The Role of Health Insurance in UHC: Learning from Ghana and Ethiopia | Webinar Recording

The Role of Health Insurance in UHC: Learning from Ghana and Ethiopia | Webinar Recording


Hello everyone, my name
is Jeanna Holtz, and I would like to welcome you to today’s technical briefing hosted by
USAID’s Health Finance and Governance project. HFG is a five-year global project that
supports low- and middle-income countries to pursue universal health coverage (UHC)
while expanding access to priority health services and improved health outcomes. Today, HFG will share lessons learned
and technical insights from our work in supporting two countries, Ghana and Ethiopia, as they
each chart their own course to advance towards UHC. I’m delighted to be joined by two of my colleagues
today, who are experts in health financing, and who are very involved in the work that’s
taking place in HFG’s country programs in Ghana and Ethiopia. I’d like to introduce
right now, Chris Lovelace, Chris? Good morning everyone. And our second presenter is Hailu Zelelew.
Hailu? Good morning everyone. Welcome to both of you. The briefing is
going to last one hour, each presenter will keep his remarks brief, and will share selected
highlights about each country’s context and its efforts and challenges to move toward
UHC. I invite our listeners to submit questions at any time. You can do so by typing your
question into the question pane that should be visible on your screen. With good luck,
we plan to have about 30 minutes for Q&A, following both the presentations. And we’ll
try to get through as many as we can in the time we have. So, a few introductory remarks from my side to kick things off. Reports show that there are more than 100 countries that are home to almost three quarters of the world’s population, that have taken steps toward UHC.
But we also know that achieving this kind of progress is really hard. It takes time.It’s
uneven and it’s unpredictable. But that said, UHC is now squarely part of the global development
agenda. Many of you will be familiar with the Sustainable Development Goals (SDGs) that
you see here and which were adopted by the UN last September. The SDGs include a goal for health, and under that goal there is a specific target to achieve UHC. I also wanted to share a quote taken from
a recent paper, that’s authored by senior leaders from USAID, and that aligns with the
aspirations of the SDGs. The quote underscores that USAID’s own goals for international
development and for poverty alleviation, and to achieve specific global health objectives, all rely on countries being able to progress toward UHC. It’s also helpful to be reminded of some of the core concepts that define UHC. UHC is an aspirational goal. In reality, it’s never fully achieved, and this is because it’s not possible to pay for all services, for all people, all of the time. Rather, countries are at various stages of moving closer to this goal. Many of you are also familiar with the WHO’s coverage cube that you see on this slide. The cube reminds us of three core dimensions that comprise UHC and which our presenters will be talking about today. The three dimensions are population coverage, service coverage (or access), and financial risk protection. Providing access to needed services, and financial risk protection, are pillars of UHC, but there are other crucial elements
that our presenters are going to touch upon. These include: equity, quality, responsiveness,
and the financial sustainability of the program. One of these important aspects is equity,
and in particular, that resources are shared equally by everybody, including the poor and the vulnerable. So this version of the cube shows a hypothetical view of how the three dimensions of UHC might look across different income groups. In this example, the wealthiest group, which is in the green slice, enjoys the highest service coverage and financial protection, while the poor,
which is the orange block, have the least. This is unfortunately one scenario that many countries struggle to address. Another common remark about UHC that bears
repeating is that there’s no single pathway followed to achieve it. The unique pathway
that each country follows is determined by its own context, resources, politics, social values, and other factors, as we’ll hear about in today’s presentation. A final point that I’d like to add is that many, but not all, countries use insurance as a financing and risk-pooling mechanism to provide access to healthcare and financial risk protection. Ghana and Ethiopia are two examples. Others choose different mechanisms, such as publicly-funded healthcare systems, where care is free at the point of access. Often they are using a mix of different options and alternatives. So now let’s turn to the country cases and get into those. We’ll start first with Ghana. Chris, over to you. Thanks, Jeanna. We can go to the next
slide right away. What I’ll be discussing, very briefly,
we have ten minutes to do, is to introduce you to both Ghana and the National Health
Insurance Scheme (NHIS), talk a little bit about the achievements to-date — it has a
long history — some of the key challenges, but in particular the financial sustainability
that is pressing on the NHIS. I’ll talk a little bit about the approach that the NHIA
is taking to improve expenditure management, and then introduce you to a major national
review that’s under way in Ghana. This of course will chart their course for future
enhancements toward UHC. Ghana is classified as a lower-middle
income country with about 27 million people and a GNI per capita of around $1590. It’s
a resource-dependent country: both natural resources such as cocoa, but also gold, diamonds, and more recently — in the last ten/fifteen years — oil and gas. With dependency on commodities, of course, comes both the advantages when commodity prices are rising and the challenges when they’re falling. And Ghana, like many oil/gas-dependent exporting countries is struggling now with the price of petroleum. It has fairly typical for a lower-middle income life expectancy, under-five mortality rates, and has a significant proportion of its population under fifteen. It is quite highly urbanized and in that sense reflects where much of the world is going in terms of becoming increasingly urbanized. Reforms in the Ghana health system aren’t new. In fact, in 1957, the year that Ghana became an independent country in the post-colonial
period (one of the first in sub-Saharan Africa), the official policy of free healthcare was
introduced. If that by itself was sufficient, Ghana would have already achieved universal
health coverage. We know that’s not the case and over the succeeding decades, Ghana has
gone through various reforms attempting to improve the health system and access to health
services. Some have actually been a step backwards, like the introduction of cash and carry in
the ’80s fundamentally excluded the majority of people from accessing healthcare. Cash and carry makes you pay for the service on the spot, when it’s delivered. Others were innovative for their time, in the 1990s, the introduction of community-based mutual health insurance schemes were introduced, and later they were abandoned. And in 2003 the National Health Insurance Scheme was introduced
and has been in operation since then. So they’ve recently celebrated their thirteenth anniversary. The NHIA was, as I mentioned, established
in 2003 and its stated purpose, or purposes, was to secure financial risk protection against
the costs of healthcare and to expand access to healthcare services. It’s a semi-hybrid
model. There are characteristics of the Bervridgian system — that is to say, publicly financed
– in the case of Ghana, publicly finance through 2.5 percent of the VAT tax. Bismarkian in that contributions are made through the social security system to those who contribute to
it. And it carries forward some of the features of the mutuelle system that it replaced in
2003. You can see however, that it’s predominantly financed — in the pie chart — by the VAT
tax and the social security contributions. Next slide please. It has grown remarkably since its inception
in 2005 when the scheme was fully operational. There were approximately 1.3 million active
members, and today there are 10.2 million. Having said that, it still is only 38 percent
of the population covered. Similarly, outpatient utilization has grown enormously – from less than 600,000 visits per year to nearly 30 million. Inpatient services similarly, from 29,000 to 1.6 million. And claims payments have risen from 7.6 million CDs to nearly a billion CDs. So remarkable growth, but very clearly not comprehensive coverage yet. Certainly not achieving UHC yet, although legislatively, the framework suggests that anyone can register and premiums are not particularly an obstacle to access to care, but there are clearly obstacles to having everyone enrolled – not withstanding the fact that the legislative framework would certainly allow that. Next slide please, thank you. There are clearly achievements that can be attributed to the NHIS, including improving health seeking behavior, and you can see that through the dramatic growth in utilization and membership. For those who are covered by the NHIS, it shows positive risk protection. As say, out of pocket payments are significantly
less a part of members expenditure pattern than they are for non-members – so those who
are involved in the scheme do receive a degree of financial risk protection, although there
are still fees and charges and financial obstacles even for those who are covered. In terms of
challenges looking forward, and I’ll talk a little bit more about this later in my presentation,
there are certainly challenges of financial sustainability, concerning lack of cost containment,
that jeopradizes expansion of the system to cover more people. There is slow growth in
terms of expanding membership in recent years; something of a plateau around 35 to 38 (and some suggest up to 40) percent coverage, but that’s not anywhere near 100 percent.
There are issues related to equity in the coverage, although not as extreme as one might
have thought, and there are issues related to the coverage and it’s relationship to quality of care. Ghanaian’s and NHIS and the Department of Health, in particular, are very aware that on one hand there is much to be learned from their experience (good and bad) and on the other hand there is much they need to learn from others. Ghana is, for example, a very active participant in the Joint Learning Network (JLN). This is a really interesting table, it shows
the growth of both income and expenditure in CDs for the NHIS, and you can see in the
early years all the way up to 2008, revenue actually exceeded expenditures, and the NHIA
accumulated in the trust fund significant reserves. From 2009, however, expenditures
have exceeded, in each and every year, income. You can see the disparity of it has actually
been increasing as well, as a general trend. Clearly in the long run, that’s not sustainable.
In fact the reserves have largely been exhausted, and looking forward there needs to be some
squaring of the circle between expenditures and income. This will be one of the fundamental
challenges Ghana will be facing going forward, and one of the reasons why they have initiated
a major review. On the previous slide, just to perhaps
draw the obvious, one of the reasons you have this difference between income and expenditures
is that the two are unlinked. The contributions through social security and the contributions
through VAT are automatic and very much directly linked to the economy and how well it’s doing
– particularly the VAT. Whereas the expenditures are related to demand. And the two are unrelated,
unlike a system that primarily depends on premiums, that you can adjust the premium bases, and keep your income in line with your expenditures. So it’s an asset in some ways.
There’s predictability in terms of revenue and you can see revenue has grown each and
every year, and actually shows a fairly health growth as the economy in Ghana overall has
generally improved, and in recent years has been growing in excess of six percent. So
that’s the good news. And the bad news is the expenditures have exceeded that. Ok, sorry, next slide please. So to address this, the NHIA is attempting to move from being a passive payer of bills (using a fee-for-service type of system) to more of an evidence-based strategic purchaser. That’s being done through improving expenditure management and control to contain costs, make sure things that are paid for are provided, that there’s no duplication, no inefficiency in the way their processes work, and that opportunities for fraud or mis-expenditure are reduced. They also are
attempting to become a strategic purchaser, moving away from fee-for-service type structures
to those that allow a stronger focus on achieving health outcomes and allow better targeting
of ensuring access to the necessary services and eliminating those things that are possibly
less value-producing, and within that, using evidence to inform their decisions on how they
might structure payments to create incentives, how they could monitor and make sure those
outputs and outcomes are being achieved, and how to fine-tune the system to make sure that
the intended benefits are provided and those that might suggest duplication or inappropriateness
are eliminated. And the NHIS review that’s presently underway is part of that as well,
and one of the objectives – actually it’s a two-fold objective: first that the scheme
be financially sustainable; that’s a major challenge, from the previous slides you will
have seen that they’re tracking toward insolvency; and secondly, that they break through the
ceiling and expand coverage from the current 38 percent to something that reflects universal
health coverage, at least for a core set of Next slide please. So how are they doing that? First, in primary care, they’re moving away form a fee-for-service reimbursement system to a capitation system. A few years back, they piloted in Ashanti region. From that they took many lessons and presently are rolling out capitation in three other regions. And the capitation is being built around those lessons learned from Ashanti, including the need to establish preferred provider organizations to make sure that the potential downside to capitation (lack of incentives to provide care, for example) are
addressed, and make sure that both the providers and the public are aware of capitation, what it implies, and how it works, both to the benefit of, first and foremost, the public, and secondarily, to the provider in creating incentives for them to treat the person and the family, and move away from episodic treatment simply based on presentation. On the inpatient secondary/tertiary side of things, they are in the process of revising their Ghana-DRGs that have been in place for some time but have primarily been used as just another method of providing fee-for-service reimbursement to providers, and instead are trying to use the DRG as a comprehensive payment mechanism to ensure that all services related to an episode of care within that DRG are included irrespective of secondary conditions, irrespective of complications and the like, to make sure that by financing through DRGs you capture the efficiencies that potentially are there in a holistic approach toward case management and also to do so in a budget-neutral sort of way to make sure that the cost containment objectives are achieved and that there aren’t multiple claims against that DRG for the same patient simply because they’re presenting with other secondary conditions or require secondary sources of treatment
and the like. So a very important initiative, relatively newly underway, but over the next
year or two we would expect to see significant benefits from moving in that direction. Internally,
they’re enhancing their claims management and costing system. The system is in some
ways sophisticated but it’s based on collection of claims at a regional level, then consolidating
those claims and forwarding them and then payments, and it’s both inefficient in terms
of cost and timeliness, and it’s also inefficient in terms of making sure that only those things
that are appropriately claimed are paid for, and that where there are inappropriate patterns
of practice – whether intentionally or unintentionally – that those are captured and directed, and
that areas that are either under-serviced or over-serviced can be identified, informed
by evidence, and the scheme can be restructured in order to ensure that the claims management
process addresses those things. And then of course they’re engaged in active policy dialogue
and collaborations with others. One of the attributes of the NHIA is that they have regularly
reached out – in December 2014, for example, they had a major stakeholder consultation
on the benefits package, which is very broadly cast, inclusive of almost everything; but
not terribly well-defined, and one of the issues is whether or not that needs to be
more tightly managed, more tightly defined. And then, making sure that it’s actually available
to everyone. That’s an example. The current NHIS review that I’ll come back to later is
also a good example. The approach basically is that through strategic purchasing, you
can “close the hole” through efficiency gains. There are substantial opportunities for improving
the performance of the National Health Insurance Scheme that will reduce the financial sustainability
issues and at the same time, improve access to services and provide space for expanding
enrollment. On the evidence side of things, the NHIA
has been focusing on improving management information through development of a dashboard,
introducing rapid operations research to better inform their decision-making processes and
look for opportunities to improve services. They’ve introduced a comprehensive monitoring
and evaluation policy that’s being rolled out. Monitoring and evaluation has been escalated
in the organizational hierarchy to reflect its importance, and they are trying to take advantage of learning and knowledge exchange opportunities. Again, participation in the
Joint Learning Network is a good example of that. Our recent exchange with the Taiwan National Health Insurance Agency is another good example of that. Ghana has shown some real leadership, both in terms of welcoming others to see their system but also trying to learn from the experiences of others. Next slide please. This is the last slide, and I will go
through it very quickly as my time is being exhausted. There is a major national review
underway of the scheme. It is composed of a technical review committee of senior health professionals, led by Dr. Chris Atim, and a number of prominent people, including the CEO of the NHIA. They will be producing a report that will then be considered by a broader-based advisory committee that will in turn make recommendations to the government. This review was established by the Office of the President, it’s very high-profile and is being supported by both the government and the opposition. The final report is expected some time in mid-2016. Great, thank you very much Chris. We’ll
move into our second presentation, so Hailu, I would like to invite you now to talk to
us about the experience of Ethiopia. Thank you, Jeanna. My presentation on Ethiopia will focus on first giving you a general background about Ethiopia and the Ethiopian health system, especially before the mid-1990s, and also introducing some of the initiatives, including the financing reforms and where Ethiopia is currently in terms of health outcome trends. Then my focus will be more on community-based health insurance in the subsequent slides. Ethiopia is the second largest country in terms of population, in Africa, with a population of close to 100 million, and it is predominantly young in terms of population age. Life expectancy has substantially improved in the last decade or so. It is still a high poverty country, with a poverty level of 29.6 percent. It is a low-income country with a
GNI per capita of $550 (in 2014). And unlike Ghana, as you saw from Chris’s presentation, Ethiopia is predominantly a rural country, with more than 85 percent of the population living in the rural and informal economy. When the different reforms started in the early 1990s, Ethiopia had limited physical and financial resources in the health sector. There were significant shortages of operational budgets, and essential drugs were not available. There was also misallocation of resources. Like in some facilities you see staff, but there are no operational budgets to buy essential drugs or to function effectively. It was a highly centralized country and sustainability of the health sector was in a very low situation and it was frustrating. There was high inequality: services were more available in urban settings and for a relatively better-off population. So in the 1990s and early 2000s, Ethiopia introduced a wide range of reforms. As you can see from this health expenditures slide, in the mid-1990s (like 1995/1996) per capita spending was very low – $4.5 per capita spending on health; which was maybe one of the lowest in the world even by then. It is still low but has made substantial progress in the last ten years or so. So in 2010/11, the per capita spending was around $21. Regarding source of spending in 2010, the bulk of the money was coming from the rest of the world, which is donor money. About 50 percent of funding for health was coming from donors. Households were the second largest financer for health, around 34 percent was covered by households. The government covered around 16 percent and other sources were insignificant. In terms of the different initiatives
in Ethiopia, I think it’s good to make it clear that when we talk about universal health coverage, we need to see different aspects of universal health coverage; including increasing access to health service, increasing the population coverage, and also the financial protection
aspect, as Jeanna mentioned in her highlights. So, regarding that Ethiopia substantially
expanded health services, as you can see. Many of you may know, Ethiopia introduced
a new innovative flagship program, a health extension program which enabled the
country to assign two health extension workers per village In the last two decades, this number has increased from zero to 42,000 health extension workers. In terms of health facilities, as well, I mentioned, the health posts that the health extension workers are stationed at, but also Ethiopia substantially increased the health centers. In the mid-1990s there were only 300 health centers, but as recently as last year this number has increased more than ten-fold. And then Ethiopia introduced the Health Sector Development Program, which was key in terms of prioritization of services, including focusing on preventive and promotive healthcare. From the financing side, there were different reforms introduced, including harmonizing and alignment of donor resources, and also donors and government collaborated to establish the Millennium Development Goals performance pooled fund, which was a huge amount of resources and key to cover priority areas. Ethiopia also introduced a fee-waiver system for the poor to give financial protection for the poor while also expanding priority services through free provision of services. This includes immunization, maternal healthcare services, and other services. Another important development in Ethiopia is the decentralization of the health system, part of the overall government decentralization. District level planning and budgeting were critical, and
that enabled prioritization of services at the facility level and the community level. And another major development in terms of financing is to allow health facilities to retain and use the fees that they collect from users, and that was important in terms of dealing with financial gaps. In the last ten years or so, the major new development that’s come in the Ethiopian health financing system is health insurance. In terms of health outcomes, Ethiopia has showed tremendous progress, I mentioned that the life expectancy has improved significantly and also Ethiopia achieved MDG 4 in 2012, which was before 2015. Ethiopia also showed significant progress in achieving two others: reducing maternal mortality and also improving
sanitation and hygiene services. Coming to the community-based health insurance.
Why community-based health insurance in Ethiopia? One, as I mentioned, Ethiopia is a predominantly
rural and informal economy-based country. Greater than 85 percent of the population
is rural and in the informal sector. And again, as I mentioned, household spending, even in
this highly-donor-financed health sector, is still significantly high, around 34 percent of
total health expenditure comes from households. Even though there was significant expansion
of health services, health service utilization was still very low. And from the opportunity-side,
Ethiopia has a strong community-level solidarity system which was critical in terms of serving as a foundation for introducing community-based health insurance. So, starting from the mid-2000s, Ethiopia
started working on health insurance broadly, and also community-based health insurance specifically. In relation to that, I think as Chris mentioned, one of the oldest health insurance experience countries was Ghana, and people from Ethiopia visited Ghana, Rwanda, Senegal, Mexico, and other countries to learn from their experiences. Different policy documents were produced and in 2008, the health insurance strategy was developed, during which the government decided to establish two different health insurance schemes. Social health insurance for the formal sector, and community-based health insurance for the informal sector. So, first to draw lessons and also to contextualize community-based health insurance, the government decided to pilot community-based health insurance. And 13 districts in the largest four regions were identified. Starting in January 2011 a pilot was conducted in those districts. And we had an evaluation by independent evaluators in 2014. These are the highlights of the evaluation. As I mentioned, this was piloted in 13 districts, and the average population in each district is around 140,000. So the pilot districts had a total household size of 300,000, which is a population of 1.8 million In terms of the actual performance, the contribution was made form households, which accounted for about 52 percent of the fund, and also a government subsidy accounted for 48 percent of the total fund through targeted subsidies for the poor, and general subsidies for the schemes to cover any shortcomings in earnings in the community-based health insurance schemes. I think, as Jeanna showed in the cube, one of the most important things to see is who is covered in the financial protection programs. So, in the CBHI schemes, one of the important developments is to provide coverage for the poor through the government covering the payments for that group. In terms of enrollment coverage, about 52 percent of eligible households in the pilot schemes were covered through the community-based health insurance. That is the average of the 13 districts; there were half in some districts and as high as 100 percent, and in some there were 25 percent. But overall, there was an average of 52 percent coverage: 157,000 households/700,000 beneficiaries were covered through the CBHI schemes. 15 percent of enrollees were poor and their payment was covered by the government. Another achievement of the community-based health insurance was that utilization among the CBHI members and beneficiaries has substantially increased. As I mentioned, health service
utilization was only 0.3 per annum, which is one out of 3 persons visiting health facilities,
whereas among the CBHI members it increased to 0.7, which means almost 1 percent is visiting
health facilities annually. So health seeking behavior has substantially improved. The financial
protection aspect is also another important achievement from the CBHI schemes as you can
see. Among the CBHI members, out-of-pocket expenditure, which exceeds 15 percent of non-food
expenditure was only for 7 percent of the insured, whereas for non-insured it was 19
percent. So the financial protection was significant. However, there are still major challenges.
One of the challenges is that there is low membership renewal among CBHI members, it could be for different reasons, structure and other things, but the surveys show there is interest to renew their membership. New enrollment is very low, but again, the evaluation showed, among non-members, there
is interest to enroll in the CBHI schemes. We observed that some schemes are experiencing
financial difficulty, like spending more than the amount of revenue they collected; especially
in urban settings. We also found from the evaluation that the local officials commitment,
which is an important ingredient for the community-based health insurance schemes, varies from locality
to locality. Again, facilities also differ in their readiness to deliver quality which includes availability and quality of staff, medicines, laboratory facilities, and other aspects. And also, inadequate
mechanisms to address complaints. Final points: what are the current developments? We saw the evaluation, but what are the current developments? One, the government is satisfied
by the pilot results and decided to scale-up community-based health insurance. So in the
last two years, a total of 185 new districts are establishing community-based health insurance
schemes, and in fact this year, an additional 131 districts are launching community-based
health insurance schemes. As of the end of last year, 1.6 million households, and 7.3 million beneficiaries are enrolled and covered through their community-based health insurance scheme. On average, 22 percent of the households are poor and their premiums are covered by local government. The pilot is about to start in urban settings and pastoral areas, as the CBHI pilot schemes focused on the agrarian areas. It has significant resource implications, but the government is ready and willing to commit
the resources. So, the scale-up strategy is developed and the strategy for implementation
is also developed. In the government’s health sector development plan, the plan is to increase
the district coverage to 80 percent, and also the population coverage to 80 percent by 2020.
In fact, recently they were also discussing even to reach all districts, which means 100 percent of the districts and 80 percent of the population by 2020. I think in terms of lessons form Ethiopia,
I think CBHI is a significant coverage mechanism, and can serve as a pathway to UHC. As I mentioned,
it provides financial protection, including for the poor. It enhances health service utilization
and creates pressure on health service delivery and quality improvement in health facilities.
It requires strong government commitment, and I think other countries can learn from
the Ethiopian experience in terms of that. Partner support is always critical. I think
in Ethiopia, the subsequent USAID projects played a significant role in initiation and
implementation of community-based health insurance. Thank you very much. Thank you, Hailu. We will, I think, begin with some questions that have come in from our listeners, we’re just sorting through these right now. Why don’t we start with one just as a follow-up for Ethiopia and Hailu’s presentation? So, the question is, Hailu, around, how does enrollment take place, and how does it work in Ethiopia? Is it mandatory or voluntary, and how do subsidies that the government provides, how are those subsidies distributed? Thank you very much. I think in terms of the first case, as I mentioned, Ethiopia is predominantly rural and informal country, so the decision for the government is to start enrollment on the CBHI scheme as voluntary. And so far, it’s voluntary, and as I mentioned the coverage has increased to 52 percent on average, with significant variation from district to district, but so far, and the policy direction so far, is to continue it as a voluntary scheme. But I think as lessons are learned, the possibility of introducing other ways of increasing the enrollment, including considering, maybe, some incentive or even a mandatory system could be there. Okay, thanks Hailu. Let’s go to Ghana, and call on a couple of the questions that we have for Ghana now. Chris, we have a question really about the evolution of the NHIS, and the question is: Could you expand on how the historical presence of community-based health insurance schemes evolved into the NHIS? Maybe tell a little bit more about how that occurred. Sure. CBHI schemes in Ghana never were comprehensive in terms of covering all of the country, and they had considerable promise but always struggled both with enrollment and income, and never really fully achieved their objective, although they had considerable promise. So there was both a problem in terms of the comprehensiveness, the financial protection. They were contributory schemes, so there were financial barriers to access, I think at some point the government realized that if they wanted to have a comprehensive national scheme, it was not going to be made up of individually established CBHI’s, but rather could be built upon that as a starting point, and move towards a national system. So that’s what they did. It was part of the political culture of the time when the NHIS was established, it was very much a plank in the governments program, and has evolved ever since. So CBHI can be seen as a building block toward achieving a national health insurance scheme. Lessons were taken from it, but it was viewed as something that by itself was not going to be long term sustainable. And maybe just as follow up to that, the question is about the governance of the NHIS: Is the NHIS managed by the Ministry of Health, and is there a purchaser and provider split? Thanks. Both of those are good questions. NHIA is officially a part of the Ministry of Health, though it functions autonomously and it has an independent board over top of it. So there’s the senior management and then there is an appointed board that is overall responsible for its operation. Sorry what was the second part of the question – oh purchaser/provider split. Sorry. Yes, absolutely, in fact baked in to this model is that the NHIS and the NHIA, which is the executive agency that oversees it, is the purchaser, and provides those services itself. It makes payments to providers, so it is quintessentially the purchaser/provider split. Great thanks, this is a question that maybe can be answered by both Chris and Hailu. How are Ethiopia and/or Ghana dealing with issues around retention rates and renewal of members. Hailu would you like to respond to that first? Sure. That’s a great question. As I mentioned, it’s one of the challenges in Ethiopia, and the government is working with the CBHI schemes to maintain and even to increase enrollment through using local community-based and government structures. The CBHI structure itself is being strengthened, so that there is continuous renewal, follow-up, and registration of new members. So government and the CBHI schemes are working on that. Chris, from the Ghanaian perspective? In Ghana, individuals need to register at one of the regional or district level NHIA offices, and they have to be current in their payments of premiums. Both of those represent challenges. Obviously there’s not an NHIA office in every town and every village. Secondly, although premiums represent less than four percent of the income of NHIA, for an individual or individual household, it could represent a financial barrier though the premium rates are set very low and there are exceptions to the payment of them. So both of those things need to be addressed, they’re almost certainly going to be addressed in the NHIS review that’s under way. Options could include everything from moving away from the premiums entirely to the extent that that’s an obstacle to enrollment, to separating enrollment from payment of premiums – so that once you’re enrolled, you remain enrolled irrespective of whether you’re active or not active in the scheme. And there are other issues that could be addressed. But it’s an area that I think, in order to expand beyond that 38 percent, there needs to be a reach out mechanism. Technologies also offer a lot of opportunity; maybe people could be registered at the point of service if they’re not already registered, for example, with mHealth and eHealth opportunities, and the like. Registration doesn’t necessarily mean physically presenting yourself in a place, it could be done in more efficient ways. I’m sure all of those things are going to be considered in the context of the review. Thank you. This is a follow up question for Hailu about Ethiopia. So Chris had elaborted on this sort of historical context of community-based health insurance schemes in Ghana, and one of our listeners has asked, is there a plan to integrate the CBHI schemes into a singular larger risk pool. What might be the challenges and/or opportunities for doing that?