Problem BackgroundAlthough NHIS has been regarded as an effective intervention in removing financial barriers to healthcare access and providing Universal Health Coverage, but throughout the period of its implementation so far significant number of flaws have been identified that strongly challenge the sustainability of this scheme. According to a study in 2016, major factors that challenge financial and operational sustainability of NHIS in Ghana are cost escalation, possible political interference, insufficient technical capacity, spatial distribution of health facilities and healthcare workers, insufficient monitoring mechanisms, broad benefits package, large exemption groups, insufficient customer education and partial community engagement. According to the regulations, enrollment in National Health Insurance Scheme is an obligation to each resident of Ghana. Section 27.1 of the ACT 852  states that: “A resident of Ghana shall belong to the National Health Insurance Scheme.” However, 12 years after implementation of this scheme actually initiated, only 40% of the population have been enrolled . Higher number of informal sector and insufficient administrative capacities of National Health Insurance Authority (NHIA) were highlighted as the main reasons why enforced membership was not implemented successfully. Low premium payments, extended benefits package without co payment and large exemption groups are the major factors that threaten the financial sustainability of NHIS. Premium exemption category is consisting of over 60% of the active members  and this makes the scheme exceedingly generous and financially unsustainable. Almost 80% of the NHIS members include children, informal sector workers and exempted groups  and yet they are the least effective customers when it comes to contributing through tax and premium payments. From the time its implementation started, NHIS has experienced growth in coverage without a conforming increase in resources or premiums. As a result of increased coverage, claims payment raised from 7.60 GHS million in 2005 up to 758.68 GHS million in 2014 . Over the time expenditure of NHIS overtook revenue, hence posing serious threat to financial sustainability of the scheme. By 2012, the National Health Insurance Levy (NHIL) of 2.5% tax on selected goods and services, Social Security and National Insurance Trust (SSNIT) and premium payment accounted for 70%, 17.4% and 4.5% of funding of NHIS respectively . However, by 2014 funding contribution transformed to 74% (NHIL), 20.4% (SSNIT) and 3.4% from premium payments . These evidences suggest that revenue generation through premium payments has dropped even further and consequently increased the burden on other financial sources of NHIS. Although NHIS succeeded to increase the level of utilization of healthcare centers to some extent, but there hasn’t been any progress in quality improvement in NHIS accredited healthcare facilities. Based on a study in 2016 , most of the patients are not satisfied with the quality of service and often complain about long waiting times and queuing, shortage of medicine and healthcare workers and inappropriate behavior of the stuffs in health facilities. Long delays on issuance of membership cards and lack of enough awareness among the community on benefits of the NHIS have added to the current challenges surrounding this scheme. According to SEND Ghana report 2010, some registered NHIS members in Upper West, Northern, Upper East and Greater Accra regions had to wait long before receiving their membership cards; during this period they were either denied or forced to pay out of pocket while seeking healthcare services despite being registered in NHIS scheme. Mostly inside the cities, NHIS enrollment has proven to have positively influenced citizen’s health seeking behavior especially that of women. According to a study on health seeking behavior of women in Accra metropolitan area, 76,3% of women enrolled in NHIS seek formal care when sick compared to 50.2% of women who are not enrolled in NHIS. However, there is significant difference when it comes to utilization of healthcare services in rural areas and disparity in the provision of health services is recognized as the key factor. Lack of information on exemptions, inability of bearing travel cost to a health facility or to a NHIS registration center and inability of paying registration fees among the vulnerable groups in the society are included in the list of valid reasons for not having fair access to healthcare. These vulnerable groups mainly include poor, aged, disabled, mentally challenged and migrants . In addition to financial hurdles, there are few nonfinancial barriers to access healthcare in most regions. Mostly, traditional leaders play vital role in coordinating services provided through government to local communities. Nonexistence of traditional leaders have led to communication gap between NHIA and related communities resulting in low NHIS registration rates and limited utilization of healthcare services provided through NHIS accredited healthcare centers. Poor social infrastructure in various sectors such as transport and communication has also contributed to low enrollment in NHIS. Many communities stopped enrollment in NHIS or stopped updating their membership cards once NHIA introduced the capitation system. According to this system, clients select their preferred health facility for their primary health care and the main idea behind introducing this system was to simplify claims process. However, this modification was not well received by the communities as it was limiting their options for accessing healthcare services. In addition, low level of trust between the stakeholders mainly between NHIA and service providers led to poor service delivery to NHIS members as compared to clients purchasing the services through out-of-pocket system in healthcare centers. As of April 2017, the total claim NHIS was required to reimburse to service providers was estimated to be GHS 1.2 billion, with debts of at least 12 months . Delay in claims reimbursement resulted in service providers running out of stock hence either denying or applying extra charges on provision of service to NHIS card holders. There have been deficiencies in performing all round publicity and ensuring that communities understand the actual concept of the NHIS; hence there is clear evident of low level of community engagement. Most of the community members define the system as the one for individual benefit rather than collective benefit and they believe that health insurance is supposed to be for sick people. Reform Proposal In response to rising challenges concerning the financial and operational sustainability of NHIS, Vice President of Ghana Dr. Mahamudu Bawumia assigned a committee consisting of 17 members led by health economist Dr. Chris Atim to review the NHIS and present recommendation on applying much required reform policies . Committee started their work by collecting inputs from all stakeholders including the community members who seemed to be dissatisfied with the health insurance scheme. Direct meetings with public and interaction through electronic media were scheduled in order to get maximum feedback on running system and its shortcomings. In addition, the committee met international experts and reviewed international reports on Ghana NHIS to acquire overall knowledge of the current situation. The committee agreed on making seven subcommittees led by local experts in different fields. The subcommittees were assigned to collect evidences that will assist in producing final recommendation on NHIS reform. Identification of main root causes of current challenges was the focus point of all subcommittees. Findings of the CommitteeAfter reviewing the current system and collecting all required evidences, the committee defined some of the major challenges that need to be addressed quickly in order to resuscitate NHIS. Some of the key findings are as follows:1. The committee pointed out that benefit package is too broad and therefore unfeasible in the long run. According to the committee, the package should be redesigned based on country’s health priorities that would be more realistic when it comes to implementation on the field. 2. The committee found out that there are no measures on cost control or any strategic purchasing approach that will ensure sustainable expenses of the scheme. Thus, throughout the course of its operation, NHIS experienced intensified expenditures accompanied with limited revenue generation. 3. One of the main targets of NHIS was to achieve universal health coverage through inclusion of the whole population in the scheme. However as of 2013, only 40% of the population are enrolled in the scheme and more than half of the population are still left out due to numerous reasons. 4. Quality of care is one of the main aspects of universal health coverage and NHIS was expected to prompt improvements in this field. The committee however found out that people were complaining about low quality care in NHIS accredited healthcare centers. Long waiting times at health facilities, regular lack of medicine that would force the patients to purchase them from pharmacies outside the health facility and difficulties in acquiring insurance registration card were pointed out as the main indicators of low quality of care. 5. The committee also figured out that around half of the health facilities at primary care level were lacking adequate number of personnel, equipment, and facilities required to provide full package of benefits. Committee Recommendations The committee proposed redesigning and restructuring of the scheme with more emphasis on primary care. The technical committee suggested short term approach or quick wins and long-term reforms: Short term approach includes improvement of the relationship between stakeholders mainly in between NHIA and service providers through immediate reimbursement of all outstanding claims. For the amendments to have bigger impact in the long run, technical committee proposed reform in 4 extended areas: sustainability, equity, efficiency, and accountability/user satisfaction. Impactful reforms in those 4 areas will transform NHIS into a more sustainable scheme that will ensure high quality care to the whole population including poor and the most vulnerable citizens. This will also help in building public confidence on the scheme. According to health finance and governance report prepared by USAID and NHIA, major reforms recommended by the technical committee are as follow:Cost Effective Package: In order to contain costs, the committee recommended formation of an affordable primary health package covering all basic health services including preventive care and major priorities of the government including maternal and child care. Affordable Benefit Package: To ensure sustainability of the program, it was highly recommended to reduce the broad benefit package. Reforms like application of premiums on additional services were recommended to transform the package into a more realistic one. Strategic Purchasing Approach: Applying this approach is vital in order to get maximum value of the budget spent on purchasing health services. Presently service providers are open in purchasing items like medicine from open market; this turns out to be a hugely expensive deal for NHIA. Instead, NHIA is advised on making most of the purchasing power and negotiate directly with suppliers for cheaper prices. This approach will also assist in forecasting, planning and efficient procurement of the items. Budget Neutral Approach: This approach is mainly applied to contain costs and move resources to priority areas of the primary care where they are most needed. According to this approach, an annual budget will be specified for all the services that are expected to be provided to the patients; all services must be covered through that single approved budget. That means the more services there are, the lesser will be paid per item of service and vice versa. Patient Protection Council: This would be an independent government agency having no links with NHIS. It will provide support for the patients dealing with challenges in quality of care; these challenges include tracing medical errors, investigating complaints related to clinical practice etc. Provider Network System: This system allows the patients to access full network associated with a facility. A registered patient in Community Based Health Planning and Services (CHPS) compound will have access to the full network of the facility in that region. This will pave the way for coordination of existing resources in community and will also help in addressing capacity gaps. Coordination among Government Agencies: Certain regulations have proven to negatively impact working abilities of the system. For instance, CHPS workers are supposed to visit people inside the community and help them out with their health issues but NHIS is not allowed to pay for it. In addition, NHIS is prohibited by regulations from paying for assisted delivery by a skilled nurse or midwife to women at CHPS level. The committee recommends amendments in some of the rules and regulations so that the system will perform to its maximum potential. National Health Commission: The committee proposed creation of this independent commission that will directly report to Ministry of Health. According to the committee, this commission is supposed to coordinate regulations, finance healthcare from all public resources and set priorities to guide NHIS payment reimbursement practices. A Technical Subcommittee: This subcommittee will be required to look for new medicine or procedures that could be included in NHIS.