UHC Forward: Towards Universal Health Coverage

Dr. Irene Agyepong is a physician trained at the University of Ghana Medical School (1986) with a Masters in Community Health from the University of Liverpool School of Tropical Medicine (1991) and a DRPH (Health Policy and Administration) from the University of North Carolina at Chapel Hill (2000).

She has worked with the Ministry of Health Ghana /Ghana Health Service as District Director of Health in the Dangme West district from 1989 to 2003 and Regional Director of Health for Greater Accra from 2003 to the present.

Currently, Dr. Agyepong chairs the Provider Payment Mechanism Technical Sub-Committee (PPM TSC) which has been providing technical advice to the National Health Insurance Authority (NHIA) on the design and implementation of a pilot per capita payment system for primary health care services under the Ghana NHIS. The PPM TSC is a multi-stakeholder advisory committee with representation from the National Health Insurance Authority (NHIA), Ministry of Health (MOH), Ghana Health Service (GHS), Christian Health Association of Ghana (CHAG), Ghana Armed Forces Medical Unit, and the Korle-Bu Teaching Hospital (KBTH).

Wellington: Ghana’s National Health Insurance Scheme (NHIS) has been noted for its progress in comparison to its peers. What do you think has accounted for the success of NHIS?

Agyepong: I think the term “success” is relative since we are nowhere near where we would like to be. The idea of Universal Health Coverage (UHC) has been around in Ghana for years, but we’re still trying to figure out how to do it. I think it began with democracy – the parties want to offer the change that people wanted and health access and financing were definitely a problem people wanted addressed. Once an acceptable solution was offered in the form of the National Health Insurance Scheme (NHIS), no one wants to be the one who destroyed it. Everyone would like to be the one who helped to make is better and to succeed. The second facilitating factor was the fortunate meeting of the technical, political, and social components or streams.

Wellington: In your opinion, were there any key political decisions that helped to drive Ghana’s success?

Agyepong: It really makes a difference to have major political backing if you want to implement major social change. Social change is different from bureaucratic change. At the national level, you need to have political will and I think that holds true in every country. You also need societal backing; politicians will not push for change unless the society supports it.

Wellington: In spite of some success, you said that Ghana is nowhere near where you would like to be. What are some of the challenges that NHIS is currently facing?

Agyepong: One of the challenges in a low/lower middle-income country is capacity. You really need a certain level of capacity to administer a NHIS. We use the term insurance, but we use it loosely. Ghana is really a 70 – 75% tax funded NHIS system; and 20 – 25% classical social insurance funded. However, I think it is unnecessarily rigid and not useful to say that this is social insurance and this is tax financing; because it is not just the financing that makes a system an NHIS. Other things like the management arrangements, access issues, provider payment systems, how effectiveness and efficiency issues are addressed are all critical components. To really put all of these things in place you need a certain capacity to manage it.

In low and lower middle-income countries, that’s a challenge because apart from being under-resourced financially as well as in terms of human resource we are constantly losing the little human resource we develop because of the real challenges of how to retain and adequately compensate highly skilled professionals. Less than 50 percent of the people that graduated from medical school with me remained in Ghana. The rest went to the United Kingdom, United States etc. When you have that kind of context, it becomes difficult.

The other issue is financing. Some countries can develop systems at lower costs than others, but it is absolutely not cheap. You need to have a certain arrangement to get money and that has been one of our challenges because the initial objective is universal coverage. In part we are not there yet because despite the will, the resources are inadequate. One of the debates right now in the background is how do you raise more money? 70 – 75% of the money for the NHIS comes from a dedicated 2.5% Value Added Tax (VAT) known as the National Health Insurance Levy (NHIL); and currently research shows that it is mildly progressive. Clearly VAT has been critical in getting and maintaining the NHIS, but can Ghana as a country afford to raise the percentage VAT beyond the current total of 15% as a way of raising more resources to expand coverage? At some point it becomes regressive to further increase taxation, so that is a major challenge. As a country, we are still managing a voluntary insurance scheme knowing that we’re not going to get to universal coverage this way. However, if we suddenly declare that everyone is automatically covered regardless of making any contribution, the infrastructure will not support it. Some money has to come from somewhere to pay for universal coverage.

Wellington: You played a large role in the capitation program as the chair of the Sub-committee. What are the challenges that you are facing outside of the private interest. Are there issues?

Agyepong: I think we can do it and it will help us as a country, but whether the current level of understanding, challenges, and opposition will allow an effective pilot remains a major question. I do not have an answer to at this point in time. The opposition has several angles to the best of my observation and understanding. One is a genuine lack of understanding of the issues, and inadequate stakeholder education, which we have tried to address by providing more information. For example, we realized that many providers did not understand what payment by per capita meant. Under capitation, providers receive a payment regardless of whether the patient visits and it’s calculated as an average so the denominator is the population of active members or insured people. The payment is done prospectively (in advance) based on the number of clients enrolled to the provider regardless of whether there are any planned or anticipated visits by the client to the provider. On the other hand, under the case based payment (Ghana Diagnostic Related Groupings – G-DRG) with itemized fees for medicines that Ghana currently operates under the NHIS the payment is done retrospectively (after the event) per client encounter. We realized that providers thought the per capita rate was a reduced per encounter payment rather than an average per enrolled subscriber advance payment. They also do not appear to have understood that the per capita payments are only for primary care and higher levels of service remain paid for retrospectively by the G-DRG and itemized fees for medicines. Other driving factors, to my observation, are that there is a lack of trust in our system between providers and payers (insurer) and a fear that undue risk is going to be shifted to providers. Major reform like capitation requires an ability to have open dialogue and collaborative problem solving. A lack of trust makes it that much harder. Providers do not trust that they will be treated fairly and that undue risk is not being shifted to them. Part of the answer to this problem lies in making sure that there is an open and transparent monitoring and evaluation system with the participation of all stakeholders.

Wellington: If you had any advice for other countries what would be the top three things that you would share?

Agyepong: First, I would say to realize that universal coverage is a long term goal. It is not an easy goal but in my opinion it is achievable – albeit at different rates depending on the country starting point. First and foremost you must build a system, realizing that it’s a road. You must also deliberately start building technical and administrative capacity and retaining that capacity to support universal coverage.

Second, the leadership has to come from within country. If it comes from external sources it’s probably not going to work. That’s a lesson for the countries and the donors.

Third, context and history matter. You need to tailor your system to fit your context and your history. For example in Ghana, if we had not had the experience of user fees it would have been much harder to implement a NHIS. The cash and carry system was hated and detested, and there were lots of horror stories about its effects. Under those circumstances, it was possible to get social support for the idea of contributing through premiums and taxes to have a pre-payment system in the form of an NHIS. Conversely, if you have a country that has had free care and you try to introduce taxation and premium payment for an NHIS, you may face much more resistance because the negative experience of user fees is missing. You may have to look for ways to introduce a very indirect less obvious tax based system.