Mr Speaker, I wish therefore, to conclude that, taking cognisance of the breach of our national Constitution as per the articles referred to above and the fact that instead of ameliorating the out-of-pocket expenditure for subscribers, the Capitation policy has rather increased the per capita out-of- pocket expenditure. Instead of improving the cash flow of providers and then the operational and service provision of the provider, the Government, through the Hon Minister for Health, be urged by this august House to immediately terminate the implementation of the Capitation policy in the Ashanti Region.
Mr Speaker, we would want to call on the august House to urge the Hon Minister to ensure that the National Health Insurance Authority collaborates with all stakeholders, to craft a compensatory mechanism for the subscribers and providers of the region, who have had to endure the experiment of robust capitation policy.
We thence caution all Hon Members to ensure that the good people of their various
constituencies are not exposed to the manner and form of the Capitation policy that has been pushed down the throat of the people in the Ashanti Region.
Mr Speaker, I beg to move and in so doing, table it for it to be fully captured in the Hansard.
Mr Speaker, I beg to move,
That this August House urges the Honourable Minister of Health to terminate the on-going Health Insurance ‘Capitation' programe being implemented by the National Health Insurance Authority in the Ashanti Region.
Mr Speaker, Health financing has been an area of major concern for all nations for centuries. The gravamen of the necessity to a solution to the health financing conundrum has always been underlined by the need for nations to make and facilitate financial access to health care to their citizenry.
Mr Speaker, a Health Insurance Scheme, originated under Kaiser I by his Chancellor, Otto Von Bismark in the 1890s, in its various forms over the years, has been recognized as one of the attempts of nations to facilitate health access to its citizens and thereby also reduce ‘catastrophic out-of-pocket expenditure'.
Mr Speaker, Out-of-pocket payments are well documented as a major hindrance to accessing health care. Out-of-pocket expenditure is an important measure of financial protection. It is therefore not
strange that at the global level, the World Health Assembly (WHA) in Resolutions 58.33 of 2005 and 64.9 of 2011 urged Member States to move towards pre- payment and pooled mechanisms of financing health care services in their jurisdictions. Ghana, had taken actions pre-dating the WHA resolutions!
Mr Speaker, after going the various forms of health financing, Ghana finally heaved a sigh of relief, when under the leadership of H. E. John Agyekum Kufuor, the nation took the unprecedented step of Ghana going the way of a National Health Insurance Scheme in 2001. The legal instrument to that effect was finally ratified in 2003.
Mr Speaker, the relief of the Ghanaian was seen in the very palpable rise in access in hospital care in the aftermath of the implementation of the Scheme.
Mr Speaker, it is worthy of note that our national constitution frowns on discriminatory practices as enshrined in article 17 (1), (2), & (4:d).
Mr Speaker, it is of interest to note that the NHIA, under its own study is aware of the fact that instead of creating equality or an improvement in health access, the implementation of the ‘Capitation' programme in Ashanti has skewed ‘Out- of-Pocket' expenditure against the people of Ashanti.
Mr Speaker, the expected effect of the advent of the NHIS is a reduction in the Out-of-Pocket Expenditure for seeking healthcare services in the country. That may also reflect an increase in general government expenditure, as shown:
1995. 2000. 2005. 2006. 2007. 2008. 2009. 2013
General Government expenditure 44. 41. 53. 55. 62. 59. 53 on health as a % of Total Health Expenditure (THE), %
Out-of-Pocket Expenditure as a % of Total Health Expenditure 44. 47. 37. 35. 30. 33. 37. 36*
Out of Pocket Expenditure 64* For Ashanti as % THE after Capitation
The above data shows a clear and consistant reduction in Out of Pocket expenditure after the implementation of the National Health Insurance Scheme.
Whereas, for citizens in a control population out-of-pocket expenditure for healthcare is 36% of per capita health care expenditure, citizens of Ashanti, per caput, have to expend 64.%, nearly double, out- of-pocket for a similar venture.
Mr Speaker, the difference in the two environments is the implementation of a Capitation Policy in Ashanti!
Mr Speaker, by the implementation, first, through a ‘Pilot' and then a so-called ‘Phased Implementation' the issues of Discriminatory Treatment with respect to access to health care and Discriminatory Catastrophic Out-of-Pocket expenditure have been broought to the fore.
Several protestations, since the initation of the ‘pilot' in January 2012, have been directed to the NHIA and the Government. No comforting response apart from a policy of extension of the implementation to cover other areas of the country have been received by the ‘victims' of this ‘experimentation'.
Mr Speaker, if Ashanti is complaining, and given the clear evidence of an associated increase in Out-of-Pocket expenditure for the Client/Subscriber, should this be allowed to be spread across the nation? To defeat the purpose of improving financial access to health care for the good people of Ghana?
Mr Speaker, in very simple terms, Capitation is akin to a ‘Retainership' of the lawyer who is paid some agreed upon amount whether services are rendered or not. The lawyer may receive extra payment when called upon to render some
services. The difference, Mr Speaker, is that this arrangement is not made to the detriment of the lawyer!
Mr Speaker, we wish to clarify for all that, we are not averse to the concept of Capitation in Health insurance management as we understand it to mean. We supported it as a means of health financing operational and sanitizing mechanism under Acts 650 (2003) AND 852 (2012), viz., Act 852, Section 37(c).
What we have frowned upon, and indeed have been against, has been the continued, hurried and botched implementation which have rather left a sour taste in the mouths of all who are experiencing it in Ghana.
Mr Speaker, as you know very well, the Capitation Mechanism involves three major Partners or Players, the Scheme, the Provider, and the Subscriber or Client.
It is normally expected that Capitation should inure to the benefit of the components lof the tripod:
1. The Scheme should be able to forecast expenditure and in the case of the Ghana-plan-of-action, also sanitize the expenditure of the NHIS.
2. The Provider should have a very healthy cash-flow and thus be able to operate rationally.
3. The Subscriber should benefit from a more respectful, client- oriented service with options ofr choice!
Mr Speaker, can one ever anticipate anything worse than the scenario painted above?
Under the Capitation Policy, which has seen several modifications, a Medical Provider was paid an average of GH¢1.73 now revised to GH¢2.75 for each client registered per month, whether the client seeks or does NOT seek for primary healthcare.
When this Client seeks for primary care no matter the number of times, the Medical Provider is NOT PAID for any services, e.g. Clinical examinations and diagnostic tests such as Hb, MPs etc. rendered, apart from the cost of drugs provided, e.g. the Provider is NOT PAID for the treatment of Malaria.
Mr Speaker, His Colleague in the other parts of the country is paid GH¢13.50 for every client seen for primary care at EVERY visit, e.g. GH¢13.50 x 3 = 40.50 for three visits in a month! Then the cost of drugs is also paid.
The perceived logic is that the per cent caput payment for the Provider in Ashanti, for ALL the registered clients should make up for the difference! But, does it?
While the Provider is paid the current GH¢2.75 and hence finds un-conventional means to survive, the Subscriber has to make un-prescribed payments amounting to Co- Payments not prescribed by the Law in order to access healthcare and thus pushing financial protection to citizens of Ashanti into jeopardy.
OPD Cases Capitation G-DRG Difference or Facility Chr. Adults Total In GH¢ In GH¢ (Loss) in GH¢
Ankase 11,358 37,836 49,194 177,520.63 439,338.60 261,817.97 Hospital
Suntresu 15,817 57,442 73,259 452,292.78 577,522.39 125,229.61 Hospital
Credit: GHS, Kumasi Metro
Income of Government Facilities in Capitated Ashanti vrs. Similar facilities under G-DRG (G-DRG = Ghana Diagnosis Related Groupings)
Mr Speaker, in a similar analysis, the Manhyia Hospital lost GH¢644,015.08! And as we speaker, the Manhyia Hospital has barely GH¢20,000.00 in its coffers.
In the face of this jeopardy, the Subsriber may or may not renew membership.
Mr Speaker, Membership in Ashanti
slumped on the introduction of the Capitation Policy. Eventhough, for good reasons it may be picking up, the pick-up is very slow. This is inspite of the little advantage of a health insurance coverage as against none at all.
A comparision between Ashanti and the usually similar control Eastern Region belies the situation:
Registration Coverage Distribution by Regions (Ashanti vrs. Eastern) Region 2013 2014
Ashanti 5,087,202 1,767,680 34.7% 5,198,546 33.7% 1,753,915
Eastern 2,791,143 996,658 35.7% 2,846,965 42.0% 1,195,990 Region
Credit: NHIA, 2014
It is interesting to note that while there is a a marked optimism for an increase in the Membership for the Eastern and other Regions, in Ashanti the NHIA in pessimism, expects a reduction in the Membership!
The only significant change in the environment is the continued imple- mentation of the Capitation Policy.
Where the Subsriber renews Membership, she will wait till she is in dire heed of healthcare before seeking for care. The end result is the increased cases of in-patient admissions of clients in Ashanti.
Mr Speaker, in the scenario shown above, it is only the NHIA that appears to benefit. And that is from its own expenditure accounts. Yes, the Scheme, flexing its national and legal muscle appears to be benefitting from so-called savings.
Mr Speaker, when a people are put to a pilot it usually brings some advantages to them. The peoples, both PROVIDERS and SUBCRIBERS of Ashanti have had to endure a pilot which to say the least is Punitive. While the businesses of Providers have been negatively impacted upon, the Subscribers have had to endure an increased Catasrophic Out-of-Pocket expenditure.
It is only the citizens in the Ashanti Region who are enduring this pain. Compatriots in the other parts of Ghana may not even understand what Ashanti is going through.
Mr Speaker, the results of the implementation of the Capitation Policy has amply demonstrated that it is Discriminatory, and it has defeated the
purpose of increasing financial access to healthcare by reducing ‘Catastrophic Out- of-Pocket' expenditure.
Indeed, a Private Consultant who was contacted by the Authority concluded dthat he could neither recommend the continuation nor the extension of the policy in its current form!