Something old or something new? Social health insurance in Ghana

Abstract

BackgroundThere is considerable interest at present in exploring the potential of social health insurance to increase access to and affordability of health care in Africa. A number of countries are currently experimenting with different approaches. Ghana's National Health Insurance Scheme (NHIS) was passed into law in 2003 but fully implemented from late 2005. It has already reached impressive coverage levels. This article aims to provide a preliminary assessment of the NHIS to date. This can inform the development of the NHIS itself but also other innovations in the region.MethodsThis article is based on analysis of routine data, on secondary literature and on key informant interviews conducted by the authors with stakeholders at national, regional and district levels over the period of 2005 to 2009.ResultsIn relation to its financing sources, the NHIS is heavily reliant on tax funding for 70–75% of its revenue. This has permitted quick expansion of coverage, partly through the inclusion of large exempted population groups. Card holders increased from 7% of the population in 2005 to 45% in 2008. However, only around a third of these are contributing to the scheme financially. This presents a sustainability problem, in that revenue is de-coupled from the growing membership. In addition, the NHIS offers a broad benefits package, with no co-payments and limited gate-keeping, and also faces cost escalation related to its new payment system and the growing utilisation of members. These features contributed to a growth in distressed schemes and failure to pay outstanding facility claims in 2008.The NHIS has had a considerable impact on the health system as a whole, taking on a growing role in funding curative care. In 2009, it is expected to contribute 41% of the overall resource envelope. However there is evidence that this funding is not additional but has been switched from other funding channels. There are some equity concerns about this, as the new funding source (a VAT-based tax) may be more regressive. In addition, membership of the NHIS at present has a pro-rich bias, and a pro-urban bias in relation to renewals. Only a very small proportion is registered as indigent, and there is some evidence of 'squeezing out' of non-members from health care utilisation. Finally, considerable challenges remain in relation to strengthening the purchasing role of the NHIS, and also settling debates about its structure and accountability.ConclusionSome trade-offs will be necessary between the existing wide benefits package of the NHIS and the laudable desire to reach universal coverage. The overall resource envelope for health is likely to be stable rather than increasing over the medium-term. In the longer term, the investment costs in the NHIS will only be justified if it is able to increase the cost-effectiveness of purchasing and the responsiveness of the system as a whole.

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

“…The consequence is increased cost resulting from increasing utilisation paid for from the mostly tax-based financing sources, which seems to grow more slowly than enrolment and consequent use. 13 Problems of fraud and corruption were argued to be particularly evident in the early stages of implementation of the Scheme (in the form of what participants described as client/provider shopping) with some indication from interviewees that there has been improvement in more recent years. The study acknowledges that fraud is a challenge for insurance systems the world over.…”

“…Thus, the main goal of the NHIS is to make healthcare affordable to all by removing OOP payment at the point of service, and to achieve equity of access based on need, rather than ability to pay. 1,12,13 The scheme is financed from several sources including earmarked tax (2.5% value added tax -hereafter referred to as VAT), 2.5% of the 17.5% of formal sector employees' contribution to Social Security and National Insurance Trust (SSNIT), budgetary allocation, donations, investments, grants and annual contributions from informal sector employees and formal sector employees who do not contribute to SSNIT. Membership is open to all residents of Ghana upon subscription to the scheme (exception being Ghana armed forces and police service, and those with proof of holding a private health insurance scheme).…”

“…For instance, some studies have shown dramatic increases in patient utilisation of health services and coverage , especially, by the poor and the disadvantaged in Ghana following the introduction of the NHIS. 13,16 Such increases in utilisation have, however, not only put pressure on the available facilities in hospitals but also pose serious challenges to managers of hospitals as increases in workload; over-stressed staff, have affected quality of care. 1,17,18 A number of studies report greater accessibility and fairly high levels of satisfaction with the system.…”

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

“…34,35 Because of the immense benefits inherent in prepayment health-care financing methods, quite a number of African countries have embraced it, and this have been proven as an effective means of achieving universal health coverage. 34,36 As part of the efforts to achieve universal coverage, the NHIS in Nigeria was established, which commenced operations some years ago. However, this study showed that a negligible few of the respondents were aware about and also reported paying for health care through the scheme.…”

Raising more domestic money for health: prospects for low- and middle-income countries

“…In the same vein, Ghana and Chile increased the VAT rate and specifically earmarked the additional VAT percentages to fund their health insurance programs (Witter and Garshong, 2009). Zimbabwe has since 1999 imposed an additional 3% tax on the income of formal sector employees as a national AIDS levy raising $26 million in additional revenue in 2011, enabling 70,000 Zimbabweans to access antiretroviral therapy (UNAIDS, 2012).…”