Building National Health Insurance: Lessons from Ghana Part II

An interview with Nathaniel Otoo, Director of Administration and General Counsel of the National Health Insurance Authority of Ghana

Nathaniel Otoo is the Director of Administration and General Counsel of the National Health Insurance Authority of Ghana. His 20 years of work experience has spanned both the public and private sectors, with the last 9 of them being in social protection. He holds an LLB Degree from the University of Ghana and a professional qualification in law from the Ghana School of Law. He also holds an MA degree in International Relations from the International University of Japan. Mr. Otoo has played a key role in the ongoing legal reforms in Ghana’s National Health Insurance Scheme (NHIS).

Wellington: Mr. Otoo, you have worked at the National Health Insurance Association (NHIA) for 6 years. In your opinion, what are some of the key policy decisions that have contributed to the success of the National Health Insurance Scheme (NHIS)?

Otoo: The best policy has been deciding to implement the National Health Insurance Scheme (NHIS). We have reduced out of pocket payments that were impoverishing people across the country; we have seen a reduction in poverty, and accelerated Ghana’s progress towards achieving the Millennium Development Goal’s (MDG’s). These were the three main pillars of NHIS and all other objectives revolved around these goals.

Experimentation with reform began before 2003 and at that time there were a lot of community initiatives and faith based groups that were trying to provide financial protection. The NHIS was built from there with a community based approach to scale up. We agreed to community ownership of NHIS which whilst making for decentralization contributed to a quick and successful roll out of the NHIS.

Wellington: As General Counsel of NHIA, what are some of the biggest challenges you face in implementing new policies?

Otoo: Two key things, we have a very complicated governance structure. This is one of the biggest challenges that we have. The Ministry of Health (MoH) is in charge of overall policy implementation and NHIA is set up to administer the general coordination of the scheme. NHIA is also responsible for supervising and regulating the activities of all private and public health insurance schemes. In the early years, there was a bit of confusion as to where one body’s functions began and ended, which was a challenge.

As far as implementation of the NHIS is concerned, we noticed that as a country the issue of paying or buying healthcare services in advance appeared foreign to many. Educating the public on what “risk-pooling” and “pre-payment” meant was also a significant challenge.

Wellington: Over the next five years, what do you imagine will be the biggest obstacles that NHIA will face?

Otoo: First would be mobilizing additional resources and controlling expenditure and these get to the heart of sustainability. We have implemented several new mechanisms to manage expenditures such as clinical audits and capitation.

When it comes to insurance, this is the first time it has been experimented on this scale. We note that a prerequisite for success is to have a good understanding of the business we have gotten ourselves into. The speed of growth of our scheme has outpaced the availability of critical technical capacities. Going forward therefore, we have to surmount the problem of capacity gaps in a number of areas including accreditation and quality assurance, ICT and monitoring and evaluation.

To address this challenge, have followed the traditional ways to increase capacity including rolling out training up programs both in-house and through partnerships with academic institutions , and developing manuals. In addition to these, we believe that exchange of knowledge on a global scale, whilst contributing to enriching our experience will also help us to share our experiences with the rest of the world. The NHIA therefore is looking to setting up a sub-regional center of knowledge in Ghana.

Wellington: In the near future, what do you see as NHIA’s biggest priorities? What policies would you like to see implemented?

We will need to identify new ways of generating revenue as coverage increases. Second, is the idea of targeting of vulnerable populations. We need to do a better job of identifying them and reaching them. Lastly, if we would like to ensure sustainability of the scheme we need to improve clinical audits and experiment with other payment options to ensure a mix of payments that are most suitable for the program.

Wellington: If you had to give advice to other countries that are moving towards or thinking about moving towards universal coverage; what three things that you would share?

Otoo: Universal health coverage (UHC) is a very difficult goal to reach. It is important to identify your focus extremely well and make sure that no matter what you do, you always ask yourself whether your actions are sustainable. These two things should guide everything. Should you have a perfect system before you begin? The answer is no. It is more important to begin somewhere but make sure you have critical information for effective policy making and utilize a phased and integrated approach for implementation. I believe that the community based approach for implementation is effective as far as roll out is concerned. A well defined benefit package that is not excessive and focuses on primary care is critical. The goals of financial risk protection and improved access to quality health care should never be divorced. The two should go hand in hand. You can’t say that you’re protecting people financially without ensuring that they have access to quality services.

Lastly, I would advise countries that are considering moving to universal coverage to keep their designs simple, focus on payment systems that share risk nearly equally between the provider and payer, and ensure that monitoring and evaluation are entrenched in their systems from the beginning.

This interview is Part II of a series on Ghana's National Health Insurance Scheme. Part I of this series featured an interview with Dr. Irene Agyepong.

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