The newly built headquarters of the National Health Insurance Authority. Some 18 million Ghanaians have registered for the national health insurance scheme.

Millions more people in Ghana have access to health care than they did a decade ago thanks to the country’s successful health insurance scheme. But its strength has also revealed a number of weaknesses in the system.

Ghana’s National Health Insurance Scheme (NHIS), introduced in 2003-2004 to replace the former “cash and carry” system of healthcare financing, has gained a global reputation as one of the best examples of such a programme in low and middle-income countries, particularly in Africa.

The progress made by Ghana’s NHIS is remarkable taking into consideration the difficulties that accompanied its introduction. First and foremost, Ghana had to grope around in the dark in setting it up because there were no examples from the developing world to learn from. Also, the attitude of so-called development partners was particularly discouraging as they insisted that the nascent scheme should only involve formal sector workers. When the government decided that it would make provision for all Ghanaians to be a part of it, most felt this was a recipe for failure since countries that had already implemented health insurance programmes had started with the formal sector first and only included other workers much later on. But today the likes of the World Bank are eager to be associated with the NHIS; the latter is currently supporting the scheme with a $15 million investment aimed mainly at improving the NHIS’ ICT platform as well as to build capacity at the local level.

Mr Sylvester Mensah (left), CEO of the NHIA

Moreover, no international conference on healthcare financing takes place without reference to Ghana’s success story. After registering 1.3 million Ghanaians by the close of 2005, it now has more than 18 million people on its books, a phenomenal achievement when compared with much older equivalents in other countries. The figure includes those who receive free healthcare under the scheme - including children under the age of 18, pregnant women and the elderly. Research conducted by the National Development Planning Commission in 2008 showed clearly that an overwhelming majority of Ghanaians welcomed the arrival of the NHIS. While the scheme must be congratulated for making healthcare available for a large number of people who would not have been able to afford it under the old cash and carry system - by which people paid at the point of service - the increased use of health services has highlighted the country’s inadequate healthcare infrastructure and shortage of trained staff.

The NHIS itself is not without its problems and the amount it has to pay out on claims from service providers is one of them. In December 2009, the National Health Insurance Authority (NHIA) established its Clinical Audit Division to examine all claims, including some that had been already vetted and paid for. After finding evidence of fraud, it went on to recover as much as GH¢17 million in 2010.

The audit additionally unearthed serious deficiencies in quality of care, including the prescribing of medication by unqualified personnel. Over-prescription of medicines was also found. With drugs alone constituting roughly half of all claims, one can understand why this has created such a financial haemorrhage.

As from January, all NHIS service providers are required to use a “special” prescription form in which the prescribers’ full identity and affiliated hospital or clinic must be provided. It is hoped that this new measure will discourage service providers from defrauding the system.

The way the NHIS is financed has not changed since its inception in 2003 despite the subsequent increased use of healthcare services, with the National Health Insurance Levy (NHIL) being the largest single source of funding.

NHIS is making health delivery affordable

Ghana’s GDP grew by a record 13 per cent in 2011 and is expected to continue to make a strong showing this year. Since the amount of money the NHIL generates is a function of the economy, it is envisaged that a minimal I per cent increase will generate enough income to meet future liabilities. Other possible sources of funding include the imposition of a small percentage on motor vehicle insurance premiums. Under the NHIS benefits package, motor vehicle accident victims are treated free of charge. Since the country has one of the worst road accident rates in the world, a modest increase in premiums would bring in extra money, as would so-called “sin taxes”, which are taxes imposed on products such as alcohol and cigarettes.

Lastly, the government, through routine budgetary allocations, should provide the additional funding required to plug the gaps. While the problem of funding shortfalls needs to be seriously addressed, it has transpired that last year the Ministry of Finance diverted almost GH¢93.6million from the proceeds of the NHIL to other areas. Analysts are insistent that the financial sustainability of the scheme must be confronted head-on by both the NHIA and the government working together. That said, the NHIA has already launched cost-containment measures aimed at blocking some of the more worrying leakages in finances. One significant step is the piloting of the “capitation” programme in the Ashanti Region, which was scheduled to begin this month.

With the introduction of the NHIS, the “cash-and-carry” health system has been consigned to history

The Korle Bu Teaching Hospital, Ghana’s premier hospital

Under capitation, each subscriber will be tied to a particular service provider for primary healthcare, which normally operates on an outpatient level. If there is a need for higher level care, the capitated service provider will refer the patient to an appropriate facility, having been given funds in respect of each registered subscriber for a specific period of time. The service provider must manage the funds as effectively as possible in order to provide optimum healthcare to all subscribers under their care and within the timeframe.

Hitherto, subscribers were free to roam from one service provider to another regardless of the cost this might entail for the NHIS, particularly with regard to medication, consultation fees and laboratory investigations. Under capitation, the NHIS has the responsibility to regularly and promptly provide funds to service providers on behalf of subscribers. Capitation will run alongside the present payment systems of Ghana-Diagnostic Related Groupings (G-DRGs) and Fee for Service for secondary and tertiary care. In another effort to save money, the NHIA is taking steps to strengthen the ICT platform to improve subscriber authentication. It is doing so with the help of the World Bank.

This would not only deter service providers from submitting bogus claims based on fake patient identities, it would also put paid to the practice of NHIS users going from hospital to hospital for treatment, sometimes on the same day, with all the attendant cost implications for the scheme.

The NHIA has also established a state of the art facility in Accra to vet and process claims from the country’s 10 regional hospitals and three teaching hospitals as well as a small number of selected specialist hospitals with a large subscriber base, with a view to setting up similar centres in other regions this year and also train extra staff to ensure an expert workforce. Other initiatives such as linking treatment to diagnosis, the administration of the “gatekeeper system”, which mainly enforces the referral regime put in place by the Ministry of Health, and measures to ensure quality of care for subscribers should all significantly contribute to making the NHIS more financially efficient.

An additional programme being launched this year is the One-Time Premium Payment. Since 2004, informal sector subscribers have been paying graduated amounts of between GH¢7.20 and GH¢48.00 into the scheme. The rate is based on the economic viability of a particular district and has remained unchanged. Informal sector subscribers have to renew their membership yearly through the payment of contributions, also called premiums, in order to continue accessing healthcare. But defaults on membership renewal have been widespread. This perhaps explains why many Ghanaians are looking forward to One-Time, which is being rolled out as part of new National Health Insurance Scheme legislation.

Premiums collected from informal sector subscribers contribute about 4.5 per cent to 5 per cent of the NHIS’ total income. In real money terms, this amounts to between GH¢20 million and GH¢25 million a year. It is envisaged that the introduction of One-Time Premium will slightly increase contributions. However, this is election year and the programme has already become a political hot potato, with the two main parties arguing over its rationale. It is hoped that the government will find the right mix of policy to move it forward, thereby enabling the NHIS to continue to play its frontal role in providing Ghanaians with quality healthcare well into the future.