In 2003, only 20 percent of Ghanaians had access to the care they required. In response, Ghana established a National Health Insurance Scheme (NHIS) to protect the population against the risk of catastrophic healthcare expenditure. As a key social protection policy, the NHIS has come to represent an important plank in Ghana’s medium-term poverty reduction strategy. It is key to achieving the country’s health goals.
Ghana’s National Health Insurance Scheme, created to establish equitable and universal access to good quality healthcare, is a hybrid. The system leverages the strengths of the private-for-profit, private-not-for-profit, and public sectors for healthcare provision, using lessons learned from pilot community health insurance schemes that operated before its establishment to shape its successful design.
The NHIS has seen rapid growth, attributable to its reliance on this mix of resources, and in the process it has significantly contributed to poverty reduction and achievement of national health goals.
The NHIS is regulated and supervised by the National Health Insurance Authority (the Authority), an agency of the Ministry of Health. It has established three ways to provide financial access to healthcare for the population (see below).
1. District Mutual Health Insurance Schemes
Public schemes promoted by and set up as companies (limited by guarantee) by district assemblies; the key operational arms of Ghana’s decentralized governance system.
2. Private Mutual Health Insurance Schemes
Promoted and set up by private persons as companies limited by guarantee without a motive for profit.
3. Private Commercial Health Insurance Schemes
Promoted and set up by private persons as limited liability companies with a motive for profit.
As of June 2011, 145 District Schemes had been set up. A further 10 satellite District Schemes are expected to be set up by the end of 2011. In 2008, the first private health insurance schemes were licensed; since then, five more schemes have been added to further increase coverage.
Ghanaians who do not belong to the two types of private health insurance schemes can become members of District Scheme, and there is no restriction on citizens belonging to one type of private health insurance scheme joining the other.
The quick growth in membership of District Schemes over the years is attributable to several factors:
- Significant commitment by district assemblies to establish District Schemes as establishment of schemes was a key performance indicator for district chief executives.
- Sense of community ownership of District Schemes.
- Decoupling children from their parents for the purpose of membership in District Schemes.
- Implementation of a maternal policy that provides immediate and free coverage for pregnant women.
- Extensive public education.
- Bipartisan political support following the establishment of the NHIS.
Notwithstanding the proliferation of private health insurance schemes in the past few years, membership in District Schemes accounts for over 98 percent of the population with access to one form or the other of health insurance.
District Schemes are funded from the following sources:
- Premiums paid by informal sector members.
- Consumption tax (2.5 percent).
- Social security contributions (transfer of 2.5 percentage points).
- Returns on investment.
- Sector budget support.
- Private health insurance schemes rely solely for their funding on premiums paid by their members. They are not entitled to subsidies from the National Health Insurance Fund.
- The benefit package offered by District Schemes is comprehensive, covering up to 95 percent of disease conditions in Ghana.
Private health insurance schemes are free to determine their benefit packages, but require the approval of the Authority to offer such packages to their members.
Both District Schemes and Private Schemes are free to select their healthcare service providers from the public, private-not-for-profit and private-for-profit sectors. This approach proved pragmatic, considering Ghana’s healthcare infrastructure, and it has also afforded schemes an opportunity to procure services in a way that engenders efficiency.
The accreditation of healthcare service providers started in 2005 with the granting of blanket accreditation to public, mission- and faith-based healthcare providers, as well as the grant of provisional accreditation to private healthcare providers based on a minimal documentation, as a means to ensure a quick roll-out of the scheme. As of December 2008, 1551 private and over 3,000 public and mission providers had been accredited.
In 2009, the Authority developed a set of accreditation tools which formed the basis of a full-fledged accreditation system. The tools are organized into 12 modules:
- Range of services
- Environment and infrastructure
- Basic equipment
- Organization and management
- Safety and quality
- Outpatient services
- Inpatient services
- Maternity services
- Specialized services
- Diagnostic services
- Pharmaceutical services
The provider payment system of choice for District Schemes at the point of establishment of the NHIS was fee-for-service. This payment system lent itself to easy use as most stakeholders were experiencing health insurance for the first time. Over time, other more complex systems of provider payment have been implemented or are being piloted. A Diagnosis Related Groups system was implemented in 2008 and a capitation system is expected to be piloted in a selected region of the country in the third quarter of 2011.
Notwithstanding the NHIS’s successes since its inception, it faces significant challenges. NHIS project managers and staff have outlined pragmatic steps for addressing the issues that most threaten to derail the program. They include difficulties in identifying and covering some categories of the poor and vulnerable; complex and unclear governance structures that sometimes make regulation, supervision and implementation difficult; inadequate capacity on key technical issues; challenges to sustainability of the scheme; increase in moral hazards; computerization of operations; and quality of care issues.
The Authority is in the process of finalizing a plan to directly address these challenges, and to evolve an agency that meets the original policy objectives. The plan aims to enhance the financial sustainability through additional sources of funding, cost containment strategies, prudent fund management and a mix of payment mechanisms as well as:
- Increase membership by effectively identifying and covering the poor and vulnerable and increasing enrollment within the informal sector.
- Contribute to securing universal access to healthcare through implementation of a mandatory basic health insurance scheme.
- Review the legal framework for the implementation of the NHIS to ensure improvement in governance and implementation.
- Improve computerization of operations through better specification, improved project management, and effective Information and Communication Technology governance.
- Improve quality of healthcare services through an update of accreditation tools, post accreditation monitoring, and strategic health sector investments.
- Shorten claims processing and payment turnaround time.
- Strengthen audit and risk management systems as well as reward and sanctions regimes to reduce incidents of fraud and abuse.
- Increase capacity in key technical areas.
In Africa and other developing regions of the world where healthcare reforms have become top priority for governments, Ghana’s experiences implementing a national health insurance scheme could hold valuable lessons. Not only has Ghana’s approach resulted in significant improvements in access to healthcare, it has also helped strengthen quality assurance systems and a provided a space for the development of a fledgling private sector in the healthcare industry.
Ghana’s success is attributable to political commitment, innovation, attention to local context, and experiential learning. The United Nations Development Program recognized this in 2010 when it cited Ghana’s health insurance scheme as a model for south-south cooperation, citing its attributes of being demand-driven, country-owned, innovative, efficient, sustainable, scalable and for possessing in-country leadership.