Performance Of Ghana’s NHIS: Access, Quality Or Outcome?

The National Health Insurance Scheme (NHIS) in Ghana was established by the National Health Insurance Act, 2003 (Act 658) and the National Health Insurance Regulations, 2004 (L.I. 1809). The NHIS which began with a membership of about 480,000 membership, saw membership of about 10.3 million in 2017 (Nsiah-Boateng and Aikins, 2018).

The Insurance Scheme (NHIS) is unarguably one of the best health protection strategies ever implemented by the government of Ghana. The main object behind the NHIS was to eliminate the financial barriers in accessing health care services and to promote health of the Ghanaian population, especially the poor and the vulnerable. It was also intended to do away with the “cash and carry” system so as to prevent catastrophic spending on health care services.

Coming into force of the NHIS did not come to only solidify the Primary Health Care concept, but as one of the best strategies consolidating the efforts of the Universal Health Care agenda.

The scheme, since its inception in 2003 has seen significant transformations to date. The recent one I found very innovative is the digitization of the NHIS renewal process; allowing subscribers to renew their health insurance through Mobile Money wallets. Despite these transformations however, the scheme has still not been able to overcome some of its most crucial challenges and or shortfalls.

The phenomenon of visiting some NHIS accredited hospitals or clinics with a health condition only to be told that medicines for the treatment of your condition had ran out, could be very troubling for most insured health care seekers. It appears some insured health care seekers are lamenting over the fact that they have had to pay for treatments through out-of-pocket payments, when in fact such treatments are part of the NHIS plan they subscribed to.

Constantly asking insured clients to pay certain amounts of money for treatments otherwise covered by the NHIS plan amounts to some kind of co-payment method. And this defeats the very premise establishing the NHIS as stipulated in Act 658 (2003). It is a fact that the Act establishing the NHIS was not framed to operate on the premise of co-payment. But gradually, it appears co-payment is being sneaked into the operations of the NHIS at the blind sight of the insurance subscriber by both the care provider and the insurance provider.

Could the current phenomenon of co-payment being experienced in some NHIS accredited health facilities, be a recipe for some subscribers flooding courtrooms with public health suits to seek refund and compensations from the insurance provider in the near future?

Hypothetically, Kofi visited health facility “Z” and was diagnosed with a condition, say, malaria and was told that facility “Z” had no antimalarial medicines; compelling Kofi to purchase the said medication from a pharmacy shop, out-of-pocket. What if Kofi had no money to purchase his medication at that material moment? Experiences show that low income families are mostly victims of this scenario and are usually left with limited choices in such circumstances. (Boateng et al., 2017).

The question in relation to the scenario expressed above is, how would Kofi be able to determine if indeed facility “Z” (the care provider) made reimbursement claims covering only diagnosis or the care provider rather exaggerated the claim to cover treatment/medication too?

In view of the current inefficiencies bedeviling the NHIS which largely tend to be shifting partial health care cost to the insured client, it would be prudent on the part of insurance provider to consider introducing some kind of indemnity plan for the insured health care seeker. The introduction of the indemnity plan could help curb the catastrophic spending on the part of NHIS health care seekers. It will grant them the opportunity to seek reimbursement from the insurance provider after the former is made to pay for any service which is otherwise covered by the insurance plan.

Despite the indemnity plan may not necessarily eradicate all the inefficiencies surrounding the NHIS (including delay in reimbursing the health care provider), it will definitely act as a very good check on the insurance provider and or the healthcare provider so as to reduce the current partial health care financial burden being shifted unto the insured health care seeker. This will also go a long way to help boost NHIS-client confidence in the NHIS health care services/benefits spelt out in the NHIS package.

We cannot pride ourselves with a robust health care system without an efficient and effective pro-poor health insurance system that truly and practically protect the poor from catastrophic health care spending. The “no medicines syndrome” in some of our NHIS accredited health care facilities is gradually gaining grounds and must be checked (Ashigbie et al., 2016). Is about time the National Health Insurance Authority adopted robust monitoring mechanisms for checking access to medicines by NHIS insured clients in the implementation of the NHIS so as to address some of these inequities and inefficiencies.

In fact, the performance of the NHIS should not be narrowed to include only the dimension of access, but a holistic performance assessment which takes into account, access, quality and outcome. Our continuous narrow view of the performance of the NHIS from the lenses of access could largely be undermining quality and outcome for the NHIS insured population in Ghana.

Trend analysis carried out by Nsiah-Boateng and Aikins, (2018) revealed that enrolment in the NHIS is declining. Could this decline be attributed partly to poor quality care being rendered out by some NHIS-accredited health facilities? Well, it appears to be the case, since a Meta-analysis study by Alhassan et al., (2016) pointed out poor quality care as one of the many challenges threatening the sustainability of Ghana’s NHIS. The issue of client dissatisfaction with the quality of service provided by Ghana’s NHIS by a section of the population is not new, and are well documented in scientific works (Alhassan et al., 2015; Amo-Adjei et al., 2016; Fenny et al., 2016).

Let us move beyond priding ourselves with the number of NHIS clients who access Out-patient and In-patient services in our annual reports to paying critical attention to the number of NHIS clients who receive quality care and achieved timely intended positive health outcomes. Failing to report and or underreport on quality and outcome amounts to some level of failure of the system.

Author:
Samson Gbolu
Health Promotion Activist & Social Entrepreneur

References:
Alhassan R.K, Nketiah-Amponsah E, Arhinful DK (2016) A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects? PLoS ONE 11(11): e0165151. doi:10.1371/journal.

Alhassan R. K. et al. (2015) ‘Comparison of perceived and technical healthcare quality in primary health facilities: Implications for a sustainable National Health Insurance Scheme in Ghana’, PLoS ONE, 10(10), pp. 1–19. doi: 10.1371/journal.pone.0140109.

Amo-Adjei, J. et al. (2016) ‘Perception of quality of health delivery and health insurance subscription in Ghana’, BMC Health Services Research. BMC Health Services Research, 16(1), pp. 1–11. doi: 10.1186/s12913-016-1602-4.

Ashigbie, P. G., Azameti, D. and Wirtz, V. J. (2016) ‘Challenges of medicines management in the public and private sector under Ghana’s National Health Insurance Scheme - a qualitative study’, Journal of Pharmaceutical Policy and Practice. Journal of Pharmaceutical Policy and Practice, 9(1), pp. 1–10. doi: 10.1186/s40545-016-0055-9.

Boateng, S. et al. (2017) ‘Migrant female head porters ’ enrolment in and utilisation and renewal of the National Health Insurance Scheme in Kumasi , Ghana’. Journal of Public Health, pp. 625–634. doi: 10.1007/s10389-017-0832-1.

Fenny, A. P. et al. (2016) ‘Factors contributing to low uptake and renewal of health insurance: a qualitative study in Ghana’, Global Health Research and Policy. Global Health Research and Policy, 1(1), pp. 1–10. doi: 10.1186/s41256-016-0018-3.

Nsiah-Boateng, E. and Aikins, M. (2018) ‘Trends and characteristics of enrolment in the National Health Insurance Scheme in Ghana: a quantitative analysis of longitudinal data’, Global Health Research and Policy. Global Health Research and Policy, 3(1), pp. 1–10. doi: 10.1186/s41256-018-0087-6.