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Document of
The World Bank
Report No: ICR00003337
IMPLEMENTATION COMPLETION AND RESULTS REPORT
(IDA-43450)
ON A
CREDIT
IN THE AMOUNT OF SDR 9.97 MILLION
(US$ 15.0 MILLION EQUIVALENT)
TO THE
REPUBLIC OF GHANA
FOR A
HEALTH INSURANCE PROJECT
December 22, 2014
Health, Nutrition and Population Global Practice (GHNDR)
Country Department (AFCW1)
Africa Region
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i
CURRENCY EQUIVALENTS
(Exchange Rate Effective December 2, 2014)
Currency Unit = New Ghanaian Cedi (GHS)
GHS1.00 = US$ 0.31
USD1.00 = GHS 3.21
USD1.00 = SDR 1.46198000
FISCAL YEAR
January 1 – December 31
ABBREVIATIONS AND ACRONYMS
AM Aide-Memoire
CHAG Christian Health Association of Ghana
CPC Claims Processing Center
DMHIS District Mutual Health Insurance Schemes
GDP Gross Domestic Product
GHS Ghana Health Services
GoG Government of Ghana
GPRS II Ghana Poverty Reduction Strategy for 2006-2009
HSMTDP Health Sector Medium Term Development Plan)
ICR Implementation Completion Report
ICT Information and Communication Technology
ISR Implementation Status Report
iHOST Ghana Health Service Hospital Management Information System
IT Information Technology
IO Intermediate Outcome
LEAP Livelihood Empowerment Against Poverty
M&E Monitoring and Evaluation
MTR Mid-Term review
NHIA National Health Insurance Authority
NHIC National Health Insurance Council
NHIS National Health Insurance Scheme
PAD Project Appraisal Document
PDO Project Development Objective
QER Quality Enhancement Review
ii
Vice President: Makhtar Diop
Country Director: Yusupha B. Cookes
Practice Manager: Trina S. Haque
Project Team Leader: Francisca Ayodeji Akala
ICR Team Leader: Huihui Wang
iii
GHANA
Health Insurance Project
Contents
Data Sheet
A Basic Information ....................................................................................................... iv
B. Key Dates .................................................................................................................. iv C. Ratings Summary ...................................................................................................... iv D. Sector and Theme Codes ........................................................................................... v
E. Bank Staff ................................................................................................................... v F. Results Framework Analysis ...................................................................................... v G. Ratings of Project Performance in ISRs ................................................................... xi H. Restructuring (if any) ............................................................................................... xii
I. Disbursement Profile ................................................................................................ xii 1. Project Context, Development Objectives and Design ............................................ 1
2. Key Factors Affecting Implementation and Outcomes ........................................... 5 3. Assessment of Outcomes ............................................................................................ 8 4. Assessment of Risk to Development Outcome ...................................................... 20
5. Assessment of Bank and Borrower Performance ..................................................... 21 6. Lessons Learned ....................................................................................................... 22
7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 24
Annex 1. Project Costs and Financing .......................................................................... 25
Annex 2. Outputs by Component ................................................................................. 26 Annex 3. Economic and Financial Analysis ................................................................. 32
Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 39 Annex 5. Beneficiary Survey Results ........................................................................... 41 Annex 6. Stakeholder Workshop Report and Results ................................................... 43
Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 44 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 50 Annex 9. List of Supporting Documents ...................................................................... 51
MAP .............................................................................................................................. 52
iv
A Basic Information
Country: Ghana Project Name: Health Insurance
Project
Project ID: P101852 L/C/TF Number(s): IDA-43450
ICR Date: 12/07/2014 ICR Type: Core ICR
Lending Instrument: SIL Borrower: GOVERNMENT OF
GHANA
Original Total
Commitment: XDR 10.00M Disbursed Amount: XDR 9.97M
Revised Amount: XDR 9.97M
Environmental Category: C
Implementing Agencies:
National Health Insurance Authority
Co-financiers and Other External Partners:
B. Key Dates
Process Date Process Original Date Revised / Actual
Date(s)
Concept Review: 10/10/2006 Effectiveness: 12/10/2007 12/10/2007
Appraisal: 04/10/2007 Restructuring(s): See Section H
Approval: 07/03/2007 Mid-term Review: 12/07/2009
Closing: 12/31/2012 03/31/2014
C. Ratings Summary
C.1 Performance Rating by ICR
Outcomes: Satisfactory
Risk to Development Outcome: Moderate
Bank Performance: Moderately Satisfactory
Borrower Performance: Moderately Satisfactory
C.2 Detailed Ratings of Bank and Borrower Performance (by ICR)
Bank Ratings Borrower Ratings
Quality at Entry: Moderately
Unsatisfactory Government: Moderately Satisfactory
Quality of Supervision: Moderately Satisfactory Implementing
Agency/Agencies: Moderately Satisfactory
Overall Bank
Performance: Moderately Satisfactory
Overall Borrower
Performance: Moderately Satisfactory
v
C.3 Quality at Entry and Implementation Performance Indicators
Implementation
Performance Indicators
QAG Assessments
(if any) Rating
Potential Problem Project
at any time (Yes/No): Yes
Quality at Entry
(QEA): None
Problem Project at any
time (Yes/No): Yes
Quality of
Supervision (QSA): None
DO rating before
Closing/Inactive status:
Moderately
Satisfactory
D. Sector and Theme Codes
Original Actual
Sector Code (as % of total Bank financing)
Central government administration 9 9
Compulsory health finance 82 82
Health 6 6
Sub-national government administration 3 3
Theme Code (as % of total Bank financing)
Administrative and civil service reform 33 33
Health system performance 67 67
E. Bank Staff
Positions At ICR At Approval
Vice President: Makhtar Diop Obiageli Katryn Ezekwesili
Country Director: Yusupha B. Crookes Mats Karlsson
Practice
Manager/Manager: Trina S. Haque Eva Jarawan
Project Team Leader: Francisca Ayodeji Akala Alexander S. Preker
ICR Team Leader: Huihui Wang
ICR Primary Author: Huihui Wang
F. Results Framework Analysis
Project Development Objectives (from Project Appraisal Document) The Project Development Objective is to strengthen the financial and operational
management of the National Health Insurance Scheme by improving: (i) the policy
adaptation and implementation capacity of the National Health Insurance Council in
addressing ongoing core policy issues related to contribution collection, risk equalization,
vi
and provider payment mechanisms; and (ii) the purchasing function of the District
Mutual Health Insurance Schemes, and the billing function of the Providers.
Revised Project Development Objectives (as approved by original approving authority)
(a) PDO Indicator(s)
Before June 2011 restructuring
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target
Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 : The % amount of total claims not paid within the statutory time period
(30 days) due to vetting delays caused by suspected error, abuse and fraud.
(Number, Custom)
Value
quantitative or
Qualitative)
30% 15%
Not available
because there is no
data
Date achieved 5/27/2007 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
After June 2011 restructuring
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target
Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 : # of total claims received electronically by processors (NHIS) from provider
(Number, Custom)
Value
quantitative or
Qualitative)
19537.00 1000,000 864,534
Date achieved 12/31/2010 12/31/2012 03/31/2014
Comments
(incl. %
achievement)
86% achieved
Indicator 2 :
% of total claims submitted by providers to NHIS (DMHIS or CPC) for
processing that passed the initial screening (i.e. not rejected by first
electronic/manual review) (Percentage, Custom).
Value
quantitative or
Qualitative)
45.00 59.00 99.00
Date achieved 12/31/2010 12/31/2012 03/31/2014
Comments
(incl. %
achievement)
168% achieved
vii
Indicator 3 : % of total "clean" claims that are reimbursed by payers (NHIS) to providers
within 60 days of claims receipt (Percentage, Custom).
Value
quantitative or
Qualitative)
0.03 80.00 100.00
Date achieved 12/31/2010 12/31/2012 03/31/2014
Comments
(incl. %
achievement)
125% achieved
Indicator 4 : % of population in the lowest quintile (20% of the index of socio-economic
status) registered under the NHIS with a valid card (Percentage, Custom)
Value
quantitative or
Qualitative)
14.00 40.00 47.70
Date achieved 12/31/2008 12/31/2012 11/27/2013
Comments
(incl. %
achievement)
119% achieved
(b) Intermediate Outcome Indicator(s)
Before June 2011 restructuring
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 :
Policies adopted and plans for implementation developed to address issues
related to contribution collection, risk equalization, and provider payment
mechanisms. (Text, Custom)
Value
(quantitative
or Qualitative)
None
Two of the three
policies are
adopted
GDRG tariff report
submitted to the
Bank.
Date achieved 05/27/2007 12/31/2012 06/21/2011
Comments
(incl. %
achievement)
This indicator was then changed through restructuring.
Indicator 2 : A human resources training plan is developed and executed. (Text, Custom).
Value
(quantitative
or Qualitative)
No Yes Plan not finalized
Date achieved 05/27/2007 12/31/2012 06/21/2011
Comments
(incl. %
achievement)
This indicator was then changed through restructuring.
Indicator 3 : % amount of the number of total bills submitted by the beneficiary providers are
submitted electronically (Number, Custom).
viii
Value
(quantitative
or Qualitative)
0 70 0
Date achieved 05/27/2007 12/31/2012 06/21/2011
Comments
(incl. %
achievement)
This indicator was then changed through restructuring and then similar
information was captured through other indicators after restructuring.
Indicator 4 : % amount of the number of electronically submitted bills paid to the beneficiary
providers within 30 days (Number, Custom)
Value
(quantitative
or Qualitative)
0 80
0 as the electronic
system was not
established at the
time
Date achieved 05/27/2007 12/31/2012 06/21/2011
Comments
(incl. %
achievement)
This indicator was then changed through restructuring.
Indicator 5 : % of registered members who can validate their entitlement to benefits through
verification (Number, Custom)
Value
(quantitative
or Qualitative)
0 80 0
Date achieved 05/27/2007 12/31/2012 06/21/2011
Comments
(incl. %
achievement)
This is the latest update available on this indicator in the system. This indicator
was then changed through restructuring and there was no information available
anymore.
After June 2011 restructuring
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 : HR Strategy approved by Management (MoH/IASC/NHIC Board) (Text,
Custom)
Value
(quantitative
or Qualitative)
None Developed Developed
Yes, HR strategy
has been approved
by NHIA Board
and it is being
implemented.
Date achieved 12/31/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 2 :
NHIS population exemption policy (with implementation plan and cost
projections) for the enrollment of the poor approved by Management
(MoH/IASC/NHIC Board (Text, Custom).
Value No Yes Yes Yes, common
ix
(quantitative
or Qualitative)
targeting
mechanism was
used to recruit poor
to NHIS by
working closely
with Ministry of
Employment and
Social Welfare.
Yes, population
exemption policy
has been drafted
and implemented.
Date achieved 12/31/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 3 : Provider payment policy, implementation strategy, guidelines and tools for NHIS
approved by Management (MoH/IASC/NHIC Board) (Text, Custom).
Value
(quantitative
or Qualitative)
No Yes Yes
Yes, provider
payment policy,
implementation
strategy, guidelines
and tools are
developed and
approved.
Capitation, one
form of provider
payment, has been
piloted in Ashanti
region and
expanded to three
other regions.
Date achieved 12/31/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 4 : Financial sustainability strategy for NHIS approved by Management
(MoH/IASC/NHIC) (Text, Custom)
Value
(quantitative
or Qualitative)
No Yes Yes
Actuarial analysis
has been
undertaken
regularly and used
to inform the senior
management for
decisions
Financial
sustainability
strategy has been
developed.
x
Date achieved 12/31/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 5 : Health personnel receiving training (number) (Number, Core)
Value
(quantitative
or Qualitative)
60.00 1486.00 1486.00 5900.00
Date achieved 12/31/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 6 : Health Data Dictionary approved (Text, Custom)
Value
(quantitative
or Qualitative)
No Yes Yes
Yes, health data
dictionary has been
developed
Date achieved 12/31/2011 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 7 :
HMIS Master Plan for 2011 - 2016 (including implementation plan and cost
estimates for hardware, software, training and maintenance) approved by
Management (MoH/IASC) (Text, Custom)
Value
(quantitative
or Qualitative)
No Yes Yes
Yes, HMIS master
plan has been
developed
Date achieved 12/31/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 8 : CPC has "gone live" with its first electronic claim automatically vetted and paid
(Text, Custom)
Value
(quantitative
or Qualitative)
No Yes Yes
Yes, CPC has gone
live with its
electronic claim
automatically
vetted and paid
Date achieved 12/31/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 9 : First call received through the NHIA call Center and successfully responded
(Text, Custom)
Value
(quantitative
or Qualitative)
No Yes Yes
Yes, first call has
been received
through the NHIA
call center and
successfully
xi
responded
Date achieved 12/31/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 10 : % of total claims that are submitted by providers to NHIS (CPC or DMHIS)
within 60 days of service provision (Percentage, Custom).
Value
(quantitative
or Qualitative)
64.00 75.00 75.00 100.00
Date achieved 12/31/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
Indicator 11 : Comprehensive and streamlined cost containment policy for NHIS approved by
management (MOH, IASC, NHIC Board) (Text, Custom)
Value
(quantitative
or Qualitative)
No Yes Yes
Yes, comprehensive
and streamlined
cost containment
policy has been
developed by the
NHIA including
provider payment
reform, clinical
audit, and
development of
essential drug list.
Date achieved 06/30/2010 12/31/2012 03/31/2014 03/31/2014
Comments
(incl. %
achievement)
G. Ratings of Project Performance in ISRs
No. Date ISR
Archived DO IP
Actual
Disbursements
(USD millions)
1 12/21/2007 Satisfactory Moderately Satisfactory 0.00
2 06/16/2008 Satisfactory Moderately Satisfactory 1.50
3 07/10/2008 Satisfactory Moderately Satisfactory 1.50
4 12/22/2008 Moderately Satisfactory Satisfactory 1.50
5 06/26/2009 Moderately
Unsatisfactory Moderately Satisfactory 1.58
6 11/30/2009 Moderately
Unsatisfactory Moderately Satisfactory 1.58
7 03/12/2010 Moderately
Unsatisfactory
Moderately
Unsatisfactory 1.58
8 11/24/2010 Moderately Moderately 2.58
xii
Unsatisfactory Unsatisfactory
9 06/01/2011 Moderately
Unsatisfactory
Moderately
Unsatisfactory 3.02
10 07/05/2011 Moderately Satisfactory Moderately
Unsatisfactory 3.02
11 12/24/2011 Moderately Satisfactory Moderately
Unsatisfactory 3.02
12 03/11/2012 Moderately Satisfactory Moderately Satisfactory 4.32
13 11/03/2012 Satisfactory Satisfactory 8.21
14 06/18/2013 Moderately Satisfactory Satisfactory 12.78
15 12/30/2013 Moderately Satisfactory Satisfactory 14.67
16 05/25/2014 Moderately Satisfactory Satisfactory 15.31
H. Restructuring (if any)
Restructuring
Date(s)
Board
Approved
PDO Change
ISR Ratings at
Restructuring
Amount
Disbursed at
Restructuring
in USD
millions
Reason for Restructuring &
Key Changes Made DO IP
04/25/2011 MU MU 3.02
Slow disbursement, activities
mainstreamed and PDO
indicators changed
06/24/2011 MU MU 3.02
Slow disbursement, activities
mainstreamed and PDO
indicators changed
12/03/2012 S S 8.21 Extension of closing date
I. Disbursement Profile
1
1. Project Context, Development Objectives and Design
1.1 Context at Appraisal
1. At the time of project appraisal in 2007, Ghana had experienced relative macroeconomic
stability and high real Gross Domestic Product (GDP). The GDP growth rate averaged 6.2
percent between 2005 and 2006, compared to the previous twenty-year average of 4.5 percent.
The Ghana Poverty Reduction Strategy for 2006-2009 (GPRS II) built on the country’s
macroeconomic stability and high economic growth rates, and focused on developing Ghana into
a middle-income country by 2015.
2. On the health financing side, the Cash and Carry System of user charges instituted in
1992 had shown both intended and unintended outcomes. As intended, this system contributed to
facility revenue generation and reduced unnecessary service usage; user fees accounted for 16.5
percent of the total public health services revenue in 2003. In 1985, when user charges were first
substantially increased, outpatient visits in hospitals dropped from 4.5 million to 1.6 million.
While achieving the intended purposes of generating revenue and reducing unnecessary use,
concerns were raised that such system may expose the poor and vulnerable to risks related to
catastrophic health expenditures, e.g., increased financial burden and averting necessary care. It
was also thought to have contributed to worsening health indicators. Infant mortality rates
increased from 57 to 64 per 1,000 live births and under-5 child mortality rates increased from 108
to 111 per 1,000 children from 1998 to 2003 (Ghana Ministry of Health 2006). In addition, wide
discrepancies persisted in health indicators across socio-economic and regional groups. For
example, the infant-mortality rate per 1,000 live births in 2003 varied from 33 in Upper East
Accra to 105 in Upper West Accra (Ghana Ministry of Health 2006).
3. The Health Insurance Act 650 of August 2003 was introduced in an effort to reduce
financial barriers to access. Since 2003, the Government of Ghana (GoG) has been working to
implement the Health Insurance Act. At the time of project appraisal and according to the
Government, District Mutual Health Insurance Schemes (DMHIS) were operating in all 138
districts with 38 percent of the population registered. Based on this, the National Health Insurance
Scheme (NHIS) set a target of reaching 55 percent insurance coverage by 2007, but noted that the
achievement of this target might be compromised by a number of issues at policy and
implementation level as follows:
Lack of concrete governance arrangements and responsibilities for NHIS
implementation; Challenges to maintain financial sustainability of the NHIS and the DMHIS;
Poor management of public expectations of NHIS;
Difficulties providing effective coverage for the poor and “exempt” indigents; Delays and inconsistencies in issuing health identity cards to those who are registered; Inadequate tools for processing and reimbursing claims; and
Insufficient administrative, managerial and technical human capacity.
Rationale for Bank involvement
4. The Bank’s involvement was well justified at the time of project appraisal. First, this
project would contribute to poverty reduction and the achievement of the MDGs by supporting a
health insurance scheme that could potentially mobilize additional resources for the health sector,
improve risk management, and support the poor. Second, the Bank had extensive experience in
2
fiscal policies, labor policies, and international competitiveness that are critical for designing
contributory health insurance schemes. Third, this project would provide support in
accountability, management capacity, and governance, the areas for which reforms were needed
according to analytical reports published by the World Bank and the International Labor
Organization. Finally, the proposed project support was consistent with the Country Assistance
Strategy at the time of project appraisal.
1.2 Original Project Development Objectives (PDO) and Key Indicators (as
approved)
5. The Project Development Objective is to strengthen the financial and operational
management of the National Health Insurance Scheme by improving: (i) the policy adaptation
and implementation capacity of the National Health Insurance Council in addressing ongoing
core policy issues related to contribution collection, risk equalization, and provider payment
mechanisms; and (ii) the purchasing function of the District Mutual Health Insurance Schemes,
and the billing function of the Providers.
6. The key indicator used to measure progress towards the PDO is “% of total claims ($)
that are not paid within statutory time period (30 days) due to vetting delays caused by suspected
error, abuse, and fraud”.
1.3 Revised PDO (as approved by original approving authority) and Key Indicators,
and reasons/justification
7. The PDO remained the same through the entire implementation period, while the PDO
indicators were changed through project restructuring in 2011. A level-II restructuring was
undertaken in April 2011, but due to a Government request of changing the definition of the PDO
indicators, the restructuring paper was processed again in June 2011. Therefore, while there
appear to be two restructurings in the system (there was less than two months between these two
restructuring and two project papers appear similar), in reality there was only one restructuring to
revise the PDO indicators. For this reason, only the restructuring of June 2011 is referred to in
other sections of the ICR when it is related to changes in component activities and indicators.
Through this restructuring, the original PDO indicator was dropped and four new indicators were
proposed (Table 1) to improve M&E of the project. The main reason for changes in PDO
indicators was because there was difficulty in measuring the original indicator as a result of data
unavailability.
Table 1. PDO indicators before and after restructuring
Time period PDO indicators
Before restructuring in June
2011
Indicator One: % of total claims ($) that are not paid
within statutory time period (30 days) due to vetting delays
caused by suspected error, abuse, and fraud.
After restructuring in June
2011
Indicator One: total number of claims received
electronically by processors (NHIS) from provider
Indicator Two: % of total claims submitted by providers
to NHIS (DMHIS or Claims Processing Center/CPC) for
processing that passed the initial screening (i.e. not rejected
3
by first electronic/manual review)
Indicator Three: % of total “clean” claims that are
reimbursed by payers (NHIS) to providers within 60 days
of claims receipt
Indicator Four: % of population in the lowest quintile
(20% of the index of socio-economic status) registered
under the NHIS with a valid card
1.4 Main Beneficiaries
8. As described in the PAD, the beneficiaries of the Health Insurance Project were to be: (i)
the National Health Insurance Council (NHIC), who would be more capable of managing the
National Health Insurance Scheme operationally and financially; (ii) the District Mutual Health
Insurance Schemes which would have streamlined mechanisms for local level administration; and
(iii) the Providers including Ghana Health Service (GHS), the teaching hospitals, Christian Health
Association of Ghana (CHAG), the health service providers from other ministries, and other
providers who will have improved financial management and administrative mechanisms to
improve their overall management performance.
9. In addition, users of health services and insurance members within the population were
also expected to benefit from the project as a result of improved efficiency of the health insurance
schemes and service providers.
1.5 Original Components (as approved)
Component A: Enabling Environment for NHIS Implementation (US$2.05 million)
10. This component of the Project was to strengthen the policy adaptation and
implementation capacity of the National Health Insurance Council in the following areas: 1)
Stakeholder coordination; 2) Project management and sustainability; 3) Communication strategy
to manage public expectations; 4) Standardizing fee schedules and medicines lists; 4)
Performance-based provider payment mechanisms and other policy adaptations; 5) Development
of related projects for donor support; 6) System for conducting routine audits and controlling for
fraud and abuse.
Component B: Financial and Operational Management Tools (US$8.6 million)
11. This component of the Project was to improve the purchasing function of the DMHIS and
the billing function of the Providers by moving the billing and claims process from a paper-based
to electronic-based system. Specifically, the project was to support the development and
implementation of the Provider interface in the following areas: 1) Providers’ needs analyses and
strategies for business process tools; 2) Network development, hardware, and alternative energy
solutions; 3) Software and systems integration.
Component C: Financial and Operational Management Training (US$4.35 million)
12. This component was to improve the skills in health insurance administration for staff
working for the MOH, NHIC, DMHISs, and the Providers, including actuarial analysis, insurance
daily operation, premiums management, payment mechanism, liquidity and utilization.
Specifically, the Project was to support training and capacity building in the following areas: 1)
4
Needs assessment and strategy development; 2) Management training; 3) Training in ICT
Network Operations; 4) Training for internal actuarial analysis and other core analysis skills; and
5) Financial management training.
1.6 Revised Components
13. Activities were revised and regrouped under components through the Level II
restructuring of June 2011, as follows:
For Component A, the Project was to focus on: (i) streamlining to an efficient provider
payment mechanism for NHIS; (ii) improving the sustainability of the NHIS, (iii)
improving equity in the coverage of the poor by the NHIS, (iv) support restructuring data
and analysis, and (v) support project management, coordination and monitoring and
evaluation.
For Component B, the Project was to focus on: (i) strengthening governance and
oversight of e-health; (ii) streamlining an integrated claims management system for the
NHIS; and (iii) strengthening automation in the major hospitals.
Component C was dropped, with some of the activities dropped or folded into
Components A or B.
14. The rationale for changes in components A and B was to reduce the number of sub-
components, as well as to make activities more connected and results-focused. The rationale for
dropping component C was that activities could be moved to the other two components without
losing the original intent of the project; also, the Government decided to finance some of the
Component C activities on its own. Details of these changes can be found in Annex 2.
1.7 Other significant changes
15. In addition to changes in the components and PDO indicators, there were changes in
project cost allocation, closing date, and one legal covenant.
16. Change in project cost allocation: Project cost allocation was changed through
restructuring of June 2011. While the total cost of the project remained the same through
implementation, there were changes in component costs due to changes in component activities.
Table 2 shows the funding allocation between components before and after restructuring of June
2011.
Table 2. Funding allocation between components before and after restructuring
Before restructuring of June 2011 After restructuring of June 2011
Components Cost
(US$, million)
Components Cost
(US$, million)
Component A: Enabling
Environment for NHIS
Implementation
2.05 Component A: Streamlined
purchasing policies and
mechanisms
4.0
Component B: Financial
and Operational
Management Tools
8.60 Component B: Strengthening
integrated claims management
systems
11.9
Component C: Financial 4.35
5
and Operational
Management Training
17. Extension of the Closing Date: The original Closing Date of the project was December
31, 2012. In order for the implementation agency to have sufficient time to complete all planned
project activities, the Closing Date was extended to March 31, 2014.
2. Key Factors Affecting Implementation and Outcomes
2.1 Project Preparation, Design and Quality at Entry
18. It was critical that the Bank decided to support the National Health Insurance Authority
(NHIA) in strengthening health insurance management. The Bank had been taking a leading role
in health insurance and financing globally and has accumulated a large knowledge base in this
area. When the project was prepared, both Ghana NHIS and National Health Insurance Authority
(NHIA) were in their infancy, and could benefit greatly from international knowledge and
lessons. In addition, there was no development partner working with the NHIA until this project
was prepared. Indeed, throughout the entire project period, the Bank was the only development
partner that provided significant support to NHIA. This gave enormous opportunities for the
Government to be exposed to and benefit from international expertise, e.g., the introduction of
capitation, a globally proven effective provider payment mechanism.
19. A strong technical team was deployed by the Bank to bring up-to-date knowledge and
international experiences into the project design. The design of the project included both
knowledge service and infrastructure investment at the same time. The technical arm on policy
development introduced globally proved effective policies and methodologies, creating country
specific evidence, and building domestic capacity. The operational arm on claims system adopted
advanced technology to reduce errors and expedite bill processing. In addition, these two arms of
the design together had an interactive effect in addition to their own benefit, as the electronic
claims processing system makes it much easier to obtain evidence on service delivery and
utilization, as well as implement policies on cost containment and quality assurance.
20. In March 2007, one month before appraisal, a Quality Enhancement Review was
conducted at the request of the task team. The panel endorsed the project as well designed and
commended team on the project design, as well as on the quality and appropriateness of the
background analysis. Many of the recommendations made by the panel were addressed in the
project design and implementation, such as the development of a health data dictionary, assuring
comparability of equipment, and coordinating with Ghana ICT Directorate in the Ministry of
Communications.
21. Lack of implementation readiness delayed project implementation in its early phase.
Looking retrospectively, the risk analysis at appraisal appeared to be optimistic without
adequately anticipating the risk of slow implementation by a new agency which had no
experience in implementing Bank-financed projects. Major risks identified were either IT specific
or political1. The original disbursement estimate did not appear to have considered the weak
1 The major risks included: a) delay or lack of coordination in implementing the ICT Network
Platform; b) political barriers to making unpopular but necessary changes to benefits, premiums,
or exemptions; and c) lack of flexibility of planned IT to incorporate policy changes.
6
implementation capacity and the lead time needed for procurement and policy activities. Further,
the project could have benefited from a more participatory approach during preparation to involve
additional stakeholders such as service providers. The lack of realism in designing PDO indicator
has caused that the indicator couldn’t be measured for a long period of time.
2.2 Implementation
22. The project experienced a slow start after effectiveness due to lack of readiness. On the
Bank side, the early stage ISRs reveal that the slow disbursement was not of particular concern,
as it was expected that disbursement could only take place after Government procurement of the
ICT network was completed. Looking retroactively, the Bank could have been more proactive in
addressing the slow progress and disbursement lag. On the Government side, the NHIA, as a new
institution, had to devote a significant amount of time and effort to develop a collaborative
working relationship with other key stakeholders including the Ministry of Health, GHS, CHAG
and teaching hospitals.
23. A mid-term review (MTR) was carried out in December 2009 to identify main
bottlenecks for the slow progress since effectiveness, as only 10.5 percent of project funds were
disbursed by then, two years after effectiveness. The newly on-board supervision task team rated
both the likelihood of achieving PDO and implementation progress as moderately unsatisfactory,
and identified key factors impeding the implementation as follows: 1) lack of preparedness before
implementation, e.g., information technology assessment required for Component B was not
carried out until the MTR; 2) relatively low implementation capacity of the responsible agency,
NHIA, as a four-year old institution; 3) lack of common understanding of the roles of different
institutions in implementing the project, exacerbated by changes at leadership and staff level in
MOH and NHIA following 2009 elections.
24. A project restructuring during the MTR in 2009 to revise PDO indicators and
components was deemed necessary but this did not take place until June 2011 (eighteen months
later). This long lag to process the restructuring was due to a number of factors, including
changes in Government leadership as a result of elections, change in project implementation staff
within NHIA, as well as time and efforts required to reach agreement between the Government
and Bank team. Nevertheless, through the restructuring process, the project activities were
mainstreamed and the PDO indicators became measurable. During the period between MTR and
restructuring, although no substantial progress was made on project implementation and fund
disbursement, the Bank team provided strong technical support to assist the NHIA in designing a
pilot of capitation for primary health care, which later became impactful in shaping Government’s
policy on provider payment mechanism. A number of sectoral works financed by a separate trust
fund implemented by the Bank such as health financing study and country status note, were also
undertaken during this period to generate evidence base for policy making.
25. This project was transformed from a problem project to a fully disbursed and impactful
project during the later stage of implementation after the June 2011 restructuring. About 75
percent of project fund was disbursed during an 18-month period, with disbursement ratio
increasing from 21 percent as of January 2012 to 96 percent as of June 2013. A number of key
factors have contributed to this achievement: 1) detailed review of project activities during the
two years following mid-term review; 2) enhanced project management by NHIA such as
appointing key staff (project coordinator, procurement specialist, ICT analyst), establishing a
network of focal persons for each component throughout NHIA, GHS, CHAG and teaching
7
hospitals; 3) the Bank management’s close follow up on project status and constant guidance
through portfolio reviews including Country Portfolio Performance Reviews (CPRP), etc.; 4) the
Bank team coming on board after restructuring provided timely and pragmatic implementation
support to expedite the procurement process of ICT equipment, which has been highly
appreciated by both the Government and Bank management.
26. There was a proactive and consistent focus on reaching the poor under this project.
Coverage of the poor has always been highlighted by the Bank team and management throughout
implementation, and this attention never diminished for both the Government and the Bank, even
when there was increased pressure from the perspectives of actuarial balance and financial
sustainability. To reach the poor, there was also close collaboration between the NHIA and the
Ministry of Employment and Social Welfare to use the common targeting mechanism.
27. Project implementation was integrated into the routine work of NHIA. With the project
implementation unit as an integral part of the organization, the project received close oversight
from senior management of NHIA and close collaboration with other departments within NHIA
such as finance, membership, clinical audit, and CPC. This arrangement has also ensured
consistency and synergy between project activities and other ongoing initiatives, as well as
sustainability of project achievements after the project was closed.
2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization
28. M&E design: Overall, the design of M&E was conceptually relevant. A common
evaluation framework was designed by NHIA to guide data collection, consolidation and
dissemination, ensuring stakeholder feedback captured in project implementation. The M&E
design also took into consideration the existing capacity of the Ghana Health Service (GHS) to
collect provider side information such as revenues collected and time taken to submit claims.
Looking retrospectively, some elements of the M&E design showed lack of realism and
preparedness. For example, it was raised in the ISR that the PDO indicator may not be
measurable six months after the project became effective. This issue was eventually resolved
through a project restructuring in June 2011.
29. M&E implementation: The M&E implementation was diligent. The rating for M&E in
ISRs started as Satisfactory, then downgraded to Unsatisfactory because the original PDO
indicator was not measurable. The rating for M&E was eventually upgraded as Satisfactory
reflecting the regular updates on indicators after restructuring. The documentation of component
activities was also informative. It is worth highlighting that the project not only updated
information in the results framework, but also regularly updated key developments that are
critical for the scheme’s overall performance, including scheme liquidity and financial
sustainability. There was also M&E process built into the pilot of the capitation policy, trying to
inform decision making on scale-up. It is however noted that targets used to track project progress
in ISRs and AMs are different than what are specified in the project paper of June 2011 and it is
not clear why this was the case and not identified and rectified during implementation. The M&E
for the capitation was not able to capture all the baseline information (e.g., service utilization and
quality), which may be enhanced in future operations.
30. M&E utilization: M&E data was often used for communication with key stakeholders.
The project coordinator regularly provided updates to the steering committee and Bank portfolio
performance review so that senior management on each side was kept informed of the project
progress and impact. The evaluation of the capitation pilot played a key role in informing policy
8
makers during the decision process of scale up. The Government also took advantage of the
Bank’s flagship courses/workshops on health financing and UHC, to communicate the status of
the National Health Insurance Scheme (NHIS) and share experiences with peer countries and
experts.
31. Overall, the M&E process of the project is rated as Moderately Satisfactory due to issues
with the original design and implementation.
2.4 Safeguard and Fiduciary Compliance
32. Safeguards: This project was classified as Category C and no safeguard policies were
triggered. The ratings for safeguard compliance have been Satisfactory throughout the
implementation period.
33. Financial Management: This project was fully disbursed before closing, and the last
ISR rated FM as Satisfactory. Some FM issues were raised during implementation, but were
eventually resolved as a result of enhanced project management and implementation support.
These issues were: 1) there was no FM specialist in NHIA knowledgeable on Bank procedures; 2)
some financial statements and audit reports were submitted late and not in required formats; 3)
the project had a large disbursement lag due to delays in implementation of component B
activities during early stages of implementation.
34. Procurement: Although with delays and slow implementation, there was no major
compliance issues reported to be related to procurement. In only one ISR, the procurement was
rated as Moderately Unsatisfactory, because the procurement plan was not updated. This issue
was resolved soon after it was identified, with a qualified procurement consultant recruited and
the plan updated.
2.5 Post-completion Operation/Next Phase
35. Transition arrangements: The Government has announced the plan to expand the
capitation pilot in Ashanti region to another three regions (Upper West, Upper East and Volta
regions). Transition arrangements have also been made for the electronic claims processing
system in terms of transfer of equipment and maintenance requirements. It is likely that these
systems will continue to be used even after project closing, as it has become part of the routine
business of the NHIA and concerned facilities.
36. Next phase/follow-up operation: During the recent years, more development partners
have started working together with the Government on NHIS, or broadly, on health financing.
Both DFID and USAID have started providing support on provider payment, health expenditure
review, capacity building, etc. The newly approved Bank financed project on maternal and child
health will strengthen the enrollment of pregnant women into schemes by incentivizing
community workers. The Bank also plans to engage the NHIA on technical work that will review
service utilization under insurance scheme, which will serve as critical inputs for evaluating the
efficiency and equity of insurance scheme, provide baseline information for the roll-out of
capitation in the three regions, and provide inputs to the discussions on a follow-up project.
3. Assessment of Outcomes
3.1 Relevance of Objectives, Design and Implementation
9
Rating: High
37. Country and global priorities: According to Ghana’s Health Sector Medium Term
Development Plan (HSMTDP) for 2010-2013 and 2014-2017, one of the country’s priorities is to
bridge equity gaps in access to health services, ensuring sustainable financing and financial
protection for the poor, and improving efficiency in the governance and management of the
health system. Globally, achieving health-related MDGs by 2015 and moving toward Universal
Health Coverage during the post-2015 era remain priorities for all developing countries. In the
Bank’s Country Partnership Strategy FY13-16 that embraces the Bank’s twin goals, the overall
aim is to assist Ghana in sustaining economic growth, accelerating poverty reduction and
enhancing shared prosperity in a sustainable manner, with one outcome specifically focusing on
improving access to health services.
38. Relevance of objectives: The project’s objective, “to strengthen the financial and
operational management of the National Health Insurance Scheme”, remains highly relevant to
current country and global priorities, as well as to the Bank’s assistance strategy both before and
after restructuring as the PDO did not change. The high relevance to current country and global
priorities, and the Bank’s assistance strategies is demonstrated by the project’s direct contribution
to efficiency improvement of health insurance management, which has an evident effect on health
system efficiency, equitable access to services, and poverty reduction.
39. Relevance of design and implementation: The design and implementation of the project
were well-aligned with the objective in aiming to improve the operational and management
efficiency of Ghana’s health insurance scheme. The project supported the National Health
Insurance Authority in mainstreaming health insurance policies and improving billing operations,
such as piloting an innovative provider payment policy and a sophisticated claims processing
system, which fully serves the objective and maintains its relevance to country and global
priorities. The project had a special focus on covering the poor and vulnerable by NHIS with one
PDO indicator being “percent of population in the lowest quintile (20% of the index of socio-
economic status) registered under the NHIS with a valid card”.
40. Although there are some modifications to the project design during restructuring, the
design remains highly relevant both before and after restructuring as the restructuring only made
the design more coherent and results focused. The relevance of implementation is rated
Substantial before restructuring despite the overall progress, particularly disbursement, was slow,
because there was close dialogue expediting the policy related work. The relevance of
implementation after restructuring is rated High as the implementation made sure all designed
activities were put into place, outputs achieved and objectives achieved (see more details in the
following section). There is no record of deviating from project design and intended objectives
during implementation.
41. Overall, the relevance of the project is rated as High, considering the high relevance of
the objective throughout the entire implementation period, the substantial relevance of design and
implementation before restructuring, and the high relevance of design and implementation after
restructuring.
3.2 Achievement of Project Development Objectives
Rating: Substantial
10
Achievement of PDO before restructuring
42. The original PDO indicator before restructuring was “% of total claims ($) that are not
paid within statutory time period (30 days) due to vetting delays caused by suspected error, abuse,
and fraud”. As previously indicated, this PDO turned out not measurable and was dropped during
restructuring. Prior to being dropped during the restructuring, there was no data collected for this
indicator to measure the progress towards achieving objectives. Progress was, however, made
during this period in some of the intermediate outcome indicators such as in development of cost
containment policies and population exemption policies. There was also progress in getting ready
for activities related to Component B such as preparing specification of needed IT equipment and
development of a procurement plan. With the above considerations, the achievement of PDO is
rated as modest for the period before restructuring.
Achievement of PDO after restructuring
43. Overall, the Project has achieved the PDO of “strengthening the financial and operational
management of the National Health Insurance Scheme” after restructuring. The ICR team notes
that different targets have been used to track project performance in different Bank documents
including the restructuring paper, Aide-Memoires (AMs) and ISRs. The ICR team chose to use
the targets set for year 2012 in the project paper of June 20112 to evaluate achievement of
outcomes, as there were no further official changes in the targets when the project closing date
was later extended. Table 3 summarizes the achievement of each PDO indicator, showing three
indicators over-achieved and one indicator 79 percent achieved. As shown in Table 3,
achievements for three indicators are high, and one is substantial. Considering the over-
achievement of three PDO indicators and close-to-achievement of one PDO indicator, the rating
for achievement of PDO after restructuring is rated as high.
Table 3. Results of PDO indicators
PDO Indictors
Baseline
as of
MTR
Result as of
project closing
(March 2014)
Target
(2012) Achievement
Indicator One: total claims
received electronically by
processors (NHIS) from
provider 19,537 864,534 1,000,000
86%
(substantial)
Indicator Two: % of total
claims submitted by providers
to NHIS (DMHIS or CPC) for
processing that passed the 45% 99% 59% 168% (high)
2 In the June 2011 restructuring paper, there were different presentations of project targets of
PDO indicators between the main text and the annex: in the main text, year 2012 targets were
used as final targets for the project; while in the annex, targets were set for the period up to year
2014 to envision achievement beyond project implementation period for planning purposes.
Given the official project closing date at the time of restructuring was December 31, 2012, the
ICR team used year 2012 targets as final targets of the project. No formal revisions were made to
the final project targets when the project closing date was later extended in December 2012.
11
initial screening (i.e. not
rejected by first
electronic/manual review)
Indicator Three: % of total
“clean” claims that are
reimbursed by payers (NHIS) to
providers within 60 days of
claims receipt 65% 100% 80% 125% (high
Indicator Four: % of
population in the lowest
quintile (20% of the index of
socio-economic status)
registered under the NHIS with
a valid card 14% 47.7% 40% 119% (high)
PDO Indicator One: total claims received electronically by processors (NHIS) from provider
44. The total number of claims received electronically by NHIS increased from 19,537 in
2010 to 864,534 at the end of March, 2014 when the project closed. The project has achieved
about 86 percent of the 1 million targeted for this indicator. Although not a 100 percent
achievement, this indicator has progressed impressively since the electronic claims system was
put in place in April 2013. Within a year, the number of claims received reached more than
800,000 when the project closed. Data collected beyond project closing period shows that by end
of June, 2014, the total number of claims processed electronically has exceeded the target of one
million (Figure 1).
12
Figure 1. Total number of claims received by NHIA electronically by time
PDO Indicator Two: Percentage of total claims submitted by providers to NHIS (DMHIS or
CPC) for processing that passed the initial screening (i.e. not rejected by first
electronic/manual review)
45. The percentage of claims submitted to NHIS that passed initial screening increased from
45 percent in 2010 to 99 percent in 2014. Compared with the target of 59 percent, this project has
achieved 178 percent of the target.
PDO Indicator Three: Percentage of total “clean” claims that are reimbursed by payers
(NHIS) to providers within 60 days of claims receipt
46. The percentage of total clean claims that are reimbursed by NHIS to providers within 60
days of receipt increased from 65 percent in 2010 to 100 percent in 2014. Compared with the
target of 80 percent, this project has achieved 125 percent of the target.
47. The achievement of PDO indicators one, two and three are closely related to successful
implementation of the following project activities:
A National Health Data Dictionary was developed under the project. It includes over 800
elements and enables health facilities to generate and submit uniform reports using
standardized terminology to the NHIS (IO#6).
A medical terminology and disease coding module was developed and training was
provided to 936 participants who are claims processing staff in NHIA or health facilities
and have no clinical background. The training greatly improved their capacity in
submitting and processing claims accurately (IO#5).
The installation of E-claims system and deployment of iHost under the project made it
possible for providers to submit claims electronically. The project has provided
0
200000
400000
600000
800000
1000000
1200000
1400000
May
Jun
.
Jul.
Au
g.
Sep
Oct
.
No
v.
De
c.
Jan
.
Feb
.
Mar
.
Ap
r.
May
Jun
.
Jul.
2013 2014
Target=1,000,000
Project closing
13
upgrading to the E-claims system in the CPC and targeted 47 health facilities to submit
claims electronically. When the project closed, 30 facilities were submitting claims
electronically. Trainings were also provided under the project to sensitize health care
providers about the e-claims system, and create awareness about the efficiency,
effectiveness, accuracy and transparency of the e-claims payment system. The project has
deployed the iHost to 6 facilities, and each of them is currently either submitting
electronically or undergoing testing (IO#8 and #10).
The project also supported the building of statistical reporting, data warehousing and
CPC call center. (IO#9).
PDO Indicator Four: Population in the lowest quintile (20% of the index of socio-economic
status) registered under the NHIS with a valid card
48. The percentage of population in the lowest quintile registered with a valid NHIS card
increased from 14 percent in 2010 to 48 percent in 2014. Compared with the target, 40 percent,
this project has achieved 120 percent of the target.
49. In order to reach the target, the NHIA worked closely with the Ministry of Health and the
Ministry of Employment and Social Welfare to use the common targeting mechanism. Starting in
2010, community-based targeting combined with proxy means testing was launched in 30
districts and enrolled 214, 530 poor people by 2011. The NHIA also embarked on a special
registration of the poor and vulnerable between June and August 2013. Box 1 shows criteria used
to identify the poor and vulnerable. During this process, officers of the district and regional
offices in NHIA were trained on how to identify these groups and enroll them into the scheme.
Each district held stakeholder meetings with key players, e.g., Ghana Education Service,
Department of Social Welfare, and Opinion Leaders, to discuss enrollment strategies. At the end
of this exercise, about 1.2 million poor and vulnerable people were enrolled into the scheme.
Box 1. Criteria used to identify the poor and vulnerable for NHIS enrollment
50. By supporting policy development and strengthening financial and operational
management of the NHIS, this project has enhanced the NHIA’s capacity as a strategic purchaser
1. Beneficiaries of the Livelihood Empowerment Against Poverty (LEAP).
2. Children in orphanages across the country.
3. Children who are blind, deaf and dump in special schools and in the
community.
4. Mentally retarded and mentally ill patients within mental homes and in the
community who can be reached.
5. Persons currently receiving financial support from recognized institutions
or NGOs due to extreme poverty i.e. District Assemblies.
6. Mothers with twins and triplets begging to feed them within the
community.
7. People Living with HIV/AIDS who are poor and do not have any source of
income.
8. Persons being treated for Tuberculosis on Daily Observation Treatment
(DOTs) and do not have any source of income.
9. Prisoners who are reported poor by the Prison officers.
10. Children who are receiving free school uniforms.
11. Children benefiting from the schools feeding program.
14
of health services, as well as health facilities’ capacity as key partners for policy implementation
and claims submission. Through the project implementation period, new policies have been
introduced adapting international experiences to country context. Financial sustainability of the
scheme has been evaluated, and strategies have been explored to expand coverage while ensuring
financial sustainability. The following have also been supported by the project:
A set of policies have been developed with the support of the project, including
population exemption policies, provider payment policies, and cost containment policies
(IO#2, IO#3, and IO#11).
Actuarial analysis being carried out as a regular exercise. This has not only increased the
institution’s capacity in conducting actuarial analysis per se, but also greatly raised the
management’s awareness to the financial sustainability of the scheme and urged solutions
to be found (IO#4).
A clinical auditing study identified inappropriate prescription behaviors and yielded
substantial savings in claims reimbursement, and provided training on clinical auditing.
The country’s achievement in adopting capitation is worth highlighting (IO#2, IO#3,
IO#4, IO#5, and IO#11). Box 2 summarizes key information on the pilot of capitation in
Ghana including background, implementation, evaluation results and its impact.
15
Box 2. Pilot of capitation in Ghana3
51. This project has taken a lead in using advanced Information Technology (IT) to
strengthen health financing and delivery systems in developing countries. Although some
hospitals had started using electronic medical records system before the project started, these
systems tended to be disconnected from each other. By introducing an electronic claims
processing system, it provided a momentum and platform to standardize the interface between
providers and the insurer, so that standard claims can be used across providers. More importantly,
with such a system in place, claims can be analyzed and compared between patients, physicians,
facilities, districts and regions by linking with the biometric membership database. Furthermore,
potential fraud, abuse, mistakes and underservice can be identified by such analysis. In other
words, it made it possible to implement cost containment and quality assurance policies more
3 Sources: Patrick Apoya, “Final report: capitation pilot project in Ashanti region”; Michael Opoku,
Richard Nsiah Paul Atta Oppong, “the effect of capitation payment on the national health insurance
scheme in Ashanti region, Ghana”, May 2014
Background on capitation:
Unlike Fee-for-Service that pays provider retroactively based on quantity of services
provided, capitation pays providers at a fixed rate in advance for a defined package of
services.
Based on global experiences, total health expenditures decline with capitation, because it
shifts financial risk to service providers who would otherwise have financial incentives to
induce patients to use more services under a fee-for-service system.
Pilot of capitation in the Ashanti region:
Starting in 2012, with the support of the project, capitation was piloted in the Ashanti
region as a payment mechanism for primary care services.
Evaluation results:
The evaluation of the pilot in the Ashanti Region showed that the majority of affiliates and
providers had knowledge about capitation and were satisfied with this system.
A study examining the impact of capitation in the Ashanti region shows that total claims
payment in surveyed facilities have been reduced from GHc 26.2 million in 2011 (before
pilot) to 21.3 million in 2012 and 19.3 million in 2013. This represents a substantial savings
of 10.5 percent in 2012 and 15.2 percent in 2013 out of total claims payment.
Capitation in general may cause providers to under provide services as they have to bear
eventual financial risks. The pilot and evaluation of capitation in Ashanti region has some
limitations in collecting detailed information on service utilization and quality. This has
been internalized by the NHIA and taken into consideration during the preparation for the
roll-out of capitation into the three other regions.
Impact:
A decision has been made to scale up the pilot through a phased approach, initially to
another three regions including the Upper West, Upper East and Volta regions, and
eventually across the entire country.
16
effectively. In addition, an ICT master plan was developed (IO#10) with the support from the
project. This plan can be used as a good planning document for the future development of ICT in
the health sector overall.
Overall achievement of the PDO
52. The overall achievement of the PDO is rated as Substantial, considering Modest
achievement before restructuring and High achievement at project closing.
3.3 Efficiency
Rating: Substantial
53. In order to assess project efficiency in a comprehensive manner, the economic and
financial analysis for this ICR both assesses the overall project development impact and
undertakes a cost-benefit analysis for the two main interventions supported by the project,
introduction of capitation policy and use of electronic claims processing system, which accounted
for about half of the total project cost (details see Annex 3).
Project development impact
54. The Ghana Health Insurance project has generated substantial development impact in
Ghana at a number of levels. First, at the operational level, this project strengthened operational
management of the NHIS. Second, at the policy level, this project has enhanced the NHIA’s
capacity as a strategic purchaser of health services. Both of these impacts are closely related to
improvements in technical efficiency of service delivery at facility level, and allocative efficiency
at scheme level. Third, at the health sector level, it has contributed to the achievement of health-
related MDGs and Universal Health Coverage. Fourth, at the country level, the project has
contributed to both economic growth and equity by removing financial barriers to service access
among the poor. This project will also generate long-term economic benefit by increasing the
active and productive labor force who can potentially contribute to economic growth and poverty
elimination.
Cost-benefit Analysis on introduction of capitation policy
55. This cost-benefit analysis on capitation assesses nation-wide benefit and cost of
capitation based on the piloting experiences supported by this project. A number of scenarios are
examined by using different assumptions on how benefit and cost may change from pilot to scale-
up, with assumptions at different levels of stringency. The timeframe from 2013 to 2017 is used
considering data availability, though all benefit is expected to extend beyond this period. A
discounting rate of 3 percent is used to estimate present value based on existing guidelines (WHO guide to CEA, 2003).
56. Cost-benefit analysis results show that support of capitation pilot which has led to a
scale-up decision is a highly efficient intervention. With less stringent assumptions, the net
present value is 802.1 million GHc/US$248.7 million, and the benefit-cost ratio is 15.3. Even
under a very stringent combination, the net present value is 22.8 million GHc/US$7.1 million,
and the benefit cost ratio is 1.14.
Cost-benefit analysis on the electronic claims system
17
57. The introduction of electronic claims processing system brings drastic changes to the
health insurance system. It benefits both the scheme manager and insurance provider in terms of
improving the efficiency of processing claims. It makes possible for effective implementation of
cost containment and quality assurance policies such as clinical audit. Table 5 outlines all benefits
related to the use of the electronic claims processing system. Further, it also prompts necessary
actions in standardizing disease coding and medical terminology in claims, calls for digitalization
of membership management (introduced by NHIA as biometric registration system), financial
payment, and integration with other systems such as electronic medical record system in hospitals
and health information management system in the Ministry of Health.
Table 4. Benefits related to use of electronic claims processing system
Benefits
For service
providers
Saved operational cost by not using paper-based system
Decreased rejection rate due to better quality claims
Decreased turn-around time for reimbursement
Increased fund stability and predictability
For scheme
managers
Saved operation and management cost for claim processing by not
using cumbersome paper-based system
Saved operation and management cost for clinical auditing
Increased capacity and efficiency to identify fraud claims
Increased capacity and efficiency to identify inappropriate services
and improve service quality
Increased capacity to provide evidence for policy making and
implementation
Interactive
effect between
providers and
scheme
managers
Increased capacity to link up with digitalized membership
management system, electronic insurance payment system,
electronic medical records system in hospitals and health
information management system
Improved human resource capacity to implement administration
requirement of the health insurance scheme
58. This cost-benefit analysis aims to assess the situation when the project investment on IT
hardware and software are fully operational during a three year period from 2013 to 20154. It is
expected that 4.8 million claims will be processed electronically when the system is fully
functional based on the results from a system capacity assessment. This analysis focuses only on
two benefits to demonstrate the soundness of the investment, as it is challenging to translate all
above-listed benefits into monetary values. These benefits include: 1) saved operation and
management cost for claims processing by not using paper-based system; and 2) saved claims
payment from increased accuracy of claims.
59. Results show that full operation of the electronic claims processing system yields great
returns even with only very selected benefits considered. The net present value is GHc 4.7
million/US$1.46 million, and the benefit-cost ratio is 1.29.
4 The project has procured equipment for more than 40 target facilities, but only around 20 facilities started submitting claims as of March 2014 when the project was closed.
18
Rating for efficiency
60. The impact analysis and cost-benefit analysis does not explicitly differentiate the period
before and after restructuring. This is mostly because both the project objective and total project
cost remain the same from effectiveness to closing, thus, one set of analysis shall suffice.
Nevertheless, we rated efficiency separately for the periods before and after restructuring: efficiency is rated as modest for pre-restructuring period considering that the project
implementation was quite slow and the efficacy was modest; the efficiency for post-restructuring
period is rated as high considering this project has turned around after restructuring and fully
disbursed before closing, generated significant development impact, supported policy
interventions and infrastructure investment that show impressive efficiency levels demonstrated
by high benefit-cost ratios. Overall, the efficiency is rated as substantial taking into consideration
the modest efficiency before restructuring and after restructuring.
3.4 Justification of Overall Outcome Rating
Rating: Satisfactory
61. Overall outcome rating is rated as Satisfactory. The team follows the IEG guidelines to
rate by weighting ratings before and after restructuring. A numeric value of 3 is assigned to
Moderately Unsatisfactory rating and a value of 5 is assigned to Satisfactory rating. The weighted
value based on disbursement percent is 4.6, between Moderately Satisfactory and Satisfactory and
closer to Satisfactory. Considering the overall ratings for relevance, efficacy and efficiency are all
substantial, which yields a rating of Satisfactory, the overall outcome is rated as Satisfactory for
the purpose of consistency.
Table 5. Summary of ratings
Before
restructuring
After
restructuring
Overall
Relevance Substantial High Substantial
Objective
Design and implementation
High
Substantial
High
High
High
Substantial
Efficacy Modest High Substantial
Efficiency Modest High Substantial
Overall outcome rating Moderately
Unsatisfactory,
equivalent to 3
at a 6-point
scale
Satisfactory,
equivalent to
5 at a 6-point
scale
Satisfactory,
equivalent to 4.6
at a 6-point scale
(3*0.2+5*0.8=4.6)
Weights based on disbursement % 0.2 0.8 1
3.5 Overarching Themes, Other Outcomes and Impacts
(a) Poverty Impacts, Gender Aspects, and Social Development
62. This project has contributed to poverty reduction in two ways. On one hand, this project
has greatly expanded the insurance coverage among the poor, which in turn will improve their
access to basic health services. Improved access to basic services has proved to be a strong force
for poverty reduction. On the other hand, by providing insurance coverage to non-poor people,
19
the risk of getting impoverished due to catastrophic expenses will be minimized to the extent
possible.
63. There is evidence that coverage among the poor has been expanded through this project.
As shown by PDO indicator 4, the insurance coverage among the lowest wealth quintile
population has more than tripled from 14 percent to 48 percent during the project period.
64. Evidence also shows that the disparity between poor and non-poor in service utilization
has been reduced due to expanded insurance coverage, indicating improved equity and shared
prosperity. Figure 2 plots concentration curves for skilled birth attendance by insurance status. A
concentration curve plots the cumulative percentage of the variable of interests (y axis) against
the cumulative percentage of the population (x axis), ranked by wealth status, beginning with the
poorest and ending with the richest. A diagonal line is always presented with concentration
curves to show the ideal situation where coverage of services is the same across all groups. The
distance between the diagonal line and a concentration curve shows the extent of inequality; the
larger the distance, the more inequitable the coverage of services. As shown by the graph, the
distance was much smaller between the concentration curve for the insured population and the
ideal situation shown by diagonal line, compared with the distance between the concentration
curve for uninsured and the diagonal line.
Figure 2. Concentration curves for the percent of pregnant women giving births in facilities, by
insurance status5
(b) Institutional Change/Strengthening
65. This project has greatly contributed to institutional capacity building by supporting the
NHIA to develop and implement policies that are critical to the financial and operational
management of NHIS. Through the project implementation period, the NHIA has been
introducing new policies, adapting international experiences to country context, evaluating
5 Source: Author’s own calculation based on data from “Health Financing in Ghana” by George
Schieber, Cheryl Cashin, Karima Saleh, and Rouselle Lavado.
0%
20%
40%
60%
80%
100%
0% 20% 40% 60% 80% 100%
Insured
Uninsured
Ideal
20
financial sustainability of the scheme, and exploring strategies to expand coverage while ensuring
financial sustainability. Many policies were put in place, such as M&E framework, human
resource management, IT staffing policy, provider payment mechanism (e.g., capitation). The
capacity of undertaking actuarial analysis was built through project implementation, which has
greatly helped to raise the management’s awareness to the issue of financial sustainability and the
required solutions. In addition, health facilities that implement capitation pilot or submit claims
electronically have greatly strengthened their capacity in financial and operational management.
(c) Other Unintended Outcomes and Impacts (positive or negative)
3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 66. The Government has undertaken a beneficiary survey focusing on the effectiveness of
and impact of the various training program organized under the project, as well as views of NHIS
staff and service providers on capitation policy and training programs. This survey collected a
sample of 341 NHIS staff and service providers in all 10 regions.
67. The study results show that trainees have greatly benefited from different types of
training programs. They identify the most beneficial ones include trainings on Electronic Claims
processing and vetting; Medical Terminologies and Diagnostic Billing; ICT related programs; the
revised Ministry of Health Referral Policy and Gatekeeper system, Clinical Auditing, and
programs for the actuarial division on NHIS. Beneficiaries generally reported that these training
programs have enhanced their performance.
68. The study results also show that the level of knowledge on capitation concept was high
among both NHIS district offices and service providers. Beneficiaries were able to identify key
benefits and challenges associated with capitation.
4. Assessment of Risk to Development Outcome
Rating: Moderate
69. Ghana NHIS will continue to face the challenge of ensuring financial sustainability while
expanding coverage. To address this challenge, extra attention needs be to paid to the following
in a broader context: 1) how the insurance revenue will be affected by the deteriorating
macroeconomic context, e.g., high debt level; 2) how the insurance expenditure will be affected
by the generous benefits package and medicine use that is paid under the fee-for-service system;
3) how to continue enrolling members of the informal sector and the poor; and 4) how to ensure
service quality while containing insurance cost.
70. Nevertheless, the risk to development outcome is considered as modest based on the
following considerations. First, many achievements under this project have been internalized by
decision makers. For example, the Government has announced the plan to expand pilot of
capitation to another three regions. Electronic claims processing has become part of the routine
business of the NHIA and concerned facilities. Second, NHIA’s capacity has been enhanced
during the past few years. The authority has realized the importance of ensuring the scheme’s
financial sustainability and started exploring options to improve efficiency and raise revenues.
Third, in addition to the Bank, more development partners have started working together with the
Government on the NHIS, or broadly, on health financing issues for which insurance is an
important aspect for the country.
21
5. Assessment of Bank and Borrower Performance
5.1 Bank Performance
(a) Bank Performance in Ensuring Quality at Entry
Rating: Moderately Unsatisfactory
71. The Bank engaged the Government of Ghana at a critical moment in the development of
its health insurance program, and provided strong technical inputs into project preparation,
however, the project had experienced significant delays due to lack of readiness and was not able
to fully translate good intention to good results. The Bank performance during the project
preparation phase is therefore rated as Moderately Unsatisfactory. As described in Section 2.1, a
strong technical team was deployed to bring up-to-date knowledge and international experiences
into the project design. A QER meeting was also undertaken to receive experts’ inputs. However,
looking retrospectively, the risk analysis at appraisal appeared to be optimistic without adequately
anticipating the risk of slow implementation by a new agency that had no experience with
implementing Bank-financed projects. Substantial and above risks identified were either IT
specific or political6. The original disbursement estimate, particularly for early phase, didn’t
appear to have considered the weak implementation capacity and the lead time that would be
required by the NHIA. The PDO indicator, although conceptually valid and relevant, was not
measurable by the existing system and had to be revised later.
(b) Quality of Supervision
Rating: Moderately Satisfactory
72. The Bank’s performance on supervision quality is rated as Moderately Satisfactory. This
project has experienced a trajectory from moderately satisfactory to problem project, then to
moderately satisfactory and to Satisfactory at the end of the project period. Through the entire
implementation period, the Bank as a whole has put in great efforts in maintaining policy
dialogue, identifying solutions to expedite disbursement and turn the project around. The
implementation had momentum for making operational progress and disbursing until the later
phase of the project life, but policy related work had advanced quite significantly before the
disbursement curve took off. Nevertheless, the technical and operational support provided by the
Bank team was indispensable for the full disbursement and achievement of PDOs. Although some
early ISRs and AMs appear to be a bit optimistic in expecting things to turn around on their own,
overall the AMs and ISRs are candid in documenting project status and reflecting improvements
in M&E, fiduciary compliance and disbursement. While the procurement and disbursement had
been delayed in the early phase of the project, there were no major issues in compliance to
fiduciary policies. One shortcoming during implementation after restructuring was the quality of
monitoring and evaluation; the targets used to track indicator performance appeared inconsistent
between documents including AMs, ISRs, and restructuring papers.
6 These major risks included: a) delay or lack of coordination in implementing the ICT Network
Platform; b) political barriers to making unpopular but necessary changes to benefits, premiums,
or exemptions; and c) lack of flexibility of planned IT to incorporate policy changes.
22
(c) Justification of Rating for Overall Bank Performance Overall Rating: Moderately Satisfactory
73. Overall the Bank team provided a Moderately Satisfactory level of support during the
design and implementation of the project. This rating also correlates with the overall Satisfactory
outcome rating for the project.
5.2 Borrower Performance
(a) Government Performance
Rating: Moderately Satisfactory
74. The Government performance is rated as Moderately Satisfactory. Overall the
Government was highly committed, actively involved and responsive during both preparation and
implementation stages. For some time after the mid-term review, there seemed to be confusion
about implementation arrangements partially due to the election process, which led to unclear
responsibility for project management and delays in actions. Nevertheless, the project was
eventually restructured and the implementation arrangements were organized and clarified.
(b) Implementing Agency or Agencies Performance
Rating: Moderately Satisfactory
75. The performance of the implementing agency, National Health Insurance Authority is
rated as Moderately Satisfactory. As a newly established institution, NHIA neither had
experiences in working with the Bank, nor working with other key stakeholders such as GHS,
CHAG, and Ministry of Health. As a result, it took NHIA long time to go through the learning
curve on issues such as institutional dynamics and Bank fiduciary procedures, which has
compromised the implementation and efficiency of the project during early period. However, the
agency was highly committed to deliver on the project. The agency provided high level oversight,
deployed competent staff for the project management unit, and worked closely with the Bank
team, GHS, CHAG and MOH, particularly during the later phase of the project implementation.
All these have led to the successful implementation of the project and achievement of outcomes.
(c) Justification of Rating for Overall Borrower Performance
Rating: Moderately Satisfactory
76. The overall performance of the borrower is rated Moderately Satisfactory.
6. Lessons Learned
77. It is important to get engaged at the right time. This project was prepared and approved at
a time when the counterpart needed most help as the NHIS was just established. This opened a
window of opportunity for the Bank to bring in international expertise and experiences, and for
the country to get exposed to them, discuss potential consequences, and adapt to their own
context.
23
78. By adopting a two-arm approach in the design, the project was able to provide both
knowledge service and infrastructure investment at the same time. The technical arm on policy
development introduced globally proven effective policies and methodologies, created country
specific evidence, and built domestic capacity. The operational arm on claims system adopted
advanced technology to reduce errors and expedite bill processing. In addition, these two arms
together may generate interactive effect on top of their own benefit, as the electronic claims
processing system makes it much easier to obtain evidence on service delivery and utilization, as
well as implement policies on cost containment and quality assurance.
79. It is important for the Bank to deploy a team that has a combined skill set in strategic
policy discussion, technical studies as well as operational project management. It appeared that
the momentum of project progress was driven by specific skills available at a given time,
therefore, different pieces advanced at different stages. The project implementation and support
would have been more efficient if all these skills were available at the same time for the duration
of the project life. This also raised question to the Bank management how to make such
arrangements available by committing needed skills and resources.
80. Implementation readiness is critical for project performance, in particular when the
implementation agency is not experienced. More realistic disbursement estimates should have
been prepared based on the existing capacity and the required lead time. Reality checks on
feasibility of M& E plans and fiduciary procedures are more than necessary, and they need to be
followed with rigorous capacity building measures for robust implementation. In addition,
stakeholder sensitization also plays a key role for making projects ready to be implemented,
especially for such a project that requires interactions with many stakeholders who are stronger
institutions historically.
81. Integrating project implementation with overall work on health insurance and health
financing maximizes the leveraging impact of the project and ensures sustainability. The
engagement between the Bank and the Government goes beyond implementation of specific
project activities, rather progresses with a vision of improving overall health insurance scheme
and advancing the health financing agenda. This is evidenced by the update on overall sector
situation in the ISRs. Additional resources available through a separate trust fund managed by the
Bank also made a broader engagement possible.
82. This project presents another case on the importance of strengthening M&E capacities on
both the Bank and Government teams, including design of realistic indicators, tracking
performance of indicators consistently, and verifying results. Due to the limited scope of work
and resource constraints, the ICR team used information from project records (ISRs, AMs, etc.) to
evaluate achievement of project objectives. The ICR team trusted that the Bank supervision team
had verified all these results provided by the Government through its institutional reporting. To
enhance accountability of future projects, it will be useful if the ICR teams can be provided with
the resources to undertake independent approaches to verifying project results (such as sample
checks and household surveys) and explicitly document particularly when source of information
is administrative data.
83. This project has opened doors for further engagement with various stakeholders and built
foundation for strengthening the efficiency of NHIS, however, continuous and substantial support
in this area together with other partners will be required on a long term basis. NHIA and NHIS
still face numerous challenges such as expanding coverage, ensuring financial sustainability
24
mostly through cost containment and assuring service quality. It is suggested that a
comprehensive in-depth evaluation of the insurance scheme be undertaken through a separate
modality to cover all these different aspects, e.g., efficiency of scheme, impact of insurance
(including its cost containment policies) on service utilization and service quality, as well as the
related implications on equity. This will not only complement this ICR that is mandated to focus
on the project, but provide key inputs for Bank management and government to make decisions
on follow-up actions.
7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners
(a) Borrower/implementing agencies
84. The NHIA project implementation team confirmed that the ICR reflects both the
achievements and challenges faced by the project with a clear story line and appropriate ratings.
(b) Cofinanciers
(c) Other partners and stakeholders
(e.g. NGOs/private sector/civil society)
25
Annex 1. Project Costs and Financing
(a) Project Cost by Component (in USD Million equivalent)
Components Appraisal Estimate
(USD millions)
Actual/Latest
Estimate (USD
millions)
Percentage of
Appraisal
Component A: Streamlined
purchasing policies and
mechanisms
4.00 8.56 100
Component B: Strengthening
integrated claims management
systems
11.90 6.44 100
Total Baseline Cost 15.00 15.00 100
Physical Contingencies
0.00
0.00
0.00
Price Contingencies
0.00
0.00
0.00
Total Project Costs 0.00 0.00
Front-end fee PPF 0.00 0.00 0.00
Front-end fee IBRD 0.00 0.00 0.00
Total Financing Required 15.00 15.00 100
(b) Financing
Source of Funds Type of
Cofinancing
Appraisal
Estimate
(USD
millions)
Actual/Latest
Estimate
(USD
millions)
Percentage of
Appraisal
Borrower 0.00 0.00 0.00
International Development
Association (IDA) 15.00 15.00 100
26
Annex 2. Outputs by Component
Table 1. Specific outputs by component
Component A: Streamlined Purchasing Policies and Mechanisms (US$3.3 million)
Sub-component Output
(i) Streamlining to an efficient
provider payment mechanism for
NHIS (US$0.7 m)
Review of the existing G – DRG Payment
Mechanism
Develop a performer based health care provider
payment mechanism
Healthcare providers staff trained on Capitation
implementation
DMHIS Staff were trained on Capitation
implementation
Capitation piloted in Ashanti region
Monitoring and Evaluation Strategy developed
(ii) Improving the sustainability of
the NHIS (US$0.35 m)
Developed cost containment strategy
Developed a referral policy.
Established clinical audit/quality assurance unit to
undertake regular clinical audit activities
(iii) Improving equity in the coverage
of the poor by the NHIS
(US$0.35m)
Used common targeting mechanism to enroll poor
and vulnerable into NHIS
Drafted a NHIS population exemption policy for the
enrollment of the poor.
(iv) Support restructuring data and
analysis (US$0.7m)
Capacity building provided for actuarial analysis
Established actuarial analysis unit
Analysis undertaken regularly, with results presented
to development partners and parliament
Support the conduct of the National Health Accounts
(NHA)
The report of the Ghana NHA for 2005 and 2010 was
printed in March 2013.
(v) Support project management,
coordination and monitoring and
evaluation
The NHIA hired a consultant to carry out an
evaluation of the results of the project. Qualitative
and quantitative research was carried out in 5 zones
where the same questionnaire was administered
targeting the Regional M & E Office, claims office,
MIS and the Public Relations Officer all at the
facility level.
Component B: Strengthening Integrated Claims Management System (US$11.7 million)
Sub-component Output
(i) Strengthening governance and
oversight of e-health
(US$0.775m)
Streamlined heath data terminology for more
effective exchange of data among healthcare
agencies.
Draft ICT Master Plan has been developed Development and training of Medical Terminology
27
and Disease Coding (MTDC) use in Ghana
To date the project has been able to train 936
individuals, who in return have been training their
colleagues to become familiar with the MTDC.
Under HIP the Claims Processing Center underwent
an extensive audit of manual claims.
The auditing team recovered 20 million New Ghana
Cedi from monies over paid to providers.
(ii) Streamlining an integrated claims
management system for the
NHIS (US$4.4m)
Hardware and software have been received and is
functioning. The CPC is currently receiving
electronic claims and started pilot vetting.
Target facilities started submitting close to 800,000
e-claims to CPC
(iii) Strengthening automation in the
major hospitals (US$6.25m)
Upgraded Health Information Management System
to iHost to enable healthcare providers the ability to
submit claims electronically.
Provided capacity building support of information
workers in health venues
Table 2. Specific changes and rationales for revision of components
Activities
Proposed
Change Rationale for Change
Component A (original): Enabling Environment for Implementation ($2.05 m).
A.1. Stakeholder coordination Dropped Not relevant as a stand-alone activity. Already covered
under project management.
A.2. Project management and
sustainability
Moved
It is more logical to regroup project management and
M&E in a management component of its own (New Sub-
component A.4.)
A.3. Communications strategy
Dropped
Not relevant as a stand-alone activity. Already covered
under other activities (e.g. communications to introduce a
new provider payment mechanism)
A.4. Standardizing fee schedule
and medicines list
Moved
Moved to A.2 as this activity is part of cost containment.
A.5. Provider payment
mechanisms
Moved
Moved to A.1 and repositioned to show the importance of
this activity.
A.6. Development of projects
for donor support
Dropped
Given the challenge of implementing the already- defined
activities, it is not necessary to develop more initiatives at
this stage.
A.7. Audits and fraud control Moved Moved to A.2 as this activity is part of cost containment.
Component A (new). Streamlined Purchasing Policies and Mechanisms ($3.3 million)
Component A is renamed and replaces the old Component A, which had 7 sub-components. The new
Component A has 5 subcomponents.
The new design of the component is functional and results-oriented rather than the old design that covered
various activities which were disconnected and input-oriented.
28
A.1.: Streamlining to an
efficient provider payment
mechanism for NHIS ($0.7m).
Activities are to: (i) assess the
current provider payment
system, (ii) develop a
performance-based health care
provider payment mechanism,
and (iii) design, support and
evaluate a capitation pilot in a
region of the recipient to
provide assistance in setting a
Monitoring and Evaluation
framework and a
communication strategy
Expanded
[This
expands
upon
original
A.5. and
A.3.]
Expanded to not only include the review of the current
provider payment systems, but also to give technical
assistance to the NHIC in designing a capitation pilot in a
region of the recipient, as per the request of NHIC, and
strengthening M&E and communication strategy. This is
an important reform area.
A.2.: Improving the
sustainability of the NHIS
($0.35m)
Activities are to: (i) develop a
cost containment strategy, and
(ii) undertake a gate keeping
assessment to screen patients at
primary health care centers
Expanded
[This
expands
upon
original
A.4, and
A.7]
The gatekeeping system is the first line of screening of
patients, which generally happens at the primary health
care center. The first line of health providers screen
patients and refer only those who need higher level care.
This way they control unnecessary use of higher level
care, and help contain costs. Ghana is interested to pursue
this, and further assessments and interested to pursue this,
and further assessments and discussions are required on
the feasibility and functionality of such a process.
Given the current acceleration of NHIS claims
expenditure, and no appropriate strategy in place to
contain costs, the NHIC saw this as an important element
to move the agenda forward.
A.3.: Improving equity in the
coverage of the poor by the
NHIS ($0.35m).
Activities are to: (i) develop
tools and guidelines for the
identification, verification,
enrollment and tracking of the
poor into the NHIS. and (ii)
draft a NHIS population
exemption policy for the
enrollment of the poor
Added
Given the pro-poor nature of the NHIS, and the current
low enrollment of the poor, the MOH asked for assistance
in the harmonization of the NHIS definition of the poor,
with that of the Ministry of Employment and Social
Welfare (MESW).
A.4. Support restructuring data
and analysis ($0.7m)
Activities are to: (i) provide
capacity building support for
actuarial analysis, (ii) data
analysis for National Health
Accounts, and (iii) strengthen
monitoring and evaluation
systems at the NHIS
Expanded
[This
includes
C.4.]
Monitoring and Evaluation Systems will need to be
strengthened to assist in the actuarial analysis and in the
national health accounts.
29
A.5.Support Project
Management, Coordination and
monitoring and evaluation
($1.2m).
Expanded
[This
expands
upon
original
A.2. and
A.1.]
Activities include the provision of technical assistance to
the NHIS to develop its capacity in project management,
procurement, financial management and M&E; study tours
to allow transfer of knowledge from countries more
advanced in the implementation of health insurance
systems; project operations; M&E costs; and Inter-Agency
Steering Committee (IASC) coordination.
Component B (original): Financial and Operational Management Tools ($8.6 million).
B.1.: Providers’ needs analysis
and strategies for business
process tools
Activities include carrying out
a rapid needs assessment and
developing ICT strategic plans
for the providers to fill
technical gaps and optimize
their interface with the NHIC
ICT Network Platform
Modified
and
moved
This activity would be streamlined under subcomponent
B.3.
The assessments would include the assessment of the
iHost. GHS and CHAG (and other providers) have adapted
the use of the German care2x open-source Hospital
Information System framework to form the Ghanaian
version dubbed iHost. Before proceeding further with this
option, or another one, the authorities need an independent
assessment of the strengths and weakness of the iHost
software and implementation arrangements – as well as
other possible approaches (already present in Ghana or
available internationally).
B.2. Network development,
hardware, and alternative
energy solutions
Activities include: (i) the
implementation of the ICT
strategic plans of providers by
equipping them with technical
hardware, network
connectivity, and alternative
energy sources; (ii) staff
training; (iii) technical support;
and (iv) maintenance.
Modified
and
moved
This activity has been streamlined under subcomponent
B.3.
B.3. Software and systems
integration
Activities include development,
licensing, and installation of
software for the integration of
providers’ front and back-office
systems, including staff
training, technical support, and
maintenance.
Dropped
This activity is taken up by the other Development
Partners (e.g. Dutch financed, PharmAccess)
Component B (new). Strengthening Integrated Claims Management Systems (US$11.7 million) Component B is renamed and replaces the old Component B. The new Component B has 3
subcomponents. Its design would now be functional and results-oriented rather than along broad
Information Technology needs and input- oriented.
30
B.1. Strengthening governance
and oversight of e-health
($0.775m).
Added.
The activities are to: (i) develop health data dictionary and
health management information system master plan; and
(ii) provide capacity building support of information
workers in health insurance, information technology
specialists, and health insurance staff.
B.2. Streamlining an integrated
claims management system for
the NHIS ($4.4m).
Added.
Activities are to: (i) increase performance of the claims
processing center with additional software and hardware,
(ii) develop and deploy e-claims to major hospitals, and
(iii) implement the NHIS call center.
B.3. Strengthening automation
in the major hospitals
($6.525m).
Expanded
[This
expands
upon
original
B.1. And
B.2.]
Activities are to: (i) replace and improve the computer
infrastructure in 10 major hospitals to improve
performance, reliability and maintainability, and (ii)
provide capacity building support of information- workers
in health venues.
Component C (original): Financial and Operational Management Training ($2.05 m).
Component C is dropped, as some activities are streamlined into Components A and B, and some are
dropped as they do not add value to other activities directly affecting the PDO.
C.1. Needs assessment and
strategy development
Activities include an
assessment of the technical and
managerial capacity of the
NHIS, the DMHISs and
providers, and developing a
training program to address
capacity constraints.
Modified
and
moved.
These activities are moved to Component A.
C.2. Management Training
Activities include management
training for senior staff of the
MOH, the NHIS, the DMHIS,
and the Providers in accordance
with the training strategy and
program developed under
subcomponent C.1. of the
Project
Dropped
These activities will not be financed by the project, and
will be taken up by the Government.
C.3. Training in ICT Network
Operations
Activities include training of
core ICT teams to provide
continuing support to providers
in the use of the NHIC ICT
network Platform and
providers’ ICT tools in
accordance with the training
strategy developed under
subcomponent C.1. of the
Project
Modified
and
moved
Moved to Component B.
Modified as: to build capacity (skills and education) in
ICT, ICT use, on management in an automated health
sector, and management in an insurance-based health
financing system, which are critical to realize the benefits
of claims processing systems and the Hospital MIS. These
training initiatives must cover a variety of staff / managers
across the NHIC, GHS, MOH, CHAG, providers, etc.
Effective harmonization of the training components across
the agencies will improve efficiency (reduce the unit cost)
of these activities.
31
C.4. Training in actuarial
analysis and other core analytic
skills
Activities include developing:
(i) the capacity of the NHIS, the
DMHISs, and providers in data
collection and monitoring for
health care utilization; and (ii)
the NHIS capacity in actuarial
analysis, in accordance with the
training strategy developed
under subcomponent C.1.
Modified
and
moved.
Moved to Subcomponent A.2.
Modified to improve the data collection system, conduct
actuarial analyses, and build capacity.
C.5. Financial Management
Training
Activities include financial
management training of staff in
the MOH, the NHIS, the
DMHISs, and providers in
accordance with the training
strategy developed under
subcomponent C.1.
Dropped.
These activities will not be financed by the project, but
will be financed by the Government.
32
Annex 3. Economic and Financial Analysis
1. Cost-benefit analysis provides a basis for assessing project efficiency by comparing the
total expected cost of each option against the total expected benefits, and examining whether the
benefits outweigh the costs, and by how much. Such approach fits well with the Bank’s projects
in earlier decades, because projects at that time were typically of the “bricks-and-mortar” variety
— physical rehabilitation of a road, for example. In such cases, expected project costs and
benefits could usually be readily monetized at least to a reasonable approximation. Consequently
the analyst could quickly arrive at an estimate of the rate of return.
2. Cost-benefit analysis, however, may not capture all aspects of the potential development
impact related to a project because some of them cannot be easily translated to monetary values
given constrains of existing data and methodology, e.g., efficiency improvement and equity
improvement. This health insurance project is one of such cases, but not the only one. As a matter
of fact, the Bank’s current portfolio comprises more complex and innovative operations involving
institutional redesign, incentive restructuring, decentralized decision-making, and so on.
3. In order to assess project efficiency in a comprehensive manner, this economic and
financial analysis both assesses overall project development impact and undertakes a cost-benefit
analysis for the two main interventions supported by the project, introduction of capitation policy
and use of electronic claims processing system.
Project development impact
4. The Ghana Health Insurance project has generated substantial development impact in
Ghana at a number of levels: operational level of the NHIS, policy level of the NHIA, health
sector level and country level. The following section assesses these impacts in details.
5. First, at the operational level of the NHIS, this project strengthened operational
management of the NHIS. Through standardization of medical terminology and disease coding in
submitted claims, all claims have passed initial test and improved accuracy. Through the
installation of electronic claims processing system and its interface with providers’ electronic
medical record system, close to 800,000 claims were submitted to NHIA electronically within a
one-year period. Electronic system not only saves operational and management cost by reducing
processing time, it has set up a solid operational system for NHIA to implement cost containment
and quality insurance policies more effectively.
6. Second, at the policy level of the NHIS, this project has enhanced the NHIA’s capacity as
a strategic purchaser of health services. Through the project implementation period, the NHIA
has been introducing new policies, adapting international experiences to country context,
evaluating financial sustainability of the scheme, and exploring strategies to expand coverage
while ensuring financial sustainability. The NHIA has demonstrated its capacity in undertaking
actuarial analysis independently and regularly in its interactions with key stakeholders. Another
example is the pilot of capitation policy in the Ashanti region in 2012 with support from the
project.
Based on global experiences, total health expenditures decline with capitation, a
prospective payment mechanism that reduces over utilization by shifting financial risks to
providers.
33
A study examining the impact of capitation in the Ashanti region shows that total claims
payment in surveyed facilities have been reduced from GHc 26.2 million in 2011 (before
pilot) to 21.3 million in 2012 and 19.3 million in 2013. This represents a substantial
savings of 10.5 percent in 2012 and 15.2 percent in 2013 out of total claims payment.
More importantly, this pilot and its evaluation have informed policy makers in deciding
on the scale up of capitation across country by the end of 2014.
7. Third, at the health sector level, it has contributed to the achievement of the health-related
MDGs and Universal Health Coverage. Global evidence shows that a well-managed insurance
scheme improves survival from disease and life events as it increases access to essential health
services, which in turn will contribute to improvement of health outcomes. According to WHO,
around 70 percent of early childhood deaths are due to conditions that can be prevented or treated
with access to some simple and affordable interventions. Past research results show that 80
percent of childbirth related deaths could be averted with access to essential maternity services.
The NHIS has a comprehensive benefit package that covers 95 percent of the disease burden,
which makes it possible to increase utilization of all essential services.
8. A Bank study shows that the insured population has a higher rate of utilizing essential
health services that are proved cost-effective globally. For example, the percent of pregnant
women in Ghana who delivered in a health facility was 74.3 percent among the insured,
compared with 41.4 percent among the uninsured. This result alone can be translated into an
enormous impact on women survival from pregnancy related deaths, as literature shows that up to
one-third of maternal deaths may be prevented through the presence of skilled birth attendance.
In addition, another published evaluation study shows that people are more likely to seek care
when sick with insurance coverage (78.6 vs. 90.5 percent respectively).
9. Fourth, at the country level, the project has contributed to both economic growth and
equity.
10. This project promoted equity and shared prosperity by removing financial barriers to
service access among the poor.
As shown by PDO indicator 4, the insurance coverage among the lowest wealth quintile
population has more than tripled from 14 percent to 48 percent during the project period.
Evidence shows that among the lowest quintile pregnant women, there is a significant
difference in percent who gave birth in facilities by insurance status, 34.8 percent among
the insured, versus 12.2 percent among the uninsured. Figure 1 plots the concentration
curve for this indicator by insurance status. In an ideally equitable world, the
concentration curve should be the diagonal line with each quintile having same percent of
women giving birth in facilities; the distance between the real situation and the ideal
situation shows the extent of inequity. As shown by the graph, the distance was shorter
for the insured population than for the uninsured population, indicating decreased
inequity.
34
Figure 1. Concentration curves for the percent of pregnant women giving births in facilities, by
insurance status
11. This project will also generate long-term economic benefit by increasing the active and
productive labor force who can potentially contribute to economic growth and poverty
elimination. With improved health and nutrition status, more children will survive into adulthood
and work more productively as a result of better cognitive development. Women who are saved
from maternal deaths will contribute directly to productive activities or relieve household
members who would have had to provide child care without their presence.
The most recent empirical estimates of the negative effects of stunting on worker
productivity and adult earnings range from about 10 percent per year7, to as high as 20
percent per year 8 . Anemia is associated with a 2.5 percent reduction in wages.
Productivity losses at the individual level are estimated to be more than 10 percent of
life-time earnings, which at the macro level can lead to a 2‐3 percent loss in GDP.
One study that estimates the effect of maternal mortality on GDP in Africa shows that
maternal mortality has a statistically significant negative effect on per capita GDP. An
increase in MMR by one death decreases per capita GDP by US$0.36 per year on average.
Cost-benefit Analysis focusing on introduction of capitation policy
12. This cost-benefit analysis on capitation assesses nation-wide benefit and cost of
capitation based on the piloting experiences supported by this project. A number of scenarios are
examined by using different assumptions on how benefit and cost may change from pilot to scale-
7 Hoddinott 2003, World Bank 2006, Quisumbing, Gillespie and Haddad 2003, Alderman
Hoddinott and Kinsey 2002, Ross and Horton 2003
8 Granthan-McGregor.S et al 2007
0%
20%
40%
60%
80%
100%
0% 20% 40% 60% 80% 100%
Insured
Uninsured
Ideal
35
up, with assumptions at different levels of stringency. The timeframe from 2013 to 2017 is used
considering data availability, though all benefit is expected to extend beyond this period. A
discounting rate of 3 percent is used to estimate present value based on existing guidelines (WHO guide to CEA, 2003).
Benefit scenario 1: The pilot experiences show that claims payment have reduced about
10 and 15 percent respectively in year 1 and year 2 after capitation. This scenario
assumes claims payment may be reduced compared with projected health expenditures
without capitation, with same impact of 10 percent (low bound for pilot) reduction each
year from 2013 to 2017. This scenario is considered as the least stringent assumption on
benefit size moving from pilot to scale up.
Benefit scenario 2: This scenario assumes the impact of capitation on claims payment
will decline gradually over time. Compared with projected health expenditures without
capitation, claims payment will reduce by 10 percent for 2013, 8 percent for 2014, 6
percent for 2015, 4 percent for 2016, and 2 percent for 2017.
Benefit scenario 3: This scenario assumes the nation-wide impact will only be half of
what is achieved under pilot, and the impact will be same for each year. In other words,
compared with projected health expenditures without capitation, claims payment will
reduce by 5 percent for each year from 2013 to 2017.
Benefit scenario 4: This scenario assumes the nation-wide impact will only be half of
what is achieved under pilot, and the impact will decline gradually over time. In other
words, compared with projected health expenditures without capitation, claims payment
will reduce by 5 percent for 2013, 4 percent for 2014, 3 percent for 2015, 2 percent for
2016, and 1 percent for 2017. This scenario is considered as the most stringent
assumption on benefit size moving from pilot to scale up.
Cost scenario 1: Pilot experiences showed that the implementation cost of capitation in
pilot region was GHc 3.87 per active member, and the majority of the cost was one-time
cost. Based on this, this scenario assumes that the nationwide cost in year 2013 will be
GHc 3.87 per active member, and for the following years, the cost will be 30 percent of
that for year 2013. This scenario is considered as a less stringent assumption on benefit
size moving from pilot to scale up.
Cost scenario 2: This scenario assumes that the implementation cost will be three times as
much as cost scenario 1. This scenario is considered as a more stringent assumption on
benefit size moving from pilot to scale up.
Table 1. Number of population, insured members, and total NHIS expenditures
2013 2014 2015 2016 2017
Population (million) 26.3 26.8 27.4 27.9 28.5
Insurance coverage (%) 35.3 36.4 37.4 38.4 39.5
Insured members (million) 9.3 9.8 10.2 10.7 11.3
NHIS expenditures (GHc,
million) 1129 1382 1745 2196 2764
13. Key assumptions used:
1) Population grows by 2% during the period from 2013 to 2017, projected based on census
data
2) Insurance coverage increase by 1% annually during the period from 2013 to 2017
3) Average annual inflation will not exceed 9.5% from 2013 to 2017
4) Increase in tariffs and medicines will not exceed 20% per annum
5) The benefit package remains unchanged
36
Note: all these projected numbers and assumptions are taken from the actuarial analysis
undertaken by the chief factualist’s office.
14. Table 2 shows the estimated benefit and cost for each year and each scenario, and Table 3
shows the results of net present values and benefit-cost ratios for different combinations of cost
and benefit scenarios. It reveals that support of capitation pilot which has led to a scale-up
decision is a highly efficient intervention. Under the least stringent scenario combination (benefit
scenario 1 and cost scenario 2), the net present value is 802.1 million GHc/US$248.7 million, and
the benefit-cost ratio is 15.3. Even under the most stringent combination (benefit scenario 4 and
cost scenario 2), the net present value is 22.8 million GHc/US$7.1 million, and the benefit cost
ratio is 1.14.
Table 2. Estimated benefit and cost for each year and each scenario
2013 2014 2015 2016 2017 Total
Benefit: saved health expenditures
(GHc million, value as of 2013)
Scenario 1 112.9 134.2 164.5 201.0 245.6 858.1
Scenario 2 56.5 67.1 82.2 100.5 122.8 429.1
Scenario 3 112.9 107.3 98.7 80.4 49.1 448.4
Scenario 4 56.5 43.8 39.1 31.9 19.5 190.8
Cost: implementation cost (GHc
million, value as of 2013)
Scenario 1 10.8 11.0 11.2 11.4 11.6 56.0
Scenario 2 32.4 33.0 33.6 34.2 34.8 168.0
Table 3. Cost-benefit analysis results for different combinations of scenarios
Net Present
Value
Benefit-cost
ratio
Cost Scenario 1
(less stringent)
Cost Scenario 2
(more stringent)
Cost Scenario 1
(less stringent)
Cost Scenario 2
(more stringent)
Benefit Scenario 1
(least stringent) 802.1 690.1 15.32 5.11
Benefit Scenario 2 373.1 261.1 7.66 2.55
Benefit Scenario 3 392.4 280.4 8.01 2.67
Benefit Scenario 4
(most stringent) 134.8 22.8 3.41 1.14
Cost-benefit analysis for the electronic claims system
15. The introduction of electronic claims processing system brings drastic changes to the
health insurance system. It benefits both the scheme manager and insurance provider in terms of
improving the efficiency of processing claims. Effective implementation of cost containment and
quality assurance policies such as clinical audit is made possible. Table 4 outlines all benefits
related to use of electronic claims processing system. Further, it also prompts necessary actions in
standardizing disease coding and medical terminology in claims, calls for digitalization of
membership management (introduced by NHIA as biometric registration system), financial
37
payment, and integration with other systems such as electronic medical record system in hospitals
and health information management system in Ministry of Health.
Table 4. Benefits related to use of electronic claims processing system
Benefits
For service
providers
Saved operation cost by not using paper-based system
Decreased rejection rate due to better quality claims
Decreased turn-around time for reimbursement
Increased fund stability and predictability
For scheme
managers
Saved operation and management cost for claim processing by not
using cumbersome paper-based system
Saved operation and management cost for clinical auditing
Increased capacity and efficiency to identify fraud claims
Increased capacity and efficiency to identify inappropriate services
and improve service quality
Increased capacity to provide evidence for policy making and
implementation
Interactive
effect between
providers and
scheme
managers
Increased capacity to link up with digitalized membership
management system, electronic insurance payment system,
electronic medical records system in hospitals and health
information management system
Improved human resource capacity to implement administration
requirement of the health insurance scheme
16. This cost-benefit analysis aims to assess the situation when the project investment on IT
hardware and software are fully operational during a three year period from 2013 to 20159. It is
expected that 4.8 million claims will be processed electronically when the system is fully
functional based on the results from a system capacity assessment. This analysis focuses only on
two benefits to demonstrate the soundness of the investment, as it is challenging to translate all
above-listed benefits into monetary values. These benefits include: 1) saved operation and
management cost for claims processing by not using paper-based system; and 2) saved claims
payment from increased accuracy of claims.
17. Results in Table 5 show that full operation of the electronic claims processing system
yields great returns even with only very selected benefits considered. The net present value is
GHc 4.7 million/US$1.46 million, and the benefit-cost ratio is 1.29.
Table 5. Cost-benefit analysis result for electronic claims processing system
2013 2014 2015 Total
Claims process
(actual for 2013 and projected for 2014 and 2015)
400,000 3,000,000 1,100,000 4,500,000
Benefit (GHc, million, value as of 2013)
Saved operation and management cost for claims
processing for NHIA compared with paper system 0.32 1.89 1.53 3.74
9 The project has procured equipment for more than 40 target facilities, but only around 20 facilities started submitting claims as of March 2014 when the project was closed.
38
(1)
Saved claims payment from increased accuracy of
claims (2) 1.13 8.05 8.22 17.40
Total (1)+(2) 1.45 9.94 9.75 21.14
Cost: (GHc, million, value as of 2013) 16.13 0.16 0.15 16.44
Net present value (GHc, million, value as of 2013) 4.70
Benefit-cost ratio 1.29
18. Key data and assumptions used:
1) Saved cost by not using system is estimated based on: a) one person can process 400
electronic claims per day according to NHIA staff estimation; b) the workload of paper
system is three times more than that of electronic system according to NHIA staff
estimation and direct observation; c) average monthly salary being GHc 3,566 according
to Ghana salary survey.
2) Using electronic system may improve the accuracy by 7 percent. This is considered a
fairly conservative estimate as this level of improvement was observed in developed
countries.
3) The cost for 2013 is the actual project cost for procuring the related hardware, software
and services. For the following years, it is expected that only maintenance cost will occur,
which is estimated as one percent of the start-up cost.
39
Annex 4. Bank Lending and Implementation Support/Supervision Processes
(a) Task Team members
Names Title Unit Responsibility/
Specialty
Lending
Ferdinand Tsri Apronti Procurement Specialist AFTPE -
HIS
Mohamed I. Diaw Operations Analyst DFPTF
Caroline Ly E T Consultant EASHD -
HIS
Alexander S. Preker Lead Economist, Health CICHE -
HIS
Laura L. Rose Senior Economist GHNDR
Frederick Yankey Sr Financial Management Specialist GGODR
Evelyn Awittor Sr. Operations Officer AFCFI
Supervision/ICR
Adu-Gyamfi Abunyewa Senior Procurement Specialist GGODR
Johanne Angers Senior Operations Officer GHNDR
Ferdinand Tsri Apronti Procurement Specialist AFTPE -
HIS
Hortenzia Beciu Consultant CICHE -
HIS
Samuel Bruce-Smith Consultant AFTDE -
HIS
Adriana M. Da Cunha Costa Program Assistant GHNDR
Gregoria Dawson-Amoah Program Assistant AFCW1
Jean J. De St Antoine Lead Operations Officer AFTHW
- HIS
Robert Wallace DeGraft-
Hanson Sr Financial Management Specialist GGODR
Francois P. Diop Sr Economist (Health) AFTHE -
HIS
Ronald Hendriks HQ Consultant ST GHNDR
Christopher H. Herbst Health Specialist GHNDR
Manush A. Hristov Senior Counsel LEGES
Anders Jensen Senior Monitoring & Evaluation GPSOS
Christine E. Kimes Operations Adviser SACBD
Caroline Ly E T Consultant EASHD -
HIS
Craig R. Neal Consultant GGODR
Alexander S. Preker Lead Economist, Health CICHE –
HIS
Laura L. Rose Senior Economist GHNDR
Andreas Seiter Senior Health Specialist GHNDR
Claude Rugambwa Senior Health Specialist AFTHE -
40
Sekabaraga HIS
Elizabeth Alluah Vaah E T Consultant AFTME -
HIS
Moulay Driss Zine Eddine El
Idrissi Sr Economist (Health) GHNDR
Evelyn Awittor Senior Operations Officer AFCF1
Patricio Marquez Lead Health Specialist GNHDR
Karima Saleh Sr. Health Economist GNHDR
Francisca A. Akala Sr. Health Specialist GNHDR
Stephen Tettevie Team Assistant AFCW1
Huihui Wang Sr. Health Economist GNHDR
Yvette Atkins Sr. Program Assistant GNHDR
Dominic Haazen Lead Health Specialist GNHDR
(b) Staff Time and Cost
Stage of Project Cycle
Staff Time and Cost (Bank Budget Only)
No. of staff weeks
USD Thousands
(including travel and
consultant costs)
Lending
FY07 39.21 225.42
FY08 5.72 30.19
Total: 44.93 255.61
Supervision/ICR
FY07 0.00
FY08 23.55 145.22
FY09 16.92 75.9
FY10 22.42 143.56
FY11 24.24 113.48
FY12 24.62 136.53
FY13 18.06 95.71
FY14 12.48 96.99
FY15 0.71 2.86
Total: 143.00 810.25
41
Annex 5. Summary of Beneficiary Survey Results
1. This Annex summarizes the results of a beneficiary survey undertaken by the
Government.
2. In pursuance of attaining Universal Health Insurance coverage for all people in Ghana,
the Government of Ghana established the National Health Insurance Scheme in 2003. The
National Health Insurance Authority (NHIA) was subsequently established and given the
responsibility of registration of subscribers, ensuring access to healthcare without payment at
point of service, registration and licensing of mutual and commercial health insurance schemes
and management of the national Health Insurance Fund. With assistance of the World Bank, the
Government of Ghana subsequently launched a Health Insurance Project with the primary
objective of strengthening the financial and operational management of the NHIS.
3. This study examines the effectiveness and impact of the various training programs
organized for NHIS staff and health service providers under the Health Insurance Project. It also
examined views of NHIS staff and service providers on capitation policy in the Ashanti region
and various training programs. Data was gathered through face-to face interviews on sample of
341 NHIS employees and service providers in all 10 regions of Ghana in March 2014.
Additionally, focus group discussions, and non-participant observations were used to gather
primary data. The study shows that the beneficiaries of the Health Insurance Project were
relatively highly educated young people, who have several years to work with the scheme. This is
a positive sign for the sustainability of the scheme. The level of knowledge of capitation concept
was high among health care providers and staff of NHIS district offices in the Ashanti Region,
and this suggests that training given to these actors is adequate. However, there will be a need for
further mop up training exercises for lower level officials at the health facilities, in particular.
Majority of the officials of the health facilities, in principle, support the capitation concept.
4. The major benefits of capitation identified by respondents include: reduction in the
incidence of abuse of NHIS system by clients; potential for early payments of NHIS funds to
service providers; improved patient-doctor relationships; and potential to reduce corruption.
Despite these benefits, the respondents also identified a number of challenges associated with the
capitation concept. First, while the NHIA invested heavily in the training of service providers and
NHIS officials on the capitation policy, little attention was paid to education and sensitization of
clients. Another challenge is low rate of capitation, which forces health providers to adopt
copayment. A majority of service providers and NHIS officers support the capitation policy,
despite these initial challenges. Suggestions for dealing with initial challenges include intensive
education of clients, upward adjustment of capitation rate, frequent meeting of stakeholders on
the programme, and prompt transfer of funds to service providers.
5. The study revealed that different types of training programs were organized by the NHIA
for staff of NHIS district and regional offices as well as health care providers in all the 10 regions
of Ghana. The most popular training programs identified were those on: Electronic Claims
processing and vetting; Medical Terminologies and Diagnostic Billing; ICT related programs; the
revised Ministry of Health Referral Policy and Gatekeeper system, Clinical Auditing, and
programs for the actuarial division on NHIS. Beneficiaries generally reported that these training
programs have enhanced their performance. However, some of the training programs will need to
be scaled up, as some employees have not yet benefited. These include the training in clinical
auditing and that of referral and gate-keeper system.
42
6. Although respondents were generally satisfied with the way the training programs were
organized, they also highlighted some organizational lapses which affected the success of the
training programs. These organizational lapses include: short duration of some training programs;
short notices given to employees about some of the training programs; low supply of equipment
after the training; and lack of adequate follow up training programs. We conclude that despite the
few challenges with organization of training programs, beneficiaries generally assessed all the
training programs as very useful and suggested that more of such trainings should be organized in
the near future. We recommend that the government of Ghana and its development partners must
provide adequate funds to the NHIA to organize more follow up training programs. There must
also be intensive public education on the capitation policy and referral and gate keeper systems to
ensure that clients support their implementation.
43
Annex 6. Stakeholder Workshop Report and Results
44
Annex 7. Summary of Borrower's ICR
1. Since 2003, the Government of Ghana has been working to implement the National
Health Insurance Scheme (NHIS). Several challenges ranging from broad policy decisions to
detailed implementation arrangements have hampered the process. Key among the challenges are;
A) Poor coordination among stakeholders and lack of concrete governance arrangements and
responsibilities for NHIS implementation, B) Challenges to maintaining financial sustainability of
the NHIS, C) Difficulties providing effective coverage for the poor and “exempt” indigents, D)
Implementation Issues for DMHISs and Providers. E) Inadequate technical tools for processing
and reimbursing claims, and F) Insufficient administrative, managerial, and technical human
capacity. This Project complements the efforts of the Ministry of Health (MOH, the Teaching
Hospitals, the National Health Insurance Scheme (NHIS), the Ghana Health Services (GHS), and
health service providers from other ministries, the CHAG, other providers, to ensure that the
National Health Insurance Scheme is strengthened and deliver the quality health care that all
Ghanaians seek.
2. The Health Insurance Project became effective in December 2007 to ameliorate the
challenges associated with implementation of the National Health Insurance Scheme and was
scheduled to be completed on 31st December 2012. Subsequently the completion date was
however revised to June 2013 on the basis of the Mid Term Review (MTR). The MTR
recommended restructuring of the project. A technical mission of the World Bank further
recommended an extension to March 2014 to enable the project team to complete the necessary
changes agreed between the World Bank and the Ministry of Health.
Target Groups and Project Beneficiaries
3. The key project beneficiaries of the HIP were:
The Ministry of Health (MoH)
The Ghana Health Service (GHS)
Teaching Hospitals-Korle Bu, KomfoAnokye and Tamale
National Health Insurance Council (NHIC)
District Mutual Health Insurance Schemes (DMHIS)
Christian Health Association of Ghana (CHAG)
Ghana Armed Forces Medical Service
Ghana Police Health Services
Society of Private Medical and Dental Practitioners
Project Development Objectives
4. The overall project development objective was to strengthen the financial and operational
management of the National Health Insurance Scheme by improving:
(i) the policy adaptation and implementation capacity of the National Health Insurance
Council in addressing ongoing core policy issues related to contribution, collection,
risk equalization, and provider payment mechanisms; and
(ii) the purchasing functions of the District Mutual Health Insurance Schemes, and the
billing function of the Providers.
Financing and Funding of the components of the HIP
45
5. The HIP went through restructuring in 2011, but the total project funding of $15 million
remained the same. The International Development Association (IDA) provided total funding.
There was no counterpart funding from Government of Ghana.
Components of the HIP project
6. There were two components for the HIP project; Component A and Component B.
With regard to Component A, the Project focuses on five elements or sub-components: (i)
streamlining to an efficient provider payment mechanism for NHIS, (ii) improving the
sustainability of NHIS (through addressing cost containment mechanisms), and strengthening
quantitative and actuarial analytical capacity, (iii) addressing the equity element on the coverage
of the poor under NHIS, (iv) restructuring data and analysis; and (v) Effective project
management, coordination and monitoring and evaluation. With regard to Component B, the
Project focuses on three elements: (i) strengthening governance and oversight for e-health; (ii)
streamlining an integrated claims management system for the NHIS, and (iii) linking Hospital
Management Information System (HMIS) with NHIS claims processing.
Financial and Procurement Management
7. Satisfactory Financial Management Performance rating was consistent throughout
implementation of the project, which can be attributed to the competence and skill of the Project
Finance staff at the NHIS. This resulted in the project complying fully to the Financial covenants
of the submission of quarterly reports and audits reports, albeit there were instances where these
reports were submitted late. The good FM rating is also supported by the project not having any
adverse audit opinion throughout implementation. The project, as at end of March 31 2014, had
disbursed USD 4,479,529.97 as against funds allocated of 15,305,539.97: see table below.
Table 1: Funds Disbursement Status by IDA as at 31 Mar 2014
CATEGORY
DESCERIPTION
FUNDS
ALLOCATED
USD
IDA PERCENTAGE
%
Goods 2,600,000.00 2,423,250.40 93.20%
Consultancy Services 2,950,000.00 2,847,731.59 96.53%
Training 4,750,000.00 4,691,396.84 98.77%
Operational Cost 4,705,539.97 4,250,186.87 90.32%
Non Consulting
services
300,000.00 266,964.27 88.99%
TOTAL 15,305,539.97 14,479,529.97 94.60%
8. The procurement management of the HIP project followed the World Bank’s Guidelines
for Procurement under IBRD loans and IDA credits. Guidelines for Selection and Employment of
Consultants by world Bank Borrowers, and the provisions stipulated in the Development Credit
Agreement. Other procurement and selection of consultants were based on the Ghana Public
Procurement Act (Act 663).
46
9. The procurement process under the HIP project was extremely slow in the first three
years of the project effectiveness, until 2010 when a procurement consultant was hired to
facilitate the procurement management. Based on the post procurement reviews, contracts
procured by the project met the appropriate procurement procedures in terms of the thresholds
and methods of procurement stipulated in the PIM. The procedures and the arrangements were
also consistent with provision of the Credit Agreement and practically complied with the World
Banks guidelines.
HIP Project Challenges
10. The implementation of the project activities was not without challenges culminating in
several extensions.
The project had several stakeholders with varied interest and this posed a serious
challenge in coordinating them. This challenge delayed in the implementation of some of
the project activities particularly the Electronic Claims component of the project.
Change in Government in 2009, challenged the smooth implementation of the project as
the new administration took time to understand the project governance and structure
before proceeding with it. Close to a little over a year was lost as result of this change.
Lack of consensus between GOG and the World Bank in certain activities of the project
also posed a serious challenge in implementing the project. As a result of the paradigm
shift from paper claims to electronic claims, several consultants were hired by the World
Bank to assist in the implementation process. However, most of them came with their
own understanding of the issues that was different from that of GOG and even part of the
Bank staff. This resulted in a prolonged delayed in reaching consensus on some of the
key project activities especially the electronic claims processing on which software and
methods to use in achieving the set objective.
Internal bureaucracy of the Implementation Agency and lack of clear communication and
approval channels affected the project implementation process.
The M & E system in place to track project activities was not robust and coherent. Report
submission deadlines were not adhered to, resulting in the delay of key project reports.
Achievement of Results
11. The HIP was to be measured by the following Development Objectives:
% of total clean claims that are reimbursed by payers (NHIA) to providers within 30 days
of claims receipt;
Number of total claims received electronically by processor from provider;
% of total claims submitted by provider to NHIS (DMHIS or CPC) that passed the initial
screening (i.e. not rejected by first electronic/manual review);
% of population from among the lowest quintile (20% of the index of socio-economic
status) registered under the NHIS with a valid NHIS card.
Table 2: Achievement of Key Performance Indicators
PDO Key Performance Indicator
Primary)
Baseline Target Current
(Mar
2014)
% of
target
Strengthen the
financial and
operational
Number of total claims received
electronically by processor from
provider;
19,537
2,500,000 864,534 34%
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management of the
National Health
Insurance Scheme
% of total clean claims that are
reimbursed by payers (NHIA) to
providers within 30 days of claims
receipt;
45% 90% 99% 110%
% of total claims submitted by
provider to NHIS (DMHIS or CPC)
that passed the initial screening (i.e.
not rejected by first
electronic/manual review);
0.03% 90% 100% 110%
% of population from among the
lowest quintile (20% of the index of
socio-economic status) registered
under the NHIS with a valid NHIS
card.
14% 40% 47.7 120%
12. Based on the performance indicators the project generally performed well by supporting
the introduction and enhancing the electronic claims submission by providers to NHIS to
facilitate rapid claims payment and improving the overall health delivery system. The continuous
improvement in Electronic Claims submission from the Health Facilities is an indication that the
lay down infrastructure is well placed to support this component far into the future.
13. The project has completed the following products.
Capitation Pilot in the Ashanti Region
Development of Medical Terminology & Disease Coding
Review of Ghana Diagnostic Related Groupings Tariffs
Training on Ministry of Health Referral & NHIS Gatekeeper Policies
Support Clinical Audit Directorate
Conduct Actuarial Study on NHIA (March2010)
Increase Equity in Coverage of the Poor and Vulnerable
Establishment of Health Data Dictionary
Conduct of National Health Accounts
Development of ICT Master plan
Upgrading of Ghana Health Service Hospital Management Information System – iHOST
Upgrade of NHIA Claims Processing Center
Capacity Building of Beneficiary Institutions
14. The development of the above stated project products has led to the following outcomes.
Support to the development of Medical Terminology & Disease Coding. This increases
the ability of staff of both NHIS and Providers to generate the right claims for
adjudication. The critical link between the healthcare providers and the health insurance
is the billing, adjudication and reimbursement of medical claims. However, monitoring
and other reports had suggested inadequacy of medical knowledge, diagnosis, procedures
and medical coding.
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Health Data Dictionary has been developed with over 800 data elements defined. This
was done to facilitate the exchange of data among agencies in the health sector of Ghana
and to aid in the implementation of the electronic claims. Series of workshops were held
to facilitate the definition of the data elements.
National Health Accounts was conducted. The project supported the Ministry of Health
to hire a consultant to assist in the conduct of National Health Accounts in 2013 using the
2005 and 2010 data. This was also done with the thought of building database for the
future health financing analysis and actuarial studies of the National Health Insurance
Scheme. It was successfully conducted and the report has been printed.
The development of a Health sector ICT Master Plan (2011 – 2016) is aimed at
producing a strategic plan to guide the design, acquisition, implementation and
management of health information systems in Ghana. The master plan is expected to
guide the development and deployment of ICT in healthcare for all categories of
providers in Ghana.
The development of this master plan will involve review of existing ICT projects and the
development of a support and sustainability plan. This plan will serve as the blueprint for
ICT projects in the NHIA and the health sector.
Upgrade of NHIA Claims Processing Centre: In trying to improve the billing and
adjudication process of health care providers and NHIA respectively, the project assisted
the NHIA to upgrade its Claims Processing Centre to enable it to receive and adjudicate
healthcare providers claims electronically. This was conceived with the objective to
improve efficiency in the claims processing cycle. The NHIA CPC has been upgraded
and its now receiving electronic claims from providers.
The paradigm shift of the NHIA from paper-based claims processing to electronic
necessitated the building of capacity of both healthcare providers and NHIA staff.
Beneficiary Institution of the project equally benefited from the project in building their
staff capacity identified by those agencies as pertinent to enhancing their productivity,
either through their internal capacity building process or through training institutions. A
total of 5,806 staff was trained in various areas identified by their agencies that were of
utmost important to them.
Capitation in the Ashanti Region – A capitation pilot was conducted in the Ashanti
Region and which has provided the basis for a national scale-up.
Lessons Learnt
15. A number of lessons have been learnt through the implementation of this project.
A major lesson learned from the pilot of the capitation was that because financial
constraints and poor planning did not allow training of an adequate critical mass of staff,
it fed the poor misunderstanding of the pilot and the confusion in implementation. For
National Scale up, adequate training is required to prepare the critical staff for the pilot.
The draft guidelines for a financial management and reporting system and training
modules for providers that were developed to be used to train and orient providers to the
financial and other management changes that a per capita payment system would
introduce should be revised based on the experience of the pilot. The revised modules
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should be used for training of providers and district scheme workers in the national scale
up.
In the future, the roles and responsibilities of the Implementing Agency and the
supervisory ministry should be clarified from the onset of the project to allow for the
smooth implementation.
Because of the numerous changes of the project staff at the project coordination unit,
project implementation was delayed as new staff took time to understand project
coordination issues and governance.
In the future, staffs that are dedicated to the project implementation should be selected to
coordinate the project in order to avoid situations where they had to combine their routine
work duties with that of the project. This situation will provide more stability to project
coordination and implementation.
In the future, a more robust M & E system should be developed for the project
coordination Unit to ensure that project baseline data and project tracking mechanisms
are dependable.
Way Forward
16. The way forward for the project as seen through the various recommendations from the
consultants assigned to the project and our own review are encapsulated in the following three
key areas.
The National Scale up of Capitation Payment Mechanism should be supported after
adopting the recommendations from the Ashanti Pilot.
The registration of the Poor under the National Health Insurance Scheme should be
encouraged and supported continuously. The process should be on-going.
Support should be provided for Healthcare Providers to process claims electronically.
More Healthcare Providers should be encouraged to process claims electronically by
building their capacities as well as providing them with a suitable ICT platform and
interface.
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Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders
51
Annex 9. List of Supporting Documents
Anthony Gingong, Overview of the health insurance project, December 2013
Hoddinott 2003, World Bank 2006, Quisumbing, Gillespie and Haddad 2003, Alderman
Hoddinott and Kinsey 2002, Ross and Horton 2003
Granthan-McGregor.S et al 2007
Ghana Multiple Cluster Indicator Survey (2011)
George Schieber, Cheryl Cashin, Karima Saleh, and Rouselle Lavado. Health Financing
in Ghana. 2012
Karima Saleh. The Health Sector in Ghana: A Comprehensive Assessment. 2013
Michael Opoku, Richard Nsiah Paul Atta Oppong, the effect of capitation payment on
the national health insurance scheme in Ashanti region, Ghana, May 2014
Ministry of Health, Ghana (2013). Ghana Health Financing Strategy Draft
Ministry of Health, Ghana National Health Accounts 2005 And 2010
Ministry of Health, Ghana (2013). HEALTH SECTOR MEDIUM TERM
DEVELOPMENT PLAN 2014 -2017
Ministry of Health, Ghana (2010). HEALTH SECTOR MEDIUM TERM
DEVELOPMENT PLAN 2013 -2016
N. J. BLANCHET, G. FINK and I. OSEI-AKOTO, The effect of Ghana’s National
Health Insurance Scheme on health care utilization, Ghana Medical Journal, Vol46(2)
Patrick Apoya, Final report: capitation pilot project in Ashanti region;
National Health Insurance Authority: Methodology for enrolling the poor and vulnerable
unto the NHIS
World Bank (May. 2007). Ghana Health Insurance Project Appraisal Document
World Bank (Apr. 2011). Ghana Health Insurance Project Restructuring Paper
World Bank (Jun. 2011). Ghana Health Insurance Project Restructuring Paper
World Bank (Oct. 2012). Ghana Health Insurance Project Restructuring Paper
World Bank (Aug. 2013). Ghana Country Partnership Strategy
World Bank (2014). Ghana Nutrition and Malaria Control Project Implementation and
Completion Report
World Bank (2014). Maternal and Child Health and Nutrition Project Appraisal
Document
World Bank (Sep. 2014). Universal health coverage for inclusive and sustainable
development : country summary report for Ghana
World Bank (2007-2014) Ghana Health Insurance Project AMs and ISRs
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MAP