Healthcare is the backbone of every nation. Governments everywhere have taken the health sector as a priority sector. In the wake of the COVID-19, the healthcare delivery system has received some level of attention. The global pandemic has exposed inefficiencies and overwhelmed healthcare systems globally. In 2003, the Government of Ghana decided to improve health coverage and access and thereby introduced a social intervention known as the National Health Insurance Scheme (NHIS).
One of the primary goals of Ghana’s NHIS was to increase the affordability and utilisation of drugs and health services in general among the poor and vulnerable populations, in particular. Ghana’s NHIS was created by the National Health Insurance Act (Act 650) of 2003 and became one of very few attempts by a sub-Saharan African country to implement a national-level, universal health insurance program. Since its introduction, the scheme has helped mobilize revenue for providers, thus, helped in health financing. Health service utilisation has also increased significantly and out-patient visits per capita increased abruptly after 2005, the same year NHIS operations began. The introduction of the NHIS experienced a massive improvement in life expectancy and infant mortality, under-5-year mortality, with the country having a lower burden of major diseases.
For life expectancy, Ghana had 58 and 59 years for males and females, respectively, in 2000, in 2010. It increased to 63 and 65 years for males and females, respectively. A recent survey indicated that about 50 percent of Ghanaians are registered on the Scheme. The majority of these are the working class, poor and vulnerable in the underserved rural communities who cannot afford an alternative scheme like the private mutual health insurance scheme.
Whilst Ghana’s NHIS has gained admiration within the sub-Saharan African region, it is still challenged in many ways. The scheme’s challenges can be grouped into those faced by service providers, government, and Subscribers’. Findings from research work carried out across five regions in Ghana; Ashanti, Central, Eastern, Greater Accra and Northern regions in 2021 by CUTS International, Accra in collaboration with Open Society Initiatives for West Africa (OSIWA), titled: “Making the National Health Insurance Scheme Work for the People” revealed the following challenges from different stakeholders of the scheme:
Service providers’ perspective (Pharmacies & Health Facilities)
They mentioned certain major challenges. These include; delays in government payments to service providers; non-transparency and lack of information on the coverage of the scheme; frequent policy review under successive governments has contributed to the lack of clear policy direction of the scheme; price quote difference between pharmaceutical and the NHIS regarding the sale of drugs; and cumbersome claim processes and procedures.
The more than 50% of Ghana’s population who are subscribers’ of the Scheme mentioned the following as their key issues; poor service delivery from health workers to NHIS subscribers; more out-of-pocket expenses mainly for drug prescription, laboratory test and scan; no redress mechanism for lodging concerns and addressing same; refusal of health facilities to offer services, including drugs that fall under the scheme; fraud and collection of unapproved fees by healthcare workers; lack of information on key terms, conditions, subscribers’ rights and entitlement under the scheme; and there is limited coverage of diseases under the scheme, delays in registering and receiving the NHIS card, and limited NHIS registration centres in rural areas
Issues of insufficient funding emanating from difficulties in tax mobilization and premiums have contributed to the delay in payments by the government; fraudulent and dishonest activities by some subscribers and service providers by making claims for unsubscribed relatives or conniving with healthcare workers to make claims for services not provided. These fraudulent activities have contributed to inefficiencies and a lack of trust in the scheme. Some subscribers try to outsmart the system by using different names and biographic data to register multiple times, thus creating data integrity issues with the central database. This also allows the same person to access healthcare using different names and at various facilities systems.
From the survey, the following key recommendations were made to the National Health Insurance Authority and relevant policymakers were:
The scheme needs to overcome challenges of limited funds for provider reimbursements and administrative activities; improve quality of health care and insurance services to enhance subscriber trust and increase utilisation of NHIS services. There is also the urgent need to establish a Monitoring & Evaluation desk to check activities of health facilities and registration centres, this will prevent health workers from charging unapproved fees from subscribers and improve the patient-health worker relationship.
More to the point, National Health Insurance Authority (NHIA) ought to conduct a regular needs assessment to identify lasting goals and insurance needs of subscribers’ and to constantly design products to meet these goals and needs. NHIA should consider expanding the coverage of the scheme to cover life-threatening diseases and major surgeries like prostate cancer, dialysis, diabetes, kidney/ renal/ liver tests and treatment. Lastly, the NHIA should often organise workshops and media Sensitization programmes to educate subscribers on their rights and entitlements under the scheme.
The writer is with CUTS International Accra, a research and public policy Think Tank in Accra. For more information visit (www.cuts-aacra.org)