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

Overview

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

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
6

Board oversight committee for

i. Scheme Operations

Key Players in NHIS

Architecture
MINISTRY OF
HEALTH
(MOH)

PROVIDERS
(Public &
Private)

Provision
of quality
services
7

Stewardship
(Policy & Regulation)

Submission of Claims
Payment of Claims

Utilizati
on of
services

SUBCRIBER

PURCHASER
(NHIS)

Pays
Premi
um

Ensure
provision
of quality
services

Revenue Sources & Allocation

(Act 852)

NHIL
(2.5% VAT)

SSNIT
Contributions
(2.5% of
payroll)on
Interest
Fund
(Investment
Road Accident
Income)
Fund
Workmens
compensation
Premium &
Registration
Fees
Other Income

Ministry of
Finance

National Health
Insurance Fund
(NHIF)
Transfers
for
Claims
Pmt
District Offices
of the NHIA

Payment to
Healthcare
Providers
Admin. &
General
Expenses of
Support
to the
NHIA
Ministry of
Health

[Capped @ 10%]

Payments to
Health care
Providers
8

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
2008
2012

FFS

FFS

G-DRG for
outpatient
& inpatient
Capitation for
services
outpatient
primary care

FFS

G-DRG for inpatient,

outpatient
specialist and
emergency care.

FFS

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 Ghanas Health

System
1957
1970s
1985
1990s

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
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
Under 18 years

Exempte
d from
premium
payment

70 years and
above
SSNIT
contributors
SSNIT pensioners
Indigents
Pregnant women
LEAP beneficiaries

12

Premiu
m

Proc.
Fee

NHIS Value Chain

RESIDE
NTS IN
GHANA

Reviewing Benefit Package, Medicines

& Tariffs
ICT Infrastructure, Data Management &
Call Centre
Communication, HR, Training,
Conflict Resolution & Stakeholder
Management
Provider
Financi
Membership
Certification
Provider
al Risk
& ID card
Claims Mgt.
& Quality
Payment
Protecti
Mgt.
Assurance
on
Monitoring & Evaluation, Risk
Assessment, Research & Development
Financial/Clinical Auditing & Controls
Financing

Adapted by Sylvester A. Mensah

IMPROVI
NG
HEALTH
STATUS
ENSURING
PATIENT
SATSFACT
ION

Operational
Performance

14

Membership, Utilization &

Claims
2005
Active
Members
hip
Outpatie
nt
Utilizatio
n
Inpatient
Utilizatio
n
Claims
Payment
15

2012
8.9 million

1.3 million

m
7 ti

es

23.9 million
598 thousand

40 s
e
tim

1.4 million
29 thousand

48 s
e
tim

GH 616 million
GH 7.6 million

81 s
e
t im
Source: Unaudited Financial
Statements

Milestones

16

Milestones (2003 - 2005)

2005
Claims
Payment
2004
started
(Fee for
LI 1809 passed
service)
NHIS officially
launched
2003

17

Act 650
passed
1 st 45 pilot
schemes
formally
established
by law

1 st Actuarial
Study
Blanket
accreditation
granted

Milestones (2007 - 2009)

2009

2008
F ree
2007
2 nd Tariff
review
started
National
ICT project
started

Maternal
Program
started

G-DRGs

introduced

1 st Actuarial
Review
Decoupling of
Children
Full scale
Accreditation
started
Scheme Audit by
NHIA
Review of Act
650 started

Milestones (2010 - 2013)

2013
Established CPC 2 & 3

2011

2010

Review of Free
Maternal Care
Policy
implementation

Clinical Audit
started
Claims
Processing Centre
(CPC 1) established

2012

Introduced E-claims on
pilot and scaling up

Capitation
Pilot (Ashanti)

Electronic linkage of
Diagnosis to Treatment

Call centre

Intensified Clinical
Audits

Review of Act 650

Act 852 passed
Started preparation
towards e-claims
management.

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

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 BioData
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
25

Piloting NHIS medicines at negotiated

price

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
IV. Challenges
Way Forward
Scale up instant
ID &Card
issuance
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
IV.(PPP)
Challenges & Way Forward
partnership
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