10 years of Financial Access to Quality Healthcare.
“Towards Universal Health Coverage: Increasing Enrolment
whilst Ensuring Sustainability”
National Health Insurance Scheme in Ghana:
Reforms & Achievements
Sylvester A. Mensah
(Chief Executive, NHIA)
International Conference Centre,
Accra, Ghana
November, 2013
Contents
Overview
Operational Performance
Milestones
Achievements
Challenges & Way Forward
2
Overview
3
Major Characteristics of NHIS
The NHIS was established by an Act of Parliament in
2003 (Act 650).
Initiative by Government to secure financial risk
protection against the cost of healthcare services for all
residents in Ghana.
Act was revised in 2012 – NHIS Act 850
4
Major Characteristics of NHIS
Funding - Combination of the following models
Beveridgean: National Health Insurance levy - 2.5% VAT
Bismarckian: 2.5 percentage points of Social Security contributions
MHO: Graduated informal sector premium based on ability to pay
Earmarked funds (NHIL & SSNIT) constitute over 90% of
total inflows
Benefit package covers 95% of disease conditions
5
The New NHIS Act 2012 (Act 852)
Significant revisions in the Law include the following:
A Mandatory NHIS
A Unified NHIS with District Offices
Premium exemptions for persons with Mental
Disorders
Expenditure cap of 10% on non-core NHIS activities
Relevant family planning package
Board oversight committee for
i. Scheme Operations
ii. Private Health Insurance schemes
iii. Fund Management
6
Key Players in NHIS Architecture
MINISTRY OF HEALTH
(MOH)
PROVIDERS
(Public & Private)
Submission of Claims
Payment of Claims
Utilization
of services
Provision of
quality
services
7
Stewardship
(Policy & Regulation)
PURCHASER
(NHIS)
Pays
Premium
SUBCRIBER
Ensure
provision of
quality
services
Revenue Sources & Allocation (Act 852)
NHIL
(2.5% VAT)
SSNIT Contributions
(2.5% of payroll)
Ministry of Finance
Payment to
Healthcare Providers
Interest on Fund
(Investment Income)
Road Accident Fund
Workmen’s
compensation
Premium &
Registration Fees
National Health
Insurance Fund (NHIF)
Transfers for
Claims Pmt
Admin. & General
Expenses of NHIA
Support to the
Ministry of Health
[Capped @ 10%]
Other Income
District Offices of the
NHIA
8
Payments to Health
care Providers
8
I. Overview
A mix of provider payment mechanisms:
FEE FOR SERVICE
Medicines
G-DRG
Secondary & Tertiary care
CAPITATION*
Primary care*
2005
FFS
FFS
2008
G-DRG for outpatient
& inpatient services
FFS
2012
Capitation for outpatient
primary care
FFS
G-DRG for inpatient, outpatient
specialist and emergency care.
9
NHIS & MDGs
MDG 1
Poverty & Hunger
MDG 4
Child Mortality
MDG 5
Maternal Health
MDG 6
HIV/AIDS,
Malaria & TB
Free registration and access to healthcare for the
poor and vulnerable. Thus, preventing catastrophic
health expenditures and poverty
All persons under 18 years have free access to
health insurance. They represented almost 50%
of registered members as at December 2012.
Free maternal care policy introduced in July
2008
Malaria, TB, HIV opportunistic diseases are
covered
Reforms in Ghana’s Health System
1957
Free health care policy implemented.
1970s
Ghana experienced economic shocks and began structural
adjustment programs.
Nominal payments for health services introduced.
1985
User fees (cash & carry) was introduced. This policy excluded
majority of people from access to healthcare
1990s
Community-based mutual health insurance schemes were
introduced.
2000
High out-of-pocket expenditure on health and very low
utilization of health services.
2003
National Health Insurance introduced.
Exemption Policy
Category
Informal sector
Exempted
from
premium
payment


Under 18 years

70 years and above

SSNIT contributors

SSNIT pensioners

Indigents
Pregnant women
LEAP beneficiaries
12
Premium Proc. Fee
NHIS Value Chain
Reviewing Benefit Package, Medicines & Tariffs
ICT Infrastructure, Data Management & Call Centre
RESIDENTS
IN GHANA
Communication, HR, Training, Conflict Resolution
& Stakeholder Management
Membership
& ID card
Mgt.
Provider
Certification
& Quality
Assurance
Claims Mgt.
Provider
Payment
Monitoring & Evaluation, Risk Assessment, Research
& Development
Financial/Clinical Auditing & Controls
Financing
Adapted by Sylvester A. Mensah
Financial
Risk
Protection
IMPROVING
HEALTH
STATUS
ENSURING
PATIENT
SATSFACTION
Operational Performance
14
Membership, Utilization & Claims
8.9 million
Active
Membership
1.3 million
23.9 million
Outpatient
Utilization
598 thousand
1.4 million
Inpatient
Utilization
29 thousand
GH¢ 616 million
Claims
Payment
GH¢ 7.6 million
Source: Unaudited Financial Statements
15
Milestones
16
Milestones (2003 - 2005)
Claims Payment
started
(Fee for service)
LI 1809 passed
NHIS officially
launched
1st Actuarial Study
Blanket accreditation
Act 650 passed
granted
1st 45 pilot
schemes formally
established by law
17
Milestones (2007 - 2009)
1st Actuarial Review
Decoupling of Children
Free Maternal
Program
started
G-DRGs
2nd Tariff
review started
National ICT
project started
introduced
Full scale Accreditation
started
Scheme Audit by NHIA
Review of Act 650
started
Milestones (2010 - 2013)
Established CPC 2 & 3
Introduced E-claims on pilot and
scaling up
Review of Free
Maternal Care
Policy implementation
Clinical Audit
started
Claims
Processing Centre
(CPC 1) established
Capitation
Pilot (Ashanti)
Electronic linkage of Diagnosis to
Treatment
Call centre
Intensified Clinical Audits
Review of Act 650
Instant ID Cards on pilot and
scaling up
Act 852 passed
Started preparation towards
e-claims management.
Scale up Capitation on
incremental basis
Increase in NHIL
Full scale implementation of ERM
Framework
Achievements
20
Achievements (1)
Innovative funding:
o Earmarked fund – NHIL (2.5% VAT)
o 2.5 % Social Security Contributions
o Informal sector contributions
Promotion of acceptability through community ownership
using district based sub-schemes
Non-partisan support
Comprehensive credentialing system and post credentialing
inspection
Involvement of both public and private health care providers
Clinical audit based on sampling for promotion of quality and
cost containment
Claims verification based on detailed and comprehensive
review
Achievements (2)
Call Centre
Claim Processing Centres
Electronic Claims Management
Instant issuance of ID Cards based on Bio-Data
Revised NHIS Act 2012 (Act 852)
Stakeholder engagement
Restructured organization
Reviewed vision and mission
New work ethic
Challenges & Way Forward
23
Challenges
INTERNAL
Financial sustainability of the scheme
Identification of the poor in the informal sector
ID card management challenges
ICT Challenges
EXTERNAL
Moral hazard (Both demand & supply side)
Pharmaceutical supply chain challenges (High cost of
medicines)
Ability to pay premium/Renewal Challenges
Quality of care
Waiting times
Measures to ensure sustainability (1)
Cost containment
Clinical Audits
Claims Processing Centre
Consolidated Premium Account
Capitation
Unique Prescription Form
Linking Diagnoses to Treatment / E-claims
Medicines List and Prescribing Levels
Piloting NHIS medicines at negotiated price
Contracting for medicines to drive down prices
25
Measures to ensure sustainability (2)
Additional Funding
Increase in Health Insurance Levy (NHIL)
Review NHIL exemptions policy
5% Road Fund
Levy on tobacco and alcoholic beverages
20% Communications service tax
Levy on Petrochemical Industry
26
Way Forward (1)
Enhance financial sustainability through cost
containment and additional sources of funding.
Intensify Clinical Audits
Scale up instant ID Card issuance
IV. Challenges & Way Forward
Increase coverage of the poor
Improve computerization of operations
Shorten claims processing and payment time
o E-Claims & Additional CPCs
Way Forward (2)
Strengthen audit and risk management systems as well
as reward and sanctions to reduce fraud and abuse.
Establish a Health Insurance Institute in partnership
(PPP)
IV. Challenges
& Way Forward
Scale up CPC claims
management
coverage
Rollout capitation in a stepwise approach
Encourage high level evidence-based research into
health insurance policy issues to inform future policy
direction
Thank You