Post on 27-Mar-2015
OPERATIONALISING
HEALTH INSURANCE IN GHANA:
CHALLENGES AND WAY FORWARD
Dr Nicholas A. TweneboaDirector of Operations
National Health Insurance Authority
OUTLINE OF PRESENTATION
1. Introduction2. Population coverage3. Benefit package4. Sources of funding5. Implementation architecture of NHIS6. Provider selection and reimbursement7. Claims administration8. Implementation outputs9. Challenges10.Strategic direction11.Conclusion
Operationalising health insurance in Ghana 21-10-09
INTRODUCTION
NHIS of Ghana established by National Health Insurance Act, 2003 (Act 650) and National Health Insurance Regulations, 2004 (L.I. 1809)
3 types of health insurance schemes•District mutual schemes (DMHIS)•Private mutual schemes•Private commercial schemes
All regulated by National Health Insurance Authority (NHIA)
Operationalising health insurance in Ghana 21-10-09
POPULATION COVERAGEPolicy objective• “To secure the provision of basic
healthcare services to persons resident in the country”
Exempt from premium payment• Indigents • Social security contributors (formal
sector)• Pensioners• 70 years and above• Under 18• Pregnant women
Operationalising health insurance in Ghana 21-10-09
BENEFIT PACKAGE
Comprehensive• Out-patient, in-patient, surgeries• GP consultation, specialist • Comprehensive diagnostic
Exclusions few, notably:• Infertility• Dialysis for chronic renal failure• Anti-retroviral medications• Conditions covered by vertical
programmesOperationalising health insurance in
Ghana 21-10-09
SOURCES OF FUNDING
National Health Insurance Fund (NHIF)• 2.5% of social security• 2.5% consumption tax (NHIL)
Premium from informal to DMHISMiscellaneous Sources• Donations• DP support
Operationalising health insurance in Ghana 21-10-09
IMPLEMENTATION ARCHITECTURE
(of the National Scheme)District mutual health insurance
schemes• 145 companies limited by guarantee;
boardsNational Health Insurance Authority
(NHIA) is body corporate responsible for regulation of schemes
Governing Board of NHIA is National Health Insurance Council (NHIC)
Responsible ministry is the Ministry of Health
Operationalising health insurance in Ghana 21-10-09
Implementation Architecture (2)Relationship between NHIA and DMHIS• NHIA registers and licenses DMHIS• NHIA approves premiums for DMHIS• NHIA supports DMHIS: logistics, salaries,
administrative costs, subsidies, reinsurance for claims payment, capacity building
• DMHIS send requests and reports to NHIA • NHIA cannot register members for DMHIS• NHIA accredits providers but cannot contract
providers for DMHIS; DMHIS cannot accredit
Operationalising health insurance in Ghana 21-10-09
PROVIDERS SELECTION AND REIMBURSEMENT
Accreditation of health care facilities by NHIA
Contracts between DMHIS and providersReimbursement mechanism• Payments are made to health care
facilities, not professionals or subscribers
• Started with fee for service• G-DRG in effect since April 1, 2008
Operationalising health insurance in Ghana 21-10-09
CLAIMS ADMINISTRATION
Claims processing by DMHISClaims reimbursement by DMHIS• Premiums collected locally• Subsidy from NHIA• Reinsurance from NHIA
Operationalising health insurance in Ghana 21-10-09
IMPLEMENTATION OUTPUTS
Membership (cumulative as at June 2009)• 13,840,198 registered (67% population –
2004 estimates)• 12,146,526 total ID cards issued to date• 87.8% of registered to date issued cards • 309,110 indigents registered• 721,163 pregnant women under free
maternal care since July 2008
Operationalising health insurance in Ghana 21-10-09
Implementation Outputs (3)
Accreditation of providers• Provisionally accredited: all public and
CHAG facilities (circa 4,000) and 1,551 private facilities
• Formal accreditation: 618 facilities inspected July-August 2009; analysis completed; results for publishing soon
• Over 1,500 new applications being processed for inspection beginning Nov.
Operationalising health insurance in Ghana 21-10-09
Implementation Outputs (4)
NHIS ICT platform (870 sites hooked up)• All 145 schemes hooked up• 714 provider sites hooked up• 11 NHIA
NHIS uniform ID card• Production in progress• 4,500,000 produced
Operationalising health insurance in Ghana 21-10-09
Implementation Outputs (5)
G-DRG tariffs and NHIS Medicines List• Implemented since April 1, 2008• Review: medicines completed and in
effect since 1st October 2009; tariffs review initiated
Operationalising health insurance in Ghana 21-10-09
CHALLENGESImplementation Architecture• Standardisation and governance challenges• Weak portability• Career progression issues
Claims administration• Providers: delays submission; misapplication
of tariffs; gaming • Schemes: capacity; reimbursement • Subscribers indulge in provider shopping
and abuse of gatekeeper system
•
Operationalising health insurance in Ghana 21-10-09
Challenges (2)
ICT implementation• Provider site challenges• Scheme site challenges
Membership • Coverage: vulnerable groups; renewals
Quality of care‘Linen washing’ rampant, e.g. about
indebtedness
Operationalising health insurance in Ghana 21-10-09
STRATEGIC DIRECTION
Goal• To deliver on the NHIS promise of
providing access to quality health care for all residents in Ghana
Operationalising health insurance in Ghana 21-10-09
Strategic Direction (2)
Strategic Objectives (Sep ‘09 – Dec ’10) are to:• Implement one-time premium• Review legislative framework• Improve claims administration• Achieve full portability with fully
operational ICT solution• Overhaul NHIS communication
strategyOperationalising health insurance in
Ghana 21-10-09
Strategic Direction (3)
Implement one time premium payment• Preliminary actuarial analysis
concludedReview legislative framework• Aims to remove implementation
bottlenecks• Complete by end of 2009
Operationalising health insurance in Ghana 21-10-09
Strategic Direction (4)
Improve claims administration• Pilot claims centre in Accra• Pilot electronic claims submission at
selected provider site(s)Achieve full portability• Address ICT implementation challenges • Improve ID card production-distribution
cycleOverhaul communication strategy• Increased engagement with stakeholders• Innovative deployment of marketing mix
Operationalising health insurance in Ghana 21-10-09
CONCLUSION
NHIS is acceptedAchievements and challenges recognisedStrategies have been advanced towards:
• One National Scheme. one corporate entity, one governing board
• One ID card, one ICT platform• One premium, one-time payment• One claims administration system
WE KNOW WE CAN“YES, WE CAN!”
Operationalising health insurance in Ghana 21-10-09
Thank you!!
for your attention
and for continued partnership
Operationalising health insurance in Ghana 21-10-09