Beware NHIS Reforms
Fina part
Let us work with this 90% figure, while noting that it has been n a downward trend since the extensive introduction of the NHIS Scheme in 2005 (when it contributed about 75%).
The latest figures suggest that a little more than GHC150 million was recorded in first half of this year in NHIL collections. As economic activity generally picks up in the latter half of the year, it is safe to conclude that NHIL contributions to the NHIF would not total less than GHC300 million this year.
The same arithmetic yields about GHC33 million as the amount of direct private contribution to the NHIS (assuming no donor support or additional government allocation). As coverage now extends to 10 million Ghanaians, the suggestion is that average contribution per user amounts to about GHC3.3 per year or a little more than this.
Of significant note, also, is the report that the National Health Insurance Authority has arrears amounting roughly to GHC120 million as of June this year, mainly in the form of unpaid claims by service providers. Quite clearly, there are significant shortfalls in the flow of funds into the NHIS reserve, which compounded by the fact that at least a half of the user population is exempted from contributing indicate strongly that the financial base of the NHIS is tottering even at a time when a proportion of financing comes from private sources. It makes no logical sense to assume that this pressure would alleviate upon the curtailment of continuing private contribution.
The combined effect of the various back of the envelope calculations above demonstrates clearly that what is urgently required is a policy that will boost private contributions by at least 5 times the current figure and not to abolish it.
Because, even taken together with the NHIL pool, the per capita user contribution to the NHIS amounts to less than GHC33, taken into account that there are, from the available figures, at least 8 million people who contribute to the NHIF without enjoying the benefits.
The annual effective per user contribution is therefore closer to GHC20. This is sub-optimal in a country with a GDP per capita of GHC1000.
We cannot as a country expect to contribute 2% of per capita income to healthcare and derive quality outcomes. Nor can we ignore the inequitable structure of the contribution system.
If the 10 million users of NHIS services are distributed uniformly across the population, and there is no reason why they shouldn't be, then at least 1 million of them earn in the top quintile of the income pyramid, with a household income of roughly GHC5000 per annum (extrapolating liberally from the latest Ghana Living Standards Survey).
If these users were to pay 5% of their income as contributions to the health kitty, that alone would lead to a tripling of the private contribution pool.
The feasibility of the suggested scenarios is easily tested by examining the private health insurance market in Ghana, where premiums are easily 20 times what prevail in the NHIS.
But the most important insight is that recurrent premiums ARE REQUIRED in order to manage the dynamic and complex factors that contribute to smart and equitable pricing in the health risk market.
The introduction of a one-off premium would, in our view, lead to no better end, but shall instead precipitate chaos across all levels of the healthcare delivery system.
If we are unable to convince the Minister of Health and the President of the Republic to be wary about the encouragement of their technical advisors towards this dangerous policy, we hope that at least we shall be able to touch off a debate.
Kofi Bentil, Bright B. Simons & Franklin Cudjoe are affiliates of IMANI-Ghana (www.imanighana.com) and www.AfricanLiberty.org