Healthcare financing continues to stir debates around the world. Many low and middle income countries, continue to explore different ways of financing their health systems. This is due to the fact that their health systems are chronically under-funded. In Ghana, most healthcare is provided by the government and largely administered by the Ministry of Health and Ghana Health Services. The healthcare system has five levels of providers: Health posts – which are first level primary care for rural areas: Health Centres and Clinics, District Hospitals, Regional Hospitals and Tertiary Hospitals. The government, financial credits, Internally Generated Fund (IGF) and donors-pooled health funds these programs. Some hospitals and clinics are run by the Christian Health Association of Ghana who provide healthcare. Ghana has about 200 hospitals, some for-profit clinics exist, but they provide less than 2% of healthcare services. Healthcare varies through the country with urban centres having most healthcare facilities, whilst rural areas are often deprived. Patients in these areas either rely on traditional medicine or travel great distances for healthcare. The system of health, which was formerly operated, was known as the “Cash and Carry” system, where many people died because they did not have money to pay for their healthcare needs. Under this system, the health need of an individual was only attended to after initial payment for the service was made even in cases of emergency.
In order to promote universal coverage and equity in healthcare delivery services, the government of Ghana adopted the National Health Insurance Scheme (NHIS) in 2003, which was fully implemented in 2005. This was to assure equitable and universal access for all citizens to an acceptable quality package of essential healthcare services and to abolish “out-of-pocket” payment. The ultimate goal of the NHIS is the provision of universal health insurance coverage for all Ghanaians, irrespective of their socio-economic background. The NHIS is based on District Mutual Health Insurance Schemes (DMHIS), which operates in all 170 districts of the country. This covers both formal and informal sectors of the economy. As of June 2009, about 67% of the population had subscribed to the NHIS, which is financed by a National Health Insurance levy of 2.5% on certain good and services, 2.5% monthly payroll deduction being part of the contribution to the Social Security and National Insurance Trust (SSNIT) for formal sector workers, government budgetary allocation and donor funding. The formal sector workers pay a registration fee for an identity card for access healthcare services. Contributions from members of the informal sector are also made to the NHIS with the minimum and maximum premium being GH 7.20 and 47.70 respectively. However, the core poor, pregnant women, pensioners, people above 70 and below 18 years are exempted from premium payment.
The benefit package of the NHIS consists of basic health care services, including outpatient consultations, essential drugs, inpatient care and shared accommodation, maternity care (normal and caesarean delivery), eye, dental and emergency care. About 95% of the diseases in Ghana are covered under the NHIS. However, some services classified to be unnecessary or very expensive are on the exclusion list. Among these are; cosmetic surgery, drugs not listed on the NHIS drugs list (including antiretroviral drugs), assisted reproduction, organ transplantation, and private inpatient accommodation.
Since it’s inception, the country’s health facilities have seen a constant rise in patient numbers and a considerable reduction in deaths, however some major loopholes have been identified with this scheme. According to research carried out by health economists, a major challenge disclosed by healthcare workers was a delay in reimbursement. Providers were not paid on time, in some cases for as long as 6 months. But the NHI Act (650) stipulates that providers should be reimbursed four weeks following the month for which claims were submitted. The main reason for the delay in payment was identified to be the inability of the National Health Insurance Authority (NHIA) to provide funds for payment. The NHIA seems to be overwhelmed with the amount of claims submitted by the various health care systems for payment. But other reasons that could result in delays in payment included inadequate and incompetent staff in the facilities who were responsible for the submission of claims. Contentious claims between the facilities and the DMHIS could sometimes result in delays as well. Due to the delay in reimbursement, providers were unable to procure drug and non-drug supplies for the smooth operations of the facilities.
Some providers perceived that the introduction of the NHIS had led to service abuse by the insured. The insured frequent the facilities with minor ailments and even attend to collect drugs for their uninsured relatives and friends. Some insured clients even offer their insurance ID cards to the uninsured for a fee to use to access health care. The high attendance and perceived service abuse by the insured had led to an increased workload for providers. Providers experience long working hours with little or no break times. However, providers were not motivated enough by the NHIS and government to compensate for the heavy workload experienced. Some insured patients also complain of having being turned away and longer waiting times because the provider chose to prioritize those who were ready to pay in cash over them. Other problems identified included inadequate logistics and human resources, limited space within the hospitals to cope with the increasing number of service users and “moral hazard” on the part of policy holders.
The Way Forward
To overcome these challenges, services under the health insurance authority need to be streamlined to remove cash flow bottlenecks. The immediate policy required would be on the issue of the delay in reimbursement by the NHIS. There is an urgent need for action to streamline the reimbursement procedure in order to maintain providers’ confidence in the NHIS. Central government and the management of the NHIA should search for an effective and permanent way of addressing the issue, if not the success and sustainability of the NHIS would be affected. Also, accredited hospitals need to adopt and use new technology, especially computerization and automation of the health insurance service delivery system. This would enable the authority to cope with the huge management problems confronting hospitals and the national insurance scheme. The staff should also be motivated to carry out their duties efficiently due to the heavy workloads. Above all, appropriate fund management systems would have to be established in the hospitals to reduce moral hazards.
There is urgent need to address these issues in order to promote confidence in the NHIS, as well as its sustainability for the achievement of universal health insurance coverage.