KEY LESSONS LEARNED AND CHALLENGES FACED: THE GHANA EXPERIENCE. Nathaniel Otoo

Transcription

1 KEY LESSONS LEARNED AND CHALLENGES FACED: THE GHANA EXPERIENCE Nathaniel Otoo

2 Content History of health coverage in Ghana Evolution of CBHI in Ghana Design of the NHIS NHIS Operational Performance Financial Sustainability Achievements & Challenges

3 History of healthcare coverage in Ghana

4 Healthcare coverage during internal self- government period Policy framework for enhanced health services developed Indigenization of health human resources accelerated Health Infrastructure expansion & improvement starts Scale-up of primary healthcare and village health services Removal of user fees recommended by Maude Commission, inspired by UK NHS

5 Evolution of healthcare coverage in Post Independence Ghana Policies Policies expansion of infrastructure re-introduction of user fees Input shortages High Gov t expenditure removal of user fees/reimbursement of mission hospitals cessation of private practice in public facilities Continued high expenditure Input shortages Constriction of access suspension of user fees due to public dissatisfaction reinstatement of user fees to take effect after government change Hospital Fee Act of 1971 passed to enable part cost recovery User fees unchanged Low fee recovery income Constriction of access Attendance at rural facilities made free Continued investment in rural health infrastructure Chronic shortages Deterioration in health status Development of primary healthcare health for all policy Drastic reduction in funding for health due to poor economy

6 Period before rapid evolution of community health insurance ( ) policy/program Surcharges on imported medicines and medical equipment effect Shortage of medicines & poor state of equipment User fees & full cost recovery for drugs (Hospital Fee Law, Legislative Instrument 1313) Bamako initiative (direct input supply to communities) Cash & Carry (payment for drugs by facilities at collection, Cost recovery for medicines & user fees for services) Improved drug availability Full benefits not realized. Abandoned after 3 years Healthcare unaffordabl e to 69% of population Reduced demand for services Improved drug availability Revenue loses due to ill-defined exemptions Illegal charges and fraud

7 Ghana s healthcare system prior to the NHIS Founded on free health care model. Could not be sustained therefore token user fees first introduced in Fully-fledged user fee system known as Cash and Carry came into effect 1985 to recover 15% of operating costs. System was not ideal, given Ghana s socio-economic, cultural and political context. Community health insurance schemes were developed as a response to these challenges however most schemes were not viable. The NHIS was therefore developed with a view to extending financial access to healthcare for the population.

8 Evolution of CBHI in Ghana

9 Ghana s first formal Mutual Health Organization Name: Nkoranza Mutual Health Organization Sponsor: Catholic Diocese of Sunyani Implementer: St. Theresa s Hospital Year of Establishment: 1986 (formal launch in 1992) Funding Partner: Memissa (Dutch Christian NGO) Objectives of Scheme: Encourage residents of district district to pool financial resources to pay for hospitalization needs. Improve the district population s access to curative care by making health care delivery more affordable. Provider Payment Method: Fee for Service Contributions: GHC1.2 Membership: Family based membership Benefits: hospitalization, including medical consultations, drugs, laboratory services, surgery, X-ray services, admission fees, and complicated delivery. Outpatient services for snakebites. Ailments related

10 Lessons Learnt from Community Health Insurance initiatives in Ghana (1) Best practices in scheme design are required for CBHIs to be viable. Small risk pools present challenges as few schemes had in excess of 10,000 members. Inadequate quality of care, especially at public health facilities, a key factor constraining growth. Perception that CBHIs offer poor quality is off-putting for potential members. Strong provider contracting regimes are important for CBHI survival. Direct reimbursement of claims to members encourages fraud. Strong population willingness to participate in the NHIS due to previous exposure to risk pooling principles.

11 Lessons Learnt from Community Health Insurance initiatives in Ghana (2) CBHIs helped decrease in OOP. CBHIs often use fee-for-service as they lack the capacity to develop more complex provider payment methods. Most CBHIs lack suitable managerial and insurance-specific technical knowledge, community mobilization and monitoring and evaluation skills. Enrolment of informal sector workers presents numerous problems. Good regulatory regime essential for sustainability of CBHIs. Political will and public support critical for scaling up CBHIs as a basis for moving towards UHC. Scaling up CBHIs into national models require critical adaptations/leveraging of governance structures at all levels.

12 Transition from CBHI to NHI Lessons learned from CBHI shaped design of NHIS. The NHIS was established by an Act of Parliament in 2003 (Act 650). IV. Challenges & Way Forward Majority of the258 CHBIs in existence in 2003 were integrated into NHIS. Initiative by Government to secure financial risk protection against the cost of healthcare services for all residents in Ghana. Act was revised in 2012 NHIS Act 852.

13 Design of the NHIS

14 NHIS Risk Pooling Architecture NHIL (2.5% VAT) SSNIT Contributions (2.5% of payroll) Interest on Fund (Investment Income) Road Accident Fund Workmen s compensation Premium & Registration Fees Other Income Ministry of Finance and Economic Planning National Health Insurance Fund (NHIF) 1. Transfers for Claims Payment/Admin 2. Processing Fee Retention Support to Partner Institutions (MOH) 10%] Admin. & General Expenses of NHIA Payment to Healthcare Providers District Offices of NHIA

15 Percentage of Income NHIS sources of funding Mainly comprises a combination of the following three sources: National Health Insurance levy (NHIL) 2.5% VAT 2.5 percentage points of Social Security (SSNIT) contributions Graduated informal sector premium 100% 90% 80% 70% 60% 2,2% 13,9% 3,9% 4,6% 23,6% 8,2% 6,4% IV. Challenges & Way 18,0% Forward 21,2% 5,2% 11,9% 17,9% 5,8% 4,3% 16,6% 15,7% 11,9% 4,3% 5,3% 3,7% 4,7% 1,6% 3,4% 4,5% 3,6% 3,4% 17,4% 18,0% 20,0% 20,4% 50% 40% 30% 83,5% 67,8% 64,2% 60,5% 61,8% 65,0% 72,7% 73,1% 71,9% 73,8% 20% 10% 0% NHI Levy SSNIT Contributions Premium Income

16 Benefits package Outpatient Services General and specialist consultation including reviews. Requested investigations including laboratory investigations, x-rays and ultrasound scanning. Out Medication, namely, IV. Challenges prescription & Way Forward drugs on National Health Insurance Medicines List, traditional medicines approved by the Food and Drugs Board and prescribed by accredited medical and traditional practitioners. HIV/AIDS symptomatic treatment for opportunistic infections. Out-patient/Day Surgical Operations. Out-patient Physiotherapy.

17 Benefits package (2) Outpatient Inpatient Services General and Specialist in-patient care. Requested investigations including laboratory investigations, X-Rays and Ultrasound scanning for inpatient care. Medications: prescription IV. Challenges drugs & Way Forward on National Health Insurance Medicines List, traditional medicines approved by the Food and Drugs Authority and prescribed by accredited medical and traditional medicine practitioners, blood and blood products. Cervical and Breast Cancer Treatment. Surgical Operations. In-patient physiotherapy. Accommodation in the general ward. Feeding (where available).

18 Benefits package (3) Emergencies All emergencies covered. These refer to crisis health situations that demand urgent intervention and include: Medical emergencies. IV. Challenges & Way Forward Surgical emergencies including brain surgeries due to accidents. Pediatric emergencies. Obstetric and gynecological emergencies including caesarian sections. Road traffic accidents. Industrial and workplace accidents.

19 Exemptions policy Is the Exemption Regime sustainable under the current benefit package? Category Premium Processing Fee Informal sector Under 18 years No IV. Challenges & Way Forward 70 years and above No SSNIT contributors No SSNIT pensioners No Indigents/LEAP beneficiaries No No Pregnant Women No No Persons with mental disorder No No

20 NHIS Operational Performance

21 Proportion of population covered (%) NHIS membership trend ` 45% 40% 35% 41% (11.3 million) 30% IV. Challenges & Way Forward 25% 20% 15% 10% 5% 0% 6% (1.3 million) Year

22 NHIS membership by category ` UNDER 18 44,0% ABOVE 70 3,9% INDIGENTS 13,1% IV. Challenges & Way Forward INFORMAL 29,1% SSNIT PENSIONERS 0,2% SSNIT SECURITY SERVICES 0,2% PREGNANT WOMEN 5,7% active membership as at December Million

23 NHIS accredited facilities by grade (2014) GRADE NUMBER OF FACILITIES PERCENTAGE (%) GRADE A GRADE A GRADE B GRADE C Grade D TOTAL

24 NHIS accredited facilities by type (2014) Type Number Of Facilities Percentage (%) Chemical Shops Pharmacies CHPS Clinics Dental Clinic Diagnostic Centres Eye Clinic ENT Health Centres Laboratories Maternity Homes Physiotherapy Polyclinics Primary Hospitals Secondary Hospital Tertiary Hospital Ultrasound Total

25 Utilization Outpatient Utilization Trend IV. Challenges & Way Forward

26 Amount (GH Million) Claims Payment Trend (GH Million) , IV. Challenges & Way Forward 787, ,71 616, ,64 395, , ,60 35,48 79,26

27 Financial Sustainability

28 AMOUNT (GH MILLION) NHIS Income & Expenditure Trend (GH Million) INC > EXP IV. Challenges & Way Forward INC < EXP 0 (200) (400) Income Expenditure Surplus/Deficit

29 5) Establishment of Claims Processing Centers. Efficiency measures (1) The NHIA has embarked on a number of cost containment measures to ensure financial sustainability including: 1) Institution of Clinical Audits. 2) Linking Diagnoses to treatment to: i. Improve quality of care IV. Challenges and contain & Way cost. Forward ii. iii. Improve efficiency in claims processing. Simplify claims processing. 3) Enforcement of prescribing levels as stipulated in the Essential Medicines List of the Ministry of Health to ensure quality care for subscribers and minimize supply-side moral hazard. 4) Enforcement of adherence to treatment protocols.

30 Efficiency measures (2) 6) Strengthening the monitoring of provider payment methods. 7) Introduction of electronic claims submission and processing to inject greater efficiency, speed and uniformity in claims management. IV. Challenges & Way Forward 8) Improving information systems to obtain credible data for analysis to provide pointers towards unusual trends. 9) Reviewing operational processes to ensure efficient use of resources.

31 Sustainability levers Key Income side factors Level of Control Impact Level NHIL Limited Very High SSNIT Contributions Limited High Premium Little Control Low IV. Challenges & Way Forward Efficiency gains Full Control Medium Key Expenditure side factors Benefits Package (Cost of services and medicines). Membership coverage. Utilization of health care services.

32 Achievements & Challenges

33 Achievements of the NHIS Ghana s NHIS has: Made significant progress in providing financial risk protection for residents in Ghana over the past decade. Improved health-seeking behaviour of a significant proportion of the population IV. evidenced Challenges & by Way substantial Forward increase in membership and utilization of health care services. Increased financial flows for health service delivery, however, there has been a retrogression in the last few years. Engendered private sector investment in the delivery of healthcare services thereby improving access. Been recognized as a promising model for social protection in health.

34 Challenges How to sustain the pro-poor focus. Financial sustainability Fraud and abuse. Poor evidence bases for the formulation of the NHIS benefits package. Agitation for higher tariffs. IV. Challenges & Way Forward Increasing enrolment under current financial constraints. Quality of healthcare services. Governance & stakeholder management. Excessive politicization of the NHIS undermining ability to take critical decisions. Poorly developed strategic purchasing systems. Patchy and uncoordinated health information systems that inhibit effective monitoring and generation of evidence for decision

35 Emerging NHIS Challenges based on limited media content analysis membership card issuance delays 5% quality of provider services/extra charges 10% delays in provider reimbursement 30% inadequate funding 10% delays in releases from MOFEP 5% high admnitrative costs 5% too broad benefits package 5% fraud & abuse 15% uncovered diseases 5% inadequacy of tariffs 10%

36 Review of NHIS instituted by the Government in September 2015 To establish a sustainable, pro-poor and a more efficient NHIS, by redesigning, reorganizing and reengineering the scheme. To create a solid IV. ground Challenges for & Way improved Forward service delivery across the scheme, in order to facilitate better provision of services to residents. To create a smart scheme based on knowledge and evidence.

37 Objectives of NHIS Review Improve financial sustainability of the scheme. Increase public confidence of the scheme. Increase coverage of poor and vulnerable groups in the scheme. Increase efficiency in health service purchasing. IV. Challenges & Way Forward Improve knowledge and information systems for decision making. Increase accountability and efficiency in the operations of the scheme. Provide a framework for periodic review of the scheme. Alignment the scheme to broad health sector goals.

38 Partnering with Private Sector for Successful NHI implementation If well planned and conceived, the private sector could be a reliable partner for: Regulation. Governance. Health service provision. Quality improvement. Financial intermediation. Information systems support. IV. Challenges & Way Forward Commodity supply chain improvement. Customer care.

39 THANK YOU Ndiyabulela Siyabonga Dankie Asante Sana Shukran Obrigado