Source:NHIA

The National Health Insurance Scheme (NHIS) is leveraging the Ghana National
Electronic Pharmacy Platform (E-pharmacy) to combat illegal charges, commonly referred to as co-payments.

Co-payment in the NHIS context involves NHIA-credentialed facilities charging
scheme members for services and medications paid for by the Scheme.

The NHIA’s Chief Executive, Dr. Da-Costa Aboagye, shared this information
during a series of staff durbars held across the country, where he engaged with
employees on enhancing the Scheme and his welfare enhancement plans.
The most recent gathering occurred last Friday at the Authority’s head office in
Accra.

Dr.Da-Costa Aboagye, CEO NHIA
He appealed to all credentialed facilities and staff members to support his vision of eliminating illegal charges.
Dr. Aboagye emphasized that ending this illegality is a shared responsibility,
urging staff and other stakeholders to refrain from aiding such acts and to remain
vigilant against facilities that perpetuate these practices.
He underscored the necessity of this effort for the Scheme’s sustainability and the
jobs of all staff members.
He indicated that co-payments represent a significant concern for the Authority
and NHIS beneficiaries, as they often lead to unexpected out-of-pocket expenses
for services and medications fully covered under the NHIS

He noted that such practices create barriers to access and undermine the NHIS’s
core objective of ensuring equitable healthcare for all.

He reiterated that the NHIS covers diagnosis and treatment for 95 percent of
primary healthcare needs, and the NHIS expects that no scheme member will incur additional charges for these services and medications.
“Unfortunately, despite extensive efforts and awareness creation, illegal charges
continue to persist, especially in the dispensing of prescribed medications to
members.

“As part of my commitment to address this issue and enhance the performance of
the Scheme and health outcomes, the E-pharmacy policy is currently being
integrated with the NHIS. It is currently being piloted in the regions of the North, with plans for a nationwide rollout to follow.”

E-pharmacy Policy
Elaborating on the E-pharmacy initiative, Dr. Aboagye explained that the policy
requires that if a credentialed pharmacy, whether within a healthcare facility or
standalone, does not have prescribed medication in stock, it must upload the
prescription to the E-pharmacy platform.

“This enables the system to locate another credentialed facility within the
member’s community that has the medication available, allowing the member or
patient to be directed to that location for collection.
“Alternatively, with the assistance of the property addressing system, the
medication can be delivered to the member at home in line with terms and
conditions,” he said.

He said the E-pharmacy is currently being piloted in the regions of the North, with plans for a nationwide rollout soon.

He explained that the integration of this digital platform with the NHIS will
significantly reduce opportunities for illegal charges on medications that should be covered. Members can verify the availability of their medications in real time,
ensuring they are not pressured into making unauthorized payments.

“This move aligns with our mandate to protect beneficiaries and ensure that all
services covered under the scheme remain free at the point of delivery,” he
emphasized.

“This approach not only promotes collaboration among pharmacies but also
ensures that patients can receive their medications without undue delay,” he said.Other Benefits

The NHIA Boss said the E-pharmacy initiative also promises to utilize real-time
data to track medication dispensing patterns across pharmacies.

He said that capability will empower the NHIS to identify and address
discrepancies in co-payments more effectively.

“By centralizing the pharmacy services, the NHIA can swiftly address cases of
non-compliance among accredited facilities, implementing sanctions as necessary
to uphold the integrity of the Scheme.

“The E-pharmacy integration is expected to increase transparency and
accountability within the scheme, easing the financial burden on NHIS members.
This effort is part of the NHIA’s broader agenda to streamline service delivery
under the NHIS and expand access to quality healthcare

“By tapping into digital solutions like the E-pharmacy platform, the NHIS hopes to significantly reduce illegal charges and enhance the overall experience for NHIS
subscribers.

Dr Aboagye said this initiative comes at a critical time as the NHIS seeks to
enhance its effectiveness and sustainability. The NHIS is designed to provide
comprehensive healthcare coverage to the entire population.

“Co-payment has become a major challenge for our scheme. We are committed to
addressing this issue through systems, enforcement, and meaningful engagements
with service providers,” he said.
Co-payment Drivers / Solutions

Dr. Aboagye said the co-payment issue has long been a concern for the Authority
and NHIS members, who report frequent charges at hospitals and pharmacies.
He noted that some health facilities have cited delays in claim payment and low
tariffs for medications under the NHIS, compared to market prices, as reasons for
charging NHIS members additional fees.

Insisting that no reason justifies illegality, the NHIS appreciates their concerns and has worked hard to ensure prompt payment of claims.
“In tandem with the E-pharmacy initiative, the NHIS has been proactive in
addressing payment delays that have contributed to the co-payment issue,” he said.Dr. Aboagye noted that the government has made substantial financial
investments to bridge payment gaps and improve service provider tariffs, ensuring
that healthcare facilities can operate sustainably without resorting to illegal
charges

Dr. Aboagye reported that the government, through the NHIA, has been proactive
in ensuring that all submitted and vetted claims are paid promptly. “We have
worked hard to ensure that there are no outstanding claims.

“Currently, we have paid up to August and are calling on NHIA-credentialed
facilities to submit their claims for prompt vetting and payments,” he said.
He said by streamlining the reimbursement process, the NHIA aims to eliminate
the financial pressures that can lead healthcare providers to impose illegal charges.

These efforts are designed to ensure that healthcare facilities can operate
sustainably without resorting to illegal charges.
“Our commitment to addressing the issue of co-payments is a significant aspect of our reforms,” Dr. Aboagye affirmed.
Tariffs

On Low tariffs, Dr. Aboagye stated that while the Authority has been collaborating with stakeholders to frequently review tariffs to help service providers break even,
it is currently working around the clock to ensure an automatic tariff adjustment
policy that will address their concerns.

“Currently, the tariffs in force are based on consensus by all stakeholders and
therefore, while we have ensured that claims are paid promptly, we expect that no member is charged any additional fees.

“This is illegal and will soon be punishable by law. Currently, service providers do not have any moral grounds to continue charging NHIS members for any service
and medication on the inclusion list of the NHIS.

“The NHIA’s commitment to eliminating co-payments is part of a broader strategy to enhance service delivery and improve access to quality healthcare for all
Ghanaians,” he said.
Background

The E-pharmacy platform, which officially launched in January 2023 following a
successful six-month pilot, has been welcomed by both the government and
stakeholders in the pharmaceutical industry.
Vice President Dr. Mahamudu Bawumia, who played a pivotal role in the
initiative’s development, expressed his enthusiasm for the convenience it will bring Ghanaians.

The platform enables registered pharmacies to offer a streamlined process for
uploading and purchasing prescribed medicines. Upon registration with their
Ghana cards, these medicines can then be delivered directly to patients’ homes.