In many cases the countries which rushed into such schemes without proper consultations and discussions with stakeholders reported low enrolment, insufficient risk management, poor quality health care, high overhead costs and cost escalations
By Rattan Khushiram
Universal access to good quality health care remains a major concern of health systems globally. In view of this, countries have adopted different health financing mechanisms including a National Health Insurance (NHI) to ensure universal access to quality basic health care. Here, government has announced that soon after this year’s Budget it will be implementing a Government Medical Insurance Scheme (GMIS) for the public service.
health insurance systems have been implemented with varying outcomes in different countries. The operational and financial sustainability of these health insurance interventions has been a major challenge to many of the low- and middle-income countries. For instance, in many cases the countries which rushed into such schemes without proper consultations and discussions with stakeholders reported lack of clear legislations, low enrolment, insufficient risk management, poor quality health care rendered to NHI-insured clients, weak managerial and monitoring capacity, high overhead costs and cost escalations that were key operational challenges threatening the financial sustainability of NHI schemes.
Some of our stakeholders are already concerned with the indecent haste with which the national health insurance is being implemented. They have ample questions that need to be answered on whether there are sufficient guarantees for the government to properly carry out its role as steward; for our healthcare providers, whether public or private, to offer care according to certain professional standards; for consumers on the flexibility of the scheme and the extent of coverage: inpatient/outpatient/tertiary care, or catastrophe cover, etc. At the same time, the costs and implementation modules have yet to be worked out. The (administrative) efficiency and sustainability of the scheme as well as its impact on the level of health system responsiveness should also be examined.
Jayen Chellum of ACIM is concerned that, in the absence of regulatory oversight for standards, private sector hospitals can try to game the system by upping their tariffs/prices of services. So, while people will be getting low-quality services despite government spending the money, the net gainers will be insurance companies and private hospitals. Thus, it is critical that before launching any major scheme, the necessary problem areas have to be identified and addressed. Institutional reform by way of the establishment of an Authority is necessary to carry out the various functions required to implement the GMIS, such as standard setting, monitoring for quality, minimizing unnecessary hospitalisation, etc.
With ageing populations, the huge demand will need to be sustained and effectively contained with strong regulations on price, quality and gate keeping. Thus, a robust regulatory system for quality and price control, supported by periodic technical and social audits, would be needed to ensure that the imperfect market mechanisms of private health care provision do not lead to inappropriate or unduly expensive care.
What about outpatient care, especially drugs? Will these be covered? If the latter is covered, how are we to ensure that the stakeholders — physicians, pharmacists, patient, etc., — do not influence the outcome? We are aware that physicians may have the incentive to increase the number of visits of patients; the prescribers and the pharmacists would be encouraged to prescribe unnecessary and expensive medicines. And insurers on their part could influence outpatient visits by levying a high deductible on the patients.
In addition, the administrative cost of managing drug reimbursements could be a nightmare for insurers, as it involves low-value but high-frequency transactions. And our prescribers and chemists have the habit of prescribing and dispensing drugs in expensive branded names.
Should we keep out outpatient care and drug reimbursement out of the health insurance programme, considering the problems of its practical implementation and the difficulties of enforcing medicine reimbursement to patients which could prove to a fiscal strain to the coffers of government? These are just some of the issues that need to be discussed and attended to before we can even think of implementing the GMIS.
Averting the possible predicament of a half-baked GMIS with its glaring inadequacies that are exposed even before the scheme comes into operation, will largely depend on concerted efforts of key stakeholders such as health insurance managers, service providers, insurance subscribers, trade unions, policy makers and political actors to put in place the solid foundations before the GMIS is effectively launched.
* Published in print edition on 24 May 2019