A Critical Review on Ghana’s Health Insurance Policy: Systemic Barriers

 Ghana is one of the first African countries to aim for universal coverage (Skolnik, 2016).  The National Health Insurance System was developed in 2003 as an attempt to address the financial barriers for Ghanaians to access health care services (Ministry of Health, 2004; Skolnik, 2016).  The National Health Insurance Policy (NHIP) was created in 2004 to make the National Health Insurance System happen (Ministry of Health, 2004).  This policy did not quite accomplish what it was set out to do.  This critical analysis will discuss why NHIP was created, its overall effectiveness, and explore systemic barriers it has created that causes Ghanaians not to be able to access health care services fully.  The systemic barriers that will be discussed are accessibility and culture.  Future implications for each systemic barrier will also be discussed.

 Thesis statement: This critical analysis will analysis the NHIP, explain its effectiveness and explore systemic barriers it has created towards accessing health services.  Accessibility and culture barriers are systemic barriers that will be discussed.     

Before National Health Insurance Policy

 Ghana is a lower middle-income country that has a checkered history in financing health care (Ministry of Health, 2004; Skolnik, 2016).  When Ghana was under colonial rule, health care was mostly catered to colonials and their workers (Mcintyre et al., 2008).  When Ghana became independent, the health care system switched to providing health care “free” to all Ghanaians through tax revenue (Ministry of Health, 2004).  The health care system struggled because the economy was beginning to decline and there were other competing forces for the tax revenue resource (Ministry of Health, 2004).  Ghana by 1985 introduced user fees for those who received services from the health system (Ministry of Health, 2004; Skolnik, 2016).  The implementation of user fees became known as the “cash and carry system” in Ghana (Ministry of Health, 2004; Skolnik, 2016).  The “cash and carry system” created a financial barrier for the poor to access health care services (Ministry of Health, 2004).  About 18% of Ghana’s population requires health care at any given time (Ministry of Health, 2004).  Only 20% out of the 18% mentioned can access health care services (Ministry of Health, 2004). This indicates that around 80% of Ghanaians cannot afford health care if needed (Ministry of Health, 2004).  

National Health Insurance Policy

 The National Health Insurance System was developed in 2003 to replace the “cash and carry system” to take down financial barriers (Ministry of Health, 2004). The NHIP was developed in 2004 to make the National Health Insurance System happen (Ministry of Health, 2004).  The NHIP’s vision is to develop health insurance schemes that can guarantee unbiased and universal access to health care for all Ghanaians (Ministry of Health, 2004). 

The National Health Insurance System is financed by different sources (Alhassan, Nketiah-Amponsah, & Arhinful, 2016). Taxes on certain goods and services, a small amount from Social Security, and the National Insurance Trust help finance the insurance system (Alhassan et al., 2016).  The National Health Insurance System also gets funding from premiums, donor funds, grants, donations, gifts, and interest from investments (Alhassan et al., 2016).  The money collected funds the health insurance schemes that the NHIP’s implements (Ministry of Health, 2004).        

There are three health insurance schemes that the NHIP developed that Ghanaians can choose to be a part of (Ministry of Health, 2004). The three health insurance schemes are District Mutual Health Insurance Schemes, Private Mutual Health Insurance Schemes, and Private Commercial Health Insurance Schemes (Ministry of Health, 2004). The District Mutual Health Insurance Scheme makes every district develop a health insurance scheme to recruit residents to register as members (Ministry of Health, 2014).  This health insurance scheme is a not for profit and is a decentralized system that is owned by the members of a district (Ministry of Health, 2014).  Any surpluses made at the end of the year will be put back into the health insurance scheme to reduce contributions or enhance the benefit package (Ministry of Health, 2014).  The District Mutual Health Insurance Scheme receives subsidies from the government (Ministry of Health, 2014).

Private Mutual Health Insurance Scheme is where any group of Ghanaians can develop their own health insurance plan (Ministry of Health, 2004).  Such groups that can develop their own health insurance plans can be religious groups, occupational based groups, or community-based groups (Ministry of Health, 2004).  Private Mutual Health Insurance Schemes do not receive subsidies from the government (Ministry of Health, 2004).

Private Commercial Health Insurance Schemes are owned by companies and are made to make a profit (Ministry of Health, 2004).  The calculated risks for groups or individuals that are part of this health insurance determines the cost of premiums (Ministry of Health, 2004).  Companies can offer different health insurance plans and benefit packages with the Private Commercial Health Insurance Scheme (Ministry of Health, 2004). 

The National Health Insurance Council will coordinate, facilitate, and regulate health insurance schemes to implement the NHIP to make the National Health Insurance System a success (Ministry of Health, 2004). The National Health Insurance System and the NHIP, however, have been under critical review.  The following section will discuss the effectiveness and systemic barriers in relation to the NHIP.

Critique

Effectiveness

 The NHIP that implemented the National Health Insurance System in 2004 has made notable achievements in making health services more accessible by addressing financial barriers (Gajate-Garrido & Owusua, 2013; Ministry of Health, 2004).  Less than 1% of the Ghanaian population was enrolled in an insurance scheme when there was no National Health Insurance System (Gajate-Garrido & Owusua, 2013). Seven years after the creation of the National Health Insurance System the number rose to 33% of the Ghanaian population enrolled in an insurance scheme (Gajate-Garrido & Owusua, 2013).  The number of health facilities rose from 1,672 to 3,344 between 2008 to 2011 (Gajate-Garrido & Owusua, 2013).  The use of outpatient care services increased from 0.6 million in 2005 to an impressive 25.5 million in 2011 (Gajate-Garrido & Owusua, 2013).  Inpatient utilization care services also rose from 28,906 to 1,451,596 in between 2005 and 2011 (Gajate-Garrido & Owusua, 2013).  The National Health Insurance System made a significate change in reducing the impact of financial barriers on accessing health care services.

  Different trends were observed in Ghana between 1995 to 2014 when Ghana started putting more money into health care (Adua, Frimpong, Li, & Wang, 2017).  Ghana’s life expectancy between 1995 and 2014 rose from 60.7 to 64.8 years of age (Adua et al., 2017).  The positive changes with increased life expectancy can be traced to the health system in place but also aspects such as education, social structures, income distribution, and lifestyle changes (Adua et al., 2017).  The infant mortality rate in Ghana decreased from 72 out of 1000 live births to 44.2 out of 1000 live births between 1995 and 2014 (Adua et al., 2017).  The mortality rate of children under five reduced from 111 out of 1000 live births to 78 out of 1000 live births in Ghana between 1995 and 2014 (Adua et al., 2017).  Decreased mortality rates can be linked to the health system and the implementation of different policies (Adua et al., 2017). 

 The NHIP contributed to Ghana’s improvement in life expectancy and mortalities rates.  Unfortunately, despite the contributions by the NHIP and the National Health Insurance System to life expectancy and mortality rates, Ghana is doing poorly compared to first world countries (Adua et al., 2017). For example, in 2014 Canada had a life expectancy of 81.96 years which is impressively higher than Ghana’s 64.8 years (Adua et al., 2017).  Canada’s under-five mortality rate and infant mortality rate are five out of 1000 live births and four out of 1000, respectively (Adua et al., 2017).  Ghana had an infant mortality rate of 44.2 out of 1000 live births which is high compared to Canadas five out of 1000 live births (Adua et al., 2017).  Canada’s under five mortality rate is four out of 1000 which is significantly lower than Ghana’s 78 out of 1000 live births (Adua et al., 2017).

 The NHIP helped many Ghanaians overcome financial barriers to access health services.  Despite the NHIP’s accomplishments, there are weaknesses in coverage, health care quality, and financial sustainability (Alhassan et al., 2016).  The benefit package covers diagnostic testing, specialist care, most surgeries, hospital accommodations, oral health treatments, maternity care services, emergency care and some drugs (Blanchet, Fink, & Osei-Akoto, 2012).  The benefit package, unfortunately, excludes coverage in some expensive surgeries, treatment for most cancers, organ transplants, and dialysis (Blanchet et al., 2012). 

 The NHIP may have improved access to health care but it did not improve the quality of health care (Alhassan et al., 2016).  After the implementation of the NHIP, the health system has created more pressure on the staff and health infrastructure (Alhassan et al., 2016).  This extra pressure caused longer waiting times and non-adherence to professional standards (Alhassan et al., 2016).  The staff also started to charge illegal fees on patients because of the extra pressure on the system (Alhassan et al., 2016).

 The NHIP is not financially sustainable (Alhassan et al., 2016).  More than 60% of people in the National Health Insurance System are not paying for premiums because they are in the exemption category (Alhassan et al., 2016). The NHIP is not financially sustainable because of the high number of people not paying for premiums and the increasing costs of medical supplies and health service delivery (Alhassan et al., 2016). 

 The NHIP weaknesses are it has a limited benefit package, created negative pressure on the health system, and is not financially stable (Alhassan et al., 2016).  The NHIP has weaknesses and has created and has systemic barriers such as accessibility and culture.  These systemic barriers impact the older adults, the poor, and women.  

Systemic Barriers

 Accessibility.  One of the principles in the NHIP is equity (Ministry of Health, 2004).  The principal equity states that all Ghanaians regardless of socioeconomic status should have access to health insurance and those with health insurance should never be denied access to health services (Ministry of Health, 2004).  Despite such a promising principle the NHIP failed to make health insurance accessible to older adults especially older adults living in rural areas (Van der Wielen, Channon, & Falkingham, 2018).  The NHIP does exempt individuals over aged 70 and over from paying premiums but the exemption is moot if the benefit package does not address health needs of older adults and if health care services are not physically accessible (Van der Wielen et al., 2018).  Emergencies, oral health, eye care, and maternity care are some services that are covered in the benefit package (Van der Wielen et al., 2018).  Dentures, home care, and hearing aids are health services that older adults need but are unfortunately not covered in the health benefit package (Van der Wielen et al., 2018). The NHIP needs to make a benefit package more applicable to older adults to provide beneficial health care (Van der Wielen et al., 2018). 

Health care services need to be physically accessible to older adults.  The enrollment rates older of adults in rural areas are low because of transportation and mobility issues (Van der Wielen et al., 2018).  Older adults in rural areas are more likely to be enrolled in health insurance if they live within five kilometers of a health care facility (Van der Wielen et al., 2018).   To improve the accessibility for older adults to health care services, the NHIP should consider improving health care services in rural areas and consider providing home treatment (Van der Wielen et al., 2018).  

In the NHIP there is a heavy focus on equity (Ministry of Health, 2004).  The policy states that regardless of socio-economic status, everyone should be able to have access to health insurance (Ministry of Health, 2004).  Cross-subsidization is another NHIP principle that indicates that insurances schemes will be paid by premiums that are based on how much a person can pay (Ministry of Health, 2004).  To provide health insurance to the poorest segment of the population exemptions to paying premiums were applied in an attempt to provide health care services to them (Ministry of Health, 2004).  Ironically, the policy failed to provide health insurance that is accessible to poor Ghanaians (Kotoh, & Van der Geest, 2016).   A study found that richer Ghanaians have a higher enrolment rate than poorer Ghanaians (Kotoh, & Van der Geest, 2016).  Two reasons for the low enrolment rates in poorer Ghanaians are poverty and the lack of commitment by policy makers to implement the NHIP equity goal (Kotoh, & Van der Geest, 2016).  The poor cannot pay for the yearly premiums because many of them are not able to afford them due to unstable incomes (Kotoh, & Van der Geest, 2016). 

The poorest of the population are not getting exceptions because the criteria outlined excludes them (Kotoh, & Van der Geest, 2016).  The criteria state that the poor people that can be excluded from paying premiums are those who are unemployed and do not have a permanent residence (Kotoh, & Van der Geest, 2016).  In Ghana, the poorest of the population do have residences and jobs (Kotoh, & Van der Geest, 2016).  However, the residences are with friends, family or poor housing and the jobs are seasonal, menial, or lacking (Kotoh, & Van der Geest, 2016).  The criteria outlined excluded almost every poorest person in Ghana (Kotoh, & Van der Geest, 2016).  The reason why policy makers had this in the criteria is that in 2011 about a third of Ghanaians were below the poverty line (Kotoh, & Van der Geest, 2016).  The government would have to pay 35 million dollars a year to cover all the premiums of people living in poverty (Kotoh, & Van der Geest, 2016).  The criteria were set there by policy makers to make it look like to voters that the government was providing health care to the poor and to lessen the financial burden (Kotoh, & Van der Geest, 2016). 

If policy makers were serious about implementing the NHIP to target the population living below the poverty line they would change the exclusive criteria to the community’s definition of core poor (Kotoh, & Van der Geest, 2016).  The District Mutual Health Insurance Scheme is not addressing its poor in communities like it is supposed to (Kotoh, & Van der Geest, 2016).  The District Mutual Health Insurance Scheme staff are not enrolling people because the staff does not get paid to enroll the exempt group and the concern for not getting revenue to support the exemption groups (Kotoh, & Van der Geest, 2016).  The staff’s attitudes and the policy’s criteria are barriers for the poor to access health insurance (Kotoh, & Van der Geest, 2016).  To overcome these barriers, it is recommended that the District Mutual Health Insurance Scheme staff get paid when enrolling the exempt group so that there is not a focus on revenue generation (Kotoh, & Van der Geest, 2016).  It is also recommended to policy makers to invest in the District Mutual Health Insurance Schemes because of the economic cost of prolonged illness that will affect the country’s future development (Kotoh, & Van der Geest, 2016).  

Culture. The NHIP failed in addressing cultural gender roles (Dixon, Luginaah, & Mkandawire, 2014).  Women and men in Ghana have distinct culture roles that impact their choices in reenrolling for health insurance every year (Dixon et al., 2014).  A Ghanaian woman’s main responsibilities are fending for her children and family (Dixon et al., 2014).  Women are more likely to drop out of the National Health Insurance System if they are food insecure and do not have reliable incomes (Dixon et al., 2014). Cultural norms for women with lack of resources dictate that feeding and caring for children and family has a higher priority than reenrolling for insurance (Dixon et al., 2014).  Despite that the National Health Insurance System provides free enrollment for children under 18, women still need to pay for processing and renewal fees for their children (Dixon et al., 2014).  Women are expected to pay for processing and renewal fees for each of their children every year and are also likely to be responsible to pay for school uniforms and food and other basic family needs (Dixon et al., 2014).  These extra financial responsibilities can pressure a woman to not reenroll for health insurance (Dixon et al., 2014).   

Men, on the other hand, are more likely to drop out of the National Health Insurance System if they are not satisfied with the health insurance scheme (Dixon et al., 2014). Ghanaian men are not as influenced by socio-economic factors as much as women are in choosing to drop out of the National Health Insurance System (Dixon et al., 2014).  Men in Ghana are more financially independent and are pressured less to pay for the daily needs of the family (Dixon et al., 2014).  Gender roles play a huge part who spends on what resources (Dixon et al., 2014).

The NHIP must take into consideration the gender roles in society to fulfill its principle to provide universal health care.  To address the extra financial responsibilities that Ghanaian women have, policy makers should be finding ways to help poor women to continuously stay enrolled in health insurance (Dixon et al., 2014).  Such ways to keep poor women enrolled in health insurance are flexible payment plans or changing payment exemption statuses (Dixon et al., 2014). 

Conclusion

 The NHIP did not quite accomplish breaking down financial barriers for all Ghanaians.  More and more Ghanaians since the NHIP came into effect have been enrolled in an insurance scheme (Gajate-Garrido & Owusua, 2013).  Unfortunately, the NHIP had weaknesses and shortcomings.  The weaknesses were the benefit package did not provide the full needs of the population, poor quality health care, and the health system is not financially stable (Alhassan et al., 2016). NHIP’s shortcomings were the systemic barriers that it created the prevented certain parts of the population from accessing health services.  Ghana has made big leaps to provide health care to the people and with research and teamwork, Ghana can keep working on providing universal health care to all Ghanaians.    

References

• Abiiro, G., & McIntyre, D. (2012). Achieving universal health care coverage: Current debates in Ghana on covering those outside the formal sector. BMC International Health And Human Rights, 12(1). doi: 10.1186/1472-698x-12-25
• Abiiro, G., & McIntyre, D. (2013). Universal financial protection through National Health Insurance: A stakeholder analysis of the proposed one-time premium payment policy in Ghana. Health Policy and Planning, 28(3), 263-278.
• Abuosi, A., Domfeh, K., Abor, J., & Nketiah-Amponsah, E. (2016). Health insurance and quality of care: Comparing perceptions of quality between insured and uninsured patients in Ghana’s hospitals. International Journal For Equity In Health, 15(1). doi: 10.1186/s12939-016-0365-1
• Adua, E., Frimpong, K., Li, X., & Wang, W. (2017). Emerging issues in public health: a perspective on Ghana’s healthcare expenditure, policies, and outcomes. EPMA Journal, 8(3), 197-206. doi: 10.1007/s13167-017-0109-3
• Alhassan, R. K., Nketiah-Amponsah, E., & Arhinful, D. K. (2016). A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects? PLoS ONE, 11(11), e0165151. Retrieved from http://link.galegroup.com.uml.idm.oclc.org/apps/doc/A471845754/HRCA?u=univmanitoba&sid=HRCA&xid=ba20143d
• Blanchet, NJ., Fink, G., & Osei-Akoto, I. (2012). The Effect of Ghana’s National Health Insurance Scheme on Health Care Utilisation. Ghana Medical Journal. 46(2):76-84.
• Bonfrer, I., Breebaart, L., & Van de Poel, E. (2016). The Effects of Ghana’s National Health Insurance Scheme on Maternal and Infant Health Care Utilization. PLOS ONE, 11(11). doi: 10.1371/journal.pone.0165623
  • This study provided an insight on how the policy impacted mothers and infants and poor families. 
• Dixon, J., Luginaah, I. N., & Mkandawire, P. (2014). Gendered inequalities within ghana’s national health insurance scheme: Are poor women being penalized with a late renewal policy? Journal of Health Care for the Poor and Underserved, 25(3), 1005-1020. Retrieved from http://uml.idm.oclc.org/login?url=https://search-proquest-com.uml.idm.oclc.org/docview/1629327013?accountid=14569               
• Fenny, A., Enemark, U., Asante, F., & Hansen, K. (2014). Patient Satisfaction with Primary Health Care – A Comparison between the Insured and Non-Insured under the National Health Insurance Policy in Ghana. Global Journal of Health Science, 6(4). doi: 10.5539/gjhs.v6n4p9               
• Gajate-Garrido, G., & Owusua, R. (2013). The national health insurance scheme in ghana: Implementation challenges and proposed solutions: St. Louis: Federal Reserve Bank of St Louis. Retrieved from http://uml.idm.oclc.org/login?url=https://search-proquest-com.uml.idm.oclc.org/docview/1698100980?accountid=14569
• Kotoh, A., & Van der Geest, S. (2016). Why are the poor less covered in Ghana’s national health insurance? A critical analysis of policy and practice. International Journal for Equity in Health, 15(1). doi: 10.1186/s12939-016-0320-1
• Mcintyre, D., Garshong, B., Mtei, G., Meheus, F., Thiede, M., Akazili, J., . . . Goudge, J. (2008). Beyond fragmentation and towards universal coverage: Insights from Ghana, South Africa and the United Republic of Tanzania. Bulletin of the World Health Organization, 86(11), 871-6.
• Ministry of Health. (2004). National health insurance policy framework for Ghana.  Ghana.  Retrieved from https://www.ghanahealthservice.org/downloads/NHI_policy%20framework.pdf
  • This reference is used because this is the policy document that is being critiqued.
• Skolnik, R. (2016). Global health 101 (3rd ed.). Burlington, MA: Jones & Barlett Learning. 
• Van der Wielen, N., Channon, A., & Falkingham, J. (2018). Universal health coverage in the context of population ageing: What determines health insurance enrolment in rural Ghana?. BMC Public Health, 18(1). doi: 10.1186/s12889-018-5534-2