Eight Years of National Health Insurance in Ghana: Evaluation of the Health Financing Sub-Functions

By Nsiah-Boateng, E.; Jousten, Alain | Current Politics and Economics of Africa, October 1, 2015 | Go to article overview

Eight Years of National Health Insurance in Ghana: Evaluation of the Health Financing Sub-Functions


Nsiah-Boateng, E., Jousten, Alain, Current Politics and Economics of Africa


INTRODUCTION

Ghana, a lower middle-income country in sub-Saharan Africa, introduced National Health Insurance Scheme (NHIS) in 2003 through an act of parliament, NHIS Act (Act 650) and Legislative Instrument (L.I 1809) [1, 2]. The NHIS is one of the key social sector initiatives to support the Ghana Poverty Reduction Strategy (GPRS) policy objective of ensuring sustainable financial arrangements that protects the poor. The policy objective of the NHIS states that:

"Within the next five years, every resident of Ghana shall belong to a health insurance scheme that adequately covers him or her against the need to pay out-of-pocket at point of service use in order to obtain access to a defined package of acceptable quality health service" [2].

Although this has not been fully achieved, the NHIS has made significant strides in population coverage, access to health care, mobilization of public and private resources to purchase health services, and contribution of revenue to health care providers [3, 4, 5].

Since 2005, a number of evaluation studies have been conducted on the NHIS; however, most of them focused on policy implementation, access and utilization of health services, and financial feasibility [6, 1, 7]. Therefore, little is known about performance of the NHIS in terms of the health financing targets of revenue generation, risk pooling, and purchasing of health care. The study sought to fill this gap by providing performance evaluation of the NHIS using Ashiedu Keteke District NHIS Office as a case study.

The Ashiedu Keteke District NHIS Office is one of the 10 NHIS district offices in the Greater Accra region. It is the smallest district office in the region in terms of catchment area. Like all the NHIS District Offices, the Ashiedu Keteke District Office embarked on its membership mobilization in 2005. It has 158,466 registered members, 12 accredited Health Service Providers (HSP), and a staff strength of 18 [8].

This study would provide important lessons for developing the NHIS to achieve its long-term goal of universal coverage. The lessons would also be significant to Ghana's quest to attain the MDGs 1, 3, 4, 5 & 61. In addition, this study would provide valuable lessons for other developing countries which are at early stages of health insurance development.

History of Health Care Financing in Ghana

Health care financing in Ghana has gone through series of reforms since independence in 1957 [2]. Over the period of 1957 and 1970, access to health care at public health facilities was free, entirely financed through tax revenue and external donor support [9]. In the early 1970s, sustainability of the tax financing system for health care became difficult as the economy began to shrink and competing demands on the same source increased. There were shortages of medicines and supplies which led to deteriorating quality of care and avoidable deaths [2]. In 1972, the government introduced low user fees at the point of service use in public health facilities to discourage unnecessary use of health care [1]. In 1985, as part of the Structural Adjustment Program (SAP), the government liberalized the health sector and raised the user fees, popularly known as "cash and carry." This was meant to recover at least 15% of the recurrent costs for improving quality [1, 10].

In the 1990s, the out-of-pocket payment for health care at the point of service delivery posed financial barrier to health care access to many Ghanaians especially the poor and vulnerable. Indeed, it was estimated that out of 18% of the population who needed health care at any given time, only 20% of them were able to access it [11, 2]. That is, about 80% of 18% of the population who needed health care could not afford to pay out-of-pocket at the point of service use. This resulted in delays in seeking health care, non-compliance to treatment, and premature deaths. In response, Non-Governmental Organizations (NGOs) established Community-Based Health Insurance Schemes (CBHIS) with support from international donors including DANIDA and Partnership for Health Reform-plus (PHR-plus) [1,9]. …

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