Building up Health Insurance: the Experience of Ghana

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1 Building up Health Insurance: the Experience of Ghana Dr. Caroline Jehu-Appiah Ghana Health Service 5 th April 2011, Basel

2 Presentation outline Background Achievements Challenges Success factors Way forward

3 Health financing reform milestones in Ghana At independence (1957) public health services were free in the 1970s introduced nominal fees due to economic decline leading to insufficient financing In the 1980s instituted user fees_ LI1313 Hospital fees with the aim of recovering at least 15% of cost In 1993 full cost recovery for drugs (cash & carry) with lots of public dissatisfaction and horror stories Piloting of Community-based health insurance schemes in 1990s grew to 159 by 2002, (of which 57 were district-wide) but only covered 1% of the population.

recovering at least 15% of cost In 1993 full cost recovery for drugs (cash & carry) with lots of public dissatisfaction and horror stories

4 . And in August Based on an earlier electoral promise - Government took a political decision to introduce by law - a Social Health Insurance the National Health Insurance Scheme (NHIS). The NHIS is unique and a hybrid of Classical single payer scheme for the organised formal sector Multiple payer semi-autonomous (DMHIS) for the non-formal sector Whilst allowing for private mutual's and commercial schemes

Social Health Insurance the National Health Insurance Scheme (NHIS).

5 Key Structures The National Health Insurance Authority (NHIA) Regulates, registers, licenses, supervises schemes, accredits health care providers and manages the NHI Fund. The National Health Insurance Fund (NHIF) Premiums from subscribers. 2.5% National Health Insurance Levy on all goods and services. 2.5% Social Security and National Insurance Trust (SSNIT), deductions from the formal sector. Funds from Government of Ghana (GoG) allocated by Parliament Returns on investments Support from Donor eg DANIDA Support and DFID District Mutual Health Insurance Schemes (DMHIS) district mutual health insurance schemes (145), private commercial health insurance schemes (4) private mutual health insurance schemes (3)

Funds from Government of Ghana (GoG) allocated by Parliament Returns on investments Support from Donor eg DANIDA Support and DFID District Mutual Health Insurance Schemes (DMHIS)

6 Relationship between NHIA and DMHIS NHIA registers and licenses DMHIS NHIA approves premiums for DMHIS NHIA supports DMHIS: logistics, staff salaries, administrative costs, subsidies, reinsurance for claims payment, capacity building DMHIS are semi-autonomous DMHIS send requests and reports to NHIA NHIA accredits providers but cannot contract providers for DMHIS 6

subsidies, reinsurance for claims payment, capacity building DMHIS are semi-autonomous

7 Defined benefits under the NHIS.. Membership structure Informal sector workers annual premiums GH 7 48 cedis ($5 -$32) Formal sector employees (SSNIT contributors) Exemptions for indigents, children under 18 yrs, elderly and pregnant women Benefits package Covers 95% of disease burden in Ghana Outpatient care Inpatient care (including feeding) Deliveries, including complications Diagnostics Drugs All emergencies

employees (SSNIT contributors) Exemptions for indigents, children under 18 yrs, elderly and pregnant

8 Profile of NHIS membership Schemes in operation 145 Total Registered 14,282,620 % Population Registered 60.1% Total ID Card Bearers 12,123,338 (50.1%) ID Card Bearers as % of Total Registered 84.9% CATEGORIES, NUMBERS AND % TO TOTAL CARD BEARERS Category Number % of ID Card Bearers Informal Adult 4,132, % Aged (>=70 years) 960, % Under 18 years 7,071, % SSNIT Contributors 876, % SSNIT Pensioners 75, % Indigents 444, % Pregnant Women 721, %

9% CATEGORIES, NUMBERS AND % TO TOTAL CARD BEARERS Category Number % of ID Card Bearers Informal Adult 4,132,783 28.

9 NHIS sources of revenue in 2009.

10 Results Achieved

11 Impact on coverage (Source: MOH 2010)

12 Impact on care seeking GLSS4 (1999) GLSS5 (2006) Had a medical problem Sought care 43 60

13 Impact on OPD utilization

14 Trends in OPD attendance per capita

15 Impact on OOP (Source: WHO 2010 and WHO Global Health Observatory)

16 Impact on OOP Among those ill/injured in the two weeks before the survey, the insured paid 72% less than the uninsured for treatment (7,259 cedis and 25,682 cedis respectively, p<0.01). About 86% of the uninsured had positive expenditures on treatment, compared to 38% of those insured by the NHIS at time of illness (p<0.01). Average expenditures for hospitalization decreased from 357,262 to 199,488 cedis (p=0.08). The proportion of hospitalized individuals who incurred any outof-pocket expenditures for their inpatient treatment was halved, from 87% to 43% (p<0.01). Pooled probit regression analysis showed a decline of 55 percentage points in the likelihood of incurring hospitalization expenditures between 2004 and 2007.

08). The proportion of hospitalized individuals who incurred any outof-pocket expenditures for their inpatient treatment was halved, from 87% to 43% (p<0.01).

17 Impact on quality of care 99% of patients thought they were treated in a friendly way 81% thought they were given sufficient information on their illness Source: Ghana public expenditure tracking survey (2008) Source : Jehu-Appiah et al 2011 Community perceptions and their implications on the NHIS (HP&P forthcoming)

illness Source: Ghana public expenditure tracking survey (2008) Source :

18 TREND OF FINANCIAL INFLOWS TO HEALTH SECTOR

19 Disbursement to schemes Item (GH ) (GH ) (GH ) (GH ) Subsidy disbursed to schemes Total Reinsurance Support paid Admin & Logistical Support Grand Total 34.63m 70.10m m m 0.85m 9.17m 21.55m 39.85m 8.10m 13.60m 14.82m 8.37m 43.58m 92.87m m 341.0m

Logistical Support Grand Total 34.63m 70.10m 118.53m 333.01m 0.85m 9.

20 Comparison of actual income and expenditure (Source NHIA 2010) 20

21 Implementation challenges

22 Cost-escalation Fraud and moral hazard Unreliable eligibility authentication at provider site Weak enforcement of gatekeeper system (referral system) Providers gaming the system to maximize reimbursement payments Inefficiencies and high administrative costs Fragmented claims processing centres (145)

23 Provider payment mechanisms FFS for medication- increase in the # of drugs per prescription from 2.4 in 2004 to 6 in Resulting in cost escalation as drug prices are on average 300% of median international reference price DRG system leading to an immediate increase in claims and tariff creep

24 Claims cost per card bearer

25 Supply side and other constraints Infrastructure, drugs and logistics, human resources Delays in reimbursing providers 14% drop-out rate from the NHIS Legal challenges 59 legal issues Inequities in NHIS coverage and utilization difficulty identifying indigents

26 Inequity in enrolment (Asante and Aikins 2008, DHS 2008, Jehu-Appiah et al. 2011).

27 Proposals for change. Cost containment strategies Mixture of provider Payment Mechanisms; Capitation for all outpatient primary care services (Piloting in Ashanti) Centralization of claims processing and payment systems Enforcement of gate-keeper system Introduction of centralized consolidated premium account Manual to electronic claims submission to reduce delays Extending coverage to the rest of the population and the very poor Linking financing to results 27

28 Key success factors The overall performance of the NHIS may be attributed to Strong political drive and leadership, Learning from the previous MHO experience in social protection, and Willingness to be bold and innovative.

29 Conclusion Coverage against the risk of illness and financial protection has grown rapidly and is now more than half the population and climbing; The NHIS has increased the financial resources available to the sector very significantly, so much so that Ghana has attained its Abuja target. The NHIS has demonstrated that it is possible to design and implement a social health insurance scheme not only for formal sector employees in Africa but also for rural and informal sector populations as well.

30 Thanks for your attention!

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