Background
Feature | Description |
---|---|
Funding | National Health Insurance Fund (NHIF) established to pay for: |
▪ Subsidies to schemes | |
▪ Reinsurance for schemes | |
▪ Cost of enrolling the indigent | |
▪ Supporting access to health care | |
Funds to come from: | |
▪ National Health Insurance Levy (NHIL) – 2.5% of V.A.T. | |
▪ Payroll deductions (2.5% of income) for formal sector | |
▪ employees | |
▪ Other funds voted by Parliament, income from investments, any donations, or loans | |
In addition, DHMIS will raise funds from premia for informal sector members, to be set by agreement with the National Health Insurance Authority (NHIA) | |
Membership | Membership is mandatory (either via the DHMIS or a private insurance policy). Formal sector workers have involuntary payroll deductions (SSNIT contributions). Informal sector are charged premia which should be income-related. Initially, there is a six-month gap between joining and being eligible for benefits. |
Exemptions | Some groups will be exempt from paying for membership (originally SSNIT pensioners, over-70s, under-18s where both parents are members; indigents). The NHIA will transfer subsidies to cover the cost of their enrolment. An indigent is defined as someone who meets four criteria: |
▪ is unemployed and has no visible source of income; | |
▪ does not have a fixed place of residence according to standards determined by the scheme; | |
▪ does not live with a person who is employed and who has a fixed place of residence; and | |
▪ does not have any identifiable consistent support from another person. | |
Benefits package | All providers must offer a minimum package, which is specified and broad. National Health Insurance Drug List is established. 95% of all health care is covered – all services are included other than: rehabilitation other than physiotherapy; appliances and prostheses; cosmetic surgery; HIV retroviral drugs; assisted reproduction; echocardiography; photography; angiography; orthoptics; kidney dialysis; heart and brain surgery other than those resulting from accidents; cancer treatment other than cervical and breast cancer; organ transplantation; non-listed drugs; treatment abroad; medical examinations for visas etc.; VIP wards; and mortuary services. |
Eligible providers | All providers are eligible, once accredited. Accreditation is reviewed every five years. Quarterly reports to be sent to the NHIC by providers. Providers are to be paid within four weeks of claim being made to DMHIS. |
Organisation | National Health Insurance Authority (NHIA) established to regulate the market, including accreditation of providers, agreeing contribution rates with schemes, resolving disputes, managing the NHIF, and approving cards. Each district to have a DMHIS (with a minimum of 2,000 members). Benefits to be transferable across district schemes. Each DHMIS to submit annual reports to NHIA and to undertake annual audit of accounts. Private MHIS not eligible for subsidies from NHIA. |
Accountability | National Health Insurance Council (NHIC) established to oversee NHIA and licence schemes (every two years). Includes representatives of main stakeholder groups, such as Ministry of Health, Ghana Health Services, regulatory bodies, consumers, and Executive Secretary of the NHIA. Chair and Executive Secretary appointed by the President. NHIC proposes formula for allocation of funds to Parliament for annual approval, and provides annual report to Parliament on its use of funds. Each DHMIS governed by a Board. Rules established for handling complaints against providers or schemes. |
Methods
Results
Funding sources
Coverage
2005 | 2008 | |||
---|---|---|---|---|
Membership categories | Number of registrants | Proportion of total population | Number of registrants | Proportion of total population |
Formal sector | 468,092 | 2.24% | 811,567 | 3% |
Informal sector | 615,450 | 2.94% | 3,727,454 | 16% |
Paying members | 1,083,542 | 5.18% | 4,539,021 | 19.25% |
Pensioners | 43,208 | 0.21% | 71,147 | 0.30% |
Children | 1,751,175 | 8.37% | 6,305,727 | 27% |
70+ | 266,421 | 1.27% | 816,956 | 4% |
Indigent | 790,078 | 3.77% | 302,979 | 1% |
Pregnant women | 432,728 | 2% | ||
Overall exempt | 2,850,882 | 13.62% | 7,929,537 | 34% |
Total | 3,934,424 | 18.79% | 12,468,558 | 54% |
% of registrants paying | 28% | 36% |
Key criteria | How the NHIA performs |
---|---|
Is legislated by government and requires regular, compulsory contributions by specified population groups (usually initially covering those in formal employment and their dependants, and then gradually extending to other groups) | The NHIA meets these criteria to some extent, but rather than building up coverage of non-formal groups over time, it has built those in from the start, funded from large tax subsidies. Only around one-third of members have made any financial contribution. 70% of the funding is tax-based. |
Has an income-related contribution schedule (i.e. premiums are calculated according to ability to pay), which is uniform even if the SHI consists of a number of health funds serving as the financing intermediaries for the SHI | The NHIA payments are only income-related for the 3% of the population which are formal sector members. For informal members, there is a flat rate premium per person. |
Has a standardized, prescribed minimum benefit package | The NHIS does have a standardized, prescribed minimum benefit package |
Equity
Impact of NHIS on members
Financial protection
Utilisation of services
Financial sustainability
The emergence of cash flow problems
Underlying challenges to financial sustainability
Dimension | Current challenges |
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Funding sources | Majority of income grows with growth in consumption, not with membership. Very low premia for informal sector in relation to cost of care. |
Benefits package | Benefits package comprises an estimated 95% of all treatments in Ghana, with no limit to consumption. |
Coverage | Large proportion of population is exempt and these categories continue to grow Membership is growing and with a growing rate of utilisation by members |
Payment systems | Prices have risen with new DRG payment system Drug costs additional – incentive to over-prescribe Anecdotal evidence of 'tariff creep' and gaming by providers Reported increase in fraudulent claims Increasing role of private sector (increases access but also raises costs) |
Cost-control | No co-payments Gate-keeping not effective – patients self-refer to secondary hospitals and tertiary ones use their polyclinics as an entry point into specialist care |
Monitoring | Poor monitoring and control systems within the NHIS, although a new IT system is being introduced which may improve the situation |