Increased utilisation of health services: A case of success or failure for the Ghana's National Health Insurance Scheme?

NHIS Boss, Mr. Sylvester Mensah

Introduction
Good health is indispensable to human welfare and to sustained economic and social development. Ghana made a bold decision in 2003 to implement a National Health Insurance Scheme (NHIS) as a cardinal means of financing and promoting healthcare.

The NHIS covers nearly 95% of disease burden of children, the elderly, the indigents and members who have paid a premium as well as registered formal workers. In the heat of the ongoing political campaign for the 2012 elections, the performance and the sustainability of the scheme have become an important subject for discussion in recent weeks.

Of particular importance has been the discussion related to whether the increased utilisation of out-patient and in-patient services reflects a success or failure of the NHIS.

While the ruling government (i.e. the National Democracy Congress (NDC)) considers it as a success of the scheme, some opposition parties particularly the New Patriotic Party (NPP) believes otherwise. The sole objective of this article is to contribute to this (polarised) debate.

This piece of writing does not aim to support the position of any political party nor does it aim to attack the NHIS but its sole intention is to shed lights on the need to take into account the issue of coverage on the discussion of the success or otherwise of the NHIS.

It must be emphasised that the figures on the out-patient services utilisation released and presented in the NDC manifesto is just only one out of the several indicators that can inform a better understanding of the performance of health system as well as health outcomes including equity, accessibility, financial protection, coverage and financial sustainability of the scheme. For lack of space, this article will only focus on the discussion of the increased utilisation of services which generated considerable debate recently.

The bone of contention
Even though divergent views on the performance of the NHIS are not uncommon, it was not until after the launch of the NDC Manifesto that the heated partisan debate resurrected at least in 2012.

At the page 23 of the said manifesto, the NDC notes that “the significant increase in the number of people who have registered and are utilizing the NHIS has also resulted in a quantum increase in claims payments.

These trends are not only indicative of Government's commitment to widening access to healthcare, but are also proof of a health insurance scheme that is working for the people”.

The Manifesto further provides a graphical presentation which demonstrate that cases for out-patient utilisation under the NHIS moved from about 2 million in 2005 through to approximately 9 million in 2008 and then to 25 million by the end of 2011.

Whilst the NDC believes this is an indication of success, its main opponent the NPP thinks it's rather a failure as it could mean more people are getting sick.

This banta reached a crescendo during the IEA Presidential Debate held in Tamale on November 2012---where the leaders of both NPP and NDC re-echoed their position on this matter.

Should we be concerned or be jubilating if utilisation figures under NHIS are rising?

The question as to whether the increasing numbers of out-patient utilisation reflects a success or failure of the NHIS is one which is not easier to answer on its surface. The increased figures could indeed be an indication of the confidence reposed by the populace in relation to the benefits, efficiency and effectiveness of the system.

It could mean that the system might be working well—and hence the increased numbers but a further analysis is needed before we can draw such conclusion. On the other hand, the increased figures in the utilisation may not necessarily also reflect the success of the scheme. It should be noted that the utilisation figures does not equate to the number of people using the services. Rather, it reflects the number of times at which a section of the population is utilising health service.

In the context of the ongoing debate, the figure put out is that of the utilisation so an important and related question which must therefore be asked is: how many people are utilising the services? In the health parlance, this is known as the coverage (of the population).

The discussion on whether increased utilisation of services is a demonstration of success or failure should be linked directly to the coverage—the number of people covered or has valid/active cards under the scheme.

It will be of interest to note that the laws regulating the NHIS permits one to access (unlimited) services under the scheme so far as he or she has an active card. So the fundamental question we have to ask is how many Ghanaians have the NHIS card which permits them to access the prescribed services? Gladly, such information is not hard to find.

The most recent Annual Report of the National Health Authority published in 2011 mentions that 34% of Ghanaians are covered or in other words have active membership NHIS card at the beginning of 2011.

This suggests that the 'assessment' of whether the increased utilisation figures is an indication of success or not needs to be looked at in perspective—but not in isolation.

Since the release of the 2010 Annual Report of the NHIS, it is possible that more people have joined the scheme so the 34% coverage may be an underestimation in 2012—although it is possible that some people have died or emigrated too. But just over a month ago, Mr Sylvester Mensah, the CEO of the National Health Insurance Authority (NHIA) mentioned on a CROSSFIRE program on Joy FM that the coverage figure is now about 40% of the population. Considering therefore that there are only few private insurance schemes, this figure is therefore apparently low—a recognition given by the NHIA in the said report.

In view of the fact that the NHIA and the Ministry of Health now plans to achieve a universal coverage—where everybody will be covered under the scheme—the present low coverage portends a worrying signs for the NHIS after nearly a decade of its implementation.

This coverage figure could therefore mean that there are more than 50% of the Ghanaian population who are still living the cash and carry system---because they are not covered presently by the scheme. A discussion on the reasons accounting for the lack of registration or the renewal goes beyond the scope in this article (and has been discussed in another article).

The figure of 25 million representing the utilisation rate of OPD under the scheme in 2011—as contained in the NDC Manifesto—may therefore not tell a full story. The reason why it could mislead as an indicator of success is that because the NHIS law permit for unlimited access to the prescribed services, it is possible for that figure to even go as high as 100 million while only about say just 10% of the population might be having valid NHIS cards and hence utilising the services—leaving nearly 90% out.

In other words, if you have for example just 10% of the population who are visiting the hospital more regularly, the utilisation figures would be going high anytime they visit and neatly conceal the fact that nearly 90% do not enjoy the services under the NHIS.

In the foregoing discussion, the 25 million representation of the OPD neatly conceal the startling information that more than 50% of the population are still under cash and carry system—after nearly a decade of the implementation of the NHIS.

Whether the present administration has achieved so much or not should therefore NOT be an issue; rather the NHIA should be more concerned to ensure that more people get enrolled and benefit from the scheme.

Compared the NHIS to the former cash and carry system, there is no doubt that, the system has promoted some health outcomes including for example increasing access to health services by the poor, the pregnant women and children.

Of course there are challenges that need to be addressed by the NHIA including ensuring fast processing of cards, prompt payments of claims to service providers and reducing cost escalation.

For this paper, one of the most important determinants for the success of the NHIS—that should engage politicians—is the number of people who are covered rather than just the utilisation figures which can masks the actual number utilising the service.

Other factors such as reducing out of pocket payments for greater number of people and reducing inequality in the utilisation of services are equally important ideal objectives.

Moving forward, this paper believes that more needs to be done to increase enrolment and coverage of the people especially those in the remotest part of the country. Again, it is also important that more evidence is gathered for an understanding of the dynamics or the drivers of the increasing rate of OPD utilisation.

At present, there is no scientific basis for the claims been propagated by both parties, other than speculations. More importantly, in spite of the fact that NHIS was born out of an election promise, the political cloud surrounding the NHIA and NHIS has to be removed and made it function as a strong institution.

Until we decouple the overly partisan interest that surround the scheme, much will not be achieved.

Albert A Arhin
[email protected]
*The writer is a PHD student at the University of Cambridge, UK*.