National Health Insurance Scheme in Ghana:Reforms & Achievements

International Conference Centre,

Accra, Ghana

November, 2013

Sylvester A. Mensah(Chief Executive, NHIA)

10 years of Financial Access to Quality Healthcare.“Towards Universal Health Coverage: Increasing Enrolment

whilst Ensuring Sustainability”

Contents

Overview

Operational Performance

2

Milestones

Achievements

Challenges & Way Forward

Overview

3

4

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

Major Characteristics of NHIS

5

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

Major Characteristics of NHIS

6

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

The New NHIS Act 2012 (Act 852)

7

MINISTRY OF HEALTH(MOH)

PURCHASER(NHIS)

PROVIDERS(Public & Private)

SUBCRIBER

Provision of quality services

Utilization of services

Stewardship(Policy & Regulation)

Submission of Claims

Payment of Claims

Pays Premium

Ensure provision of quality services

Key Players in NHIS Architecture

8

Revenue Sources & Allocation (Act 852)

NHIL(2.5% VAT)

Interest on Fund (Investment Income)

Ministry of Finance

National Health Insurance Fund (NHIF)

Admin. & General Expenses of NHIA

Support to the Ministry of Health

[Capped @ 10%]

Payment to Healthcare Providers

Premium &Registration Fees

Other Income

Workmen’s compensation

Road Accident Fund

SSNIT Contributions(2.5% of payroll)

District Offices of the NHIA

Payments to Health care Providers

Transfers for Claims Pmt

88

I. Overview

9

Provider Payment Mechanism A mix of provider payment mechanisms:

FEE FOR SERVICE MedicinesG-DRG Secondary & Tertiary care CAPITATION* Primary care*

MedicinesMedicinesServicesServices

2005 FFS

G-DRG for outpatient & inpatient services

Capitation for outpatient primary care

G-DRG for inpatient, outpatient specialist and emergency care.

FFS

FFS

FFS

2008

2012

MDG 1Poverty & Hunger

MDG 4Child 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

NHIS & MDGs

1957 Free health care policy implemented.

Ghana experienced economic shocks and began structural adjustment programs.Nominal payments for health services introduced.

User fees (cash & carry) was introduced. This policy excluded majority of people from access to healthcare

1970s

1985

1990s

2000

Community-based mutual health insurance schemes were introduced.

2003

High out-of-pocket expenditure on health and very low utilization of health services.

National Health Insurance introduced.

Reforms in Ghana’s Health System

Exemption Policy

12

Category Premium Proc. Fee

Informal sector

Under 18 years

70 years and above

SSNIT contributors

SSNIT pensioners

Indigents

Pregnant women

LEAP beneficiaries

Exempted from

premium payment

Membership & ID card

Mgt.

Provider Certification

& Quality Assurance

Claims Mgt. Provider Payment

Financial Risk

Protection

Reviewing Benefit Package, Medicines & Tariffs

ICT Infrastructure, Data Management & Call Centre

Communication, HR, Training, Conflict Resolution & Stakeholder Management

Financial/Clinical Auditing & Controls

Financing

Monitoring & Evaluation, Risk Assessment, Research & Development

RESIDENTS IN GHANA

IMPROVING HEALTH STATUS

ENSURING PATIENT

SATSFACTION

Financial/Clinical Auditing & Controls

Financing

Monitoring & Evaluation, Risk Assessment, Research & Development

NHIS Value Chain

Adapted by Sylvester A. Mensah

Operational Performance

14

15

Membership, Utilization & Claims

15

1.3 million

8.9 million

598 thousand

23.9 million

29 thousand

GH¢ 7.6 million

GH¢ 616 million

1.4 million

20052005 20122012

7 times

40 times

48 times

81 times

Active Membership

Outpatient Utilization

Inpatient Utilization

Claims Payment

Source: Unaudited Financial Statements

Milestones

16

17

20032003

Act 650 passed1st 45 pilot schemes formally established by law

LI 1809 passedNHIS officially launched

1st Actuarial Study

Blanket accreditation granted

20042004

20052005

Claims Payment started(Fee for service)

Milestones (2003 - 2005)

20072007

20082008

20092009

2nd Tariff review started

National ICT project started

Free Maternal Program started

G-DRGs introduced

1st Actuarial Review

Decoupling of Children

Full scale Accreditation started

Scheme Audit by NHIA

Review of Act 650 started

Milestones (2007 - 2009)

20102010

20112011

20122012

Clinical Audit started

Claims Processing Centre (CPC 1) established

Review of Free Maternal Care Policy implementation

CapitationPilot (Ashanti)

Call centre

Review of Act 650

Act 852 passed

Started preparation towards e-claims management.

Milestones (2010 - 2013)

20132013

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 up Capitation on incremental basis

Increase in NHIL

Full scale implementation of ERM Framework

Achievements

20

Innovative funding: o Earmarked fund – NHIL (2.5% VAT)o 2.5 % Social Security Contributionso 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 containmentClaims verification based on detailed and comprehensive

review

Achievements (1)

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

INTERNALFinancial sustainability of the schemeIdentification of the poor in the informal sectorID card management challengesICT Challenges

EXTERNALMoral hazard (Both demand & supply side)Pharmaceutical supply chain challenges (High cost of medicines)Ability to pay premium/Renewal ChallengesQuality of careWaiting times

•

Challenges

Measures to ensure sustainability (1)

25

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

Cost containment

Measures to ensure sustainability (2)

26

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

IV. Challenges & Way Forward

Enhance financial sustainability through cost containment and additional sources of funding.Intensify Clinical AuditsScale up instant ID Card issuanceIncrease coverage of the poorImprove computerization of operationsShorten claims processing and payment time o E-Claims & Additional CPCs

Way Forward (1)

IV. Challenges & Way Forward

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 coverageRollout capitation in a stepwise approachEncourage high level evidence-based research into health insurance policy issues to inform future policy direction

Way Forward (2)

Thank You