MONITORING SYSTEM by sofiaie

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									        OPERATIONALISING
HEALTH INSURANCE IN GHANA:
  CHALLENGES AND WAY FORWARD


       Dr Nicholas A. Tweneboa
        Director of Operations
  National Health Insurance Authority
         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
            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 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
            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
         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
  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
     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 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
      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
     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
               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
                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 strategy

                Operationalising health insurance in
                         Ghana 21-10-09
           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
           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
                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
Operationalising health insurance in
         Ghana 21-10-09

								
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