Format for Desk Review

Each Document
Document Title: National Health Insurance Thumbnail
Scheme (NHIS)

Document Type: Official Websites Target Audience: Insurance Companies,

Year of Publication: 2018 Publishing Authority/ Organisation: NHIS

Geographical area: Ghana Source: http://www.nhis.gov.gh

SNo Research Key Findings

Question
1 What is the The National Health Insurance Authority (NHIA) was established under the National Health
regulatory Insurance Act 2003, Act 650, as a body corporate, with perpetual succession, an Official Seal,
system of health that may sue and be sued in its own name. As a body corporate, the Authority in the
insurance performance of its functions may acquire and hold movable and immovable property and may
enter into a contract or any other transaction.
A new law, Act 852 has replaced ACT 650 in october 2012 to consolidate the NHIS, remove
administrative bottlenecks, introduce transparency, reduce opportunities for corruption and
gaming of the system, and make for more effective governance of the schemes. The NHIS is
divided into District Mutual Health Insurance Schemes (DMHIS), Private Commercial Health
Insurance Schemes (PCHIS) and Private Mutual Health Insurance Schemes (PMHIS).
However, only the DMHIS receives subsidy from the National Health Insurance Fund
(NHIF). NHIS is financed by a National Health Insurance Levy (NHIL) of 2.5% tax on
selected goods and services, a 2.5% deduction from individuals’ contribution to the Social
Security and National Insurance Trust (SSNIT), contributions from individuals working in
the informal sector and budget allocations. All subscribers have access to full benefits of the
scheme with no additional coinsurance, co-payment or deductibles required
NHIA Functions
 Implement, operate and manage the National Health Insurance Scheme
 Determine in consultation with the Minister contributions that should be made by
members of the National Health Insurance Scheme;
 Register members of the National Health Insurance Scheme;
 Register and supervise private health insurance schemes
 Issue identity cards to members of the National Health Insurance Scheme
 Ensure equity in health care coverage access by the poor to healthcare services,
protection of the poor and vulnerable against financial risk
 Grant credentials to healthcare providers and facilities that provide healthcare services to
members of the National Health Insurance Scheme
 Manage the National Health Insurance Fund
 Provide a decentralised system to receive and resolve complaints by members of the
National Health Insurance Scheme and healthcare providers
 Receive, process and pay claims for services rendered by healthcare providers
 Undertake public education on health insurance on its own or in collaboration with other
bodies
 Make proposals to the Minister for the formulation of policies on health insurance
  Undertake programmes that further the sustainability of the National Health Insurance
Scheme
 Develop guidelines, processes and manuals for the effective implementation and
management of the National Health Insurance Scheme
 Ensure the efficiency and quality of services under the national and private health
insurance schemes
 Protect the interest of members of private health insurance schemes
 Identify and enrol persons exempt from payment of contribution to. National Health
Insurance into the National Health Insurance Scheme
 Monitor and ensure compliance with this Act and any Regulations, guidelines, policies,
processes and manuals made under this Act
 Perform any other function conferred on it by this Act or that are ancillary to the ob.ect of
the Authority

National Health Insurance Fund: The objective of the Fund is to pay for the cost of
healthcare services for members of the National Health Insurance Scheme. For the purpose of
implementing the object, moneys from the Fund shall be expended as follows
 to pay for the healthcare costs of members of the National Health Insurance Scheme
 to pay for approved administrative expenses in relation to the running of the National
Health Insurance Scheme
 to facilitate provision of or access to healthcare service;
 to invest in any other facilitating programme to promote access to health service as
determined by the Minister in consultation with the Board.
The sources of money for the Fund are
 the National Health Insurance Levy provided for under section 47
 Two and one half percentage points of each person's 'contribution to the Basic
National Social Security Scheme
 Moneys that are approved for the Fund by Parliament; (d) moneys that accrue to the
Fund from investments made by the Authority
 Grants, donations, gifts and any other voluntary contributions made to the Fund; (f)
fees charged by the Authority in the performance of its functions
 contributions made by members of the Scheme
 moneys accruing under section 198 of the Insurance Act, 2006 (Act 724)

The National Health Insurance Authority (NHIA) is mandated by National Health Insurance
Act, 2012 (Act 852) to register, license and regulate Private Health Insurance Schemes
(PHIS) in Ghana. In performing its regulatory functions the Authority registers, licenses and
supervises the operations of PHIS in Ghana. The law established two types of private health
insurance schemes:

Private Mutual Health Insurance Scheme (PMHIS)

Private Commercial Health Insurance Scheme (PCHIS)

s What are the Third Party Administrators under Private Health Insurance Scheme (PHIS): Where a
administrative PHIS use the services of a third party manager/administrator (independent body corporate),
and this must be indicated in the business plan and a copy of the agreement to regulate this
management relationship shall be submitted to the Authority. The third party administrator shall be licensed
provision of by the Authority. A PHIS CANNOT appoint a related party as a Third Party Administrator for
health insurance an entity in which it has a business interest. A PCHIS shall NOT be managed by a Third Party
Administrator. The Authority will assess the relationship between a Third Party Administrator
and the schemes they manage by requesting for details of the governing structures in addition
 to other relevant information. PCHIS desirous of serving as Third Party Administrators to other
schemes shall set-up a subsidiary company for the purpose and apply to the Authority for
licensing.
Membership, Provider Relations and Regional Operations (MPRO): This is a division
created with regional offices with the sole function to monitor the operations of the District
Offices and Health Care Providers (HCPs).
The Point Assessment System (PAS): Established to introduce healthy competition among
districts and regional offices. It is designed along the performance targets of the MPRO mainly
with targets on membership, revenue mobilisation and enforcement of internal controls. These
indicators are then weighted and scored.
The Annual Programme of Work (POW): In line with the strategic objective and key
activities of the Midterm plans, each directorate and department develops a detailed annual
programme with corresponding budget. The POWs also include specific measurable targets
which form the basis for signing a performance contract between the CEO and respective
directors. The contracts are evaluated at the end of the accounting year.
Consolidated Premium Account (CPA): Established to ensure the NHIA’s full oversight of
all revenues, including contributions received from the informal sector clients and links
treatment to diagnosis.
Claims Processing Centres (CPC): Four centres have been established and equipped with
experts, including medical doctors and pharmacists to speed-up claims processing.
Clinical and Internal Audit Divisions: Their capacity has been strengthened to ensure
effective auditing of claims.
Provider payment reform: To minimise the cost and delays in claims payment, the NHIA
introduced capitation as an alternative to its fee for services and G-DRG provider payment
system.
Accreditation of Health Services Providers: A set of protocols have been laid out for
accreditation of health services providers to the NHIS.
Independent call centre: Provides NHIS information and receives complains on behalf of
NHIA.
Compliance Unit: Established to investigate the astronomical increases in claims. It includes
both internal and external clinicians.
Research and Development Directorates: This was created in 2007 and has since led the
review of tariffs and medicines list; and developed a number of concept papers aimed at
enhancing the efficiency of the scheme’s operations, including papers which linked diagnosis
to treatment and levels of prescription.
Management Information System (MIS): A Data Centre Upgrade project involved the
replacement of the old 32-bit hardware and operating systems with 64-bit ones. It has been
completed. The Line-of-Business Application (Oracle E-Business Suite) was also upgraded
from version 11 to 12. In 2013, NHIA introduced biometric membership registration and
instant ID card issuance system. This is intended to improve the integrity of the membership
database and subscribers’ authentication at healthcare facilities, and generate unique code
(Claims Check Code) for subscribers who access health care, for claims processing.
3 What are micro- In the 1990s, the Ghana government initiated a health policy reform, including the
insurance establishment of a national health insurance programme, to minimise the financial burden of
regulation accessing health care, especially among the vulnerable population. This led to the introduction
of a compulsory social health insurance for all Social Security and National Insurance Trust
(SSNIT) contributors and registered cocoa farmers in 1995, and the proliferation of district
mutual health insurance schemes in the early 2000s.
In pursuance of the provisions of the Non-bank Financial Institutions Act, 2008 (Act 774) and
the Banking Act, 2004 (Act 673) as amended by Act 738 for the microfinance sector.
The microfinance activities are categorized under four sub tier of activities
Tier 1 activities shall comprise those undertaken by Rural and Community Banks, Finance
Houses and Savings and Loans Companies – These institutions are regulated under the Banking
Act, 2004 (Act 673).
 Tier 2 activities – Those activities undertaken by
 Susu companies and other financial service providers, including Financial Non-
Governmental Organizations (FNGOs) that are deposit taking and profit making.
 Credit Unions. However, credit unions are not regulated under this Notice. A
Legislative Instrument under the Non-Bank Financial Institutions (NBFI) Act, 2008
will soon be passed to regulate their activities.
Tier 3 Activities – Those activities undertaken by
 Money lenders
 Non-deposit taking Financial Non-Governmental Organizations (FNGOs).

Tier 4 activities
 Susu collectors whether or not previously registered with the Ghana Cooperative Susu
Collectors Association (GCSCA)
 Individual money lenders.
All the tier are regulated under categories of Business form , paid up capital, branch expansion,
loans and deposits
4 How Grievance/ A scheme may terminate or suspend a member on any of the following grounds only:
Disputes are
managed and  failure to pay contribution within ,the stipulated time
quality  submission of false or fraudulent claim
assurance  commission of any act of fraud in relation to the scheme or 37 Act 852 National Health
Insurance Act, 2012
 Non-disclosure of material information requested by the scheme.

The Regulations may provide further for matters relating to termination or suspension of
members of schemes.
A scheme shall provide a procedure for settlement of complaints from its members and its
healthcare providers and ensure that the members and healthcare providers are aware of their
right to submit complaints to the Adjudication Committee established under Part Four where
there is failure to settle a complaint raised with the scheme.
Quality Assurance: The authority shall endeavour through the means determined by the Board
including providing credentials, that healthcare. providers put in place programmes that secure
quality assurance, utilisation review and technology assessment to ensure that
 the quality of healthcare services delivered are of reasonably good quality and high
standard
 the basic healthcare services of standards that are uniform, throughout the country
 the use of medical technology and equipment consistent with actual need and standards
of medical practice
 medical procedures and the administration of drugs are appropriate, necessary and
comply with accepted medical practice and ethics;
 Drugs and medications used for the provision of health care in the country are those
included in the Essential Medicines. List of the Ministry of Health.