| In August2003, the Ghanaian Government made history by implementing the first National Health Insurance System (NHIS) in Sub-Saharan Africa. Within three years, over half of the country’s population had voluntarily enrolled into the National Health Insurance Scheme. The healthcare of people stands paramount and the health insurance scheme concept is one that would guarantee the health of all, thereby abolishing the "cash and carry system". Health care claims from providers are a major source of expenditure for the health insurance scheme. This is made up of the cost of drugs and the cost of non-drug related services. The financial performance of the NHIS is a function of the premium collected, the cost of health care services of the insured, the level of external subsidy, the size of the pool, and degree of economies of scale that is achieved. This study had six objectives:First to model health insurance claims using risk characteristics of policyholders. Secondly, determine whether other variables mediate the association between socio-economic variables and health insurance claims. Thirdly, determine the gender disparities in the Ghana national health insurance claims. Fourthly, find out the preference for health care financing method in Ghana. Furthermore, assess the influences of risk factors on health status. Lastly, determine the effect of the level of price on key performance indicators of health insurers in the Ghanaian health insurance market. The significance of this study is to provide a basis for research by other researchers who may undertake similar studies into the subject in the future, to inform policy makers on the appropriate pricing of the NHIS using characteristics of policyholders, provide valuable information for policy makers’vis-a-via the National Health Insurance Authority (NHIA) and the government of Ghana in general, to inform policymakers on the appropriate pricing of the NHIS using characteristics of policyholders. The result of this study is expected to inform Ghanaian policymakers on early term corrections needed to increase the sustainability of the NHIS.In this work, data was collected from the policyholders of the Ghana National Health Insurance Scheme with the help of the National Health Insurance database and the patients’attendance register of the Koforidua Regional Hospital, from1st January 2010to31st December2012. The generalized linear regression (GLR) models and the unit root testing; co-integration and Vector Error Correction Models (VECM), as well as the game theory were used to analyze the data. The (GLR) models are a natural generalization of the familiar classical linear models. The logistic regression model which was used is a generalized linear model with two components namely, random and systematic.This is being done using the age of policyholders, previous claim status, distance, sex of policyholder, number of children, level of education, employment, cigarette smoking, alcohol drinking, living condition and billed charges as the predictor or influential variables. The study also undertakes modern econometric models including unit root testing, co-integration and Vector Error Correction (VECM) for empirical analysis. Both the short-run and long-run effects of socio-demographic variables were studied. A game theoretical approach is introduced that deals with how decision makers want to optimize on key performance indicators simultaneously. We consider health insurance market as a model with players (health insurers) that have specific strategies (premiums). Well known solution concepts of game theory are used to determine the effects of the level of price on key performance indicators.The results suggest positive and significant long-run and short-run relationship between socio-demographic variables and health status. However, it was found that the risk factors; health status, number of children, level of education, employment, billed charges and income level are not good predictors of national health insurance claim. The model indicates that alcohol drinking contributes more, among other factors, in terms of influencing policyholders making health insurance claims in Ghana. Distance is the next most influential factor in determining national health insurance claims. Thus the further the town is from the health centre, the more disadvantaged the policyholders are in terms of getting early health care and making an insurance claim.The study showed that patients within5km of hospital were more likely to make an insurance claim than those beyond5km, and does reflect the fact that nearness to the hospital improved early access to care. It was also observed that females were at higher chance of making an insurance claim compared to their male counterparts, after adjusting for distance and other risk factors. This suggests that more females access health care services more than males. With regard to the age of policyholders, there was inverse relationship with health insurance claims. Hence, as people grow the risk of making an insurance claim reduces. This suggests that by and large younger people access health care more than older people. The study also showed that those living in rented single/double room apartment are more exposed to make an insurance claim, compared to their counterparts living in flats/self contained apartments. This suggest that the poor environmental conditions at which people who live in rented single and double rooms are exposed to eventually affect their health condition and cause them to visit the hospital frequently than their counterparts living in flats and self contained apartments. The outcome of the study shows that sex, age, marital status, cigarette smoking, alcohol drinking, living condition, distance and length of stay at the hospital are statistically significant in the determination of the Ghana National health insurance premiums since they considerably influence claims.This paper put forward some countermeasures to enhance the operations of the Ghana National Health Insurance Scheme.The main innovations are as followings. Firstly, the paper systematically analyzed the main factors that affect the pricing of National Health Insurance premiums in Ghana using generalized regression models and proposed that sex, age, marital status, cigarette smoking, alcohol drinking, living condition, distance and length of stay at the hospital should be used in the determination of the Ghana National health insurance premiums since they considerably influence claims. Secondly, based on the statistically significant influential factors which should be used to determine claims, the study with the help of logistic regression has developed a model to predict the likelihood of the Ghana National Health Insurance claims. The paper has designed a mechanism for evaluating prospective policyholders and determining their risk factors which will help the insurance company to determine the appropriate premium for prospective clients. Lastly, the paper established that policyholders who stay5km away from the hospital make less National health insurance claims. The paper has established a scientific model for insurance premium that include the cost of transportation. This will enable the poor to have access to means of transport easily especially in times of emergency. This measure will relieve majority of the insured who may be denied access to health care at the time when they cannot afford the cost of transportation to the health facility. The paper provided a new research method for related issues in health insurance research and expanded the application of the logistic regression model to social science research area. |
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