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Ghana’s journey to UHC so far: Successes and Challenges Irene Agyepong Amarteyfio Nov 4 th 2013 1.

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Presentation on theme: "Ghana’s journey to UHC so far: Successes and Challenges Irene Agyepong Amarteyfio Nov 4 th 2013 1."— Presentation transcript:

1 Ghana’s journey to UHC so far: Successes and Challenges Irene Agyepong Amarteyfio Nov 4 th

2 Introduction Major reform like an NHIS is social and political as well as technical What has been our socio-political as well as technical journey towards UHC Outline of presentation – The Vision behind the NHIS – Health policy environment /context Past to present Processes and pathways – Health System – Successes and Challenges Population coverage Service access and Health Systems Strengthening Financial protection (reducing fees and cost sharing) What next? 2

3 The vision behind the NHIS “Ultimately, the vision of government in instituting a health insurance scheme in the country is to assure equitable and universal access for all residents of Ghana to an acceptable quality package of essential healthcare. …….. every resident of Ghana shall belong to a health insurance scheme that adequately covers him or her against the need to pay out of pocket at the point of service use in order to obtain access to a defined package of acceptable quality of health service’.” (MOH 2002, MOH 2004) NHI policy framework for Ghana 3

4 The Vision & UHC 4

5 Policy Environment (Context) Historical Political Social Economic Demographic External - International 5

6 Policy Environment (Context) PRE-INDEPENDENCE (COLONIAL ERA) Payment for health services mostly private out of pocket Some public financing mainly for expatriate civil servants Public and private service delivery Developing a reasonably comprehensive, universally accessible and affordable national health system for the population does not appear to have been a priority 6

7 Policy Environment (Context) IMMEDIATE POST INDEPENDENCE Government of 1 st republic ( ) tried to attain universal access to comprehensive health services Approach: – Tax funded public sector health services free at point of use – Improvement of access by rapidly expanding public sector infrastructure and human resource numbers and skills Private sector continued to be user fee financed At independence Ghana had a net budget surplus Adequately financing a universal health service free at point of service through taxes increasingly difficult as economy failed to grow significantly and country experienced increasing budget deficit Political instability – British type parliamentary constitution -> One party state -> 1966 coup - > multiparty elections >1972 coup 7

8 Policy Environment (Context) Brief spell of multi-party democracy followed by 1972 coup Recorded mention of consideration of health insurance as a financing option – but ?no action actually taken Continuing economic challenges – A drastic devaluation of the cedi as a response to increasing external debt and donor pressure to do something or no more credits was one of the triggers of the Jan 1972 coup Almost a decade of military government ( ) and continuing economic problems (inadequate growth) Token user fees 8

9 Historical, Political and Economic Context GNI Data source: 9

10 The eighties to the present (GNI Data source: 10

11 Policy Environment (Context) 11

12 Policy Environment (Context) Small formal sector Large non formal sector Only about 4% of Ghana’s population is registered in the SSNIT Not all formal sector workers are registered in SSNIT (e.g. University workers) However even at a generous estimate formal sector may not reach 10% of the population 12

13 Some Dynamics that affected process How to raise enough money internally for UHC in the context of Ghana – LIC in 2003 when law was passed – Difficulties in mobilizing tax /premiums – Skeptical donor community Wide spread social discontent with the cash and carry system combined with the desire to fulfill a popular election promise opened the window of opportunity The tapping into the lessons of the previous decade on what could and could not work in terms of health insurance in Ghana The tensions between political expediency and technical quality Stakeholder dynamics both positive and negative including enthusiasm, suspicions, mistrust and how they were managed Administrative and technical capacity Rent seeking behavior System weaknesses 13

14 The Dynamics “Successful public policies and programs are rare because it is unusual to have progressive and committed politicians and bureaucrats (saints) supported by appropriate policy analysts with available and reliable information (wizards), that manage hostile and apathetic groups (demons) and consequently insulate the policy environment from the vagaries of implementation (systems)” Aryee J.R.A (2000) Saints, Wizards, Demons and Systems. Explaining the success or failure of public policies and programs. Department of Political Science, University of Ghana, Legon 14

15 The Design 15

16 The Evolution of NHIS Governance Arrangements - Act Devolved Payers (District Schemes) Governing body Scheme Manager Clients General Assembly Providers Public Private Registration, licensing and regulation NHIC

17 The Evolution of NHIS Governance Arrangements (Act 852 – 2012) 17 Single Centralized Payer (NHIA) (Deconcenteration) Clients Providers Public Private ?????? Regulator

18 Health System and Service Access 18

19 Payment and Provision Inter-relationships Public Sector GHS Quasi govt. e.g. Military, Police & Universities Private Mission (CHAG) Private Self Financing GOG-CF Budgets Salaries Donors SBS Programs GOG-NHIF (NHIA) G-DRG (services FFS with schedule (Meds) Clients (OOP) FFS no schedule 19

20 Service Delivery Resource Constraints WHO (2006) Working together for Health. The World Health Report Current public spending about USD 30/capita on health – bulk on HR payment 20

21 National Level Expenditures by line item (GOG consolidated funds) 21

22 2012 MOH Expenditure 22

23 Trends in Public Sector Revenue Greater Accra 23

24 Population Coverage (Source: NHIA 2011 annual report) 24

25 SHINE project 2009 Central & Eastern region Overall insurance coverage 30% Evidence of inequity in enrollment Higher enrollment in richest quintile (41%) compared to HH in the other quintiles (p=0.000). Non-renewal rate of 14.3%, significantly higher among the rich (Q5) 25

26 Service Utilization Numbers – Claims per active member – Utilization insured and uninsured Inputs – Services content – Prescription content 26

27 Trends in insured visits and claims per active NHIS member 27

28 OPD visits/person insured (active) and uninsured (non active) 28

29 Survey data gives same message as HMIS data SHINE project – CR & ER 2009 Insured individuals are 2.5 times more likely to utilise OPD services (p<0.001) Equity in utilization for the insured, inequities for the uninsured 29

30 Inputs – Services (2013 G-DRG evaluation data) Shifting (referring of cases) – “……you can imagine somebody bringing an ulcer ….. and you know that (dressing) a big sore daily….the cost will go up so you will lose… so we were losing, so that was why most of us were not dressing this thing, we refer them to the hospital… … yes, even the suturing too was a problem the money was just a token ….” Rural Health Center nurse Under supply – “… the grouped billing…. is a disincentive to carry extensive investigations” Pharmacist, Urban Polyclinic – Reduction of lab tests /out of pocket payment for laboratory tests: “Payment for lab test…” client at exit interview on reasons for dissatisfaction with NHIS 30

31 Service Inputs - Prescribing & Dispensing (2013 G-DRG Evaluation Data) 31

32 Medicines (2013 G-DRG Evaluation data) Client exit interview data suggests problems in medicine access under the NHIS 93% of clients in the exit interviews were positive about the NHIS However of 7% (41) who felt the NHIS was bad, a little over half (22) gave a reason related to the failure of the NHIS arrangements in relation to medicines prescribed. E.g. – “The aspect where the scheme does not cover all the drugs is worrying to us especially we the poor …..”; – “Situations where I have to buy some drugs”; – “They do not give all the drugs”; – “Buying drugs outside the hospital while you still have a valid insurance”; – “Dislike the NHIS because initially it was supposed to be free but now I'm made to buy drugs anytime”. 32

33 Medicines – Why? The NHIS policy requires that medicines prescribed are on the NHIS Essential Medicines List (EML) and that they are prescribed by generic name. The NHIS EML is a sub-set of the national EML. Providers have repeatedly complained that the reimbursement rates for some medicines on the NHIS EML are too low. It is possible that this perception of a too low tariff would negate any desire to prescribe more medicines since it would not necessarily increase income. Indeed it might increase loss. There is a contextual problem. Medicine prices in Ghana are extremely high. This is a problem whose solution lies beyond the NHIS but would still affect the NHIS - this and also already existing irrational prescribing behavior (rather than massive gaming per see) may explain why medicines are consistently a large part of the NHIS payment over the years 33

34 Fees and Cost sharing SHINE project CR & ER (2009) 34

35 Fees and Cost Sharing (SHINE project ER & CR 2009) 35

36 Achievements Single pooled fund – no fragmentation Local mobilization of the funds through local taxation system (VAT) and payroll (SSNIT) is sustainable – it is the amounts that are currently a challenge A scheme that has survived for 10 years and that nobody wants to go away A scheme that has clearly had some of the desired effects – Increased OPD utilization – Protective effects for the insured poor (OOP and catastrophic expenditure) Strong and genuine continuing high level government commitment to successful reform 36

37 Challenges – Inadequate funds (NHIS income and expenditure) 37

38 Challenges All dimensions of UHC – Population coverage – Services access and coverage – Out of pocket expenditures The challenges are linked in their effects and solutions 38

39 What next? “Would you tell me, please, which way I ought to walk from here?” “That depends a good deal on where you want to get to,” said the Cat. – From Alice in Wonderland by Lewis Carroll. 39

40 What next? Strategies to sustainably push the dimensions to complete the box Sustainability = meeting the needs of today without compromising those of tomorrow 40

41 What next? 41

42 Thank You 42


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