OPERATIONALISING HEALTH INSURANCE IN GHANA: CHALLENGES AND WAY FORWARD Dr Nicholas A. Tweneboa...

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)


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


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


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


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


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


CLAIMS ADMINISTRATION

Claims processing by DMHISClaims reimbursement by DMHIS• Premiums collected locally• Subsidy from NHIA• Reinsurance from NHIA


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


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.



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



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


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

•


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


STRATEGIC DIRECTION

Goal• To deliver on the NHIS promise of

providing access to quality health care for all residents in Ghana


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


Implement one time premium payment• Preliminary actuarial analysis

concludedReview legislative framework• Aims to remove implementation

bottlenecks• Complete by end of 2009



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


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!”


Thank you!!

for your attention

and for continued partnership


OPERATIONALISING HEALTH INSURANCE IN GHANA: CHALLENGES AND WAY FORWARD Dr Nicholas A. Tweneboa...

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