Ghana’s journey to UHC so far:
Successes and Challenges
Irene Agyepong Amarteyfio
Nov 4th 2013
1
Introduction
• Major reform like an NHIS is social and political as well as technical
• What has been our socio-political as well as technical journey
towards UHC
• Outline of presentation
– The Vision behind the NHIS
– Health policy environment /context
• Past to present
• Processes and pathways
– Health System
– Successes and Challenges
• Population coverage
• Service access and Health Systems Strengthening
• Financial protection (reducing fees and cost sharing)
• What next?
2
The vision behind the NHIS
“Ultimately, the vision of government in instituting
a health insurance scheme in the country is to
assure equitable and universal access for all
residents of Ghana to an acceptable quality
package of essential healthcare. …….. every
resident of Ghana shall belong to a health
insurance scheme that adequately covers him or
her against the need to pay out of pocket at the
point of service use in order to obtain access to a
defined package of acceptable quality of health
service’.”
• (MOH 2002, MOH 2004) NHI policy framework for Ghana
3
The Vision & UHC
4
Policy Environment (Context)
•
•
•
•
•
•
Historical
Political
Social
Economic
Demographic
External - International
5
Policy Environment (Context)
PRE-INDEPENDENCE (COLONIAL ERA)
• Payment for health services mostly private
out of pocket
• Some public financing mainly for expatriate
civil servants
• Public and private service delivery
• Developing a reasonably comprehensive,
universally accessible and affordable national
health system for the population does not
appear to have been a priority
6
Policy Environment (Context)
IMMEDIATE POST INDEPENDENCE
• Government of 1st republic (1957-1969) tried to attain universal
access to comprehensive health services
• Approach:
– Tax funded public sector health services free at point of use
– Improvement of access by rapidly expanding public sector
infrastructure and human resource numbers and skills
• Private sector continued to be user fee financed
• At independence Ghana had a net budget surplus
• Adequately financing a universal health service free at point of
service through taxes increasingly difficult as economy failed to
grow significantly and country experienced increasing budget deficit
• Political instability
– British type parliamentary constitution -> One party state -> 1966
coup - > multiparty elections 1969 ->1972 coup
7
Policy Environment (Context)
• Brief spell of multi-party democracy followed by 1972
coup
• Recorded mention of consideration of health insurance
as a financing option – but ?no action actually taken
• Continuing economic challenges
– A drastic devaluation of the cedi as a response to
increasing external debt and donor pressure to do
something or no more credits was one of the triggers of
the Jan 1972 coup
• Almost a decade of military government (1972-79) and
continuing economic problems (inadequate growth)
• Token user fees
8
Historical, Political and Economic Context
GNI Data source: http://www.indexmundi.com/facts/ghana/gni-per-capita
Ghana
1600
GNI/capita US$
1400
1200
1000
800
600
400
200
0
9
The eighties to the present
(GNI Data source: http://www.indexmundi.com/facts/ghana/gni-per-capita)
GNI per capita (US$) - Ghana
1600
1200
1000
800
600
400
200
0
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
GNI per capita (US$)
1400
10
Policy Environment (Context)
Poverty Incidence
(PL=GHC371)
70
60
%
50
40
30
20
10
0
1991/92 1998/99 2005/06
Urban
Rural
All Ghana
11
Policy Environment (Context)
SSNIT membership
1,600,000
1,400,000
1,200,000
No
1,000,000
800,000
600,000
400,000
200,000
-
2011
Registered
Active
• Small formal sector
• Large non formal sector
• Only about 4% of Ghana’s
population is registered in
the SSNIT
• Not all formal sector
workers are registered in
SSNIT (e.g. University
workers)
• However even at a
generous estimate formal
sector may not reach 10%
of the population
Pensioners
12
Some Dynamics that affected process
• How to raise enough money internally for UHC in the context of Ghana
– LIC in 2003 when law was passed
– Difficulties in mobilizing tax /premiums
– Skeptical donor community
• Wide spread social discontent with the cash and carry system combined
with the desire to fulfill a popular election promise opened the window of
opportunity
• The tapping into the lessons of the previous decade on what could and
could not work in terms of health insurance in Ghana
• The tensions between political expediency and technical quality
• Stakeholder dynamics both positive and negative including enthusiasm,
suspicions, mistrust and how they were managed
• Administrative and technical capacity
• Rent seeking behavior
• System weaknesses
13
The Dynamics
“Successful public policies and programs are rare
because it is unusual to have progressive and
committed politicians and bureaucrats (saints)
supported by appropriate policy analysts with
available and reliable information (wizards), that
manage hostile and apathetic groups (demons) and
consequently insulate the policy environment from
the vagaries of implementation (systems)”
Aryee J.R.A (2000) Saints, Wizards, Demons and Systems. Explaining the
success or failure of public policies and programs. Department of Political
Science, University of Ghana, Legon
14
The Design
15
The Evolution of NHIS Governance
Arrangements - Act 650
Devolved Payers
(District Schemes)
•Governing body
•Scheme Manager
Registration, licensing
and regulation
NHIC
Clients
•General Assembly
Providers
•Public
•Private
16
The Evolution of NHIS Governance
Arrangements (Act 852 – 2012)
Single Centralized
Payer (NHIA)
(Deconcenteration)
?????? Regulator
Clients
Providers
•Public
•Private
17
Health System and Service Access
18
Payment and Provision Inter-relationships
Public Sector
• GHS
• Quasi govt. e.g.
Military, Police &
Universities
GOG-CF
• Budgets
• Salaries
Donors
• SBS
• Programs
Private
Mission
(CHAG)
Private Self
Financing
GOG-NHIF (NHIA)
• G-DRG (services
• FFS with
schedule (Meds)
Clients
(OOP)
• FFS no
schedule
19
Service Delivery Resource Constraints
8000
7000
6000
5000
4000
3000
2000
1000
0
US$
35.00
30.00
25.00
USD
Population per category of staff
WHO (2006) Working together for
Health. The World Health Report 2006.
Current public spending about USD
30/capita on health – bulk on HR
payment
20.00
15.00
10.00
Canada
Pop/Docter
South
Africa
Ghana
Pop/nurse
5.00
2001 2003 2005 2007 2009
20
GHC
National Level Expenditures by line
item (GOG consolidated funds)
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
PE
Admin
Service
Investment
2001
511,300
124,070
338,200
88,750
2002
714,460
169,620
273,100
122,020
2003
811,860
183,850
655,510
254,410
2004
1,015,899
282,325
837,540
560,108
2005
1,469,000
382,000
898,000
732,000
21
2012 MOH Expenditure
1800
1600
Millions of GHC
1400
1200
1000
800
600
400
200
0
Employees
Goods and Services
Assets
22
Trends in Public Sector Revenue
Greater Accra
23
Population Coverage
(Source: NHIA 2011 annual report)
25,000,000
Numbers
20,000,000
15,000,000
10,000,000
5,000,000
2005
2006
2007
Registered members cumulative
2008
2009
2010
2011
Active members (Old method)
Active membership (new method)
24
SHINE project 2009
•Central & Eastern region
•Overall insurance
coverage 30%
•Evidence of inequity in
enrollment
•Higher enrollment in
richest quintile (41%)
compared to HH in the
other quintiles (p=0.000).
•Non-renewal rate of
14.3%, significantly
higher among the rich
(Q5)
Insurance status by wealth quintiles
70%
60%
50%
40%
30%
20%
10%
0%
Q1
Q2
Currently insured
Q3
Q4
Previously insured
Q5
Uninsured
25
Service Utilization
• Numbers
– Claims per active member
– Utilization insured and uninsured
• Inputs
– Services content
– Prescription content
26
Trends in insured visits and claims per
active NHIS member
No./Active NHIS member
3.50
3.00
2.50
2.00
1.50
1.00
0.50
-
OP visits
OP Claims
IP claims
2005
2006
2007
0.44
0.02
0.97
0.05
0.70
0.05
2008
0.99
0.94
0.06
2009
1.20
1.56
0.09
2010
1.98
2.07
0.09
2011
2.50
3.10
0.18
2012
2.66
2.74
0.24
27
OPD visits/person insured (active) and
uninsured (non active)
Mean OPD visits per head
3
2.5
2
1.5
1
0.5
0
Active
Non Active
2005
2006
2007
2008
0.99
0.37
2009
1.20
0.40
2010
1.98
0.31
2011
2.50
0.30
2012
2.66
0.35
28
Service utilization by insurance
status
16
14.7
13.7
14
12
% of households
Survey data gives
same message as
HMIS data
SHINE project – CR &
ER 2009
• Insured
individuals are
2.5 times more
likely to utilise
OPD services
(p<0.001)
• Equity in
utilization for the
insured,
inequities for the
uninsured
10
8
7.3
6.9
6
4
2.1
2
1.2
0
OPD
Insured
Admission
Self treat
Uninsured
29
Inputs – Services (2013 G-DRG
evaluation data)
• Shifting (referring of cases)
– “……you can imagine somebody bringing an ulcer ….. and
you know that (dressing) a big sore daily….the cost will go
up so you will lose… so we were losing, so that was why
most of us were not dressing this thing, we refer them to
the hospital… … yes, even the suturing too was a problem
the money was just a token ….” Rural Health Center nurse
• Under supply
– “… the grouped billing…. is a disincentive to carry extensive
investigations” Pharmacist, Urban Polyclinic
– Reduction of lab tests /out of pocket payment for
laboratory tests: “Payment for lab test…” client at exit
interview on reasons for dissatisfaction with NHIS
30
Service Inputs - Prescribing & Dispensing
(2013 G-DRG Evaluation Data)
All Medicines prescribed were:
120
96
% of prescriptions
100
80
100
90
85
79
78 77
95
78
77
66
64
60
40
20
0
Supplied at health facility
All
listed on EML
GAR
BAR
by generic name
UWR
31
Medicines
(2013 G-DRG Evaluation data)
• Client exit interview data suggests problems in medicine access
under the NHIS
• 93% of clients in the exit interviews were positive about the NHIS
• However of 7% (41) who felt the NHIS was bad, a little over half (22)
gave a reason related to the failure of the NHIS arrangements in
relation to medicines prescribed. E.g.
– “The aspect where the scheme does not cover all the drugs is worrying
to us especially we the poor …..”;
– “Situations where I have to buy some drugs”;
– “They do not give all the drugs”;
– “Buying drugs outside the hospital while you still have a valid
insurance”;
– “Dislike the NHIS because initially it was supposed to be free but now
I'm made to buy drugs anytime”.
32
Medicines – Why?
• The NHIS policy requires that medicines prescribed are on the NHIS
Essential Medicines List (EML) and that they are prescribed by
generic name. The NHIS EML is a sub-set of the national EML.
• Providers have repeatedly complained that the reimbursement
rates for some medicines on the NHIS EML are too low. It is
possible that this perception of a too low tariff would negate any
desire to prescribe more medicines since it would not necessarily
increase income. Indeed it might increase loss.
• There is a contextual problem. Medicine prices in Ghana are
extremely high.
• This is a problem whose solution lies beyond the NHIS but would
still affect the NHIS - this and also already existing irrational
prescribing behavior (rather than massive gaming per see) may
explain why medicines are consistently a large part of the NHIS
payment over the years
33
Fees and Cost sharing
SHINE project CR & ER (2009)
%
% THHE spent OOP
50.0
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
-
44.7
25.8
13.0
6.8
Q1(Poorest)
13.0
9.3
9.9
4.9
Q2
Q3
Insured
Q4
7.3
2.6
Q5(Richest)
4.7 4.1
All
Uninsured
34
Fees and Cost Sharing
(SHINE project ER & CR 2009)
GHC
Mean monthly OOP expenditure
40
35
30
25
20
15
10
5
0
Insured
Uninsured
Lab tests
Medicines
Transport
15
10
29
34
3
3
Under the
table
0.4
0.04
Total OOP
11.4
28
35
Achievements
• Single pooled fund – no fragmentation
• Local mobilization of the funds through local taxation
system (VAT) and payroll (SSNIT) is sustainable – it is the
amounts that are currently a challenge
• A scheme that has survived for 10 years and that nobody
wants to go away
• A scheme that has clearly had some of the desired effects
– Increased OPD utilization
– Protective effects for the insured poor (OOP and catastrophic
expenditure)
• Strong and genuine continuing high level government
commitment to successful reform
36
Challenges – Inadequate funds
(NHIS income and expenditure)
37
Challenges
• All dimensions of UHC
– Population coverage
– Services access and coverage
– Out of pocket expenditures
• The challenges are linked in their effects and
solutions
38
What next?
“Would you tell me,
please, which way I ought
to walk from here?”
“That depends a good
deal on where you want to
get to,” said the Cat.
– From Alice in
Wonderland by Lewis
Carroll.
39
What next?
• Strategies to sustainably push the dimensions
to complete the box
• Sustainability = meeting the needs of today
without compromising those of tomorrow
40
What next?
41
Thank You
42