National Health Insurance Scheme in Ghana: Reforms & Achievements

1. 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

2. Contents Overview Operational Performance Milestones Achievements Challenges & Way Forward

3. Overview

4. 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

5. 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

6. 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

7. Key Players in NHIS Architecture MINISTRY OF HEALTH (MOH) Stewardship (Policy & Regulation) Submission of Claims PROVIDERS (Public & Private) PURCHASER (NHIS) Payment of Claims Utilization of services Pays Premium Provision of quality services Ensure provision of quality services SUBCRIBER

8. Revenue Sources & Allocation (Act 852) • NHIL • (2.5% VAT) Ministry of Finance SSNIT Contributions (2.5% of payroll) Payment to Healthcare Providers Interest on Fund (Investment Income) National Health Insurance Fund (NHIF) Road Accident Fund Admin. & General Expenses of NHIA Workmen’s compensation Support to the Ministry of Health [Capped @ 10%] Premium & Registration Fees Transfers for Claims Pmt Other Income District Offices of the NHIA Payments to Health care Providers 8 8

9. I. Overview Provider Payment Mechanism • A mix of provider payment mechanisms: • FEE FOR SERVICE Medicines • G-DRG Secondary & Tertiary care • CAPITATION* Primary care* Medicines Services 2005 FFS FFS G-DRG for outpatient & inpatient services FFS 2008 Capitation for outpatient primary care G-DRG for inpatient, outpatient specialist and emergency care. 2012 FFS

10. NHIS & MDGs MDG 1 Poverty & Hunger Free registration and access to healthcare for the poor and vulnerable. Thus, preventing catastrophic health expenditures and poverty MDG 4 Child Mortality All persons under 18 years have free access to health insurance. They represented almost 50% of registered members as at December 2012. MDG 5 Maternal Health Free maternal care policy introduced in July 2008 MDG 6 HIV/AIDS, Malaria & TB Malaria, TB, HIV opportunistic diseases are covered

11. Reforms in Ghana’s Health System 1957 • Free health care policy implemented. • Ghana experienced economic shocks and began structural adjustment programs. • Nominal payments for health services introduced. 1970s 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.

12. Exemption Policy Exempted from premium payment

13. NHIS Value Chain Financial Risk Protection Reviewing Benefit Package, Medicines & Tariffs ICT Infrastructure, Data Management & Call Centre Communication, HR, Training, Conflict Resolution & Stakeholder Management RESIDENTS IN GHANA IMPROVING HEALTH STATUS Membership & ID card Mgt. Provider Certification & Quality Assurance Claims Mgt. Provider Payment ENSURING PATIENT SATSFACTION Monitoring & Evaluation, Risk Assessment, Research & Development Monitoring & Evaluation, Risk Assessment, Research & Development Financial/Clinical Auditing & Controls Financial/Clinical Auditing & Controls Financing Financing Adapted by Sylvester A. Mensah

14. Operational Performance

15. Membership, Utilization & Claims 2005 2012 8.9 million Active Membership 7 times 1.3 million 23.9 million Outpatient Utilization 40 times 598 thousand 1.4 million Inpatient Utilization 48 times 29 thousand GH¢ 616 million Claims Payment 81 times GH¢ 7.6 million Source: Unaudited Financial Statements 15

16. Milestones

17. Milestones (2003 - 2005) 2005 Claims Payment started (Fee for service) 2004 LI 1809 passed NHIS officially launched 1stActuarial Study Blanket accreditation granted 2003 Act 650 passed 1st45 pilot schemes formally established by law

18. Milestones (2007 - 2009) 2009 1st Actuarial Review Decoupling of Children Full scale Accreditation started Scheme Audit by NHIA Review of Act 650 started 2008 Free Maternal Program started G-DRGs introduced 2007 2ndTariff review started National ICT project started

19. Milestones (2010 - 2013) 2013 Established CPC 2 & 3 Introduced E-claims on pilot and scaling up Electronic linkage of Diagnosis to Treatment Intensified Clinical Audits Instant ID Cards on pilot and scaling up Scale upCapitation on incremental basis Increase in NHIL Full scale implementation of ERM Framework 2012 Capitation Pilot (Ashanti) Call centre Review of Act 650 Act 852 passed Started preparation towards e-claims management. 2011 Review of Free Maternal Care Policy implementation 2010 Clinical Audit started Claims Processing Centre (CPC 1) established

20. Achievements

21. Achievements (1) • Innovative funding: • Earmarked fund – NHIL (2.5% VAT) • 2.5 % Social Security Contributions • 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

22. 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

23. Challenges & Way Forward

24. 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

25. 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

26. 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

27. Way Forward (1) • Enhance financial sustainability through cost containment and additional sources of funding. • Intensify Clinical Audits • Scale up instant ID Card issuance • Increase coverage of the poor • Improve computerization of operations • Shorten claims processing and payment time • E-Claims & Additional CPCs IV. Challenges & Way Forward

28. 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) • 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 IV. Challenges & Way Forward

29. Thank You