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In 2003, the Government of Ghana passed the National Health Insurance Act. The Dangme West
district in the Greater Accra region began its first district health insurance scheme in 2000. In 2005, it
adopted new guidelines under the National Health Insurance Scheme (NHIS). Studies performed on the
national level have demonstrated human resource shortages, major debts in unpaid reimbursements to
health facilities, and weak mechanisms for monitoring quality of care. According to the Dangme West
District 2008 Annual Report, (DHMT, 2008) by the end of 2008, NHIS owed a total of GHc 160,891.33
to district facilities in unpaid claims reimbursements. One study was conducted specifically on the
District Mutual Health Insurance Scheme (DMHIS) in Dangme West. It found that perceived poor
quality of care was of great importance in community members’ choice to enroll or not enroll (Bruce,
2007). A major component of this perceived poor quality of care was poor interpersonal relations
between patients and providers.
Objectives
This study’s objectives were to explore provider’s perspectives and experiences serving insured
patients and the challenges with the claims reimbursement system. The study was exploratory and
purely qualitative. Data collection involved semi-structured in-depth interviews and focus group
discussions at public, accredited health facilities throughout the Dangme West district. Participants
included facility in-charges, accountants, nurses, and other general health staff. Data was transcribed
and manually coded, indexed, and categorized into major themes: service demands, drugs, claims
and reimbursements, staff morale and human resources, registration, and knowledge of insurance
scheme.
Results
Providers presented an overall contentment with the scheme in practice. Increases in attendance were
attributed to increased financial access and some issues with subscription abuses. A positive effect of
this was earlier reporting, resulting in less complicated cases and more cost-effective care provision.
Negative effects were an overwhelming workload, causing increased burden on facilities that were
already understaffed. The availability and the cost of drugs were identified as a cause of poor relations
between patients and providers and a source of financial loss for the facility. Reimbursement issues
identified were delays and inadequate financial coverage. Delays were attributed to failures on the
part of both the insurance office and the facility. An amalgamation of overwhelming workload, a
disorganized claims system, and unfulfilled promises of incentives were the reported causes of low
staff morale. Another common concern was long delays and fraud in the registration process. Providers
were aware of many common patient complaints. Many of these complaints were attributed to poor
patient knowledge of the scheme. Providers strongly expressed a need for better community education
on the health insurance scheme.
The issues raised by providers are not symptomatic of the Dangme West scheme alone. Some problems
such as patient knowledge, subscription abuses, and low staff morale could be addressed on a local level.
However, the issues of understaffing, poor reimbursements, the availability of drugs, and registration
failures are related to prevalent problems within the health system. Improved communications between
the community, health facilities, and the insurance office may help effectively address provider and
patients’ frustrations. Providers do wish the insurance scheme to continue and recognize overall, its
benefit to communities’ health. Further research must be done in order to ascertain the extent and
urgency of these reported issues.
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