Ghana
Previously piloted in the 1980s, the concept of a national health insurance scheme was again revitalized in 2000 as a reaction against an unpopular out of pocket payment system. In rolling out the new scheme, the government aimed to cover 50-60% of the population within the first 10 years. NHIS's eventual goal is achieving universal health coverage. Expenditure on health in Ghana has almost doubled since the end of the 1990s. At present Ghana devotes 12% of its budget to health, well above average for African nations.
Previously piloted in the 1980s, the concept of a national health insurance scheme was again revitalized in 2000 as a reaction against an unpopular out of pocket payment system. In rolling out the new scheme, the government aimed to cover 50-60% of the population within the first 10 years. NHIS's eventual goal is achieving universal health coverage. Expenditure on health in Ghana has almost doubled since the end of the 1990s. At present Ghana devotes 12% of its budget to health, well above average for African nations. Prior to independence, financial access to modern health care was predominantly through out-of-pocket payments at the point of service. Following independence, the government switched to tax-based financing of public sector health services and all such services were made free. Private sector health services continued to be paid for by out-of-pocket fees at the point of service.
By the early 1970s, general tax revenue in Ghana, with its stagnating economy, could not support a tax-based health financing system. In 1972, very low out-of-pocket fees at the point of service were introduced in the public sector. The stagnation of Ghana’s economy was followed by a decline and in the health sector there were widespread shortages of essential medicines, supplies and equipment, and poor quality of care.
In 1983, the PNDC government adopted a traditional IMF and World Bank economic recovery program.
In 1985, public sector user fees for health care were raised significantly as part of structural adjustment policies and became known as ‘cash and carry’. The aim of the 1985 user fees was to recover at least 15% of recurrent expenditure for quality improvements. The financial aims were achieved. Shortages of essential medicines and some supplies improved. However, these achievements were accompanied by inequities in financial access to basic and essential clinical services. User fees also resulted in a major deterioration in the number of people utilizing health services. Long delays in reporting ill-health for those who did finally consult health services (resulting in more serious illnesses and expensive treatment), incomplete prescription purchases, and the sharing of prescription drugs were some of the other adverse effects reported. In addition, although exemptions from user fees for pregnant women and those classed as ‘indigent’ did officially exist, in practice these exemptions did not work well and many of those who should have been exempted were not.
The inherent and largely predictable problems of a user fee health system did not go unrecognized by the Ghanaian Government. At various intervals since the early 1980s, proposals to institute a National Health Insurance Scheme (NHIS) have been considered at national level. The ILO, WHO, EU and London School of Hygiene and Tropical Medicine were all requested by the Ministry of Health to provide technical advice on such a scheme and in 1997 a NHIS pilot project was launched. Due to a lack of consensus on health financing policy in general however, the pilot project broke down.
The NHIS concept was revitalized in Ghana in 2000 when the New Patriotic Party (NPP) came into power. One of NPP’s key policy platforms was the abolishment of the unpopular cash and carry system, and the introduction of a new system of national health insurance. The stated goal of the new government was to have 50-60% of the population covered by health insurance within 10 years of the implementation of the new scheme, with a final goal of universal health insurance coverage.
It is important to note that the Christian Health Association of Ghana’s providers began to experiment with hospital-based health insurance, called community health insurance, as early as 1992. By the time the NPP government introduced health insurance nationally, there were already at least 57 district wide health insurance schemes and over a hundred other group schemes. These community-based schemes greatly influenced and informed the development of national insurance.
Additionally, public sector health services were decentralized during the 1990s. The 1996 Ghana Health Service and Teaching Hospital Act removed administrative and service delivery responsibilities from the Ministry of Health (MoH) and delegated them to an autonomous body known as the Ghana Health Service (GHS). The MoH has retained responsibility for policy formulation, planning, donor co-ordination and resource mobilization. Figure 1 presents an illustrative depiction of the institutional structure of Ghanaian public health services. Teaching hospitals are now responsible for teaching, research, and for the provision of specialist health care. Insert Private providers account for 35% of total health services in Ghana, and include hospitals, clinics, company clinics, and maternity homes. The Government target is to raise private healthcare provision to 65% over the next 10 years. Faith-based providers also play a very large role in the delivery of care in Ghana. The Christian Health Association of Ghana (CHAG) plays a complementary role to the public sector and is the second largest provider of health services in the country. It is estimated that approximately 42% of total health services in the country are provided by CHAG’s member institutions.
Since the end of the 1990s, expenditure on health in Ghana per capita has almost doubled. At present Ghana devotes 12% of its budget to health, below the target set under the Abuja and Maputo Declarations (which committed African states to setting aside 15% of their national budget for this purpose), but still well above average for African nations.
Ghana
Historical Context
Previously piloted in the 1980s, the concept of a national health insurance scheme was again revitalized in 2000 as a reaction against an unpopular out of pocket payment system. In rolling out the new scheme, the government aimed to cover 50-60% of the population within the first 10 years. NHIS's eventual goal is achieving universal health coverage. Expenditure on health in Ghana has almost doubled since the end of the 1990s. At present Ghana devotes 12% of its budget to health, well above average for African nations. Prior to independence, financial access to modern health care was predominantly through out-of-pocket payments at the point of service. Following independence, the government switched to tax-based financing of public sector health services and all such services were made free. Private sector health services continued to be paid for by out-of-pocket fees at the point of service.
By the early 1970s, general tax revenue in Ghana, with its stagnating economy, could not support a tax-based health financing system. In 1972, very low out-of-pocket fees at the point of service were introduced in the public sector. The stagnation of Ghana’s economy was followed by a decline and in the health sector there were widespread shortages of essential medicines, supplies and equipment, and poor quality of care.
In 1983, the PNDC government adopted a traditional IMF and World Bank economic recovery program.
In 1985, public sector user fees for health care were raised significantly as part of structural adjustment policies and became known as ‘cash and carry’. The aim of the 1985 user fees was to recover at least 15% of recurrent expenditure for quality improvements. The financial aims were achieved. Shortages of essential medicines and some supplies improved. However, these achievements were accompanied by inequities in financial access to basic and essential clinical services. User fees also resulted in a major deterioration in the number of people utilizing health services. Long delays in reporting ill-health for those who did finally consult health services (resulting in more serious illnesses and expensive treatment), incomplete prescription purchases, and the sharing of prescription drugs were some of the other adverse effects reported. In addition, although exemptions from user fees for pregnant women and those classed as ‘indigent’ did officially exist, in practice these exemptions did not work well and many of those who should have been exempted were not.
The inherent and largely predictable problems of a user fee health system did not go unrecognized by the Ghanaian Government. At various intervals since the early 1980s, proposals to institute a National Health Insurance Scheme (NHIS) have been considered at national level. The ILO, WHO, EU and London School of Hygiene and Tropical Medicine were all requested by the Ministry of Health to provide technical advice on such a scheme and in 1997 a NHIS pilot project was launched. Due to a lack of consensus on health financing policy in general however, the pilot project broke down.
The NHIS concept was revitalized in Ghana in 2000 when the New Patriotic Party (NPP) came into power. One of NPP’s key policy platforms was the abolishment of the unpopular cash and carry system, and the introduction of a new system of national health insurance. The stated goal of the new government was to have 50-60% of the population covered by health insurance within 10 years of the implementation of the new scheme, with a final goal of universal health insurance coverage.
It is important to note that the Christian Health Association of Ghana’s providers began to experiment with hospital-based health insurance, called community health insurance, as early as 1992. By the time the NPP government introduced health insurance nationally, there were already at least 57 district wide health insurance schemes and over a hundred other group schemes. These community-based schemes greatly influenced and informed the development of national insurance.
Additionally, public sector health services were decentralized during the 1990s. The 1996 Ghana Health Service and Teaching Hospital Act removed administrative and service delivery responsibilities from the Ministry of Health (MoH) and delegated them to an autonomous body known as the Ghana Health Service (GHS). The MoH has retained responsibility for policy formulation, planning, donor co-ordination and resource mobilization. Figure 1 presents an illustrative depiction of the institutional structure of Ghanaian public health services. Teaching hospitals are now responsible for teaching, research, and for the provision of specialist health care. Insert Private providers account for 35% of total health services in Ghana, and include hospitals, clinics, company clinics, and maternity homes. The Government target is to raise private healthcare provision to 65% over the next 10 years. Faith-based providers also play a very large role in the delivery of care in Ghana. The Christian Health Association of Ghana (CHAG) plays a complementary role to the public sector and is the second largest provider of health services in the country. It is estimated that approximately 42% of total health services in the country are provided by CHAG’s member institutions.
Since the end of the 1990s, expenditure on health in Ghana per capita has almost doubled. At present Ghana devotes 12% of its budget to health, below the target set under the Abuja and Maputo Declarations (which committed African states to setting aside 15% of their national budget for this purpose), but still well above average for African nations.
In 2004, Ghana embarked on a process of developing and implementing a National Health Insurance Scheme (NHIS) to replace out-of-pocket fees at point of service. The solution was a ‘hub-satellite’ model of a national fund and authority (the hub) that regulates and subsidizes a national network of community-based health insurance schemes (the satellites). As of October 2008, the NHIS had insured 12 million people out of a total population of 21 million (61% of the total population).
In 2004, Ghana embarked on a process of developing and implementing a National Health Insurance Scheme (NHIS) to replace out-of-pocket fees at point of service. The solution was a ‘hub-satellite’ model of a national fund and authority (the hub) that regulates and subsidizes a national network of community-based health insurance schemes (the satellites). As of October 2008, the NHIS had insured 12 million people out of a total population of 21 million (61% of the total population).
The NHIS is funded primarily through general tax revenues, the largest source being a 2.5% health insurance levy which has been added to the national Value Added Tax (VAT). Other sources of funding include payroll contributions and direct premium contributions from members. Exemptions from premium payments are made for several population groups, including pensioners, the elderly, children and indigents; other population groups pay premiums determined by income level.
The NHIS offers a comprehensive benefits package, including both inpatient and outpatient care. While some exceptions exist, the benefits package is said to cover 95% of all health problems reported in Ghanaian health facilities. There is a particular emphasis on maternal and child health, with benefits including antenatal and postnatal care.
The NHIS is interesting in that it has adapted a social health insurance (SHI) model so that informal workers can be included into the scheme. This has been done by fusing elements of SHI with elements of Community Based Health Insurance (CBHI). By combining a network of CBHI schemes with a centralized authority and source of funds (the SHI component) to ensure nationwide coverage and to guarantee the financial sustainability of the schemes, the NHIS has attempted to adapt the best aspects of these two very different health financing models to fit the particular socio-economic landscape of Ghana.
Ghana
Summary of Reforms
In 2004, Ghana embarked on a process of developing and implementing a National Health Insurance Scheme (NHIS) to replace out-of-pocket fees at point of service. The solution was a ‘hub-satellite’ model of a national fund and authority (the hub) that regulates and subsidizes a national network of community-based health insurance schemes (the satellites). As of October 2008, the NHIS had insured 12 million people out of a total population of 21 million (61% of the total population).
The NHIS is funded primarily through general tax revenues, the largest source being a 2.5% health insurance levy which has been added to the national Value Added Tax (VAT). Other sources of funding include payroll contributions and direct premium contributions from members. Exemptions from premium payments are made for several population groups, including pensioners, the elderly, children and indigents; other population groups pay premiums determined by income level.
The NHIS offers a comprehensive benefits package, including both inpatient and outpatient care. While some exceptions exist, the benefits package is said to cover 95% of all health problems reported in Ghanaian health facilities. There is a particular emphasis on maternal and child health, with benefits including antenatal and postnatal care.
The NHIS is interesting in that it has adapted a social health insurance (SHI) model so that informal workers can be included into the scheme. This has been done by fusing elements of SHI with elements of Community Based Health Insurance (CBHI). By combining a network of CBHI schemes with a centralized authority and source of funds (the SHI component) to ensure nationwide coverage and to guarantee the financial sustainability of the schemes, the NHIS has attempted to adapt the best aspects of these two very different health financing models to fit the particular socio-economic landscape of Ghana.
Ghana has made significant progress towards its goals and achievement of universal health coverage. Despite this generally encouraging progress, the National Health Insurance Scheme still has some challenges to overcome.
Ghana has made significant progress towards its goals and achievement of universal health coverage. Despite this generally encouraging progress, the National Health Insurance Scheme still has some challenges to overcome. These challenges range from policy and design issues, such as assuring the financial sustainability of the scheme, to implementation and administrative issues, such as improving back end functions such as claims reimbursements.
A set of ongoing challenges on which the NHIS might focus over the coming months and years follows:
- Improving financial processes such as claims reimbursements
- Addressing the financial sustainability of the scheme
- Extending registration to poorer sections of society (and balancing this with the cost of the premiums)
- Scrutinizing quality of care provided by the Ghanaian health system under the NHIS
- Improving enrollment and claims backlogs
Ghana
The Way Forward
Ghana has made significant progress towards its goals and achievement of universal health coverage. Despite this generally encouraging progress, the National Health Insurance Scheme still has some challenges to overcome. These challenges range from policy and design issues, such as assuring the financial sustainability of the scheme, to implementation and administrative issues, such as improving back end functions such as claims reimbursements.
A set of ongoing challenges on which the NHIS might focus over the coming months and years follows:
- Improving financial processes such as claims reimbursements
- Addressing the financial sustainability of the scheme
- Extending registration to poorer sections of society (and balancing this with the cost of the premiums)
- Scrutinizing quality of care provided by the Ghanaian health system under the NHIS
- Improving enrollment and claims backlogs