The “Universal” in UHC and Ghana’s National Health Insurance Scheme: policy and implementation challenges and dilemmas of a lower middle income country

Abstract

BackgroundDespite universal population coverage and equity being a stated policy goal of its NHIS, over a decade since passage of the first law in 2003, Ghana continues to struggle with how to attain it. The predominantly (about 70 %) tax funded NHIS currently has active enrolment hovering around 40 % of the population. This study explored in-depth enablers and barriers to enrolment in the NHIS to provide lessons and insights for Ghana and other low and middle income countries (LMIC) into attaining the goal of universality in Universal Health Coverage (UHC).MethodsWe conducted a cross sectional mixed methods study of an urban and a rural district in one region of Southern Ghana. Data came from document review, analysis of routine data on enrolment, key informant in-depth interviews with local government, regional and district insurance scheme and provider staff and community member in-depth interviews and focus group discussions.ResultsPopulation coverage in the NHIS in the study districts was not growing towards near universal because of failure of many of those who had ever enrolled to regularly renew annually as required by the NHIS policy. Factors facilitating and enabling enrolment were driven by the design details of the scheme that emanate from national level policy and program formulation, frontline purchaser and provider staff implementation arrangements and contextual factors. The factors inter-related and worked together to affect client experience of the scheme, which were not always the same as the declared policy intent. This then also affected the decision to enrol and stay enrolled.ConclusionsUHC policy and program design needs to be such that enrolment is effectively compulsory in practice. It also requires careful attention and responsiveness to actual and potential subscriber, purchaser and provider (stakeholder) incentives and related behaviour generated at implementation levels.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1758-y) contains supplementary material, which is available to authorized users.

Prevalence of diabetes among homeless and slum dwellers in Accra, Ghana: A survey study

“…[15] Patients with diabetes mellitus will require regular visits to health care facilities for medical care which could be very expensive for individuals, families, society, health professionals and could have effects on national productivity [16]. The national health insurance scheme (NHIS) in Ghana has been helpful in reducing the cost of health care in the country, however, the country is still struggling to achieve NHIS's goal of universal health care because many members do not renew their insurance policies annually, [17] especially the homeless men and women including the "Kayayei" who cannot afford to renew their policies because of financial constraints and lack of awareness of existence of exemption policies if any.…”

Analysis of the implementation of a social protection initiative to admit the poorest of the poor to mutual health funds in Burkina Faso

“…The advent of UHC, which involves strategies adapted to each category of the population, has aroused interest in mutual health schemes among governments. For example, Ghana and Rwanda have supported the establishment of “progressive compulsory membership” schemes (Letourmy, ; Agyepong et al, ). However, in French‐speaking West Africa, the uptake of such mutual schemes has never reached more than 10 per cent of the target population (De Allegri, Sanon and Sauerborn, ).…”

To: Plos One Knowledge, experiences and perceptions of the Ghana National Health Insurance Scheme in three districts

“…Act 650 established the National Health Insurance Authority (NHIA) – which has 10 regional offices and 159 District Mutual Health Insurance Schemes (DMHISs) – as the implementer of the NHIS. The DMHISs act as agency offices and are responsible for registration, card processing, revenue generation through premium collection, reimbursement of service providers and community engagement [9,16,17]. The Scheme is now widely recognised as a good pro-poor Social Health Insurance scheme [14,18].…”

“…Membership is compulsory for all persons living in Ghana based on an annual renewable system. This is however currently not being enforced [6,17,20,21]. At the point of registration, potential enrolees provide biometric information, which then serves as their identification within the system [16].…”

“…Enrolees are either premium-exempted or premium-paying. The premiums are set by the DMHISs, usually higher for urban and lower for rural populations, but within a range determined by the NHIA [6,17, 20,21]. An inclusion list of inpatient, outpatient and emergency services is covered at full cost by the curatively-inclined NHIS Benefits Package with no prior authorization before member access [3,22,23].…”