Assessing equity in health care through the national health insurance schemes of Nigeria and Ghana: a review-based comparative analysis

Abstract

BackgroundNigeria and Ghana have recently introduced a National Health Insurance Scheme (NHIS) with the aim of moving towards universal health care using more equitable financing mechanisms. This study compares health and economic indicators, describes the structure of each country’s NHIS within the wider healthcare system, and analyses impacts on equity in financing and access to health care.MethodsThe World Bank and other sources were used to provide comparative health and economic data. Pubmed, Embase and EconLit were searched to locate studies providing descriptions of each NHIS and empirical evidence regarding equity in financing and access to health care. A diagrammatical representation of revenue-raising, pooling, purchasing and provision was produced in order to analyse the two countries’ systems.ResultsOver the period 2000–2010, Ghana maintained a marked advantage in life expectancy, infant mortality, under-5 year mortality, and has a lower burden of major diseases. Health care expenditure is about 5% of GDP in both countries but public expenditure in 2010 was 38% of total expenditure in Nigeria and 60% in Ghana. Financing and access are less equitable in Nigeria as, inter alia, private out-of-pocket expenditure has fallen from 80% to 66% of total spending in Ghana since the introduction of its NHIS but has remained at over 90% in Nigeria; NHIS membership in Nigeria and Ghana is approximately 3.5% and 65%, respectively; Nigeria offers a variable benefits package depending on membership category while Ghana has uniform benefits across all beneficiaries. Both countries exhibit improvements in equity but there is a pro-rich and pro-urban bias in membership.ConclusionsMajor health indicators are more favourable in Ghana and overall equity in financing and access are weaker in Nigeria. Nigeria is taking steps to expand NHIS membership and has potential to expand its public spending to achieve greater equity. However, heavy burdens of poverty, disease and remote settings make this a substantial challenge. Ghana’s relative success has to be tempered by the high number of exemptions through taxation and the threat of moral hazard. The results and methods are anticipated to be informative for policy makers and researchers in both countries and other developing countries more widely.

Payment for Health Care and Perception of the National Health Insurance Scheme in a Rural Area in Southwest Nigeria

“…36 The situation of the low performance of the scheme in Nigeria could be attributed to many factors among which is that at present, health insurance is voluntary, whereas it is mandatory in Ghana. 35,37 Sensitization and therefore awareness and knowledge about an issue or activity usually precede arousal of interest and possible active participation in such an activity. 23,30 In this study, awareness about the NHIS or any prepayment scheme was very low as only 6.4% of them reported having heard about it for the first time through the radio or the TV.…”

The Politico-Economic Challenges of Ghana’s National Health Insurance Scheme Implementation

“…[19][20][21][22] Equity in healthcare through the NHIS of Nigeria and Ghana has also been the concern of Odeyemi and Nixon's study, where they noted that in spite of Ghana's uniform benefits across all beneficiaries and improvements in equity, there is a pro-rich and pro-urban bias in membership. 23 The effects of the NHIS on healthcare utilisation has also engaged the attention of researchers with evidence that individuals enrolled on the scheme are more likely to obtain prescriptions, visit clinics and seek formal healthcare when sick. 24 The conclusion, therefore, is that government's objective of increasing access to the formal healthcare sector has at least been partially achieved.…”

Determinants of attending antenatal care at least four times in rural Ghana: analysis of a cross-sectional survey

“…In 2004, the Ghanaian government introduced a policy to ensure free medical care for pregnant women via the Ghana National Health Insurance Scheme (NHIS) [18], which aims to offer women, particularly those in rural areas, the opportunity to seek maternal health services [19]. It includes a comprehensive exemption package that provides ANC, skilled delivery, and postnatal care services [20].…”