Ghana National Health Insurance Scheme: Improving Financial Sustainability Based on Expenditure Review (World Bank Studies)

The Ghana National Health Insurance Scheme (NHIS) was established in 2003 to achieve the country s commitment of universal health coverage. The government has earmarked valueadded tax to finance NHIS in addition to a deduction from the Social Security and National Insurance Trust premium payment. However, the scheme has been running at a deficit since 2009 because of expanded coverage, increased service use, and a surge in expenditures. Consequently, the Ghana National Health Insurance Authority had to reduce its investment fund, borrow loans, and delay claims reimbursement to providers to fill the gap.
Ghana National Health Insurance Scheme: Improving Financial Sustainability Based on Expenditure Review provides policy recommendations on how to improve the efficiency and financial sustainability of the NHIS, based on health sector expenditures and NHIS claims expenditures review. The analysis started with an overall health sector expenditure review, focused on NHIS claims expenditures in the Volta region, and then identified the factors that affect the level and efficiency of expenditures.
It is recommended that NHIS establish a stronger expenditure control system for long-term sustainability. The majority of NHIS claims expenditures is for outpatient consultations, district hospitals, and certain member groups (for example, informal group members with more than five visits in a year). These distribution patterns are closely related to NHIS design features that encourage expenditure surges. The claims processing system is mostly manual and does not collect information on service delivery and results. No mechanisms exist to monitor and correct providers abnormal behaviors, or to engage NHIS members for information verification, case management, and prevention.