Social Protection and Healthcare Financing: Ghana s NHIS Experience by Danaa Nantogmah, FES Ghana

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1 Social Protection and Healthcare Financing: Ghana s NHIS Experience by Danaa Nantogmah, FES Ghana Introduction and Background The 2010 provisional census results estimated Ghana s population at 24,233,431 made up of 11,801,661 males (48.7 %) and 12, 421,770 females (51.3 %). Ghana s population growth rate declined from 2.7 percent per annum to 2.4 percent (Ghana Statistical Services, February 2011). In Gross Domestic Product (GDP) terms, Ghana has achieved a significant economic growth in the past 25 years. Over last two decades, GDP growth rate has averaged 5 percent. In the last three years, average growth has exceeded 6 percent. According to the Ghana Statistical Services Ghana s GDP growth in 2008 was 7.2 percent. A recent rebasing of the economy by the Ghana Statistical Services saw Ghana moved from a developing country to low middle income country with a per capita income of GHc 1, (US$ 1,289). The rebasing also saw the services sector taking over as the largest contributor to GDP from the agriculture. Ghana s traditional export products include cocoa, gold, timber and manganese. In December 2010, Ghana began production of oil in commercial quantities. Until the establishment of the National Health Insurance Scheme (NHIS) in 2004, the provision of health care in Ghana was based on a pay-as-you-go system known as cash and carry : whilst the Government meets around 80 per cent of the cost for public health care, the remainder is paid by the end user at the time of use. For over twenty years successive governments have recognized the unsatisfactory nature of this system, which acts as a disincentive to use of health care facilities; excludes the poorest; and limits access generally. The National Health Insurance Scheme (NHSI) is a social protection initiative with the primary objective to provide financial risk protection against the high costs of healthcare expenditure for all residents in Ghana. The scheme prioritizes protection of poor and vulnerable in society through the principles of equity, solidarity, risk-sharing, cross-subsidization, re-insurance and subscriber/community ownership. Notwithstanding its challenges, the NHIS has evolved into a model of healthcare financing in the global South and in recognition of it as a learning hub and innovation, the NHIS won the coveted UN award for Excellence in November The primary objective of this paper is to discuss the evolution of NHIS, challenges and prospects and lessons for Africa and the global South. Evolution of the Ghanaian Health Sector Healthcare delivery in Ghana has a chequered history. Following the country s independence in 1957, Osagyefo Dr. Kwame Nkrumah, first President of Ghana, introduced a policy of free education and health. Between 1957 and 1966, all Ghanaians could seek medical attention in any government hospital or health center and pharmacy at no financial cost to the individual. However, hospital fees were re introduced in 1969 and continued in some variety until the introduction of the cash and carry system in In 1983, the Rawlings administration

2 adopted the International Monetary Fund (IMF) and World Bank promoted Structural Adjustment Program (SAP). Since a key component of the SAP was to reduce government expenditure to the barest minimum, the full burden of paying for health care was borne by patients. For example, government expenditure on health was reduced from 10% of the national budget in 1982 to 1.3% in As many people could not afford to pay the requisite fees at point of delivery to seek medical attention, they avoided going to hospitals and health centers; instead they engaged in self medication or other cost saving behaviors or practices. In 1995 proposals were made in a report, A feasibility study for the establishment of a National Health Insurance Scheme in Ghana, but this was limited to formal sector workers and registered cocoa farmers. An attempt to pilot the scheme in 1997 stalled for a variety of reasons. However, in parallel to this effort, a number of voluntary Mutual Health Organizations (MHOs) were established with the help of donor funding. In 2002 there were around 159 MHOs in Ghana, with 67 districts involved. The oldest MHO in Ghana is at Nkoranza, in the Brong Ahafo region, which was established in The Ministry of Health also helped establish an MHO in the Dangme West district, Greater Accra region, in 1998, to test the feasibility of such schemes in the context of a possible national system. National Health Insurance Scheme (NHIS) Due to the increasing health inequality and the lack of access by poor and vulnerable to healthcare in Ghana, the New Patriotic Party (NPP) government established the National Health Insurance Scheme (NHIS) with the enactment of the National Health Insurance Act, 2003 (Act 650). Act 650 established an independent council known as the National Health Insurance Authority (NHIA), a statutory body mandated to secure the implementation of the National Health Insurance Scheme. It is responsible for the registration, licensing and regulation of health insurance schemes in the country. It also has the role of supervising the operations of District Mutual Health Insurance Schemes (DMHIS), grant accreditation to healthcare providers and to monitor their performance for efficient and quality service delivery. It is responsible for managing the National Health Insurance Fund and devising mechanisms to ensure that indigents are adequately catered for under the NHIS. Furthermore, the National Health Insurance Regulation, 2004 (LI 1809) provide operational guidelines for the implementation of the National Health Insurance Scheme. The Act established three types of insurance schemes, namely i) District Mutual Health Insurance Scheme (DMHIS), ii) Private Mutual Health Insurance Schemes (PMHIS), and iii) Private Commercial Health Insurance Scheme (PCHIS). The DMHIS which would be not for profit and subsidized by government was to be created by every district in the country for its residents. In this respect, the DMHIS is said to be district focused. Unlike the DMHIS, the PMHIS may be established and operated by any group of persons, community, occupation, or religious group in Ghana. Not only would it be not for-profit, the PMHIS would not receive government subvention and may not have a district focus. The PCHIS would be established and

3 operated for profit and therefore premiums of subscribers would be based on the calculated risks of the subscribers, and would not have a district focus. The membership of NHIS is opened to all persons resident in Ghana by subscription. However, the Act 650 exempts some sections of the population from paying premiums to access the benefits provided by the scheme. They include: Children under 18years. Residents aged 70 years and above. The indigent (poor). In 2008, a free maternal care policy was instituted to provide free ante-natal and postnatal care to all pregnant women. In 2010 the scheme is operational in 145 districts across the country with a total cumulative membership of over 18 million (60% of total population), out of which over 8 million, representing 34% of Ghana s current population are active card bearing members. Upper West Region had the highest active population coverage rate of 53% whiles Central Region recording the lowest active coverage rate of 23%.(see Table 1). Out of a total number 2915 health facilities inspected, 2647 of them received formal accreditation since the inception of the exercise in Table 1: New Member, Renewing and Active Membership in 2010 Region 2010 New Members 2010 Renewals 2010 Active Members Ashanti 606, ,748 1,585,097 Brong Ahafo 323, ,462 1,014,554 Central 303, , ,717 Greater Accra 316, , ,343 Northern 349, , ,335 Upper East 238, , ,867 Upper West , ,065 Volta 263, , ,305 Western 466, , ,976 Ghana 3,519,590 4,644,124 8,163,714 Source: NHIS Annual Report, 2010 A further analysis of active NHIS subscribers by category shows that 47.7% were less than 18 years, 31.8 % non-except group (informal sector), SNNIT Pensioners-0.4%, pregnant women- 8.6, SNNIT contributors-4.7%, 70 years and above-5.4 and indigents-1.4%. (NHIS Annual Report, 2010) Financing the NHIS In terms of financing the NHIS, Act 650 clearly delineated the funding sources:

4 2.5% Social Security and National Insurance Trust (SSNIT) contributions Premium from subscribers (GH 7.20 to GH 48.00) 2.5% National Health Insurance Levy (NHIL-VAT) on goods and services Funds from Government of Ghana as allocated by Parliament Returns on Investment and Donations Table 2: NHIS funds-2009 Sources % NHIL 61.7 SNNIT 15.0% Premiums 3.8% Returns on Investment 17.0% Budgetary allocation 2.3% Other (e.g. donations) 0.2% Total 100% Source: Social Protection in Africa, unpublished Governance and Management The Scheme is governed by a 16-member council drawn from various stakeholder organizations. The management of the scheme is led by a Chief Executive with ten (10) divisions, regional and district offices. The primary activities are membership registration and ID card management, provider accreditation and quality assurance, claims management and provider payments. These are supported by secondary activities which include research and development, monitoring and evaluation, an ICT infrastructure and data management, financial and clinical audits, effective communication with internal and external publics, human resource management, conflict resolution and stakeholder management. Another key supporting activity is financing, which refers to how funds are mobilised from different sources to pay for services rendered under the NHIS services. Additionally, the NHIS in collaboration with stakeholders develops and maintains the NHIS medicines list and tariffs system in accordance with the benefits package. Achievements Increased Coverage from 1.3 million 2005 to 18 million in 2010, with over 8 million active subscribers UNDP/WHO Excellence Award for leadership in health insurance implementation within the global south. Claims Processing Centre (CPC) Financial and clinical Audit- clinical audit alone recovered a total of GHc 16.8 million from services provider

5 Capitation pilot in Ashanti Region. Proposed establishment of National Health Insurance Institute Challenges Notwithstanding these achievements, the NHIS is faced with a number of Challenges; including: Politicization of the Scheme Financial Sustainability of the scheme Administrative bottlenecks (delay in processing membership and claims) Identification of the indigents (poor) in the informal sector Corruption-scheme staff and service providers Limited healthcare facilities Conclusion and Recommendations A recent evaluation of NHIS suggest that the reason for enrolling is cost effectiveness and financial security, NHIS members have significantly better health outcomes and more likely to have prenatal health care, have birth in hospital and attended by trained health care professionals, less likely to experience infant deaths and birth complications and most NHIS members (over 60%) are satisfied with the system (Frimpong et al 2009). However, since the main reason for non-enrolment is finance (90%), finance is a major barrier to NHIS enrolment suggest the need review/improve issues related to equity in insurance coverage Like Ghana most countries in Africa, in the 1980s and 1990s were compelled by financial constraints to remove government subsidies on health care and now trying to use social insurance to alleviate financial burden and improve access in health care delivery. Health care provision is quite similar across countries in Africa (public health facilities provide health care to about 60% of pop compared to 30% by private). References Ghana Statistical Services (GSS) November New Series of Gross Domestic Product (GDP) Estimates. (accessed 6 November 2011) Government of Ghana (2003) The National Health Insurance Act (Act 650, 2003) National Health Insurance Scheme (NHIS) Annual Report International Labour Organization (2005) Improving Social Protection for the poor: Health Insurance in Ghana, ILO, Accra

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