Ghana’s National Health Insurance Scheme: A Look At Some Rudimentary Challenges And The Way Forward(1)

Ghana’s National Health Insurance Scheme according to the records, came into being in the year 2003 as an establishment of Act 650 to take care of equitable access and financial coverage for basic health care services of Ghanaians.

Among some of the factors which necessitated introduction of the scheme is the challenges that came with the cash and carry policy.The cash and carry policy, which required patients including those with emergency cases to make initial payments before they could receive medical services, no doubt,created so much difficulty for Ghanaians in terms of the urgency of raising money to finance treatment of the rather highly unpredictable yet unavoidable question of ill health.

In other words,the National Health Insurance scheme came in as a proactive way of dealing with the issue of health financing in Ghana.

It also worth mentioning that the scheme is essentially a pro-poor policy which is intended to ease the difficulty of the poor and other vulnerable groups, in the financing of health care.The provisions of the NHIS Act therefore allow People With Disabilities(PWDs),children as well as the poor, who according to the Livelihood Empowerment Against Poverty(LEAP) programme, are said to people with no visible source of income, to access free medical services .Others include;free maternal health care.

The National Health Insurance Authority, was subsequently instituted with a mandate to secure the implementation of the National Health Insurance Policy.

In order to make the scheme efficient in the delivery of health financing services etc in the country,a new law namely,Act 852 came into being to among other things, consolidate the scheme,remove administrative bottlenecks,ensure effective governance,introduce transparency and reduce opportunities for corruption.

This notwithstanding,the Country’s National Health Insurance Scheme like any social intervention policy,has been saddled with challenges that as of now threaten to collapse it.A close look these apparently rudimentary challenges however leaves one in a great wonder as to how they have succeeded in bringing the scheme to its present sorry state.

Perhaps,the foremost challenge which has stirred up so much debate in recent times, as regards the sustainability of the scheme, is the question of delays in payment for services provided by health facilities under the scheme.

Some NHIA Regional managers attribute the problem of delays in payment to insufficient funds arising primarily from over utilization of the scheme.They explained that some category of people who are exempted from payment of premium or such other forms of contributions toward the scheme for instance, enjoy services that attract higher prices.

They gave for example,the entitlements of children to free health care under the scheme which did not envisage the present situation where Ghanaian children are becoming notorious for developing complicated health conditions such as cancer because of contemporary lifestyles.They added, that such children are usually sent to health facilities with minor health conditions but are later diagnosed of the aforementioned serious health conditions,hence the increase in utilization of NHIS and the attendant shortfall in the financial resources of the scheme.

The problem with this explanation is the logic in categorizing children who can afford lifestyles that are obviously associated with the well to do in society as vulnerable groups who should be entitled to free health care under the scheme.

Interestingly,careful observation by these managers reveal the use of very sophisticated mobile phones,ipads,laptops and other expensive gadgets by these children which certainly brings out the fundamental flaws in the classification of all children as vulnerable people who should automatically enjoy free health care under NHIS.

The argument can be extended to include some people with disabilities who from all indications, are well placed to contribute to the financing of health care services under the scheme.

Another issue that needs a careful assessment, with respect to protecting the rather limited funds of the scheme so as to make it sustainable,is the inability of the Department of Social Welfare to tell when a beneficiary of the LEAP programme can be said to have an appreciable improvement in his or her economic circumstances and should therefore be taken off the programme and for that matter free health care under NHIS.

District Directors of the Department have often denied responsibility for graduation of LEAP beneficiaries,with the explanation that the matter of targeting and profiling the poor for LEAP and all other matters that come with it, such as,determination of when an individual should be taken off the programme, is the responsibility of an inter-departmental body called the District LEAP Interview Programme( DLIP )or in other jurisdictions,DCLIP which is made up of the Social Welfare,Ghana Education Service,National Health Insurance Scheme and the Planning Departments of MMDAs.

Evidence on the grounds however, indicate that the DLIP is not even sure of the modalities for declaring that an individual should be taken off the programme.The result, according to most NHIA District managers, is the provision of free health services to people with improvement in their economic circumstances and who are instead, in a better position to contribute significant funds to the scheme and enhance its financial resource base, because they still have valid LEAP registration.

Now the point is,the NHIA is the ultimate loser in the aforementioned situation and so the onus lies on the scheme managers to ensure that the institutions which are responsible for weeding out people who should no longer be on LEAP, are taken off the programme in order to reduce the burden on its finances and indeed,get more people to contribute to the scheme.

Another challenge that is creating so much problem for the image of the scheme, is the present frustrations its clientele go through in order to renew their registration or sign on as new members.

Where as the NHIA District offices attribute the problem to removal of their agents from the service chain as a result of the introduction of the biometric means of registration, the Regional offices consider technological challenges as the main cause of delays at the various registration centres.

In the first instance,it is rather surprising that an important institution such the NHIA decided to remove its agents in the communities without putting in place, the necessary measures that will enable patrons of the scheme to go about registration matters without the difficulties that they are currently going through.

Granted that it does not have the wherewithal to procure the required facilities for all the agents to continue with their work in the communities,it could at least keep a small number of registration centres in the various Districts to supplement the work of the respective offices in the MMDAs.

At any rate,there have been instances where some Assembly members have succeeded in taking the biometric registration exercise to people in the communities,a clear indication that the biometric registration can be done in the communities.

It will therefore be in the interest of the NHIA to reduce the present sorry sight of queues of clients at the premises of its offices,and more importantly, save the people from the huge frustrations and long hours they spend on renewal or registering with the scheme.

In the second instance,some analyst have been wondering whether the technological problem of poor reception which slows down the biometric registration process cannot be solved by changing providers of that service.They believe that in a competitive market environment like what is prevailing in Ghana, one should be able to either demand better service from service providers or change them.

Finally,the issue of gaps between NHIA approved prices for health services and products and the actual demands at the health facilities is a huge challenge for the scheme as NHIS contributors are compelled by staff of health facilities across the country, to make extra payment for services and products.

Surprisingly,the Regional offices are emphatic on the involvement of all stakeholders including; Ghana Health Service,Ghana Pharmaceutical Council etc in the fixing of prices for services and products that are covered by the scheme.

They explain further that the scheme even covers feeding but their own survey reveals that the majority of the health facilities do not include it in their package.Some staff and clinicians of the facilities, according to their survey rather compel patients, especially women in labour ,to patronize pastries and beverages,including the popular local brand called “Sobolo”, on grounds that they are usually brought to the facilities on empty stomach and must therefore eat such food items in order to save them from losing consciousness.

Perhaps,what the NHIA is failing to do in this respect in order to save itself from blames and other negative image problems, is failure to educate the public on some of these matters.A good education on the subject will enable patrons of the scheme to insist on their right to health services without making extra payments to staffs of the facilities and help to hold health providers and the scheme managers accountable, as far as,the use of NHIS funds is concerned.

It is clear from the foregoing that the National Health Insurance Scheme of Ghana is going through some challenges,but a closer look at the challenges reveals that they can be addressed with re-consideration of some of its provisions on payment of premium in relation to benefits,enhancing the registration and renewal process by adopting a more efficient technology for the exercise,making the scheme more accessible to the people by creating more registration centres in the communities and embarking on intensive education on the agreements they have with other stakeholders especially,Ghana Health Service.

Joseph Tetteh
Executive Director,Foundation for Youth,Peace and Development(FYPD)

0244571090
e-mail:[email protected]