At a meeting in Addis recently, officials of the Federal Ministry of Health gave glowing accounts of a recent visit to understudy Ghana’s globally acclaimed health insurance scheme. After ten years of dynamic implementation , it is fitting that the National Health Insurance Authority (NHIA) is in the next two months rolling out activities and opening up conversations to take stock, recognize achievements and challenges and chart new paths forward.
The theme for the tenth anniversary celebration is “Towards Universal Health Coverage: Increasing Enrolment whilst Ensuring Sustainability.”
At independence Ghana had aspirations for Universal Health Coverage (UHC) under Nkrumah’s free healthcare program. In 1971, Dr Felix Konotey Ahulu is reported to have made proposals for the introduction of an insurance scheme leading to the enactment of the Hospital Fee Act 387 of 1971 under the Busia administration. The PNDC government in 1985 then extended an invitation to one Mr. Amenyah, a U.S-based National Health Insurance Consultant when the issue of NHIS was revisited. This led to several pilot schemes in places like Koforidua and Akyem Oda. The role of the Catholic Church of Ghana in establishing the Nkoranza District Mutual Health Scheme in Brong Ahafo is also acknowledged. In 2003, National Health Insurance Scheme Act 650 was passed, establishing a scheme aimed at removing cost as a barrier to healthcare delivery at the point of need. By the end of 2012, membership stood at 8.8 million, up from 1.3 million in 2005, and the world marveled at the rapid expansion and success of the scheme.
Today, the NHIS has grown to become a major instrument for financing health care delivery in Ghana, accounting for over 85% of the revenue base of public and quasi-public health facilities. The scheme is also credited with improvements in the health-seeking behaviour of many people in the country.
Over the years, a number of initiatives have been put in place to simultaneously address sustainability challenges and Universal Health Coverage (UHC) goals. These were driven by a re-engineering program that was accelerated in 2009, drawing on lessons from previous experiences, with the view to re-positioning the scheme for efficiency and effectiveness.
Amongst others, these initiatives, projects and experiences include the:
• The establishment of 145 autonomous schemes in 2003
• The growth in core indicators from 2004 - 2009 that also brought challenges
• Development of an ICT infrastructure in 2007
• introduction of the Free Maternal Care Program in 2008
• commencement of a legal review process in 2009 to review Act 650
• establishment of a Claims Processing Centre (CPC) in 2010
• institution of Clinical Audit in 2010
• establishment of the Consolidated Premium Account (CPA) in 2011
• establishment of the NHIS Call Centre in 2012
• passage of the new National Health Insurance Act, 2012, (Act 852)
The scheme is currently issuing instant ID cards through a pilot biometric registration program and is reviewing capitation as a provider payment mechanism.
The challenges of the scheme will be viewed against its original objective – removing cost as a barrier – and its UHC and sustainability-related tenth anniversary theme.
When an appreciable coverage – based more or less on cumulative figures - was quoted in the periods before 2010, it was mistakenly believed that this figure was synonymous with the proportion of active card holders. Down the line, this assertion has been seriously challenged. In 2013, the actual proportion of the population with active cards currently stands at 35% , thus raising fundamental questions about the root causes of the apparent low active membership, relative to UHC ideals. Also not in contention are associated prolonged delays to receiving valid insurance ID cards even after clients have taken steps to renew them. Perhaps this will be rectified by the ongoing pilot biometric registration exercise.
The reasons for the slow growth in active enrolment need to be better understood and addressed if UHC is to be achieved. If only 35% of the population can access care as active card holders, what then are the implications for the remaining 65% of the population; have they reverted to the retrogressive out of pocket payment at the point of service delivery or have they resorted to alternate practices? More precariously, have we ended up with the situation where the bulk of the nation’s resources in health are being spent on only a few (35%)? The point is that Universal Health Coverage (UHC) is gaining traction as an overarching framework for the post-2015 development agenda with the WHO’s Director General Dr. Margaret Chang repeatedly saying “UHC is the single most important tool in public health.”
As NHIA commemorates its tenth anniversary, it will be necessary for Ghana to clarify its policy focus and implementation strategy for achieving universal coverage.
Health systems experts like my mentor Professor Irene Agyepong and others have long argued that crucial though expanding access to healthcare may be, insufficient attention seems to have been paid to supply side quality concerns. What is the state of the equipment and infrastructure in the facilities that the NHIA pays for its clients to go to? How long do clients wait before they are attended to? As the NHIS directly engages providers through its clinical audits and is confronted with evidence bordering on poor quality of care, it remains unclear what ongoing mechanism exists for tackling same.
There is also an extent to which the NHIA and to a larger extent the entire health system have been compartmentalized as opposed to adopting a systems approach with the patient at the heart of the matter. The non-inclusion of blood transfusion services within the free Maternal care program even as post-partum bleeding remains a leading cause of maternal mortality is one such example. With this function located squarely within the National Blood Transfusion service, it is clear that more needs to be done to engender the interdependence and interrelationships that are necessary within the health system to provide total solutions to the patient. That said, many mothers still have no knowledge of the exact components of this free maternal care program.
Ghana’s comprehensive NHIS benefit package has become a two edged sword by simultaneously raising serious sustainability concerns. In addition to providing coverage for vulnerable groups like mothers, children, the poor and the aged, the Minister of Health Hon. Sherry Ayittey this week reiterated government’s pledge “to further improve access by expanding coverage to people with mental health, physical disability, prostate cancer and family planning services.” While the proponents say this is good for social protection and UHC, the critics say it is a bankruptcy trap. How does Ghana reconcile the two? Indeed this issue of sustainability in the face of intense discussion as to how to expand funding options for the scheme makes the theme very appropriate and worth the vigorous planned public debate.
Today, Act 650 has been replaced by Act 852 of 2012 which creates a unitary scheme; there is a faster response time in claims processing for service providers; there is improved efficiency through clinical audit; a controlled accounting procedure through a consolidated premium account; better interaction with subscribers through the call center; better human resources practices, and improved financial access to health care for the people of Ghana. With these significant enhancements to the scheme since inception, we need to see a new image of the scheme, especially if additional funding concerns are addressed, that is truly sustainably repositioned in word and in deed.
Indeed, the ten year story of health insurance in Ghana is one in which all – client, NHIA, providers- who have played various and diverse roles must take pride.
5th September, 2013
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