Sustaining Ghana’s Health Insurance Scheme

The National Health Insurance Scheme (NHIS) in Ghana was established by the National Health Insurance Act, 2003 (Act 658) and the National Health Insurance Regulations, 2004 (L.I. 1809). It came into place with the view of improving financial access to health and to limit out-of pocket payments at the point of service delivery.

The NHIS, since its inception, had received a lot of commendations from the entire citizenry. Prior to the introduction of this pro-poor intervention, many Ghanaians, particularly the poor and the vulnerable lost their precious lives to curable health conditions due to the “cash and carry” method of healthcare financing.

The story of NHIS, so far, for the past few years of its implementation, is that it has come to be accepted by Ghanaians as one of the best social interventions to be introduced in this country. I think it has been able to chalk its sustainability this far because it is not one of those programmes that were sponsored by the donor community or the World Bank and the International Monetary Fund (IMF).

Statistics has it that, as at 2005, the scheme had 489,912 active members and as at the end of 2012, the scheme has about 9 million active subscribers.

With this overwhelming increase of healthcare seekers on the scheme, government of Ghana has always resorted to using fee-for-service method or what is otherwise known as Diagnostic Related Groupings (DRG) method in payment of services rendered by healthcare providers. Recently, government is considering a paradigm shift from DRG method to the capitation payment method, hence its pilot in the Ashante Region.

Explaining the roles of the major players in the operations of the NHIS; government is a third party to the healthcare provider and the patient (client). Government claims the sole responsibility of paying the healthcare provider on behalf of the patient who receives care from the healthcare provider. Government who is also the healthcare purchaser may decide to reimburse or pay the healthcare provider for services rendered prospectively or retrospectively under myriad of payment methods such as; fee-for-service (DRG), capitation, per diem, mixed systems among others.

Since the inception of the scheme, government has always used the fee-for-service or the Ghana Diagnostic Related Groupings method in reimbursing funds to the healthcare provider. This is otherwise known as the retrospective payment in the sense that healthcare providers (hospitals, clinics, health centres and pharmacies) typically list all the services that they have provided to the client (patient) and the cost of each service and request payment from the purchaser through claims after such claims have been vetted by the National Health Insurance Authority on behalf government. In real life situation, it is like picking up the items you want from a supermarket shelf and then going to the payment counter for the individual cost of each item to be entered into the cash register and added up so that you pay your final bill.

The incentive or the advantage of this payment method to the healthcare provider is that he is likely not to leave anything off the shopping list. Since the provider is also the “owner” of the “shop” and the one choosing the items to be purchased for the client (patient), it is likely for the provider to provide unnecessary services to maximize profit.

The recent outcry of the healthcare purchaser (government) about the increasing cost of health insurance claims by providers could be alluded to the moral hazard above.

On the other hand, capitation matches with prospective method of reimbursing funds from the healthcare purchaser to the healthcare provider. Literally, it means government who is the third party to the client and the healthcare provider, pays the provider ahead of services yet to be rendered by the provider to the client (patient). The services yet to be rendered under the capitation method is calculated in advance, based on specific defined population on per patient basis, regardless of health status. The per patient amount is adjusted for age, sex, and urban versus rural residence.

Interestingly, unlike the DRG, under capitation method, more services provided do not increase the payment nor do fewer services decrease the payment. If the provider contracts with a third party payer to provide services to a group of clients for a capitated rate, the provider receives the payments for each member of the group regardless of whether all the members receive the provider's services. However, if the provider incurs costs that exceed the per capita budget, the provider is liable for them. On the contrary, if the provider achieves efficient gains and incurs costs that are less than the per capita budget, it can usually retain and reinvest their surplus. Countries like; Germany, Czech Republic, France among others has adopted this method successfully.

What are the realistic factors accounting for government's decision to opting for the capitation method? My investigations revealed that most providers and some officials from the National Health Insurance Scheme attributed one of the factors to abuse of NHIS services by clients (patients) under the Ghana Diagnostic Related Groupings. The nature of the abuse is in the form of: too many visits to more than one health facility by a client with the same health condition and non-compliance with treatment regimen.

The luxury of clients jumping from one healthcare facility to the other is facilitated by health insurance and DRG method. This could be curbed by the nationwide introduction of capitation method. When the capitation method was introduced in the Ashante Region, it has received a lot of criticisms from pharmacists, clinicians, civil society organizations and the general public. I agree there are challenges such as under treatment, poor dispensing, and limited access to healthcare choices on the part of clients with the capitation payment method.

The challenge of under treatment and poor dispensing can be curtailed by proper management practices by the leadership of various healthcare institutions as well as regular monitoring and evaluation by external and internal supervisors, strict adherence to proper diagnosis and treatment protocols. In this vein, authorities responsible should endeavour to educate the general public or clients on the fact that; it is not really about being given more drugs at the hospital or clinic that really depicts quality healthcare. Clients should also be enlightened on the health implications of long term dependence on unnecessary drugs.

In my candid opinion, limited access to healthcare choices should not be an impediment to the nationwide implementation of the capitation payment method. This is because; it will help curb the hazard of clients jumping from one healthcare facility to the other indiscriminately. We have various levels of healthcare in our Primary Health Care system: primary, secondary and tertiary levels. Under normal circumstances, a primary care facility should be the first point of call when one is taken ill, and it follows in that order to the tertiary level. What do we see under the DRG method today? A client or patient with common malaria or headache would want to be treated at the tertiary level; overlooking the first and the second levels.

Capitation, if introduced would give an equal opportunity to various primary care facilities to be effective but not to be rendered white elephants as it is under the DRG method. The only thing that must be checked and well supervised would be continuity of service and proper referral system so that cases that are beyond the expertise of care providers at the primary and secondary levels would be referred on time.

Apart from the challenges elaborated above, capitation payment method, if implemented nationwide would bring some incentives and overall improvement in our healthcare delivery and health status.

a. Promotion of public health education and preventive medicine. Unlike the DRG method where the care provider would want to treat more patients to maximize claims and profit, capitation method compels the care provider to provide all the necessary preventive education needed to its capitated clients to stay healthy. The healthier their clients' stay the more profit they (care providers) make and the opposite is true.

b. There is also an incentive on the part of clients to enrol more clients at their facility. This will also go a long way to boost NHIS client registration hence, maximizing the risk pool of the scheme.

c. The cumbersome administrative web around claims processing and vetting under the DRG method leading to delay in reimbursement of funds to providers would be a thing of the past under capitation method.

If government is considering nationwide implementation of capitation method;

Government should endeavour to reengage the general public and the healthcare providers on many forums to have a proper dialogue on the operations and the advantages of the capitation method as one of the greatest means of sustaining the NHIS.

Measures should also be put in place to ensure that government meets its mandate of disbursing funds per client to healthcare providers in advance before health services are rendered. This should strictly be adhered to because pre-paying care providers before services are rendered is one of the crucial principles of the capitation payment method as against the DRG method.

Considerations should also be given to increasing the capitated amount per enrolled client. This would give the care providers the right edge to providing effective treatment and prevent poor dispensing that would be mounted out to clients by providers in an attempt to containing cost.

Gbolu Samson
National Service: Asunafo South District Health Directorate

Email: [email protected]
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