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Population coverage: from pilot to nationwide scale-up of the “NHIS mobile renewal and digital authentication project”

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On June 4, 2019, the Facility, in partnership with AFD and with support from the Joint Learning Network for Universal Health Coverage (JLN), organized a webinar on NHIS mobile renewal and digital authentication in Ghana.

The National Health Insurance Authority (NHIA) administers Ghana’s National Health Insurance Scheme (NHIS), which was established in 2003. Up until 2018, around 10.5 million scheme members needed to renew their membership annually and in person at a NHIA District Office. This time-consuming process deterred members from renewing and resulted in lapsed coverage. Partly as a result of these low renewal rates, the Scheme’s national penetration plateaued at around 40% of the population and remained roughly static from 2014 to 2018.

In 2017, the NHIA partnered with the ILO’s Impact Insurance Facility and started a project to digitize the renewal process, allowing members the option to renew their membership digitally on their mobile phones. Secondly, the project planned to establish the related systems for membership and identity verification at healthcare providers.

The project has been a huge success; following the launch of the mobile renewal platform by Dr Mahamudu Bawumia, Vice President of the Republic of Ghana, in December 2018 the number of renewals over the mobile phone has increased exponentially. As at March 2019, more than 65% of all renewals were taking place over the mobile phone.

The webinar is aimed at a wide local and international audience interested in learning more about digitizing operational processes that can lead to greatly enhanced efficiency. These solutions are applicable in both public and private sector contexts, and help to build scale.

Panelists of this webinar were Dr. Lydia Dsane-Selby (Chief Executive, NHIA Ghana), Mariam Musah (Senior Manager, Research, Policy, Monitoring & Evaluation, NHIA Ghana) and Shilpi Nanda (Impact Insurance Fellow alumna, NHIA Ghana). This webinar was moderated by Lisa Morgan (Technical Officer (Health Actuary), ILO).

Published in: Government & Nonprofit
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Population coverage: from pilot to nationwide scale-up of the “NHIS mobile renewal and digital authentication project”

  1. 1. In Partnership With NHIS Mobile Renewal & Digital Authentication in Ghana June 2019 1 Staff at NHIS West Mamprusi District Office coaching members on the use of NHIS Mobile Renewal Solution Photo courtesy: Mr. Orison Afflu 
  2. 2. In Partnership With Interfacing with the webinar system Tell us what you think. Type your questions/ comments here even while the presentation is going on. These will only be visible to the presenters. Hide/unhide the control panel
  3. 3. In Partnership With Introduction to the ILO’s Impact Insurance Facility The ILO’s Impact Insurance Facility’s mission: to enable the private sector, governments, and their partners to realise the potential of risk pooling mechanisms (such as insurance or other coverage plans) • Achieved through a strategy of stimulating innovation and unlocking capacity • Our work is guided by three principles: • 1) solutions are people-centred • 2) they are driven by both evidence and experience-based learning • 3) collaboration among various stakeholders is necessary to deliver results Our project, focused on improving the renewal process of the National Health Insurance Scheme (NHIS) of Ghana, is made possible with the generous support of Agence Française de Développement (AFD) 3
  4. 4. In Partnership With NHIS in Ghana • NHIS was established in 2004, and has a goal of universal healthcare in Ghana • NHIS offers comprehensive healthcare scheme to all citizens of Ghana and is subsidised by tax (National Health Insurance Levy) • The scheme is distributed via a network of 165 branches • Scheme penetration reached 40% in 2014 and plateaued • In 2017 NHIS, with support from ILO Impact Insurance Facility, started a project to digitalise the NHIS renewal process aimed at accelerating population coverage 4 40% 2014 - 2017 11% 2006 NHIS Statistics 165 District Offices c.3,000 Branch Staff 10.8m Active Members NHIS Comprehensive Healthcare Benefits NHIS Population Coverage In-patient Out-Patient Medicines Diagnostics c.4,000 Healthcare Providers 31% 2010
  5. 5. In Partnership With The problem to solve: reduce those queues! Save time and money for everyone involved.
  6. 6. In Partnership With NHIS Mobile Renewal Project - Highlights 6 Data highlights as at 30th April 2019 1.44 million mobile renewals since launch in December 2018 $3.93 million collected via mobile 10.53 million healthcare attendances validated via digital channel since launch c.3,500 healthcare providers using digital authentication service on a regular basis c.580,000 higher transactions in 2019 Jan-Apr period as compared to similar periods in prior years (2017 – 2018) 5% increase in share of informal category since launch of mobile renewal
  7. 7. In Partnership With Agenda The NHIS Ghana, problem statement & solution Research, monitoring, & expected impact Journey from pilot to nationwide scale-up 1 2 3 Q&A4
  8. 8. In Partnership With 8 NHIS Mobile Renewal and Digital Authentication in Ghana Presenter: Dr Lydia Dsane-Selby Chief Executive, NHIA Presenter: Shilpi Nanda, Actuary ILO Impact Insurance Fellow alumni, NHIA Presenter: Mariam Musah Senior Manager, Research, Policy, Monitoring & Evaluation, NHIA Facilitator: Lisa Morgan, Health Actuary Impact Insurance Facility
  9. 9. In Partnership With Dr Lydia Dsane-Selby Chief Executive, NHIA 1. The NHIS Ghana, problem statement & solution
  10. 10. In Partnership With Problem Statements ==> Desired Solutions from Project 10 Members had to TRAVEL FAR to renew. Renewals took a LONG TIME at the NHIS office (often hours); Members LOST INCOME whilst they waited. NHIA LOST PREMIUM REVENUE due to these hurdles NHIS district offices were OVERWHELMED with people queuing. Process bottlenecks and network issues led to POOR MEMBER and STAFF EXPERIENCE Large proportion of healthcare providers had NO DIGITAL METHOD for VALIDATING MEMBERSHIP which required NHIS to physically print expiry dates on back of NHIS membership cards An EFFICIENT renewal method was desired that could be accessed by members at their CONVENIENCE without them needing to travel far to NHIS district offices REMOTE RENEWAL and ENROLMENT processes were required that reduced queues and RELIEVED OPERATIONAL BURDEN at NHIS district offices DIGITAL MEMBERSHIP VALIDATION methods needed to be IMPLEMENTED at all healthcare facilities in order for remote enrolments to be possible
  11. 11. In Partnership With Solution in Three Parts 11 1. Renewal Reminder Two SMS reminders sent to every member, 2 months and 2 weeks before membership expiry 2. Mobile Collection NHIS Members can renew their policies by paying their requisite premium and processing fees from their mobile wallet 3. Digital Authentication and Member Feedback NHIS membership status is verified digitally at all credentialed healthcare facilities in Ghana. Members respond to SMS to notify if they did not attend healthcare facility
  12. 12. In Partnership With NHIS Mobile Renewal Solution BENEFIT PACKAGE: This option gives a brief overview of benefit package with call center number to find out more MEDICINE LIST: This option lists top 10 medicines and prompts members to call Call Centre to know about comprehensive medicine list and package CHECK EXPIRY: Using this option, members are able to check when their policy is due to expire RENEW: This option requires NHIS (or GHANA CARD) number, prompts requisite premium amount and completes payment from mobile money wallet *929#
  13. 13. In Partnership With Increased Engagement between NHIS and Members Remote Renewals Membership Expiry Reminders Reduced Waiting Time Reduced Transportation Costs Reduction in Lost Income Mobile Renewals and Digital Authentication Benefits to NHIS members
  14. 14. In Partnership With NHIS: Move towards Digitalisation 14 60% - 70% of renewals are via mobile c.90% of healthcare facilities that actively serve NHIS members have adopted digital validation of membership Both cash and mobile premium collections are accounted via electronic receipting system. This has increased accounting transparency
  15. 15. In Partnership With Move towards financial sustainability by achieving better balance between inflows and outflows 15 Achieving better balance in Scheme Inflows and Outflows • Simpler renewal process encourages more people to renew which leads to higher premium revenue • Digital payments and electronic receipting reduce pilferage that is chronic is cash collection systems Increase Income • Digital authentication (with feedback loop) helps align NHIA and provider interests leading to reduction in negative provider behaviour • Simpler enrolment processes hold potential to reduce adverse selection Reduce Claims • Channelling transactions via mobile channel reduces ICT expenditure at NHIS district offices Reduce Expenses
  16. 16. In Partnership With 16 LINK TO COMMENDATION OF NHIS MOBILE RENEWAL IN 2019 STATE OF THE NATION ADDRESS, BY HIS EXCELLENCY MR. NANA ADDO DANKWA AKUFO- ADDO, PRESIDENT OF THE REPUBLIC OF GHANA: HTTPS://WWW.YOUTUBE.COM/WATCH?V =JHHIW9COAYS LINK TO LAUNCH SPEECH AT JUBILEE HOUSE, BY HIS EXCELLENCY DR. MAHAMUDU BAWUMIA, VICE PRESIDENT OF THE REPUBLIC OF GHANA: HTTPS://WWW.YOUTUBE.COM/WATCH?V =C6H2GSL0CL8
  17. 17. In Partnership With Mariam Musah Senior Manager Research, Policy, Monitoring & Evaluation NHIA 2. Research, monitoring, & expected impact
  18. 18. In Partnership With • Telephonic Survey: 300 respondents selected randomly amongst members who renewed via mobile • Focus Group Discussions: 2 focus group discussions in pilot district covering 15 members in total • Call Center and IT Helpdesk Feedback: Analysis and monitoring of feedback received at call center and IT helpdesk • Transaction and Attendance Data: Analysis and monitoring of membership and renewal data to identify trends Research and monitoring to evaluate progress Key ActionsKey FindingsMethodology • 55% of respondents sought help from NHIS staff and/or informal mobile money agents to renew via mobile • Males and members with higher education level were more likely to self-renew • 92% of respondents found the 1 GHC m-renewal convenience charge to be reasonable • 96% of respondents said renewing via mobile took less than 5 minutes • Several survey respondents and FGD participants reported learning about mobile renewal via ‘word-of-mouth’ • There was an uptick in share of informal sector post launch of intervention • Based on feedback in survey, roll-out of digital authentication was prioritized at referral healthcare providers • Members and staff from pilot districts reported gaps/bugs in renewal process to call center and helpdesk, The chinks in process were ironed out prior to scale-up • Staff feedback was used to design supporting processes, e.g. district accounting and reconciliation processes, to support scale-up
  19. 19. In Partnership With Expected Impact – Member Experience 19 100% of members surveyed said that they would recommend the mobile renewal service to their friends and family 98% of members surveyed (who had claimed since renewing via mobile) said that the authentication experience at provider site was ‘Good’ or ‘Excellent’ On average, members saved 11.3 hours when they renewed via mobile vs. at the NHIS district office. In total this is 3 to 5 million working days saved for NHIS members every year* On average, members saved 4.20 GHS in transportation costs when they renewed via mobile vs. at the NHIS district office. This translates to savings of c.20m GHS for NHIS members every year* Costs saved per memberAuthentication ExperienceRenewal Experience Excerpts from a survey conducted amongst 300 members who used NHIS Mobile Renewal Service at Pilot District *Assuming 50% of renewals go through the mobile channel as has been evidenced in the two pilots Time saved per member
  20. 20. In Partnership With 20 “I was really excited because if it hadn’t gone through I will have to wait in a queue… I renewed mine and left all the people in the queue behind. The mobile renewal is convenient and easy”FGD feedback
  21. 21. In Partnership With 21 “I was sick and I went to the Clinic. I did not know that my membership has expired. The nurse asked me to go and renew via mobile money, my card was renewed and I used it to take my medicine ” FGD feedback
  22. 22. In Partnership With Effect on membership categories • Share of the informal category has shown a discernible increase (from 30% to 35%) since the launch of the mobile renewal • Formal, indigent, elderly and pregnant categories have not exhibited any significant changes yet 22 49% 49% 44% 45% 45% 45% 44% 4% 4% 5% 5% 5% 5% 5% 5% 5% 6% 5% 5% 5% 6% 30% 30% 31% 35% 36% 36% 36% 7% 6% 7% 7% 6% 6% 6% 4% 6% 8% 3% 3% 3% 3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Oct Nov Dec Jan Feb Mar Apr 2018 2018 2018 2019 2019 2019 2019 Split by Membership Category as a % of total transactions Child Elderly Formal Informal Pregnant Indigent
  23. 23. In Partnership With Shilpi Nanda, Actuary ILO Impact Insurance Fellow alumni, NHIA 3. Journey from Pilot to Nationwide Scale-Up
  24. 24. In Partnership With Journey from Design to Scale-Up 24 Design Pilot Scale-Up Mar – Oct 2018May - Nov 2017 Nov 2018 – Jan 2019 The design of the mobile renewal and digital authentication solution was done via application of design thinking methodology Link to prior webinar on this topic The development work was completed by Feb 2018, and pilots were launched in two districts Feedback from members, staff, management, and stakeholders used to upgrade solution to suit nation-wide scale-up Nationwide scale-up of solution commenced in Nov 2018 and completed by early Jan 2019 Continuous evolution of solution ongoing in line with NHIA’s digitalisation agenda
  25. 25. In Partnership With 25 People hanging phones off trees to get mobile network connectivity for mobile money transactions Project Field Visit, Tanatala, Northern Region Community Sensitisation Project Pilot, Yigba-Kibori, Northern Region Solution Testing For Member Feedback Project Pilot, West Mamprusi Project team configuring mobile phones for healthcare providers Project Pilot, West Mamprusi Link to video: https://www.youtube.com/ watch?v=OjKjMjqNzR4
  26. 26. In Partnership With Upgrading Solution for Nation-Wide Scale-Up Solution Launched in ILO Pilot Work in Progress Key April2018 26 The green portion was the only part of the solution that was piloted. The expansion of user options, and backward and forward integrations to supporting processes were undertaken based on learnings from pilot in preparation for the nationwide launch. Some of this development is still ongoing as the solution continues to evolve as new learnings come in
  27. 27. In Partnership With What does it take to go from 2 to 200 districts in 6 weeks? 1 2 3 4 5 6 7 8 Developed a comprehensive solution that worked in all contexts and terrains, in partnership with excellent 3rd party service partner, In-person training for ALL staff (c.4,500 people) supported by email and social media campaign Design of simple, flexible and standardized onboarding process (web portal) for all healthcare providers In-person training for representatives from 3,500 healthcare providers (c. 7,000 people) in c.200 districts supported by site visits to all facilities by NHIS staff Stakeholder engagement at all levels from regulators, public sector bodies, community chiefs, representatives from local government Community outreach by NHIS district staff supported by local radio and mass media campaigns to sensitize and educate members Continuous support from call center, HO IT helpdesk and 3rd party developers to ensure problems continuously identified and resolved Engagement at high levels in government, local development partners and key stakeholders to organize Launch by Vice President at Jubilee House (1) Lots of Excellent People (2) Tons of Hard Work (3) A bit of luck!
  28. 28. In Partnership With Healthcare Providers Using Digital Authentication 28 • Rapid scale-up of digital authentication at thousands of healthcare provider sites possible due to: • Simple and flexible registration process for healthcare providers • Large-scale stakeholder engagement at all levels (from grass-roots to healthcare apex bodies) • Efforts on-behalf of hundreds of NHIS district, regional and head office staff • c.10.5 million healthcare attendances have been validated via this solution as at 30 April 2019 Key Inferences Up to 3,500 healthcare providers use the digital authentication service to validate c.500,000 healthcare attendances every week Nationwide Launch
  29. 29. In Partnership With Mobile Renewals as % of Total Renewals 29 • 1.44 million mobile renewals in total as at 30 April 2019 • On average, c.90,000 mobile renewals every week • c.200,000 members have renewed over weekends as at 30 April 2019. Weekend renewals were not possible before m- renewal • 60% to 70% of renewals are now via mobile which has resolved operational bottlenecks and reduced long queues at NHIS district offices Key Inferences Nationwide Launch
  30. 30. In Partnership With Amount Collected via Mobile Renewal 30 • Collection amounts via mobile now averaging c. $1.0 million every month • Average collection via mobile channel is 33.5% higher than average collection via cash channel. This could be due to: (a) greater penetration in urban areas (b) rise in share of informal category and (c ) fully exempted groups disallowed from use of mobile renewal Key Inferences
  31. 31. In Partnership With Impact on Population Coverage? 31 • Higher scheme coverage possible via higher renewals and new member registrations • In period Jan – Mar 2019, there were c.200,000 additional new member registrations compared to similar periods in 2017 – 2018 • Similar improvements in trends in renewals; c.380,000 additional renewals in Jan – Apr 2019 compared to similar periods in 2017 – 2018 • However, trend of new member registration relatively flat since launch suggesting that other ecosystem factors, e.g. quality of healthcare delivery, may continue to act as a barrier to enrolment behaviour Key Inferences Bring lapsed members back to scheme via simple mobile renewal process Refocus staff capacity towards acceleration of new member registrations Increase NHIS Scheme Membership
  32. 32. In Partnership With Key Priorities for NHIA going forward Focus on Improving Active Membership NHIS aim to reverse membership trends from last 3 years to achieve an increase in 2019 on the back of simpler renewal processes and utilization of spare staff capacity at district offices Leverage New and Legacy Data for Actionable Insights A big focus area going forward is in the field of applying data analytics tools to generate actionable insights for better healthcare usage monitoring, identification of fraud and improvement of claims processes Pushing Digital Agenda Forward More processes will be digitalized in coming years, with a particular focus on claims submission, vetting and payment functional areas Pursue Policy Reform for Financial Sustainability Large scale policy reform options will be evaluated in coming years to bring scheme back to full financial sustainability
  33. 33. In Partnership With 33 NHIS Mobile Renewal and Digital Authentication in Ghana - Q&A Session Presenter: Dr Lydia Dsane-Selby Chief Executive, NHIA Presenter: Shilpi Nanda, Actuary ILO Impact Insurance Fellow alumni, NHIA Presenter: Mariam Musah Senior Manager, Research, Policy, Monitoring & Evaluation, NHIA Facilitator: Lisa Morgan, Health Actuary Impact Insurance Facility
  34. 34. In Partnership With Introduction to the Joint Learning Network for Universal Health Coverage (JLN) The Joint Learning Network for Universal Health Coverage (JLN) is an innovative, country-driven network of practitioners and policymakers from around the globe actively engaged in exchanging tacit knowledge on challenges faced and co-developing practical solutions to extend health coverage. • Resulting tools equip countries with the how-to’s of designing and implementing efficient, equitable and sustainable healthcare systems, while contributing to global knowledge resources for achieving Universal Health Coverage (UHC). Ghana is a founding member country of the JLN. 34
  35. 35. Thank you! /ImpactinsuranceFacility @IIFacility /in/impactinsurance Follow us on social media! Visit our website! www.impactinsurance.org For further questions, please contact Lisa Morgan at morgan@ilo.org

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