2008 Citizens Assessment of the NHISAfrica Workshop on Health Insurance

Accra, 22 September 2009

Presentation titlePage 2 2

Human Resource Development

The key policy interventions prioritised under this thematic area include:

• Education;

• Training and skills development;

• Access to health care;

• Malaria control;

• HIV/AIDS prevention and treatment;

• Safe water and Sanitation;

• Population management; and

• Housing and slum upgrading.

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Strategy for Improved Access to Health Care

► Bridge equity gaps in access to quality health care and nutrition services:

► Including developing health infrastructure in favour of deprived communities;

► Ensure Sustainable Health Care Financing Arrangements That Protect the Poor:

► Including accelerating the implementation of the National Health insurance, Strengthening the exemption policy to enhance access of poor and vulnerable groups to healthcare;

► Strengthening Efficiency in Service Delivery:► Including providing incentive schemes to support the retention

and redistribution of trained health personnel;

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Objectives of Study

► General objective The goal of this study is to ascertain whether NHIS

provides effective healthcare financial arrangements for the poor.

Specific objectives1. To obtain feedback from citizens about how the NHIS is

performing from perspective of the local communities.

2. To determine whether the NHIS is achieving its goal of ensuring equitable access to quality basic health care to all residents (including vulnerable and excluded) in Ghana.

3. To gain insights into how to bridge the equity gaps in access to quality healthcare services.

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Study analyzed the effects of NHIS on:

► Financial protection against the cost of illness;

► Access by households to affordable health care;

► Behaviour of health workers and health seekers;

► Incidence of ailment or injury;

► Publicity/coverage of the NHIS and how it is understood by beneficiaries and prospective beneficiaries; and

► Issues related to the process of registration and after registration.

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Methodology

► National representative survey of about 1,988 households

► 1,000 exit polls ► conducted from 100 health service facilities from the districts that

the household survey was undertaken.

► Health care providers and scheme managers► interviewed 87 health care providers; and ► 58 scheme managers in the selected districts

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Results and key findings

► Results are weighted to enable regional representation but not district representation

► Datasets are available from NDPC for further analysis

► Discussions are organized in 3 sections► Demand issues► Effects on access to health care► Citizens perception on the scheme’s performance

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Findings – demand issues

► 2 aspects of demand for NHIS are discussed► overall uptake in terms of individuals across various localities

and attributes of citizens► uptake in terms of households in different socio-economic

settings

► Issues on registration and renewal, and how demand is related to operational challenges are also discussed

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Findings – demand issues

► Overall uptake of NHIS► Data show an appreciable level of registration under the scheme► About 56 percent (55.6%) of Ghanaians have registered► Some have registered but do not hold valid NHIS cards for a number of reasons that will be discussed later

Fig. 1: Individual registration

Insured (with valid card)

47.9%

Registered (no valid card)

7.7%

Not-registered44.4%

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Findings – demand issues

► the data reveals that nearly one-third of households in Ghana have registered all their members

► a little over a quarter have registered some members of their households► whilst a large proportion of them continue to remain outside the scheme

Fig. 2:Household registration

All insured33%

Some insured26%

None insured41%

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Findings – demand issues

► The picture from urban and rural areas► The proportion of individuals registered under the scheme is higher in

the urban areas than in the rural areas. ► The uptake is about 10% more in urban areas (53.6%) than the uptake

in rural areas.

► Gender and NHIS status► More females have registered with the NHIS than males. ► For example close to 50% of females (49.7%) are NHIS registrants with

valid cards as compared to 45.9% of males that hold valid cards. ► Females form nearly 53.4% of registered members.► The policy for maternal health partly explains the differences

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Findings – demand issues

► Age and NHIS status► About two-thirds (64.6%) of persons aged 70 years and above are

registered members of NHIS with valid cards.► This means that more will have to be done to enable the rest to take

advantage of exemptions provided for the group.

► Representation of persons aged 18 – 69 (46.7%) in the NHIS may have led to the exclusion of over 40% of children (43.5%) from the scheme.

► It is also observed from the results that the higher the number of children, the higher the proportion of households that do selective registration. ► The danger of selecting “bad risk” individuals is real and hence serious drain

on scheme’s resources cannot be avoided.

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47.9 46.7

64.6

8.5 7.0 6.9

43.546.3

23.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Child (<18 yrs) Adult (18-69 yrs) Aged (70 yrs & above)

Insured (with valid card) Registered (no valid card) Not-registered

Fig. 3: Individual membership of NHIS by age group (%)

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Fig. 5: Individual membership of NHIS by sector of employment (%)

62.2

41.737.9

5.5 7.2 7.1

32.3

51.254.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Formal sector worker Informal sector worker Unemployed

Insured (with valid card) Registered (no valid card) Not-registered

There is a significant number of formal sector workers (32.3%) who do not hold valid NHIS cards.

Reasons assigned to this relate to the need for “top-up” schemes.

This raises the need to intensify recent attempts to offer such schemes by the private sector.

Given that less than 10% of the labour force is engaged in the formal sector, the scheme’s sustainability with regards to contribution from beneficiaries depends on the enrolment of informal sector workers.

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Fig. 6:Individual NHIS membership by socio-economic group (%)

There is a direct relationship between the proportion registered under the NHIS and socio-economic status. Less than 4 in every 10 people from the poorest 20% of Ghanaians are covered.

This demands policy attention to address the significant number of poor individuals who are excluded from the scheme.

28.7

39.2

49.4

58.5

63.9

7.9 9.1 8.75.7 6.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Lower 20% Next 20% Next 20% Next 20% Upper 20%

Insured (with valid card) Registered (no valid card)

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Fig 7. Household NHIS membership by socio-economic group (%)

The relationship is not very clear among households that register some members and leave some out of the scheme. This implies that selection of individuals into the scheme is common among all types of households, irrespective of socio-economic status.

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Table 1: Reasons for non-registration (% of non-registered individuals)

Reasons assigned for non-registration relate to:Affordability (more for poor households); and Health needs (more for the richer 40%).

The second reason reinforces the need for top-up schemes.

Reason Lower 20% Next 20% Next 20% Next 20% Upper 20% Total

Not heard of NHIS 2.5 0.9 1.0 0.9 0.3 1.3Premium is expensive 91.0 87.0 81.7 64.9 36.0 77.0Does not trust the organisers 1.4 2.2 4.8 7.5 10.7 4.4Do not need health insurance 1.2 2.0 4.8 13.4 21.1 6.6NHIS does not cover health insurance needs 0.0 0.7 0.4 1.3 10.4 1.8Other 4.0 7.2 7.3 12.1 21.5 8.9

Total 100 100 100 100 100 100

Socio-economic group

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Table 2: Reasons for non-renewal (% of those with expired cards)

Reasons assigned for non-renewal relate to: Affordability (more for poor households); Registration process (rises with socio-economic status); and Non-use of previous card.

Reason Lower 20% Next 20% Next 20% Next 20% Upper 20% Total

Has not been sick 19.3 17.0 20.7 20.0 10.3 17.7Premium is expensive 65.1 68.2 51.4 42.3 34.8 50.3Poor quality care for insurance card holders 1.1 0.0 2.1 0.0 8.3 2.5Waiting time for card too long 8.9 6.5 12.7 15.3 27.6 15.0Preferred services not covered 1.1 0.0 0.6 0.0 0.0 0.4Use non-participating clinics or traditional practioners 1.1 0.0 0.0 0.9 0.0 0.4Other 3.6 8.3 12.5 21.4 19.0 13.8

Total 100.0 100.0 100.0 100.0 100.0 100.0

Socio-economic group

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Health care providers consulted for health care:

The data suggest that a significantly higher proportion of insured households consult quality/skilled health providers than the non-insured.

As many as 11% of uninsured did not consult a health provider even though they reported sick.

Of those who consult medical doctors the NHIS was the main source of payment of the bills for more than 80% of households in Ghana.

Effects on access to health care in Ghana

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Table 3: NHIS membership status and health care providers consulted for general health care within the last 4 weeks

Doctor/Medical

Assistant Nurse/

Midwife DrugStore/ TBA/Other None Total

NHIS Status Insured (with valid card) 71.9 15.3 10.5 2.3 100 Registered (no valid card) 41.3 14.5 41.6 2.6 100 Not-registered 39.0 10.6 39.0 11.4 100

Main source of payment

Household 40.8 13.4 45.2 0.6 100

NHIS 82.4 16.7 0.9 0.0 100

Other 73.0 8.8 18.2 0.0 100

Total 61.9 14.6 23.3 0.3 100

The proportion of those who consult skilled health care providers for general health conditions has risen from 45% to about 62% between 2005 and 2008, with the implementation of the scheme.

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Fig. 8: Main source of payment for general health care within the last 4 weeks by household NHIS status

0

10

20

30

40

50

60

70

80

90

None insured Some insured All insured

Perc

ent

Household NHIS Status

Household

NHIS

Other

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Table 4: NHIS membership status and health care providers consulted for deliveries within the last 12 months

Medically

assisted Home OtherNHIS StatusInsured (with valid card) 75.2 10.7 14.1Registered (no valid card) 81.5 0.0 18.5Not-registered 61.5 13.7 24.8

Main source of paymentHousehold 45.3 25.6 29.1NHIS 93.4 0.0 6.6Other 85.7 0.0 14.3

Total 71.3 10.9 17.8

Assistance at deliveryThe proportion of those who consult skilled health care providers for deliveries has risen from 50% to about 71% between 2006 and 2008.

Many factors could account for this but one cannot rule out the role of the scheme.

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Delivery of social services, e.g. education and health, is largely influenced by the accountability relationships across the delivery chain:

► not just resource constraint problem► but also one where accountability relationships are weak

► More resources don’t necessarily mean better service Strength of voice Client power

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With the exception of drugs not covered by the scheme, citizens are generally satisfied with what is provided by the NHIS

Close to 70% of Ghanaians indicate the need for the inclusion of drugs not covered by the scheme.

This is particularly high in the Eastern, Ashanti and Volta regions. 91.8%, 86.6% and 82.3% of the people interviewed in these three regions respectively indicate the need for these additional drugs to be added.

Citizens’ perceptions on the performance of NHIS

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Fig. 10: Percent of respondents expressing the need for additional services by NHIS

status – Household Survey

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0

Appliance and protheses

Cosmetic surgeries and aesthetic treatment

HIV retroviral drugs

Assisted reproduction & gynaecological treatnent

Echocardiography

Photography

Anglography

Dialysis for chronic renall failure

Organ transplantation

All drugs not listed on NHIS list

Heart & brain surgery

Cancer treatment

Mortuary services

Diagnosis and treatment abroad

Medical examination from other facilities

VIP ward

Free medical care for all children (under 18 yrs)

Not-registered Registered (no valid card) Insured (with valid card)

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Perception on the effects of NHIS on quality of health care

An important concern in health care management is often how to maintain quality of service as demand increases

There is a high indication that with the introduction of NHIS, the number of people who visit health care facilities will increase substantially thereby putting pressure on the existing facilities of health.

This can certainly compromise the quality of health care services if the increase is not matched proportionately by increases in personnel and infrastructure.

The performance of the scheme will then depend very much on whether or not the NHIS card bearing members are getting better health care than non-holders.

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Perception on the overall performance of NHIS

Overall, 53.9% of Ghanaians are satisfied with the performance of the NHIS and 27.9% are very satisfied.

11% of Ghanaians are not satisfied with the scheme with just 1% expressing strong dissatisfaction with the scheme.

These concerns are corroborated by other findings during interviews with scheme managers and providers

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Box 1: Concerns raised by scheme managers

Operational issues

Late renewal of membership

Inadequate logistics, staff and low motivation

Low monitoring of service providers by schemes

Abuse of scheme by members and foreigners

Delay in submission of claims by providers

High claims submitted by service providers

Non-compliance to the gate-keeper system

Untimely and inadequate releases of funds to schemes

Environment

Difficulty in accessing communities

High poverty level among members

High rate of illiteracy among scheme members

Inadequate health care facilities

Unfriendly attitude of service providers toward scheme members

Politicisation of scheme

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Box 2: Concerns raised by service providers

Claims Delays in reimbursement of claims Lack of software to ease difficulty in processing claims Complicated format for processing claims Claims presented for payment are slashed substantially, especially for drugs Lack of feedback to service providers with regards to vetting of claims and payments

Benefit package Some essential drugs are not covered by NHIS Prescribing according to NHIS drug list is too restrictive High cost of treating ulcers e.g. buruli ulcer, not sufficiently covered by NHIS Members do not know the drugs that are excluded from the benefit package Terrible access roads and long distances to facilities as well as accredited drug stores

Cost While the cost of drugs and non-drugs keep rising, tariffs are fixed Tariffs are lower than actual costs e.g. laboratory services Cannot afford to purchase drugs outside the approved list

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Recommendations

The exemption policy needs further improvement to adequately serve the health needs of the poor.

Other social interventions provided by faith-based organisations, NGOs and others should incorporate sustained NHIS registration as part of their assistance.

The schemes should endeavour to sustain and strengthen their communication mechanisms.

Recent interventions to offer schemes that appear to be more attractive to high income groups (top-up schemes) are encouraged.

NHIA will have to continue its efforts to de-politicise structures in the various regions and strengthen its neutral hold on issues so as to ensure sustainability of the scheme.

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Thank you