NEWS & EVENTS

Earmarking in Ghana: Impacts on the Financial Sustainability of the National Health Insurance Scheme

JLN Network Manager

By Daniel Asare Adin-Darko 1 

This piece is one in a series of blog posts reflecting health financing practitioner’s perspectives on domestic resource mobilization reforms and dynamics around health financing in their countries. This work stems from the Joint Learning Network’s Dynamic Inventory of DRM Efforts. The findings, interpretations, and conclusions expressed in this work reflect the views of the authors and do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. Please contact [email protected] if you have experiences that you would like to share.

Costal Development Authority (CODA) in Ghana registering citizens within the costal belt onto the NHIS in 2020.

In 2003, Ghana’s National Health Insurance Scheme (NHIS) was established using a set of unique earmarked funding sources to help move the country toward Universal Health Coverage (UHC). This funding provided a critical source of domestic revenue that allowed Ghana to remove its previous “cash and carry” system of paying for health services and implement one of the best-known public insurance schemes in the region.

Although the reforms enabled the formation of the NHIS and led to an initial increase in domestic public spending for health, fiscal gains declined over time, slowing down the overall impact and additionality of resources (both per capita and as a share of GDP; see Figure 1). [i]  Additionally, while the earmarked funds provide on average 91 percent of NHIS’s funding and 26 percent of resources for public programs in the health sector, Ghana continues to face financial sustainability challenges including increasing costs of medical claims due to rising population coverage of the scheme and utilization of health services, delays in the release of funds and inadequate expenditure controls. As such, the NHIS began experiencing financing deficits in 2009, utilizing investments to finance the gap.[ii]

Table 1. Indicators
Population (thousands) 29,767
Life expectancy (years) 64
Fertility rate 4
Human Capital Index (HCI) score .45
GDP per capita (current US$) 2,826
Current health spending (CHE) Per capita (US$) 78
Share of GDP (%) 4
Share of CHE (%)
Domestic government 39
External health expenditure 12
Social Health Insurance (SHI) 11
Out-of-pocket 38
GGHE- D (% GGE) 6
Share of total government expenditure (%) Health 6
Education 19
Military 2

Sources: Health expenditure data from WHO Global Health Expenditure Database (2018); other data from World Development Indicators (2018) and Human Capital Index (2020)

Note: Data in Table 1 downloaded on April 15 2021. HCI score from September 2020 includes measures of survival, education, and health. See HCI for further details.

New reform initiated in 2018—namely the decoupling of the National Health Insurance Levy (NHIL) from the Value-Added Tax (VAT), which made it a straight levy on the consumption tax—changed the structure of one of the initial earmarks to provide potential revenue gains for the NHIS. However, a separate capping system introduced in 2017 limited the amount of revenue that could flow to the NHIS and weakened the potential of the new reform to support Domestic Resource Mobilization (DRM) for health. This resulted in NHIS recording a total revenue shortfall of about GH₵1.5 billion (US$302.89 million) from 2017 to 2020.[iii] 

Figure 1. Domestic Public Funding on Health per Capita and as a share of GDP, 2000–2017

Source: Author’s calculation using data from WHO Global Health Expenditure Database.

1. Structure of NHIS.

Established through the National Health Insurance Act of 2003 (Act 650), the NHIS evolved as a result of political motivation to remove the previous “cash and carry” system of health care financing and move away from overreliance on out-of-pocket payments. The Act established the National Health Insurance Authority (NHIA, the managing body of the NHIS), the Council (the governing body or the Board of the Authority), and the National Health Insurance Fund (NHIF) (see Section 2). Since then, a single-payer system has been established through the new National Health Insurance Act, 2012 (Act 852). The passage of Act 852 replaced Act 650, made District Mutual Health Insurance Schemes (DMHIS) and NHIA one body to help harmonize activities, and injected some efficiency into the NHIS. DMHIS that had autonomously operated within districts—managing the enrollment, budget preparation, and claims of health care providers as independent legal entities with their own board of directors—became branches of the National Health Insurance Authority. Consequently, enrollment evolved into a national registry with biometric ID cards issued for members to access care across the country, to ensure full portability. District budgets were incorporated into the NHIA’s national budget as one entity, and a consolidated premium account was created.

In the NHIS, membership is mandatory but enrollment is voluntary: members must enroll annually, leading to challenges in service utilization and access as well as disparities in enrollment because of financial constraints which can impact vulnerable populations.[iv],[v],[vi] Despite this, utilization rates—especially of outpatient services— are strongly correlated with enrollment and have increased steadily since 2005 (Figure 2). Enrollment in NHIS increased from 1.3 million people in 2005 to 8.9 million people in 2012. As of 2018, NHIS was operational in 163 districts across the country with a population coverage of 36 percent (10.8 million people), up from 6 percent in 2005.[vii] . The NHIS membership coverage of the population rose to 41 percent (12.29 million people) at the end of 2019. One factor that likely contributed to the increase in membership in 2019 is the introduction of mobile membership renewal in December 2018 where NHIS members are able to renew their membership anywhere using money from their mobile phone wallets without having to go to the NHIA District Offices for the renewal, which comes with transportation cost, opportunity cost and other inconveniences.

Figure 2. Growth in Membership, Inpatient and Outpatient Service Utilization 2005–2018

Source: NHIA Statistical Bulletin 2019.

Note: There is not a 1:1 relationship between utilization/number of visits at health facility and registration as individuals registered as members may use services multiple times within the year.

The Minister of Health under Section 30 (1) of the National Health Insurance Act, 2012 (Act 852) also established a benefits package, which covers about 95 percent of the most commonly occurring disease conditions in Ghana. The package includes inpatient and outpatient services and medications related to the covered conditions. The benefits package comprises inclusion and exclusion lists of services.[viii] In addition, vaccines, antiretroviral (ARV) medicines, sickle cell and cancer screening, contraceptives, tuberculosis commodities, tetanus immunization, anti-snake medicines, malaria vector control program, ambulance service, construction of health training schools, lifts to public hospitals, and health provider system integration, among others, are provided by the Ministry of Health (MOH) but funded by the NHIA under the category of Public Health and Preventive Care and Health Service investment in the NHIA Annual Allocation Formula.

In terms of provider payment, capitation at the primary health care level was piloted in one region (Ashanti), but ultimately suspended due to implementation challenges (Box 1). Ghana Diagnostic Related Groups (G-DRGs)—a form of case-based payments—now covers services at all levels of care.[ix] The tariffs for public health care providers’ services to NHIS members are lower than that for private health care providers because government bears the labor cost and capital investment of the public service. Costs of medicines are reimbursed using fee for service at all levels of care.

2. First wave of DRM reform.

From a DRM perspective, Ghana’s reforms are interesting as they have helped the government move from a system that was largely funded out of pocket to a National Health Insurance Scheme financed by a set of earmarked taxes (National Health Insurance Levy), a social security contribution earmarked from payroll, the Road Accident Fund, premium and investment income, among other sources.

First, the National Health Insurance Act of 2003 (Act 650) expanded the consumption tax to include a 2.5 percent earmark called the National Health Insurance Levy (NHIL), which is collected by the Ghana Revenue Authority (GRA). The government raised the Value Added Tax (VAT) from 12.5 to 15.0 percent in 2004 to contribute to the NHIL, and then to 17.5 percent in 2014 to provide an additional marginal 2.5 percent to the Ghana Infrastructure Investment Fund. Linking an expansion of the consumption tax to health provided an opportunity for the GRA, which would have otherwise faced resistance to increasing the rate.

A share of social security funds was also earmarked for the scheme as a second source of statutory revenue. To secure this earmark, the government had to guarantee that worker pension payouts would not be affected and that they would make up any future shortfalls. As a result, 2.5 percentage points from a 17.5 percent contribution for old employees covered under the 1991 Social Security Law (PNDCL 247) and 2.5 percentage points from an 18.5 percent contribution for any new employees under the National Pension Act, 2008 (Act 766 amended) are both earmarked for the NHIF.[x] The Social Security and National Insurance Trust (SSNIT) manages contributions that come from both pension schemes, although 5 percent of the contributions under the new Act are managed under private pension funds. The SSNIT is then required to transfer 2.5 percentage points from the contributions received into the NHIF.

Figure 3. Funding Flows and Areas of Spending for NHIS

 

 

 

 

 

 

 

 

 

Source: Adapted from Cashin et al 2017 and NHIA Strategic Plan (2015-2018).

Notes: NHIL = National Health Insurance Levy; SSNIT = Social Security and National Insurance Trust; NHIF = National Health Insurance Fund; MOH = Ministry of Health.

 

Funds from both the GRA and SSNIT are first paid into a National Health Insurance Levy Account at the Bank of Ghana, then based on instructions from the Ministry of Finance and Economic Planning  (MOF) to the Controller and Accountant General, funds are released to NHIA (Figure 3). [xi]

The third source of statutory revenue for NHIS in Ghana is the Road Accident Fund, with contributions mobilized by the National Insurance Commission (NIC). A portion of vehicle insurance paid by vehicle owners is ceded to NHIA by NIC to cover road accident victims. Revenue from this source is relatively small and NIC transfers this money directly to the NHIA operational account.

Other sources of revenue include Internally Generated Funds (IGF), such as premiums and registration fees, credentialing fees from health care providers and investment income, which together in 2019 made up 7.5 percent of all revenue for NHIA. Formal sector workers contribute to the NHIS through Social Security payroll contributions, while other beneficiaries, including those in the informal sector, pay flat-rated premiums. The NHIS introduced a flat-rated premium to simplify implementation, in response to challenges of assessing income levels outside the formal sector. Children (under 18 years), pregnant women, those aged 70 years and above, pensioners under SSNIT Scheme, SSNIT contributors, as well as indigents (those classified as poor according to Ghana’s social cash transfer program, Livelihood Empowerment Against Poverty [LEAP]) are exempt from premium payments. However, it is a challenge to identify and target the poor for exemption. When delays occur in the release of funds from the NHIL account by the government, other sources of funds act as a cushion to the NHIA. Funds from international donors that directly support any aspect of NHIA’s operations also go straight to NHIA operational accounts.

NHIA spends its revenue in three main areas: payment to health care providers including private providers, administrative and operational expenses, and support to the Ministry of Health (Figure 3). Of the funds mobilized for running the NHIS, approximately 70 percent go to health care providers, 20 percent to administrative and general expenses, and 10 percent to the Ministry of Health through a capped “release valve” that allows for emerging priorities to be funded.

3. Revenue impacts of first reform.

In 2014, total earmarked revenue was just under GH₵1 billion (US$338.20 million), amounting to 91 percent of total funding (Table 2), with the NHIL and SSNIT making up an average share of 69 and 22 percent of NHIS revenue, respectively. The earmarked funding per beneficiary was GH₵92.96 (US$32.07).[xii] Despite this revenue base and the use of investment reserve funds to finance gaps, NHIS revenues fell short of recurrent expenditures by GH₵16.84 million (US$11.92 million) in 2009; payments to health care providers were delayed, and the NHIS went into arrears.

The liquidity challenges facing the NHIS are explained by the NHIA recording a cash ratio of less than  20 percent on the average (2013-2019). This means that the bank and cash balances together with short-term deposits of the NHIA are unable to meet 20 percent of its short-term obligations at a given time. This is attributable to a decline in investment reserves, delay in the release of funds to the NHIA and increased cost of the scheme. The delay in release of funds distorts the cash plan of NHIA, which causes early redemption of investment to finance the obligations at a cost.

Delay in payment of health care providers negatively affects the operations of the providers by limiting their ability to pay for medical supplies. In order to keep their operations running, some providers unlawfully bill NHIS members causing out of pocket (OOP) payments, which affect access to health care and make the poor more vulnerable and impact both member satisfaction and overall equity of the Scheme. In some cases, there is the possibility of unscrupulous providers re-billing NHIA for services that were paid OOP, which could go undetected due to the largely manual and unintegrated system in place.

The low NHIS population coverage of 41 percent as at the end of 2019 having operated for over fifteen years could be attributed to low service quality of the Scheme. The service quality is influenced by timeliness in release of funds to health care providers, timeliness in review of tariffs for medicines and services covered by NHIS, quality of service delivery to NHIS members at NHIA district offices and health care providers’ sites, strong system in place to detect and prevent levying of unauthorized charges by providers and strong legal system in place to timely sanction health care providers and NHIS members who misconduct themselves.

Box 1. Ghana’s Experience with Provider Payment Reform

Ghana has had mixed experiences with provider payment reform. NHIS started with the fee-for-service payment method in 2005, but it rewarded providers indiscriminately as they provided services to members even if the services were not needed. The Ghana-Diagnostic Related Grouping (G-DRG) payment method was introduced in 2008, leaving in place the itemized fee-for-service mechanism for medicines. The G-DRG method groups related diagnoses and procedures and determines the average cost per treatment in that group, which forms the basis of the tariffs used by health care providers. Ghana began introducing capitation in 2012 but suspended it in 2017 due to implementation and political challenges as well as complaints from health care providers.

While the passage of Act 852 helped to rectify some issues with harmonization across district offices and injected efficiency into the NHIS, other challenges persisted, including continued delays in release of earmarked funds to NHIA. For instance, the time lag from revenue collection of NHIL and SSNIT contributions to actual release of funds to NHIA is about five to six months due to delays in government paying social security contributions of public sector workers to SSNIT and different NHIL collection, reconciliation, and transfer mechanisms for domestic and import taxes. Additionally, there have been inadequate expenditure controls, such as through low implementation of strategic purchasing modalities that might improve efficiency (Box 1); increase in tariffs for medicines and services rendered to insured members; and largely manual submissions and vetting of health care providers’ claims as well as high administrative and operational costs.

Reforms such as membership authentication at health care provider sites and increased clinical and compliance audits have been instituted to curb the open-ended provider payment systems that were the main source of unchecked growth; however, concerns regarding the financing of the NHIS continue to persist. To mitigate issues involving late payment of claims to health care providers as a result of delay in release of funds, in 2011 and 2012 the NHIA secured alternative funding at a cost to finance the gap. Additionally, on a number of occasions, NHIA has made proposals to the government to increase funding, for instance, by lobbying for increases in the National Health Insurance Levy, upward review of premiums, introduction of new direct contributions from employers and employees outside of their social security contributions, introduction of a health/sin tax, and communications service tax, to name a few. These proposals, contained in review documents as recommendations, had not been granted as at the close of 2020. In fact, politicization of the NHIS has negatively affected the ability to make any effective requests for additional revenue for health. While the premium has not seen any major adjustment in some time due to lack of political will on the part of government,  an increase in premiums remain unpopular, as opposition political parties can exploit the issue to campaign against the incumbent, declaring this would lead to worsened outcomes for the poor majority. As such, no other significant revenue-raising efforts for the NHIS has been made. By 2017, the funding gap was reported as GH₵379.69 million (US$87.20 million).[xiii]

4. Second wave of DRM reform.

To address the NHIS funding gap while circumventing political issues associated with consumption tax rate adjustments, in 2018 the government decoupled the NHIL and the GETFund Levy[xiv] for education from the VAT and made them straight levies with individual constant marginal rates, which allowed the government to increase revenues without changing the rate value. To apply this change, the NHIL (2.5 percent) and GETFund Levy (2.5 percent) remained at their current rates, and VAT remained at 12.5 percent. However, NHIL and GETFund Levy are computed and added first to the value of taxable supplies of goods and services. The 12.5 percent VAT is then charged on the total value, which includes the NHIL and GETFund Levy.

This proposal was initially well-received by those in the health sector, as it was considered to have positive impacts on revenue for health. However, there was a catch. In 2017, a nonsector-specific cap, setting the amount of earmarked revenue that can go to a source, was also put in place under the Earmarked Funds Capping and Realignment Act, 2017 (Act 947). On an annual basis, the cap for each statutory fund is determined by an overall assessment of current government priority programs for that year, with the allocation of domestic resources aligned accordingly. Under Act 947, all allocations to the various statutory funds must not exceed 25 percent of all government revenue. The capping provides an avenue to deal with budget rigidities and create enough fiscal space for government to undertake its economic policies. While this provided a “check” on overspending, it also created a mechanism for the Ministry of Finance and Economic Planning to retain additional revenue that was raised for health, education and others, realigning funding flows to weaker areas and avoiding the need to increase taxes in other ways. The budget statement now includes both how much the government will collect and how much it expects to pay to the NHIF—plausibly leaving unused revenue to be reallocated for other fiscal purposes. As such, the cap is seen as a negative measure by the health sector, weakening the power of the 2018 reform and constraining potential revenue for NHIS operations.

In March 2020, Ghana recorded the first incidence of the coronavirus disease (COVID-19) and the effect of the pandemic caused the Ghanaian economy to contract in the second and third quarters of 2020.  The impact of the pandemic caused government total revenue to fall while government total expenditure increased, thereby widening the fiscal deficit for 2020.  The Fiscal Responsibility Act, 2018 (Act 982) requires that the budget deficit shall not be more than 5% of Gross Domestic Product (GDP). The projected budget deficit for 2020 was 4.7% of GDP. However, by the end of 2020 this had increased to 11.7% of GDP due to the expenditure on the pandemic, and as such the fiscal rule was suspended under section 18 of the Public Financial Management Act, 2016 (Act 921), which is allowed in times of natural disaster, public health epidemic and war among others. The pandemic affected the annual GDP growth rate as the country recorded 0.4 percent as opposed to the initial projected figure of 6.8 percent for the year 2020.

The COVID-19 pandemic negatively affected government tax revenue for 2020 and consequently the National Health Insurance Levy. The Ghana Revenue Authority was able to mobilize for the National Health Insurance Levy a total amount of GH₵1.80 billion (US$321.37 million) out of the initial budgeted revenue of GH₵2.01 billion (US$358.86 million) leaving an adverse variance of GH₵210 million (US$37.49 million). To mobilize domestic resources, to deal with the COVID-19 pandemic,  the government introduced a COVID-19 Health Levy by increasing the NHIL from 2.5 percent to 3.5 percent per the COVID-19 Health Recovery Levy Act, 2021 (Act 1068) in 2021.[xv] This is to provide the requisite resources to sustain government’s effort in dealing with the COVID-19 pandemic from 2021.

5. Revenue impacts of second reform.

The new financial dynamic between the NHIF, the cap, and the straight levy are complicated (see notes to Table 2). The straight levy is estimated to generate an additional GH₵250 million (US$54.46 million) annually for NHIS. While resource transfers have seen gradual increases over time, the NHIF has never been credited with all resources raised within the same year for its purpose, with the amount transferred to NHIF averaging approximately 70 percent of total revenue raised annually. As a result of the cap, NHIA had a revenue shortfall of about GH₵1.5 billion (US$302.89 million) from 2017 to 2020. As of 31st December 2019, most health care providers’ bills had only been paid on average up to April 2019, and eight months of claims (May to December 2019) were outstanding. Given that there is a three-month window to adjudicate claims, this leaves five months of outstanding payments. By the end of 2020, the arrears had reduced from five months to three months due to improvement in release of funds to NHIA, which helped to manage provider complaints in 2020.[xvi] While there are discussions to exempt the NHIL and Social Security contributions levies from the capping system, this situation is still unfolding. NHIA through its constant engagements was able to dialogue successfully with MOF and SSNIT so in April 2020, it was agreed that SSNIT directly transfer SSNIT contributions to NHIA, including arrears starting from December 2018. This had positive effect on the total revenue position of NHIA and increased the liquidity of the Scheme in 2020.

Further, there have been secondary impacts of the revised tax structure. For instance, both the NHIL and GETFund Levy are now treated as “business expenses,” where businesses can no longer claim input tax credits against them, and these are thus at a cost to the firm.[xvii] On the positive side, the reengineering of the indirect tax on goods and services increased visibility of funds to the education sector. On VAT receipts, the GETFund levy has been added as a separate line along with the NHIL, providing additional transparency for consumers.

As a more recent development, and in order to combat the effects of the COVID-19 pandemic and put the Ghanaian economy back on track, the government is seeking to increase domestic resources mobilization and has increased the NHIL by one percentage point. The additional funds to be generated in 2021 through this increase, which is estimated at GH₵889.07 million (US$153.29 million) will be earmarked as a COVID-19 Health Recovery Levy, and will not go directly to NHIA but instead allocated to MOH to procure COVID-19 vaccines and other commodities. In the 2021 Budget Statement and Economic Policy, the Ghana government is expected to raise a total amount of GH₵3.02 billion (US$525.16 million) from the existing 2.5 % NHIL and SSNIT contributions, out of which GH₵1.90 billion (US$330.40 million) will be allocated to the NHIA and the difference of GH₵1.12 billion (US$194.76 million) to be channeled to other priority areas due to the capping system in place.

Table 2. Ministry of Finance, Total Revenue to NHIA, by Source and Amount Generated from Earmarks   

 

6. Broader impacts of both reforms on public spending for health.

The earmarked funds provide on average 26 percent of funding for public programs in the health sector. During the first wave of reform and establishment of the NHIS, the earmarks had a positive impact on overall public spending for health: from 2004 to 2010, public spending on health rose from 0.75 percent of GDP to 2.38 percent of GDP (see Figure 1). While the NHIF has led to an increase in domestic public spending on health, over time the total allocation to health as a share of government expenditure decreased after an initial period of overall growth (Figure 4) due to competing demands of other sectors, weakening the net impact and additionality of these reforms, and indicating that there has not been long-lasting reprioritization between health and other sectors.[xviii]

Figure 4. Evolution of Ghana’s Domestic general government health expenditure (GGHE) as a Percentage of Government Expenditure, 2000-2018[xix]

Source: WHO Global Health Expenditure Database (2021) 

Furthermore, trends starting in 2014 indicate that the straight levy or cap may have an impact on the relative position of the NHIA to the overall government budget (Table 3).  For instance, the NHIA budget as a proportion of the overall government budget reduced from 3 percent in 2018 to 2 percent in 2019 and 2020. Similarly,  there was a reduction of the total health budget as a proportion of the overall government budget from an average of 12% (2014 to 2016) to 9% (2017 to 2020).

Table 3. Trends in Relative Budget Estimates for NHIA compared to Overall Health and Government Budget

 

 

7. Conclusion.

Earmarking was critical in allowing Ghana to establish its lauded National Health Insurance Scheme. However, some operational inefficiencies and inadequate expenditure controls impacted the financial sustainability and caused the scheme to operate at a deficit for some years. While a variety of reforms aimed at improving efficiency have helped to reverse this trend, experience has shown that earmarked resources did not lead to long-term reprioritization of health within the government budget. Subsequent reform that aimed to increase the amount of revenue collected through the National Health Insurance Levy (NHIL) was limited by a general cap on earmarked revenue. As such the additionality of the reform aimed at increasing revenue for NHIA remains in question. Most recently, the introduction of the COVID-19 Health Recovery Levy through an increase in the NHIL represents a major change that will provide a beneficial stream of funding to the health sector to meet emergency needs, although longer term impacts remain to be seen. In the case of the initial earmark as well as in subsequent reform, earmarking for health did provide a way for the government to expand tax collected from VAT to channel toward health as well as other priorities.

 

1 This note is written by Daniel Asare Adin-Darko ([email protected]) with support from Danielle Bloom and Jewelwayne Salcedo Cain, as well as inputs from Ajay Tandon, Ali Hamandi, Maria Eugenia Bonilla-Chacin, Somil Nagpal and the Joint Learning Network’s Domestic Resource Mobilization (JLN DRM) collaborative.

 

Daniel Asare Adin-Darko is a Deputy Director in the Finance and Investment Division of NHIA. He is a chartered accountant, chartered tax practitioner, and a chartered economist.

 

 

 

With gratitude, we acknowledge the guidance and technical review from colleagues in the National Health Insurance Authority of Ghana, Ministry of Health, Ghana, and in the World Bank: Vivian Addo-Cobbiah,1 Francis Owusu,1 Yaa Pokuaa Baiden,1 Gustav Cruickshank,1 Francis Asenso-Boadi,1 Francis-Xavier Andoh-Adjei,1 Nicholas Afram Osei,1 Rudolf Zimmerman,1Magnus Owusu-Agyemang,1 Eric Nsiah-Boateng,1 Emmanuel Kwakye Kontor,2 and Anthony Theophilus Seddoh.3

1 National Health Insurance Authority of Ghana.

2 Ministry of Health, Ghana.

3 The World Bank Group.

The World Bank’s support to the Joint Learning Network for UHC is made possible with financial contributions from the following partners:

[1] This note updates information provided in the 2017 WHO working paper: C. Cashin, S. Sparkes, and D. Bloom. 2017. “Earmarking for Health: From Theory to Practice.” Geneva: World Health Organization. License: CC BY-NC-SA 3.0 IGO.

[i] Reversal of the upward trend in domestic public health expenditure observed circa 2011 (Figure 1) may be attributable to documented reductions in growth of both the health share of general government expenditure and the general government expenditure as a share of GDP.

[ii] Except during 2015–2020.

[iii] GH₵ = Ghanaian cedi.

[iv] Section 27 (1) of the NHIA 2012, Act 852, says, “A resident of Ghana shall belong to the National Health Insurance Scheme.”

[v] I.A. Agyepong, D.N.Y. Abankwah, A. Abroso, C.B. Chun, J.N.O. Dodoo, S. Lee, S.A. Mensah et al. 2016. “The Universal in UHC and Ghana’s National Health Insurance Scheme: Policy and Implementation Challenges and Dilemmas of a Lower-Middle-Income Country.” BMC Health Services Research 16: 504.

[vi] A. Kwarteng, J. Akazili, P. Welaga, P.A. Dalinjong, K.P. Asante, D. Srpong, S. Arthur et al. 2020. “The State of Enrollment on the National Health Insurance Scheme in Rural Ghana after Eight Years of Implementation.” International Journal for Equity in Health 19: 4.

[vii] NHIA Statistical Bulletin 2018 puts the coverage at 37 percent for 2017.

[viii] Type of care covered under NHIS benefits package includes outpatient and inpatient services, oral health and eye care services, maternity care and emergencies. It excludes services like rehabilitation (other than physiotherapy), cosmetic surgeries and aesthetic treatment, HIV retroviral drugs, dialysis, orthoptics, organ transplanting, and mortuary services among others.

[ix] Case-based payments can be developed based on a schedule of payments linked to diagnosis, often called diagnostic-related groups. These can be linked to standard disease classification systems such as International Classification of Diseases (ICD)-10

[x] All employees born before December 31, 1959, fall under the old pension scheme and contribute 5.0 percent of their basic salaries, while employers contribute 12.5 percent bringing the total to 17.5 percent.

[xi] Adapted from Cashin C., Sparkes S., Bloom D. Earmarking for health: from theory to practice. Geneva: World Health Organization; 2017. License: CC BY-NC-SA 3.0 IGO.

[xii] Note that this estimate was the revenue per beneficiary in 2014 and not per capita expenditure. Active membership in 2014 equaled 10.545 million.

[xiii] According to the NHIA’s 2017 Allocation Formula (budget).

[xiv] The Ghana Education Trust Fund (GETFund) levy was established in 2000 and is also funded through VAT.

[xv] Taking effect from 1st May, 2021, Act 1068 is a straight levy and is not allowable as an input tax deduction. This has the effect of increasing business expenses and prices of goods and services.

[xvi] The direct transfer of funds from SSNIT to NHIA in 2020,  improvement in release of funds by the Government to enable health care providers to manage the COVID-19 pandemic and the priority of the Government in 2020 contributed to this performance.

[xvii] World Bank. 2019. Doing Business 2020: Comparing Business Regulation in 190 Economies. Washington, DC: World Bank Group.

[xviii] Cashin C., Sparkes S., Bloom D. Earmarking for health: from theory to practice. Geneva: World Health Organization; 2017. License: CC BY-NC-SA 3.0 IGO.

[xix] Presented on February 1, 2020, by N. Otoo at Prince Mahidol Award Conference, “Parallel Session 2.1 Fiscal Space for Health: A Country Perspective from Ghana.” Data from 2019.

 

Have any reflections from your JLN experiences? Please share them using the comments feature, below.

99 Comments

  1. Solomon Appah

    You have done a great work. Thank you for enlighten me.

    Reply
    • Francis Frempong

      Great article. Very well structured and well researched. I have to be reading over and over.

      Reply
      • Leticia Osei-Poku

        A very detailed and informative article on the NHIS. As a nation, we must have the political will to ensure the sustainability of the scheme by looking at some of the points raised. Kudos, my brother.

        Reply
        • Samuel Kpakpo Allotey

          A very insightful article with facts and figures. Well done Mr Adin-Darko. I have actually learned a lot about the scheme through this write up.
          I have, however, observed that challenges highlights on funding partners or agents of funds mobilization and the political players. Their inability to review standing policies essentially the premium.
          The difficulties faced the scheme managers was somewhat subtle. There seem to be a gap between the the NHIS and the service providers with regard to the control and checks on fraud perpetuated by service providers. They defraud both the vulnerable beneficiaries and the scheme by making clients pay for services being covered by the scheme and putting claims to the nhis office at the same time.

          I humbly suggest the scheme establishes a customer service desk independently at least on all major Government health facilities. That desk should desplay all services available to subscribers in print boldly at entrances, the labs and most importantly at the pharmacy. These should boldly indicate what medicines are fully covered and those partially covered that beneficiaries need to top up as I personally experienced paying for what might have been covered from lab to the pharmacy at a District Hospital in the Greater Accra Region. This will bring some openness and fairness to both stakeholders.
          Alas the system must start to work from a point

          Reply
          • Daniel Asare Adin-Darko

            Thank you for sharing your personal experience at the hospital. Indeed the out of pocket payments need urgent attention in order to restore confidence in the Scheme.

      • Gilbert Oppong

        A well researched article, it can be predicted that in future increasing funding for the NHIF will mean increase in taxes if the capping system is still in place.

        Reply
      • Emmanuel Akomaning-Adofo

        This is a comprehensive report on the activities of the National Health Insurance Scheme right from its inception and how it has performed over the years.
        The author has done a very work. Very informative. All stakeholders should have access to this report.

        Reply
      • Moses Owereko-Mensah

        You have done an excellent work. It is well structured. I find this article as one with a difference.
        Great work done

        Reply
      • Eric Entsie

        This very comprehensive information. Well done this write up.

        Reply
    • Asare Samuel

      Excellent Article bringing out the strengths and weakness (performance) of the NHIA and the way forward.
      Congratulations

      Reply
      • Nii Anang Adjetey

        Well written, excellent piece of researched work. Informative, insightful, reflective and very readable. A good addition to the growing literature on the NHIS
        Kudos Dan

        Reply
  2. Nathaniel Otoo

    A very informative blog on the evolution of domestic resource mobilization for health in Ghana.Some of the key lessons that have been highlighted are that for domestic resource mobilization for health to be effective, it must be underpinned by deliberate efforts to improve fund flows and the implementation of efficiency gain, equity inducing and quality improving measures such as strategic purchasing. These considerations are all predicated on strong political will.

    Congratulations on the publication of this timely blog Daniel!

    Reply
    • Daniel Asare Adin-Darko

      I agree! Strategic purchasing of health services is the way to go, which must be backed by strong political will. Thank you.

      Reply
  3. Felix Mensah Agbo

    Very educative, insightful and factual. More grease to your elbows.

    Reply
    • Samuel Adu-Nyarko Qolyns

      Hardly do we often get to read this kind of well-researched information on our health systems. Great work! Waiting to be enlightened more.

      Reply
      • Osei-Sintim

        A very brilliant informative piece. This is useful for the continuous growth of the NHIS in Ghana and beyond.

        Reply
  4. Ismaila

    The writer has succinctly highlighted the financial issues and the current solutions being implemented.

    It’s a very good information on the NHIA and encourage him to do further publication on the financial of the private mutual health insurance schemes as well.

    Thank you.

    Reply
  5. Atta Brenya-Bonsu jnr.

    This paper has brought alot of interesting revelation about the sustainability of the health insurance with regards to financing. The pictorial diagrams are very useful too. This work will benefit the academial, the technocrats as well as public officials. Cheers Dan!!! Congrats

    Reply
  6. Abdul-Rahaman Moomen

    Very educative. Congratulations

    Reply
  7. Theophilus Owusu-Ansah

    A simplified version of economic terms to make the reader appreciate the economics informing health care financing in the country Ghana from an insider and its implications, how to improve upon the revenue generation and to keep the scheme sustainable. It has helped shape my understanding.

    Reply
  8. George Omaboe

    This paper is on all fours. I look forward to more publications in other areas that will also ensure the sustainability of the health insurance system.

    Reply
  9. Dominic Yaw Peh, ACMA,CGMA

    This is a very insightful paper.I wish all those in corporate leadership could read this and have the gist at the center of their strategic decisions. Financial sustainability is a serious and common issue within SOEs that needs to be seriously addressed.
    Earmarking of funds by the Government and within the Institutions and adherence to same by the key stakeholders is key in the financial sustainability of the SOEs.

    This paper is therefore, clearly on point in addressing this matter. Kudos.

    Reply
  10. Emmanuel Addo Asare

    Personally, I am so excited for this publication. For the fact that emperical research in the area of “Financial Sustainability of the NHIS” in Ghana is scanty to the best of my knowledge.

    The writer has done a great job by bringing to bear some of the pertinent issues surrounding the NHIS, and the way forward.

    Policy makers should pay attention to the content of this paper for implementation of a much better improved service.

    In so doing, the SDG goal 3: Good Health Care and Wellbeing would be materialised.

    Whilst I congratulate the writer for a good job done, I equally encourage him to do further publications in the coming years.

    Once again, well done Sir!

    Thank you.

    Reply
  11. EMMANUEL AVINU

    This is an excellent work. My boss kudos. Wao!

    Reply
    • Charles Kwadwo Binney

      This is a well researched paper and insightful and opens a discussion for decision makers and further research. Keep the good work

      Reply
  12. Somil Nagpal

    It is very exciting to see this level of activity and interaction around the Practitioner Perspective Series and congrats to Daniel for an excellent contribution that is receiving so much positive feedback and interaction. It makes the entire DRM collaborative team very happy and motivated, and we hope other members of the DRM collaborative will consider contributions to this series soon.

    Reply
    • Danielle Bloom

      Agree! Kudos to Daniel for doing such an amazing job pulling together this post and all of the inputs!

      Others, please be in touch with the team at [email protected] if you are interested in sharing a write up on your own country experience.

      Reply
  13. Christian Kwapong Bekoe

    This article has highlighted the true picture of healthcare financing in Ghana. This is timely for the health insurance industry. Excellent work! I look forward for more publications.

    Reply
  14. Alex Peasah-Koduah

    A very elaborate approach to this article. Well done Daniel.
    A major problem to the financial sustainability of the NHIS stems from lack of commitment from the government to place the needed premium on health. It is sad to note that the 2020 health budget is only 7% of the national budget and that tells us how the government priortizes the health of its citizens.
    In an era when we are looking at Universal Health Coverage, 7% of national budget allocation to health is very abysmal and ought to be looked at again, especially, in times of the Covid 19 pandemic.
    For lack of discipline even if reforms are developed to increase revenue to fund the NHIS, government would introduce an Act – Earmarked Funds Capping and Realignment Act, 2017 to deny the health sector and for that matter the NHIS, the much needed funding.
    Indeed, the repercussions of this is seen in the poor quality of care offered to the citizenry under the NHIS. In as much as I believe in this social insurance for health for Ghanaians, and that healthcare providers must buy in and support it, we should not lose sight of the fact that quality care is paramount and yet not cheap.
    Someone ought to pay for the services provided and it is high time the government got truly committed and prioritised healthcare financing in this country.

    Thank you, Dan for this research paper.

    Reply
    • Daniel Asare Adin-Darko

      I agree! Allocating adequate resources to the NHIS and ensuring prompt release of funds to health care providers with adequate monitoring system in place would help to improve the quality of service delivery. Thank you.

      Reply
  15. Jeff

    This is an insightful research which had thrown light on the issues of financing and sustainability of the health insurance in Ghana. This could be a useful resource to other countries who are also trying to implement this system.

    Reply
  16. Abigail Tetteh-Mensah

    Very informative! Well done Daniel

    Reply
    • Rosemond Hesse

      This is very disheartening to see some of the public and private sector hospitals collapsing the nhis in their dealings. It’s about time this message is known to all in other to help sustain the NHIS to the betterment of the nation, especially, my natives in the rural. God bless u for enlightening me more. Kudos Brother.

      Reply
      • Daniel Asare Adin-Darko

        Sure! There is the need to address the out of pocket payments and alleged fraud to instill confidence in the Scheme. Thank you.

        Reply
    • Precious Boakye-Mensah

      Looking at the rate at which the cedi is depreciating against the United States dollar, it is clear that the value of the premium at the inception of the policy will have to be reviewed upwards in order to meet the revenue requirements of the scheme. Are there any plans for the premium to be reviewed in the short term?

      Reply
      • Daniel Asare Adin-Darko

        Good question!

        A premium of GH₵7.20 (USD8.05) was charged in the poor communities and GH₵10 (USD11.18) in other places at the inception of the Scheme in 2004. This premium was subsequently increased to GH₵18 (USD17.13) on the average in 2008 and has remained unchanged. The value of the GH₵18 premium in dollar terms as at 31st March 2022 is USD2.53 due to the continuous depreciation of the Cedi.

        An upward review of the premium in the short term is necessary to increase revenue for the Scheme.

        Reply
  17. Papa Israel Quarme Ayer

    A very elaborate blog on the NHIA and its sustainability coupled with the socio-political systems affecting smooth management to achieve Universal Health Coverage in Ghana. It is also appropriate for government to completely separate other operations of state funding from the NHIL to be directly remitted to a reserved account for reimbursement to Healthcare Providers timely.
    Great work and a paper for the National Health Insurance Authority to adopt as one of the reference books.
    You research work from inception to date on NHIA can not be overemphasized.

    Kudos! My brother

    Reply
  18. Daniel Ababio

    This is a comorehensive piece which touches on the pertinent issues of sustainable health insurance financing with specific experience from Ghana. The author has done a great job by chronicling the sequence of health insurance financing policies as well as the structure of the NHIA.

    It’s fascinating to know the proportion of health expenditure to total government expenditure reduced from 12% (2014-2016) to 9% (2017-2020). Though I do not have the data this could be due to the government’s policy on free SHS hence such reduction in health spending would have gone into funding education.

    It will be good to ascertain the impact of this shift on the wider economy.

    Well done Daniel!!!

    Reply
    • Daniel Asare Adin-Darko

      Yes! Further studies can determine the reason for the fall, how it was allocated and the impact. Thank you.

      Reply
  19. Sylvester A Mensah

    An excellent and true piece of researched work that reflects the past and present circumstances of the NHIS in Ghana.
    Perhaps the time has come to interpret sustainability in a much broader context to include and reflect increasing allocation and inflow of funds to accommodate percentage growth in enrollment, active membership, physical access and improving quality of healthcare delivery. In effect Sustainability and Growth must presuppose each other.
    A stronger political will and commitment is required to develop a road map and time frame towards the achievement of the ultimate objective of UHC
    Congratulations Dan

    Reply
    • Daniel Asare Adin-Darko

      Thank you and to add to this, Scheme would experience rapid growth in membership in the coming years with the formalization of the economy. The linkage of the NHIS card to the Ghana Card currently ongoing, and the Ghana Card eventually replacing the NHIS card, members can easily renew their cards at their convenience. Your suggestions are therefore very important for policy consideration.

      Also, in our progress towards UHC, high growth in membership level of the Scheme is only a NECESSARY CONDITION. The SUFFICIENT CONDITION will be adequate measures put in place to prevent out of pocket payment at the point of accessing health care. This has serious implications for membership renewal and new enrollments onto the Scheme, which are influenced by member satisfaction and perceived satisfaction respectively.

      Reply
  20. Vitus G. Kaleo-Bioh

    Good work, Dan. Your publication is very educative and informative. It highlights the key issues to ensuring the continuous sustainability of our social healthcare system in Ghana.

    Reply
  21. Alex Nartey

    A well-chronicled information on the NHIS giving a good insight on the efforts of the NHIA and Government to ensure sustenance of the scheme from inception. Great coverage on the revenue side. Well done Daniel. As the conversation continuous on UHC more articles are needed on the broad categorization of the expenditure side especially on payments to providers against tertiary health, secondary health and primary health to foster more reforms for sustainability. Excellent work.

    Reply
    • Daniel Asare Adin-Darko

      I agree! The expenditure side will help to show the allocative efficiency of the resource utilization. Thank you.

      Reply
  22. REV JUSTICE ATARA AGYEI

    Well done my brother Dan. This publication is as a results of more experience gained in the sector. It takes selfless and more discipline to present this well structured and educative publication. I believe that the authorities will dive more into this to solve part of our health issues in the country in terms of it sustainability of our social healthcare system in Ghana. Good job.

    Reply
  23. Franklin Adjei Tannor

    An excellent and true reflection of the past and present of NHIS in Ghana. I have no doubt on your capabilities for such educative publication.
    Your publication gives much details on the inflows and outflows of the scheme and for that matter the possible financing gap which is a threat to Financial Sustainability of the scheme.
    Whilst I congratulate you for a good job done, I equally encourage you to do further publications in the coming years on the genuineness of Claims (bills) from service providers which is a serious threat to Financial Sustainability of the scheme.
    well done my Director.

    Reply
    • Daniel Asare Adin-Darko

      I agree! Claims cost is the major cost driver so all efforts is required to check its authenticity in order to control cost. Thank you.

      Reply
  24. Frank Attah-Poku

    Actually, this study on the financial sustainability of the NHIS in Ghana is very thought provoking. A lot of salient points and areas have been raised and I would like to commend the author for the effort.
    I believe the study would go a long way to influence decisions of policy makers on how to ensure financial self- sufficiency of the scheme.
    I wish to respectfully submit that the study should form the basis for further studies into monitoring indigents registration processes and excesses in claims generation, processing and payment in order to plug the loopholes that could drain the finances of the Scheme and threaten its financial self- sufficiency.
    Once again, I thank you tor this piece and I hope it will assist in finding solutions to the challenge of ensuring financial sustainability of the Scheme to be able to operate into the foreseeable future.

    Reply
    • Daniel Asare Adin-Darko

      Sure! There should be continuous strengthening of the controls in the registration of people classified as indigents so the premium paying members don’t sneak in.

      Also, the deployment of integrated ERP Claims Management System with adequate controls would help to check the generation of claims from health care providers so it can be free from any material errors and fraud. Thank you.

      Reply
  25. Christian Ashiagbor

    This is very detailed and very informative. Mr. Adin Darko has done a thorough and great work. Kudos

    Reply
  26. Ankomako Philip

    Insightful and provocative. Good job. Can we review “the-same-rate-for-all” for members from the informal sector too to bring in more proceeds to help address the funding gap? The current state where everybody from the informal sector pays the same when earnings aren’t the same does not ensure equity. I can recollect some experiences we had when I joined in 2004. Payment by a member to enroll under the scheme was always influenced by some socio-economic circumstances of the member. Although it had its own weaknesses we can still learn from some positives it presented. Possibly the modalities in past may need to be polished now.

    Reply
    • Daniel Asare Adin-Darko

      I agree! The flat-rated premium for those in the informal sector does not ensure equity. Premium payment should be based on ability to pay so that the rich can cross-subsidize the poor. The difficulty in the past has been the lack of data to properly assess the income levels of the large numbers in the informal sector. With the gradual formalization of the Ghanaian economy, where Ghana Card is issued to each individual and the unique identification number on the Card also becoming the Tax Identification Number, I believe policy makers can leverage on that going forward to set new premium levels.

      Reply
  27. Paul Darkpani

    It is a well researched article on earmarked funding with detailed analyses from a practitioners perspective. It gives a very detailed account of funding for health insurance in Ghana from beginning to its current form. One thing that remains clear is that the sustainability of the scheme is still a challenge and this will take a bold political will to put the scheme on a sound footing. The capping of funds generated for the Scheme has not help matters and I side with the writer for keystakeholders to consider exempting the fund from being capped. This will free more resources to help build a healthy nation and inure to the benefits of Ghana. The article is a master piece that has shaped my thoughts on health financing in Ghana. No doubt, it has contributed to literature and will serve as rich research material for everyone. Great job Dan.

    Reply
    • Danielle Bloom

      This is a great point! The exemption from capping could help to unlock an important policy bottleneck.

      Reply
      • Francis

        The major threat to the sustainability of the NHIS programme in Ghana is the capping of all statutory funds not to exceed 25% of tax revenue. By the capping, technically, there is no earmarked funds for the NHIS. The NHIS is currently funded by the use of “warrants” from the Ministry of Finance. Thus, the Minister of Finance is using his discretionary powers to allocate resources for the Scheme. All those who believe in the concept of the NHIS as it was designed need to add their voices to ensure that the Minister of Finance sends amendment to that Act which capped the NHIF as part of the capping of statutory funds.

        This coupled with elimination of corruption in the management of the funds will gona long way to sustain the scheme.

        Reply
        • Danielle Bloom

          Thanks for this insightful contribution. You raise an important question about whether the cap only weakens, or rather negates completely the benefit of an earmark. Exempting NHIS from the cap may be one necessary condition, while a sufficient condition will be to ensure that there is an environment established that also ensures efficiency in resource use and value for money.

          Reply
  28. ERIC OWUSU YEBOAH

    Excellent write up! It is surely going to generate interest and discussions on the financing of NHIS in Ghana to make it more sustainable, especially at a time where some group of people are advocating for expansion of NHIS benefits package to include more ailments.
    The article is very insightful and I believe it will be a very good resource material for further research into healthcare financing in Ghana. Well done, Mr. Adin-Darko.

    Reply
    • Daniel Asare Adin-Darko

      Sure! Expansion of the benefit package will mean the Scheme will require more resources to meet this expenditure. Thank you.

      Reply
      • Mark Kumordzi-Ablo (SHRM-SCP, MGhIS)

        Excellent piece explaining the various funding sources and what actually gets remitted to the NHIS.
        Why is it an offense not to pay the health insurance tax/levy but okay to delay and cap remittance to the beneficiary institution in the name of law!
        Will the NHIS/NHIA become richer than Ghana?
        Future reforms must include direct remittance from all sources to the Scheme and removal of all caps, with the required controls sitting with the NHIA.

        Reply
        • Danielle Bloom

          Important points- it is interesting to see such wide support for removal of the caps!

          Reply
  29. Daniel Asare Adin-Darko

    Thank you all for the feedback. My appreciation goes to the NHIA and the World Bank technical team for the support, inputs and excellent review to help come out with this publication.

    Reply
  30. Samuel Lobber

    The paper has fully captured the NHIA/NHIA’s journey noting the various stop-overs, changes and its current state of affairs in terms of funding. It is clear from the data that even without any additional taxes, the NHIA is financially sustainable if current the revenue from the various sources are allowed to flow without diversions, capping ‘biting’ and delays in releases. The NHIA has been used and is still being used by various governments to tax and collect revenue in the name of the NHIL but those funds never get to their target destiny (NHIF).
    Works such as this paper are necessary in contributing to efforts in pulling funding to the NHIA and the health sector as a whole by CSOs, Development partners, opinion holders etc.
    Congratulations using your vast expertise, knowledge and training to contribution this much to the ongoing discourse in looking for adequate funding for the NHIA.

    Reply
    • Daniel Asare Adin-Darko

      Sure! The Scheme could be on a good footing with the full flow of funds to NHIA and adequate expenditure controls. Thank you.

      Reply
  31. Francis Lawson

    This is a very comprehensive report touching on the efforts being made from inception to ensure financial sustainability of the Scheme.
    This report could influence timely release of funds, and identify other sources of funding.

    Congratulations, Daniel

    Reply
  32. Edna Gyau Baffour

    The issue of ‘Provider shopping’ by members should be looked at carefully because the sustainability of the scheme is key. There should be broader consultations on how to manage members in terms of multiple attendance which also increase cost unnecessarily. Technology may assist in our quest to monitor members abuse but other modes of payments may be explored; however it may require a strong will power on the part of all key stakeholders.

    Reply
    • Daniel Asare Adin-Darko

      I agree! The deployment of robust and integrated Enterprise Resource Planning (ERP) system of Claims Management across the health care provider sites with adequate controls would help to check provider shopping and impersonation by members to reduce claims cost. Thank you.

      Reply
  33. Kasimu Abudulai

    A really informative piece. Indeed, the manual and unintegrated systems of healthcare provision and claims adjudication is a really big source of leakage to the NHIA. All required efforts and investments must be put in this area to block that major loophole.

    Reply
    • Daniel Asare Adin-Darko

      Yes! A robust and integrated ERP claims management system would help to address this. Thank you.

      Reply
  34. Foster Awudi

    𝑽𝒆𝒓𝒚 𝒊𝒏𝒔𝒊𝒈𝒉𝒕𝒇𝒖𝒍 𝒑𝒊𝒆𝒄𝒆 𝒔𝒉𝒐𝒘𝒊𝒏𝒈 𝒉𝒐𝒘 𝑮𝒉𝒂𝒏𝒂’𝒔 𝑯𝒆𝒂𝒍𝒕𝒉 𝑰𝒏𝒔𝒖𝒓𝒂𝒏𝒄𝒆 𝑺𝒄𝒉𝒆𝒎𝒆 𝒉𝒂𝒔 𝒆𝒗𝒐𝒍𝒗𝒆𝒅 𝒐𝒗𝒆𝒓 𝒕𝒊𝒎𝒆. 𝑾𝒉𝒂𝒕 𝒍𝒊𝒕 𝒖𝒑 𝒇𝒐𝒓 𝒎𝒆 𝒘𝒂𝒔 𝒘𝒉𝒆𝒏 𝒚𝒐𝒖 𝒉𝒊𝒈𝒉𝒍𝒊𝒈𝒉𝒕𝒆𝒅 𝒕𝒉𝒆 𝒆𝒇𝒇𝒆𝒄𝒕 𝒐𝒇 𝒅𝒆𝒍𝒂𝒚 𝒊𝒏 𝒑𝒂𝒚𝒊𝒏𝒈 𝒉𝒆𝒂𝒍𝒕𝒉 𝒄𝒂𝒓𝒆 𝒑𝒓𝒐𝒗𝒊𝒅𝒆𝒓𝒔 𝒂𝒏𝒅 𝒉𝒐𝒘 𝒕𝒉𝒆𝒚 𝒂𝒍𝒔𝒐 𝒖𝒏𝒍𝒂𝒘𝒇𝒖𝒍𝒍𝒚 𝒆𝒙𝒑𝒍𝒐𝒊𝒕 𝑵𝑯𝑰𝑺 𝒎𝒆𝒎𝒃𝒆𝒓𝒔 𝒃𝒚 𝒄𝒂𝒖𝒔𝒊𝒏𝒈 𝒐𝒖𝒕 𝒐𝒇 𝒑𝒐𝒄𝒌𝒆𝒕 𝒑𝒂𝒚𝒎𝒆𝒏𝒕 𝒂𝒏𝒅 𝒍𝒂𝒕𝒆𝒓 𝒓𝒆-𝒃𝒊𝒍𝒍𝒊𝒏𝒈 𝑵𝑯𝑰𝑨 𝒇𝒐𝒓 𝒔𝒆𝒓𝒗𝒊𝒄𝒆 𝒓𝒆𝒏𝒅𝒆𝒓𝒆𝒅 𝒇𝒐𝒓 𝒘𝒉𝒊𝒄𝒉 𝒕𝒉𝒆 𝒎𝒆𝒎𝒃𝒆𝒓 𝒉𝒂𝒔 𝒂𝒍𝒓𝒆𝒂𝒅𝒚 𝒑𝒂𝒊𝒅.

    𝑾𝒆 𝒄𝒂𝒏 𝒄𝒖𝒓𝒃 𝒕𝒉𝒊𝒔 𝒎𝒆𝒏𝒂𝒄𝒆 𝒃𝒚 𝒊𝒏𝒗𝒆𝒔𝒕𝒊𝒏𝒈 𝒊𝒏 𝒂 𝒓𝒐𝒃𝒖𝒔𝒕 𝑰𝑪𝑻 𝒑𝒍𝒂𝒕𝒇𝒐𝒓𝒎 𝒘𝒉𝒆𝒓𝒆 𝑵𝑯𝑰𝑺 𝒎𝒆𝒎𝒃𝒆𝒓𝒔 𝒐𝒓 𝒕𝒉𝒆 𝒔𝒖𝒃𝒔𝒄𝒓𝒊𝒃𝒆𝒓 𝒘𝒊𝒍𝒍 𝒃𝒆 𝒎𝒂𝒅𝒆 𝒕𝒐 𝒔𝒊𝒈𝒏 𝒐𝒓 𝒄𝒐𝒏𝒔𝒆𝒏𝒕 𝒕𝒐 𝒕𝒉𝒆 𝒄𝒍𝒂𝒊𝒎𝒔 𝒔𝒖𝒃𝒎𝒊𝒕𝒕𝒆𝒅 𝒐𝒏 𝒕𝒉𝒆𝒊𝒓 𝒃𝒆𝒉𝒂𝒍𝒇 𝒕𝒐 𝒃𝒆 𝒓𝒆𝒊𝒎𝒃𝒖𝒓𝒔𝒆𝒅 𝒃𝒚 𝑵𝑯𝑰𝑨. 𝑻𝒉𝒊𝒔 𝒎𝒆𝒂𝒏𝒔 𝒕𝒉𝒂𝒕 𝒃𝒆𝒇𝒐𝒓𝒆 𝒕𝒉𝒆 𝒎𝒆𝒎𝒃𝒆𝒓 𝒍𝒆𝒂𝒗𝒆𝒔 𝒕𝒉𝒆 𝒉𝒐𝒔𝒑𝒊𝒕𝒂𝒍, 𝒉𝒆 𝒐𝒓 𝒔𝒉𝒆 𝒌𝒏𝒐𝒘𝒔 𝒉𝒐𝒘 𝒎𝒖𝒄𝒉 𝑮𝒐𝒗𝒆𝒓𝒏𝒎𝒆𝒏𝒕 𝒘𝒊𝒍𝒍 𝒑𝒂𝒚 𝒐𝒏 𝒉𝒊𝒔 𝒃𝒆𝒉𝒂𝒍𝒇 𝒂𝒏𝒅 𝒘𝒉𝒆𝒏 𝒕𝒉𝒆 𝑯𝒐𝒔𝒑𝒊𝒕𝒂𝒍 𝒇𝒊𝒏𝒂𝒍𝒍𝒚 𝒔𝒖𝒃𝒎𝒊𝒕𝒔 𝒕𝒉𝒆 𝒄𝒍𝒂𝒊𝒎𝒔 𝒆𝒍𝒆𝒄𝒕𝒓𝒐𝒏𝒊𝒄𝒂𝒍𝒍𝒚, 𝒕𝒉𝒆 𝒎𝒆𝒎𝒃𝒆𝒓 𝒔𝒉𝒐𝒖𝒍𝒅 𝒃𝒆 𝒏𝒐𝒕𝒊𝒇𝒊𝒆𝒅 𝒂𝒈𝒂𝒊𝒏 𝒗𝒊𝒂 𝒕𝒉𝒆 𝑰𝑪𝑻 𝑷𝒍𝒂𝒕𝒇𝒐𝒓𝒎 𝒇𝒐𝒓 𝒄𝒐𝒏𝒇𝒊𝒓𝒎𝒂𝒕𝒊𝒐𝒏. 𝑻𝒉𝒊𝒔 𝒊𝒔 𝒕𝒉𝒆 𝒐𝒏𝒍𝒚 𝒘𝒂𝒚 𝒘𝒆 𝒄𝒂𝒏 𝒔𝒕𝒐𝒑 𝑯𝒆𝒂𝒍𝒕𝒉 𝒄𝒂𝒓𝒆 𝒑𝒓𝒐𝒗𝒊𝒅𝒆𝒓𝒔 𝒇𝒓𝒐𝒎 𝒎𝒊𝒍𝒌𝒊𝒏𝒈 𝒕𝒉𝒆 𝒔𝒚𝒔𝒕𝒆𝒎 𝒂𝒕 𝒕𝒉𝒆 𝒅𝒆𝒕𝒓𝒊𝒎𝒆𝒏𝒕 𝒐𝒇 𝒕𝒉𝒆 𝒔𝒄𝒉𝒆𝒎𝒆.

    𝑰𝒇 𝑮𝒐𝒗𝒆𝒓𝒏𝒎𝒆𝒏𝒕 𝒄𝒐𝒖𝒍𝒅 𝒕𝒂𝒌𝒆 𝒔𝒕𝒆𝒑𝒔 𝒕𝒐 𝒔𝒆𝒑𝒂𝒓𝒂𝒕𝒆 𝑵𝑯𝑰 𝒇𝒖𝒏𝒅 𝒇𝒓𝒐𝒎 𝒕𝒉𝒆 𝑪𝒐𝒏𝒔𝒐𝒍𝒊𝒅𝒂𝒕𝒆𝒅 𝑭𝒖𝒏𝒅 𝑨𝒄𝒄𝒐𝒖𝒏𝒕, 𝒊𝒕 𝒄𝒐𝒖𝒍𝒅 𝒈𝒐 𝒂 𝒍𝒐𝒏𝒈 𝒘𝒂𝒚 𝒕𝒐 𝒄𝒖𝒓𝒃 𝒅𝒆𝒍𝒂𝒚 𝒊𝒏 𝒑𝒂𝒚𝒎𝒆𝒏𝒕 𝒐𝒇 𝒐𝒖𝒓 𝒄𝒍𝒂𝒊𝒎𝒔. 𝑨𝒍𝒍 𝒕𝒉𝒆𝒔𝒆 𝒄𝒂𝒏 𝒎𝒂𝒕𝒆𝒓𝒊𝒂𝒍𝒊𝒛𝒆 𝒐𝒏𝒍𝒚 𝒊𝒇 𝒕𝒉𝒆𝒓𝒆 𝒊𝒔 𝒂 𝒔𝒕𝒓𝒐𝒏𝒈 𝒑𝒐𝒍𝒊𝒕𝒊𝒄𝒂𝒍 𝒘𝒊𝒍𝒍

    𝑪𝒐𝒏𝒈𝒓𝒂𝒕𝒖𝒍𝒂𝒕𝒊𝒐𝒏𝒔! 𝑫𝒂𝒏𝒊𝒆𝒍 𝑨𝒅𝒊𝒏-𝒅𝒂𝒓𝒌𝒐 𝒇𝒐𝒓 𝒕𝒉𝒊𝒔 𝒈𝒓𝒆𝒂𝒕 𝒘𝒐𝒓𝒌.

    Reply
    • Daniel Asare Adin-Darko

      Great points for policy consideration.

      The out of pocket payments erode confidence in the Scheme. Apart from the delay in release of funds to health care providers, out of pocket payment is also caused by non-competitive payment rate to providers, inadequate knowledge of the benefits package by members, low empowerment of members about their rights and responsibilities, inadequate monitoring of health care providers’ activities and ineffective sanction regime among others, which require urgent redress.

      Reply
  35. Cynthia Bentum

    Good work done bro. This insightful research has brought to light our beginnings as well as our current state. it is no doubt that the challenges this study has enumerated on the sustainability of the NHIS is KEY to the attainment of Universal Health Coverage. Thanks for this well researched piece

    Reply
  36. Daniel Asare Adin-Darko

    In reference to Figure 3, the direct transfer of funds from SSNIT to NHIA stopped in July 2021. This is to ensure that the SSNIT contributions go through the Ministry of Finance as before and capped appropriately.

    Reply
    • Albert Nyarko Antwi

      Does the introduction of capping system apply to the SSNIT contributions retrospectively?
      To clarify the above question, if SSNIT owed contributions prior to July 2021 will the capping affect such contributions?

      Reply
      • Daniel Asare Adin-Darko

        Good question-The capping law is already in force so the Controller & Accountant General Department (CAGD) has applied the capping to the SSNIT contributions retrospectively.

        This means that the total revenue shortfall to the Scheme from 2017 to 2020 has increased from the initial GH₵1.5 billion (US$302.89 million) to GH₵2.96 billion (US$599.57 million). It implies that transfer of funds to the Scheme in 2021 will be adversely affected.

        The sustainability of the Scheme is therefore seriously threatened by this and so the removal of the capping is very necessary.

        Reply
        • Ohemaa Afia Ago

          Great work done on this article!

          What is the percentage of funds taken from the scheme as a result of the capping?

          Reply
          • Daniel Asare Adin-Darko

            Good question-Of the total amount mobilized from the NHIL & SSNIT contributions from 2017 to 2020 amounting to GH₵8.97 billion (US$1.82 billion), the total amount taken for other priorities represents 33%.

            In the year 2021, 37% of the earmarked funds for health was allocated for other purposes, which is more than one-third and so very significant.

            The Scheme could face liquidity challenges from the third quarter of 2021 if the capping remains in full force.

    • Albert Nyarko Antwi

      Will the capping apply to the SSNIT contributions retrospectively?

      Reply
      • Daniel Asare Adin-Darko

        Responded above

        Reply
        • Yaw Opoku-Boateng

          Great piece of work. Very detailed and informative.
          Revenue generation should be more pregressive, tax on investments should be considered.
          Benefit package should be looked at again to create some space for PHIS to complement the NHIS.
          Capping of revenue to NHIF should also cease to allow the levies collected come to the fund to bridge the gap.
          I hope this article is read by the power brokers.
          Congratulations Mr. Adin-Darko

          Reply
  37. Baba S. Zankawah

    A well-researched, educative and thought provoking paper.
    On the revenue end, it is refreshing to know that attempts are being made to circumvent the bureaucracy to allow at least SSNIT to transfer the 2.5% directly to the NHIA, same should happen to the NHIL as well. It is interesting to learn also that the NHIS lost or was deprived of about GHS 1.5billion between 2017 and 2020, that is an average of GHS 500million a year as a result of the ‘Capping System’. This amount could have done so much in claims payment.
    As far as the expenditure bit is concerned, are we able to estimate the cost/value of waste and claims fraud if any?, and how these will affect sustainability. What about illegal out-of-pocket payment? How is that affecting the integrity of the Scheme, uptake of healthcare services and ultimately the attainment of UHC?.
    I gather from the piece that earmark funding obviously is the mainstay of the NHIS, which needs enhancement, restructuring etc modification to meet growing demand. Equally, there seem to be an innovative effort at improving membership and operational efficiency which is good and must be sustained.
    Earmark funding and for that matter funding (Revenue) generally is one of the key pillars/legs of sustainability of the NHIS. We hope to read on the other legs in your subsequent series.
    Kudos

    Reply
    • Daniel Asare Adin-Darko

      Yes, the direct transfers from SSNIT to NHIA from 2020 improved the liquidity of the Scheme and payments to health care providers and suppliers were much regular, which helped to reduce arrears and provider/supplier complaints. Unfortunately, these direct transfers ceased in July 2021.

      Further studies may answer the questions raised. Thank you.

      Reply
      • William Kwasi Sabi

        Very good article. Could you please also give the historical development of the payment systems:
        1. Itemised bill
        2. GDRG
        3. then capitation
        And provide reasons why they kept changing

        Reply
        • Daniel Asare Adin-Darko

          Good questions-Box 1 throws light on Ghana’s experience with provider payment reforms.

          Reply
  38. Collins Akuamoah Danso

    This is a detailed and well-researched article worth reading. Excellent work. Congrats Daniel

    Reply
  39. Emmanuel Badusi Bukari

    A very succinct chronicle of the financial trajectory of Ghana’s social health insurance scheme. I hope the relational analysis of the legislative strictures and rigidities in the timely release of funds will help policy makers fashion practical ways of enabling full financial and operational efficiency of the NHIS

    Reply
  40. Isaac Gideon Akonde

    This is a great piece of work which is well structured and thoroughly researched, providing an clear journey of the NHIS so far. From this research, it appears the scheme could be financially sustainable with the current sources of funding provided efforts are made to ensure consolidation of all earmarked funds, prompt releases of funds and further consideration on government fiscal policy reforms such as the capping of revenue. The scheme will be more sustainable if it is possible to decouple the NHIF from the consolidated fund and have all other revenue sources consolidated into a single earmarked revenue pool. This will reduce fragmentation and make it easier for management to make strategic purchasing decisions for the population as fragmentation in revenue pooling usually leads to fragmentation in purchasing of health services including delays in payment of claims.
    Secondly, as these measures are being considered at the policy level to ensure adequate funding for the scheme, the NHIS being the single largest purchaser of health services in Ghana can leverage on immerging technology that improve its purchasing function through the tracking of service quality and checking provider-site moral hazards especially illegal payments. This will inspire confidence in the scheme and ensure population coverage as we make progress towards the attainment of UHC.
    Congratulations Dan

    Reply
    • Daniel Asare Adin-Darko

      Great points especially leveraging on technology to monitor service quality and billing of members will help to improve member experience.

      The use of technology can make it easier to institute an award scheme to reward high performing service providers on an annual basis in a transparent manner. The providers can be given financial and non financial rewards. Publishing their names alone will serve as an advert for them to receive more patients, which will increase their revenue generation . This will ultimately have a trickling down effect and improve the overall service quality of the Scheme.

      Reply
      • Naomi Adu-Nyarko

        This article gives an in-depth analysis of the operations of NHIS. I’m particularly happy with the introduction of mobile renewal of membership and the fact that road accident victims are given some coverage under the scheme. A good information to all stakeholders. Congratulations

        Reply
  41. Abass Suleymana

    Respectfully, I write to add my comments to those already made by colleagues and very senior and highly respected health financing experts herein.

    Dan, congratulation on this publication, and, for sharing your perspectives from the practitioner’s eye regarding domestic resource mobilization for health, with particular emphasis on Ghana’s NHIS.

    Indeed, to guarantee the sustainability of the NHIS in the medium to long term, there is the need to look at: (a) revenue-side interventions – ensure timely release of NHIS funds for timely claims payments and seek additional inflows i.e. upward review of premium amount, special health tax on alcohol, sugar and related commodities; (b) expenditure-side interventions – re-focus on primary health care and reduce/eliminate fraud and abuse associated with manual processes through the use of technology and innovation; (c) supply-side intervention – leverage the Authority’s purchasing function to enforce the gatekeeper system/policy through strategic purchasing; and (d) demand-side intervention – leverage the Authority’s purchasing function through strategic purchasing to rollout payment arrangements that can deter insured members from self-referring themselves to higher facilities while ensuring that the poor and vulnerable are catered for.

    Congrats once again Dan for this wonderful research work.

    God bless us all.

    Reply
  42. Constance Addo-Quaye

    Congratulations Dan for a comprehensive work done. This article indeed touches relevant issues affecting sustainability of Ghana’s National Health Insurance. I recommend amongst others, a vigorous and effective electronic system for claims submission to reduce or avoid over reimbursement and also system for monitoring the billing of services rendered to clients especially to check double billing ( billing both the clients and NHIA for the same services rendered yet, giving wrong impression to the client that NHIA doesn’t cover those services) to encourage more registration for membership for more premium and registration fees etc.

    Well done Dan.

    Reply
  43. Mark Hellowell

    This is a wonderfully detailed and thought-provoking article, with useful lessons for future policy in Ghana, but also for all other countries who are considering earmarked funds for NHI / SHI. It appears that earmarked financing can help to strengthen the political and technical argument for setting up an NHI/ SHI fund. But the benefit of the NHI/ SHI fund will be undermined unless there is continued commitment to sustain the additionality principle – which requires, I guess, increasing the allocation of rising GDP to health through a broader set of revenue streams.

    Reply
  44. aryaarmdn

    Thank you for nice information

    Reply
  45. Edward Nyarko

    Congratulations to the author for providing such a thorough practitioner’s review of one of the important social interventions implemented in Ghana and arguably, in Africa, the Ghana National Health Insurance Scheme.

    The elaborate analysis and the highlights on the financial sustainability of the scheme from the standpoint of funding are critical for future reforms. In particular, the spotlights on the relative contributions to scheme from Internally Generated Funds (IGF) and earmarked public funds ( such as Value Added Tax and Social Security Contributions, etc.) is an important consideration for future reform.

    The declining share of government expenditure on the health sector as a result of competing sectors is a critical concern policymaker should carefully consider for review of budgetary allocations to the health sector and subsequent reforms of the scheme. As observed by the author, the declining share of government expenditure could be indicative of a possible threat to the financial sustainability of the National Insurance Scheme. Policymakers need to pay critical attention to this.

    Consistent with the suggestion of earlier commentators, I recommend that the funding sustainability adequately addressed by the author in this paper, should be considered together with other perspectives of sustainability during future reforms of the scheme. As argued by Sylvester Mensah, budgetary allocation to the scheme should be based on enrolment, the quality of the health delivery system, and accessibility. I also recommend effective financial controls to address the threats to sustainability emanating from outflows as observed by the author.

    Reply
  46. James Quophy Wumen

    Very insightful and well written piece of research. I’ve learned a lot from it as it highlights the financial sustainability of the NHIS.

    I think it would be great if the author can add after the conclusion some practical recommendations on how to improve the financial sustainability of the scheme: The following are some recommendations I would suggest after my review:
    – NHIA, civil society and all stakeholders (service providers, general public etc) should advocate for the NHIS Levy to be transferred directly to the NHIA.
    – NHIA, civil society and all stakeholders should advocate for the NHIS levy and SSNIT levy to be exempted from the capping system
    I believe if these two recommendations are implemented, the NHIS will be more financially sound and the major issue of delay in payment to providers will be greatly reduced which will in turn improve the quality of service received by the scheme members.

    The following suggestion will also help curb the bad practice of some healthcare providers billing patients to pay out of pocket and at the same time billing the NHIS:
    My experience with private health insurance providers is that: anytime I visit the hospital and the hospital bills the insurance company, the insurance company sends me a text message/email indicating that the hospital has billed them xx amount for my healthcare service. For me this text message is a control mechanism for me to lodge a complaint to the insurance company if I was made to pay out of pocket before the hospital is again billing the insurance company to pay. I’m also able to lodge a complaint to the insurance company if the amount being billed by the hospital to the insurance company is unrealistic.
    I think if the NHIS has such a system in place where patients can be sent a text message or email indicating how much the hospital is billing the NHIS for the services rendered and encourage patients to lodge a complaint if they suspect anything fishy that will help curb the issue of double billing or over-billing by some of the healthcare providers.

    Also, the NHIS should intensify mystery shopping/mystery client as a monitoring mechanism to help detect some of the fraudulent practices undertaken by health providers and also ascertain the quality of services provided by the healthcare providers for redress.

    Lastly, I think the NHIS should be innovative in their premium arrangements. Again my experience with private health insurance schemes is that: there are different premium schemes for different quality of services. Those who pay higher premium access higher quality healthcare services and those who pay the normal/minimum premium enjoy normal service package under the scheme. I believe if the NHIS adopt similar premium arrangement where those who can afford higher premium can pay to enjoy better quality services (i.e better quality health facilities, medications, wider disease coverage etc) it will offer the NHIS additional revenue. This arrangement will encourage the middle and higher income earners to patronize the NHIS as most of these people do not find the current NHIS scheme attractive enough due to the poor quality of service and the lack of opportunity to pay higher premium to enjoy higher quality service.

    In conclusion, I will reiterate that this is a very insightful piece of research and I believe it will provoke discussions and ideas on how to improve the financial sustainability of the scheme. Good job.

    Reply
    • Daniel Asare Adin-Darko

      Thank you James for all the useful suggestions especially having a system in place to promptly notify NHIS members of their medical bills after visiting a health facility so they could report any adverse observations for redress.

      Reply
  47. Dickson Nuku Dansu

    Congratulations Daniel on your in-depth and well researched publication.

    Reply
  48. Doctor Emmanuel Apori Obeng

    Congrats Dan for such an educative well researched piece.

    Reply
  49. Doctor Emmanuel Apori Obeng

    Congrats Dan for such an educative well researched piece.

    Upon your persistent encouragement, i have decided to post this write-up entitled -“Achieving Financial Sustainability of the National Health Insurance Scheme in theCovid-19 Era” on the JLN Platform.

    My hope is that it will add to the body of knowledge on sustainability available on the said platform.

    Thanks a million for acting like the Chief Cupbearer of Pharaoh who remembered that there was a Joseph in prison who could interprete his Master’s dream

    Reply
  50. Doctor Emmanuel Apori Obeng

    ACHIEVING FINANCIAL SUSTAINABILITY OF THE NATIONAL
    HEALTH INSURANCE SCHEME IN THE POST COVID-19 ERA

    INTRODUCTION
    I wish to, first and foremost, acknowledge Daniel Asare Adin-Darko, a Chartered Accountant, Tax Practitioner and Economist at the National Health Insurance Authority. He prodded me to read his publication entitled;
    “Earmarking in Ghana: Impacts on the Financial Sustainability of the National Health Insurance Scheme” at the website of the JOINT LEARNING NETWORK (JLN) and share my experiences on the vexed question of the sustainability of the scheme on the JLN platform.

    The said publication is a well-researched educative and rave review of the impact of Earmarking on the Financial Sustainability of the National Health Insurance Scheme.

    Though the decoupling of the National Health Insurance Levy (NHIL) from the Value-Added Tax in 2018, which made it a straight levy on the consumption tax to provide potential revenue gains for the NHIS, a separate capping system introduced in 2017 limited the amount of revenue that could flow to the NHIS. Under the Earmarked Funds Capping and Realignment Act, 2017 (Act 947), all allocations to the various statutory funds must not exceed 25 percent of all government revenue. As a result of the capping, these was a shortfall of GH¢ 1.5 billion in transfers between 2017 and 2021 (1).

    This huge shortfall was a contributing factor to the cash ratio of less than 20% within National Health Insurance Authority (NHIA). A testament to the fact that National Health Insurance Scheme (NHIS) was tethering on UNSUSTAINABILITY. ie. The NHIS has COLLAPSED (in local parlance) because the cash balances and short term deposits together are unable to meet 20 percent of NHIA short term obligations at a given time.

    The obvious repercussions were the inability of NHIA to reimburse providers timeously forcing them to adopt coping mechanisms including demand for out-of-pocket (OOP) payments, delivering services of less than average quality in addition to engagement in Fraud and Abuse such as Phantom Billing, Up coding, Double Billing, Unbundling etc. to increase claims cost to compensate for the time value of their earnings. Eventually quality of care is compromised and the negative experiences become a disincentive for increase in Active Membership through renewal of cards on expiration.

    Out of pocket payments have been christened ‘Survival Fees’ by some Healthcare Providers. The fact that clients were paying out-of-pocket even for services and medicines covered by NHIS meant that the second objective for the establishment of NHIS, ie. Financial risk protection against Catastrophic Health Expenditure (CHE), was not being achieved.

    It is however instructive to note that it takes two to tango. Whilst numerous appeals go to the Government to consider removing the capping, reducing the time lag and reimbursing at more than the current 70 percent, conscious efforts should also be made by NHIA to efficiently reduce expenditure. Providers should eschew Fraud and Abuse and present genuine claims for reimbursement. Moral hazards such a Provider-shopping, frivolous use of services and third party use of health insurance cards, on the part of clients should be reduced to the barest minimum and citizens advised to take measures to ensure good health.

    FINANCIAL SUSTAINABILITY OF THE NHIS

    Dennis Asante et al, 2018 summarized Leon’s argument in her Four Pillars of Financial Sustainability in the following mathematical equation.

    FINANCIAL SUSTAINABILITY => TOTAL INCOME – TOTAL COST = SURPLUS (2)

    If Expenditure (cost) exceeds Income (Revenue) Deficit occurs.
    Expenditure increases are usually due to increase in price and quantity of service and Medicines as well as increase in Administrative Costs.

    It is pertinent to note that the establishment of the NHIS in 2003 by Act 650, replaced by Act 852 in 2012, did not, ab initio, strictly satisfy the basic requirements for Sustainability of a Social Health Insurance Scheme recommended by the World Health Organization (WHO). The two basic requirements are
    i) A MEDICAL LOSS RATIO (Claims to Administrative Costs) of 90 : 10

    ii) A minimum reserve of nine (9) months of estimated claims cost per month.

    The Allocation Formula for disbursements from the National Health Insurance Fund (NHIF) of 70% CLAIMS, 20% – ADMINISTRATIVE COST and 10% – SUPPORT TO THE MINISTRY OF HEALTH (1) connotes a higher than normal allocation for Administrative and other costs to the detriment of Claims Cost.

    Act 852, Sections 73 and 79 make Security Deposits mandatory for the establishment of both Private Commercial and Private Mutual Health Insurance Schemes.

    One wonders why the NHIA (the Regulator / Implementer) was precluded from such a vital requirement. A positive balance could therefore be achieved if NHIA embarked on increased revenue mobilization combined with efficient reduction in both claims and administrative expenditure.

    REVENUE MOBILIZATION
    Little diversification of the Income sources of NHIS with overdependence on NHIL (62%) and SSNIT contributions (29%) was identified as one of the greatest threats to financial sustainability of the NHIS (2). With about 91% of total revenue coming from only two (2) sources, any hiccups in revenue mobilization and below par performance of the National Economy would greatly affect income due NHIS.

    Agyei Ampofo et al, 2021 stated, inter alia that Ghana was identified as one of Africa’s fastest rising economies in the year 2020. However just as Ghana’s economy emerged from the crisis and consolidated recent gains for growth and jobs, the country was hit by a Coronavirus outbreak resulting in tight movement restrictions. Whist the primary impact of the Covid-19 epidemic focused on human health and public health systems, the country also experienced indirect effects on all sectors of the economy (UNICEF, 2021). The hotel and hospitality business, foreign direct investment, trade and industry, agriculture health, transportation, manufacturing, real estate, finance and education have all been heavily impacted. The National Preparedness and Response Strategy which was developed by the Ministry of Health (MOH) and World Bank, to facilitate early diagnosis and rapid detection during the outbreak, was to be paid for by the Government of Ghana (3).

    The Covid-19 Pandemic era, which started in the country in March, 2020 resulted in the contraction of the economy resulting in a GPD growth rate of 0.4% in 2020 as opposed to the projected 6.8 percent for the said year.

    A total of GH¢ 1.80 billion out of the initial budgeted revenue of GH¢ 2.01 billion was realized by the Ghana Revenue Authority leaving an adverse variance of GH¢ 210 million (1).

    In 2021, a projected GH¢ 3.02 billion was expected from 2.5% NHIL and SSNIT but GH¢ 1.9 billion will go to NHIA and GH¢ 1.12 will be channeled to other priority areas due to the capping system depicting how inimical this system is to Revenue mobilization for NHIS to achieve sustainability.

    Leon (2001) opined that for a system to be financially sustainable greater than 60 percent of its revenue should emanate from five (5) different sources. Revenue mobilization could be bolstered through
    i) Diversification of revenue sources to include sin taxes on alcohol and tobacco, environmental health tax on mining, quarrying, cement production and oil extraction entities whose activities impinge negatively on the environment and ultimately on health (polluter pays principle), allocation of some determined percentages from the Petroleum Receipts (Heritage Fund),the Road Fund and the recently established Covid-19 Health Recovery Fund. National Health Insurance Levy (NHIL) was increased by one percentage point in 2021. The estimated increase of about GH¢ 889.07 million was earmarked as a Covid-19 Health Recovery Levy going directly to Ministry of Health (MOH) to purchase Covid-19 vaccines and other commodities. Once the Covid-19 Health Recovery Levy achieves some measure of success, the 10 percent given to MOH in the allocation formula of disbursements from NHIL could be assigned to Claims Cost. With the allocation of this 10 percent to claims cost and reduction in administrative costs to shore percentage allocation to claims, NHIA could be inching towards the WHO’S recommended Medical Loss Ratio of 90:10.

    ii) The Internally Generated Funds which consist of Premiums, Registration Fees, Credentialing and Investment Income totaling 7:5% of revenue in 2019 could be enhanced by graduated actuarially determined increases in Premium, Registration and Credentialing Fees which have remained stagnant since the inception of NHIS. An upward review of these fees would have a positive impact on revenue if active membership increases pari passu.

    iii) Increase in Active Membership with reduction in adverse selection through compulsion by making the possession of a valid NHIS Card a prerequisite for accessing services such as Acquisition of National Identification Card and Driver’s License, Registration of Businesses Employment and Admission into Secondary and Tertiary Institutions (4). Section 27 (1) of Act 852 makes the membership of NHIS mandatory.

    iv) The huge number of Active members exempted from Paying Premiums (69%) negatively impacts on receipts from Premiums (2).

    The payment of Premiums of this Exempted Group by Government (SUBSIDIZATION) should shore up revenues.

    In Rwanda, membership of the Health Insurance Scheme is mandatory (COMPULSION) and the government pays premiums on behalf of the Exempted Group (SUBSIDIZATION). This policy is in line with the twin-effects of COMPULSION AND SUBSIDIZATION on coverage and sustainability advocated by FUCHS.

    Voluntarism engenders adverse selection, the rich usually opting out. Lack of subsidization precludes the poor and vulnerable from membership of such social health insurance schemes (INEQUITY).

    The increase in active membership should however be undertaken with caution and done only after an actuarially determined year-on-year percentage increase has been determined based on the gap between the number of active members now and the year 2030, when 80 percent of the estimated population are expected to have access to basic quality healthcare without adverse financial encumbrances.

    Any unbridled, catastrophic and sudden increases in membership, with its attendant increase in utilization and average cost per claim per active member (expenditure) could return NHIS to the dark years of 2018 to 2014, where such increases in active membership, introduction of Ghana Diagnostic Related Groupings (GDRGs) and Portability among others without efficient measures to reduce Fraud and Abuse to the barest minimum culminated in deficits starting from 2009.

    v) There should be a conscious effort to build up Reserves up to the average nine (9) months of claims cost over a period of three (3) to five (5) years.

    Section 79 (1,2) of Act 852 requires the Private Mutual Health Insurance Schemes to Constitute a Reserve Fund equivalent to six (6) months of operational income within three (3) years of the scheme.

    The Reserve Fund is to be invested in Government Treasury Bills, Bonds etc. if permissible to generate additional income to boost return on investments (ROI). The NHIA could fall on the Reserve Fund to make up for shortfalls in revenue, within a strict policy as to what percentage could be withdrawn at a time and the time-frame for replacement.

    Act 852 Section 74 (i) allows for the withdrawal of an amount not more than ten percent (10%) of the Security Deposit which shall be replaced by the Private Commercial Insurance Scheme not later than ninety (90) days after the date of withdrawal.

    The Reserve Fund of NHIA declined from GH¢ 447 million (14 months claims cover) in 2009 to GH¢ 100.3 million (1.2 months claims cover) in 2014. This was a result of disinvestment of the reserves to pay from claims and administrative expenditure.

    The return of investments reduced significantly from GH¢ 75.64 million in 2009 to GH¢ 16.00 million in 2014 (Table 1)

    TABLE 1 – FUNDING SOURCES OF GHANA’S NATIONAL HEALTH INSURANCE SCHEME

    Source – Dennis Asante et al, 2018

    The deficits started in 2009 but the effects became manifest in 2012 as a result of the decision to disinvest the reserves in order to meet claims and administrative costs. NHIA started borrowing to finance payments in 2011 and paid interest in 2012. Such financial maladministration should be curbed in future through strict supervision by the Board of NHIA.
    EXPENDITURE
    NHIA expenditure covers CLAIMS (c. 80%) and Administration (c.20%)

    CLAIMS EXPENDITURE
    The following were identified as factors contributing to expenditure increases at NHIA by Dennis Asante et al.

    a. The ever-increasing claims payments which more than quadrupled from 2008 to 2014 (Figure 1).

    FIGURE 1

    FIGURE 1: Claims payment trend. Source: Adapted from Jehu-Appiah (2015) (2)

    Average claims per active member increased from GH¢ 48.41 in 2010 to
    GH¢ 84.40 in 2014. A further increase to GH¢ 92.82 was recorded in 2017
    (Figure 2).

    Figure 2: Claims per active member (2010 – 2017)

    Source: NHIA Statistical Bulletin, 2017

    b. Increase in claims cost even in the face of decrease in utilization.
    Claims per active member increased from GH¢ 66.67 in 2011 to GH¢ 92.82 (41% increase) in 2017 whereas OPD utilization per active member decreased from 3.1 to 2.37 (24% decrease) within the same period (Figure 3).

    Figure 3: Out Patient Department (OPD) Utilization per active member (2010 – 2017)

    Source: NHIA Statistical Bulletin, 2017

    Similarly impatient department (IPD) utilization decreased from 0.18 to 0.14 (22% decrease) between 2011 – 2017 (Figure 4).

    Figure 4: IPD Utilization per active member (2010 – 2017)

    Source: NHIA Statistical Bulletin, 2017

    Though increase in tariffs for services and medicines through reviews could have accounted for the increases in claims cost, the last major review of tariffs occurred in 2015, and was implemented in 2016. It is palpably obvious that other factors like Fraud and Abuse from providers and moral hazard on the part of clients could have influenced the escalation of costs.

    c. Expenditure has been exceeding income and NHIA has been operating with deficits since 2009 (Figure 5).

    Figure 5: Income and Expenditure trends at NHIA (2008 – 2014)

    Source: Dennis Asante et al, 2018

    EXPENDITURE CONTROL

    1) Redesigning of the Health system with a paradigm shift towards Quality Primary Health Care (PHC) with its preventive, promotive, curative, rehabilitative and palliative components up to the District Level of Healthcare (7). It is envisaged that the revisiting of the Regenerative Health concept and introduction of a twice yearly free screening of clients for early detection and management of Non-communicable Diseases like Hypertension, Diabetes Mellitus, Cancers of the Breast, Cervix and Prostate as well as Sickle Cell Disease could reduce the number of people who report late at Healthcare centres requiring higher cost of services and medicines, but with diminished expected health outcomes. In Ghana, about 79% of all expenditure on healthcare goes to the Secondary and Tertiary Institutions with a meager 21% for Primary Care. Government plans to achieve at least 50:50 allocations as envisaged in the Document on Ghana’s Roadmap to Achieving Universal Health Coverage (UHC) by 2030 launched on December 31, 2019 (8).

    2) Revisiting the concept of Preferred Primary Provider (PPP), Strengthening of the Referral and Feedback systems and limiting Portability to emergency situations in the healthcare sector would act as a valuable GATE-KEEPER system to reduce frivolous use and provider shopping and by-passing the primary care system to Secondary and Tertiary Levels where services cost more. The crowding of such clients who do not need specialist services initially or after they have been referred to the Secondary and Tertiary levels for management and achieved stabilization, tend to reduce the quality of care because physicians are overwhelmed thereby reducing doctor-client contact time.

    3) Reviewing our Provider Payment Systems to include the despised CAPITATION and COST-SHARING at the Secondary and Tertiary levels, are Hobson’s choices we shall have to consider in future. Capitation is a very preferred means of payment for services at the Outpatient Department worldwide with Diagnostic Related Groupings (DRG’s) and others reserved for Inpatients. We need to leverage on the lessons learnt from the failure of Capitation Implementation in the Ashanti Region (2012 – 2017) to design an acceptable system.

    4) Efficient Claims administration which ensures that the processes of claims preparation and submission by Healthcare Providers, vetting of Claims at Claims Processing Centers (CPC) are carried out transparently to minimize Fraud and Abuse. There is the need to reduce manual vetting to the barest minimum by being part of the Digitalization drive of Government and ensure that reimbursements to healthcare providers are devoid of preference/ discrimination and Claims Leakages (payment in excess of genuine cost of claims). The World Health Organization (WHO) estimates that about 7% to 15% of all healthcare costs are lost to FRAUD and ABUSE.

    It was revealed during a National Health Insurance Authority Management Retreat in Accra in 2013, that between 2010 and 2012 through Clinical Audit of less than 10% of Provider Claims an amount of GH¢ 20, 103, 976 ($9,307,396) was found to have been paid as unearned claims as a result of Provider-side moral hazard (9). One can imagine the quantum of claims leakage had about 50% or more been reviewed.

    Ironically, only one reported case of imprisonment as a result of Health Insurance Fraud involving Doctor Ametewe and his nephew in the Western Region in 2018 has been cited. He was jailed 10 years whilst his accomplice received 5 years.

    Measures to reduce Fraud and Abuse to the barest minimum and ensure efficient claims vetting include;
    a) Continuous education and re-education of the Ghanaian People on the Benefits Package, Rights and Responsibilities of members and prevention and promotion of health.

    b) Clients should be encouraged to report potential Fraud and Abuse including Collusion, Unauthorized demand for Out-of Pocket payments and desist from provider-shopping, ganging, third party usage of client’s card which impact negatively on the sustainability of the NHIS.

    c) Healthcare Providers should be made aware of the impact (Unsustainability) and consequences (Legal Action) of fraud. They should eschew fraudulent practices such as Phantom Billing, Upcoding, Double-Billing Provision of unnecessary services, and Unbundling of services. Outreaches without authorization, Self-referrals and other referrals for private gain, Transfer of Documents from non-credentialed to credentialed facilities for claims submission and Post credentialing use of lower-cadre professional staff.

    d) NHIA employees should avoid collusion with Healthcare Providers which results in
    – Leakage of Privileged Information concerning claims
    – Deliberate Ignorance ie. Ignoring obvious infractions during vetting and approval for payment by Adjusters.
    – External influences to alter credentialing status, audit findings and seek preferential treatment during claims reimbursement.

    e) Digitalization of claims processing with less dependence on Manual Vetting. Nsiah-Boateng et al, (2017) reported that electronic-based review made overall adjustment of 17.0% from GH¢ 10.09 million (USD 2.64m) claims cost whilst the paper-based review adjusted 4.9% from a total of GH¢ 57.50 million (USD 15.09m) claims cost received and the difference was significant (P˂0.001). They concluded that the electronic-based review adjusted significantly higher claims cost than the paper-based claims review. Scaling up of electronic-based review to cover claims from all accredited care providers could reduce spurious claims cost to the schemes and ensure long term sustainability. Herein lies the wisdom to upscale the CLAIM-IT software, developed internally by NHIA, with an updated version to enhance the vetting of claims.

    The piloting of the Claim-IT software at CPC – Cape Coast revealed that it had an Analytic Component which could assign numbers to the reasons for deductions. This enabled the Provider to determine which areas of their practice needed particular attention to minimize reductions from their claims at the CPCs.

    The manual paper-based vetting only lists the causes for deductions without assigning any quantum to each reason.

    f) Incorporation of National Benchmarks into the CLAIM-IT software to detect outliers for scrutiny. Fortunately such Benchmarks as Average cost per claim for OPD and IPD Services and Medicines are available in the yearly NHIA Statistical Bulletins. Other Benchmarks such as Ratio of average Service to Medicine costs at the OPD and IPD as well as the IPD/OPD ratio, Detention Rates (Retention/OPD) and Total Admissions vis-a-vis Bed capacity could also be determined to enhance the vetting process.
    Robert A. Sowah et al, 2019 advocate the use of Decision Support Systems (DSS) such as Genetic Support Vector Machines (GSVMs) for Fraud Detection in Health Insurance. Their experimental results showed a significant reduction in computational time on claims processing while increasing classification accuracy via the various SVM classifiers Linear (80.67%), Polynomial (81.22) and Radial Basis Function (RBF) Kernel (87.9%) – (11)
    It would be worthwhile for NHIA to contact the said researchers to help design, develop and deploy a decision support system (DSS) which incorporates the fraud detection model, business intelligence and knowledge representation for Claims Processing.

    g) Elimination of Medical Identity Theft and Third Party Beneficiaries by adding Biometric verification to the *929# facility now available at the point of service. At the moment, one could use an active member’s card to obtain a claims check code for submitting claims because there is little or no biometric verification to ascertain the authenticity of the card holder.

    h) Enactment of legally deterrent measures which prescribe specific punishment for Health Insurance Fraud and Abuse. In the United States of America, the Health Insurance Portability and Accountability Act, 1996 (HIPAA) prescribes the following on conviction for Health Insurance Fraud.
    a. 10 years imprisonment plus fines
    b. 20 years in Federal Prison if there is injury to the client.
    c. Life imprisonment on the death of a client

    A Reward System Policy could be developed by the National Health Insurance Authority to motivate those Healthcare Providers who maintain zero tolerance for Fraud and Abuse by presenting genuine, unadulterated claims which fall within acceptable National Benchmarks in the course of a year.

    i) Update of the Database / Profile as well as the Historical Data of Healthcare Providers could provide a valuable source for claims trend analysis during vetting. A documentation of a previous fraud and abuse infraction would be valuable in determining whether a recent case is a one-off event or part of Racketeering-Racketeering is a persistent deliberate and conscious misrepresentation of claims amount for financial gain (12).

    j) The redesigning of the Prescription and Request Forms for laboratory and other diagnostic services, together with the assignment of a PRESCRIBER’S PERSONAL IDENTIFICATION NUMBER (PPIN) are very crucial. This policy would allow NHIA to trace every request for service and medicines to a particular Practitioner and help to curb incidences of irrational prescription of medicines and referrals for personal gain. Requests from only Prescribers of Good Standing in the year from their respective Regulatory Bodies should be accepted for vetting and reimbursement (13).

    k) Prompt vetting with timely and predictable reimbursement of claims based on economically-friendly, regularly reviewed tariffs would spare healthcare providers the ignominy of engaging in fraud and abuse (13).

    l) Establishment of an Anti-Fraud Department at NHIA to efficiently detect, prevent, investigate Fraud and follow up claw back of claims leakages and behavioral change are more effective means of minimizing this canker than waiting for its occurrence or late detection through occasional clinical audits. Claw back rates are usually very unacceptable. Pro-activeness is better than Reactiveness should be the guiding principle of an efficient Antifraud Department (12).
    m) Formation of COMPLIANCE UINTS within the Healthcare Facilities would ensure the preparation and submission of claims with minimal infractions, using the reports on claims from the Claims Processing Centers as a guide to shape the practice of healthcare workers (14).

    n) Regular 2-yearly review of the Benefits Package based on clear-cut criteria for inclusion and exclusion determined by Health Technology Assessment. Knee-jerk additions based on agitations from lobbyists, equalization and political expediency without adequate thought on how the add-ons are going to be financed sustainably should be avoided.

    Other measures to reduce claims expenditure include;
    i. Revisiting the concept of Strategic Purchasing and Framework Contracting in respect of Medicines. Chile has successfully used this strategy to reduce the cost and ensure availability of effective generic medicines to enhance sustainability of their Health Insurance Scheme. Selection of medicines to be included in this policy should be based on analysis of the huge claims data on reimbursement for medicines at NHIA with special emphasis on the cost-drivers.

    ii. The role of the Private Commercial and Private Mutual Insurance Schemes should be assessed with a view to scaling up their penetration significantly to act as a second-tier mainly for reimbursement for conditions not adequately covered under the Benefits Package of NHIS in practice Childhood Cancers, Cancers of the Cervix, Breast, Prostate and Dialysis for Chronic Kidney Diseases as well as Eye and Orthopedic implants could be on the Benefits Package of such schemes.

    The Ghana National Association of Teachers’ (GNAT) Private Mutual Health Insurance Scheme is worth case studying to ascertain how organized groups such as Churches, Ghana Private Road Transport Union (GPRTU) Progressive Transport Owners Association (PROTOA) and Ghana Union of Traders’ Association (GUTA) could be encouraged to form such schemes to complement the efforts of the National Health Insurance Scheme.

    iii. The contributions of Civil Society Organizations (CSO’s) in the areas of Transparency and Accountability cannot be underestimated in our quest to achieve sustainability of NHIS

    The United States of America depends to a large extent on the activities of the National Health Care Anti-Fraud Association (NHCAA) to shape policies to minimize Healthcare Fraud and Abuse.
    For example the Accredited Healthcare Fraud Investigator (AHFI) is a unique professional designation granted by NHCAA to individuals who meet the necessary qualifications related to their professional experience, NHCAA membership, specialized training and demonstrated knowledge in the detection, investigation and/or prosecution of healthcare fraud.

    A similar coalition against Health Insurance Fraud in Ghana should be formed with membership from
    i) Clients
    ii) Healthcare Providers
    iii) NHIA
    iv) Government
    v) Judiciary
    vi) Parliament
    vii) Press
    viii) Civil Society Organizations like Ghana Anticorruption Coalition (GACC), Ghana Integrity Initiative (GII) and IMANI AFRICA
    ix) Representatives from the Religious and other groups that may be deemed necessary.

    ADMINISTRATION
    Administrative expenditure constitutes about 20 percent of NHIA expenditure and attempts should be made to reduce this percentage to ensure sustainability.

    Administrative reforms should include;
    a. Efficient Human Resource Management to avoid overemployment and underemployment at the NHIA Headquarters and District Levels respectively.

    The development of a clear-cut career progression and adequate comparative remuneration for junior, middle-level and management staff are crucial. Any increases in salaries should be graduated with the higher percentages going to those in the junior and middle levels of staff rather than a flat rate covering the top to the bottom. Any review of salaries and emoluments should be guided by ability to pay based on a well-defined sustainable medical loss ratio.

    Staff motivation should be encouraged to avoid loss of job satisfaction which engenders apathy, resort to anti-service activities and high staff attrition rate. A pyramidal human resource structure is preferable to an inverted cone, top-heavy one.

    b. Effective and efficient collection and accounting for the use of Internally Generated Funds (IGF) combined with untainted procurement practices would minimize over expenditure.

    c. Improved electronic Linkages between the various Departments instead of the creation of Independent silos of information in spite of the massive investment in ICT at the NHIA Headquarters which nearly equals one employee one computer.

    d. Transparency and Accountability in the management of the scheme through regular Internal and External audits combined with the necessary compliance and the production of yearly reports based on relevant key performance indicators. In Estonia publishing of yearly reports of their Health Insurance publicly is mandatory. Does anyone remember the last time NHIA published an annual report? Ghana would require a review of the relevant portions of Act 852 to establish a PUBLIC INTEREST AND ACCOUNTABLITY COMMITTEE (PIAC) at NHIA similar to what pertains with the use of PETROLEUM REVENUE.
    • Formation of a Joint Consultative Committee (JCC) with representation from NHIA, Healthcare Providers, Ministry of Health, Clients and other Stakeholders which meet once in a quarter to deliberate on delicate matters such as Fraud and Abuse, Review of tariffs vis-à-vis cost of services and medicines and New Legislative Instrument (LI) to replace LI 1809 which has been in existence since 2004, despite the passage of Act 852 in 2012 to replace Act 650. Such regular, transparent interactions between NHIA, Healthcare Providers, Clients and other stakeholders would erase the notion that NHIA is dictatorial when it comes to relationships between the three arms of NHIS.

    • A required minimum number of management meetings in a year should be part of the key performance indicators (KPIs) for Executive Management to avoid a situation where they decide to meet other management team members at their own convenience. The lack of regular interactions and follow-up on decisions taken leave other management members oblivious of happenings at their own backyard. This engenders mistrust, lack of cooperation and diminished esprits de corps and camaraderie within the NHIA.

    e. Politicization of the NHIA cannot be completely eliminated, because no one buys palm wine and gives it to his adversary to pour libation on his behalf. Moreover, the prerogative is given to the President to appoint the Executive Management at NHIA. However, the continued stay in office and renewal of contracts should be predicated on their ability to achieve some key performance indicators embedded in their contracts of employment. We need men and women who know their onions as far as Healthcare Financing is concerned irrespective of gender and political affiliations.

    f. A well-grounded, result oriented integrous Board of NHIA devoid of conflict of interest and partisanship would be the icing on the cake.

    CONCLUSION
    There is no gainsaying that the Post Covid-19 era presents a challenging scenario for the mobilization and spending of revenue in view of the slowing down and gradual recovery of the economics of all countries worldwide. The recent invasion of Ukraine by Russia would undoubtedly compound the envisaged slow recovery.

    Whilst we urge the Government of Ghana to revisit and revise the issues of Capping, ensure prompt release from the NHIF Fund as well as increase the 70 percent of funds accruing, these should be complemented by a paradigm shift towards Primary Health Care, responsible and appropriate behavior on the part of Clients and Healthcare Providers and measures to avoid claims leakage and spurious over expenditure at NHIA.

    You cannot fill a jar with water if you fetch same from a river with a basket. The Health of a Nation determines her Wealth and Governments who ignore the Sustainability of their Health Insurance Schemes do so at their own electoral peril.

    DR. EMMANUEL APORI OBENG
    • Health Insurance Sustainability Advocate, Medical Practitioner / Public Health Specialist.
    • Former Medical Director for Eastern Regional Hospital, Koforidua and Greater Accra Regional Hospital, Ridge.
    • Technical Advisor NHIA (March 08, 2016 – March 08, 2020)

    REFERENCES
    1. Adin-Darko, 2021
    Earmarking in Ghana: Impact on the Financial Sustainability of the National Health Insurance Scheme
    https/www/jointlearning network.org/news

    2. Dennis Asante et al, 2018
    Assessment of Financial Sustainability of Health Insurance Schemes in Africa: A case study of Ghana’s National Health Insurance Scheme.
    International Journal of Advanced Research (IJAR)

    3. The National Health Insurance Act 2012, Act 852

    4. Agyei Ampofo et al, 2021
    The Impact of Covid-19 on Ghana Governments Reforms
    Academia.edu.

    5. Moses Aikins et al, 2021
    Positioning the National Health Insurance for Financial Sustainability and Universal Health Coverage in Ghana: A Qualitative Study among Stakeholders.
    Journal.PLOS.org

    6. NHIA Statistical Bulletin, 2017

    7. Ministry of Health’s, Presidential NHIS Technical Review Committee, 2016. Proposed Redesign and Restructuring of the National Health Insurance Scheme.

    8. Ministry of Health (MOH), 2019
    Ghana’s Roadmap for Achieving Universal Health Coverage 2020 – 2030

    9. Andoh-Adjei, 2019
    Provider Payment Reforms in Ghana’s National Health Insurance Scheme: Monitoring and Evaluation of Capitation as a Provider Payment Mechanism for Primary Outpatient Services.
    Doctoral (PhD) Thesis.

    10. Nsiah-Boateng et al, 2017
    Reducing Medical Claims Cost to Ghana’s National Health Insurance Scheme: A cross-sectional comparative assessment of paper and electronic-based reviews.
    BMC Health Services Research

    11. Robert A. Sowah et al, 2019
    Decision Support System (DSS) for Fraud Detection in Health Insurance Claims using Genetic Support Vector Machines (GSVMs)
    Journal of Engineering
    Hindawi.com/journals/je/2c

    12. Kumari et al, 2014
    Federation of Indian Chambers of Commerce and Industry (FICCI) Working Paper on Health Insurance Fraud.

    13. Obeng Apori, 2018
    Minimizing Fraud and Abuse in Claims to enhance Financial Sustainability of the National Health Insurance Scheme. Paper presented to the Chief Executive Officer (CEO) and Chair of the NHIA Board in 2018.

    14. Office of the Inspector General (OIC) HHS, May 2000
    Draft OIG Compliance Programme for Individual and Small Group Physician Practices.

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