereafter provide a basis for future policy research for development of CHI schemes.
An analytical grid of 10 distinctive items pertaining to the nature of CHI schemes was developed so as to have a uniform lens of comparing country situations of CHI.
Results and conclusions
The majority of the schemes have been in existence for a relatively short time of less than 10 years and their number remains small. There is need for further research to identify what is the mix and weight of factors that cause people to refrain from joining schemes. Specific issues that could also be addressed in subsequent studies are whether the current schemes provide financial protection, increase access to quality of care and impact on the equity of health services financing and delivery. On the basis of this knowledge, rational policy decisions can be taken. The governments thereafter could consider an option of playing more roles in advocacy, paying for the poorest, and developing an enabling policy and legal framework.
PMCID: PMC3270905  PMID: 22312207
community health insurance; low enrolment; policy and Africa
19.  Is Ghana’s pro-poor health insurance scheme really for the poor? Evidence from Northern Ghana 
Protecting the poor and vulnerable against the cost of unforeseen ill health has become a global concern culminating in the 2005 World Health Assembly resolution urging member states to ensure financial protection to all citizens, especially children and women of reproductive age. Ghana provides financial protection to its citizens through the National Health Insurance Scheme (NHIS). Launched in 2004, its proponents claim that the NHIS is a pro-poor financial commitment that implements the World Health Assembly resolution.
Using 2011 survey data collected in seven districts in northern Ghana from 5469 women aged 15 to 49 the paper explores the extent to which poor child-bearing age mothers are covered by the NHIS in Ghana’s poorest and most remote region. Factors associated with enrolment into the NHIS are estimated with logistic regression models employing covariates for household relative socio-economic status (SES), location of residence and maternal educational attainment, marital status, age, religion and financial autonomy.
Results from the analysis showed that 33.9 percent of women in the lowest SES quintile compared to 58.3 percent for those in the highest quintile were insured. About 60 percent of respondents were registered. However, only 40 percent had valid insurance cards indicating that over 20 percent of the registered respondents did not have insurance cards. Thus, a fifth of the respondents were women who were registered but unprotected from the burden of health care payments. Results show that the relatively well educated, prosperous, married and Christian respondents were more likely to be insured than other women. Conversely, women living in remote households that were relatively poor or where traditional religion was practised had lower odds of insurance coverage.
The results suggest that the NHIS is yet to achieve its goal of addressing the need of the poor for insurance against health related financial risks. To ultimately attain adequate equitable financial protection for its citizens, achieve universal health coverage in health care financing, and fully implement the World Health Assembly resolution, Ghana must reform enrolment policies in ways that guarantee pre-payment for the most poor and vulnerable households.
PMCID: PMC4268792  PMID: 25494816
National health insurance scheme; Universal health coverage; Pro-poor; Poor; Ghana
20.  National health insurance scheme: How receptive are the private healthcare practitioners in a local government area of Lagos state 
National Health Insurance Scheme (NHIS) is one of the health financing options adopted by Nigeria for improved healthcare access especially to the low income earners. One of the key operators of the scheme is the health care providers, thus their uptake of the scheme is fundamental to the survival of the scheme. The study reviewed the uptake of the NHIS by private health care providers in a Local Government Area in Lagos State.
To assess the uptake of the NHIS by private healthcare practitioners.
Materials and Methods:
This descriptive cross-sectional study recruited 180 private healthcare providers selected by multistage sampling technique with a response rate of 88.9%.
Awareness, knowledge and uptake of NHIS were 156 (97.5%), 110 (66.8%) and 97 (60.6%), respectively. Half of the respondents 82 (51.3%) were dissatisfied with the operations of the scheme. Major reasons were failure of entitlement payment by Health Maintenance Organisations 13 (81.3%) and their incurring losses in participating in the scheme 8(50%). There was a significant association between awareness, level of education, knowledge of NHIS and registration into scheme by the respondents P-value < 0.05.
Awareness and knowledge of NHIS were commendable among the private health care providers. Six out of 10 had registered with the NHIS but half of the respondents 82 (51.3%) were dissatisfied with the scheme and 83 (57.2%) regretted participating in the scheme. There is need to improve payment modalities and ensure strict adherence to laid down policies.
PMCID: PMC4262851  PMID: 25538373
Knowledge; NHIS; private private healthcare providers; uptake
21.  Financing equitable access to antiretroviral treatment in South Africa 
BMC Health Services Research  2010;10(Suppl 1):S2.
While South Africa spends approximately 7.4% of GDP on healthcare, only 43% of these funds are spent in the public system, which is tasked with the provision of care to the majority of the population including a large proportion of those in need of antiretroviral treatment (ART). South Africa is currently debating the introduction of a National Health Insurance (NHI) system. Because such a universal health system could mean increased public healthcare funding and improved access to human resources, it could improve the sustainability of ART provision. This paper considers the minimum resources that would be required to achieve the proposed universal health system and contrasts these with the costs of scaled up access to ART between 2010 and 2020.
The costs of ART and universal coverage (UC) are assessed through multiplying unit costs, utilization and estimates of the population in need during each year of the planning cycle. Costs are from the provider’s perspective reflected in real 2007 prices.
The annual costs of providing ART increase from US$1 billion in 2010 to US$3.6 billion in 2020. If increases in funding to public healthcare only keep pace with projected real GDP growth, then close to 30% of these resources would be required for ART by 2020. However, an increase in the public healthcare resource envelope from 3.2% to 5%-6% of GDP would be sufficient to finance both ART and other services under a universal system (if based on a largely public sector model) and the annual costs of ART would not exceed 15% of the universal health system budget.
Responding to the HIV-epidemic is one of the many challenges currently facing South Africa. Whether this response becomes a “resource for democracy” or whether it undermines social cohesiveness within poor communities and between rich and poor communities will be partially determined by the steps that are taken during the next ten years. While the introduction of a universal system will be complex, it could generate a health system responsive to the needs of all South Africans.
PMCID: PMC2895746  PMID: 20594368
22.  Background and Data Configuration Process of a Nationwide Population-Based Study Using the Korean National Health Insurance System 
Diabetes & Metabolism Journal  2014;38(5):395-403.
The National Health Insurance Service (NHIS) recently signed an agreement to provide limited open access to the databases within the Korean Diabetes Association for the benefit of Korean subjects with diabetes. Here, we present the history, structure, contents, and way to use data procurement in the Korean National Health Insurance (NHI) system for the benefit of Korean researchers.
The NHIS in Korea is a single-payer program and is mandatory for all residents in Korea. The three main healthcare programs of the NHI, Medical Aid, and long-term care insurance (LTCI) provide 100% coverage for the Korean population. The NHIS in Korea has adopted a fee-for-service system to pay health providers. Researchers can obtain health information from the four databases of the insured that contain data on health insurance claims, health check-ups and LTCI.
Metabolic disease as chronic disease is increasing with aging society. NHIS data is based on mandatory, serial population data, so, this might show the time course of disease and predict some disease progress, and also be used in primary and secondary prevention of disease after data mining.
The NHIS database represents the entire Korean population and can be used as a population-based database. The integrated information technology of the NHIS database makes it a world-leading population-based epidemiology and disease research platform.
PMCID: PMC4209354  PMID: 25349827
National Health Insurance; National Health Insurance Service; Population-based data; Korea
23.  The influences of Taiwan's generic grouping price policy on drug prices and expenditures: Evidence from analysing the consumption of the three most-used classes of cardiovascular drugs 
BMC Public Health  2008;8:118.
Controlling the growth of pharmaceutical expenditures is a major global challenge. Promotion of generic drug prescriptions or use is gaining increased support. There are substantial contextual differences in international experiences of implementing pharmaceutical policies related to generic drugs. Reporting these experiences from varied perspectives can inform future policy making. This study describes an experience of Taiwan, where patients with chronic (long-term) conditions are usually managed in hospitals and drugs are provided in this setting with costs reimbursed through the National Health Insurance (NHI). It investigates the effects of Taiwan's reimbursement rate adjustment based on chemical generic grouping in 2001. This research also demonstrates the use of micro-level longitudinal data to generate policy-relevant information. The research can be used to improve efficiency of health care resource use.
We chose the three most-used classes of cardiovascular drugs for this investigation: beta blocking agents, calcium channel blockers mainly with vascular effects, and plain ACE inhibitors. For each drug class, we investigated changes in daily expense, consumption volume, and total expenditures from a pre-action period to a corresponding post-action period. We compared an exposure or "intervention" group of patients targeted by the action with a comparisonor "control" group of patients not targeted by the action. The data sources are a longitudinal database for 200,000 NHI enrolees, corresponding NHI registration data of health care facilities, and an archive recording all historical data on the reimbursement rates of drugs covered by the NHI. We adopted a fixed effects linear regression model to control for unobserved heterogeneity among patient-hospital groups. Additional descriptive statistics were applied to examine whether any inappropriate consumption of drugs in the three classes existed.
The daily drug expense significantly decreased from the pre-action period to the post-action period for the exposure group. The average magnitudes of the decreases for the three classes of drugs mentioned above were 14.8%, 5.8% and 5.8%, respectively. In contrast, there was no reduction for the comparison group. The number of days of the prescription increased significantly from the pre- to the post-action period for both exposure and comparison groups. The total expense also significantly increased for both patient groups. For the exposure group, the average magnitudes of the growth in the total expenditure for the three classes of drugs were 47.7%, 60.0% and 55.3%, respectively. For the comparison group, they were 91.6%, 91.6% and 63.2%, respectively. After the action, approximately 50% of patients obtained more than 180 days of prescription drugs for a six-month period.
The 2001 price adjustment action, based on generic grouping, significantly reduced the daily expense of each of the three classes of cardiovascular drugs. However, in response to this policy change, hospitals in Taiwan tended to greatly expand the volume of drugs prescribed for their regular patients. Consequently, the total expenditures for the three classes of drugs grew substantially after the action. These knock-on effects weakened the capability of the price adjustment action to control total pharmaceutical expenditures. This means that no saved resources were available for other health care uses. Such expansion of pharmaceutical consumption might also lead to inefficient use of the three drug classes: a large proportion of patients obtained more than one day of drugs per day in the post-action period, suggesting manipulation to increase reimbursement and offset price controls. We recommend that Taiwan's government use the NHI data to establish a monitoring system to detect inappropriate prescription patterns before implementing future policy changes. Such a monitoring system could then be used to deter hospitals from abusing their prescription volumes, making it possible to more effectively save health care resources by reducing drug reimbursement rates.
PMCID: PMC2377257  PMID: 18405385
24.  Incorporation of Personal Single Nucleotide Polymorphism (SNP) Data into a National Level Electronic Health Record for Disease Risk Assessment, Part 2: The Incorporation of SNP into the National Health Information System of Turkey 
JMIR Medical Informatics  2014;2(2):e17.
A personalized medicine approach provides opportunities for predictive and preventive medicine. Using genomic, clinical, environmental, and behavioral data, the tracking and management of individual wellness is possible. A prolific way to carry this personalized approach into routine practices can be accomplished by integrating clinical interpretations of genomic variations into electronic medical record (EMR)s/electronic health record (EHR)s systems. Today, various central EHR infrastructures have been constituted in many countries of the world, including Turkey.
As an initial attempt to develop a sophisticated infrastructure, we have concentrated on incorporating the personal single nucleotide polymorphism (SNP) data into the National Health Information System of Turkey (NHIS-T) for disease risk assessment, and evaluated the performance of various predictive models for prostate cancer cases. We present our work as a miniseries containing three parts: (1) an overview of requirements, (2) the incorporation of SNP into the NHIS-T, and (3) an evaluation of SNP data incorporated into the NHIS-T for prostate cancer.
For the second article of this miniseries, we have analyzed the existing NHIS-T and proposed the possible extensional architectures. In light of the literature survey and characteristics of NHIS-T, we have proposed and argued opportunities and obstacles for a SNP incorporated NHIS-T. A prototype with complementary capabilities (knowledge base and end-user applications) for these architectures has been designed and developed.
In the proposed architectures, the clinically relevant personal SNP (CR-SNP) and clinicogenomic associations are shared between central repositories and end-users via the NHIS-T infrastructure. To produce these files, we need to develop a national level clinicogenomic knowledge base. Regarding clinicogenomic decision support, we planned to complete interpretation of these associations on the end-user applications. This approach gives us the flexibility to add/update envirobehavioral parameters and family health history that will be monitored or collected by end users.
Our results emphasized that even though the existing NHIS-T messaging infrastructure supports the integration of SNP data and clinicogenomic association, it is critical to develop a national level, accredited knowledge base and better end-user systems for the interpretation of genomic, clinical, and envirobehavioral parameters.
PMCID: PMC4288069  PMID: 25599817
health information systems; clinical decision support systems; disease risk model; electronic health record; epigenetics; personalized medicine; single nucleotide polymorphism
25.  Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria 
The National Health Insurance Scheme (NHIS) in Nigeria was launched in 2005 as part of efforts by the federal government to achieve universal coverage using financial risk protection mechanisms. However, only 4% of the population, and mainly federal government employees, are currently covered by health insurance and this is primarily through the Formal Sector Social Health Insurance Programme (FSSHIP) of the NHIS. This study aimed to understand why different state (sub-national) governments decided whether or not to adopt the FSSHIP for their employees.
This study used a comparative case study approach. Data were collected through document reviews and 48 in-depth interviews with policy makers, programme managers, health providers, and civil servant leaders.
Although the programme’s benefits seemed acceptable to state policy makers and the intended beneficiaries (employees), the feasibility of employer contributions, concerns about transparency in the NHIS and the role of states in the FSSHIP, the roles of policy champions such as state governors and resistance by employees to making contributions, all influenced the decision of state governments on adoption. Overall, the power of state governments over state-level health reforms, attributed to the prevailing system of government that allows states to deliberate on certain national-level policies, enhanced by the NHIS legislation that made adoption voluntary, enabled states to adopt or not to adopt the program.
The study demonstrates and supports observations that even when the content of a programme is generally acceptable, context, actor roles, and the wider implications of programme design on actor interests can explain decision on policy adoption. Policy implementers involved in scaling-up the NHIS programme need to consider the prevailing contextual factors, and effectively engage policy champions to overcome known challenges in order to encourage adoption by sub-national governments. Policy makers and implementers in countries scaling-up health insurance coverage should, early enough, develop strategies to overcome political challenges inherent in the path to scaling-up, to avoid delay or stunting of the process. They should also consider the potential pitfalls of reforms that first focus on civil servants, especially when the use of public funds potentially compromises coverage for other citizens.
PMCID: PMC3686590  PMID: 23764306
Case study; Health financing; Nigeria; Social health insurance; Universal coverage

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