NHIS Is Seeing Better Days

By Tommy Ekpe
The introduction of a Consolidated Premium Account to collect payments made at the scheme level into one composite account has led to greater accountability and improvement in the efficiency of the National Health Insurance Scheme’s financial operations.
Prior to this measure, about 70 percent of premiums collected were not properly accounted for.
The scheme is, therefore, better organized and better managed than what was met by the current administration in 2009, contrary to claims by the New Patriotic Party (NPP)’s flagbearer at the IEA debate on 21st August, 2012 that the NHIS was ‘collapsing,’ which he later amended to ‘collapsed’.
At the IEA Encounter, the NPP standard bearer, Nana Akufo-Addo, said a certain Esenam from Vakpo told him that the scheme had broken down. Hear him: “NHIS Egblen”, he reported.
What is not clear is whether one could generalize a challenge confronting a scheme in one district and interpreting it to mean that the whole scheme is broken down, that is, if it’s really true that one Esenam exists in Vakpo and actually told Nana Addo this.
Meanwhile, available records, backed with empirical evidence on the ground, clearly show that since the current administration took over management of the scheme, giant strides have been made, putting the scheme in a better shape and condition than what it came to meet.
A few examples will suffice. Before 2009, the schemes operated as 145 autonomous entities limited by guarantee with their own individual Boards. This autonomy resulted in the lack of accountability leading to multiple corruption points in the system, including collusion between scheme staff and service providers to game the system.
Audits conducted in 2010 revealed the scale of the malfeasance and malpractices including falsification of records to inflate attendance at healthcare facilities; over-billing for services rendered to NHIS patients e.g. routine observation recorded as admissions in order to take advantage of higher tariffs; over-prescription of medicines (for profit); and abuse of the Free Maternal Care Programme e.g. claims for caesarean sections that were never carried out, or for deliveries that never took place.

There was also the lack of capacity, resulting in perfunctory and inefficient claims vetting which caused financial loss to the scheme, as well as inefficiencies and low productivity in other areas of scheme operations.
With a non-existent Human Resource Department there was complete discord and inadequacies in management structure. There were no Directorates for Strategy, Corporate Affairs, Claims Management and Internal Audit, leading to improper coordination and non-adherence to any strategic plan.
The problems are not over. Poor Financial Management, Record Keeping and Data Management rendered the scheme inefficient succumbing under the weight of inadequate Financial Accounting and Reporting System.
With no Accounting Ledgers on Investments, cash collections were short-banked and unaccounted for coupled with poor fixed assets management.
These are not all. It was realized that most of the offices, including the Head Office and Regional Offices, were operating from rented accommodation at a cost
There were also shortcomings in Stakeholder/Subscriber Issues Management with its attendant lack of effective structure for resolving difficulties, queries and complaints of subscribers. A dedicated Contact Centre was absent. Delays in claims re-imbursements, in some cases between six to 12 months, were the norm.
Enter a new administration and the story began to change and still improving tremendously. An Internal Audit Division was established and all 145 district schemes audited since 2009 to ascertain the financial status of the NHIS. Those found culpable for malfeasance appropriately sanctioned. The audits have instilled financial discipline in the schemes and is playing pivotal role in reforming the NHIS and uncovering malpractice.
There have been vast improvements in claims management with the establishment of a state-of the–art Claims Processing Centre (CPC). It has improved the claims processing turnaround time and minimised delays in reimbursements. Claims reimbursements schedule for properly submitted claims has been reduced from up to nine or more months in the past to 60-days barring hiccups in the flow of funds. There is a unit dedicated to NHIS Fund and Investment management.
The NHIS Call Centre is the first of its kind in the West African sub region. The Call centreaddresses issues, enquiries and complaints of NHIS subscribers and other stakeholders promptly. It is designed to deepen the partnership between the NHIS and its stakeholders, particularly subscribers.
With the introduction of a Call Centre, management/policy makers can now afford to pool complaints and will now be armed with data on subscriber issues to be able to assess the impact of interventions and originate informed ideas and policies to improve the scheme altogether.

There is more. Reforms in the Provider Payment System with the piloting of Capitation for OPD services in Ashanti Region which, despite initial difficulties, is providing useful lessons and informing plans for a possible country-wide scaling-up in 2013.
Capitation has the potential to improve quality of care through improved doctor-patient relationship, ready access to medical history of patient, and competition between providers for clients.
Enrolling subscribers to their chosen healthcare facilities helps eliminate frivolous misuse of healthcare though provider-shopping and assist in maintaining the Referral system.
It is sure bet that advance payments to healthcare facilities eliminates delays in reimbursement to providers and makes it possible for forecasting and budgeting.
There has been a massive upgrading of the ICT system through the creation of an ultra modern data centre.
A new Head Office building was constructed as well as Regional office buildings in all 10 regions.

The completion of the necessary processes for electronic linking of diagnosis to treatment to facilitate electronic claims processing and inject speed and efficiency into the NHIS claims management and payment system is another plus.
The Financial Administration has improved leading to better financial management, accounting and reporting system as well as improved record keeping and data management.
Cooperation and collaboration with key Stakeholders and Development Partners have been stepped up. Examples - Medium Term Strategic Plan drawn up with Stakeholder input. Capitation Technical Sub-committee constituted by representatives of key stakeholder institutions
It is gratifying to note that the profile of the NHIS in the global arena continues to rise. It has become a favourite destination for delegations from foreign countries and institutions seeking to learn from Ghana’s experience, just as the NHIS also learns from best practice around the world.
The study tours confirm the status of Ghana’s NHIS as an emerging model for countries in the Developing World and beyond and a hub for knowledge and experience sharing.
The international interest and confidence in Ghana’s health insurance scheme has generated offers of partnership and support from abroad (USAID & South Korea).
In November 2010, the NHIS won the UN award for excellence. It was cited by the United Nations at the Global South-South Development Exposition in Geneva, Switzerland for showing leadership in health insurance implementation in the developing world. The criteria for the award included: Leadership, Innovation, Knowledge-Sharing, Creativity, Local Initiative, among others
That is not all. To deal with emergent structural challenges in the Scheme, the revision of the law governing the NHIS, currently before Parliament, is aimed at correcting structural and systemic difficulties in the scheme’s administration. A new governance framework for the administration of the schemes is about to be introduced. Under the new law the 145 DMHISs become a consolidated unitary NHIS. This would enhance accountability and make for more effective governance of the schemes. With the review come new opportunities for staff progression
There have been training programmes for staff, improvements in remuneration, collective bargaining agreement reached with local Union over proper framework for negotiating staff salaries and Conditions of Service and the creation of opportunities for staff progression. Staff are also encouraged to broaden/ upgrade their skills and qualifications. This has led to a considerable boost in staff morale.
A Clinical Audit Division has also been established which is instrumental in promoting the quality of health care by uncovering, reporting, and correcting sub-standard/ poor healthcare practices. In fact, Clinical Auditing of some selected healthcare facilities has led to the recovery of more than GHC18 million in false claims.
Clinical Audit has also brought various malpractices to the attention of management. Such information feeds into reform initiatives which are driving change in the NHIS. Clinical Audit also has a deterrence effect on fraud/ abuse by service providers. The probability of inspection by the audit team tends to deter blatant malpractice in many facilities. Healthcare facilities are cleaning up their act as a result of Audit findings.
It is a fact that there has been massive growth in NHIS membership and the evidence is there for all to see. That notwithstanding, mass registration exercises continue to be conducted across the country to further expand coverage, particularly of the poor and vulnerable, which would lead to increase in utilization of healthcare.
The NHIS, no doubt, is seeing better days and despite the numerous challenges it has to confront and still confronting, it would strive to surmount them and become one of the best, if not the best, of health insurance schemes in the world. The NPP and Nana Akufo-Addo should come again.
This article was originally published in The Business Analyst of Wednesday, 29th August – Tuesday, 4th September, 2012. E-mail:thebusinessanalystgh@gmail.com