Ghana’s National Health Insurance Scheme : A Look At Some Rudimentary Challenges And The Way Forward(2)

Framers of Ghana’s National Health Insurance scheme liken the system to an object placed on a tripod which can be kept well in place, only when all the three elements effectively play their role of providing the required support for the object.

The importance of this analogy is appreciated when one considers the extent to which the National Health Insurance Authority alone, has been blamed for the challenges that the scheme is currently facing.

In the context of the scheme,the three elements of the tripod are; the managers of the scheme called; National Health Insurance Authority,health facilities that have entered into contract with the other stakeholders to take care of required services called; service providers, and a group of Ghanaians who have chosen to take proactive measures toward their health needs, by contributing towards a fund that will be used to finance health services that is delivered to them when the need arises called;subscribers.

It therefore goes,without saying that for the system to function effectively,the primary stakeholders,namely scheme managers,service providers and subscribers,must not only perform their separate roles effectively but also work in partnership with each other.

Apparently,the crucial role of Health care service providers in ensuring efficient and sustainable National Health Insurance scheme has largely been overlooked by commentators and analyst of the scheme.

Starting from the perspective of the scheme managers,a careful look at some of the factors leading to the much talked about challenge of non-payment of claims, and delays of such payments to service providers under the scheme brings to the fore, some salient shortcomings of managers and owners of health care facilities that contributes significantly to the payment challenges that they themselves, and other Ghanaians often lament about.

A very good case in point, according to managers of the scheme, is the failure of service providers to furnish the claims office with information on changes in staff(facility managers) and related matters.

Additionally,although the scheme’s new policy guidelines requires service providers to ensure that all transactions between the scheme and service providers are presented on the letterheads of the facilities and signed by both the facility owner and managers,most service providers do not adhere to the guidelines and that affects processing of their claims adversely.

Another major cause of delay in making payment to service providers,according to NHIA officers, is improper filling of claim forms with instructions such as filling of forms in capital letters,provision of District codes etc,often ignored by facility owners.

Mention is also made of wrong statement of diagnosis and treatments, which usually leads to mismatch of claims to service delivered, and thus adversely affects computation of claims,delivery of quantity of drugs in excess of what is prescribed and substitution of prescribed drugs by chemist all of which affects vetting of claims for services delivered by facilities,and auditing of payment made by the scheme for such services, hence the tendency for the exercise of great caution by officers in the processing of claims submitted by the facilities which unfortunately, leads to delays in the entire payment exercise.

Related to these are fundamental challenges such as errors of billing for items of which payments have already been made,overbilling,giving prescription without confirming diagnosis,inappropriate prescribtions of drugs and duplication of claims,among several other simple, but crucial errors on the part of service providers.

There is no doubt that although,these are very elementary issues,they have great effect on the operations of the scheme,especially in respect of delays in making payments for services rendered by health care facilities.

It is therefore important that owners and staff of the various health care facilities under the NHIS take a critical look at the aforementioned shortcomings on their part, in order to fashion out the most appropriate and effective measures for addressing them for the sake of unimpeded transactions between the two stakeholders of the scheme,and for the efficient service delivery to subscribers.

The question of readiness of Ghanaians for the use of Information,Communication Technology in transactions of all kinds is perhaps,one thing that is slowing down the progress of the nation in all sectors,including the health services sector.

One of the issues that the NHIA has raised as a key challenge between the scheme and service providers in the overall quest for efficient and sustainable delivery of quality and accessible health service under the National Health Insurance Scheme, is the reluctance of owners of health care facilities in the country to train themselves and their staff in the uses of the various technologies that have been adopted for the scheme.

Notwithstanding frequent explanations by the NHIA that the use of technology in transactions with stakeholders is the way forward for the scheme,and persistent calls for service providers to update themselves in the various technologies,they are still not abreast with details of the uses of the technologies.

Specific mention is made in this regard, of the biometric device that makes it possible for very useful information on subscribers, including blood group,to be provided on the NHIS card.

According to the scheme managers, it appears service providers have not realized the extent to which this could guide them in assessing both medical and health financing conditions of subscribers and thus enable them to contribute effectively to health service delivery of the nation in its entirety.

Obviously,this is a cogent matter raised by the scheme managers and should therefore be treated with all the seriousness it deserves by service providers in order to avoid further widening of discrepancies in perspectives and approach to operations of the scheme arising from differences in stakeholders knowledge of adopted technologies.

Subscribers on the other hand, have on several occasions accused service providers of extortions in the forms of demanding payment for services and products which are clearly covered by the scheme,charging extra fees for services,refusal to give out prescribed drugs with the pretence that such drugs are not covered by the scheme and compelling clients to patronize non essential products which are usually sold by staffs of health care facilities.

They also complain of discriminations against NHIS card holders in the forms of rude conduct,lack of attention to complaints and sufferings,undue delay in attending to them, referrals to non-service providers and negligence in the provision of treatment and drugs to clients as against delivery of favourable services to patients who make payments in cash.

Certainly,service providers do have misgivings about some of the accusations but as as long as the human element cannot be dealt away with in the running of these facilities,it is imperative that staff are made to adhere strictly to the ethics of their respective professions,in order to fulfill their obligation as contained in the contract with other stakeholders.

On the wider scale,efforts at providing Ghanaians financial access to health care has not come with corresponding availability of health care facilities thus making it difficult for the goal of the scheme to be attained.

According to the records,a significant number of local government areas including municipalities, can only boast of Community-Based Health Planning and Services(CHPS) compounds,maternity homes and health centres, which of course,do not have the capacity to handle the greater number of health conditions.

This state of affairs,leaves one in a great wonder as to the relevance of the scheme to a card holder who cannot access the required health service in his or her locality simply because facilities that provide such services are no where near that place but rather has to incur more financial cost and risk of moving about,sometimes,over very long distances and on very bad roads with the already poor health condition,to access health care.

In as much as private people can assist by providing health care facilities,the financial requirement for provision of polyclinics, primary hospitals such as District hospitals,and secondary hospitals, places the onus unquestionably on government.

It is well that the Government of Ghana is working towards providing all local government areas in the country with polyclinics and district hospitals, but in order to make the NHIS more meaningful to the people,it should consider increasing the number of such facilities for each area in the not too distant future taking of course, into consideration,the proximity of such facilities to communities in the various local government areas.

It is also important that government provides the enabling environment for private people to provide some of these hospitals and other crucial health facilities such as pharmacies,licensed chemical shops and diagnostic centres, in the local areas.

Another challenge, in this regard is frequent strikes by clinicians and other specialist of health facilities that are under the management of the state.The records still mention the state controlled health care facilities as the largest service providers under the scheme and for that reason, frequent strike actions by staff of such facilities has greater implications for the availability of services to subscribers and therefore makes the scheme less meaningful to subscribers.

It is therefore imperative that Government takes proactive measures, to ensure that the delivery of health care services to Ghanaians is not crippled by frequent strike actions by staff of health care facilities.

The National Health Insurance Scheme of Ghana like any other initiative, is surely going through challenges,but certainly, if efforts are made to engage stakeholders periodically as the Adentan Municipal Office for instance, has started,these rudimentary challenges which collectively have created the perception among Ghanaians that the scheme is facing a monstrous challenge that is bound to collapse it in no time,could be easily identified and addressed in order to revive hope in it.

Joseph Tetteh Executive Director,Foundation for Youth,Peace and Development(FYPD)

Phone: 0244571090.e-mail:[email protected]