Background

Universal access to good quality care remains a major concern of health systems globally.¹ Ghana was the first country in sub-Saharan Africa to introduce a national health insurance scheme (NHIS) to promote attainment of universal health coverage. The NHIS was introduced as a social intervention to replace out-of-pocket (OOP) payment at the point of health service delivery. Implementation of the NHIS contributed significantly to improved outpatient and inpatient service utilization and health outcomes.² Notwithstanding these positive contributions, sustainability of the NHIS is increasingly threatened barely a decade of its implementation.³ Active participation in the NHIS remains low with approximately 65% of Ghanaians still not enrolled.This blog discusses the operational and financial sustainability threats to the NHIS and the way forward.

Operational sustainability threats

Perceived poor quality of healthcare in accredited health facilities: Long waiting times of clients and perceived poor quality of drugs in NHIS-accredited health facilities are increasingly reducing client trust and confidence in the NHIS. In view of this perception, some insured clients prefer to hide their insurance cards and pay out-of-pocket to enjoy the perceived better quality care rendered to uninsured clients. This emerging trend if not controlled could further stagnate (re)enrolment rates into the NHIS.

Administrative lapses in NHIS district and regional offices: Even though delayed production and distribution of membership cards are important challenges confronting the scheme, introduction of biometric registration and instant issuance of membership cards by the national health insurance authority (NHIA) seem to have improved the status quo in recent times

Ineffective gate-keeper system: Health facility shopping by clients emanating from ineffective gate-keeper system potentially puts undue pressure on secondary level facilities which possibly affects quality of healthcare delivery and confidence in the scheme.

Delayed reimbursement of health service providers: This has compelled instances of co-payments on drugs and services such as laboratory procedures. Some accredited healthcare providers have also threatened to exit from the NHIS.

Other NHIS sustainability threats include spatial distribution of accredited health facilities and staff, and weak human resource capacity development of NHIS district schemes

Financial sustainability threats

Fraud and corruption at health insurance schemes: unprofessional practices at the NHIA district and regional offices have been cited as important threats to NHIS. Independent scientific basis are however limited.

Low premiums payments: Approximately 35% of the NHIS membership pays premiums because they work in the informal sector. Yearly premium payment per head for enrolment appears to be one of the lowest in the world without co-payments. Even though the cost of goods and services have increased since implementation of the scheme in 2005, these premiums have not increased in commensurate terms to meet the increasing demand for healthcare.

Escalating reimbursement cost: Claims payment to service providers is a key cost driver of the NHIS in Ghana accounting for about 78% of the NHIS recurrent expenditure in 2012. Reimbursements cost rose from GHC 7.6 million (USD 8.4 million) in 2005 to GH¢616.47 million in 2012 (USD 317.77) in 2012 (see Figure 1).

Broad benefits package without co-payment: The NHIS benefits package is arguably of the most generous in the world covering over 90% of the disease burden of Ghanaians without co-payment. Moreover, great percentage of the NHIS membership are exempt from premium payments (over 70%) meaning the scheme is predominantly tax-based.

False-claims by service providers: Huge sums of money are reportedly attributed to false claims tendered in by accredited health service providers. However, establishment of a claims processing center and strengthening clinical audits unit of the NHIA appear to have helped improve the incidence of these fraudulent acts. The NHIA reports an amount of GHC 6.7 million was saved in 2012 as a result of this computerized claims processing system.⁴

Another potential sustainability threats to the NHIS is political interferences in the management of the NHIS. For instance, appointment of the Chief Executive Officer by the sitting president of Ghana raises concerns on the autonomy of the scheme.

Figure 1: NHIS active membership by category and claims cost trend over time

                                                Source: NHIA Annual Report, 2012.

Conclusion and way forward

Ghana cannot afford to retrogress into a cash-and-carry system of healthcare financing bearing in mind the huge consequences on universal health coverage and public health outcomes. There is the need for greater concerted efforts towards stemming the marauding threats to the pro-poor social health insurance and guarantee its sustainability.

 Sustainability challenges at the level of healthcare providers could be addressed through improved monitoring and supervision by the NHIA coupled with further strengthening of the clinical audits units and claims processing centres to control unprofessional practices. Moreover, expanding the tax base of the scheme could be beneficial towards meeting the increasing cost of healthcare provision.

Furthermore, review of the exemption list for the scheme could help reduce the financial burden and reimbursement cost. Likewise, the benefits package for diseases and medicines could be reviewed to identify the most critical health needs of Ghanaians for exemption.

Timely release of funds from the finance ministry to the NHIA for provider reimbursements could also help reduce the frustrations service providers go through to render services to premium holders. Early processing and submission of claims from health providers to the NHIA for vetting could be enhanced through routine capacity building trainings for NHIA officers and health providers to reduce errors and claims rejection rate. The above points are not exhaustive but intended to stimulate further policy discourse on interventions needed to contribute towards sustaining the NHIS.

References

1.World Health Organization (WHO): Atlas of African Health Statistics 2012: Health Situation Analysis of the African Region, World Health Organization, Africa Regional Office, Brazzaville, Republic of Congo, 2012.

2. Blanchet NJ, Fink G and Osei-Akoto I: The Effect of Ghana’s National Health Insurance Scheme on Health Care Utilization, Ghana Medical Journal, 2012, 46 (2).

3. Odame EA, Akweongo P, Yankah B, Asenso-Boadi F and Agyepong I: Sustainability of recurrent expenditure on public social welfare programmes: expenditure analysis of the free maternal care programme of the Ghana National Health Insurance Scheme, Health Policy and Planning 2013; 1–9

4. National Health Insurance Authority (NHIA): Annual Report, National Health Insurance Authority. Accra, Ghana, 2012.