HEALTH INSURANCE BAROMETER MANUAL

Transcription

1 HEALTH INSURANCE BAROMETER PERFORMANCE ASSESSMENT ON GOVERNANCE AND FINANCIAL MANAGEMENT MANUAL SNV GHANA July 2009

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3 Table of Contents 1 Introduction Purpose of the Health Insurance Barometer manual The National Health Insurance Act Analysing existent data Data generated by the Schemes Definitions and formulas of data Data use to calculate performance indicators Insight in the real figures: absolutes and percentages Description of the Health Insurance Barometer Basic elements and breakdowns in sub levels Sub levels and indicators of Vision and Planning Sub levels and indicators of Financial Management Sub levels and indicators and Decision making Perceptions on Service delivery Scoring Scoring on Vision and Planning Scoring on Financial Management Scoring on Decision making Scoring on Service Delivery Reporting Discussions on the results with the Scheme The final reporting format...38 Annexes Annex 1. Annex 2. Annex 3. Annex 4. Annex 5. 3

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5 1 Introduction 1.1 Purpose of the Health Insurance Barometer manual This manual is meant to assist decentralised National Health Insurance Schemes in applying the Health Insurance Barometer (HIB) tool, contributing to their improved performance, particularly on financial management and key governance aspects. The manual explains the use of the HIB in the specific context of NHIS in Ghana. Application of the manual assists a scheme to: 1. identify and understand its key performance indicators, 2. collect data, which it can analyse and monitor at its own level, in order to 3. make informed management decisions to improve performance, and to 4. guide further capacity building Recommendation: applying this tool is more effective when it is done with strong participation of relevant Scheme core staff. This will enable Scheme staff to discuss and to work together on improvements that can be introduced immediately during the application of the tool. Although it is primarily written to support the schemes, it may also be helpful for the Regional offices of the NHIA in monitoring aspects of schemes performance. This manual contains all aspects of performance on Good Governance (in annex < >), but provides detailed information on three priority areas: Vision and Planning Financial Management Quality of service delivery by schemes and health providers Short history of HIB and current information need of schemes The Health Insurance Barometer is based on the Local Governance Barometer (LGB), developed by an International group of NGO s (Pact International, Idassa and SNV) under the umbrella of Impact Alliance. This instrument is meant to measure performance of governmental institutions, in a participatory manner, on all, internationally recognised, 5 aspects of good governance: (1) Efficiency and Effectiveness, (2) Rule of Law, (3) Accountability, (4) Participation and (5) Equity. SNV adapted the LGB to the specific context of health insurance, adding specific performance indicators already identified by ILO. SNV applied the LGB in 5 schemes supported local partners SEND Foundation and New Energy to apply the LGB in more schemes. SNV reviewed the tool with its partners SEND Foundation, New Energy and a selection of schemes. Based on the current information need of schemes three elements of the LGB were identified as most crucial: (1) vision & planning, (2) financial management & cost effectiveness and (3) quality of service delivery. The remaining aspects of good governance - participation, accountability and rule of law - remain relevant for the performance of any organisation. However collecting data on all 5 aspects takes too much time and schemes feel they need management information first and foremost on the 3 identified priority areas. 5

6 1.2 The National Health Insurance Act Act 650 on National Health Insurance in Ghana was accepted by Parliament in Its Rules and Regulations guide the operations of the NHIS and its organisation. Schemes were progressively operational at the end of Monitoring on performance is done through monthly, quarterly and annual reports, for which formats are provided by the NHIA. Note: currently the system and governance of monitoring on performance is serving the interest of NHIA more than that of the Schemes. This manual focuses on the information need at district scheme level, using existing NHIA formats Basic elements of NHI - Financial access for all Ghanaians to quality health care. Universal coverage, quality and equity are guiding principles of the NHIA. - Responsibilities of implementing agencies: National Health Insurance Authority National Health Insurance Schemes Regional Health Insurance Authority Policies, funding, support and monitoring Membership recruiting and membership relations Payments to health providers (claims) and relations with health providers Publicity Monitoring of performance of scheme Regional offices have opened in 2008, taking over monitoring roles of the NHIA and payment of claims Organisational set up of the NHIS - Schemes are responsible for implementation on decentralised level. - Human resource; core staff, is prescribed by NHIA. Extra staff has to be paid for by the Schemes themselves from eventually surplus on premiums paid. NHIA strongly encourages the engagement of personnel from the National Service and the Youth Employment Programmes. Financial support - Income sources for schemes are: premium paid by NHIA; premium paid by members of the informal sector ; subsidy of NHIA on salaries for 6 core staff; and subsidy on administrative costs. - Next to this support by NHIA the Schemes also received some basic equipment, computers and software. - Their costs for accommodation are paid for by the District assembly or in some cases also from their own income sources. 6

7 2 Analysing existent data Before going into the content of the three priority areas, we share experiences on data generation by schemes, definitions and formulas, indicators and ways to calculate and make useful analysis. 2.1 Data generated by the Schemes Data supply The Schemes report every month to the National Health Insurance Authority on their performance on Membership, Claims management and Income and Expenditure. Most important sources of data are captured in the following reporting formats: Operational status report (income per category; informal and exempt) Claims management report (hospital attendance; cost of services and drugs) Utilization report (OPD/IPD overview per category) Overview of income and expenditure See annex 1 for standard formats. Most of the data can be aggregated through the software each Scheme uses. On claims management most Schemes feed the data in by hand. Note: after the introduction of a new ICT platform, it has become more difficult for schemes to retrieve their own management data from the system. It is limiting the ability of schemes to take informed management decisions. Data need The formats of these reports are in such a way that it is not easy for Scheme Management to see at first glance how the Scheme is performing. Recalculation and different ways of grouping the data are needed. The following important data for analysing performance of a Scheme on output can be derived from the reports and is needed by management: Valid members ship, or ID cards issued Categories of valid membership Income on premium Income from other sources Expenditure on claims = costs of attendance Costs of attendance broken down in IPD and OPD and costs on drugs and costs on services Expenditure on operational costs 7

8 2.2 Definitions and formulas of data All data used in the analysis is already generated by the Schemes in the various reports to the NHIA. However, some data is differently interpreted in practice, which may lead to varying analysis and calculation of indicators (see next chapter). It is important to have a common understanding on definitions and formulas of the following key data: valid membership, categories of memberships, income on premium, expenditure on claims, cost of attendance and operational cost. Valid ID cards (instead of membership, registered, ID cards issued) The Operational Status Report (see attachment 1) gives data on: Number of registrations; number of renewals; number of ID Cards issued; breakdown per category of ID cards issued; male and female; and income received by the Scheme from informal members. Number of valid ID card holders is not part of this format. However for financial analysis this category needs to be used. Note: Only holders of valid ID cards are able to create costs on attendance for the Scheme. All the others, registered or with an ID Card with either an expired validation date or a validation date that lies in the future, cannot be helped by a health facility as a NHIS member and can therefore not make cost. For financial analysis one needs to calculate with holders of valid ID cards. Two ways of arriving at the correct number of valid ID cards: 1 In case of a scheme with a more or less stable number of members with ID Cards issued, and with short periods of waiting between the date the ID Card was issued and the date the ID Card becomes valid, can use Number of ID Cards issued as a good approximate figure for Valid ID Cards. 2 In case the Scheme is growing rapidly in membership numbers, Issued ID Cards is not a good approximate figure. In that case we should use valid ID cards. The following box provides information on how to calculate valid ID cards. Box 1: Calculation of number of Valid ID Cards Number of valid ID cards = Number of ID Cards Issued over a 1 year period minus number of ID Cards Issued in the last 3 months of that period plus the ID Cards Issued 3 months before the period of measuring Notes: - ID cards issued = ID cards printed - Validity of a card is only over a 1 year period. - In case the waiting period between Cards Issued and validation is 6 months, the 3 months period in the formula changes of course to 6 months. 8

9 Categories of membership The figures can be directly derived from the Operational Status Report. The data on the categories are only available on the number of ID Cards Issued. It will give you a good insight in the representation of each category in the Scheme s membership. Note: Do not use the data on gender, because children are included. This makes it impossible to recognise possible differences between adult males and females. Some schemes have added a category pregnant women. Income on premium Data on income and expenditure can be found on the quarterly Overview of Income and Expenditure. Some schemes use the Financial Claims Management Report (annex 1). The latter is monthly and less reliable than the quarterly overview of Income and Expenditure, because it uses un-vetted claims. Income on Premium is build up from 2 different sources: - The Informal sector: who pay premium themselves. They are mostly farmers and (small scale) traders. - The Exempt members and SSNIT contributors: their premium is paid by, or through the NHIA. Note: Income is always related to a time period. Income received after the period has passed, but is related to that period should always be taken up as an income over the period under study. Thus: Premium income received from NHIA in 2009, but covering premium over 2008 should be part of the total income on premium over It is not relevant if this money is factually spent in In case the income related to the previous year is received after preparation of the annual report, the report has to be adjusted accordingly. This is normal financial procedure. Expenditure on claims = costs of attendance (use vetted claims) Costs made by members with Valid ID cards by attending a health facility are brought forward to the Schemes Claims Manager as a claim by the health facility. Claims can be found in the Overview of Income and Expenditure and are also reflected in the Claims Management Report (see attachment 1). However this data is not compatible: - Claims in Claims Management Report are claims brought forward over the period, but not yet vetted. - Claims paid in the Overview of Income and Expenditure are vetted claims paid. Often these claims paid are not the vetted claims over the period, but include outstanding vetted claims from earlier periods. Box 2: Formula for cost of attendance (= vetted claims) Cost of attendance over a period = Claims paid in the period minus portion of claims paid in that period, but related to a previous period plus outstanding vetted claims in that period 9

10 Costs of attendance broken down in IPD, OPD, costs on drugs and services To get the figures on costs of IPD and OPD you have to follow the same procedure. So: claims on IPD (or OPD) over that period, minus portion of claims on IPD (or OPD) in that period, but related to a previous period plus outstanding vetted claims on IPD (or OPD) in that period The same applies for costs on drugs and services. Expenditure on operational costs Expenditure on operational costs can be found in the quarterly Overview of Income and Expenditure. It is total expenditure of the Scheme over the period minus the costs paid on claims over the period (for calculations see: costs of attendance). Note: According to NHIA operational costs should not be more than 20% of total costs. This can be used as a benchmark. If it does then the breakdown of the operational costs in the official overview of income and expenditure should be able to provide information on what caused the high operational costs. Note also that too low % expenditure on operational costs can be a signal of under spending. Salaries and administrative costs NHIA supports the Schemes by paying the salaries of the 6 core staff. Comparing this support with the factual expenditure on salaries by a Scheme gives an indication of extra personnel needed for the tasks to be performed. NHIA also gives a contribution on administrative costs. But the way the cost categories are presented now makes it difficult to draw any conclusions on the total of administrative costs. Note: Administrative costs are not the same as operational costs. They are part of the operational costs. General note on income and expenditure It is important to have a quarterly financial reporting system that consists of: - A quarterly status report to be prepared by management, dealing with all relevant operational and financial matters, including the Performance Indicators (see next chapter 2.3) - Quarterly financial statements, to be annexed to the status report consisting of: A balance sheet as per the last date of the quarter under review. Comparative figures should be taken up. (Same quarter prior year, or year-end prior year). A Statement of Income and Expenditure for the period January 1 st till the last date of the quarter under review. Comparative figures should be taken up. (Same period prior year) There should also be a column presenting the budget for the period under review. Notes to the balance sheet and statement of Income and Expenditure, including a schedule presenting the composition and depreciation of Property and Equipment. 10

11 In the most ideal case expenditure should be assigned to the activity it is related to. This means that allowances for instance should be allocated to different activities: allowances related to PR, allowances related to Board meetings etc.. This way it becomes easy to follow the development in costs of certain activities. However, at the moment this is not practice in any scheme. For analytical purposes the overview of income and expenditure can be simplified to enable simple, but crucial, comparisons: Income Expenditure Amount % Amount % Premium informal sector Premium from NHIA Total Premium received Total claims Other income Operational costs Total Income 100% Total expenditure 100% This overview enables insight in relation between premium income received and expenditure on attendance. A healthy scheme should have a surplus on premium income received and operational costs should not exceed 20% (previous comment). 2.3 Data use to calculate performance indicators With the definitions of data as provided in the previous chapter we can now calculate relevant performance indicators for the Scheme Performance indicators are averages on membership and costs that enable Schemes to compare changes in membership and costs over periods of time in one scheme and to compare membership and costs between Schemes. By analysing these changes the Scheme will be able to plan its policies and activities better. It also helps to identify cost centres that disproportionately contribute to the expenditure of the scheme. SNV selected performance indicators that are easy to calculate from already existing reports produced by the Schemes for NHIA. They give a good insight in coverage, attendance and financial state of affairs. The indicators are based on an ILO report to the NHIA from : 1 ILO: Performance Indicators for District Mutual Health Insurance Scheme (March 2007) 11

12 Table: List of Performance Indicators GH GH PERFORMANCE INDICATORS Division in words Division in nr Perf.Ind Division in nr Perf.Ind 1 Total premium informal and NHIA Income per valid ID total members with valid ID 2 Total expenditure Total Expenditure per valid ID total members with valid ID 3 Income per valid ID (inform. Premium informal sector Sect) total inform. members with valid ID 4 Premium from NHIA Income per valid ID (exempt+ssnit) total formal members with valid ID 5 Total claims (drugs & services) Cost of attendance per valid ID total members with valid ID 6 Total service cost in & out patient Service costs per patient number of in & out patient 7 Total drugs cost in & out patient Cost of drugs per patient number of in & out patient 8 Total claims Cost per attendance Total attendance 9 Cost per hospital Cost per attendance per hospital attendance of that hospital 10 Total cost per attendance-out Total cost out patient patient attendance out patient 11 Total service cost out patient Service cost per out patient attendance out patient 12 Total drugs cost out patient Drugs cost per out patient attendance out patient 12

13 GH GH PERFORMANCE INDICATORS Division in words Division in nr Perf.Ind Division in nr Perf.Ind 13 Total cost per attendance in Total cost in patient patient attendance in patient 14 Total service cost in patient Service cost per in patient attendance in patient 15 Total drugs cost in patient Drugs cost per in patient attendance in patient 16 Total expenditure (excl.claims) Other expenditure (excl claims) total valid ID 17 Total nr of attendances Attendance per member total valid ID 13

14 If produced quarterly the developments on costs can easily be followed. Two examples of how these indicators can be used by management of a Scheme. Box 3: Rising attendance cost; what is causing it! Example 1: Costs of attendance are rising per quarter. The Scheme wants to know what is causing this rise. First look into the breakdown of the costs per inpatient and the cost per outpatient. It seems that particularly the cost of inpatient is rising fast and cost for outpatients are relatively stable over the quarters. Secondly, look into the breakdown of the costs per inpatient. It seems the costs for services is rising faster then the costs on drugs. Conclusion: - The rise in costs of total attendance is created by higher costs per inpatient and to a large extent by a sharp rise in costs on service of inpatients Action - The claims manager has a breakdown of costs on attendance per health facility. So he or she is able to see which facility is creating the rise in service costs per in patient. Together with the Manager of the Scheme an open discussion with the hospital should be started. - Show them the data and discuss which role the hospital can play in bringing the costs for service for inpatients down. Box 4: Effect of policy change 14

15 Example 2: An example in figures Performance indicator on IPD costs per attendance over 3 quarters 1 st quarter nd quarter rd quarter 2008 Service Drugs Total Total IPD attendance 17,000 (over all three quarters) Total IPD cost 850,000 (over all three quarters) Performance indicator on OPD costs per attendance over 3 quarters 1 st quarter nd quarter rd quarter 2008 Service Drugs Total Total OPD attendance Total OPD cost 155,000 (over all three quarters) 1,750,000 (over all three quarters) Analysing these tables: - IPD costs per attendance are much higher then OPD costs per attendance - The first quarter was the cheapest per attendance for both IPD and OPD - Service costs for both IPD and OPD are rising sharply in the second and third quarter - Service costs in IPD have more then tripled over three quarters. What can explain the rising cost? Look for: changes between the 1 st quarter and the 2 nd and 3 rd quarter. In this case the explanation could be the introduction of the new treatment list, which fell between the 1 st and 2 nd quarter. 15

16 2.4 Insight in the real figures: absolutes and percentages Performance indicators are averages per patient or per member. They do not give an insight in development in absolute figures. As a scheme you also want to know how many people are creating which kind of costs. Actual absolute figures and percentages inform on growth (or decline) in membership, attendance and costs. Box 5: Performance indicators Interpretation of absolute figures and percentages Absolute figures - Give the actual growth or decline Percentages - Inform on the proportion of a certain data set as part of a total Applying these definitions, using figures presented in box 4 We see that service costs of IPD are the main cause of rising attendance cost. Now it will be interesting to know which proportion of the total membership is causing these high costs. Dividing the absolute number of IPD service attendance by the total number of attendance times 100 = % IPD service attendance of total attendance. And Interesting to know the proportion of costs of IPD service attendance of the total costs of attendance Absolute costs of IPD service attendance divided by total costs of attendance times 100 = % of costs of IPD service attendance of total attendance costs. Together these percentages show which % in attendance is creating the high % of IPD costs in the total attendance costs. Relating to the example in figures: And IPD attendance in nr over 3 quarters in 2008 = 17,000 = 10% Total attendance in nr over 3 quarters in 2008 = 172,000 Costs of IPD attendance over 3 quarters in 2008 = 850,000 = 33% Total costs on attendance over 3 quarters in 2008 = 2,600,000 Conclusion 10% of the attendance numbers make up for 33% of the total costs of attendance 16

17 3 Description of the Health Insurance Barometer 3.1 Basic elements and breakdowns in sub levels The Health Insurance Barometer is made up of the 5 basic elements of Good Governance. The main elements are further broken down in more detailed relevant sub elements. The sub elements can sometimes again be broken down in sub-sub elements. This breakdown can go into several levels. The lowest level is the one that can be measured by an indicator. This indicator should be verifiable in an objective and simple manner. It will lead to a score at the lowest level. The complete format may be found in Annex < >, containing all elements on 1 st, 2 nd and 3 rd level. Indicators are attached to the 3 rd level and there is a column mentioning where you can find the data (source). All levels have a column on scores attached. Box 4: Example: measuring vision and planning We want to measure the performance of a Scheme on Vision and Planning. This is the first level. On the second level vision and planning is broken down in sub elements. One of these sub elements is looking into the availability of a Strategic Plan that can be used as a guideline for planning. Level of measurement On 1 st level: Vision and Planning Indicator On 2 nd level: Availability of strategic plan Indicator: copy of the strategic plan 2 On 3 rd level: Is it used as reference for decision making? On 3 rd level: Was the General Assembly involved? Another breakdown of vision and planning On 2 nd level: Availability of an annual plan for the running year On 2 nd level: Availability of an annual budget for the running year On 3 rd level we want to know from the annual plan and budget how far realisation has gone. Nr of decisions based on strategic plan Item on agenda of General Assembly Copy of the annual plan Copy of the annual budget And define indicators to measure the realisation The performance indicators and data on membership (identified in chapter 2) will be fed into the HIB as a measurement in Vision and Planning and in Financial Management. 2 At the NHIS offices 17

18 3.2 Sub levels and indicators of Vision and Planning Vision and Planning is key to the performance on governance. Good planning will guide the Scheme in monitoring and decision making. Planning is done from generic to specific. - Strategic plans are global and plan the general targets over a couple of years. The budget is not detailed but gives realistic indications of costs involved. - Annual plans are detailed in actual proposed activities and budgets - Activity plans are detailed prescription and costing of activities mentioned in the Annual plan. Note Some Schemes use quarterly plans, mostly in cases where strategic plans and annual plans and budgets are not available. Quarterly plans in absence of annual plans are an indication of lack of long term planning The breakdowns of Vision and Planning on 2 nd level are: a. Availability of a strategic Plan b. Availability of a business plan c. Availability of Annual Plan for the running year d. Availability of Annual budget e. Comprehensiveness of operational plan f. Level of realisation of annual plan Ad a. Availability of a Strategic Plan First level Second level Third level Indicator Vision and Planning Availability of strategic plan Is it used as reference for decision making? Was the General Assembly involved? Copy of the strategic plan Nr of decisions made with reference to strategic plan Item on the agenda of AGM The breakdown on third level gives an indication about the relevance of the Strategic Plan for decision making. And the involvement of the General Assembly is a minimum requirement for involvement of the members in the Planning. 18

19 Ad b. Availability of a Business Plan First level Second level Third level Indicator Vision and Availability of Business plan Copy of the Business plan Planning Is it used as reference for decision making? Nr of decisions made with reference to business plan The breakdown on third level gives an indication about the relevance of the Business Plan for decision making. Ad c + d. Availability of Annual Plan and Budget for the running year First level Second level Third level Indicator Vision and Planning Availability of Annual plan for the running year Availability of Annual plan for the running year Availability of Annual plan for the running year Availability of Annual budget for the running year Copy of the Annual Plan Copy of the Annual Budget Are annual plans and budgets realsitic? References made in Annual plan and budget to available data on performance in previous period References made in Annual Plan and Budget to measurable targets Availability of annual plans and budgets is not sufficient. An Annual plan is only of use if it is based on actual data and when it is planning for targets and results that are reachable with the resources on human capacity, time frame, and available finances. Budgets should be realistic and based on the financial performance of the previous periods. Budgetary performance can be found in the financial statements over previous periods. The data sources for the plan are: - Performance Indicators - From data on growth in membership (ID Cards Issued) and categories of members, in the previous periods. It is possible to calculate a growth rate per annum. - Data on workload - Data on number of communities visited for PR activities - Data to explain need for policy discussions with providers (come from performance indicators on attendance) 19

20 Ad e. Comprehensiveness of annual plan First level Second level Third level Indicator Vision and Planning Are all aspects of operations included in plan? targets on membership and PR activities; utilization and attendance; policy making; contacts with providers. Check on all aspects By law the National Health Insurance Schemes have certain tasks to perform. It is necessary to check if all tasks have been included in the plan. How realistic the annual plan is, can be measured by comparing targets set for the year with the targets reached the previous year. This can be done by looking into: Financial resources - Financial resources over the previous year: - Income received in the previous year used as an indication for the income budgeted for the year of planning. Both come from the Quarterly income statements of previous periods Membership realisation - Membership realised: Issued ID Cards in the previous periods compared with population figures. - Population figures have to be updated from the 2000 census data with an annual % that can be obtained from the Planning Department of the DA. Equity - Representation of different categories of membership of total membership. - Male and Female can not be used because this category in the Operational Status Report includes children. Differences between adult males and adult women are not visible anymore. - Membership should be divided in membership per area or town council. This will give a clear insight in areas of high and low coverage. Human Resource capacity - Check on core staff in place - Check on qualifications of core staff compared to requirements for the jobs as stated by NHIA in their personnel advertisement daily Graphic Check on workload of data entry: Number of ID Cards Issued/ number of data entry clerks (maximum of 15,000 per clerk per year) - Check on workload of claims manager Number of attendances/ number of staff working on claims (maximum of 30,000 attendances per claim officer per year) 20

21 - Describe tasks and duties of temporary staff: National Service Personnel and Youth employment program. - Add them to staff working on claims and/or data entry when applicable. - Monitoring capacity of staff measured by: - calculation of correct Performance Indicators - correct data on claims and ID Cards issued - special check on production of reporting formats: special on claims management report Ad e. Level of realisation of annual plan First level Second level Third level Indicator Vision and Planning level of realisation of annual plan Available financial resources for plan implementation resource gap: gap between income budgeted and income received Financial statements previous periods performance indicators: premium income expected compared to actual premium income received previous year premium income received per informal member premium income received through NHIA membership realised in previous year % members with valid ID cards as proportion of total population members in a category as a % of total number of valid ID cards Available human resource capacity all 6 staff positions filled Extra capacity needed List tasks not filled by staff paid by NHIS Required certificates for positions taken level of operational monitoring key indicators calculated based on reports software able to give relevant data check on accurate data: valid ID cards+ vetted claims ability to use software all possibilities of software used 21

22 3.3 Sub levels and indicators of Financial Management Financial management is at the heart of the Scheme business, which entails: a. Realistic budgeting b. Accurate Income and Expenditure Statements c. Performance Indicators based on correct data d. Regular monitoring e. Adherence to financial standards f. Decision making based on all the financial data (see 3.4) Realistic budgeting is also part of Vision and Planning. The data obtained under that heading can be feed into Financial Management, where it can be measured separately as part of Financial Management. Ad a. Availability of approved and realistic budget First level Second level Third level Indicator Financial Management Availability of approved and realistic budget Copy of the Annual Budget Budget related to actual income received in previous period (= Level of realisation of annual plan (Vision and Planning)) resource gap: gap between income budgeted and income received performance indicators: premium income expected compared to actual premium income received previous year premium income received per informal member premium income received through NHIA Ad b. Gap between budgetary expectations and factual costs over previous period First level Second level Third level Indicator Financial Management Gap between budgetary expectations and factual costs over previous period Is basis of revenue projection factual? Performance indicators on: Income per valid ID cards of previous periods divided in informal and exempt Expenditure per valid ID card divided in informal and exempt Claims per valid ID Card Service costs per patient, divided in costs OPD and costs IPD Costs of drugs per patient divided in costs OPD and costs IPD Cost per attendance divided in costs OPD and costs IPD Costs per attendance per hospital divided in costs OPD and costs IPD 22

23 Other expenditure (exclusive claims) Comparison of members per category with Utilisation per category Ad c+ d. Performance indicators based on correct data (regular monitoring) The use of the Performance Indicators to discover trends in costs is described in Costs per attendance per hospital. Schemes have these data. The Claims Manager uses them as input to the Claims Management report Insight in costs per hospital is necessary to contain costs. It enables fact-based discussions with the hospitals. - Equity Utilisation reports are used to give insight in utilisation per category of membership. With the new formats given by NHIA this is no longer possible. But it is possible and necessary to create categories on: - Rural and urban: via grouping according to area council and/or town councils. This is an administrative issue for the Schemes. It is a method to group your members according to collector areas. - Relevant age categories compatible to age categories used in District planning Ad e. Adherence to financial standards Adherence to financial standards is a pre requisite for sound financial management. If not done according to the rules there will always be money unaccounted for. Strong indications are: Daily entries in cashbook Stock keeping through a stock register. Audit reports First level Second level Third level Indicator Financial Management Existence of financial standards Standards of Ghana Accounting Regulations in place? copy of financial procedures Adherence to financial standards. Compare between practice and regulations Quarterly comparison of income and expenditure against the budget Level of frequency of book entries Quarterly income and expenditure statements available Daily basis or not Adherence to financial standards (continued) Quality of stock keeping Comparison between stock records kept against the regulations 23

24 First level Second level Third level Indicator Financial Management (continued) Level of financial efficiency Level of financial efficiency noted by auditor Audit report Level of adherence to standards noted by auditor Audit report Auditors remarks implemented Audit implementation committee in place 3.4 Sub levels and indicators and Decision making The way decisions are taken in a Scheme is very important for sound management. If the decision making structure is not clear this will lead to confusion and sometimes even conflicts. In their turn confusion and conflicts lead to a considerable loss of efficiency, because much time is taken up by solving the confusion. The relation between Board and Management is described in Act 650. All Schemes were obliged to base their constitution on the Act. This was most time s done. But the issue is of course: is it actually followed? If not, confusion will still be there. The Act also describes how members can be part of the decision making structure. Also on this issue we have to find out what is actually realised. To measure efficient and effective management it is also important to know if there are bodies who can overrule the decisions making of the Board and General Assembly. In the Act 650 the roles and responsibilities between the NHIA and the Schemes are described, but are they actually followed? Decision making First level Second level Third level Indicator Decision Making Existence of a constitution based on Act 650 Is constitution followed? appointing/electing Board members yes or no composition of Board on representation gender rules followed at least 2 women Board members knowledgeable on NHI list of Board members and their professional background 24

25 First level Second level Third level Indicator Decision Making (continued) Relation management - board Is constitution followed on representation of groups? document on relation Board staff Common understanding about division of roles and responsibilities Level of utilisation of the decision making structure Chics established and working number of Chics as % of possible Chic's General Assembly involved meetings held ones a year decisions made by Board actually implemented proportion of board decisions implemented Authority of other over sight bodies decisions of Board not in agreement with oversight body proportion of decisions not implemented because of contra decisions by oversight body 3.5 Perceptions on Service delivery The third important measure for efficient management is the perception of members and Health Providers on the quality of services the Scheme delivers. Members perception on quality of Services delivered by the National Health Insurance is affected by the perception people have of the quality of services Health providers deliver. In this format measurement is done on (see annex < > & < > for details): Services delivered by - The Scheme to the members - Health Providers to the members - The Scheme to the Providers Perceptions have to be gathered at the source: Adult members Adult non members Providers see annex < > for details on method and process on focal group discussions Idem annex < > see annex < > for details on method and process of individual interviews 25

26 4 Scoring Breaking down from first level to third level gives a detailed insight in the performance of the Schemes on the elements of good governance. To be able to use these insights and to be able to monitor progress on these elements, the breakdowns have to be scored. Scores are given on the third level and is bound to the indicator. - Scores are from 0 to is the most negative score and 10 the most positive. - Scores are standardised as much as possible. In case this is not possible the outcome is subject of discussion between the Scheme management and the advisor. Together they set the score for an indicator. Step 1 Step 2 Step 3 Step 4 Step 5 Scoring third level based on the indicator Scores on third level that are related to an issue on third level are added and divided by the number of scores on 3 rd level on that issue. This outcome gives the score on the issue on 2 nd level. All scores on 2 nd level related to one item on first level are added an divided by the number of issues on second level This outcome gives the score on 1 st level. Reporting is done on first level and second level using the second level as an explanation for the first level. Example: Scoring sub level Availability of a Strategic Plan First level Scores Second level Scores Third level Scores Indicator Vision and Planning Availability of strategic plan 6 22,5/ 4 = 6 Is it used as reference for decision making? Did the Board set the targets before planning? Was the General Assembly involved? Yes = 10 No reference made = 0 2 targets found out of 8 = 2,5 Yes = 10 Copy of the strategic plan Nr of decisions made with reference to strategic plan Item on the Agenda of Board Item on the Agenda of AGM Scores on availability of strategic plan; business plan; annual plans and budgets; comprehensiveness and level of realisation (all second level) feed into the Vision and Planning (1 st level) and are scored in similar ways on their third level indicators. 26

27 4.1 Scoring on Vision and Planning In the column Standardised Scores on 3 rd level it is described how to score each of the indicators. Availability of a Strategic Plan Second level Scores 2 nd level Third level Standardised Scores on 3 rd level Indicator Availability of strategic plan Is it used as reference for decision making? Not available = 0 Available = 10 Nr of decisions based on strategic plan / Number of possible decisions based on strategic plan. Copy of the strategic plan Nr of decisions made with reference to strategic plan Range from 0 (no decision) to 10 (all possible decisions) Did the Board set the targets before planning? Nr of targets set by Board before planning / Total nr of targets in strategic plan. Item on the Agenda of Board Range from 0 (not targets set) to 10 (all targets set by Board) Was the General Assembly involved? Item on de agenda = 10 No AGM, or not on the agenda = 0 Item on the Agenda of AGM Availability of a Business Plan Second level Score 2 nd level Third level Standardised Scores on 3 rd level Indicator Availability of Business plan Is it used as reference for decision making? Not available = 0 Available = 10 Nr of decisions based on busyness plan / Number of possible decisions based on business plan. Copy of the Business plan Nr of decisions made with reference to business plan Range from 0 (no decision) to 10 (all possible decisions) 27

28 Availability of an Annual Plan and Budget for the running year Second level Scores 2 nd level Third level Standardised Scores on 3 rd level Indicator Availability of Annual plan for the running year Availability of Annual plan for the running year Not available = 0 Available = 10 Copy of the Annual plan Availability of Annual Budget for the running year Availability of Annual budget for the running year Are annual plans and budgets realistic? Not available = 0 Available = 10 No references made to available data from previous periods on performance = 0. Data used as base for planning = 8 Copy of the Annual budget References made in Annual plan and budget to available data on performance in previous period. Some data used as a base for planning = 4 No measurable targets = 0 Measurable targets = 8 References made in Annual Plan and Budget to measurable targets Some measurable targets, but many not = 4 Comprehensiveness of annual plan Second level Scores 2 nd level Third level Standardised Scores on 3 rd level Indicator Are all aspects of operations included in plan? Targets on membership and PR activities; utilization and attendance; policy making; contacts with providers. Only 1 or 2 targets = 3 Targets between 2 and 6 = 6 All 6 targets included = 8 Check on all aspects 28

29 Level of realisation of annual plan Second level Scores 2 nd level Third level Standardised Scores on 3 rd level Indicator level of realisation of annual plan Available financial resources for plan implementation Income previous period used as basis for plan implementation = 8 Plan implementation not calculated realistically = 2 Financial statements previous periods resource gap: gap between income budgeted and income received Premium Income budgeted is not more then 10% higher then income received in pervious period = 8 Premium income budgeted is between 10% and 30% higher then income previous period = 4 performance indicators: - premium income expected compared to actual premium income received previous year *premium income received per informal member Premium Income budgeted is more then 30% higher then income received in pervious period = 0 *premium income received through NHIA Use the data on premium for informal and premium via NHIA as background for describing where the mistake is made. membership realised in previous year Membership planned for the year is about 5 % higher then the previous period % members with valid ID cards as proportion of total population = 8 Membership planned between 5 and 30% higher then previous period = 4 Membership planned is higher then 50% from last year = 0 Use % on categories as description in which category main growth can be expected members in a category as % of total number of valid ID cards 29

30 Level of realisation of annual plan (continued) Second level Scores 2 nd level Third level Standardised Scores on 3 rd level Indicator level of realisation of annual plan Available human resource capacity All 6 in place = 10 1 staff not in place = 10 1,5 all 6 staff positions filled 2 staff not in place = 10-3 Etc. Extra capacity needed See attachment for requirements: All Qualification in place = 10 Required certificates for positions taken 1 staff not qualified = 10-1,5 2 staff not qualified = 10 3 Etc. Data entry: 1 staff per 15,000 ID Cards Issued = 8 1 staff on more then 15,000 ID cards issued = 2 Claims: Workload on data entry and on claims 1 staff per 30,000 attendances per year = 8 1 staff on more then 30, 000 = 2 level of operational monitoring Key indicators produced quarterly = 10 Key indicators produced yearly = 4 Key indicators calculated based on reports software able to give relevant data Discuss problems with MIS and software supplier. Score with scheme management check on accurate data: valid ID cards+ vetted claims ability to use software Not all possibilities used = 2 Possibilities used including claims management report = 8 all possibilities of software used 30

31 4.2 Scoring on Financial Management Availability of approved and realistic budget Second level Scores 2 nd level Third level Standardised Scores on 3 rd level Indicator Availability of approved and realistic budget Budget related to actual income received in previous period (= Level of realisation of annual plan (Vision and Planning)) Not available = 2 Available = 8 Premium Income budgeted is not more then 10% higher then income received in pervious period = 8 Premium income budgeted is between 10% and 30% higher then income previous period = 4 Premium Income budgeted is more then 30% higher then income received in pervious period = 0 Use the data on premium for informal and premium via NHIA as background for describing where the mistake is made. resource gap: gap between income budgeted and income received Copy of the Annual Budget performance indicators: premium income expected compared to actual premium income received previous year premium income received per informal member premium income received through NHIA Gap between budgetary expectations and factual costs over previous period Second level Scores 2 nd level Third level Standardised Scores on 3 rd level Indicator Gap between budgetary expectations and factual costs over previous period Is basis of revenue projection factual? Look at Performance Indicators over a couple of previous periods. Describe the trend on: Income per valid ID Card (formal and NHIA paid) against expenditure on claims per valid ID Card (formal and NHIA paid) Break down of costs in attendance in IPD and OPD and services and drugs. performance indicators on: Income per valid ID cards of previous periods divided in informal and exempt Expenditure per valid ID card divided in informal and exempt 31

32 Gap between budgetary expectations and factual costs over previous period (continued) Look into conclusions drawn in chapter 2.3) Compare with actual budgeted for the running year. Are PI and other data not used for realistic projections on budget on expenditure = 0 Are some data used = 4 Are all data used = 8 Claims per valid ID Card Service costs per patient Divided in costs OPD and costs IPD Costs of drugs per patient divided in costs OPD and costs IPD Cost per attendance divided in costs OPD and costs IPD Costs per attendance per hospital divided in costs OPD and costs IPD other expenditure (exclusive claims) comparison of members per category with utilisation per category Adherence to financial standards Second level Scores 2 nd level Third level Standardised Scores on 3 rd level Indicator Existence of financial standards Standards of NHIA financial standards and Accounting Regulations in place? Not available = 4 Available = 6 copy of financial procedures available at the office Adherence to financial standards. Compare between practice and regulations Quarterly comparison of income and expenditure against the budget Not available = 0 Available on annual basis= 4 Available on quarterly basis= 8 Quarterly income and expenditure statements available Level of frequency of book entries Daily = 10 Not daily = 0 Cash books kept at daily basis or not 32

33 Quality of stock keeping No stock register = 0 Stock register entries lacking behind = 3 All according to regulations= 8 Comparison between stock records kept against the regulations Level of Financial Efficiency -Level of financial efficiency noted by auditor Discuss with scheme management audit remarks and score together the level of financial efficiency Audit report Level of adherence to standards noted by auditor Discuss with scheme management audit remarks and score together adherence to standards Audit report Auditors remarks implemented Audit Implementation committee in place = 6 3 Some procedure in place for follow up on audit committee = 4 Audit implementation committee in place No procedure for follow up on audit remarks = Scoring on Decision making All Schemes had to write a constitution. It was necessary to become a recognised Scheme by the Board for receiving subsidies. Although we still ask the question it is not scored, because it does not tell us anything. For our purpose it is important to score if the constitution is followed. We do that on 2 issues: representation of groups in the Board and the presence of women in the Board. Representation: According to Act 650 the Board has a minimum of 7 and a maximum of 15 members. They have to come from: - Area Councils - Communities - Traditional rulers - Occupational groups and associations - District Assembly or Region 3 Audit implementation committee in place does not necessarily mean that all audit remarks are followed up 33