The National Health Insurance Scheme in Ghana: Best Practices. Regional Conference on Social Health Protection in East African Community

Transcription

1 The National Health Insurance Scheme in Ghana: Best Practices Regional Conference on Social Health Protection in East African Community Dr. Lydia Dsane-Selby Director, Clinical Audit National Health Insurance Authority, Ghana 11 th September, 2012

2 Outline of Presentation Brief background & milestones Membership, Income & Expenditure Adaptable lessons Challenges & Conclusion

3 Background of NHIS (1) The NHIS was established by an Act of Parliament in 2003 (Act 650) in response to challenges posed by Cash and Carry system A Social Health Protection Policy initiated by Government of Ghana to secure financial risk protection against the cost of healthcare services for all residents in the country. Act makes provision for 3 types of schemes o District (Public) Mutual o Private Mutual o Private Commercial

4 Innovative (takes into account Ghana s unique situation). Covers both the formal and informal sectors Contribution mechanism Background of NHIS (2) o National Health Insurance levy (NHIL) - 2.5% VAT o 2.5 percentage points of SSNIT contributions o Graduated informal sector premium based on ability to pay Earmarked funds (VAT & SSNIT) constitute over 90% of total inflows Started as pilot with 45 districts and is now nationwide (155 districts) 4

5 Benefit Package (1) 95% of disease conditions in Ghana o In-patients services o Out-patient services o Maternal health services (Antenatal, Deliveries including Caesarean Section & Postnatal) o Emergencies Outpatient services include HIV/AIDS symptomatic treatment for opportunistic infections. 5

6 Benefit Package (2) Exclusions o Cosmetic surgeries o Echocardiography o Dialysis for chronic renal failure o HIV Antiretroviral drugs o Cardiac & Neuro-surgeries except resulting from accidents o Mortuary services o Organ transplant o Prosthetic implants 6

7 Milestones (1) LI 1808 passed 2005 Claims Payment started (Fee for service) nd Tariff review started National ICT project started Free Maternal Program started G-DRGs introduced Act 650 passed 1 st Actuarial Study 1 st Scheme established Blanket accreditation granted

8 Milestones (2) st Actuarial Review Full scale Accreditation started 2010 Clinical Audit started Claims Processing Centre (CPC) established 1 st annual report published Review of Act 650 started 2011 Review of Free Maternal Care Policy implementation 2012 Capitation Pilot (Ashanti) Call centre established Review of Act 650 of 2003 laid in parliament To introduce Electronic Claims mgt. To establish CPC (2) Increase in NHIL Electronic linkage of Diagnosis to Treatment Rollout Capitation nationwide Intensify Clinical Audit Full implementation of ERM Framework

9 Active Membership (New Members & Renewals) by Region as at Dec 2011 Region Population 2010 Active Members (New Members & Renewals in 2011) Active Members as percent of Population ASHANTI 4,780,380 1,939, % BRONG AHAFO 2,310, , % CENTRAL 2,201, , % EASTERN 2,633, , % GT. ACCRA 4,010,054 1,056, % NORTHERN 2,479, , % UPPER EAST 1,046, , % UPPER WEST 702, , % VOLTA 2,118, , % 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% Active Members as % of population as at Dec 2011 WESTERN 2,376, , % 0.0% AS BA CR ER GA NR UE UW VR WR TOTAL 24,658,823 8,204, % REGION Note: Figures are provisional & Population based on 2010 census figures 9

10 Distribution of Active Members by Category 2011 (EOY) Informal sector 36.9% SSNIT contributors 4.4% SSNIT pensioners 0.4% Under 18 years 49.7% Indigents (18-69) 3.8% Note: Figures are provisional 70 years & above 4.8% Note: Pregnant Women - 5.9% 10

11 Distribution of Income by Source (2011) SSNIT Contributions 17.4% Premium Income 4.5% Interest on Fund 5.3% Other Income 0.1% IDA Funding (Worldbank) 0.03% NHI Levy 72.7%

12 Expenditure by Category (2011) NHIS ID Card Expenses 1.3% Operating Expenses (NHIA) 4.0% Support to MOH 18.4% Admin & Logistical Support (SCHEMES) 2.6% IDA Project (Worldbank) 0.5% Fixed Assets (Capital Expenditure) 1.0% Claims Payment 72.2%

13 Measures to ensure financial Sustainability Cost containment Clinical Audits Consolidated premium account Uniform prescription form with prescriber identification Link diagnosis to treatment Electronic claims management Support disease prevention activities Proposed additional funding sources Increase in Health Insurance Levy (NHIL) Levy on Petrochemical industry Review NHIL exemptions policy Road Fund e.t.c. 13

14 Adaptable Lessons from NHIS (Ghana) (1) ICT Infrastructure, Data Management & Call Centre Source: Adapted by Sylvester A. Mensah (2010) (NHIA : 2010 Annual Report)

15 Adaptable Lessons from NHIS (Ghana) (2) Innovative ways of covering the poor and vulnerable through exemptions policy Exempted from premium payment Category Premium Proc. Fee Informal sector Under 18 years 70 years and above SSNIT contributors SSNIT pensioners Pregnant women Indigents LEAP beneficiaries Paying Non-Paying 15

16 Adaptable Lessons from NHIS (Ghana) (3) The NHIS and MDGs MDG 1 Poverty & Hunger Free registration and access to healthcare for the poor and vulnerable. Thus, preventing catastrophic health expenditures and poverty MDG 4 Child Mortality All persons under 18 years have free access to health insurance. They represented almost 50% of registered members as at December MDG 5 Maternal Health Free maternal care policy introduced in July 2008 MDG 6 HIV/AIDS, Malaria & TB Malaria & HIV opportunistic diseases are covered

17 Adaptable Lessons from NHIS (Ghana) (4) Non-partisan political will and commitment Comprehensive Accreditation system o Public, Private & Mission facilities o Assess staffing, management systems (including quality and safety) o Health care delivery systems and processes o Well accepted due to participation by all stakeholders A mix of provider payment mechanisms (i) Fee for Service (ii) The Ghana DRG system (iii) Capitation (Pilot state) Clinical audit for the promotion of quality and cost containment Call Centre Annual stakeholder meetings 17

18 Challenges (1) 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 drugs Ability to pay premium/renewal Challenges Quality of care challenges Waiting times 18

19 Challenges (2) EXTERNAL (Cont d) Clinical Audit findings Wrong application of Tariffs Irrational Prescription of medicines Inflation of quantities of medicine supplied Unauthorized co-payment Provision of services above accreditation level Patient folder retrieval challenges Overbilling of medicines 19

20 Conclusion Ghanaian initiative, home grown and local leadership Learning through experience and adaptation. Improved health seeking behaviour of subscribers/patients Over 90% of patients in both private and public facilities are health insurance subscribers. Over 85% of IGF of Public facilities are derived from the NHIS. High public confidence in the NHIS. Bi-partisan political will and support. Healthy collaboration, cooperation and support of the Ministry of Health 20

21 GLOBAL RECOGNITION FOR GHANA S NHIS Thank You