Research

Go back to

West Gonja Health Insurance Schemes

Part 1: Assesment of the Benefit Package, OPD Services, Exemptions and Expansion of Health Insurance to Bole District

The intention behind the health insurance scheme is the provision of an alternative means of financing health care at the hospital with the ultimate aim of reducing the high in-patient indebtedness and also increasing access to the hospital's services.

However after nearly 5 years of operation, the West Gonja Hospital Health Insurance Scheme (WGHHIS) like all new initiatives in the hands of "amateurs", is saddled with institutional, operational and management problems which its Advisory Board and management genuinely seek to rectify. This report examines the main constraining factors and makes recommendations to minimise them.

The first part, gives a brief aetiology of health insurance in Ghana with the Ministry of Health as the pacesetter. The "birth" of West Gonja Hospital Health Insurance Scheme is also discussed.

Part 2 examines the benefit package of WGHHIS and identifies some of the major problems such as adverse selection and moral hazards. To address these, an internal verification system of bills must be put in place, graduated premiums must be introduced to ensure complete family registration, the waiting period must also be used for consistency check on the insured and action must be taken against other frauds and abuses. Other coverage strategies such as forging local partnerships with cooperatives, groups and associations have been thoroughly discussed. The expansion of WGHHIS to cover OPD services requires further studies at both the health facility and community levels.

Part 3 focuses on the implementation and management of the MOH Exemption policy. Generally there was no training for its administration in the district, it seems to be working well except for the laxity in the exemption categories of Children under 5 years and Elderly over 60 years.

Part 4 explores the possibility of introducing a mutual health organization scheme in Bole district also under the Diocese of Damongo. Initial exploratory studies suggest that, the key stakeholders are willing to have the scheme. The Diocesan Health Committee have been given the initial facilitating role. Furthermore, given the lessons learnt from WGHHIS, a baseline survey prior to the inception of Bole's scheme is very crucial.

Part 5 looks at the challenges by way of conclusion and lessons learnt and summaries the issues under broad heading such as Fostering political commitment, collaboration between key partners and the community; Building on existing community resources and organizational systems; Strengthen the support infrastructure; The programmatic context and Bole's scheme.

Finally, the annexes contain the Terms of Reference for the assignment, WGHHIS Constitution, List of cooperatives, groups and associations and tables of exemption costs by health facilities.

In health financing, health insurance scheme/mutual health organisation is one important means of mobilising financial and human resources for promoting health partnership between providers and users for ensuring better health. It is hoped that this report will serve several purposes. In areas where there have been no systematic activities in promoting mutual health organisation, the report will be a guide no how to tackle some the issues addressed, what to look out for and build partnerships. In Bole district it is hoped that lessons learnt form WGHHIS will help carry forward the ideals and enthusiasm for a stronger mutual health organization.

Part 2: Management and Financial Audit, Strengths and Weakness

This aspect of the study focusing on Management and Financial Audit, three methods were used for collection of data and analysis. These are literature review, management committee interview using management control questionnaire and in-depth individual interviews.

Main Findings

On organizational structure, the constitution is sketchy and does not provide for the scheme's officers, their qualifications, reporting authority and mode of appointment. It does not provide for accountability, either to the Bishop as the project holder or to a general assembly. There has been no Annual General Meeting (AGM) for members since the start of the Scheme.

Staffing is inadequate and the ones that are presently at post require training either through short or long courses. Both have their respective benefits and roles and should be investigated for appropriateness.

The staff of the Scheme enjoys a relaxed and friendly working atmosphere. This is good for productivity.

The Scheme has 20 field staff known as contact persons who are engaged on contract basis to collect premiums from members for a commission of 10%.

On Financial Management Audit, the Scheme's staff does not prepare annual accounts. Audited accounts for the years 1996, 1997, and 1998 were prepared and audited by external auditors. It is hoped that with the employment of an Accounts Officer with effect from 1st July 2000, Financial Reporting will improve as well as budgeting becoming a normal part of the Scheme's operations.

Strengths

		Staff, though few are dedicated and committed and work in a friendly atmosphere.
		For the year 2000, the waiting period has been increased from three to six months, in an apparent effort to check adverse selection, which has been evident in the past.
		The use of photo identification cards reduces fraud.
		Continuous registration 12 months of the year means generations of funds throughout the year.
		The Scheme has an excellent financial record keeping system. Pre-numbered receipts bearing the name of the Scheme are issued to all who make payments.
		Good public image. The Scheme is known and praised for its good work by all people met during the assignment. This is both in the Damongo and Bole Districts.
		All contact persons or revenue collectors issue receipts to members for both registration and renewals. The revenue collectors in turn are issued with receipts for total amount paid into the Scheme's office and the details of the members who made the payments in the first place recorded. This internal control ensures funds collected by the revenue collectors are paid into the Scheme's office.

Weaknesses

		There is no well-defined relationship between the Scheme and other bodies such as the District Assembly, DHMT, Traditional Authorities and the Hospital. These bodies know of the existence of the Scheme and praise its good work; a well-defined closer working relationship would promote the Scheme's work tremendously.
		The DHMT for instance, important as its role is in the health care delivery in the District, is not represented on either the Management Team or Advisory Board of the Scheme.
		Senior staff of both the Hospital and the Scheme differs as to whether the Scheme is a department of the Hospital or an autonomous body on its own. Some of them question why the Scheme maintains its separate accounts if is a department. Others maintain because of its unique nature, it should maintain its own accounting system.
		The letter seconding the Coordinator from the hospital to the Scheme states clearly that the Scheme is a department of the Hospital.
		Both the Scheme's Coordinator and his assistant do not have job descriptions, which makes evaluation of their performance very difficult, if not impossible.
		Community ownership, which is critical for sustainability, is lacking. No AGMs, so members have no means of contributing to the management and total welfare of the Scheme.
		The Scheme started with no baseline survey, as such critical factors necessary for such organisations were not considered. For instance, the premium was fixed without analysing the Scheme's environment and as such no idea of income levels of communities.
		No democratic administrative structures are provided for the current constitution, which is rather sketchy.
		Individual registration encourages adverse selection and also a possible of low membership but high claim bills.

I	The current staff level of four (4) is too small for the volume of work required and should be increased to include a Claims Officer and a Public Relations Officer. A Claims Officer will handle all claims before payment. But for the timely vigilance of the Coordinator, a bill of ¢49,575 on a patient's admission's folder was billed as ¢495,752 and another of ¢125,460 was billed as ¢215,460. These errors are purely typographical and could cost a lot of money if not detected through careful check.
II	The current Management Team of four (4) should be increased to include the Finance Officer.
III	Premium needs an upward review to include administrative overheads and a margin for safety. Acceptance of new upward rate will require public education.
IV	Ceiling on benefits and types of illnesses that are covered must be determined. Currently, there is no limits to amount of claims and type of in-patient care, including abortions, AIDS, are covered.
V	Promote family registration. Family registration reduces adverse selection and has the possibility of increasing membership. This is essential for sustainability. Premium could be graduated for different family sizes to encourage acceptance.
VI	Define relationships and strengthen intersectoral collaboration with such bodies as the Hospital, DHMT, District Assembly, and Traditional Council. This could be done by including representative of the DHMT to serve on the Management Team of the Scheme. Representatives of District Assembly and Traditional Council are also to be invited to serve on the Advisory Board. This is after defining the relationship. With a better relationship, the Scheme could be promoted during Traditional meetings when all chiefs of the Gonja Traditional Council are present. The chiefs could help identify field workers
VII	In the face of expansion of Scheme calling for more responsibility, ability to perform, personal confidence and motivation, there is an urgent need for training for project staff. This could be by both short and long duration for certification. For the Scheme's Coordinator especially, will need training in the following disciplines: Management Principles and Practice Insurance Administration & Management and Modern Methods in Management Information Systems
VIII	Institute an Annual General Meetings (AGM). This is essential for feeling of belonging and ownership for members and community.
IX	Waiting period of six months as proposed is commendable and must be maintained. This would discourage and minimize adverse selection.
X	The Scheme needs more office accommodation. The current two rooms, which also serve as stores, is grossly inadequate for the current staff strength. The Coordinator and Finance Officer need separate offices.
XI	There is need for a safe for valuables, especially cash.
XII	A second vehicle, preferably, a 4-wheel drive, will promote outreach especially to more remote areas of the district. This is critical in the rainy periods when it almost impossible to travel off the main roads. The bus currently in use is inadequate and too low a clearance for outreach.
XIII	Introduce out of pocket overnight allowances for office staff on official duties. The current situation where staffs are required to provide for themselves and use the bus for the accommodation is not the best.
XIV	Give job descriptions for staff, especially the Coordinator and his assistant. This is essential for performance evaluation at suitable periods.