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From Nkruma to health Insurance CASH and CARRY scheme vs. the National Health Insurance scheme.

Under the First Republic, from the late 1950s up to 1966, when Dr. Kwame Nkrumahs Convention Peoples Party government was overthrown, healthcare financing in Ghana was in line with the Socialist philosophy of Dr. Nkrumahs CPP Government, and was v irtually free as was education and other social services. Following the overthrow of President Kwame Nkurmah, Healthcare financing in Ghana saw a complete U-Turn. Under the military-cum-civilian junta- the National Liberatio n Council (NLC), Ghanaians were asked to pay for their healthcare. The 1966 military coup-detat was to set in motion a series of coups leading to political instability of the country, which in turn led to economic deterioration until 1981 when F lt Lt. J. J. Rawlings came to power in what was described as a revolution. The Provision al National Defence Council (PNDC) which became the ruling entity after 1981 held on to power until 1992 when the country was returned to multi-party democratic dispensati on. The challenge since 1981 has been how to find the best combination of Government-Pe oples-Partnership that would meet each other part of the way and satisfy the needs and p ockets of Ghanaians as well the Governments finances in the healthcare sector. Cash and Carry the system of healthcare financing introduced by the PNDC survived until 2004 when the present health insurance system came into being. Even then a large number of Ghanaians (about 30 percent) still subsist on cash and carry for their healthca re requirements as they have not registered to join the NHIS. This is one of the major ch allenges facing the Government and Management of the National Health Insurance Aut hority. Under Cash and Carry, patients were required to pay for drugs and some medical consu mables, as and when they visit hospital, while the state bore all other costs including co nsultation, salaries and emoluments for Doctors, Nurses and other healthcare workers in state hospitals. Under Cash and Carry, people went to hospital only when they were very sick and had money to readily meet their side of the bargain, to pay for those stipulated expenditures . That meant most often people went to hospital when they were really very sick and oft en at the terminal end of their lives. It was pointed out that cash and carry constrained citizens from assessing healthcare except when they were in very dire situations resultin

g in needless deaths. but could not materialize for implementation though the foundation was laid with some pilot projects in the Dangme West District in the Greater Accra Region and Nkoranza D istrict of the Brong Ahafo Region as a means of laying a firm foundation for what event ually became the National Health Insurance Scheme(NHIS). The New Patriotic Party (NPP) Government under former President J. A. Kufuor which took over from the NDC Administration in 2001 moved to finally implement the concei ved new healthcare financing regime of a health insurance scheme with a statutory enact ment , the National Health Insurance Act, Act 650 in 2003 and the establishment of a N ational Health Insurance Scheme(NHIS) in 2004 under a National Health Insurance Aut hority(NHIA) with a governing council. This has been the system of healthcare financin g in Ghana for the past five years. The National Health Insurance Act, established three types of health insurance schemes in the country consisting of the District Mutual Health Insurance Schemes(DMHIS), Pri vate Mutual Health Insurance Schemes(PMHIS), and Private Commercial Health Insura nce Schemes(PMHIS). ABOUT FUNDING Funding for healthcare financing under the National Health Insur ance Scheme as established by Act 650, comes from a Fund created by the Act, with inc ome from two main sources, also created by the act. These are the National Health Insur ance Levy (NHIL), a 2.5percentage top up of the Value Added Tax (VAT), and a 2.5per centage transfer from the existing Social Security and National Insurance Trust. The story of the National Health Insurance Scheme, so far, for the past five years of its i mplementation, since 2004, is that it has come to be accepted by Ghanaians as one of th e best social intervention programmes to be introduced in this country. More so because it was not one those programmes that were sponsored by the Donor Community or the World Bank and the International Monetary Fund (IMF) As at the end of November, last year, 14,282,620 Ghanaians were registered with the 14 5 District Mutual Health Insurance Schemes operating the countrys healthcare system.

NUMBER OF GHANAIANS REGISTERED UNDER THE NATIONAL HEALTH IN SURANCE SCHEME YEAR ACTIVE ME MBERS HOSPITAL/C LINIC HOSPITAL E NCOUNTERS 2005 489,912 597,859 2006 2,422,106 2,428,008 2007 7,275,435 4,630,692 2008 11,064,581

7,070,306

28,906

135,221

303,250

475,568

2009 YEAR ACTIVE M EMBERS HOSPITAL /CLINIC HOSPITAL ENCOUN TERS FACILITY TYPE NUMBER OF FACILITIES 1. SECONDARY HOSPITALS 4 2. PRIMARY FACILITIES 62 3. CLINICS 94 4. HEALTH CENTRES 74 5. MATERNITY HOMES 130 6. CHPS ZONES 74 7. PHARMACY SHOPS 80 (JAN-SEPT .) 12,123,338 5,553,806

351,765

8. CHEMICAL SHOPS 55 9. DIAGNOSTIC CENTRES 45

PROVIDER PARTICIPATION IN NHIS PRIVATE (PROVISIONAL) PROVIDER CATEGORIES (PRIVATE) 1. HOSPITALS AND CLINICS 395 2. DENTAL CLINICS 5 3. MATERNITY HOMES 237 4. PHARMACIES 451 5. CHEMICAL SHOPS 329 6. DIAGNOSTIC CENTRES/IMAGING 128 The above present some rosy pictures of the National Health Insurance Scheme as has b een operated since 2004, and indeed, it is an interesting story to tell. All across the count ry, the over 14,282,620 registered card bearing members of the scheme constituting som e 69.73 percent of the population(2004 base population estimates) are getting treated wit hout paying anything at the point of use, for conditions that would have cost them millio ns of Ghana Cedis, under the former Cash and Carry system.

Thousands of women receive free maternal and child care under the free maternal progr amme. Women are undergoing fibroid operations and breast and cervical cancer treatme nt with their NHIS cards as Visa To Free Health Care. Men, especially those in rural areas who had long suffered from hernia are getting treate d at no other cost than their transport to and from the health facility. People with chronic debilitating diseases such as diabetes testify to the immense benefits of the scheme as t hey pay next to nothing towards the high cost of medication for various ailments. While Act 650 created schemes which are almost autonomous it made it mandatory for t

he National Health Insurance Authority to make financial resources available to them fr om the Health Insurance Fund on a continuous basis. Section 33 of the Act states, A Di strict Mutual Health Insurance Scheme shall be provided with subsidy from the Nationa l Health Insurance Fund. Another source of funding is the premiums which are collecte d from the in formal sector subscribers on the schemes.

While Act 650 created schemes which are almost autonomous it made it mandatory for t he National Health Insurance Authority to make financial resources available to them fr om the Health Insurance Fund on a continuous basis. Section 33 of the Act states, A Di strict Mutual Health Insurance Scheme shall be provided with subsidy from the Nationa l Health Insurance Fund. Another source of funding is the premiums which are collecte d from the in formal sector subscribers on the schemes. While the law does not make it mandatory for the schemes to render accounts on their fi nancial dealings to the Authority even with funds made available to them from public m oney, the Authority regularly funnels huge sums of money to them without the schemes being accountable for anything. This has opened the flood gates for the huge corrupt pra ctices that have engulfed the schemes country-wide. Act 650 and the system of health insurance schemes it created could be summed up as: A legal system that created over 145 independent health insurance Schemes across the country with their own Boards of Directors that took decisions independent of each othe r and shared no risks together. Massive financial impropriety by the motley assortment of 145 independent schemes f uelled by a legal regime that made it impossible for them to be controlled by any higher authority, not even the National Health Insurance Authority which on the surface was th e regulator of the national scheme. An increasingly unsustainable health insurance bill that was multiplying exponentially due to massive fraudulent claims facilitated by a collusion of the schemes and some hea lthcare service providers. Lack of motivation and career progression for staff of the schemes as they are unitary entities that have no room for staff to uplift themselves up the progression ladder. Lack of portability of benefits under the scheme as subscribers could not be served any

where else other than their own schemes. DELIVERING ON THE NATIONAL HEALTH INSURANCE PROMISE The new strategic direction of the National Health Insurance Scheme is dictated by the Social- Democratic philosophy of the ruling National Democratic Congress(NDC), as c ontained in its campaign manifesto of 2008, the salient points of which are: The NDC Government will implement a Universal Health Insurance Scheme which wi ll reflect the universal contribution of all Ghanaian residents to the Scheme. Our univers al Health Insurance scheme will guarantee access to free health care in all public health institutions. It will be listed in the health insurance schedule, will not be district-specific and will allow for one time premium payment for registration with the scheme. It will a lso cut down on the health insurance bureaucracy and plough back the savings into healt h care as well as review the disease and drug categories under the scheme.( NDC Mani festo, 2008, page 68) To achieve this vision and mission of President J. E. A. Mills and the NDC government, the National Health Insurance Authority (NHIA), has set for itself, the arduous task of delivering on what it calls the NHIS promise. The salient ingredients of this gargantua n task set by the Authority for itself are: 1. A health insurance system that guarantees a one-time premium payment. 2. A fully portable and sustainable national health insurance scheme fully supported and driven by a robust information technology (ICT) solution. 3. A new legal regime that fully addresse the internal horizontal and vertical inconsisten cies that have characterized the scheme since its inception in 2004 4. An entirely restructured administrative and legal architecture of the Authority and sch eme 5. An improved communication strategy that effectively markets the National Health ins urance scheme to the Ghanaian people. 6. A National Health Insurance Authority that is fully focused on its core business of del ivering a fully portable, workable, and affordable health insurance scheme that meets th e healthcare needs of Ghanaians with one-time premium payment. As we enter the second year of the administration of His Excellency President John Eva

ns Atta Mills, the new management of the National Health insurance Authority are jus t too aware, as our CEO stated at our very first Tactical and Strategic seminar on the t heme Delivering On the NHIS Promise held at Sogakope in the Volta Region in Aug ust 2009, successful organizations do not emerge through chance, faith and coincidenc e, they are always a product of sufficient thinking, strategy formulation, diligent implem entation and dispassionate measurement of outcomes. Management of the Authority imbued with the above realization is determined in this ye ar, to realize the Mills administrations avowed promise to the Ghanaian people of a on e-time premium payment for all subscribers of the National Health Insurance Scheme. T he scheme has to be sustainable into the future to cater for the health needs of generatio ns of Ghanaians yet unborn. The new Management of the National Health insurance Authority has set itself the ard uous task of lifting the National Health Insurance Scheme to new heights by embarking on very important programmes and policies among which are: a. A centralized electronic claims processing system to replace the motley assortment of 145 odd manual claims centres spread across the country which is one of the main caus es of massive fraud associated with the current claims management of the schemes. b. A new legal regime to completely streamline and overhaul the operations of the sche mes and the Authority, resulting in the creation of a single scheme under the complete c ontrol of the National Health Insurance Authority, which would be the implementer of t he scheme c. An Internal Audit and fraud Control Directorate headed by a fully Charted Accountan t to work in association with qualified Accountants and Auditors in the regions and acro ss the country to instil financial discipline into the management of funds made available to the various schemes. d. A clinical audit unit headed by a qualified and experienced medical doctor to criticall y audit all claims that are submitted for payment to make sure that the Authority pays fo r actual services which are actually rendered to our subscribers by accredited healthcare service providers to minimise to the barest minimum, if not totally eliminated, the fraud that is associated with claims processing in the past. As clearly spelt out by the new Chief executive Officer (CEO), at a management semina r on August 2, 2009 at Sogakope, The strategic intent and focus of the new Manage ment of the National Health Insurance Authority is to build a new national health insura nce scheme that would stand out as a model in Africa and beyond, providing affordable,

accessible and quality healthcare services for all domiciled in Ghana, with highly enthu siastic professionals who value customer intimacy and delight. The above is a formidable task that calls for strategic thinking, sacrifice and commitmen t, benchmarking best industry practices , teamwork, efficient use of resources, sympathy and empathy for the deprived and socially marginalized, reception for new ideas and co nstantly keeping an eye on the core business of the scheme as contained in our strategic intent clearly detailed above. In preparing to deliver the new National Health Insurance promise this year, the Authori ty has taken steps to create some new directorates while revamping and strengthening e xisting ones to better position it to discharge its assignments. For example, the directorat e of administration which was also responsible for projects, procurement and human res ource requirements of the Authority has had carved out of it a directorate for projects an d procurement, headed by a well qualified professional in the field and a human resourc e directorate headed by a Deputy Director. As the new legal regime takes effect later in the year, all the 145 existing independent sc hemes would cease to exist in their current forms and would become district offices of t he National Health Insurance Authority. It is only rational that the directorate of admini stration should be freed to take care of its core business of administering the Authority. Another unit which has recently been strengthened to place it in good stead to perform it s functions better is the Internal Audit Directorate. It is headed by a well qualified Chart ered Accountant as Chief Internal Auditor of the Authority. The unit has generally been strengthened with qualified accounting professionals in the regions and the schemes acr oss the country. The lessons learnt from snap audits undertaken across the country revea led horrendous fraudulent practices in the schemes leading to large financial bleeding of the schemes and great loss to the Ghanaian Tax Payer. The newest of the creations to strengthen the Authority in its fight against fraud is the C linical Audit unit which is headed by a qualified Medical Doctor. Clinicians are being re cruited to staff the unit in order to properly vet claims submitted by healthcare service p roviders. The National Health Insurance Scheme has come to be accepted as a welcome relief for Ghanaians in the area of healthcare financing. The challenge is how to sustain the syste m and make it viable into the future. That is the challenge facing the new Management of the Authority and the NDC Government under Professor Mills. There is no doubt that with total commitment, dedication to duty, cooperation among the staff and political su pport, the new strategic direction of the scheme of a one time premium payment shall be

a reality this year. As the year 2010 wears on, Ghanaians can look up to the Management of the National Health Insurance Authority in confidence that it would deliver unto them a health insura nce system that is workable and affordable and which would meet the needs of Ghanaia ns for effective healthcare financing well into the future. A National Health Insurance S cheme that is our passport and visa to a healthy wealthy nation. Produced by Directorate of Corporate Affairs & Strategic Direction, NHIA

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