Increasing the Efficiency, Effectiveness and Sustainability of Ghana’s National Health Insurance Scheme

The Challenge

In 2003, Ghana launched the National Health Insurance Scheme (NHIS), a government-led health insurance program which aimed to replace a system dubbed “cash-and carry” that required patients to pay user fees at the point of service. The NHIS, which is funded mostly by a 2.5% value-added tax, is the only health insurance scheme in sub-Saharan Africa that aims to provide a standardized, nearly comprehensive package of health services to all residents with no fees at the point of service. Over the past 13 years, the NHIS has achieved 40.2% population coverage, increased user access to curative services, and reduced out-of-pocket payments for those who are enrolled.

Despite these extraordinary gains, Ghana’s National Health Insurance Authority (NHIA) – the governing body of the NHIS – still faces a number of challenges, including escalating costs that threaten the long-term sustainability of the NHIS and inadequate use of evidence and monitoring and evaluation tools that would allow management to improve the quality and efficiency of health care for Ghanaians. To assess some of these issues, a 17-member committee has been inaugurated to review the NHIS. The committee has been tasked to review the NHIS, propose options for reform, and provide a blueprint for the NHIS that is national in character and transcends political transitions.

The Opportunity

Health provider payment mechanisms – the way health care providers are paid to deliver the covered package of services – are an important but often under-utilized tool in the overall health financing policy toolkit. As coverage expands in most countries, issues of financial sustainability, efficiency, and quality of care quickly rise to the surface.  In 2010, Ghana’s NHIA began piloting capitation – a payment mechanism in which health providers are paid a uniform per capita fee for a set number of health services – in an effort to control escalating costs, as well as improve the efficiency and effectiveness of health services and simplify claims processing. As the NHIA is in the process of scaling up capitation in three additional regions, there is a need to reflect on lessons learned from the Ashanti Region pilot to ensure that the NHIA, regional health officials and the providers themselves have information about the capacity of providers to deliver the capitation services, where capacity gaps exist, and what options are available for closing capacity gaps such as through structured training of trainers and forming Preferred Primary Care Provider Networks.

Routine and systematized generation and use of data is necessary to successfully reform provider payment and achieve the NHIA’s other priority goals. The NHIA, which already regularly collects clinical, financial and membership data is developing tools and policies to make better use of data to inform decisions at all levels of the organization.

Our Work

As part of USAID’s five-year Health Finance and Governance (HFG) Project, R4D worked with Abt Associates to support the NHIA’s transition to a more strategic and evidence-based health purchaser to promote financial sustainability of the scheme.

R4D implemented two streams of work in support of these goals.

The strategic health purchasing work stream focused on four activity areas:

1. PHC capitation scale-up and formation of preferred PHC provider payment networks. Under this activity, R4D supported the NHIA to put in place routine tools to better manage and align provider payment systems, including the institutionalization of routine provider mapping to track provider capacity to deliver essential services, an early warning system to manage provider responses to the incentives of capitation, and a Training of Trainers program that will build capacity on how capitation works;
2. Refinement of G-DRGs focused on corresponding service delivery improvements;
3. Claims management, information system improvement and development of a national unified cost reporting system;
4. Support ongoing policy and strategy dialogue and communications. As part of this work, the strategic health purchasing work stream participated as a member of the strategic purchasing sub-committee as a part of the national review, and provided policy inputs in the form of a deeper examination of the Ghana VAT and SSNIT earmarks for health.

R4D also helped the NHIA build capacity to generate and use data for effective health purchasing through five interconnected tasks:

1. Co-developed data dashboards that track key performance indicators for managerial action and feature real time access to data;
2. Strengthened capacity in the foundations of monitoring and evaluation at the NHIA and facilitated the development of an organization-wide policy that will coordinate M&E activities across directorates;
3. Improved the use of short-term operations research projects to address inefficiencies, including those identified by the dashboards;
4. Fostered improved knowledge management and exchange within NHIA and among its partners;
5. Supported the NHIS review. The evidence-based purchaser participates as a member of the governance sub-committee as part of the national review, and contributes to data collection and analysis used to identify current limitations and potential future improvements in NHIS governance.