Re-engineering exemption strategies under National Health Insurance: Ghana’s experience

1. Re-engineering exemption strategies under National Health Insurance: Ghana’s experience Workshop on Financial access for the poor, Dakar, 2 – 4 November 2010

2. Overview of the health sector in Ghana • Agency-based with purchaser-provider split • MOH provides policy direction and stewardship, and purchaser for public health • GHS, CHAG, TH, PH and others provide health services • NHIA channels funding for clinical care on behalf of insured clients • Regulatory bodies • Deconcentrated structure through GHS • Regional Health Directorates • District Health Directorates • Hospitals and sub-districts, including CHPS

3. Key funding flows in Ghana Taxes, NHIL MDBS, SBS Household income GOG revenues Development partners EM NHIF User fees Health Fund, EM eg GFATM Earmarked, eg USAID, UN NHIA Premia Subsidy Txfrs DMHIS MOH MPs Salaries (to indiv) Claims Adapted from Enemark et al 2005 Health service providers

4. Objectives of the move to NHIS • “..to assure equitable universal access for all residents of Ghana to an acceptable quality of a package of essential health services without out-of-pocket payment being required at point of service use.” (2004 Policy Framework) Source: Aikins & Arhinful, 2006 Phase-out traditional exemptions Key focus on pro-poor strategy NHIS scaling up

5. Main pillars of exemption policy Pre-NHIS NHIS Exemption from NHIS premium for priority groups Under-18s, elderly 70+, SSNIT contributors (formal sector employees and pensioners), ‘Indigent’, and (since Jul ‘08) pregnant women Entitled to NHIS benefit package About 95% of conditions By accredited providers Funded through VAT levy + SSNIT contribution via a statutory fund (NHIF) • 1971/1985 - Full exemption from user charges for • Poor, U18, 65+, health workers, TB/ Leprosy/ psychiatric patients • Some services, eg immunisation, antenatal, postnatal, child welfare clinics • Partial exemption for communicable diseases • 2003-6 - exemptions from delivery charges • Funded through GOG/HIPC

6. Process of NHIS policy development • Government initiative through MOH, based on • Preference for prepayment/risk-sharing and move to universal coverage • Failure of past administrative exemptions • Steering cttee, with wide stakeholder consultations • MDAs, politicians, policy makers, academics, practitioners, development partners, civil society • Policy developed from field experience and its evaluation • community-based health insurance and mutual health organisations • Legislation: Act 650 of 2003 and LI 1809 of 2004 • Providers involved in drafting of initial legislation and consulted on recent revisions

7. NHIS policy implementation • Widespread communication on NHIS through various media • Radio most common source of info (67%) • Schemes hold community durbars, visits to churches, mosques etc • General knowledge of NHIS high but of details lower • 46% had limited or no info on exemptions (71% of lowest SE group, 22% highest) • Supervision/monitoring at several levels • NHIA through Council supervises NHIS implementation • Individual providers monitor claims reimbursements • NDPC monitoring a key pro-poor initiative under GPRS • NHIS claims and link to sector financing • Increasingly important in financing clinical care • contribute to Internally-Generated Funds and thus aligned to MOH financial reporting system

8. Process of indigent exemptions under NHIS NATIONAL LEVEL NHIA/C proposes target coverage in budget document Parliament approves NHIF allocation, including for indigent MOFEP/ CAGD channels NHI Fund to NHIA NHIA channels subsidy to the Schemes Scheme works w community/ DSWO to identify and register Indigent Scheme sends report to NHIA on no of registered Indigents Indigent member seeks care from accredited provider Provider submits claim to Scheme Scheme vets and reimburses provider DISTRICT /COMMUNITY LEVEL

9. M&E of the initiative Pre - NHIS NHIS Annual reporting by NHIA of No of exempt members, including indigents, by region Indigents as % of registered members Small scale studies 2008 national survey to assess NHIS progress - “Citizens’ Assessment” Joint monitoring with MESW under development • Periodic independent reviews • Small scale studies • Academic study (eg Immpact) • “From HQ down to the regional and district level, there are no efficient and effective structures for exemption monitoring” (2006 in-depth review)

10. Progress with NHIS registration, June 2010 *residual of population estimate less estimated in exempt groups Sources: 2010 NHIF allocation formula, NHIS website www.nhis.gov.gh; Ghana Statistical Service website www.statsghana.gov.gh

11. Strengths of NHIS exemptions • Availability of earmarked Govt funding (NHIL/NHIF) • Explicit target group – definition in legislation, coverage target in allocation formula approved by Parliament • Potentially greater physical access as private sector also accredited • Accredited health providers aware of NHIS benefit package (and do not have to identify exempt groups) • Public knowledge of NHIS very high • Mechanism in place to reimburse facilities for provision of exemptions

12. Challenges with pre- and post-NHIS exemptions

13. Perspectives going forward • Identification of poor is mandate of Min of Emp’t & Social Welfare • MOH/NHIA role is to work with MESW and support the National Social Protection Strategy • MOH/sector in process of developing a common targeting instrument (proxy means test) and joint monitoring mechanisms with MESW • Interim linkage with LEAP, a cash transfer prog. targeting extreme poor and vulnerable • Community LEAP Implementation Cttees mobilising LEAP beneficiaries to register with NHIS

14. Lessons learned • Adequate budgetary provision must be made • Timely reimbursements/transfers are critical to maintain incentives at provider level • Clear criteria and transparent processes for identification of the poor must be agreed and applied • Regular monitoring and supervision are key to accountability and sustainability • Adequate consultation around and communication of policy content is necessary • Possibility of stigma among the very poor must be addressed

15. THANK YOU FOR LISTENING! • We would also like to acknowledge the following: • MOH, GHS and NHIA colleagues back in Ghana for their helpful inputs • The organising committee for their useful comments • WAHO, Danida and the World Bank-funded Health Insurance Project for their financial support • The leadership of the MOH, NHIA and MESW for giving us this opportunity