THE POTENTAIL ROLE OF COMMUNITY HEALTH INSURANCE SCHEMES IN A NATIONAL HEALTH INSURANCE SCHEME David Lambert Tumwesigye 10...
Objective <ul><li>To highlight the role of Community Health Insurance Schemes (CHI) in a National Health Insurance Scheme ...
The starting point <ul><li>“ SHI can only be successfully introduced if the conditions are suitable. It must make a contri...
INTRO <ul><li>Access to basic health care is limited by: </li></ul><ul><ul><li>inadequate supply (infrastructure , health ...
INTRO <ul><li>Community initiatives  will continue to play a key role for the foreseeable future </li></ul><ul><li>BUT:Com...
What is a Community Health Insurance  <ul><li>NHI Bill 2009 defines  community health insurance  as not-for-profit health ...
The National Health Insurance Scheme <ul><li>The general object of the Scheme is to develop health insurance as a  complem...
The specific objectives of the Scheme are to: <ul><li>(a) set standards, rules and regulations necessary to ensure quality...
The specific objectives of the Scheme contd: <ul><li>(d) determine requirements and issue guidelines  for the accreditatio...
Expected outcomes <ul><li>diversify  and strengthen health care financing  in support of National Health Policy priorities...
Expected outcomes contd... <ul><li>provide an enabling environment for: </li></ul><ul><ul><li>the  development of Ugandan ...
Issue 1:Coverage <ul><li>.  </li></ul><ul><li>(1) The Scheme shall be implemented in  a phased manner   to cover all citiz...
Issue 2: Equity <ul><li>Starts with a small and relatively well -off group ~2% vs 98% of population </li></ul><ul><li>Is s...
Issue 3:Quality assurance <ul><li>Can the current system meet the demand for services (both in terms of quality and quanti...
Issue 4: Financing <ul><li>Does the NHI Fund  complement or replace  existing financial flows to the health sector? </li><...
Issue 5:Concensus <ul><li>Is the NHI task force  preaching or listening ?  </li></ul><ul><li>There is consensus about the ...
Conclusion <ul><li>Let’s be open minded and flexible </li></ul><ul><li>Allow sufficient time to rethink the design, planni...
<ul><li>Session 3: </li></ul>Overview and contribution of CHI to the development of Health Insurance coverage in selected ...
Health Insurance in Ghana <ul><li>In 2003, Ghana passed legislation to introduce NHI scheme. </li></ul><ul><li>The main ai...
Ghana’s NHIS at a glance <ul><li>Population:  23.4m  (est 2009) </li></ul><ul><li>NHI coverage: 14,3m </li></ul><ul><li>Sc...
Source: Ghana National Health Insurance Authority
Real money spent Source: Ghana National Health Insurance Authority 1$=1.42 GH¢ ITEM 2006 2007 2008 2009  JAN-NOV GH¢ GH¢ G...
Background to the NHIS and the role of Community Health Insurance <ul><li>At the time, Ghana boasted of a  successful  Com...
Background to the NHIS and role of CHI <ul><li>Most CHIs enjoyed External support from donors, especially during the start...
The role of CSOs <ul><li>NGOs provided 40% of health services and led the crusade for CHI </li></ul><ul><ul><li>Feasibilit...
Political will and support <ul><li>Political will </li></ul><ul><ul><li>NHIS was a campaign issue </li></ul></ul><ul><ul><...
The beauty about CHI <ul><li>provides financial resources to promote better health and to prevent diagnose and treat illne...
BUT... <ul><li>Coverage was limited <10% of local population-enrolment rates had stagnated and poor people excluded </li><...
Also... <ul><li>Lack of awareness and information about the need for health insurance </li></ul><ul><li>(Un)Affordability ...
Design of the NHIS <ul><li>In 2003/4, the Min of Health developed a prototype of a District Mutual  Health Insurance (DMHI...
How the NHIS works DWHIS Regional NHIA office  NHIA/NHIF Health Provider 2.5% VAT 2.5%  SSNIT Contributions/Premiums Subsi...
How it works-Admin <ul><li>The NHIS is managed by a NHI Authority </li></ul><ul><li>A network of 145 district mutual healt...
How it works-Membership and contributions <ul><li>Formal  sector workers are compulsorily registered into these schemes, w...
How it works-Membership & Financing <ul><li>Informal Sector and dependants-Premiums+ Registration fees </li></ul><ul><li>F...
Issues <ul><li>Inadequate preparations-no training, no logistics till 2007 </li></ul><ul><li>Too much independence of the ...
Emerging issues: 2010 <ul><li>Dismantling of DMHIS and creation of a single scheme under the complete control of the Natio...
A New chapter in Ghana! <ul><li>“  The strategic intent  and focus  of  the ‘new’ Management  of the  National Health Insu...
<ul><li>Session 3 contd: </li></ul>The potential role of CHI in the extension of social health protection coverage in Uganda
Is CHI ripe for Uganda? <ul><li>FACT CHECK: </li></ul><ul><li>The NHIS does not plan to cover the informal sector in 15 ye...
Benefits of CHI <ul><li>Improves financial access to health care </li></ul><ul><li>Prevents potential loss of income and a...
The writing on the wall <ul><li>CHI could play a key role in the extension of social health protection </li></ul><ul><li>T...
Prerequisites for success of CHIs  <ul><li>Ability to address adverse selection and rent seeking provider behaviour throug...
CSO ACTION NEEDED <ul><li>Engage government to develop an equitable SHI policy </li></ul><ul><li>Proactively support the d...
Specific actions for CSO <ul><li>Advocacy </li></ul><ul><ul><li>Promote and link community schemes to the centre for techn...
Specific actions for CSO contd... <ul><li>Promote , mobilise and sensitise communities to embrace CHI </li></ul><ul><li>Ch...
What is the role for CHI in expanding social health protection <ul><li>Galvanise communities towards a culture of self hel...
Conclusion <ul><li>It can be done! </li></ul><ul><li>It has been done! </li></ul><ul><li>The conditions are ripe! </li></u...
Thank you!
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Exploring the Potential Role Of Community Health Insurance Schemes In A National Health Insurance Scheme

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Exploring the Potential Role Of Community Health Insurance Schemes In A National Health Insurance Scheme-Presented to CHI practitioners of the Uganda Community Based Health Financing Association

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Exploring the Potential Role Of Community Health Insurance Schemes In A National Health Insurance Scheme

  1. 1. THE POTENTAIL ROLE OF COMMUNITY HEALTH INSURANCE SCHEMES IN A NATIONAL HEALTH INSURANCE SCHEME David Lambert Tumwesigye 10 February 2010
  2. 2. Objective <ul><li>To highlight the role of Community Health Insurance Schemes (CHI) in a National Health Insurance Scheme using the experience of MHOs especially in Ghana. </li></ul><ul><li>To trace lessons for Uganda’s National Social Health Insurance Scheme from the Ghanaian experience </li></ul><ul><li>To delineate the role of CHI and civil society (esp Uganda Community Based Health Financing Association) in the broader social health protection framework </li></ul>
  3. 3. The starting point <ul><li>“ SHI can only be successfully introduced if the conditions are suitable. It must make a contribution...to the improvement of health status, and it must serve to improve both funding for health services and access to care for the population” </li></ul><ul><li>WHO (1994)SHI-A Guidebook for Planning </li></ul>
  4. 4. INTRO <ul><li>Access to basic health care is limited by: </li></ul><ul><ul><li>inadequate supply (infrastructure , health workers and drugs) as well as </li></ul></ul><ul><ul><li>financial barriers (the poverty wall) to seeking care. </li></ul></ul><ul><li>Problem could be alleviate by SHI. </li></ul><ul><li>BUT: </li></ul><ul><li>Attempt to introduce social health insurance will begin with the formal salaried public and formal private sector workers (after 3 years) </li></ul><ul><li>the informal sector population will be the last to be covered (15 years!!). </li></ul>
  5. 5. INTRO <ul><li>Community initiatives will continue to play a key role for the foreseeable future </li></ul><ul><li>BUT:Community initiatives to generate health care financing require a complex development process. </li></ul><ul><li>CSO will need NEED TO STEP IN DEEP </li></ul>
  6. 6. What is a Community Health Insurance <ul><li>NHI Bill 2009 defines community health insurance as not-for-profit health insurance schemes developed for the informal sector and created on the basis of an ethic of mutual aid and collective pooling of health risks , in which the members participate in the management </li></ul>
  7. 7. The National Health Insurance Scheme <ul><li>The general object of the Scheme is to develop health insurance as a complementary  mechanism of health care financing and to avail good quality, accessible, equitable and affordable health care to all Ugandan citizens  and residents.   </li></ul>
  8. 8. The specific objectives of the Scheme are to: <ul><li>(a) set standards, rules and regulations necessary to ensure quality and equity of care, appropriate utilization of services, fund viability, member satisfaction and overall accomplishment of the Scheme; </li></ul><ul><li>(b) register, licence, supervise, monitor and regulate health insurance schemes and accredited health care providers; </li></ul><ul><li>(c) formulate and implement guidelines on contributions and benefits, cost containment and quality assurance, health care provider arrangements, payment methods </li></ul>
  9. 9. The specific objectives of the Scheme contd: <ul><li>(d) determine requirements and issue guidelines  for the accreditation of health care providers; </li></ul><ul><li>  </li></ul><ul><li>(e) collect, deposit , invest, administer and disburse the funds of the Scheme in accordance with this Act; </li></ul><ul><li>(f) negotiate and enter into contracts with  health care institutions, professionals and other persons regarding pricing, payment mechanisms, design and implementation of administrative and operating systems and procedures, financing and delivery of health services; </li></ul>
  10. 10. Expected outcomes <ul><li>diversify  and strengthen health care financing in support of National Health Policy priorities. </li></ul><ul><li>raise additional funds for provision of health care services , </li></ul><ul><li>increase welfare gains in health care , risk pooling, financial risk protection, and consumer satisfaction for the covered population. </li></ul>
  11. 11. Expected outcomes contd... <ul><li>provide an enabling environment for: </li></ul><ul><ul><li>the development of Ugandan capacities and skills to implement collection, payment and care management; </li></ul></ul><ul><ul><li>release public resources to provide for equity improvements for the non insured until universal coverage is attained. </li></ul></ul><ul><ul><li>the regulation of a modern health financing system; and </li></ul></ul><ul><ul><li>the promotion  of private sector growth in quantity and quality of healthcare provision. </li></ul></ul><ul><li>undertake on its own or in collaboration with other relevant bodies, a sustained public education on health insurance </li></ul>
  12. 12. Issue 1:Coverage <ul><li>. </li></ul><ul><li>(1) The Scheme shall be implemented in a phased manner   to cover all citizens and residents of Uganda. </li></ul><ul><li>(2) The Scheme shall at the commencement of this Act, cover all employers and employees within the public sector  in Uganda . </li></ul><ul><li>(3) The Minister shall on recommendation of the Board and by statutory instrument prescribe other category of employees or population groups including the informal sector to be included in the Scheme. </li></ul><ul><li>  It’s not clear when the phasing actually takes place (15 years?) </li></ul>
  13. 13. Issue 2: Equity <ul><li>Starts with a small and relatively well -off group ~2% vs 98% of population </li></ul><ul><li>Is silent about the poor and vulnerable people </li></ul><ul><li>Kenya, Tanzania started with public sector employees and stalled </li></ul><ul><li>  This is inequitable and doesn’t promote social health protection! </li></ul>
  14. 14. Issue 3:Quality assurance <ul><li>Can the current system meet the demand for services (both in terms of quality and quantity) </li></ul><ul><li>Is there a concrete plan to improve service delivery (infrastructure, people, drugs) in the public sector? </li></ul>
  15. 15. Issue 4: Financing <ul><li>Does the NHI Fund complement or replace existing financial flows to the health sector? </li></ul><ul><li>Is the contribution base (1m people max) reasonable to make an impact on the financing of health care? </li></ul><ul><li>Is a tax financed insurance system still an option? </li></ul><ul><li>Where will the money for the public sector (8%) come from? </li></ul>
  16. 16. Issue 5:Concensus <ul><li>Is the NHI task force preaching or listening ? </li></ul><ul><li>There is consensus about the need for SHI but are the stakeholders agreed about the current design of the scheme </li></ul>
  17. 17. Conclusion <ul><li>Let’s be open minded and flexible </li></ul><ul><li>Allow sufficient time to rethink the design, planning and consultations </li></ul><ul><li>The NHIS must not be seen as just another body but as a clear route to equitably extending health coverage and improving financial and physical access to quality health care for the country </li></ul>
  18. 18. <ul><li>Session 3: </li></ul>Overview and contribution of CHI to the development of Health Insurance coverage in selected African countries
  19. 19. Health Insurance in Ghana <ul><li>In 2003, Ghana passed legislation to introduce NHI scheme. </li></ul><ul><li>The main aim: </li></ul><ul><ul><li>to make health care more accessible through the prepayment of fees instead of the “cash and carry” system </li></ul></ul><ul><ul><li>provide health care providers with steady income flows . </li></ul></ul>
  20. 20. Ghana’s NHIS at a glance <ul><li>Population: 23.4m (est 2009) </li></ul><ul><li>NHI coverage: 14,3m </li></ul><ul><li>Scheme started 2004 </li></ul><ul><li>No of schemes-145 </li></ul><ul><li>Percentage covered -61% </li></ul><ul><li>Phenomenal Growth </li></ul>Source: Ghana National Health Insurance Authority
  21. 21. Source: Ghana National Health Insurance Authority
  22. 22. Real money spent Source: Ghana National Health Insurance Authority 1$=1.42 GH¢ ITEM 2006 2007 2008 2009 JAN-NOV GH¢ GH¢ GH¢ GH¢ SUBSIDY 34.63M 70.09M 129.65M 217.75M REINSURANCE 0.85M 9.17M 8.32M 39.85M ADMIN/LOGISTICS 8.09M 13.6M 13.68 6.54M GRAND TOTAL 43.57M 92.86M 151.65M 264.14M
  23. 23. Background to the NHIS and the role of Community Health Insurance <ul><li>At the time, Ghana boasted of a successful Community Health Insurance sector -small (approx 250,000 members) but rapidly growing across the country covering. </li></ul><ul><li>Schemes were set up by community leaders, work-based associations, mission hospitals, local churches or mosques, schools, local government, NGOs or any combination of these. </li></ul><ul><li>Ownership was largely in the private and collective hands of the CHI’s users, something which strengthened their durability. </li></ul><ul><li>Most CHIs ensured membership control through regular meetings which have significant power over management appointments and decisions. </li></ul><ul><li>A key aspect of the CHI experience is the diversity of formats, each adapted to its own local environment. </li></ul>
  24. 24. Background to the NHIS and role of CHI <ul><li>Most CHIs enjoyed External support from donors, especially during the start up period, in the form of funds , technical advice , equipment or training (DANIDA, GTZ, ILO). </li></ul><ul><li>Premiums were generally low (heavily subsidised by public/mission funds) and encouraged enrolment </li></ul><ul><li>Most schemes covered catastrophic/ in-patient care </li></ul>
  25. 25. The role of CSOs <ul><li>NGOs provided 40% of health services and led the crusade for CHI </li></ul><ul><ul><li>Feasibility studies </li></ul></ul><ul><ul><li>Consensus building </li></ul></ul><ul><ul><li>Promotion of CHI </li></ul></ul><ul><ul><li>Design and admin support </li></ul></ul><ul><ul><li>Training and ICT + other logistics </li></ul></ul><ul><ul><li>Monitoring </li></ul></ul>
  26. 26. Political will and support <ul><li>Political will </li></ul><ul><ul><li>NHIS was a campaign issue </li></ul></ul><ul><ul><li>President set targets </li></ul></ul><ul><ul><li>Parliament passed the bill in record time (even with reservations from key DPs) </li></ul></ul><ul><ul><li>Enabled technocrats to take risks and fly! </li></ul></ul><ul><li>DPs rallies around a noble cause and provided the necessary support-WB, DANIDA, ILO,UNICEF,GTZ etc </li></ul>
  27. 27. The beauty about CHI <ul><li>provides financial resources to promote better health and to prevent diagnose and treat illness. </li></ul><ul><li>provides an opportunity to protect individuals and households against direct financial cost of illness through risk-sharing mechanisms. </li></ul><ul><li>gives the poor a voice and makes them active participants of the scheme. </li></ul>
  28. 28. BUT... <ul><li>Coverage was limited <10% of local population-enrolment rates had stagnated and poor people excluded </li></ul><ul><li>Technical and management skills were inadequate-promotion and enrolment, financial management, claims processing, ICT etc </li></ul><ul><li>Financial sustainability was an issue-low coverage, the poverty wall and moral hazard </li></ul><ul><li>Logistical challenges- </li></ul>
  29. 29. Also... <ul><li>Lack of awareness and information about the need for health insurance </li></ul><ul><li>(Un)Affordability of premiums relative to competing uses of household income(especially for bigger families) </li></ul><ul><li>The level of benefit coverage (some schemes only covered in-patient care and consequently attract only “bad risks”/adverse selection) </li></ul><ul><li>Poor quality of service and interpersonal relations at the provider (Inadequate and or even “perceived”poor quality of drugs) </li></ul>
  30. 30. Design of the NHIS <ul><li>In 2003/4, the Min of Health developed a prototype of a District Mutual Health Insurance (DMHIS) scheme based on the model of community health insurance -voluntary registration, member controlled board, premiums setting </li></ul><ul><ul><li>A hybrid scheme –fusion of SHI and CHIs </li></ul></ul><ul><li>All Community based scheme were absorbed into DMHIS </li></ul><ul><li>Only one DMHIS is allowable in a district; the rest can be private </li></ul>
  31. 31. How the NHIS works DWHIS Regional NHIA office NHIA/NHIF Health Provider 2.5% VAT 2.5% SSNIT Contributions/Premiums Subsidies Services Claims Payment Technical Assistance
  32. 32. How it works-Admin <ul><li>The NHIS is managed by a NHI Authority </li></ul><ul><li>A network of 145 district mutual health insurance schemes (DMHIS), managed with some form of community involvement (control by members elected BOD, oversight by District Assemblies) </li></ul><ul><li>Regional Offices of NHIA have monitor NHIS activities at provider sites and the district schemes </li></ul><ul><li>DHIS are supported financially by a National Health Insurance Fund (NHIF)-subsidies for risk equalisation and re-insurance . </li></ul><ul><li>Part of the NHIF is allocated to capital developments in the health sector </li></ul>
  33. 33. How it works-Membership and contributions <ul><li>Formal sector workers are compulsorily registered into these schemes, with their (wage-related) contributions deducted at source (SSNIT) and collected by the NHIF before being allocated to the schemes. </li></ul><ul><li>Informal sector workers and their dependents have immediate and voluntary access to these schemes, for a flat rate premium . </li></ul>
  34. 34. How it works-Membership & Financing <ul><li>Informal Sector and dependants-Premiums+ Registration fees </li></ul><ul><li>Formal sector and dependants- 2.5% of wages + registration fees </li></ul><ul><li>National Health Insurance Levy (NHIL)- 2.5 % VAT </li></ul><ul><li>Exempted: </li></ul><ul><ul><li>Children under 18 years </li></ul></ul><ul><ul><li>Indigents </li></ul></ul><ul><ul><li>Pregnant women (July 2008) </li></ul></ul>
  35. 35. Issues <ul><li>Inadequate preparations-no training, no logistics till 2007 </li></ul><ul><li>Too much independence of the DMHIS-the NHIA failed to manage the autonomous districts boards </li></ul><ul><li>Alleged Scheme Accountability problems and collusion with providers </li></ul><ul><li>No portability of benefits across districts </li></ul><ul><li>No risk sharing between districts </li></ul>
  36. 36. Emerging issues: 2010 <ul><li>Dismantling of DMHIS and creation of a single scheme under the complete control of the National Health Insurance Authority ? </li></ul><ul><li>all the 145 existing independent schemes would cease to exist in their current forms and would become district offices of the National Health Insurance Authority </li></ul><ul><li>one-time premium payment by the end of 2010-a move towards tax financed HI for the informal sector </li></ul>
  37. 37. A New chapter in Ghana! <ul><li>“ The strategic intent and focus of the ‘new’ Management of the National Health Insurance Authority is to build a new national health insurance scheme that would stand out as a model in Africa and beyond, providing affordable, accessible and quality healthcare services for all domiciled in Ghana, with highly enthusiastic professionals who value customer intimacy and delight”. </li></ul>
  38. 38. <ul><li>Session 3 contd: </li></ul>The potential role of CHI in the extension of social health protection coverage in Uganda
  39. 39. Is CHI ripe for Uganda? <ul><li>FACT CHECK: </li></ul><ul><li>The NHIS does not plan to cover the informal sector in 15 years </li></ul><ul><li>The informal sector is massive: </li></ul><ul><ul><li>NSSF- 300,000 only </li></ul></ul><ul><ul><li>PSPS- 400,000 only </li></ul></ul><ul><ul><li>Add dependants-700,000 X 3 (HHs)-2,100,000 </li></ul></ul><ul><li>Total maximum HI coverage with successful NHIS implementation: </li></ul><ul><li>9% i.e. 2.8m (relatively well off) out of 31 million Ugandans </li></ul><ul><li>The growth in the private medical insurance sector has shown potential for extending health protection for the formal sector </li></ul><ul><li>Yet the scope of CHI is still limited-33 schemes: covering 120,000 members in 9 districts </li></ul><ul><li>Self help community initiatives like Burial and Micro lending groups provide a unique opportunity </li></ul>
  40. 40. Benefits of CHI <ul><li>Improves financial access to health care </li></ul><ul><li>Prevents potential loss of income and a slip into poverty following catastrophic illness </li></ul><ul><li>Provides steady resources to the health sector </li></ul><ul><li>Empowered communities (backed by effective demand in form of CHI premiums) will demand for services </li></ul>
  41. 41. The writing on the wall <ul><li>CHI could play a key role in the extension of social health protection </li></ul><ul><li>The current design of the NHI is inequitable and almost defeats the national health policy objective </li></ul><ul><li>Civil society needs to pick it from here </li></ul><ul><li>BUT IT WILL TAKE REAL ACTION </li></ul>
  42. 42. Prerequisites for success of CHIs <ul><li>Ability to address adverse selection and rent seeking provider behaviour through revenue collection, pooling and purchasing instruments </li></ul><ul><li>Active community involvement in scheme management </li></ul><ul><li>Durable relationship between scheme and providers to achieve better value for money for the members through the provision of quality service. </li></ul><ul><li>Sustained donor and government support (including political will) </li></ul><ul><li>Knowledge and acceptance of the insurance concept </li></ul>
  43. 43. CSO ACTION NEEDED <ul><li>Engage government to develop an equitable SHI policy </li></ul><ul><li>Proactively support the development of CHI </li></ul>
  44. 44. Specific actions for CSO <ul><li>Advocacy </li></ul><ul><ul><li>Promote and link community schemes to the centre for technical guidance and support </li></ul></ul><ul><ul><li>Identify issues and challenges and find solutions/present them to government-equity, quality, access </li></ul></ul><ul><li>Technical support </li></ul><ul><ul><li>Directly seek and provide support to design and manage CHIs </li></ul></ul><ul><ul><li>Train and build a core of technical staff to manage CHIs </li></ul></ul><ul><ul><li>Conduct research, M&E , document and disseminate best practices </li></ul></ul><ul><li>Mobilise and provide financial support and subsidies to CHI schemes-from Donors and Government </li></ul>
  45. 45. Specific actions for CSO contd... <ul><li>Promote , mobilise and sensitise communities to embrace CHI </li></ul><ul><li>Challenge government to provide solutions to health problems-quality and access issues </li></ul>
  46. 46. What is the role for CHI in expanding social health protection <ul><li>Galvanise communities towards a culture of self help </li></ul><ul><li>Supports the government to promote pre-financing of health care and guarantee access to health care </li></ul><ul><li>Could be used as a model for spreading social health protection coverage (cf Ghana and Rwanda </li></ul><ul><li>It is not a panacea but it could be a good start </li></ul>
  47. 47. Conclusion <ul><li>It can be done! </li></ul><ul><li>It has been done! </li></ul><ul><li>The conditions are ripe! </li></ul><ul><li>But we must overcome ideological differences and focus on the goal... </li></ul><ul><li>CHI must have the support of government </li></ul><ul><li>15 years is very a long time.... </li></ul>
  48. 48. Thank you!

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