Scribd Logo
Upload

Welcome to Scribd!

  • 256 views

    Nhis Ghana - Overview Reforms Achievements Version 3

    Uploaded by

    Nana Virtuoso Essel
    The document summarizes the 10 year history and achievements of Ghana's National Health Insurance Scheme (NHIS). Key points include: - NHIS was established in 2003 through legislation to provide financial access to healthcare for all residents. It is funded through a combination of tax revenues and contributions. - Over the 10 years, membership has increased 7 times to nearly 9 million people. Utilization and claims payments have also increased substantially. - Milestones include expanding benefits, introducing case-based payments and electronic claims processing to improve efficiency. - Challenges remain around long-term sustainability, reducing costs while maintaining quality. Future plans include increasing revenues, expanding coverage of the poor, and continuing reforms to ensure universal

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Nhis Ghana - Overview Reforms Achievements Version 3

    Uploaded by

    Nana Virtuoso Essel
    256 views29 pages
    The document summarizes the 10 year history and achievements of Ghana's National Health Insurance Scheme (NHIS). Key points include: - NHIS was established in 2003 through legislation to provide financial access to healthcare for all residents. It is funded through a combination of tax revenues and contributions. - Over the 10 years, membership has increased 7 times to nearly 9 million people. Utilization and claims payments have also increased substantially. - Milestones include expanding benefits, introducing case-based payments and electronic claims processing to improve efficiency. - Challenges remain around long-term sustainability, reducing costs while maintaining quality. Future plans include increasing revenues, expanding coverage of the poor, and continuing reforms to ensure universal

    Original Description:

    kok

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document summarizes the 10 year history and achievements of Ghana's National Health Insurance Scheme (NHIS). Key points include: - NHIS was established in 2003 through legislation to provide financial access to healthcare for all residents. It is funded through a combination of tax revenues and contributions. - Over the 10 years, membership has increased 7 times to nearly 9 million people. Utilization and claims payments have also increased substantially. - Milestones include expanding benefits, introducing case-based payments and electronic claims processing to improve efficiency. - Challenges remain around long-term sustainability, reducing costs while maintaining quality. Future plans include increasing revenues, expanding coverage of the poor, and continuing reforms to ensure universal

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    256 views29 pages

    Nhis Ghana - Overview Reforms Achievements Version 3

    Uploaded by

    Nana Virtuoso Essel
    The document summarizes the 10 year history and achievements of Ghana's National Health Insurance Scheme (NHIS). Key points include: - NHIS was established in 2003 through legislation to provide financial access to healthcare for all residents. It is funded through a combination of tax revenues and contributions. - Over the 10 years, membership has increased 7 times to nearly 9 million people. Utilization and claims payments have also increased substantially. - Milestones include expanding benefits, introducing case-based payments and electronic claims processing to improve efficiency. - Challenges remain around long-term sustainability, reducing costs while maintaining quality. Future plans include increasing revenues, expanding coverage of the poor, and continuing reforms to ensure universal

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    You are on page 1of 29

    10 years of Financial Access to Quality Healthcare.

    Towards Universal Health Coverage: Increasing Enrolment


    whilst Ensuring Sustainability

    National Health Insurance Scheme in Ghana:


    Reforms & Achievements
    Sylvester A.
    Mensah
    (Chief Executive, NHIA)

    International Conference Centre,


    Accra, Ghana
    November, 2013

    Contents
    Overview
    Operational Performance
    Milestones
    Achievements
    Challenges & Way Forward

    Overview

    Major Characteristics of NHIS


    The NHIS was established by an Act of
    Parliament in 2003 (Act 650).

    Initiative by Government to secure


    financial risk protection against the cost
    of healthcare services for all residents in
    Ghana.

    Act was revised in 2012 NHIS Act 850


    4

    Major Characteristics of NHIS


    Funding - Combination of the following
    models

    Beveridgean: National Health Insurance levy - 2.5%


    VAT
    Bismarckian: 2.5 percentage points of Social
    Security contributions
    MHO: Graduated informal sector premium based on
    ability to pay

    Earmarked funds (NHIL & SSNIT)


    constitute over 90% of
    total inflows

    The New NHIS Act 2012 (Act


    852)

    Significant revisions in the Law include


    the following:
    A Mandatory NHIS
    A Unified NHIS with District Offices
    Premium exemptions for persons with
    Mental
    Disorders
    Expenditure cap of 10% on non-core NHIS
    activities
    Relevant family planning package
    6

    Board oversight committee for


    i. Scheme Operations

    Key Players in NHIS


    Architecture
    MINISTRY OF
    HEALTH
    (MOH)

    PROVIDERS
    (Public &
    Private)

    Provision
    of quality
    services
    7

    Stewardship
    (Policy & Regulation)

    Submission of Claims
    Payment of Claims

    Utilizati
    on of
    services

    SUBCRIBER

    PURCHASER
    (NHIS)

    Pays
    Premi
    um

    Ensure
    provision
    of quality
    services

    Revenue Sources & Allocation


    (Act 852)

    NHIL
    (2.5% VAT)

    SSNIT
    Contributions
    (2.5% of
    payroll)on
    Interest
    Fund
    (Investment
    Road Accident
    Income)
    Fund
    Workmens
    compensation
    Premium &
    Registration
    Fees
    Other Income

    Ministry of
    Finance

    National Health
    Insurance Fund
    (NHIF)
    Transfers
    for
    Claims
    Pmt
    District Offices
    of the NHIA

    Payment to
    Healthcare
    Providers
    Admin. &
    General
    Expenses of
    Support
    to the
    NHIA
    Ministry of
    Health

    [Capped @ 10%]

    Payments to
    Health care
    Providers
    8

    I. Overview
    Provider Payment Mechanism
    A mix of provider payment mechanisms:
    FEE FOR SERVICE
    Medicines
    G-DRG
    Secondary & Tertiary
    care
    CAPITATION*
    Primary care*
    Medicines
    Services

    2005
    2008
    2012

    FFS

    FFS

    G-DRG for
    outpatient
    & inpatient
    Capitation for
    services
    outpatient
    primary care

    FFS

    G-DRG for inpatient,


    outpatient
    specialist and
    emergency care.

    FFS

    NHIS & MDGs


    MDG 1

    Poverty &
    Hunger

    MDG 4

    Child Mortality

    MDG 5

    Maternal
    Health

    MDG 6

    HIV/AIDS,
    Malaria & TB

    Free registration and access to


    healthcare for the poor and
    vulnerable. Thus, preventing
    catastrophic health expenditures
    and poverty
    All persons under 18 years have
    free access to health insurance.
    They represented almost 50% of
    registered members as at
    December 2012.
    Free maternal care policy
    introduced in July 2008

    Malaria, TB, HIV opportunistic


    diseases are covered

    Reforms in Ghanas Health


    System
    1957
    1970s
    1985
    1990s

    Free health care policy


    implemented.
    Ghana experienced economic shocks and
    began structural adjustment programs.
    Nominal payments for health services
    introduced.
    User fees (cash & carry) was introduced.
    This policy excluded majority of people from
    access to healthcare
    Community-based mutual health insurance
    schemes were introduced.

    2000

    High out-of-pocket expenditure on health


    and very low utilization of health services.

    2003

    National Health Insurance introduced.

    Exemption Policy
    Category
    Informal sector
    Under 18 years

    Exempte
    d from
    premium
    payment

    70 years and
    above
    SSNIT
    contributors
    SSNIT pensioners
    Indigents
    Pregnant women
    LEAP beneficiaries

    12

    Premiu
    m

    Proc.
    Fee

    NHIS Value Chain

    RESIDE
    NTS IN
    GHANA

    Reviewing Benefit Package, Medicines


    & Tariffs
    ICT Infrastructure, Data Management &
    Call Centre
    Communication, HR, Training,
    Conflict Resolution & Stakeholder
    Management
    Provider
    Financi
    Membership
    Certification
    Provider
    al Risk
    & ID card
    Claims Mgt.
    & Quality
    Payment
    Protecti
    Mgt.
    Assurance
    on
    Monitoring & Evaluation, Risk
    Assessment, Research & Development
    Financial/Clinical Auditing & Controls
    Financing

    Adapted by Sylvester A. Mensah

    IMPROVI
    NG
    HEALTH
    STATUS
    ENSURING
    PATIENT
    SATSFACT
    ION

    Operational
    Performance

    14

    Membership, Utilization &


    Claims
    2005
    Active
    Members
    hip
    Outpatie
    nt
    Utilizatio
    n
    Inpatient
    Utilizatio
    n
    Claims
    Payment
    15

    2012
    8.9 million

    1.3 million

    m
    7 ti

    es

    23.9 million
    598 thousand

    40 s
    e
    tim

    1.4 million
    29 thousand

    48 s
    e
    tim

    GH 616 million
    GH 7.6 million

    81 s
    e
    t im
    Source: Unaudited Financial
    Statements

    Milestones

    16

    Milestones (2003 - 2005)


    2005
    Claims
    Payment
    2004
    started
    (Fee for
    LI 1809 passed
    service)
    NHIS officially
    launched
    2003

    17

    Act 650
    passed
    1 st 45 pilot
    schemes
    formally
    established
    by law

    1 st Actuarial
    Study
    Blanket
    accreditation
    granted

    Milestones (2007 - 2009)


    2009

    2008
    F ree
    2007
    2 nd Tariff
    review
    started
    National
    ICT project
    started

    Maternal
    Program
    started

    G-DRGs

    introduced

    1 st Actuarial
    Review
    Decoupling of
    Children
    Full scale
    Accreditation
    started
    Scheme Audit by
    NHIA
    Review of Act
    650 started

    Milestones (2010 - 2013)


    2013
    Established CPC 2 & 3

    2011

    2010

    Review of Free
    Maternal Care
    Policy
    implementation

    Clinical Audit
    started
    Claims
    Processing Centre
    (CPC 1) established

    2012

    Introduced E-claims on
    pilot and scaling up

    Capitation
    Pilot (Ashanti)

    Electronic linkage of
    Diagnosis to Treatment

    Call centre

    Intensified Clinical
    Audits

    Review of Act 650


    Act 852 passed
    Started preparation
    towards e-claims
    management.

    Instant ID Cards on pilot


    and scaling up
    Scale up Capitation on
    incremental basis
    Increase in NHIL
    Full scale
    implementation of ERM
    Framework

    Achievements

    20

    Achievements (1)
    Innovative funding:

    o Earmarked fund NHIL (2.5% VAT)


    o 2.5 % Social Security Contributions
    o Informal sector contributions

    Promotion of acceptability through


    community ownership
    using district based sub-schemes
    Non-partisan support
    Comprehensive credentialing system and
    post credentialing inspection
    Involvement of both public and private
    health care providers
    Clinical audit based on sampling for
    promotion of quality and
    cost containment
    Claims verification based on detailed and
    comprehensive review

    Achievements (2)
    Call Centre
    Claim Processing Centres
    Electronic Claims Management
    Instant issuance of ID Cards based on BioData
    Revised NHIS Act 2012 (Act 852)
    Stakeholder engagement
    Restructured organization
    Reviewed vision and mission
    New work ethic

    Challenges & Way


    Forward

    23

    Challenges
    INTERNAL
    Financial sustainability of the scheme
    Identification of the poor in the informal
    sector
    ID card management challenges
    ICT Challenges
    EXTERNAL
    Moral hazard (Both demand & supply side)
    Pharmaceutical supply chain challenges
    (High cost of medicines)
    Ability to pay premium/Renewal
    Challenges
    Quality of care
    Waiting times

    Measures to ensure
    sustainability (1)
    Cost
    containment

    Clinical Audits
    Claims Processing Centre
    Consolidated Premium
    Account
    Capitation
    Unique Prescription Form
    Linking Diagnoses to
    Treatment / E-claims
    Medicines List and Prescribing
    Levels
    25

    Piloting NHIS medicines at negotiated


    price

    Measures to ensure
    sustainability (2)
    Additional
    Funding

    Increase in Health Insurance Levy


    (NHIL)
    Review NHIL exemptions
    policy
    5% Road Fund
    Levy on tobacco and alcoholic
    beverages
    20% Communications service
    tax
    Levy on Petrochemical
    Industry
    26

    Way Forward (1)


    Enhance financial sustainability through
    cost containment and additional sources of
    funding.
    Intensify Clinical Audits
    IV. Challenges
    Way Forward
    Scale up instant
    ID &Card
    issuance
    Increase coverage of the poor
    Improve computerization of operations
    Shorten claims processing and payment
    time
    o E-Claims & Additional CPCs

    Way Forward (2)


    Strengthen audit and risk management
    systems as well as reward and sanctions
    to reduce fraud and abuse.
    Establish a Health Insurance Institute in
    IV.(PPP)
    Challenges & Way Forward
    partnership
    Scale up CPC claims management
    coverage
    Rollout capitation in a stepwise
    approach
    Encourage high level evidence-based
    research into health insurance policy
    issues to inform future policy direction

    Thank You

    You might also like