Implementation of the National Health Insurance Scheme (NHIS) in Ghana: Lessons for South Africa and Low- and Middle-Income Countries

Introduction

National Health Insurance (NHI) is the lifeblood of Universal Health Coverage (UHC) globally, especially in sub-Saharan Africa.^1,2 Many advanced nations have implemented various modifications of the Beveridge, Bismarck, or private health insurance models.³ In sub-Saharan African countries such as Ghana, Kenya, Nigeria, Tanzania, and Uganda, different forms of health insurance were observed. These health insurances are primarily community-based.^4–6

In Ghana, the National Health Insurance Scheme (NHIS) was established in August 2003 to promote access to equitable and quality healthcare for all citizens, irrespective of the individual’s socio-economic features.⁷ The National Health Insurance Authority (NHIA) governs the scheme. The National Health Insurance Fund (NHIF), as stipulated in Act 650 of 2003, was set up to fund the healthcare of Ghanaians.⁷ The NHIF generates its cash inflow from five sources including 2.5% of the 17.5% Value-Added Tax (VAT), 2.5% of the 17.5% Social Security and National Insurance Trust (SSNIT) from formal sector employees, dividends of investments made by the NHIA, donations, and premiums paid by scheme subscribers.^8,9 The scheme provides premium exemptions for the elderly (70 years and above), SSNIT pensioners, children below 18 years, pregnant women, and the beneficiaries of the Livelihood Empowerment Against Poverty (LEAP) – a pro-poor social intervention carried out by the central government.¹⁰ The insurance scheme covers 95% of the burden of diseases in Ghana.¹⁰ Services covered by the scheme include out-patient services, in-patient services, maternity care, eye care, and oral healthcare services.¹⁰

At the inception of the NHIS, the payment of healthcare providers was through itemized fee-for-service. However, in 2008, the Ghana Diagnostic Related Groupings (G-DRGs) for services and fee-for-service for medicines at all levels of service delivery was introduced in a reform. Under this system, the NHIS District/Municipal/Metropolitan offices engage the various NHIS certified health facilities on a contract basis. The health facilities then provide services for the NHIS subscribers and submit claims for services rendered to the NHIS District/Municipal/Metropolitan offices for reimbursement.¹¹

Like any other policy, the implementation of the NHIS achieved some successes but had challenges. South Africa is having difficulties in rolling out the NHI policy. There are ongoing arguments on whether the NHI will produce the access, equity, and quality healthcare it is intended to, and whether South Africa is ready to implement the policy.¹² Many stakeholders believe the country needs more preparation if the policy will be successful.¹³ Ghana, on the other hand, has successfully implemented the NHIS for over 15 years. South Africa and other countries with similar geography, disease burden, economic grouping, and sociocultural context could learn from the successes and the challenges of Ghana in developing National Health Insurance and Universal Health Coverage funding models for low- and middle-income countries.

Aim

This scoping review sought to explore the 15 years of implementation of the NHIS in Ghana and the lessons South Africa and other low- and middle-income countries can learn from such a process.

Design

A scoping review is either a pre-systematic review or a standalone review that seeks to map the breadth and depth of evidence in a field of study.^14,15 This scoping review was conducted using the Joanna Brigs Institute’s (JBI) System for the Unified Management, Assessment, and Review of Information (SUMARI) and Mendeley reference manager to manage the review process.¹⁶ The scoping review method was chosen because it better synthesizes findings from both the positivist and the constructivist paradigms than other review methods.¹⁷ The JBI SUMARI provides a computerized framework for the reviewers to follow in conducting the review.

Search and Inclusion

Journal articles published on the NHIS in Ghana from January 2003 to December 2018 were searched from Science Direct, PubMed, Scopus, CINAHL, and Medline using the keywords; Ghana, Health, and Insurance. The search terms used were made broad so as to find approximately all studies on the National Health Insurance Scheme of Ghana over the 15 years. The PCC criteria, representing Population of interest (P), Concept (C), and the Context (C) guided the inclusion of studies in this review.

• The population of interest (P): represents all institutions and individuals involved in the implementation of the National Health Insurance Scheme in Ghana.
• The Concept (C): is the Implementation of the National Health Insurance Scheme.
• Context (C): represents the healthcare system of Ghana.

The review question, “how was the National Health Insurance Scheme implemented in Ghana” guided the scoping review. Studies were included if they were full journal articles published in English, written on the implementation of the National Health Insurance Scheme of Ghana from January 2003 to December 2018.

Critical Appraisal

The JBI evidence-based critical appraisal tools were used by three JBI trained reviewers to appraise the studies included in this study. . A minimum of two recommendations were necessary for inclusion. A study was included if it met 80% of the quality criteria set by the appraisal tool. All full-text articles appraised were included.

Data Collection

The second author extracted the findings from all studies included onto the SUMARI page for this review. The findings extracted onto the SUMARI were reviewed by the first author to ensure it was accurate. The finalized data extraction sheet is presented in a data matrix (Table 1).

Table 1 Data Matrix

Data Synthesis

Quantitative data were transformed through a qualitizing process then synthesized with the qualitative data using a convergent integrated approach.^18,19 The assessment of the certainty of the evidence from the studies was not done due to the complexity of recommendations from studies included and the quantitative data transformation process. Also, this was a scoping review, and the reviewers did not seek to compare phenomena and make judgments, hence the exclusion of assessment of certainty. The review process and the results were reported according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) reporting checklist.²⁰ The findings extracted on the data matrix were coded independently by the two reviewers, and the codes were compared and discussed for intercoder agreement. The codes were refined based on the intercoder agreement for final coding. Similar codes were combined into sub-themes and related sub-themes into themes, as presented in the Results section.

Results

Seventy-seven of the 418 studies found on the NHIS were included (Figure 1). Figure 2 shows the trend of publications from the year of inception until December 2018. There were no empirical studies published within the first 4 years (2003–2006) of the implementation stage. Studies increased from 2007 to 2012, decreased from 2012 to 2015, then recorded a sharp rise in 2016, which remained constant in 2017 and then sharply decreased in 2018. Generally, the trend line shows a steady increase in publications from the inception of the scheme in 2003 to December 2018. The findings from the studies included in the review were synthesized below.

Figure 1 Search, appraisal, and inclusion of studies.

Figure 2 Yearly distribution of studies included in the review.

Clarity of Policy

Social policy affects the total population. The National Health Insurance policy is written in English only. Even the academics are seeking clarification on the content of the policy.^4,21 Aryeetey et al²² discovered that the users do not understand the concept of poverty as stated in the NHIS document. Also Agyei-Baffour et al²³ found that some Ghanaians do not fully understand the premium payment concepts though they hear of them. Researchers are advocating for a white paper that clearly defines the major concepts, comprehensive stakeholder engagement, and public education on the NHIS policy document.^4,21

Coverage

The NHIS has made care accessible and affordable in Ghana.^24–28 Some groups of people such as the aged, children, and pregnant women are given immunity against premium payment.^28,29 This helped in removing some socio-economic barriers to healthcare.^29,30 In terms of healthcare-seeking behavior, people who are registered in the scheme use healthcare services more than those who are not insured.^30–33

Though the NHIS increased access to healthcare, this access is far from universal, as it demands premium payment before one can access healthcare. Many studies^{8,–32,–34–36} reported varying proportions of the population who are not covered by the scheme; a World Bank study⁷ reported that only 40% of the Ghanaian population were enrolled in the scheme by 2013. The actual figures and percentage of the population covered by the scheme from 2005 to 2017 are presented in Figure 3.

Figure 3 NHIS Active Membership from 2005 to 2017 (Source: National Health Insurance Authority118 119; Nsiah-Boateng & Aikins120 2018).

Though the scheme covers the major disease burden of the country, other services are not under the scheme. Many citizens are not eligible to access care because they are not enrolled in the scheme due to financial problems. The scheme is expected to protect Ghanaians against the cost of healthcare but it rather excludes the very poor, thereby increasing the financial burden on the poor. Ghanaians should not use the international definition of poverty as exemption criteria for premium payment as many local context variables are unique to the concept of poverty in Ghana.^22,32,37 Fenny et al³² also suggested that the poor should be exempted from making insurance payments. The financial barriers need to be eliminated if the scheme is to fulfil the Universal Health Coverage mandate.^{26,–37–39} Asundep et al³⁰ believe that minimizing the premium and increasing access is essential. The free maternal, child, and aged care policy is laudable and should be continued. The more vulnerable groups should be exempted from paying the NHIS premium. This will ensure that coverage is extended to the poor.^40,41

Financing

Both health revenue and expenditure increased because of NHIS.⁴² Enrolment in the scheme increased continually, though there was a high rate of non-renewal putting the scheme under high financial stress. This section describes the sources of funding, subscription, and renewal. In a study to enlist the challenges that the implementation of the NHIS has encountered, Sodzi-Tettey et al⁴³ discovered that the scheme was threatened by organizational, financial, and administrative problems. The authors recommended, amongst other things, the adoption of a more modern payment system to salvage the future of the scheme.

Funding

The scheme is predominantly funded through taxes, specifically 2.5% of the 17.5% VAT, 2.5% of the 17.5% SSNIT from formal sector employees, dividends of investments made by the NHIA Council, donations, and premium payments.^44–46 Addae-Korankye³⁸ revealed that there is inadequate funding for the NHIS. Costs incurred in funding the free maternal health policy were almost 5-times the seed grant provided by donors.⁴⁷

Enrolment and Resubscription

Enrolment and resubscription is a major barrier under the scheme.⁴⁸ Enrolment in the scheme increased in multiple folds since its inception.⁴⁴ Many studies^8,32,34–36 reported varying proportions of enrolment. Boateng and Awunyor-Vitor³⁵  discovered that out of the 61.1% of their respondents who were enrolled in the NHIS, 23.9% had not renewed their insurance after enrolment.³⁵ High rate of non-renewal put the scheme under financial stress.³⁴ Factors that influenced resubscription included age, economic status, usefulness, accessibility, affordability, and perception of the quality of service provided.^36,41 Also, the probability of resubscription was proportional to having used the services in the previous year.⁴⁹ Adei et al³⁴ advised that the government should consider implementing the one-time premium payment.

Reimbursement of Providers

Default in paying service providers for the services provided for clients under the scheme negatively affected the implementation of the NHIS.^42,50,51 Between 2011 and 2014, there was at least 4 months delay in paying almost all the financial claims made.⁵² This was as a result of poor funding, manual processing of claims, and mismanagement of scheme funds.^43,53 To tackle the financial challenges surrounding the scheme, researchers^45,53 advocated that proper financing mechanisms should be implemented.

Service Delivery

Quality, Attitudes of Providers, and User Satisfaction

Primary healthcare centers lacked adequate resources to discharge their services, thereby providing poor quality of preventative services under the scheme.^50,54 User satisfaction with the services provided under the NHIS was below average. Only one-third of the facilities delivered efficient services, public facilities delivered more efficient services than private and mission facilities.^55,56 Those insured under the scheme were more dissatisfied with service provided than the uninsured,^10,11 in contrast to the findings of Yawson et al⁵⁷ that the insured received a better quality of care than the uninsured. Dalinjong and Laar⁵⁸ also reported that both insured and uninsured were satisfied with the quality of treatment they received.

The poor mostly used community health centers, whilst the rich and the uninsured mostly patronized public hospitals and private centers, respectively.³¹ Wealthy men perceived the services of the scheme as inferior to other mmodes, however, wealthy women did not perceive the services of the scheme to be inferior to other alternatives.⁵⁹ Unlike community health compounds, dominant proportions of women who sought ANC services at hospitals and health centers delivered their babies at these facilities.²⁹ Rural facilities had higher chances of being more competent than urban ones.⁵⁵ Asundep et al ⁶⁰ found that 20% of women accessing care through the scheme experienced adverse health outcomes.⁶⁰ A high proportion of citizens did not have access to an MRI scanner.⁶¹ Also, long waiting time in the hospitals was a disincentive for people to subscribe to the scheme.³⁶ Quality improvement measures should be instituted to improve the quality of services provided to the clients, especially in the private healthcare facilities.^62,63

The access and financial protection provided by the scheme have improved health-seeking behaviors and reduced risky health behaviors such as self-medication among Ghanaians.⁶⁴ Though some studies^42,65 reported a positive attitude of providers towards service delivery, others¹⁰ reported poor attitudes of providers. Use of traditional medicine was high amongst both insured and uninsured but had no association with insurance status.⁶⁶ Quality of care and proximity were two factors that influenced the choice of care provider.⁶⁷

Outcomes

Those insured under the scheme believed that providers had poorer attitudes towards them than those who are not insured under the scheme.⁵⁸ There was no statistically significant difference in the occurrence of low birth weight in before and after the implementation of the NHIS.⁶⁸ However, the proportion of infant mortality recorded before the implementation of the scheme was halved during the insurance period; likewise, more maternal deaths were recorded in the previous system as compared to the NHIS regime.⁶⁹ Also, a higher number of cesarean sections were conducted in the NHIS period than before.⁶⁹ Lambon-Quayefio and Owoo⁷⁰ observed that insurance significantly reduced neonatal death. Mensah et al⁴⁰ also recorded that insurance leads to improvements in perinatal health indicators for women. Nguyen et al,⁸ Strupat and Klohn,⁷¹ and Aryeetey et al⁷² also found that the uninsured had more health expenses than the insured. Therefore, the insured sought to use health services more than the uninsured.^57,58,73

Failures/Challenges

After 10 years of implementation (2003–2013) less than 40% of the population of Ghana had subscribed to the NHIS. National coverage or UHC is far from reach at this pace. National Health Insurance as portrayed by the government and the policy document is to protect the population against the negative consequences of the cost of healthcare. Though the NHIS was envisaged to be more preventive than curative it has lost its preventive nature and is currently more curative .²⁴ The scheme is not as pro-poor as it has been envisaged.⁷⁴ Mills et al stated that the policy favored the rich rather than the poor it was intended to, creating much more burden on the poor.⁷⁵ Because, the rich and the poor pay the same amount to subscribe to the scheme but the rich access private fee-for-service healthcarewhen the NHI accredited facilities run out of medicines and other healthcare supplies.

Systemic corruption in sub-Saharan African institutions is a threat to the sustainability of the financial model in Ghana. Healthcare institutions issue false claims for reimbursement; some healthcare users admitted conniving with healthcare providers to defraud the scheme.^25,76 Systems need to be put in place to keep the policy relevant to its purpose. As the health system develops and the health needs of the population change, a policy review will be necessary to make it effective.

Governance

This section covers system design, coalition building, transparency, oversight, and accountability.⁷⁷ The sustainability of the NHIS in Ghana is of grave concern. It seems as though the implementation of the scheme was rushed.⁷⁸ There was more emphasis on the roles of political actors than the technical insight provided by experts in the field of public health insurance policy.⁷⁸ Whilst recognizing the crucial role that the political elite play in the formulation of public policy, Agyepong and Adjei⁷⁸ cautioned that the overarching influence that the political class had on the program design and implementation could be a threat to the realization of its goals and objectives .

Financial Management

There are enough sources of funding for the scheme; corruption, mismanagement, lack of transparency in the funding, claims, and reimbursement issues should be checked by the leadership of the scheme. The government should implement the electronic claims, verification, and reimbursement system across the entire country to curb corruption and default in reimbursement of facilities.^46,52 There is too much wastage in the NHIS, which should be dealt with by various stakeholders.⁵⁵ Measures should be put in place to reach 100% subscription and resubscription status to raise more funds for the scheme.⁴⁹ Also, the rich should be made to pay more to increase the funds for the scheme.³⁸

System Design and Oversight

Political machinations and poor monitoring and evaluation hinder the smooth running of the scheme.⁵⁴ Other challenges to the scheme are in the form of inadequate workforce and weak institutional arrangements and transparency.^43,44,79 Administration at both central and local levels affect the decision of people to subscribe to the scheme and continue their subscription.⁸⁰ The NHIS needs to be reviewed to ensure good leadership and governance, transparent and accountable institutional arrangement, and effectiveness and sustainability of the scheme.^79,81,82

Community Participation

Lack of community participation is a common phenomenon in SSA. Many studies^{23,50,51,59,74,83} reported lack of community participation in the NHIS policy formulation and implementation. The policy resulted from a political campaign and the stakeholders knew only the intended political messages. They were not further educated on the consequences of registering or not as well as the details of the technical language that was contained in the policy document. Many people cannot demand services because they either do not understand or are afraid to ask questions about the package.⁸⁴ People need to be empowered to demand services they are due. ⁸⁴ Researchers recommended the need for stakeholder consultation in improving and sustaining the scheme.^{50,51,59,74,83}

Competing Interest

Politicians attempted to make political gains out of the finances of the scheme at the expense of the development of the scheme.⁸⁵ Because it was a political campaign promise, stakeholder consultation and input produced friction, as the politicians pushed to achieve their campaign promises, whether realistic or not. It is necessary for the politicians to know their boundaries and delegate the technocrats to superintend policies of such a magnitude.⁷⁸ Other stakeholders of the scheme also tried to swing the policy in their favor using all means.⁸⁶ Institutional arrangements among all stakeholder groups should be determined with terms of reference that will enhance the policy implementation. There is need for all stakeholders to clearly understand the content of the policy to avoid ambiguity and role conflicts.^4,85

Discussion

From the results, Ghana has contributed much in efforts and funding to make the NHIS work but has struggled with issues of coverage, funding, stakeholder participation, and governance. Corruption and political interference are also seen as major threats to the sustenance of the scheme.

The proportion of the population enrolled in the NHIS from its inception has been less than 41%, apart from 2008 and 2009 where the scheme unexpectedly recorded 54.66% and 61.97%, respectively. This was attributed to the inability of the Scheme management to exclude the members who had not renewed their membership since the inception of the scheme. In 2008, the NHIS was at the center stage of the national election campaign, and politicians were seen enrolling people as part of the election campaign. This may also account for the higher figures in 2009 as elections were held in December 2008. Other reports cited indicated that the scheme had difficulty in reimbursing service providers coupled with administrative challenges, resulting in dissatisfaction of members who intentionally did not renew their membership. This resulted in a sharp decline in membership to 32.95% in 2010. The scheme recorded a slow increase in membership from 2010 to 2015; then took another downward stroke due to apathy among subscribers as a result of the delay in reimbursement of health service providers and charging of unapproved fees.^87,88

Unlike Ghana, South Africa will not have issues with subscription, premium payment, and waivers for certain groups of people. The NHI bill provides for free healthcare for all South Africans.⁸⁹ This allows healthcare to be completely accessible to all the population. Many stakeholders in South Africa are seeking clarification on the source of funding, modes of facility reimbursement, and the ability of the system to resist corruption.^90–96 These critical questions need to be addressed to avoid system collapse. Various forms of inclusive sources of funding should be prioritized as well as efficient use of resources within the NHI in South Africa.^91,96 The gross inequity in South Africa may be deepened if the system is not designed to address resource allocation and funding mechanisms.

The financial stress that the NHIS is subjected to is partly because 65% of the active members are exempted from paying premiums. This group is made up of mostly pregnant women, children under 18 years of age, the aged (70 years and above), and indigents. Though the exemption has led to increased access to quality healthcare by the exempted groupings, the burden of the care provided stresses the NHIS financially. Enough funding is made available from the various sources of funding, for example, the highest claims paid to health facilities was 81.1% of total income by the scheme. Poor governance and corruption as a result of poor stakeholder participation and political influence were cited as the major challenges threatening the financial sustainability of the scheme.^{43,4547,52,53}

Even though the private sector caters for the health needs of 16% of the South Africans as opposed to the 84% that the public sector serves, private sector consumers account for 52% of the nation’s health sector budget, whilst the public sector accounts for a paltry 48%.⁹⁷ The gross inequality created by the huge but less funded public sector and small but heavily funded private healthcare system is alarming and needs a system redesign. The National Health Insurance is a strategic political attempt to bridge the healthcare access and quality gap between the poor and the rich by the African National Congress.⁹⁸ The entire NHI policy was expected to be rolled out in three phases within 14 years from 2012.⁹⁹ After 7 years, stakeholders are concerned about the implementation of the NHI, especially in the areas of quality of the healthcare, corruption, mismanagement of funds, fear of overcrowding of private hospitals, poor attitudes of healthcare workers, and reimbursement mechanism.^{90,98,100–103}

As seen in Ghana, both private and public healthcare sectors in South Africa have come under intense criticism regarding the quality of healthcare provided.¹⁰⁴ Many believe that the current public health system needs a system clean-up and reorientation because of gross mismanagement, corruption, and poor quality of services provided.⁹⁸ Though there is a general positive perception about the quality of healthcare provided in the private sector, ¹⁰⁴ findings from a study conducted by the University of Cape Town revealed high malpractice within the private sector in South Africa.¹⁰⁵ Though the NHI/UHC policies increase access to healthcare, it is necessary to look at the quality of care provided within the UHC, as poor quality of care tends to be costly in the long-term.^106–108

In South Africa, the majority of the stakeholders believe that the policy-shift is inevitable. The fear, however, is the clarity in the roles of all stakeholders.¹⁰⁹ General practitioners and specialists who practice or moonlight in the private sector, the private medical schemes, and the private hospital groups feel threatened and targeted by the policy. Stakeholders are calling for the NHI bill to clarify issues regarding the role of existing medical schemes, the NHI referral pathway, the benefit packages, and sources of funding.^93,96

Policymakers should endeavor to involve frontline workers in addressing the concerns of the scheme.⁸⁴ Communities should be encouraged through public education to expand the coverage of the scheme.³⁵ Public awareness programs should be instituted to improve user knowledge and confidence in the scheme.¹¹⁰ Encouraging stakeholder participation in decision-making is widely recommended.^{91,109,111–113} Barker and Klopper¹¹² reported that the community studied resisted taking power and decision-making roles in planning and delivering care. Participation in decision-making is the constitutional right of the communities in South Africa and must be respected by engaging them in critical decisions that affect their livelihood.¹¹⁴ Lastly, communities need to be empowered to demand accountability.

Many bright institutions have fallen because of poor and ineffective leadership in sub-Saharan Africa. Political influence in institutions that are expected to be autonomous is evident across the continent, especially when the government has a role in the appointment of the leadership and funding the institution. Corruption among healthcare leadership is a cancer that eats deep to the core of the healthcare sector in South Africa.⁹⁵ Corruption is capable of making healthcare institutions resource-poor, ineffective, and produce poor quality health outcomes. Therefore, the South African healthcare system needs to be redesigned to curb corruption, especially when the NHI bill seeks to consolidate healthcare funds to be managed by boards that are accountable to a political authority, the Minister of Health.^95,115

Many stakeholders also believe that the policy confers too much power on the Minister of Health to appoint and superintend committees; an ineffective or corrupt Minister of Health could destroy the well-intended healthcare system and funding mechanism. Opposition parties in parliament also believe that the NHI is a mechanism for the ruling party and its appointees to steal taxpayers’ money to enrich themselves. The Minister of Health, Dr Zweli Mkhize, however, said that the president recognizes the threat corruption poses to the insurance and has inaugurated health sector anti-corruption forum to check corruption within the NHI system.⁹⁴ Good leadership and governance are essential to the implementation of NHI. Despite the imminent need for the implementation of the NHI in South Africa, the systems need to be redesigned to provide quality and resist corruption and mismanagement.⁹⁸

Conclusion

The implementation of the NHIS in Ghana has provided access to healthcare for the underprivileged despite the numerous challenges. The scheme has successfully expanded care and protected the poor against the negative consequences of healthcare cost for a decade and a half. Nguyen et al⁸ recommended that other countries learn from the NHIS policy in Ghana, and implement a similar policy towards UHC. South Africa has a more robust economy and double the population of Ghana but has historical and sociocultural similarities with Ghana. Despite the huge capital ingestion into the healthcare sector, South African health indicators have not improved compared to countries that have similar or lesser capital inputs. This has been mainly attributed to the public–private, rich–poor, and rural–urban inequalities in healthcare delivery.^116,117 The NHI policy is widely accepted as the means of eliminating inequalities in the healthcare system. Therefore, the success of NHI is imperative. Learning from a system that worked within the same region and building systems that overcome the mistakes, challenges, and roadblocks in the already implemented systems are essential.