Unbinding NHIS’ potential for universal health coverage

The introduction of the National Health Insurance Mutual Scheme in 2003, and the subsequent enactment of the relevant legislative (ACT 852) and implementation frameworks have resulted in Ghana’s huge leap towards a reduction in financial hardship in individual and household healthcare costs, the mitigation of catastrophic health expenditure and a consequent expansion in universal access to health care.

The continuous increase in health insurance enrolment and utilisation as evidenced in nationwide patronage of NHIS services attests to the significance of the scheme. Successive governments have acknowledged the role of this social solidarity form of safety net and have thus put in place comprehensive management and implementation strategies through the National Health Insurance Authority (NHIA) to churn out distinctively innovative and client-centred health insurance services.

Yet, there appears to be a lacuna between the ideal goals set by leadership and the actual healthcare needs required by both service providers and members of the scheme. The need to unbind the ex-ante and ex-post mechanisms in this heterogeneous NHIS scheme as it does not clearly align to a single universally recognised health insurance system is a sine qua non.

Subscriber premium

Ghana’s NHIS bears semblance to the United Kingdom’s NHS due to its reliance on general revenue and earmarked taxes, but at the same has deviated from same because of its dependence on annual subscriber premium payment as in the case of some known public and private health insurance systems.

Mandatory social security contributions made by employers and employees onto the scheme also makes it an employee insurance. These pluralistic modes of funding, not leaving out earmarked taxes, external aid and the NHIS levy, clearly complicate the mobilisation, and pooling of NHIS funds, and thus affect the timeliness of payments made by the scheme.

To the substantive issue, for the NHIS to strive towards universal coverage, there is the need to move for a nationwide net enrolment of at least 80 per cent to 90 per cent. The issues pertaining to enrolment as permitted by the various pathways among which is subscriber premium payment, exclusion payment by SSNIT contributors, various forms of aid given to members on LEAP and people living with functional difficulties, and special enrolment drive are all meant to increase coverage.

However, another deviation from general health insurance enrolment principles leads to a structural bottleneck in enrolment.

Parameter

This parameter pertains to mandatory subscriptions. The voluntary subscription to the scheme as permitted by the NHIS Act (Act 852) needs urgent amendment. This directly affects revenue mobilisation, pooling and the predictive ability of the insurance regulatory in determining the annual inflow of funds, and at the same time contributes to challenges in early reporting and diagnosis as a result of subscription and renewal delays.

Provider adverse selection and client self-induced moral hazard should not be entertained in any health safety net in the country. Thus, the NHIA should be commended on its enrolment of all residents in Ghana in the scheme without varying premiums based on existing health conditions and personal factors.

However, there is an urgent need to introduce compulsory annual basic medical examination prior to subscription and renewal as it will enhance the predictive ability to estimate annual expenditure levels and determine the availability of funds, especially when enrolment becomes legally mandatory while putting in mechanisms for social inclusion.

Further, there is a need for a national-level discourse and action on the premium levels and duration for renewal. Though the debate might favour the current annual subscription of less than GH¢50 which can be paid on electronic mobile platforms using a USSD code (*929#), there is a need for a systematic review of all the contributions generated from the pluralistic funding sources, and the actual expenditure incurred and funded on the various funding lines as a net proportion of the pool funds.

Also, there is the need to conduct needs and situational assessments to determine subscriber preferences and capacity to pay as part of the sustainable financing modalities. Short-term subscriptions and graduated premium payments determined on a point-based system are thus encouraged to mitigate funding challenges and delays in reimbursement to service providers.

As a subsidiary national health account, the implementation of a separate national health account backed by appropriate legislation and regulatory framework for the mobilisation, pooling and purchasing of health insurance services will facilitate speedy but efficient transactions by the NHIA.

As electronic modes of claims generation, processing and submission have been established for service providers, similar systems should be enhanced for claim reception, processing, auditing and reimbursement with appropriate timelines established.

By and large, the heightened political commitment, expertise and public interest in the NHIS emphasise its crucial role in the advancement of the health of the nation. Though the writer does not point out any issue relating to the recent developments on the inclusion of coverage for certain chronic conditions in the current NHIS, the writer supports this in principle.

However, it is strongly recommended that such efforts should be piloted in a separate or subsidiary chronic disease and long-term disability National Insurance Scheme which outlines subscription modalities, funding sources and implementation strategies under the legal mandate of the NHIA.

Efforts

In sum, efforts need to be made to streamline the funding sources of the NHIS. If general revenue and earmarked taxes will remain a major funding source, then mandatory enrolment should be a major component of the scheme.

In choosing this pathway, there is a need to put across propositions for a post-treatment co-payment component of between one to 20 per cent upon every usage at a facility while a point-based premium component is evaluated and incorporated.

A basic medical examination backed by law should be tied to enrolment and renewal while negating any possibility of adverse selection.

Careful analysis of the funding sources and pooling should be done to ensure financial sustainability and reduce catastrophic expenditure in healthcare costs on individuals and households.

The electronic systems for claims generation, processing, submission and reception should incorporate adequate feedback loops, monitoring and validation mechanisms to enhance timely reimbursement of NHIS services.

To this end, Ghana needs our support to advance the health of the nation through the application of a resilient but adaptive health insurance system.