Does insurance protect individuals from catastrophic payments for surgical care? An analysis of Ghana’s National Health Insurance Scheme at Korle-Bu teaching Hospital

Abstract

Background: According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe. Methods: We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017-October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income. Results: Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05). Conclusion: This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care. Trial registration: Registered at www.clinical trials.gov identifier NCT03604458.

National health insurance and surgical care for injured people, Ghana

“… 32 – 34 Patients insured through the national health insurance scheme who underwent various surgical procedures at the study hospital were reported to be less likely than uninsured patients to face financial catastrophe as a result of their surgery. 35 However, over half of those patients still faced financial catastrophe because of out-of-pocket payments, even with insurance through the national health insurance scheme. 35 Although the national health insurance scheme provided protection against catastrophic health expenditure in our study, only 13/834 (2%) of our insured patients did not make any out-of-pocket payments.…”

“… 35 However, over half of those patients still faced financial catastrophe because of out-of-pocket payments, even with insurance through the national health insurance scheme. 35 Although the national health insurance scheme provided protection against catastrophic health expenditure in our study, only 13/834 (2%) of our insured patients did not make any out-of-pocket payments.…”

“…Estimations show that 60% of Ghanaians would be unable to afford surgery without resorting to some form of hardship financing, such as borrowing or liquidation of assets, despite being insured through the national health insurance scheme. 35 , 40 Women are more likely to be in this position as they have lower median individual income than men in Ghana. 10 Ensuring that the national health insurance scheme covers essential services, including emergency and trauma care, is not only good for health and future productivity, but also for gender equity.…”

Capacity of intensive care units in Ghana

“…In terms of financing of health services, there is a National Health Insurance Scheme (NHIS), publicly financed through taxes on goods, services and income, that is theoretically expected cover about 95% of disease conditions [ 12 ]. In reality, however, a significant component critical care is not covered by the NHIS and is usually paid out of pocket [ [12] , [13] , [14] ]. Further details of the Ghanaian Health System are described in the Appendix 2 of the Supplementary material.…”

Challenges in healthcare financing for surgery in Sub-Saharan Africa

“…We recently published a paper evaluating the impact of the national health insurance scheme of Ghana (NHIS) on the risk of financial catastrophe for surgical care at a teaching hospital. We found that despite the benefits of NHIS, more than 60% of insured patients still risk facing financial catastrophe as a result of OOPs for surgical care [ 6 ]. We began to explore the experiences of countries in SSA with national health insurance schemes that include surgical care to develop recommendations for health reform in similar countries in the region.…”