Excerpt
EVALUATION OF GHANA’S NATIONAL HEALTH INSURANCE SCHEME (NHIS)
INTRODUCTION
Evaluation is a sine qua non and inevitable exercise (Khan & Rahman, 2017); an analytical device for measuring a policy’s significance, performance and efficacy. Evaluation may be conducted at a pre-policy or formulation stage (ex ante evaluation), implementation stage (interim or mid-term evaluation) and post-implementation stage (ex post evaluation). Generally, policy evaluation is a systematic and objective assessment of a policy design, implementation processes and results in order to determine its relevance, and attainment of its objectives, and to ensure efficiency, effectiveness and sustainability (IOB, 2009; Schoenelfeld & Jordan, 2017). It is a meticulous assessment of design, implementation, results and impacts of a policy intervention (IOB, 2009). This paper evaluates Ghana’s National Health Insurance Scheme (NHIS), which was launched in 2003 by an Act of Parliament (Act 650); but replace in 2012 by the Act 852. The aim is to ascertain the level of eff iciency, effectiveness, impact, relevance, sustainability and policy consistency.
A BRIEF APPRAISAL OF GHANA’S NHIS POLICY
Efficiency: This may refer to maximum fulfilment of policy objectives from given resources. In economic terms, it denotes c ost-effectiveness: i.e. productivity of given resources in achieving given objectives often measured in financial terms (IOB, 2009); but may also be measured in a non-economic sense (Gasper, 2006). It may also be measured in terms of the ratio of a non-financial output to a non-financial input, and a financial output to a non-financial input (Gasper, 2006). Therefore, efficiency measures relationship between outputs (i.e. products or services of an intervention) and inputs (i.e. the resources invested). A policy intervention may be considered efficient if it uses the least costly resources available and relevance for achieving the desired outputs or deliverables both quantitatively and qualitatively (Peersman, 2014; IOB, 2009; Gasper, 2006). In measuring the NHIS’ efficiency, attention has to be paid to both the total number subscribers and or beneficiaries and the quality of services received at the hospital. For example, in terms subscription, the policy may be doing fairly well, with over 8.8 million active subscribers and 3500 healthcare providers (both private and public). In terms of service delivery, assessment of the quality of service provided is very crucial, thus the NHIS when measured by this may have several lapses which requires urgent attention to address as many people are sometimes turned away by service providers or mostly charged extra-amount for certain services and failure to afford such extra costs are often met with poor medical attention in some hospitals even though the NHIS accounts for over 85% of service delivery income of public and quasi-public healthcare facilities (Alhassan, Nketia-Amponsah & Arhinful, 2016).
Effectiveness: This measures extent to which intervention’s intended outcomes (i.e. specific objectives or intermediate results) are achieved. Effectiveness is the relationship between intervention’s outputs (i.e. its products or services; its immediate results and its outcomes). But it has often considered the intended benefits for targeted group of beneficiaries. Therefore, an intervention is considered effective only when its outputs produce the desired outcomes (IOB, 2009). It implies producing the approved effects; which is often interpreted as fulfilling a project objective (Gasper, 2009). The major challenge may arise where objectives are not well established and are also not time-bound (Ibid). In the context of the NHIS, the objective are to: 1) provide financial-risk-protection against the cost of quality basic healthcare for all residents in Ghana; 2) reduce mortality (maternal and infant mortality) in order to attain the MDGs 1, 4, 5 and 6; 3) attain financially sustainable health insurance scheme or system in the country that affords the poor and vulnerable opportunities to access basic health care; 4) achieve universal financial access to basic healthcare services by abolishing the cash and carry system. For effectiveness measure, all the individual objectives must be assessed vis-à-vis how beneficiaries fare as regards healthcare access and benefits. With the objective 1, 2, and 4, largely speaking, the policy has made significant strides, amidst some challenges.
Impact: This measures all significant effects of an intervention (positive or negative, expected or unexpected), on its beneficiaries and all other affected parties (IOB, 2009; Trochim, 2009). Whereas effectiveness focuses on the intended outcomes of a particular intervention, impact is a measure of the broader consequences of the intervention, including economic, social, political, technical or environmental effects (locally, regionally, or nationally), on the target group and other directly or indirectly affected parties. For example, what are the long-term effects of the NHIS policy on healthcare delivery and the economy in Ghana? For example, in terms of health, many, including the poor and those in rural communities are now able to access basic services and visit health facilities more compared to previous years before 2003 when the NHIS was enrolled. Also, economically, as more people are able to get access to quality basic healthcare at an affordable rate, they are not only able to save costs, they are also able to work more hours for money. Again, as dependents’ healthcare financial burdens on breadwinners are largely reduced, they are able to save some extra money for other activities. However, there are still some major challenges in terms of access to the physical facilities, drugs and health professionals in most remote rural areas across the country. The main problem with a broad impact assessment of the NHIS include, boundary judgment (i.e. deciding what effects to select for consideration), and attribution (what effect is due to what?). This is because effects may be numerous and varied; and may typically result from complex interactions. Thus, impact assessment is difficult in most circumstances (IOB, 2009). A useful way of dealing pragmatically with issues associated with selection of effects, levels and groups for evaluation of impacts, is making choices consistent with intended use of the evaluative information. Finally, it must be said that, usually, evaluations estimate impact on probability-based inferences derived from assumptions of simplified cause-effect nexus.
Relevance: In public policy evaluation, relevance emphasizes the extent to which a particular intervention meets population needs and country priorities, and are consistent with donor policies (Trochim, 2009; IOB, 2009; Peersman, 2014). For example, the relevance of the NHIS could be assessed in terms of the overall rationale, e.g. to achieve a parochial partisan agenda of a few or exploit its real health potentials on all residents in Ghana. It may also focus on healthcare givers or professionals and all residents especially the poor and vulnerable groups in Ghana’s responses to the NHIS initiative. Any changes in society’s priorities may imply that the interventions are now accorded less importance or lose the rationale for their introduction. Put differently, relevance is simply a question of usefulness; and its assessment leads to higher level decisions as to whether a policy intervention in question ought to continue or be terminated. In cases where the former is considered, what changes are required, and in what direction? Are the agreed objectives still valid? Do they represent sufficient rationale for continuing with the activities?
Sustainability: The sustainability aspect of public policy evaluation looks at whether benefits of an intervention would continue after external support ends. This aspect of evaluation addresses the effects of the development process itself over the long term. For example, the sustainability of the NHIS can be measured in terms the likelihood of maintaining, or the extent to which Ghanaians can enjoy both the programme and associated benefits in the future. It could also be measured in terms of financial and economic viability of government’s domestic sources and that of the supporting institutions or donor partners (see Gasper, 2006; IOB, 2009; Peersman, 2014). For example, Ghana government has a whole levy (the NHIS levy) and fund managed by the NHIA purposely for ensuring the policy’s sustainability. The NHIA also invests available funds for more returns in order to succeed. Sustainability, is by far, a higher-level test of whether or not a particluar intervention has been a success. Many development initiatives fail once the implementation phase is over, because either the target group or all stakeholders do not have the means or sufficient motivation to provide the resources needed for it to run (IOB, 2009). In assessing policy sustainability, there is the need to address the extent to which capacity has been developed (through e.g. participation, empowerment, ownership, local resources availability and sustained political will). Also, it is important to consider whether or not positive impacts justify required investments, and beneficiary communities’ value benefits enjoyed and so, would devote their scarce resources for the sustencnace of the intervention. In terms of capacity, tremendous progress has been made as several neighbouring countries come and learn lessons about Ghana’s NHIS policy so as to replicate same. On how beneficiaries behold its impacts, it has largely been positive and most see it as a very useful policy and its impact on their health and finances largely positive. Usually, since sustainability is concerned with happenings after completion of an intervention; ideally, it is measured years afterwards. Also, it is difficult to provide reliable assessment of sustainability of an intervention whiles activities are still ongoing, or immediately afterwards (Peersman, 2014; IOB, 2009).
Policy Consistency: Finally, consistency is an essential component of policy evaluation. It considers the absence of any inherent contradictions between different policy interventions (IOB, 2009). Consistency evaluation is particularly important for decompartmentalised policy interventions as some development objectives may conflict with certain interests. Thus, it is particularly important to determine extent of interventions performance from different perspectives, and ensure that they are coherent and do not obstruct one another. This is to help achieve the intended objectives without any one of the intervention’s effects neutralising those of others (Ibid). Largely speaking, many stakeholders are consistent when it comes to focus, usefulness and impact of the NHIS in Ghana. However, political actors often politic with it and talk about perceived challenges or otherwise. Sometimes, there are also contradictions in terms of financial sustainability, payment of claims and coverage of the NHIS between the service providers and the NHIA as well as the government of the day. Addressing these challenges is very imperative.
CONCLUSION
Summarily, policy evaluation is very important and it involves several central analysis and preparation of ideas about values, objectives, priorities and claims about facts and cause-effect linkages. This enable analysts to produce valuations about past or possible future actions by public agencies. Policy evaluation, as discussed, involves six primary criteria; and this paper examined these criteria vis-à-vis the NHIS policy in Ghana. Largely, amidst some major problems, the NHIS, it can be said, is performing quite well in terms of efficiency, effectiveness, relevance, impacts, sustainability and consistency. However, a lot more is desired to make it more sustainable and deliver the intended deliverables.
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