Evaluating the Impact of the National Health Insurance Scheme of Ghana on Surgical Care

Evaluating the Impact of Health Insurance on Financial Risk Protection for Surgical Care: an Analysis of Ghana' Insurance Scheme at Korlebu Teaching Hospital

Ghana, a Low-Middle Income Country (LMIC) situated in the heart of West Africa started a national health insurance scheme in 2003.The scheme was designed to provide a comprehensive benefit package inclusive of surgical care and to protect against the need to pay out of pocket at the point of service. As of 2013, close to 40% of the population of Ghana was actively enrolled and ongoing plans to expand coverage by the government. This study tests the extent to which the national health insurance scheme of Ghana provides financial risk protection against catastrophic payments as a result of access to surgical care.

Study Overview

• Status: Completed
• Conditions: General Surgery, Costs and Cost Analysis

Detailed Description

It is estimated that 11%-33% of the global burden of disease is attribute to surgical conditions. Yet, globally 3.7 billion people face financial catastrophe if surgical care is needed. Ghana, a country of 27 million people has a 14-year experience with a national health insurance scheme (NHIS) that provides coverage for 95% of the health conditions afflicting Ghanaians and includes access to surgical care. Despite much progress in providing Universal Health Coverage through NHIS, prior work shows that up to 18% of insured households make catastrophic health payments for routine care which is largely unaffordable for the poor. Particularly in Ghana where 1 out of 4 individuals live on less than 1.25 dollars per day. More importantly in 2015, the Lancet Commission on Global Surgery called for national surgical plans that provide 100% coverage against catastrophic health expenditures as a result of seeking surgical care.

The premise of Dr. Okoroh's GloCal project is to describe the surgical conditions that are included in the health insurance scheme and to evaluate whether insurance protect surgical patients against catastrophic health payments through a single institutional review at Korle-bu Teaching Hospital. With this work she hopes to develop a set of recommendations to the ministry of health and the national health insurance authority on how to improve health-care financing for surgical care in Ghana.

Early results of our study show that NHIS provides coverage for most common surgical conditions including symptomatic hernia, breast cancer, and appendicitis. 70% of the total cost of surgical care was covered by NHIS, yet 56% of insured individuals made catastrophic payments for surgical care. Surgery is unaffordable as on average insured individuals spent close to 40% of their annual income on surgical care. Particularly the coverage of medicines, supplies, imaging, and other ancillary services are sparse which are necessary to the provision of surgical care. Our recommendations include; NHIS increasing the proportion of the total cost of surgical care covered for the poor and addressing the gaps in coverage of ancillary services. Further work includes understanding how households economically cope with making payments and the contribution of borrowing and other financing mechanisms in reducing the burden of cost. Our new study characterizes the cost of trauma care which is a major source of disability and injury for young adults in Ghana. Efforts are being made to engage policymakers on healthcare reform in Ghana.

• Study Type: Observational
• Enrollment (Actual): 203

Contacts and Locations

Study Locations

• Ghana
  • Accra, Ghana
    • Korle-Bu Teaching Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

• Sampling Method: Probability Sample

Study Population

The study was conducted in the Korle Bu teaching hospital, which is situated in the southwestern part of Accra, the capital of Ghana. The hospital receives and treats patients referred from other centers all over Ghana and also patients referred from other neighboring West African countries. The population of Accra, which is largely cosmopolitan, has inhabitants who are natives and a large population who have migrated from other parts of the country on account of economic reason as well as educational pursuit. It is also home to a significant population who are nationals of neighboring West African countries and a small proportion of the population being from Europe, Asia and North America. Inhabitants are therefore mostly urban or suburban with a small proportion of rural and slum dwellers. The Department of Surgery at the Korle Bu hospital has four general surgical units and sees a variety of cases in general surgery encompasses colorectal, hepatobilary, and oncology

Description

Inclusion Criteria:

• All adult patients admitted to the general surgery ward between February 1st and October 1st 2017.

Exclusion Criteria:

• Patients treated on the subspecialty wards
• Individuals less than 18 years of age.
• If unable to provide informed consent

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Out of Pocket Expenditure for Surgical Care	Out of pocket expenditure for surgical care is defined as all of the direct and indirect expenses incurred by an individual seeking surgical care at Korlebu Teaching Hospital during the study time period.	During the hospitalization or episode of surgical care (respondents are interviewed prior to discharge from the hospital, on average less than two weeks)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Catastrophic Health Expenditure for Surgical Care	Catastrophic Health Expenditure for Surgical Care is defined as out of pocket expenditures which exceed 20% of the individual's income, 10% of the household expenditures, or 40% of net food expenditures	During the hospitalization or episode of surgical care (respondents are interviewed prior to discharge from the hospital, on average less than two weeks)

Collaborators and Investigators

• Sponsor: University of California, San Francisco
• Collaborators: Fogarty International Center of the National Institute of Health; Office of Research on Women's Health (ORWH); University of California Global Health Institute - UCGloCal Program; Brigham and Womens' Hospital, Center for Surgery and Public Health; UC Global Health Institute
• Investigators: Principal Investigator: Juliet Okoroh, MD, University of California, San Francisco

Publications and helpful links

General Publications

• Okoroh J, Sarpong DO, Essoun S, Riviello R, Harris H, Weissman JS. Does insurance protect individuals from catastrophic payments for surgical care? An analysis of Ghana's National Health Insurance Scheme at Korle-Bu teaching Hospital. BMC Health Serv Res. 2020 Jan 17;20(1):45. doi: 10.1186/s12913-020-4887-2.

Study record dates

Study Major Dates

• Study Start (Actual): February 1, 2017
• Primary Completion (Actual): October 1, 2017
• Study Completion (Actual): November 12, 2017

Study Registration Dates

• First Submitted: June 26, 2018
• First Submitted That Met QC Criteria: July 19, 2018
• First Posted (Actual): July 27, 2018

Study Record Updates

• Last Update Posted (Actual): July 27, 2018
• Last Update Submitted That Met QC Criteria: July 19, 2018
• Last Verified: July 1, 2018

More Information

Terms related to this study

• Keywords: Universal Health Coverage, Surgery in resource limited settings
• Other Study ID Numbers: D43TW009343 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No