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Background: A robust medical claims review system is crucial for addressing fraud and abuse and ensuring financial viability of health insurance organisations. This paper assesses claims adjustment rate of the paper- and electronic-based claims reviews of the National Health Insurance Scheme (NHIS) in Ghana.Methods: The study was a cross-sectional comparative assessment of paper- and electronic-based claims reviews of the NHIS. Medical claims of subscribers for the year, 2014 were requested from the claims directorate and analysed. Proportions of claims adjusted by the paper- and electronic-based claims reviews were determined for each type of healthcare facility. Bivariate analyses were also conducted to test for differences in claims adjustments between healthcare facility types, and between the two claims reviews.Results: The electronic-based review made overall adjustment of 17.0% from GHS10.09 million (USD2.64 m) claims cost whilst the paper-based review adjusted 4.9% from a total of GHS57.50 million (USD15.09 m) claims cost received, and the difference was significant (p < 0.001). However, there were no significant differences in claims cost adjustment rate between healthcare facility types by the electronic-based (p = 0.0656) and by the paper-based reviews (p = 0.6484).Conclusions: The electronic-based review adjusted significantly higher claims cost than the paper-based claims review. Scaling up the electronic-based review to cover claims from all accredited care providers could reduce spurious claims cost to the scheme and ensure long term financial sustainability. [ABSTRACT FROM AUTHOR]

Background: Universal Health Coverage has been openly recognized in the United Nations health-related Sustainable Development Goals by 2030, though missing under the Millennium Development Goals. Ghana implemented the National Health Insurance Scheme programme in 2004 to improve financial access to healthcare for its citizens. This programme targeting low-income individuals and households includes an Exempt policy for older persons and indigents. Despite population ageing, evidence of the participation and perceptions of older persons in the scheme in cash grant communities is unknown. Hence, this paper examined the prevalence, perceptions and factors associated with health insurance enrollment among older persons in cash grant communities in Ghana. Methods: Data were from a cross-sectional household survey of 400 older persons(60 + years) and eight FGDs between 2017 and 2018. For the survey, stratified and simple random sampling techniques were utilised in selecting participants. Purposive and stratified sampling techniques were employed in selecting the focus group discussion participants. Data analyses included descriptive, modified Poisson regression approach tested at a p-value of 0.05 and thematic analysis. Stata and Atlas-ti software were used in data management and analyses. Results: The mean age was 73.7 years. 59.3% were females, 56.5% resided in rural communities, while 34.5% had no formal education. Two-thirds were into agriculture. Three-fourth had non-communicable diseases. Health insurance coverage was 60%, and mainly achieved as Exempt by age. Being a female [Adjusted Prevalence Ratio (APR) 1.29, 95%CI:1.00–1.67], having self-rated health status as bad [APR = 1.34, 95%CI:1.09–1.64] and hospital healthcare utilisation [APR = 1.49, 95%CI:1.28–1.75] were positively significantly associated with health insurance enrollment respectively. Occupation in Agriculture reduced insurance enrollment by 20.0%. Cited reasons for poor perceptions of the scheme included technological challenges and unsatisfactory services. Conclusion: Health insurance enrollment among older persons in cash grant communities is still not universal. Addressing identified challenges and integrating the views of older persons into the programme have positive implications for securing universal health coverage by 2030. [ABSTRACT FROM AUTHOR]

Background: In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations. Methods: A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES. Results: Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme. Conclusions: Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment. [ABSTRACT FROM AUTHOR]

Background: Ghana introduced capitation payment for primary care in 2012 with the view to containing escalating claims expenditure. This shift in provider payment method raised issues about its potential impact on patient-provider trust relationship and insured-patients' trust in the Ghana National Health Insurance Scheme. This paper presents findings of a study that explored insured-patients' perception about, and attitude towards capitation payment in Ghana; and determined whether capitation payment affect insured-patients' trust in their preferred primary care provider and the National Health Insurance Scheme in general.Methods: We adopted a survey design for the study. We administered closed-ended questionnaires to collect data from insurance card-bearing members aged 18 years and above. We performed both descriptive statistics to determine proportions of observations relating to the variables of interest and chi-square test statistics to determine differences within gender and setting.Results: Sixty-nine per cent (69 %) out of 344 of respondents selected hospital level of care as their primary care provider. The two most important motivations for the choice of a provider were proximity in terms of geographical access (40 %) and perceived quality of care (38 %). Eighty-eight per cent (88 %) rated their trust in their provider as (very) high. Eighty-two per cent (82 %) actively selected their providers. Eighty-eight per cent (88 %) had no intention to switch provider. A majority (91 %) would renew their membership when it expires. Female respondents (91 %; n = 281) were more likely to renew their membership than males (87 %; n = 63). Notwithstanding capitation payment experience, 81 % of respondents would recommend to their peers to enrol with the NHIS with rural dwellers (87 %; n = 156) being more likely to do so than urban dwellers (76 %; n = 188). Almost all respondents (92 %) rated the NHIS as (very) good.Conclusion: Health Insurance subscribers in Ghana have high trust in their primary care provider giving them quality care under capitation payment despite their negative attitude towards capitation payment. They are guided by proximity and quality of care considerations in their choice of provider. The NHIA would, however, have to address itself to the negative perceptions about the capitation payment policy. [ABSTRACT FROM AUTHOR]

Background: Ghana introduced capitation payment method in 2012 but was faced with resistance for its perceived poor quality of care. This paper assesses National Health Insurance Scheme subscribers and care providers’ perception of quality of care under the capitation payment method. Methods: This is a cross-sectional survey of subscribers and care providers perception of quality of care in three administrative regions of Ghana using a 5-point Likert scale for the assessment based on a set of quality of care measures. We performed descriptive analysis to determine average perception of quality of care scores for each of the measures used. Bivariate and multivariate analyses were also performed to examine relationships between respondent’s characteristics and their perception of quality of care. Results: In general, subscribers expressed positive perception about the quality of care though subscribers in Ashanti were less positive compared to those in the Central region. A chi-square analysis, however, showed significant differences in subscribers’ perception of quality of care by occupation (p = 0.002), region (p = 0.007) length of NHIS membership (p = 0.006), and age (p = 0.014). Multivariate logistic regression analysis also showed that different factors, other than region of residence, were significantly associated with perceived good quality of care. Analysis of health care providers’ responses also showed significant differences in their perception of quality of care by region (p = 0.001). Multivariate logistic model showed that health care providers in the Volta region (OR = 0.14, 95% CI: 0.03–0.58) were significantly less likely to perceive quality of care as good compared to those in the Ashanti region. Conclusion: Subscribers and care providers across the three regions have relatively good perception of the quality of health care in general though subscribers in Ashanti were less positive than those in the Central region. It is, therefore, plausible that capitation payment may have influenced the relatively low perception of quality of care in the Ashanti region. [ABSTRACT FROM AUTHOR]

Background: The introduction of health insurance in Ghana in 2003 has resulted in a tremendous increase in utilization of health services. However, concerns are being raised about the quality of patient care. Some of the concerns include long waiting times, verbal abuse of patients by health care providers, inadequate physical examination by doctors and discrimination of insured patients. The study compares perceptions of quality of care between insured and uninsured out-patients in selected hospitals in Ghana to determine whether there is any unequal treatment between insured and uninsured patients in terms of quality of care, as empirical and anecdotal evidence seem to suggest. Methods: A cross-sectional survey of 818 out-patients was conducted in 17 general hospitals from three regions of Ghana. These are the Upper East, Brong Ahafo and Central Regions. Convenience sampling was employed to select the patients in exit interviews. Descriptive statistics, including frequency distributions, means and standard deviations, were used to describe socio-economic and demographic characteristics of respondents. Factor analysis was used to determine distinct quality of care constructs; t-test statistic was used to test for differences in quality perceptions between the insured and uninsured patients; and regression analysis was used to test the association between health insurance and quality of care. Results: Overall, there was no significant difference in perceptions of quality between insured and uninsured patients. However, there was a significant difference between insured and uninsured patients in respect of financial access to care. The major quality of care concern affecting all patients was the problem of inadequate resources, especially lack of doctors, lack of drugs and other basic supplies and equipment to work with. Conclusions: It was concluded that generally, insured and uninsured patients are not treated unequally, contrary to prevailing anecdotal and empirical evidence. On the contrary, quality of care is a concern of both insured and uninsured patients. [ABSTRACT FROM AUTHOR]

Background: There is a lack of focused research on the older population in Ghana and about issues pertaining to their access to healthcare services. Furthermore, information is lacking regarding the fairness in the access to these services. This study aimed to ascertain whether horizontal and vertical equity requirements were being met in the healthcare utilisation among older adults aged 50 years and above. Methods: This study was based on a secondary cross-sectional data from the World Health Organization's Study on global AGEing (SAGE) and adult health wave 1 conducted from 2007 to 2008 in Ghana. Data on 4304 older adults aged 50 years-plus were analysed. Bivariate and multivariable analyses were carried out to analyse the association between outpatient/inpatient utilisation and (1) socioeconomic status (SES), controlling for need variables (horizontal equity) and (2) need variables, controlling for SES (vertical equity). Odds ratios with 95% confidence intervals were calculated to analyse the association between relevant variables. Results: Horizontal and vertical inequities were found in the utilisation of outpatient services. Inpatient healthcare utilisation was both horizontally and vertically equitable. Women were found to be more likely to use outpatient services than men but had reduced odds of using inpatient services. Possessing a health insurance was also significantly associated with the use of both inpatient and outpatient services. Conclusion: Whilst equity exists in inpatient care utilisation, more needs to be done to achieve equity in the access to outpatient services. The study reaffirms the need to evaluate both the horizontal and vertical dimensions in the assessment of equity in healthcare access. It provides the basis for further research in bridging the healthcare access inequity gap among older adults in Ghana. [ABSTRACT FROM AUTHOR]