Review of civil servants’ Medical Care Scheme in the Sekyere West District

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The financial constraints faced by most African governments have led to the decline in government budgetary allocation to the health sector. The situation has not been any different from what pertains in Ghana, as there has been a trend toward reduction of the amount of free health care cover offered by government in an effort to contain health care costs. In addition, different health care financing mechanisms have evolved over time notable among them is the direct out-of-pocket payment at the point of service user delivery. “Cash and Carry” which though well intentioned, has created health inqualities and barriers for access by most people. A direct response to curtail these inequalities has been the emergence of Mutual Health Organizations and employment-based schemes in Ghana. The Civil Servants’ Medical Care Scheme in Ashanti Region has been one of such MHO’s which aims to promote quality health care delivery to its members at all times by serving as financial protection, so that its members can have acceptable quality package of essential health services without out of pocket payment at the time of illness and at the point of service delivery. The study was undertaken to review the progress of the implementation of the scheme so as to address sustainability issues. Primary data were collected using semi-structured questionnaires administered to beneficiaries, health care providers, and managers of the scheme, together with focus group discussions and an interview guide. Secondary data were also collected. The study revealed that the scheme had no legal status. It received about one-third of its revenue from the government. Its design did not cover preventive or promotive services, there were no gatekeeper systems in place, no mechanisms to protect the scheme against covariate risk and no specific quality standards to measure the quality and appropriateness of care received by its members. Book keeping skills were minimally used, and it took managers about three months to reimburse claims received. Beneficiaries understanding of the principle of health insurance were low as well as their level of participation in decision making. There were techniques in place to curtail adverse selection and moral hazard. Only a little over half of the sampled population possessed identity cards creating room for fraudulent practices. A number of mechanisms are recommended to ensure sustainability of the scheme. The major ones include; the establishment of built-in risk management techniques such as mandatory reference, structuring of benefit package to include promotive and preventive services and adoption of payment mechanism that has built in incentive to control cost. Scheme managers should make the effort to increase the extent of participation of beneficiaries as well as conducting series of seminars and workshops to enlighten them on principles of health insurance and capitalization of health care providers to run independently of the lag phase. Further studies to actuarially determine realistic premium may be useful in the future.
A thesis submitted to the School of Graduate Studies, Kwame Nkrumah University of Science and Technology in partial fulfilment of the requirements for the award of Master of Science in Health Services Planning and Management, 2003