HEALTH CARE FINANCING LESSONS IN GHANA- Progress towards Achieving Universal Health Coverage.

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HEALTH CARE FINANCING LESSONS IN GHANA- Progress towards Achieving Universal Health Coverage. Wulifan Joseph Kwame IPH, University of Heidelberg, GERMANY 25.04.2014 1

Profile n= 25,545.9 (WB, 2012) Pop growth= 2.2%, TFR=4.15 HDI ranked 135 /187 C tries. Life expectancy=64.6 years Health Exp. =5.22% of GDP Regions=10 Districts =216 Piloted 45 b/n 2001 & 03 Schemes = 155 operational 2

Health care financing in Ghana 1957 Free health care 1970 1985 1990 2000 Ghana experienced economic decline & cut cost on health care. User fees introduced except specific communicable diseases. Drastic shortage of drugs, Cash & carry introduced, CBHIS emerged. Catastrophic out-of-pocket health expenditure, Lack of access, Low utilization, deaths in hosp. 2003 National Health Insurance Act 650 passed. 3

Design towards UHC WHO-UHC -3 Aspects -Height -Depth -Breadth Extend to non insured Produce cost sharing Include other services NHIF at National (VAT+SSNIT+P) Depth Breadth 4 4

Annual Amounts Paid (Act 650)... Group Who is/has/can GHs Core poor Unemployed receive support to survive free Very Poor unemployed but receive identifiable & consistent support form low sources 7.20 ( 2.00) Poor Middle Income Employed but receive low returns for their efforts and unable to meet their basic needs Employed and able to meet their basic needs 18.00 ( 5.00) Rich Able to meet basic needs & some of wants Very Rich Able to meet their basic needs and most of their wants 48.00 ( 13.00) 5

. Premium Exemptions & % Active Members Category Premium Proc. Fee Informal Sector < 18 yrs 70 + yrs SSNIT Contributor SSNIT Pensioners Pregnant Women Indigents (core poor) LEAP beneficiaries 36.4% 49.7% 4.9% 4.5% 4.2% Non-Paying (Exempt) Paying 6

Revenue Sources & Expenditure Allocation (Act 852, 2012 ) NHIL (2.5% VAT)= 73% (2.5% SSNIT) = 17.4% Interest on Fund = 5.3% Premium & Regis. Fees= 4.5% Ministry of Finance (NHIF) Transfers for Claims Pmt= 72% Payment to Healthcare Providers Admin. & General Expenses of NHIA Support to the Ministry of Health [ 18%] Other Income (GoG, NGOs, IDA) = 0.13% District Offices of the NHIA Payments to Health care Providers 7

PERFORMANCE- Membership, Utilization & Claims 111 Active Membership Outpatient Utilization 1.3 million 8.9 million (36% of pop) 598 thousand 23.9 million (cases) Inpatient Utilization Claims Payment 29 thousand GH 7.6 million 1.4 million GH 616 million Source: Unaudited Financial Statements (NHA-2012) 8

A mix of provider payment system: FEE FOR SERVICE Medicines G-DRG Secondary & Tertiary care CAPITATION* Primary care* 2005 FFS FFS 2008 G-DRG for outpatient & inpatient services FFS 2012 G-DRG for inpatient, outpatient specialist and emergency care Capitation for outpatient primary care. FFS 9

Benefit Package (>95% of disease conditions) services OPD In-Patient Oral health Maternity Eye Care Emergency General & specialist consultations,diagnostic test, lab investigation, X-rays, Ultrasound scans, Medicines on NHIS list, incision, drainage, Surgeries (hernia) Physiotherapy; Haemorrhoidectomy; HIV symtomatic treatment. Blood products, Accommodation in General ward; Feeding (where available), cervial & breast cancer. Pain relief (tooth extraction, incision & drainage); Dental restoration ( amalgam filling, dressing) Antenatal care, Deliveries (Normal & Assisted) Caesarian session; Post-natal; FP: Refraction; Vsual fields; Keratometry; Cateract removal; Eyelid surgery, Inpatient physiotherapy. All crisis in health situations demanding urgent intervention-eg; Medical; pediatric, Obstetric & Gynecological, surgical ; Dialysis & Renal failure Accidents (Road, work place etc). 10

Exclusion List 1.Cosmetic surgery/aesthetic treatment 2.Organ transplanting 3.VIP ward accommodation 4.Mortuary services 5.Artifitial insemination 6.Medical Exams for Visa 7.Drugs not on NHIS list 8.Optical/hearing Aid 9.Diagnosis & treatment abroad 11

NHIS Contribution to MDGs MDG-1, Poverty & Hunger MDG-4 Child Mortality MDG-5 Maternal Health MDG-6 HIV/AIDS,Malaria &TB Free registration & access to HC for Poor & Vulnerable (LEAP). They represent about 50% registrants. Freematernal Health Care (ANC, Delivery & PNC) introduced in 2008, Family planning sevices Opportunistic diseases are covered ie Malaria, TB, HIV. 12

Internal - Sustainability - Identifying poor Challenges External - Moral hazards (DD & SS) - Ltd health staff (eg. 6 MD in UW/R) - High cost of Phamacauticals - In effective referal system - Fraud (some staff) - In effective referal system - Delay in re-embursement - Illegal co-payment - Perceive quality of care - Addressing Equity - Political bad mouthing - Cost escalation -Generous package - Adverse selection -Weak montoring - Fraud & Abuse 13

Conclusion &Way foreward Cost containment - Clinical Audit - Gate-keeper system - Expand capitation - E-Claims vetting Additional Funds - Review Exemption policy -% of Road fund earmarked - Levy petrochemical industries - Levy communication tax Others - Intensify Biometric ID use - Compulsory for all sectors -Stepwise roll out capitation -Group population by Socioeconomic stutus. - Levies paid direct to NHIF Countries wishing to adopt- Kenya, Cameroun, Cote d Ivoire, Nigeria, Sierra Leone, Gambia, Benin and Tanzania (NHIA, 2013). 14

.. Thanks! 15 15

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