ASSESSMENT OF PERFORMANCE OF GA DISTRICT MUTUAL HEALTH INSURANCE SCHEME

ABSTRACT Background: Ghana established National Health Insurance Scheme (NHIS) in 2004 to replace out-of-pocket payment popularly referred to as „cash and carry‟, which created financial barrier to health care access to the poor and vulnerable. However, the NHIS was fully implemented in 2005 and has since faced performance challenges such as delays in issuance of ID cards to registered members and payment of provider claims. Objective: To assess performance of the Ga District Mutual Health Insurance Scheme for the period, 2007-2009. Methods: The study employed desk review method to collect secondary data to analyse membership coverage, revenue, expenditure, and claims settlement patterns of the Scheme. A household survey was also conducted in the Madina township to determine community penetration rate of the Scheme. Results: The study shows a coverage rate of 22.6% and a community penetration rate of 22.2%. About one-third of the registered members pay premium and this affects revenue base of the Scheme. Financially, the Scheme depends on NHIA support (administrative, exempt, and reinsurance funds) for 89.8% of its revenue. Approximately 92% of the total revenue was spent on medical bills. The claims settlements pattern shows that about 99% of provider claims are settled beyond the stipulated four weeks period. This poses financial challenge to healthcare providers and may force them to take measures that defeat the purpose of the scheme. Conclusion: The study shows that there are downward trends in membership coverage and revenue from contributions, and an increasing trend in claims expenses. Moreover, vi there are lengthy delays in claims settlements. An establishment of district schemes in the Ga East and Ga West sub-districts will be necessary to improve membership coverage and revenue mobilization especially from the informal sector. Also, amendment of the claims settlements period from four to twelve weeks will help ensure proper vetting of claims to minimize fraud and abuse. However, part-payment of claims to healthcare providers whilst the claims are being vetted will be important to ensure continuous provision of services to insured members. Keywords: National Health Insurance Scheme, coverage rate, revenue, claims settlements, Ghana