Dr Nicholas Crisp

Just because it is difficult does not mean that a country should not embark on health sector reform, but NHI in whatever form is not necessarily the solution, well-known South African healthcare consultant, Dr Nicholas Crisp, from Benguela Health, warned when addressing the 7th ISPOR SA Chapter Conference in Kempton Park yesterday.

No other country, he pointed out, has anything like the universal healthcare coverage system planned for South Africa through the proposed National Health Insurance (NHI) process: “No two countries are the same. Ideas are fine but don’t copy anyone else!”

He issued this warning after giving a comprehensive overview of the national health insurance experience in Ghana, a country with a far smaller population than South Africa (a little more than 28 million at the last count), has far less money to spend and which still only has 66% of its population covered by its NHI system 15 years after implementation.

Some form of government action with a system aimed at extending access to healthcare “as widely as possible with minimum standards” were among the few common denominators in the broad NHI concept that countries have implemented in several ways, Crisp acknowledged.

Big difference in Ghana, however, is that its health service, the Ghana Health Service (GHS) is no longer one of the of government services: “It is now run as a separate operation which makes the whole system fundamentally different”.

Part of this process was the National Health Insurance Service (NHIS) which, Crisp went on to explain, was funded largely from value added tax (VAT) at 78% followed by a Social Security and National Insurance Trust (14,5%, of which 2,5% was made up from mandatory contributions from workers in the formal sector and the self-employed).

While 66% of the population were covered for basic services, a whole range services which could be deemed as essential are exempt. These included heart and brain surgery not prompted by an accident, dialysis for chronic kidney failure, cancer treatment other than cervical and breast, angiography, medical examinations for non-medical purposes, and mortuary services: “The GHS still delivers these but they are not funded through the NHIS.”

If there are any lessons to be learned from the Ghana experience, top of the list, Crisp stressed, must be to understand and accept that health sector reform takes a long time: “After 15 years of operation the NHIS covers very little care for only 66% of the population.

“What is fundamentally critical is that you can’t include what you can’t afford in your package of care. And you need to secure existing and new – that is new to health – revenue sources,” he said,  citing the VAT top-up, the GHS still being paid from general revenue, and being part of pension schemes in the Ghanaian set-up as examples when concluding the point.