In 2003, the Ghanaian government launched one of the most ambitious plans to achieve universal health coverage — the National Health Insurance Scheme (NHIS). Since that time, more than 11 million people have enrolled — about 41 percent of the population. However, the NHIS has experienced challenges. To address these issues, the government created a technical committee to review the status of the NHIS and make recommendations for reform.
As executive director of the African Health Economics and Policy Association (AfHEA), Chris Atim, Ph.D., was selected by the Ghanaian government to chair the committee. Dr. Atim is also a senior program director at Results for Development (R4D). We sat down with him to discuss his role on the committee, and walk us through the review of the NHIS, as well as the committee’s findings and recommendations. His work on the committee was supported by USAID’s Health Finance and Governance project.
How does the National Health Insurance Scheme work, and what does it cover?
Chris Atim (CA): To ensure high-quality, affordable health care for Ghanaians, the government requires all citizens to enroll in the National Health Insurance Scheme, even if they are also enrolled in another, private health insurance program. Although NHIS is primarily funded by a value-added tax (VAT) on goods and services and a portion of social security taxes, only those who are enrolled, are entitled to the benefits of the scheme.
Some groups are exempt from paying the annual fees, but many are still required to pay registration fees, such as people over 70, pensioners and children under 18. Indigents and pregnant women are exempt from paying registration and annual fees.
The program offers members a single benefit package that covers 95 percent of health problems reported in Ghana. It also covers outpatient services; most in-patient services, most surgeries, and hospital accommodation visits; oral health treatments; all maternity care services; emergency care; and all drugs on the National Health Insurance Authority’s (NHIA) Medicines List. However, the scheme doesn’t cover expensive, highly specialized care, such as dialysis and organ transplants. ARVs for the treatment of HIV/AIDS are also not covered because they’re supplied by the National AIDS Control Programme.
Since the scheme was established, what notable successes have been achieved?
CA: We’ve seen improved access: over 40 percent of the population, mostly vulnerable persons, are able to receive health care under the scheme; increased utilization: hospital attendance has quadrupled in many regions; and insured patients make up over 80 percent of facility clients, according to the Ghana Health Service.
It also covers both private and public health facilities, providing considerable choice especially to people living in cities, where private facilities are concentrated. And it offers an equal benefit package under law to all its members, whether formal sector or informal sector, urban or rural; however, it’s a challenge to deliver an equal benefit package to rural dwellers who have fewer facilities, choices and a lower quality of care.
What kind of challenges has the NHIS faced?
CA: The main issue has been that coverage, particularly for the poorest who cannot afford the registration and annual fees, as well as insufficient care and lack of access to medicines for enrollees. Additionally, expenses have outpaced revenues making the entire scheme financially unsustainable.
More broadly, though, it was an especially critical time to conduct this review. As international donors for health, including the Global Fund and Gavi, begin a drawdown of funding in Ghana, more domestic resources will be critical to sustaining efforts to combat AIDS, tuberculosis and malaria and continue supporting the national immunization program. Eventually, at least some of the funding for these programs will fall on the NHIS. The scheme wasn’t designed to cover these services, but this only highlights a pressing need for coordination in the sector to help adapt to and anticipate these kinds of changes.
Where did you start? What was the process like?
CA: The committee focused on identifying the root causes of the challenges the NHIS faced and making recommendations for reforms in four broad areas: sustainability, equity, efficiency and accountability/user satisfaction.
The most important thing was that our efforts needed to be evidence-led. We started by gathering input from all stakeholders. We published a public call for feedback from anyone who had concerns regarding the health insurance system. This could be done by web, mail — we even held public meetings. We also consulted some international experts and reviewed all reports that had been done on the Ghanaian health system.
In addition, we set up seven subcommittees, made up of leading local experts in the different domains, but this is also where external expertise was much appreciated. These subcommittees amassed evidence that we used to inform our final recommendations. A few of R4D’s experts contributed to these efforts: Cheryl Cashin was a member of the strategic purchasing subcommittee; and Nathan Blanchet was a member of the governance and accountability subcommittee. In addition, Cicely Thomas and Yoriko Nakamura provided support for a couple of studies requested by the monitoring and evaluation team.
What were the findings of the committee?
CA: Overall, we found five main flaws in the original design of the scheme. First off, we found that there is a prevailing sense among stakeholders that the benefit package is too broad; that it covers too much and should be reduced to make it more realistic. Our finding was that the right approach to defining the benefit approach should focus on the health priorities of the country, and these are overwhelmingly primary health care related.
Second, a lack of cost controls or strategic purchasing has exposed the scheme to unsustainable costs. Strategic purchasing would enable the scheme to live within its means.
Third, many still can’t afford the individual contribution. The program was designed to move Ghana closer to universal health coverage; however, only 40 percent of the population is enrolled. That’s not right since everyone is paying into the system via the VAT tax.
Fourth, quality of care is low. This also came through the public commentary. People cited long waiting times at the health facilities, frequent lack of drugs forcing patients to purchase them at pharmacies outside the facilities, difficulties with getting insurance registration cards, etc.
And, lastly, more than half of health facilities at the primary care level could not provide the full package of benefits, due to lack of personnel, equipment or other issues, according to a mapping survey completed by the NHIS and USAID’s Health Finance and Governance project.
From the public fora, we learned that people were mostly concerned about the delayed payments to their providers, which they assumed were due to delays within the Ministry of Finance. However, a subcommittee actually traced the payments and found that most of the delays happened in other places. This is why evidence is so important. It enables us to make well-informed decisions that will better address the root causes of the issues.
What were the committee’s recommendations?
CA: The committee agreed the scheme needed to be redesigned and restructured, with a greater focus on primary care.
To contain costs, we proposed the creation of a primary health package that emphasizes basic health services as well as preventive and population health services and which is affordable for the scheme. In addition, maternal and child health will continue to be funded at the higher levels of care because Ghana is not doing well in those areas and it is a big priority for the government. On top of that, there will be premium for additional services. However, the 40 percent who already have health insurance would be grandfathered in and able to receive all services. It’s not right to take away services from people who already have them.
We also recommended the implementation of a strategic purchasing approach. The NHIS needs to make greater strides to stay within its budget every year. The current system in which providers purchase drugs on the open market—a huge cost item for the NHIS—is wasteful and expensive. We supported reforms aimed at instituting framework contracts to make better use of the purchasing power of the NHIS to negotiate lower drug prices with suppliers and assist with forecasting, planning and procurement. A budget neutral approach to paying for care at the higher levels would do much to reduce costs and shift resources towards the priority area of primary care. This approach means a fixed envelope of funds would be available for the annual budget and all services must be paid for within that envelope; the more services there are, the less will be paid per unit of service and vice versa.
To improve the quality of care, we proposed the creation a “Patient Protection Council.” This a government agency (independent from the NHIS) that will assist patients with quality of care issues, including tracking medical errors, investigating complaints related to clinical practice, etc.
We also proposed moving to a provider network system. If a patient registers with their local Community-Based Health Planning and Services (CHPS) facility or compound, they get access to the full network associated with that facility. This is a way to bring existing resources together to work cooperatively, and to address the capacity gaps that were noted. R4D is currently providing technical assistance to pilot this approach in two districts in Ghana.
Finally, we recommended greater coordination between the various government agencies. Currently, certain regulations are impeding the ability of the system to work well. For example, the CHPS workers are supposed to go out into the community and see people, but NHIS is unable to pay them for this outreach work, nor can they pay a qualified nurse or midwife who provides assisted delivery to a woman at the CHPS level, due to regulations. We recommend creating a National Health Commission, an independent coordinating body that reports to the minister of health and will address issues to do with coordination of regulations, financing of health care from all public sources, and priority setting to guide NHIS payment and reimbursement practices. A technical subcommittee can also look at new procedures, new drugs, etc., and advise on whether to include these in the NHIS.
What came next? How were these recommendations presented and received?
CA: In July 2016, we presented a draft of the report at a national stakeholder workshop with about 300 attendees. Ghana’s vice president, minister of finance and minister of health also attended the workshop and provided input.
We incorporated these comments and submitted a final version of the report in September 2016.
Now, that the government has the final report and recommendations. What are the next steps?
CA: Well, we had an election on Dec. 7 last year, and a new president was elected. This means the committee will need to get the new president and administration up to speed on the findings and recommendations. Their transition team did ask the NHIA for a copy of the NHIS Review report, and that is a good start. We’re hopeful President Nana Akufo-Addo is committed to NHIS reforms; in fact, he has stated repeatedly that he wants to revive the NHIS, which after all was created when his party was last in power. We stand ready to assist him and his government to take forward these recommendations and ensure they are implemented.
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