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.