Problem Statement: The inclusion of new services onto health benefit packages without ascertaining the implications of the additional costs, can affect the financial sustainability of health financing institutions.

Description: The benefit package (BP) of the National Health Insurance Scheme (NHIS) of Ghana covers about 95% of disease conditions occurring in the country. It operates with an explicit exclusion list but often receives requests for coverage of these excluded services. A review of the BP was however approached with caution in the interest of sustainability. In 2018, the National Health Insurance Authority (NHIA) in collaboration with its partners, built a new actuarial model that allowed for projections of the costs of adding new benefits to the package to be made. The new model provided a granular assessment of the future sustainability of the NHIS by modelling the financial impact of additional services that were being proposed, such as family planning, childhood leukemia, prostate cancer, breast and cervical cancer screening and sickle cell treatment using hydroxyurea. The actuarial model utilised NHIS claims and membership data, information from Global Burden of Disease Studies, national population data, budget forecasts of the Ministry of Finance and NHIS income and expenditure data to model projections. The results of the study indicated that the NHIS would remain sustainable with its current financial inflows if clinical family planning services, four childhood cancers (Acute Lymphoblastic Leukemia, Burkitt’s Lymphoma, Retinoblastoma and Wilms Tumour) and sickle cell treatment with hydroxyurea were included in the BP. Following on this, the NHIA added these services to the BP for reimbursement under the scheme.

Lessons Learned: The use of a robust actuarial model to assess available funding and project the capability of a health insurance scheme to support further BP inclusions is a prudent strategy to ensure financial sustainability.

Stakeholder perspective: Payer.