Twelve Years Of The NHIS; A Health Service Provider’s View Of The Scheme So Far

Introduction
Ghana’s venture into the arena of public health insurance effectively started through the efforts of ex President Kuffour culminating in the enactment of the legislative framework namely Act 650 of 2005. The scheme at inception was a much decentralized organization comprising of 140 district mutual health insurance schemes under the control of an apex body called the NHIA (national health insurance authority).

The scheme’s overriding objective was to remove out of pocket payments (cash and carry) at healthcare service delivery points. To achieve this, the various district mutual schemes contracted health service providers at the local level to attend to subscribers. Claims vetting, payment and other dealings with providers were all done at the local level.

The NDC in 2009 when they returned to power complained of numerous ills they saw with in the scheme among which were:

• Corruption and fraud in the claims management processes at the various mutual schemes

• Lack of financial accountability of the district schemes
• The large size of the management and boards of the schemes
• Delayed payment of claims to service providers

Reforms
From the above premise the NDC regime set out to reform the scheme. Paramount on the agenda was the amendment of Act 650. The amended law, act 852 of 2013 made one fundamental change to the operations of the scheme. It converted the scheme into a unitary organization with regional and district offices, a radical shift from the district mutual scheme concept.

Other changes made to the scheme included administrative arrangements that saw to aggressive tooling of scheme offices, adoption of capitation as the preferred provider payment mechanism for primary healthcare, and introduction of electronic devices to check fraud and moral hazard. Other measures included the introduction of centralized claims management, clinical audits and elaborate mechanisms for provider credentialing, accreditation and contracting.

Achievements
The NDC through the above measures did succeed in attaining some amount of cost containment. The NHIS after act 852 is a relatively leaner, arguably more efficient organization with a clearer management structure and centralized control. The scheme today is clearly visible in all regions and most districts and boasts of quality infrastructure, electronic equipment and human resource that were nonexistent 8 years ago.

The scheme has seen appreciable increases in the numbers of new subscribers as well as renewals. Utilization of services by subscribers keeps rising. It is fathomable that improvements in Ghana’s healthcare indicators in the past decade are attributable in part to the role of public health insurance.

Failures
Top on the list of the scheme’s failures so far is the chronic delay in claims payment. When the NDC took power in 2009, claims were an average of four months in arrears and by the time they exited office in January 2017, they had accumulated an average of nine months of outstanding claims!

In order to survive most healthcare providers have had to introduce ‘cash and carry’ under all manner of disguises. A development that has potential to reverse the gains Ghana has made in healthcare indicators.

Challenges with claims payment did not emerge out of the blue. The warning signs were there right from the beginning. For example, an actuarial review in 2009 predicted the demise of the scheme by 2012 if nothing was done. It is not clear why managers of the scheme did not take the drastic recommendations prescribed in the report.

The impact of this long delay in claims payment is evident in the health facilities. Deplorable state of infrastructure, disrepair of premises, frequent shortage of supplies, nonpayment of staff salaries, legal tussles with suppliers, poor staff motivation and many more; these are the scars left on most of our hospitals following twelve years of public health insurance.

In the face of this daunting challenge one would have expected some amount of candour from operatives of the scheme. They did the exact opposite. Aided by government communicators they went to great lengths to create the impression in the public gallery that the scheme did not owe providers, and that all was well! In spite of their best efforts the fact that the NHIS had failed in its prime objective was common knowledge and obviously contributed to the NDC’s loss in the 2016 polls.

The way forward
The NHIS will be better off if some transparency is brought to bear on the administration of funds. There are sufficient grounds for observers of the scheme’s operations to believe that some of the funds realized from the NHIL and SSNIT deductions are being misapplied. The cure for this is for government to create a separate account where these monies will be lodged and disbursed promptly for claims payment.

The scheme’s long term survival depends largely on its ability to meet the ever increasing cost of claims. The managers of the scheme are faced with two strategic options. The first is to maintain the scheme with its current generous benefits package and find additional funding sources. To this end various funding sources have been proposed among which are oil revenues and increasing the NHIL component of VAT.

The other option is to find ways to reduce the quantum of claims, mainly by cut backs in the benefits package through one or more of the following;

• A tiered scheme with progressive introduction of co-payments upward of the healthcare hierarchy. A good arrangement would be to have free access at the primary healthcare level and have progressively higher copayment tariffs up the referral ladder from district, regional up to the teaching hospital levels.
• Introduce copayments across board for the more expensive aspects of care such as surgery, prolonged hospitalization and cancer treatment.
• Reduce the benefits package to the barest minimum, covering for the most common ailments and diseases of public health concern only.

Conclusion
After twelve years of public health insurance we have succeeded in building a well oiled scheme juggernaut at the detriment of our public hospitals, most of which are on life support!

The change in government back to the NPP whose baby is the NHIS presents an opportunity to revive this laudable social intervention and with it rescue our public health facilities and the healthcare system at large. This hope is still very much alive in spite of the initial tardiness apparent in the new regime’s approach to issues concerning the scheme. It is the prayer of healthcare providers that issues of healthcare funding receive prompt attention in view of the immediacy of the needs in this area of national life.

AUTHOR
DR JOSEPH KOJO TAMBIL
A PUBLIC HEALTH PHYSICIAN
AND MEDICAL SUPERINTENDENT OF THE NEW TAFO GOV’T HOSPITAL

NEW TAFO AKYEM
Email; [email protected]
Tel; 0244688159