Rwanda has made giant strides towards achieving universal health coverage with 95 per cent of the population being active members of the country’s Community-Based Health Insurance Scheme, (CBHIS). With Ghana’s active membership in insurance coverage at approximately 38 per cent , there are serious lessons about interventions that increase coverage, ensure equity, provide risk protection for the poor and safeguard financial sustainability of the scheme.
The current design of Ghana’s health insurance scheme raises significant questions about financial sustainability and equity. In the event that the National Health Insurance Authority is even able to increase its active membership drive to the desired 100 per cent of the population, the current challenges will only escalate.
Features of NHIS
What are the current features of Ghana’s National Health Insurance Scheme (NHIS)? Inflows from flat rate premiums are minimal, forming less than five per cent of total revenues, delayed and inadequate inflows from the main tax funded revenue source at Finance Ministry, resulting in an average six months of delayed reimbursement to cash-strapped health facilities, and almost 50 per cent of expenditure going into the purchase of medication.
The latter is a reflection of the inability of the National Health Insurance Authority (NHIA) to leverage a pooled procurement effort to negotiate prices down in addition to a provider payment method that decouples services from medications, thereby recording appreciable levels of polypharmacy. These challenges are further escalated by an unbelievable benefit package – coverage of over 95 per cent of the disease burden of the country, massive exemptions to children, the aged, and indigent, accounting for a significant proportion of the client base, and absence of co-payment, even for specialist tertiary level care.
If we are not in trouble now, surely, we will be down the road with this design. It is against this background that somewhat painful but practical system redesign was undertaken by our Rwandan colleagues to address financial sustainability and equity when faced with similar challenges. At the time, everyone was paying a flat premium of 1000RWF.
Different premiums
Firstly, the Rwandans have moved away from the concept of making everyone pay exactly the same amount in premium. This is very unlike Ghana where the well-endowed and poor alike pay the same premiums and where employers with respectable margins that were once providing expensive medical care for their employees have conveniently offloaded such expenses unto the NHIS for a meagre premium. Of course, one cannot blame them if the NHIA does not evolve strategies to increase revenues from such endowed employers.
In a true operationalisation of financial risk protection for the poor, the Rwandas have evolved a system for identifying the indigent whose premium payments are fully covered by the government. Using community-based targeting methods, community leaders determine which category members belong to at the village level.
The system is managed by the Ministry of Local Government and has individuals being grouped into three categories in decreasing order of poverty – one, two, and three. Individuals in the poorest category are assigned a premium of 2000 RWF, paid for by the government of Rwanda. Individuals in categories two and three pay premiums of 3000 RWF and 7000 RWF respectively.
Copayment, an anathema in the Ghana situation, has also been embraced in Rwanda. Clients in categories two and three assessing primary and secondary care are required to pay a somewhat token 200 RWF. Clients in categories two and three assessing tertiary care pay for 10 per cent of the cost. These amounts, though not prohibitive, are reportedly sufficient to pay the salaries of some health workers. Similarly, in Ghana, given the existence of a common targeting mechanism to identify indigents, there should be nothing that stops us from offering the full benefit care package to this group while all others who are in a position to pay are made to contribute significantly to the NHIS.
Strategies
Rwanda has rolled out some performance-based financing strategies, including some being used to address overbilling by health facilities. Any facility that overbills its claims by two per cent is penalised at two levels; a reduction in the claims reimbursed, and a reduction in revenues due the facility on account of underperformance in claims management.
The sources of revenue are now being broadened too, with the following coming on board: increased internally generated revenues from premiums, contributions from other private insurance schemes which are required to transfer one per cent of their margins to the CBHIS (even as a new draft law considers increasing it to five per cent to address increasing non-communicable disease burden). Other contributions are from the Ministry of Finance, donors, new taxation on tobacco and also include plans to get motor insurance companies to pay the bills of clients involved in road traffic accidents, instead of the CBHIS.
Ghana needs not wait till we reach a real crisis point before starting the great affirmatively disruptive conversation at all levels resulting in somewhat painful but practical decisions that creatively redesign our national health insurance scheme and put it on a path of true financial sustainability and equity.
Sodzi Sodzi-Tettey
www.sodzisodzi.com
Sodzi_tettey@hotmail. com
