Susan Elden – seminar on National Health Insurance in Ghana

I’m Susan Eldon I’m a health advisor at DFID based in Ghana and my presentation is on the health financing system but within that context of how the national health insurance scheme which has been going for about ten years as a mechanism and as a part of that wider health financing scheme and then within the broader context of that with it within this notion of universal health coverage and how the nhi a the NH ISO National Health Insurance Scheme and the National Health Insurance Agency so I use both of those acronyms to describe what I mean and I think Katrina have really helpfully set the scene I’m talking about those different dimensions and Neil has already stolen most of my points about Ghana so I hope that you’ve forgotten some of those so for those of you who may know Ghana or may not know Ghana Ghana the country is roughly geographically the same size as the UK but with about half of the population so 25 million people and for the most part it’s it’s been a stable fairly quiet country I came from Nigeria so first of all start with a caveat I was working in Nigeria for four three years and so I’ve been in Ghana for four months and I’m not a health economist also start with that caveat but one of the things that my mum said when I when I moved to Uganda she said I don’t hear about Ghana in the news so I think that’s a good place to go and and I think that actually is part of you know Ghana is a smallish country it’s a stable country for the past hundred years their economy has been based on things like cocoa and gold exports but in 2010 Ghana recently moved to having discovering oil and so the big question for Ghana now is what to do with that oil revenue and what that means both for the country and that growth portfolio but my presentation today is really going to be a little bit of an overview on the demographics of Ghana and and what Ghana is about for those of you who don’t know the country context and then moving on to the NH is a little bit about you know where it started where it is now and then talking about that more broadly within the aspects of purchasing quality and universal health coverage and then because I’m a development partner in a donor what that means to us as one of the stakeholders that are sitting there in Ghana so I’ve given you a little bit of the the country context and you’ve seen it on the map there this is some of the macroeconomic picture and really where where Ghana looks at how it is you know doing on the the wider portfolio about growth GDP and those indices and I think just the graphs I mean the kind of key things that stand out to you is it’s going well it’s currently going in the right direction at present and it’s a very it looks to be a very healthy picture so if you look here on gni and how per capita income has brought up there’s two things to notice one is it’s almost been a doubling the second thing is this sort of threshold is what World Bank classified case classify as the threshold for middle-income country status so Ghana is now in middle-income country status and what that means is that that has a lot of implications for sovereign lending for how development partners see you know how we work in what’s a low income or a middle-income country but a lot of this the other interesting thing about this is in 2010 they did a rebasing of the GDP so again it’s not an exact science but you know that that also has implications of really pushing that up into middle-income country status second graph again shows another really positive trend of GDP and really towards the end a quite exponential rise and a lot of this people feel has to do with you know the discovery of oil and tapping into that and then again quite dramatic poverty decreases so at present a really healthy macroeconomic picture the questions for us are really sort of threefold what about the future so there’s no guarantees that we will stay in that middle-income country status and so if we don’t if it’s going to falls back into that low-income bracket what does that mean second thing is there’s no guarantee that growth will continue and certainly at this rate what the economists tell me in Ghana is that a lot of it is based on commodities and so there’s a lot of external factors that have nothing to do with what’s happening within Ghana and so I mean economists anticipate all sorts of things but the ones that I’ve talked to have said that we can expect a plateauing and possibly even a decline

and so if that is the case what does that mean you know within the broader picture and then thirdly it’s a nice picture on the poverty indices going down but one of the things that we look within that is the Gini coefficient and things to talk about inequalities and the two things that are concerning to us in Ghana is that within theirs there’s significant regional variations so poverty in the northern region and in the volta region have actually gone up so this is not although this is a good macro picture it’s not the picture across the board there’s still significant poverty and so what people have described it to me as Ghana looks very good on paper but it’s still behaving like a low-income country and also in terms of the human development indices and the health indices it still looks very much like a low-income country but that is trying to go the right direction so then I want to quickly whizz through the what it looks like on the health picture of that and really the kind of two graphs show again an overall positive picture on the on the macro side so dramatic increases in life expectancy we’ve seen it go let’s see in 1960 46 was the life expectancy and it’s gone up to 65 so a 40% increase in a relatively short period of time but also Ghana likes to think of itself as achieving much better than its neighbours so if you look at the the countries and the the states around it Ghana’s doing very well on life expectancy on its declines and infant and child mortality on its declines and maternal mortality so on those big health-related indices thon is doing very well and we can we can think of all sorts of reasons why that’s happening I think the big picture is on on the spin side it’s quite healthy but what we want to look at is where is that spend going and is that going on the right things and is that spend actually yielding those results when we look towards the future I think the other thing to really note here is that the portfolio of total health spending has changed dramatically so again going back to that rebasing of the GDP middle-income country status donors have started to ask the questions two questions one do we want to keep giving the same amounts of funds and resources to Ghana and two how do we want to do that in the past we were all in something called a swap and sector budget support now that’s dramatically changing and shifting we had five people in sector budget support we’re now down to three and two of those have dramatically dropped their levels to the point to where 2016 it looks like DIF it will be the only person investing in sector budget support so again the Ministry of Health and the Ghana Government is now bearing a substantial burden of the the health expenditure much more than it has in the past one of the things that so in the good side we know that money spent on health is going up and that’s a good thing but what is it going up on and what are we seeing the yields from that one of the things that’s happened recently is in 2011 in Ghana they did the wage bill they passed the wage bill and so what that meant was that was a it was a shift in all of the public sector salaries so everybody was moving into a band that pushed a lot of people up in bands but what that also did was that increased expenditure massively so what happened was the Minister of Health had a budget and then when the wage bill was passed they had to go back to the Ministry of Finance and said an actual fact this doesn’t cover our bill so when that happened Ministry of Finance said okay Ministry of Health you’ve got your money cover the wage bill but what that meant was that in 2013 on things like capital investment infrastructure the budget that was there zero was spent so if if human resources and health workers are absorbing such massive amounts of your salary and you’re not getting those gains from that where where are you moving towards the future and I think that’s one of the questions that we’re trying to ask I think the other big question we’re trying to ask us as these indices get better life expectancy increases maternal mortality drops you’re having an ageing population and you’re having non communicable diseases that’s gonna cost even more so knowing that healthy trends in the population actually mean that you need even more revenue or more efficiencies to keep this status quo or to keep the system going so I’m gonna do a snapshot through

the National Health Insurance Scheme from 2003 and to where it is today in 2014 we’ve just had our big happy birthday celebration our 10 year anniversary of the National Health Insurance Scheme I think Neil gave a really useful context and background about this and I thought one of his points that was most interesting was in the in the beginning donors and development partners and a lot of us as externals were very skeptical about what was the design and the makeup of the National Health Insurance Scheme and then NHIA but also we’re asking the questions about what is this going to do for the poor what is this going to do around poverty what is this going to do you know around those scenes that we were looking at as development partners and Ghana did two really useful things it got all of its political parties together and it said you know what we don’t really care we think this is right for us here in Ghana and they went ahead with it and what’s been interesting and useful about that process is that in actual fact that has helped the stability of the program the an investment and the the the actual financing of that has remained consistent throughout those ten years it’s had bipartisan support so it’s it’s it’s had a really healthy start it’s been Ghana owned but it’s facing really big challenges at this stage and just to kind of talk you through the journey so in 2003 the Act was passed by Parliament and then the kind of two things I’m going to talk about it really is coverage II coverage and purchasing models so you started out with coverage at 7% and then the model for purchasing was something called fee-for-service and that was something that was replacing what was called the cash-and-carry system which was just you know you go in and whatever you get you pay your cash and you have your service so the fee-for-service was really an input based thing you go to a clinic and the national health insurance reimburses you for that based mostly on volumes and on inputs so there wasn’t a lot of cost containment but as you can see utilization started really going up coverage started really going up and then something happened so all of these facilities are now accredited and then in 2010 there was this sort of shift where the expenditure started to outpace the revenue and so then things started to slow down and people were asking the question of you know timely reimbursements the providers weren’t happy about that but also that kind of big question is we’re either gonna have to create more efficiencies within the system or have better cost containment or increase the revenue because at the moment without outpacing it’s not working but you were still having this massive utilization at like 30 fold increases of outpatient attendance and then coverage started to stagnate as those you know as those different models came through they implemented something called DRGs which is the diagnostic related groups as a method of trying to say okay let’s not just have this fee for service you come in and get your service but let’s try to group please under conditions and have some uniformity so we have these 500 conditions and that was successful but it wasn’t successful and cost-containment the other thing that was interesting about 2010 was this was I was talking to Neal about this this is our equivalent of the black report there was a independent report produced in supported by Oxfam that said is this really benefiting the poor is this really doing the things that it claimed to do and is it really on a solid enough footing to continue and the two interesting things that happen from that Oxfam report was again Ghana got together and vehemently addressed those issues first of all sort of seen as an external attack but secondly what I what up from what I could see really getting their act together and making those changes but being very transparent about what was working and what wasn’t working so there was a lot of things about you know oh the coverage levels are 60 70 % and when the Oxfam report said well in actual fact is that initial enrollment or re-enrollment and who’s getting what and how much are the poor getting then NHIA started taking a really hard look at that and so in the latter years it’s really been a lot about financial sustainability about cost containment and really thinking about the future the capitation pilot in one region the Ashanti region has been one thing that they’ve been looking at as a key mechanism for cough containment and then the II claims management which is again about the timeliness so that’s the the current picture of an HIA and I just want to contextualize that because I know we’re talking about lots of

different things here today and we’re talking about universal health coverage we’re talking about health financing systems more broadly and and I thought this graph was really helpful in terms of the nice thing about universal health coverage is it kind of forces you into thinking about what are those areas of health financing you need to look at and then so your revenue collection your pooling and your purchasing and then it kind of says okay and then how does this impact on utilization quality and financial protection so I think it’s it’s a really helpful kind of contextual background and there’s lots of things that you can discuss around this but the the primary focus I think that we can talk about in relation to Ghana is really about purchasing and the benefit package but what that means about quality and I think that for the context of today I think that’s where the the relevance lies I’ll quickly go through on that side of the health system financing the the revenue side and the pool inside on the revenue side when it started out it was seen as a very progressive system so seventh and and what I mean by progressive is that the bulk of the resources came from taxation they introduced something called the value-added tax which was 2.5 percent and that had again bipartisan political support it was seen as a good thing and it was progressive because it didn’t unduly burden the poor it’s been stable from the inception so there hasn’t been dramatic if anything there have been increases in the revenue steadily rising increases but not at the same pace of expenditure and so that brings up the whole question of you know is that revenue the revenue stable but is it sufficient and I think that there’s really a general consensus that there does need to be increases in revenue somehow so it hasn’t really gone into depth here I haven’t seen the analyses yet but one of the questions is whether to increase the revenue and how you know how popular that is how to do that through legislation and you know the various procedures in doing that so we really need the evidence to show that that’s needed and the economics to show you know how that happens secondly is how much is needed to increase the revenue in relation to the cost containment that needs to happen and I again I think we’re still trying to work through the science of how much that’s needed and then finally where that revenue should come from there’s a number of different things being talked about in Ghana one of those is having a road levy tax one of the things I’d really like to see is on the tobacco and alcohol tax side things and I think those could be really positive movements but again what we’re trying to balance is priorities and politics because you can increase premiums and you could put those premiums you know on to the middle income and and the wealthier paying people is that politically popular are you going to see the drives there so there’s a lot of trade-offs it on the revenue side but that’s that’s just a sort of brief some of the issues around that then the second function is really about the pooling again Ghana from the very start had a single pool and what it used to have with these community-based health insurance schemes so these little sort of scatterings of health insurance schemes based out in the districts and so what it did was harmonize those within the whole NHIA package so again big single pool was shown to be the early evidence was that it offered good financial risk protection the only question about pooling is within the pool so within that big single pool there’s separate strands so some of that is the Social Security international insurance some of that comes from the VAT some of that comes from the donors and so there seems to be an element where we can increase some efficiency there but I want to talk about purchasing and quality and I want to talk about Grace’s story and there’s a couple things you should notice one is I’m a very bad photographer my photography skills are probably even worse than my health economic skills but um grace if I can actually see which one she is this is grace actually and that’s probably good because you’re supposed to ask for permission and get identification everything anyway grace lived in a vault in volta region in a little rural area not that little but a very typical rural area of a place called Vig mapley me and it’s about 40 kilometres from Hawaii and I don’t see anybody nodding their head who knows where the boats are yes good okay so a few people so I’m trying to get you to imagine right so so taking it out of us as you know funders and policy people and economists and all of this why does all of this matter to a woman sitting out in the middle of Ghana why does any of this what we’re talking about today

matter and I was there for a different reason but grace stood up and she said I was there for a maternal and child health Inge and she stood up and she said I’m eight months pregnant I’ve been to my clinic I’ve gotten this card but in actual fact I haven’t renewed it because I’m supposed to go to a separate office which is in another town to renew it it’s been a bit of a you know it hasn’t been easy for her to renew it but she was she was pretty disappointed and she was adamant and complaining and in an actual fact when I first heard this I liked this because I said this is civil society and this is people talking about their rights and this is people demanding what they want but I also thought her arguments were completely legitimate what she was saying is I have this card which told me I was supposed to have free mnch care but in actual fact when I go to my local clinic I don’t even know what that is because there’s no Midwife there nobody can deliver my baby then the second thing she said was I’ve got to take a taxi 40 kilometres to the big regional tertiary center out in Hawaii that’s fine but I’ve got to pay for a taxi and how is that free mnch care but not only that her biggest concern was if I go into labor in the middle of the night I’ve got to find a taxi to get myself out there and I really care about my health outcome and the birth outcome of you know my unborn child of one I’m going to give birth and so she was asking about you know what does this card actually provide that she was promised on free mnch care secondly what kind of financial protection does it provide when she’s still got to get taxis she’s got no guarantees there’s drug stock-outs in the local clinic and then finally is she even gonna get a decent birth outcome so what are the health outcomes that this this whole thing provides so of course this put us on you know okay we got to go check out the clinic and find out what their story is and when we went to the clinic basically what grace said was true there was one health care worker there the Midwife had been off for a month and fair enough I mean she’s entitled to a holiday in a break she was one Midwife serving this entire population and and I think the other thing is we have to be careful not to demonize you know clinics and come down on the enemas you don’t have drugs you don’t have health workers you don’t have those things but there was a real breakdown between the community and what that clinic provided and so this health worker who was frankly doing her best but not able to do much and so I said okay are you are you accredited under the Health Insurance Scheme she said yes we are and I said so what does that provide and she said well I know the drugs come from the National malaria control program so the prophylactic drugs under that come from there I know the vaccines come from Gavi I know some of the donors are providing the family planning so in actual fact this idea this continuum of care in this package of care wasn’t really the case the second thing she said is there’s not a midwife there’d only been ten deliveries in that clinic in the past quarter and that’s really low and that’s not what we expect but she said look I’m a health worker I’m doing my best the Midwife is doing her best in HIA doesn’t pay our salaries you know we’re paid our salaries from the Ministry of Health and the Ghana Health Service so again you’ve got that separation that there’s quality and all those expectations under NHIA when in actual fact your health worker is part of a completely different system and then secondly when I asked her I said so are you on the DRGs or the fee-for-service she said I don’t know and you know rightly so she was a health care worker she didn’t she didn’t really understand how the NHIA worked and you don’t expect I think low-level clinic health workers to know those things but what struck me was this massive separation between what the provider understands and knows about health insurance and what NHIA and what the Health Insurance Scheme says it provides all those things and so the message that goes out is you have a card you get free mnch care you go to your clinic and this is what you get and the reality was in this situation was that none of that was happening and there was levels of disappointment from the patient’s levels of disappointment from the providers and then certainly from the purchaser the NHIA obviously if those things aren’t working at that level they’re not content either so I want to talk a little bit about I hope that frames the discussion a little bit on purchasing and purchasing in relation to quality and so I think the purchasing part of the National well as you call it the Health System financing system the purchasing is that the interesting

aspect and the aspects about that and I think Katrina followed on from that is what you want to ask in purchasing is what you’re purchasing so what’s in that benefit packaging package who you’re purchasing from so what is the range of providers there and how are you purchasing that so I’ll go through that on the Ghana side is to the the experiment within Ghana so the benefit package and Ghana’s experience on the purchasing we know that there’s been a direct relationship with quality and and they’ve seen that although I would say that there hasn’t been a lot of monitoring and again we don’t really everybody has a different understanding of quality and what that quality means if you take a snapshot across gun and say are you getting a quality service if you ask different people you get very different answers but so so the actual package in Ghana again one package comprehensive covers the entire population and it’s seen as quite a generous package in the sense that 95 percent of outpatient conditions are covered the only exclusions are things such as like you know renal dialysis and cancer treatments and things like that which in actual fact you don’t really have those services in the first place so in principle you have your card most of the things if you walk into an accredited outpatient you should be able to have those services the issue has to do with and this is where the link is to quality is that NHIA isn’t actually responsible for all of those things there is a split between what the Ministry of Health provides as well as what NHIA provides and that split isn’t something that was that was a deliberate split NHIA wasn’t designed to do everything for all people it was designed to be an agency under the Ministry of Health providing a certain level of coverage and financial protection for its population but when you look at something like I guess first of all the prioritization so how do you cover your pup if you want to take that bird’s-eye view and say for the population we want to invest in the greatest Goods so things like primary health care and prevention well this is where the split becomes important because actually the Ministry of Health purchases a lot of those things you know the vaccines the the the basic commodities going out to clinics and it’s not just the Ministry of Health’s it’s a lot of donors I mean through global funds through Gavi and through all of us we say you know prevention primary health care and then that’s where we put our money so that starts to skew the NHIA towards much more of the curative and the tertiary sort of aspects and and also skewing much more towards the urban and wealthy because if you don’t have those things at the it’s your primary care center in a rural area you’re going to go to the biggest tertiary center I think secondly is the continuum of care and I talked about this a little bit with Grace’s stories there’s an assumption that you have a package but what’s provided across that package for the individual they don’t really know nor does the provider necessarily know so even though within that benefit package not everything is directly under the control of an HIA and then I think most importantly is the health worker salaries we know that in the dimensions of quality what what service your health worker provides you is a really important aspect of that but health worker salaries are linked to the Ministry of Health and the Ghana Health Service so there is not a direct relationship there and so that does have an impact on quality second aspect is who to purchase services from and I think this is another example where Ghana has been again quite bold and from the onset very very bright and very bold saying we know that people are not just going to a local clinic we know a lot of people are going to faith based services we know that a lot of different people are going to the private sector and we also know that the private sector isn’t one homogeneous group it’s you know 40 different things from your little drug seller to drugs all the way up to your services for the elites and so you want a package that can cover all of those because you recognize that your population goes to all of those for services the biggest issue is how do you create a level playing field across from those so how do you stimulate competition to make people want to be part of the scheme but then how do you make sure that it’s level for them and I want to give you two quick examples of this the public subsidized is primarily given through what’s called Chag which is the Christian Health Association of Ghana so again they’re part of the overall structure but they’re faith-based and they tend to serve rural

primary care areas now they’re taking on quite a high burden of an unhealthier population they take on a riskier part and they’re saying you’re reimbursing us at the same rate but we’re in actual fact not seeing the same patients and we’re not so if you under the DRG if you pay us all one flat rate we’re having to absorb a lot more of that we don’t feel feel that it’s fair private sector again stimulated by very different incentives again wants to see different things coming from that so I think we have to recognize that who we purchase it from matters in terms of quality because there are different incentives amongst all of those different providers and then finally how to purchase and this is about the payment provider services gun is experimented with three different models first was fee-for-service second was cut DRGs which of his diagnostic related groups and thirdly as capitation we’re currently at capitation and capitation has been a pilot in one region I think there’s a consensus that capitation will need to be rolled out across the country but there’s big questions as to how to do it well and how to maintain the support because it has been a bumpy ride within that particular region and introducing capitation I’ve already talked a little bit about that night I don’t want to go too much into the detail but you know fee for service about the coverage up it was volume based and input based DRGs was about you know making sure that you’ve got consistency across but both of those didn’t achieve cost containment so capitation was deliberately introduced to address cost containment but the issues really with with capitation are you know can you get the timely reimbursement can you get the accuracy and the forecasting right so the idea with capitation is you say okay you you have a primary provider and we’re gonna say that this population goes to this area and the idea is that we will forecast what you need and we will reimburse but it hasn’t been in an exact science it hasn’t been as accurate as it’s been thought and the reimbursement hasn’t been as ideal I think broadly all of those aspects are what we mean in relationship to quality so when we think about quality we know that purchasing what we purchase who to purchase it from and how we purchase it is one of the key drivers of quality and so this is something that we’re still sort of coming to terms with in Ghana I think it’s also fair to say that you’ve got various different stakeholders looking for different things and calling different things quality I mean obviously all of us have to achieve financial sustainability or you don’t have a scheme but that’s the key aspect of quality that a purchasers looking at but if you go all the way down to a patient I mean what grace would like to see for her card is you know she wants to see a comprehensive service she wants it to be affordable she wants it to be there at her primary care clinic and she wants it to be effective she wants to have a good birth out come and you can say okay that’s that’s a fair thing to expect as a patient but are the resources enough to ensure that across the whole of the population and so those are the sorts of trade-offs and the aspects of quality that ganas is grappling with so then just broadly to talk about the issues within health financing and national health insurance more broadly the opportunities and challenges going forward for Ghana I showed you in that little step graph as to where in HIA is today the biggest issue on everybody’s mind is financial sustainability because an actual fact to have an nhi a to have a scheme you have to have a financially sustainable model at the moment with expenditure outpacing it isn’t financially sustainable and so they’re looking at a number of different ways to do that but I think they’re grappling with the changing demographics and the increasing needs in the population as well as the different types of payment systems and the trade-offs those those entail and then I think one of the key drivers is you have to look at where’s the money going and upwards to half or more than half of the money and the national health insurance goes towards medicines and so how do we get and there seems to be two trends as one that there’s a over utilization and there’s a higher cost medicines in comparison to other countries around there so how do you actually address that aspects of medicines and the other thing is within all of those purchasing models medicines are separate so you can have capitation DRG all of these different things but medicines are separate from that and so there’s a real kind of meaty case of what we need to do specifically around the costs of medicines and that

being a key driver some of the challenges around the historical structural and the design issues have to do with the accreditation procedure and again you know so the public system is accredited and then you can say to the christen Health Association or private come on board be part of NHIA and their question is what do we get from it so what does it make sense for us to be accredited to do all of those things when in actual fact we have our patients we have our customers or clients and and you know we’ve got a system that’s largely working the other thing is there’s levels of accreditation so what stimulates you to be at the top of the accreditation or providing the best quality as a provider when in actual fact you only need to do the bare minimum so is accreditation the way forward or something like contracting possibly a different way to do that another area is a functional IT system and this really cuts across this has been something that I’ve learned about is I think having a functional IT system is is a complexity across everyone I don’t know those of you who are familiar with the US and the UK system but nobody’s got a functional IT system that works perfectly and Ghana’s trying to do this and asking all these questions but also gonna recognize this that having the functional IT system it’s something that could be really transformative within the package because what it can do is authenticate your users and so help with that time lag it can also make sure that the reimbursements happen much more in real time but the other thing is we don’t know where a lot of the leakage is happening and so in AI a good IT system can help you with all of those things so it’s quite an interesting and exciting area last two points is really about the evidence somebody in NHIA said to me Susan we don’t know the null hypothesis we went into this but we didn’t have a lot of data saying this is how bad the system is and this is what we’re going to achieve so there wasn’t a deliberate M&E system there wasn’t all of these things set up Ghana has started what I would suggest is a policy driven reform agenda but it hasn’t had the ability to have really good research really good evidence really good data collection to back it up and I think this is an area where donors and development partners can help it because they’re actually just scrambling to do the right thing this in the right way and keep that commitment going but there needs to be a learning that goes on with that and really I mean the issue on on evidence is we know now that national health insurance increases utilization so much so that you know everybody starts attending and then expenditure goes up but does that actually make a linkage to health outcomes and I think even in the most you know fantastic systems there’s really that there’s that huge difficulty in saying what does this mean in terms of a causal relationship with health outcomes we can’t really answer that but we want to get closer to answering that because for quality we really want to know is does this make a difference does this make a difference to the lives of the people not just do they turn up to a clinic but do they get the services at the clinic do they have you know safe childbirth and those things and particularly for the poor so those are those are the big issues that we’re all looking at and then I think I wanted to talk a little bit about universal health coverage because I think universal health coverage is is both a blessing and a curse in the sense that the NHIA started well before there was even this term of UHC an image ia was designed to do certain things for its population then you introduce this this global concept of universal health coverage and this is where we’re all going and then God is suddenly in the limelight but it’s got this system and here’s universal health out coverage and then now there’s all of these questions asked and holes you know picked in the system in all of this so universal health coverage has been a blessing in the sense that it actually helped you to define the areas you want to work on to improve the system but it’s been a curse I think to the extent to where it’s actually oversold the functions and the ability of the NHIA and almost over-pressured it if you if you come to Ghana and meet with the folks within HIA they’ll have a big smile on their face they’re welcome you but you can see they are running hot and they are doing everything they can and to keep the wheels from from moving off and so I think that there’s all of this global pressure because of universal health coverage and because Ghana is now seen as a model that they want they want it to be the reality in the shining example that it’s sometimes seen as and then finally I want to just quickly talk about the role for donors and development partners both within the context of NHIA but then broadly within health financing and this has been again Niels Neal stole my thunder well before and when he was talking about that now that Ghana is a middle-income

country our role as a funder is diminishing dramatically so we make the assumption that we come to the table and we say this is what you need to do and this is how you need to advocate and this is these are the kind of things you need to do but when in actual fact but their money diminishing there’s less about what we’re able to provide in terms of resources we’re still able to provide influence and advocacy but we need to very much ask the NHIA and ask our ministries of health is what ways can we help you advocate based on your priorities and your future vision within NHIA there’s I mean just to sort of give you a flavor of the tangibles we provide support to national health insurance through our sector budget support programme we also provide it through something called the army programme which is the oh I’m gonna get this wrong African health markets for equity and that is demand-side it is looking at certain aspects of NHIA and it’s it’s so the other donors are covering things they’re covering broad areas if it has a this is a centrally funded program the reason I don’t know as much about it is because it’s funded from London but I tend to work with the stakeholders there the other thing that it does is it actually has an IT platform and that’s the part that I’m really excited about but it is looking at private sector provision it is looking at demand side financing and so those are two aspects where we as differed have a niche within that and through the sector budget support what we want to say is actually with sector budget support we don’t want to over monitor eyes we don’t want to have to you know have them have massive reporting constraints it works out to being about 2 million pounds and somebody in the NHIA said Susan it’s great and you know we want donor funds but in actual fact when you look at the whole budget of NHIA we can get more through our inefficiencies and our cost containment rather than chasing after donor funding and writing proposals having to do in a knee frameworks and all of the things that you might require it’s not where our incentives are so if you can do something that benefits us that’s great but we can actually be more smart and savvy err about creating more efficiencies within the system so then more broadly within health financing I think there’s time ok three key areas health financing and and that’s through our sector budget support and we have this mantra that we want to be on budget and we want everybody to be together and all of this and we want to see efficiency gains but in actual fact the landscape and the architecture is changing dramatically we used to be one of five donors providing sector budget support and now we’re going to be one of the last ones and these these kind of old principles we have to continue to question where do we want to invest in the long term sustainability of a middle-income country secondly we want to see good primary health care and prevention because that’s obviously from our perspective that’s where you get the greatest gains but the important thing is we don’t want to hive those off you know it’s saying okay we donors are going to provide all of these things and then leave you to do the curative the expensive and the inefficient things so we need to have a clear understanding of how we do these priorities together as partners and then finally I think this just goes back to the final point about grace is having somebody like grace stand up and say I’ve got this card I’m not really sure what it provides me having good civil society is gonna be the key driver of what shapes and influences the health system so we as donors might and development partners might like to think you know we’ve got all of these ideas and we have all of this influence but when actual fact if it’s poor people and if the average population of Ghanaians can be the fundamental drive in helping the reform and reshaping the system that’s going to be the most powerful influence in what creates the sustainability of the system so that’s it but I just wanted to say in conclusion I mean again I I said I’ve been in Ghana for a short period of time I’m not a health economist but it’s an exciting time for me in Ghana because I think what they’re doing is I think they’re doing quite a bold experiment really and I mean it’s gone beyond experimentation and that it’s had 10 years I don’t think we know the answers but I don’t think there’s any health system that has it perfect and knows the answers so I think we see the Ghana both the NHIA and the health financing system is a very positive thing but with lots of questions about the futures where we need to know where our roles we can play and how we can best support something that had a very good start has a lot of potential towards the future but it just needs to be honed in this to where we can provide the best support that’s it thank you