Imagine being sent to a hospital with a bleeding accident wound and asked to pay before a doctor attends to you. You may die. Many have died for the simple reason that there was no money around to make the required advanced payment in similar cases.

So in 2004, the Government of Ghana started implementing a National Health Insurance Scheme (NHIS) to remove cost as a barrier to access quality healthcare. This changed the healthcare system significantly and had far reaching consequences for healthcare providers.

Healthcare providers’ initial experiences with Ghana’s NHIS

The healthcare services to the NHIS registered members (formal and informal sector) are provided by contracted, accredited public and private health care facilities, which in turn are reimbursed for service costs by the NHIS.  

“It was not easy giving care under cash and carry. There were times patients brought me their beads, cloths and their most treasured possessions to pay for delivery at the maternity home.”

That is Alice Dora Amoyaw, the nurse - midwife in charge of Alidor Maternity Home at Asesewa in the Eastern region of Ghana. She has delivered hundreds of babies at her facility to parents who are largely peasant farmers.

During the first few years after being contracted by the National Health Insurance Scheme, the scheme reimbursed her facility on time, resulting in an increase in the income level of the maternity home.

“I could pay my workers, buy drugs, pay my utilities and even mechanized the bore hole in the maternity home to improve water supply for the clients. It even helped me to build an administration block.” She said.

Another health facility is the Pentecost Hospital. It serves as the municipal hospital for the La Nkwantanan - Madina Municipality in the Greater Accra region. Eighty percent of its clients are registered with the National Health Insurance Scheme. Mr George Afrifa is the General Manager of the Pentecost Hospital he acknowledges seeing the NHIS as a very good social intervention program.

“People were detained; some patients absconded because they could not pay for the service. The expectation was that this intervention [the NHIS] was going to help us reduce this problem.”

Generally, expectations and experiences of healthcare providers with the NHIS were positive.

Healthcare providers’ experience with Ghana’s NHIS today

As of October 2015, the NHIS had a subscriber base of about 10.9 million people, representing 40% of the total population. The scheme is currently operational in all one hundred and seventy (170) district offices across the country.

According to Dr. Ebenezer Owusu Asiamah, medical director of Anton Memorial Hospital, the NHIS has made significant strides in improving and strengthening the system, like the introduction of the biometric system, which has helped to reduce the incidents of impersonation.

His private hospital, which is located at Kotobabi in the Greater Accra region, sees about three thousand (3000) patients every month, with over 70% of its clients being NHIS card holders.

Dr. Ebenezer Owusu Asiamah explained that currently the NHIS claims are in arrears for over eight months. “The NHIS has serious financial challenges.” Dr Owusu said.

NHIS claims financing

The NHIS is financed through multiple sources. The major sources of funding are 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. Currently, the members from the informal sector pay between 7.20 GH and 47.70 GH to the scheme. However, the core poor, pregnant women, pensioners, people above the age of 70 and those below 18 years are exempted from premium payment. There is no other cost sharing or co-payments with the NHIS, except the premium paid.

The Director of Claims of the NHIS, Dr Lydia Dsane Selby, said one of the challenges in the NHIS implementation process is the size of the benefit package, she said, Ghana started off with a benefit package which covered nearly everything; while other countries at the same development level as Ghana picked a few areas and concentrated on paying for those.

“I am not saying that is wrong, but the financing is not marching what we want to do as a country. The fact remains that there has to be some rationalization somewhere because we can’t afford everything.” Dr Selby said.

She hinted that the minister has set up a review team, to study the challenges in the NHIS and suggest reforms.

“The revenue base may have to be increased. Whether by increasing the premiums a little or having some other tax, government has to decide which way to go.”She emphasized.”

The financial challenges began in 2008, when the old tariffs, which were based on itemized billing, were replaced with the introduction of the new tariffs using the Ghana - Diagnostic Related Groupings (G-DRGs). The change resulted in an approximate four times increase in the tariffs paid to the providers.

Last year when the Christian Health Association of Ghana (CHAG) withdrew services for NHIS card holders because of the low tariffs and the delays in the claims reimbursements, the authority started an interim review of 12.5 percent increase in the tariff structure hoping to finalize the tariff review by September 2014. The tariffs have not been reviewed since.

Mr Rudolf Zimmerman the Director for Financial Accounting at the NHIS said the only way of solving the problems associated with the delays in payment of claims is by closing the funding gaps. He says the scheme paid 18 million GH in total claims in 2005; but currently the claims have risen to as much as 986 million GH in 2014. He however explains that though the claims are increasing at a very alarming rate, the funding sources have not seen any corresponding growth.

“No insurance scheme can survive with such funding gap”, he hinted.

NHIS Communications

Providers believe the NHIS have to educate Ghanaians about the services covered by the scheme. When the NHIS was introduced, most Ghanaians assumed that all NHIS card holders could walk into any of the nearly 4000 health care facilities which have been accredited for healthcare and receive every type of service without paying for the service directly.

Although the package covers 95% of the diseases in Ghana, some services  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.

Healthcare providers’ views on the future

According to Dr Selby, the NHIS has to find a strategic way of increasing its revenue while reducing its expenditure to ensure that the scheme remains sustainable.

She said another way of sustaining the scheme for the future is to ensure health system strengthening by improving and upgrading the ICT systems in the NHIS.

“Too much of our work is being done on pieces of paper; we need to go a lot more electronic than we are doing right now.”

She hopes that investing about one million cedis to improve the ICT system would save the NHIS a hundred million cedis.

Under the present arrangement, all the NHIS levies collected by the Ghana Revenue Authority go into the consolidated fund, where payments to service providers of the NHIS are paid from. However, according Pastor Eric Mintah Dankwah, administrator of Florence Maternity Home at Anloga in Kumasi this presents administrative challenges and inefficiencies.

“The delays in the claims payment would be solved if the NHIS is allowed to manage its own funds.” He said

Medical Credit Fund intervention

PharmAccess, through the Medical Credit Fund MCF and uniBank (Ghana) Ltd, with support from the NHIA recently developed a loan product to pre – finance outstanding NHIS claims. This loan product, the first of its nature in the health insurance sector, provides relief to accredited NHIS service providers while they await claims payment from the scheme to enable them for example pay salaries or restock their pharmacy. Eligible claims of registered facilities will be assigned to the bank after which the bank pays a discounted amount of the claim value to the service provider.

The product guarantees liquidity to support continuous quality healthcare delivery by NHIS service providers.

With the National Health Insurance Scheme, the health seeking behaviors of Ghanaians has improved significantly. The NHIS requires urgent financial reforms to remain sustainable. Private healthcare providers do not want the NHIS to fail.

“People will die…, thousands of people; we don’t want to go back to the Cash and Carry system. That would be like taking a step back almost twenty or thirty years ago.” One provider said.

Most healthcare providers believe that the success of Ghana’s NHIS is a key driver to achieve universal health coverage and an effective health delivery system in Ghana.