14/10/16

1

ReviewoftheGhanaianNHIS:WhatLessonsHaveWe

Learned?

ChrisAtim,PhD(AfHEA,Ghana;ChairofPresident’sNHISTechnicalReviewCommittee)

EugeniaAmporfu,PhD(KNUST,Ghana;Chair,NHISReviewSub-CommitteeonStrategicPurchasing)

4thConferenceoftheAfricanHealthEconomicsandPolicyAssocia7on(AfHEA)SofitelRabatJardindesRoses–Morocco,26th29thSeptember2016

Outlineu  IntroandArchitectureoftheGhanaNHIS

u  Promise,achievements

u  NHISReview–why,objectives,methods

u  Findings

u  Recommendations

u  Whatnext?

14/10/16

2

IntroandArchitecture

Legislativeframeworku  TheGhanaianNationalHealthInsuranceScheme

(NHIS)wasintroducedin2003byAct650ofParliament

u  Purpose:toprotectGhanaianresidentsfromfinancialrisksinhealthcare

u  TheActwasrevisedin2012:Act852

14/10/16

3

Benefitpackageu  95percentofhealthconditionsaffectingthe

populationØ OutpatientservicesØ InpatientservicesØ OralhealthØ EyecareØ MaternityØ Emergencies

u  “Generous”?

Exclusionsu  Cosmeticsurgeryandaestheticcareu  HIVretroviraldrugsu  AssistedReproductione.g.Artificialinseminationandgynecological

hormonereplacementtherapyu  Echocardiographyu  Angiographyu  Dialysisforchronicrenalfailureu  HeartandBrainsurgeryotherthanthoseresultingfromaccidents.u  Cancertreatmentotherthancervicalandbreastcanceru  Organtransplantingu  Diagnosisandtreatmentabroad

14/10/16

4

Sourcesoffundsandenrolment

u  TheNHISlevy:2.5%ofVAT=>70%ofrevenue

u  SSNITcontribution:2.5%ofSSNITContribution

u Premiumsfrominformalsector

u  Investmentincome

Exemptions

u  SSNITcontributorsdonotpayatpointofjoining

Ø Butcontributevia2.5%SSNIToff-take

u  Childrenupto18yearsold

u  Aged,above70yearsold

u  Indigents

u  Pregnantwomen

14/10/16

5

Promiseandachievements

CURRENT NHIS COVERAGE

Popula0onCoverage(Breadthofcoverage) 100%0%

Currently insured population (40%) (Inclusive benefit package covering 95% of country’s health conditions; but insured not receiving many promised benefits)

Uninsured population (60%)

Services not covered under NHIS 100%

Servicescovered(Scopeofcoverage)

0%

40%

14/10/16

6

NHIShassomegreatdesignfeaturesandadvantages

u  AnimportantoneisreducedfragmentationwithintheinsurancesystemØ Publiclyfinancedsocialhealthinsurance,notindividualpremiumsØ Equitablebenefitpackageforallmembers

u  SinglepoolandpurchaserfortheinsurancebenefitpackageØ Strategicpurchasingpotentialcurrentlyunder-utilized

u  But‘singlepurchaser’underminedbyfragmentationofwiderhealthsystemfinancingØ GoGfinancingisthrough4channels(Salaries,NHIF,goodsandservices,credits)

Ø OOPs,donors,companiesandcommunitiesareotherfinancingsources

OVERVIEW

Ghana’sNHIS’tangiblepopulationgainsu  Healthcoverage:

Ø About40%ofpopulationenrolledin2016u  Utilization:

Ø Utilization,accordingtoGHS,quadrupledfrom0.4percapitato1.6percapsince2003inmostregions

u  Financialprotection:Ø EarlystudyfoundOOPsreducedby50%forcurativecareand44%fordeliveries

Ø DHIMS2datafor2008–2015show83%ofOPDattendeesinsured Source:NHISReviewMainReport,2016

14/10/16

7

NHISReview–why,objectives,methods

WhytheReview?Keyneartermissuescausingwidespreadconcernwithpoliticalimplications

1.  Unauthorisedchargesorso-called‘co-payments’

2.  Longwaitinglinesandqueuesforregistration

3.  DelayedpaymentstoprovidersØ 8–10monthsdelaysatstartofreview

4.  ProviderdissatisfactionwithNHIStarifflevels

5.  Fraudandabuseinclaimssystemandotherareas

èUnfavorablemediastoriesaboutNHIS‘collapse’

14/10/16

8

TORsandFrameworkfortheReview

Sustainability• Financialsustainabilityofscheme• Alignmentofschemetobroadersectorgoals*

Equity • Increasecoverageofvulnerablegroups

Efficiency• Healthservicepurchasing• Operationsofthescheme• ITSystemsfordecisionmaking

Accountability&usersatisfaction

• Increasedpublicconfidenceinthescheme• Accountability• Frameworkforperiodicreviewofscheme

*Aligningtobroadersectorgoalsisalsoakeyefficiencyfactor,aswellastouchingonequityandusersa0sfac0on

Process:Evidence-basedreviewDesk

reviews(Report

,studies

)

Interviewswithkey

informants-NHIA

directors,staff,keyresourcepersonsandheadsofrelevant

institutions

Stakeholder

engagements

Callforsubmissionsinmedia

Surveys

(Nearlya

dozenareas)

Publicforainregions

Visitstoselecte

dregionsand

districts

7Technicalsub-

committees+

AdvisoryCommittee

PROCESSFORNHISREVIEWCOMPLETED

14/10/16

9

KeyFindingsofReview

Structuralissuesimpactingsustainability

u  2.5%VATasmajorfundingsourceallowsNHISrevenuestogrowbroadlyinlinewitheconomicgrowth

u  ButdoesnotenableNHISincometobeadjustedtoexpendituresormembershipgrowth

u  GraduationfromLICtoLMICu  Increasingrelianceofhealth

spendingonNHIS,fromothersourcesØ TheratiobetweenMoHexpenditureandNHIFexpendituredecreasedfrom2.9in2012to1.7in2014

14/10/16

10

RealeconomicgrowthratevsNHILrealincomegrowth

NHILcollected(realterms,GHSmillions)vs%totalpopulationcovered

0

2

4

6

8

10

12

14

16

0,00

100,00

200,00

300,00

400,00

500,00

600,00

2009 2010 2011 2012 2013

RealNHILcollected(GHSMillions)

RealrateofEcongrowth(%)

Source:NHIAdata;author’scalcula0ons

0

5

10

15

20

25

30

35

40

45

0,00

100,00

200,00

300,00

400,00

500,00

600,00

2009 2010 2011 2012 2013

RealNHILcollected %Popula0oncovered

NHISincomeandexpenditure,2005-2014:Sustainabilitytrends

14/10/16

11

Sourcesofinefficiency

u  Year-rounddesignofopen,voluntary,individualnotfamily,enrolmentfavoursadverseselection,despite1monthwaitingperiod

u  Un-empoweredmembershipisakeysourceofinefficiencyØ MembersnotincentivisedtobehaveresponsiblyorseeNHISasallyorprotector

Ø Lackofadequateinfoaboutconsequencesofcertainbehavioursincludingdiet,lifestylesandchoices

u  OperationalinefficienciesarisefromØ WeakcapacityofthepurchasingagentincrucialdimensionsØ Lackofstrategicpurchasingandhencesusceptibilitytofraudandabuses

Ø Manualclaimsprocessing,emphasisingvettingbutnotexpendituremanagement

14/10/16

12

Overviewofclaimssubmission,processing,andreimbursementsystem

Additionalsourcesofinefficiencyu  Facilitiesexpectedtodeliverspectrumofservices(bothpreventive

andclinical),buttheyonlyhaveautonomyoverNHISpaymentsandOOPsØ incentivizesfacilitiestodirecteffortstowardscurativeservices

u  NHISpayshighertariffstoprivatefacilities,whilehighlysubsidizedpublicfacilitiesappearunder-utilisedØ TheReviewteamwasabletoobservethisinsomeregionalvisits;WorldBankstudynotessame

u  NHISclaimedtooffergenerouspackage,butthatpackageexcludescost-effectivepreventiveservicesandqualityofcaredeliveredØ NHISessentiallypayingforconsequencesofunder-performanceofpublichealthprograms

14/10/16

13

Inefficiencyofbenefitpackageu  ThetoptwentycasesseenattheOPDconstitutesonaverage70

percentoftotalOPDseenatallthehealthfacilitiesinGhana.Thediseasesseencanbegroupedintothreemajorgroupsasfollows:Ø Infectiousdiseases–Malaria,Upperrespiratoryinfection,diarrhoealdiseasesetc

Ø Non-communicablediseases-Hypertension,Diabetes,Injuries,Rheumatoidjointdiseasesetc

Ø Pregnancyrelatedcomplicationsu  ButNHISnotfundinginvestmentstotacklecausesofinfectious

diseasesandNCDs,ortoactonthecausesofhighmaternalandchildmortality

Indicator Value(Ghana)

Value(LMIC)

GNIpercapita($Atlasmethod,2014)

1,590 $1,026-$4,035

Lifeexpectancyatbirth(years) 63 67Maternalmortality,per100,000livebirths

320-380 253

Child(under5)mortality,per1000livebirths

78 52.8

KEYINDICATORSUNDERMININGHEALTHPERFORMANCE

Sources:WB,WDI2015;WHO,Countryprofile,Jan2015

14/10/16

14

Efficiency–Medicallossratiosovertimeidealratio:95/5

Year Medicallossra<o2008 92/82009 85/152010 75/252011 72/282012 77/232013 77/23

Comparesomebestpracticeexamplesu  Since2007,theEstonianEHIF’soperatingexpenseshave

notexceeded1%ofitsbudget.u  Slovakianhealthinsurancefundsarelegallyrestricted

fromspendingmorethan3.5%oftheirrevenueonadministration.

u  TheaverageamonghealthinsurancefundsintheCzechRepublicis3.7%,withthelargerfundshavinglowercosts.

u  Similarly,inSouthKoreaavailablestatisticsshowonly4.4%oftotalexpenditurewasspentonadministrationasat2013

14/10/16

15

Equity

Equityinaccesshasimproved

Source:WorldBank,GhanaPER,2016

14/10/16

16

ButseveralinequitiesinremaininNHIS

u  Betweeninsuredandnon-insured

Ø Notacceptableforapubliclyfundedscheme

u  Availabilityofthebenefitpackage

u  Qualityofcareandchoice

u  BiasagainstPHCandpreventiveservices

KeyRecommendations

14/10/16

17

Buildingconsensusaroundobjectives

FocusonPHCstrategy

MissedMDGs

NewSDGs

Healthgoalsandpriori0es

Preven0on,promo0on&NCDs

MNCH

Infec0ousdiseases

KEYFEATURESOFPROPOSEDREDESIGNu  PHC and MNCH services at public and mission facilities to be

guaranteed at 100% with no user fees on such health services for all the population (ie automatic coverage)

u  Including private facilities in underserved areas or where no other option within realistic reach (ie 5 km radius)

u  Based on VAT and SSNIT contribution. So not ‘free’ service: payment of VAT by general public confers entitlement

u  NHIS card will not be a condition of primary health care but identification will still be required as an eligible resident; should piggy back on other ID systems in place

u  NHIS becomes a strategic purchaser of these services for the Ghanaian public

u  “Coverageforallbutnotcoverageforeverything”

14/10/16

18

PROPOSED COVERAGE RECONFIGURATION

Popula0onCoverage(Breadthofcoverage) 100%0%

MaternalandChildHealth Insuredpopula<on

payingpremiums

FullyExempt

Costcontainment

Fullyguaranteedbenefitpackage:UniversalaccesstoPHC

ServicesnotcoveredunderNHIS

Uninsuredpopula<on

100%

Servicescovered(Scopeofcoverage)

100%

Costcontrolswithoutanyfinancialburden

Otherrecommendationsu  Actuarialstudyofuniversal,capitation-based,primarycarepackage

u  Institutionalreforms

Ø NationalHealthCommission

Ø PatientProtectionCouncil

Ø Providernetworks

u  Medicallossratioandminimumreserverequirements

u  RoleforMOFinstrategicpurchasingandtechnicalassistancefor

financialmanagement,modelingetc

14/10/16

19

Someprocesslessonsofthereviewu  Extensivenessofconsultationsu  Beingopenmindedandinlisteningmodeu  Identifyingthestrongeststakeholdersandkeyindividualsu  Makinguseofcountry’stalentsandexpertiseu  Processofconsensus-buildingu  Politicalneutralityu  Definingtheproblemfirstu  Attributionanddistributionofownership

THANKYOU

MERCI

14/10/16

20