Ashigbie Paul G, Azameti Devine, Wirtz Veronika J
Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, 3rd floor, Boston, Massachusetts 02118-2605 USA.
Volta Regional Health Directorate, Ho, Volta Region Ghana.
J Pharm Policy Pract. 2016 Feb 24;9:6. doi: 10.1186/s40545-016-0055-9. eCollection 2016.
Ghana established its National Health Insurance Scheme (NHIS) in 2003 with the goal of ensuring more equitable financing of health care to improve access to health services. This qualitative study examines the challenges and consequences of medicines management policies and practices under the NHIS as perceived by public and private service providers.
This study was conducted in health facilities in the Eastern, Greater Accra and Volta regions of Ghana between July and August 2014. We interviewed 26 Key Informants (KIs) from a purposively selected sample of public and private sector providers (government and mission hospitals, private hospitals and private standalone pharmacies), pharmaceutical suppliers and NHIS district offices. Data was collected using semi-structured interview guides which covered facility accreditation, reimbursement practices, medicines selection, purchasing and pricing of medicines, and utilization of medicines. Codes for data analysis were developed based on the study questions and also in response to themes that emerged from the transcripts and notes.
Most KIs agreed that the introduction of the NHIS has increased access to and utilization of medicines by removing cost barriers for patients; however, some pointed out the increased utilization could also be corollary to moral hazard. Common concerns across all facilities were the delays in receiving NHIS reimbursements, and low reimbursement rates for medicines which result in providers asking patients to pay supplementary fees. KIs reported important differences between private and public sectors including weak separation of prescribing and dispensing and limited use of drugs and therapeutic committees in the private sector, the disproportionate effects of unfavorable reimbursement prices for medicines, and inadequate participation of the private sector providers (especially pharmacies and licensed chemical sellers) in the NHIS.
Health providers generally perceive the NHIS to have had a largely positive impact on access to medicines. However, concerns remain about equity in access to medicines and the differences in quality of pharmaceutical care delivered by private and public providers. Routine monitoring of medicines use during the implementation of health insurance schemes is important to identify and address the potential consequences of medicines policies and practices under the scheme.
加纳于2003年设立了国家医疗保险计划（NHIS），目标是确保医疗保健融资更加公平，以改善医疗服务的可及性。这项定性研究考察了公立和私立服务提供者所认为的NHIS下药品管理政策与实践的挑战及后果。
本研究于2014年7月至8月在加纳东部、大阿克拉和沃尔特地区的医疗机构开展。我们从公立和私立部门提供者（政府和教会医院、私立医院及私立独立药房）、药品供应商和NHIS地区办事处的有目的抽样中，访谈了26名关键信息提供者（KIs）。使用半结构化访谈指南收集数据，内容涵盖机构认证、报销实践、药品选择、药品采购与定价以及药品使用情况。基于研究问题并针对从笔录和笔记中浮现的主题制定了数据分析代码。
大多数KIs一致认为，NHIS的引入通过消除患者的费用障碍，增加了药品的可及性和使用；然而，一些人指出使用增加也可能是道德风险的结果。所有机构普遍关注的问题是NHIS报销延迟，以及药品报销率低，这导致提供者要求患者支付补充费用。KIs报告了公私部门之间的重要差异，包括私立部门开方和配药分离薄弱以及药品和治疗委员会使用有限、药品报销价格不利的不成比例影响，以及私立部门提供者（尤其是药房和持牌化学药品销售商）在NHIS中的参与不足。
医疗服务提供者普遍认为NHIS对药品可及性产生了很大的积极影响。然而，在药品可及性公平性以及公私提供者提供的药学服务质量差异方面仍存在担忧。在医疗保险计划实施期间对药品使用进行常规监测，对于识别和解决该计划下药品政策与实践的潜在后果很重要。
