Ghana introduced a national health insurance scheme (NHIS) in 2003. By 2006, the NHIS had been fully implemented in all the districts. It covers most of the health-insured people in Ghana (e.g., 99% of the health-insured population in 2012/13; see Ghana Statistical Service [GSS], 2014).
2.1 Institutional setting
There are four key players in the NHIS framework. The first is the Ministry of Health, which plays the stewardship role. The second and third are the Providers (health care professionals) and the Purchaser (NHIS). The last player is the Subscriber (residents). The Provider provides quality health services to the Subscriber. More than half of the NHIS-certified health facilities (54% in 2012) are state-owned (National Health Insurance Authority [NHIA], 2012). The NHIS aims to cover 95% of disease conditions fully. The Subscriber pays premiums to the Purchaser, who pays for the Subscriber’s utilised services when the Provider submits claims. Subscribers do not pre-finance covered services and medicines, meaning patient reimbursement is non-existent. The onus lies on the Purchaser to ensure that the Subscriber receives quality services. The main characteristics of the NHIS are presented in Table 2.
Enrolment in the NHIS is designed to be compulsory for all residents and at the individual level. Subscribers are either in the premium-paying or premium-exempt groups. In 2012, the premium-paying group (comprising informal sector workers) accounted for about 36% of NHIS Subscribers (NHIA, 2012). The Social Security and National Insurance Trust (SSNIT) contributors and SSNIT pensioners are premium exempt, as are persons under 18 years, over 69 years, pregnant women, indigents, and those with mental disorders.[3] The last three groups of people additionally have registration and renewal fee exemptions.
Registered members are issued a membership card. The card is valid for five years and can be used to check the Subscriber’s identity over that period. However, an (income-adjusted) premium must be paid annually to qualify for the NHIS-covered healthcare services and medicines.
Table 2 Summary of the NHIS design
Characteristics
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Year of introduction
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2003
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Legislative instrument
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Act 650
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Regulatory body
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National Health Insurance Authority
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Target population
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All residents, especially poor and vulnerable populations
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National coverage (year)
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33% (2010); 35% (2012); 38% (2013); 41% (2015); 35% (2017)
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Renewal rate (year)
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44% (2010); 75% (2013); 73% (2017)
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Deductible/coinsurance/copay
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Not applicable
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Benefit package/Treatment covered
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- Full coverage for 95% of disease conditions, including malaria, diarrhoea, upper respiratory tract infections, skin diseases, hypertension, asthma, and diabetes
- Covers medicines, general outpatient and inpatient services, maternity care, oral health, eye care, and emergencies
|
Excluded services
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HIV antiretroviral therapy, organ transplant, hearing aid, dentures, orthopaedics, cosmetic services, and VIP accommodation
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Provider choice
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NHIS accredited health facilities only (both private and public)[4]
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Provider payment mechanism
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- Fee for service (medicines)
- Capitation (outpatient primary care)
- Diagnosis-related groupings (inpatient services, outpatient specialist care; emergency care)
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Funding source
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National Health Insurance Fund, comprising:
- National Health Insurance Levy (2.5% of VAT, constitutes about 60% of the fund)
- Investment income (constitutes about 17% of the fund)
- 2.5 percentage points of monthly SSNIT contributions (contributes roughly 16% to the fund)
- Registration fees and Income-adjusted annual premiums (contribute less than 5% to the fund)
- Other sources (including government budget allocation, grants, gifts, and donations)
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Use of NHIS fund
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- Payment to healthcare providers on behalf of Subscribers
- Payment of NHIA administrative and general costs
- Enhance the provision of healthcare services via the health ministry
- Invest in programmes that enhance access to health services
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Premium exempt group
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Pregnant women, indigents, persons with a mental disorder, SSNIT pensioners, SSNIT contributors, persons over 69 years, and persons under 18 years
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Registration fee exempt group
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Pregnant women, indigents, persons with a mental disorder,
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Notes:HIV=human immunodeficiency virus; VIP=very important person; VAT=value added tax; SSNIT=Social Security and National Insurance Trust. Source: NHIA (2012); NHIA (2013).
2.2 Changes over time
In 2012, the government revoked Act 650 and replaced it with Act 852. The new law aimed to strengthen the NHIS, introduce transparency, eliminate administrative bottlenecks, control corruption, and enhance the scheme’s effective governing. Act 650’s review started in 2009, the same year the decoupling of children policy was introduced. Other significant changes to the system include provider payment reforms, revised medicine list, free maternal care, a mandatory NHIS, unified NHIS across districts, a premium exemption for persons with mental disorders, call centre, electronic claims management, electronic linkage of diagnosis to treatment, instant/biometric membership ID, a family planning package, mobile renewal policy, use of the national ID to access healthcare under the NHIS, an oversight committee for the scheme’s operation, private health insurance schemes, and fund management (Mensah, 2013). We detail selected reforms in the following paragraphs.
Healthcare provider payment reforms
Healthcare cost containment remains a global agenda. Provider payment method is a viable tool for addressing escalating healthcare costs (Alshreef, 2019). Some commonly used provider payment mechanisms in developed and developing countries are fee-for-service (FFS), diagnosis-related groupings (DRG), capitation, and global budget payment.
The FFS method reimburses healthcare providers for the quantity of services provided and is associated with supplier-induced demand. The DRG method categorises patients into groups. It determines an average treatment cost for related diagnoses to control hospital costs. Under capitation, a pre-determined advanced payment is made to providers to provide specific services to Subscribers over a defined period (e.g., a year). The global budget payment (a capitation) reimburses providers a fixed amount for a specific patient population over a particular time. The capitation, DRG, and global budget provider payment methods motivate healthcare providers to reduce the quantity of services supplied (Alshreef, 2019). Hence, they have the potential to control costs.
A Legislative Instrument, 2004 (LI 1809) charged the NHIA to apply a uniform payment method in reimbursing accredited providers. The NHIA adopted the FFS method in 2005 for healthcare services and medicines. A diagnosis-related grouping (DRG) payment method was introduced for outpatient and inpatient services in 2008 to control escalating costs due to the FFS. According to Andoh-Adjei (2021), no feasibility study preceded the switch from FFS to DRG. The method (DRG) worsened the escalating cost issues. Therefore, the capitation method was introduced for outpatient primary care in 2012. This decision was evidence-based. A group led by the Ministry of Health found that the DRG introduction increased outpatient services utilisation nationwide (Andoh-Adjei, 2021).
Revised medicine list
The NHIS provides a list of covered medicine, expected to be given to Subscribers at no fee. The list was reviewed and effected in 2021 (Refer to NHIA, 2021, for the new price list.) The current schedule has 532 medicines with unit prices in Ghanaian cedis and prescribing levels. The level of prescribing indicates the lowest healthcare delivery level that a particular drug can be administered. Healthcare providers in CHPS facilities can only prescribe medicines at the lowest level. Only specialists can give the specialist medicines (highest level). These protocols (medicine list and prescribing levels) aim for cost containment (Mensah, 2013).
A specialist group (comprising physicians, pharmacists, and a midwife), assisted by clinicians, developed the original NHIS medicine list based on evidence from health facilities. Following the World Health Organisation and Health Action International, the team obtained pricing data from a national survey of medicine prices. Both private and public facilities were considered. The survey intended to ascertain the reimbursable prices of the NHIS-listed medicines. The concentration was on medication for diseases covered under the NHIS. Therefore, medicines for healthcare programmes (e.g., inoculation, mental healthcare, and tuberculosis), medical devices and supplies, and anaesthetic agents are exempted (NHIA, 2021).
2.3 Value chain
This section draws from the NHIA’s 2013 annual report (see NHIA, 2013; Mensah, 2013).[5] The NHIS has four primary activities: membership registration and ID management, provider certification and quality assurance, claims management, and provider payment. The scheme aims to ensure financial risk protection against healthcare costs for all Ghanaian residents. By offering full cover for 95% of disease conditions, the scheme might reduce OOPHE. Subscribers who otherwise did not utilise healthcare services because they could not afford them can now use them. And the use of curative care when sick could have long-term effects on human capital formation. Lastly, the scheme could have unintended economic implications for low-income families if it reduces OOPHE.
2.4 Implementational issues
The NHIS encounters internal and external challenges. The internal challenges are financial stability issues and identifying the poor in the informal sector (see NHIA, 2013; Mensah, 2013; Wang et al., 2017). The external challenges include supply- and demand-side moral hazards, high cost of medicines, financial challenges with renewing cover, healthcare quality issues, and long waiting time. (Refer to NHIA, 2013; Wang et al., 2017; Nketiah-Amponsah et al., 2019; for a detailed discussion.)
The NHIA reports that the scheme’s main challenge is financial sustainability (NHIA, 2013). The insurance appears too ambitious, offering premium payment (and registration) exemption to more than 60% of its enrollees and promising full cover for 95% of disease conditions. Besides, the NHIA has failed to implement the compulsory enrolment policy among the informal sector workers (premium-paying group).[6] The scheme’s mandatory participation plan aims to make richer and healthier people pay more to cover the less healthy, poor, and vulnerable (NHIA, 2013). However, it actually attracts people with greater healthcare needs (e.g. disabled and older persons) since the informal sector has voluntary participation (van der Wielen et al., 2018; Khalid & Serieux, 2018; Salari et al., 2019). Unsurprisingly, registration and premium fees contribute less than 5% to the NHIS fund.
The NHIS struggles to reimburse healthcare providers, making them unwilling to continuously provide free services and drugs to Subscribers (Aryeetey et al., 2016; Okoroh, 2020). Hence, providers charge Subscribers for covered services and medicines and discriminate against them at healthcare facilities (Nketiah-Amponsah et al., 2019). The scheme’s participation dropped by three percentage points between 2013 and 2017 from an already low base. Most people, especially in the rural areas, had dropped out from the NHIS by 2017, citing “no money” as their primary reason for not renewing cover (Figures 2.1). “The premium is too high” was not among the four reasons most frequently cited for dropping out.
[3] The indigents are people without identifiable income source, employment, or place of abode.
[4] The NHIA provides accreditation to several health facility types, including Community-based Health Planning and Services (CHPS), maternity homes, health centres, clinics, polyclinics, primary hospitals, secondary hospitals, tertiary hospitals, pharmacies, licensed chemical shops, and diagnostic centres.
[5] The report is the most recent report published on the official NHIS website (see https://www.nhis.gov.gh/annualreports.aspx, accessed 11th May 2022), meaning up-to-date information on the NHIS is seldom available online. Understanding how the NHIS works in theory and practice is relevant for interpreting the results. Therefore, we visited Ghana with the intent to reach the key players in the NHIA office for more recent information about the NHIS. The bureaucratic procedure was discouraging, restricting the content of this paper to online sources, published works, and experts outside the NHIA.
[6] The SSNIT membership is mandatory for workers in the formal sector (private and public) but optional for the self-employed. Those in the informal sector are not compulsory SSNIT members, and it is they who are expected to pay the income-adjusted annual premium. Due to lack of data and income fluctuations, they pay a flat yearly premium ranging from GH¢15.00 in rural areas to GH¢22.00 in the cities (NHIA, 2013; Nsiah-Boateng & Aikins, 2018). This flat premium is regressive and overburdens low-income Subscribers.