1. OPERATIONALISING HEALTH INSURANCE IN GHANA: CHALLENGES AND WAY FORWARD Dr Nicholas A. Tweneboa Director of Operations National Health Insurance Authority

2. OUTLINE OF PRESENTATION 1.Introduction 2.Population coverage 3.Benefit package 4.Sources of funding 5.Implementation architecture of NHIS 6.Provider selection and reimbursement 7.Claims administration 8.Implementation outputs 9.Challenges 10.Strategic direction 11.Conclusion Operationalising health insurance in Ghana 21-10-09

3. 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

4. POPULATION COVERAGE Policy 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

5. 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 programmes Operationalising health insurance in Ghana 21-10-09

6. SOURCES OF FUNDING National Health Insurance Fund (NHIF) 2.5% of social security 2.5% consumption tax (NHIL) Premium from informal to DMHIS Miscellaneous Sources Donations DP support Operationalising health insurance in Ghana 21-10-09

7. IMPLEMENTATION ARCHITECTURE (of the National Scheme) District mutual health insurance schemes 145 companies limited by guarantee; boards National 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

8. 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

9. PROVIDERS SELECTION AND REIMBURSEMENT Accreditation of health care facilities by NHIA Contracts between DMHIS and providers Reimbursement 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

10. CLAIMS ADMINISTRATION Claims processing by DMHIS Claims reimbursement by DMHIS Premiums collected locally Subsidy from NHIA Reinsurance from NHIA Operationalising health insurance in Ghana 21-10-09

11. 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

12. 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

13. 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

14. Implementation Outputs (5) G-DRG tariffs and NHIS Medicines List Implemented since April 1, 2008 Review: medicines completed and in effect since 1 st October 2009; tariffs review initiated Operationalising health insurance in Ghana 21-10-09

15. CHALLENGES Implementation 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

16. 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

17. 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

18. 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 strategy Operationalising health insurance in Ghana 21-10-09

19. Strategic Direction (3) Implement one time premium payment Preliminary actuarial analysis concluded Review legislative framework Aims to remove implementation bottlenecks Complete by end of 2009 Operationalising health insurance in Ghana 21-10-09

20. 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 cycle Overhaul communication strategy Increased engagement with stakeholders Innovative deployment of marketing mix Operationalising health insurance in Ghana 21-10-09

21. CONCLUSION NHIS is accepted Achievements and challenges recognised Strategies 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

22. Thank you!! for your attention and for continued partnership Operationalising health insurance in Ghana 21-10-09