Ghana's national health system under strain

Designed to provide a basic level of health care coverage for everyone in the country, the Ghana National Health Insurance Scheme (NHIS) is an ambitious programme. It has been in place since 2003 and has helped many receive insurance protection that they would not otherwise have been able to afford. For the average Ghanaian, the scheme is often the first introduction to risk coverage and is helping to increase awareness and acceptance of insurance.

History

For a time following independence, the government provided direct health care to the citizens of the country, but as Ghana began to face economic hardship in the 1980s more of the burden was placed on the users of medical services. The so-called cash-and-carry system became dominant, and people were more or less on their own when it came to paying for medical treatment. The NHIS was established in 2003 to provide everyone in the country with some form of protection. It is a hybrid system, incorporating public, private and mutual programmes to meet the medical needs of a variety of individuals. The NHIS is funded from a number of sources: a tax on a number of goods and services, a portion of social security contributions, premiums which range from GHS7.20-58 ($2-16) per year and donor funding. It provides coverage for the majority of diseases and is provided premium-free to certain individuals. The elderly, low-income earners and pregnant women are insured without cost.

Biometric

In 2013 the NHIS started to issue biometric membership cards. They were tested in two pilot regions first before being rolled out more generally in the Accra area in 2015. The cards are good for five years and are considered more secure than the documents they are replacing. The information on the cards includes a membership number, date of issue, expiration date, a card serial number and an address code. While the cards will eventually improve the delivery of services, their introduction has been characterised by confusion, low-level corruption – with individuals paying others to wait in the long lines to get the cards – and technical issues related to the network, according to the local press.

Registration

The NHIS insures about 10.14m people in the country, an increase from 1.35m in 2005. But this is only about 38% of the entire population despite the fact that everyone is supposed to be registered with the scheme. Largely speaking, the people who are in the system tend to be those who are exempt from paying premiums. An estimated 70% of the participants get their coverage for free. This makes the system unstable and in need of significant funding beyond the premiums.

To address this imbalance the government is working to sign up more people who would pay in to the system to make the programme more like insurance than social support. The reason for the lack of participation largely has to do with the difficulty of reaching the informal sector – individuals who make enough to pay the premium but who are difficult to track. Research indicates that cost is a major problem for the NHIS. A paper published in early 2015 by the International Journal for Equity in Health found that people with low incomes would be required to commit a significant portion of their incomes to pay the premium and were thus less likely to participate, with larger families being particularly affected. Similarly, there are low participation rates among the wealthier segment of the population, which puts limitations on revenue streams and further exacerbates the issue of financing health care.

The sector also suffers from a dearth of relevant and up-to-date statistics for the country, which would allow for more effectively designed insurance polices. Mel Constant Kebe, Saham Insurance Ghana’s managing director, told OBG, “Ghana’s life insurance industry requires a local mortality table in order to price risk effectively. At the moment, life insurance companies in Ghana rely purely on mortality tables that come from South Africa, the CIMA region or even the UK or the US.”

Payments

In mid-2014 press reports noted that some pharmaceuticals companies have stopped selling to Ghana Health Service, which manages health services for the government, due to non-payment of previous bills. Due to this, some hospitals are attending to patients, but not offering them medication. For many, the NHIS is simply not working and providing very little care, according to press reports. Alongside systemic shortfalls, participants complain of long queues when applying for membership cards, and then long waits to receive their cards, and ultimately substandard care once they are part of the system. Some patients report that they end up paying for treatment privately as that is the only way they can see a doctor quickly and receive effective medication.

According to local press, hospitals are not receiving reimbursements from the NHIS because the government has not released funds owed to the scheme. This could, legislators say, lead to a refusal of coverage and an effective collapse of the system. The scheme has been running a deficit since 2009 and had an estimated funding gap of GHS299m ($83m) in 2014, and this is expected to increase to GHS347m ($96.3m) in 2015 and GHS803m ($222.8m) by 2018. As of May 2015, NHIS arrears totalled GHS460m ($127.7m). By mid-2015, NHIS investments covered only one month of expenses, down from nine months in 2008.

In March 2015 the Society of Private Medical and Dental practitioners ordered its participants to stop accepting NHIS cards due to non-payment. After the announcement, the members of the organisation would only take cash payments for services. The Universal Access to Healthcare Campaign (UAHC) has said that the current system is unsustainable and that the government is taking funds from individuals but not providing services in return. The group added that the system is devolving toward a cash-and-carry programme. “There is a huge gap between resources mobilised and financing for the NHIS,” said Archibald Adams, deputy coordinator of the UAHC campaign. “Ghanaians cannot be levied for NHIS while the scheme totters towards a collapse.”

Possible Restructuring

The government has recognised the problem and vows to take action. According to Seth Terkper, minister of finance, GHS1.6bn ($444m) was remitted to the NHIS is 2013 and 2014, but due to economic problems and high expenses at the government level, it has been difficult for all required transfers to be made to the programme. He also said the government would make efforts to deal with the arrears, but could not promise when the payments would be up to date. President John Dramani Mahama said in April 2015 that the government has an obligation to make sure the NHIS survives and has promised to find alternative means of funding, adding that a review is under way.

The troubles have resulted in talks about restructuring the NHIS. According to comments made to the local press by government officials, the government is looking at bailing the programme out and redesigning it. This could result in a re-examination of the capitation system which is currently in use. In June 2015 Alex Segbefia, minister of health, said that the entire system would be overhauled. He also mentioned in a speech that he would be working to get the private sector more involved in the provision of some services under the NHIS programme.