CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
The World Health Organization (WHO) defines health as "a state of complete
mental, physical, and social well-being, rather than the absence of disease, illness,
or infirmity." Many of the world's 1.3 billion people still lack access to effective
and affordable drugs, surgeries, and other interventions, according to the WHO,
due to flaws in health-care financing and delivery (WHO, 2000; World Bank,
1993 ,1997). While 84 percent of the world's poor bear 93 percent of the global
burden of disease, only 11 percent of the $2.8 trillion spent on health care reaches
low- and middle-income countries, according to Alexander and Guy (2004).
Vaccination programs implemented by modern health-care systems have reached
millions of people in need. Low-income rural households, on the other hand,
continue to use homemade remedies and seek out traditional or local healers, who
are often outside the formal health system, when they become ill. At low-income
levels, the percentage of the population covered by risk-sharing arrangements in
the form of health insurance is lower.
As a result, the wealthy and urban middle classes have easier access to modern
health-care facilities. The flow of funds through the health-care system and the
private mix is complex, and different countries use different funding schemes or
strategies. In general, for middle- and higher-income countries where income is
easily identifiable and taxes or premiums can be collected at source, a
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combination of taxation, social insurance, private health insurance, and limited
out-of-pocket user charges has become the preferred health-financing instrument.
In the United States, health care is provided by a variety of private and non-profit
organizations under various health insurance schemes (World Development
Report, 1993). The United States spends more per person on health care than any
other country on the planet. Furthermore, current estimates place US health-care
spending at around 15.2% of GDP. Within the next decade, the health-care share
of GDP in the United States is expected to continue its upward trend, reaching
19.5 percent of GDP by 2017. According to the Institute of Medicine of the
National Academy of Sciences, the United States spent $2.26 trillion on health
care in 2007, or $7,439 per person. The United States is the only wealthy and
industrialized nation without a universal health care system.
More importantly, 84.7 percent of citizens have health insurance of some kind.
Insurance is obtained through their employers in 59.3 percent of cases, privately
purchased by individuals in 8.9 percent of cases, or given by government
programs in 27.8 percent of cases. Furthermore, as of 2007, the number of
Americans without health insurance accounted for 15.3 percent of the population,
or 45.7 million people. In the United States, health-care expenses are rising faster
than wages or inflation. Public access to emergency health services in the United
States is mandated by federal law, regardless of ability to pay. Medicare,
Medicaid, Tricare, and the Veterans Health Administration are all governmentfunded health-care programs that help the aged, disabled, children, veterans, and
the poor. The US government's programs accounted for nearly 45 percent of
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health-care spending, making it the country's largest insurer. In 2004, the US
government's per capita health-care spending ranked among the top ten highest
among United Nations member countries (WHO, 2000). The National Health
Service (NHS) of the United Kingdom (UK) is a publicly funded health-care
system that covers everyone who lives in the UK.
Because no premiums are collected, charges are not levied at the patient level, and
expenditures are not pre-paid from a pool, the health system is not strictly or
essentially an insurance program. However, it accomplishes the primary goal of
health insurance, which is to share the financial risk associated with illness. The
NHS's operating expenditures, estimated at £104 billion in 2007/8, are funded
entirely from general taxation. Primary health care, in-patient care, long-term
health care, ophthalmology, and dental treatment are all provided by the NHS in
the United Kingdom. According to the World Health Organization, government
funding funded 86 percent of overall health care expenditure in the United
Kingdom in 2004, with private enterprises providing the remaining 14 percent.
The majority of health insurance in Canada is administered by provinces under
the Canada Health Act, which mandates that everyone has free access to essential
health services (WHO, 2000). Medicare is the collective name for all of Canada's
public provincial health insurance programs.
Private health insurance is allowed, but only for services not covered by public
health programs. Canadians, on the other hand, are allowed to use private health
insurance for elective medical procedures like laser eye surgery and cosmetic
surgery. Approximately 65% of Canadians have private health insurance. Many of
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them get it at work (OECD Health Project, 2004). Nearly 30% of total health-care
spending is on non-reimbursed private-sector services. In India, health care is
provided by tax-funded public providers, formal employers' insurance, and nonprofit and philanthropic groups (Dave, 1991). In India, the public health system
supports the majority of poor families, especially those who reside in rural areas
without access to private medical practitioners.
As a result, residents in these areas are forced to rely heavily on unskilled local
practitioners and faith healers. Health facilities are either non-existent or of
inadequate quality. The government's claim of free secondary and tertiary care has
not been substantiated. Certain services do charge a price (Gumber & Kulkarni,
cited in Alexander & Guy, 2004). According to Gumber and Kulkarni, only 9% of
Indian workers have health insurance. The majority of those covered are
employed. Public insurers are wary of entering the voluntary medical insurance
market due to low profitability, significant risks, and limited demand. A few
NGOs and philanthropic institutions have helped provide health services to the
poor and disadvantaged in Indian communities. Reaching out to the socially
marginalized and ensuring uninsured access to basic, affordable care is critical.
The WHO classified French healthcare as the best in the world due to high quality
and patient liberty (World Bank, 1993). Shortly after WWII, the National Health
Insurance System was formed in 1945. The insurance plan varies by profession.
A health insurance fund that pools risk and reimburses medical expenditures is
required of all employees. Children and spouses of covered adults are also
eligible. Each fund is in charge of budgeting and reimbursing medical expenses
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(Ambler, 1993). The French government sets the rate for negotiating medical
costs, working with the Ministry of Health, pharmaceutical companies, and other
experts. The French government also oversees the administration of healthinsurance payments and the coordination of the public hospital network. One of
these compulsory worker-paid schemes covers all French citizens and lawful
foreign residents (Glasser, 1991). The government provides health care to those
who are not covered by the mandatory system. Those who have never worked and
are not currently in education. Unlike the worker-funded scheme, this one
reimburses those who cannot afford to make up the difference at a greater rate
(WHO, 2000).
In Ghana, the government through the Ghana Poverty Reduction Strategy (GPRS)
has outlined a strategy for dealing with poverty (GPRS 2006) (GPRS 2006). A
major component of the strategy is to deliver accessible and affordable health care
to all residents of Ghana especially the poor and vulnerable (MOH, 2002). (MOH,
2002). The method of financing health care determines its accessibility and
affordability. As a poverty reduction strategy, the government has put in place a
policy framework for the establishment of the National Health Insurance Scheme
(NHIS) to replace the old cash and carry system which did not favor the poor and
marginalized in society. The policy framework allows for the establishment of
multiple health insurance schemes with a focus on the social-type known as
District Mutual Health Insurance (DMHI) to address the needs of the poor (GOG,
Act, 650. 2003). (GOG, Act, 650. 2003). Health care financing or funding in
Ghana like others in the rest of Africa, has had a checkered history. The
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independence of Ghana in 1957 brought, among others, free health care for all
citizens in public health facilities (Aikins, 2003). (Aikins, 2003). It meant that
there was no direct out-of-pocket payment at the point of consumption of health
care. The funding of health care was entirely through the government tax revenue
and donor support.
Unfortunately, the sustainability of a free health care system became problematic
due to competing demands on the national health budget and the allocation of
resources to the various ministries coupled with the economic decline suffered in
Ghana during the 1970s and 1980s. Consequently, there was a substantial
reduction in health care spending between 1975 and 1983. According to the health
sector review report (MOH, March, 2002), for instance, in 1983, healthcare
spending dropped to less than 2 percent of the 1975 levels. This situation
continued until 1985 when the Government introduced the “Hospital User-Fee”
for all medical conditions except certain specified diseases. According to Aikins
(2003) the free health care policy was poorly implemented because although
communicable diseases were supposed to have been exempted, in practice no
body enjoyed this facility. Moreover, a guideline for implementation was not
provided and no conscious system was designed to prevent possible financial
“leakages” in the scheme. The government's introduction of "Hospital User-Fees"
resulted in a decrease in the use of health services in the country. According to
Waddington and Enyimayew (1990), there was a severe shortage of essential
drugs in all public health facilities, resulting in a drop in the quality of health care
delivery and utilization. Notwithstanding these challenges with health funding,
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Government went ahead to introduce in 1985 full cost recovery for drugs as a way
of generating revenue to address the shortage of drugs. The payment mechanism
put in place was termed the “cash and carry” system. The implementation of the
“cash and carry” system created a financial barrier to health care access,
especially for the poor.
The Ghana Demographic and Health Survey (2003) report estimated that out of
80 percent of the population who required health care at any given time, only 20
percent were able to access it. This meant that about 80 percent of Ghanaians who
needed health care could not afford it. According to Aikins (2003) the
Government of Ghana in an effort to eliminate the negative effects of the “cash
and carry” system on the poor, commissioned various committees to search for
alternative ways of funding health care especially insurance-based ones. A lot of
resources were invested into investigating the feasibility of an NHIS in the 1980s.
Proposals to set up and run an NHIS have been an issue of discussion by
governments within the latter part of the late 1970s. Since the early 1980s, various
experts, local and international have been contracted by the Ministry of Health
(MOH) to study and make recommendations for setting up and running a National
Health Insurance Organization. The International Labor Organization (ILO),
WHO, the European Union and London School of Tropical Medicine visited
Ghana in 1994 and provided technical advice at the request of the Ministry
(Atim,1999) (Atim,1999).
In August 1995, the MOH received definite proposals from a private consultancy
group entitled “A feasibility study for the establishment of a National Health
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Insurance Scheme in Ghana”. The study proposed that a Centralized National
Health Insurance Company should be set up to provide a compulsory mainstream
social insurance scheme for all contributors to the Social Security and National
Insurance Trust (SSNIT) and all registered cocoa farmers. The report also advised
the piloting of rural- based community financed projects for the non- formal
sector but given no information or indications as to how the MOH was to do this.
The report's main focus was on the National Health Insurance System (NHIS).
The NHIS pilot project in the Eastern Region was officially launched in 1997. It
was meant to cover the districts of New Juaben, Suhum/Kraboa/Coaltar, South
Birim, and South Kwahu. According to Atim (1998), the project's goal was to
"test the grounds," "study the performance of existing schemes," "identify
problems," and "eliminate them" before a nationwide rollout of the scheme.
During the same time period, the people of the Brong Ahafo Region's Nkoranza
District, with the help of the Catholic Health Service, established the first
Community-Based Health Insurance Scheme (CBHIS) to finance their health-care
costs.
Since then, many similar schemes have emerged, particularly in the last decade,
such as the Nkoranza Community Health Insurance Scheme, Dangme West
Health Scheme, and Damongo Health Insurance Scheme. These CommunityBased Health Insurance Schemes (CBHIS) have had a huge amount of success.
According to Atim and Sock (2000), they were able to improve financial access to
health care, particularly for poor rural dwellers in the informal sector, who were
the hardest hit by the "Hospital User-Fees" effects. It has improved their health8
seeking behavior and decreased "under-the-table" fees. Furthermore, the programs
have increased the use of health services, increased community solidarity, and
indirectly improved health status while also lowering the cost of health care for
patients.
These achievements, which are in line with the Ministry of Health's vision and
objectives, prompted the Ghanaian government to expand the use of such schemes
as part of the National Health Insurance Policy. The Ministry of Health's main
goal is to improve people's overall health and reduce inequalities in health
outcomes in Ghana. One of the Ministry's strategies to achieve the above goal was
to extend prepayment schemes to replace the cash and carry system, ensuring that
financing did not become a barrier to health services. The Ghanaian government
passed the National Health Insurance Act (Act 650) in August 2003, with the goal
of enhancing access and quality of essential health care services in Ghana.
According to Stine (2003), the NHIS is a fusion of the concept of Social Health
Insurance (SHI) and Community-Based Health Insurance Schemes (CBHIS) that
usually covers a whole district. This is also known as the District-Wide Mutual
Health Insurance Scheme (DMHIS), which is a non-profit organization.
According to the policy framework for the introduction of health insurance in
Ghana (MOH, 2002), the goal is to provide equitable, universal access to highquality basic healthcare services to all Ghanaians without requiring out-of-pocket
payments at the moment of service consumption. As a result, principles including
equity, risk equalization, cross-subsidization, and quality care dictate the creation
of the NHIS. Efficiencies in premium collecting and claims administration,
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community or subscriber ownership, partnership, and reinsurance are among the
others (Sabi, 2005).
1.2 Problem Statement
The government's goal in establishing health insurance plans in Ghana was to
provide equal and universal coverage to all Ghanaians. All citizens were to
receive a satisfactory level of necessary health care without the need for out-ofpocket payment at the time-of-service utilization. The creation of health insurance
plans in the districts was mandated by the District Assemblies. The government
initially provided start-up cash for the project's launch and facilitation. However,
it appears that human capital, logistics, and existing health infrastructure at the
district and regional levels have posed severe hurdles to providing the necessary
health services that would make the health insurance plan profitable and
sustainable. According to Aikins (2003), while some of the schemes were
performing well, others had issues with staff who had the necessary analytical
abilities to successfully manage data and other scheme matters.
Sabi (2005) also discovered that, despite the fact that most schemes had solid
management structures that supported democracy and grass-root participation, the
qualifications and experience of those in various positions were insufficient to
lead the schemes effectively. According to Sabi (2005), health insurance plans
operated by people with little or no formal education and little or no expertise of
how to handle such schemes makes effective management impossible. Sabi
(2006) did a more recent study that found a shortage of trained individuals to
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operate the NHIS as well as insufficient health staff to offer the necessary health
care. The problem was considerably worse at the district level, where a lack of
managerial abilities was more obvious. NHIS subscribers have complained about
delays in the issuance and renewal of their membership ID cards, the quality of
health care provided at health facilities, and the general frustration that people
have in accessing the services of both NHIS officials and health care providers in
general across the country.
For example, according to Yeboah, the inability of certain NHIS subscribers to
use their membership ID cards to get health care across the country poses a severe
challenge to the scheme (2007). Household heads and their dependents in the
Amansie West District Assembly are occasionally forced to pay for their health
care because they are not registered members of the system or because the
issuance or renewal of their NHIS cards has been unfairly delayed (Yarboi, 2007).
The NHIS is a novel system in the country, and a critical assessment of the
obstacles of implementation would provide an alternative framework for the
scheme's implementation, as little or no study has been done on this component of
health insurance. The findings or outcomes of this study would add to the existing
literature on health insurance and serve as a foundation for future research into
other areas of health care. The knowledge and experience gained via this
academic practice inspire and excite the researcher. Other healthcare stakeholders,
in particular, stand to gain a lot from the knowledge gained by this study.
1.3 Objectives of the Study
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The general aim of this study was to examine the challenges of the
implementation of the NHIS in the Amansie West District.
The specific objectives were;
1. To examine the challenges faced by scheme managers and their staff in the
Amansie West District.
2. To identify the problems encountered by people of Amansie West in
accessing the benefits of the District NHIS.
3. To make suggestions for policy makers and government on ways to
improve upon the operations of the scheme on in the Amansie West
District.
1.4 Research Questions
The study was guided by the following research questions.
1. What are the challenges faced by scheme managers and their staff in the
Amansie West District?
2. What are the problems encountered by people of Amansie West in
accessing the benefits of the District NHIS?
3. In what ways can the operations of the NHIS at the Amansie West be
improved?
1.5 Significance of the Study
The research findings would be publicized to managers of the region's NHIS.
This, it is anticipated, would inform policymakers and aid in the improvement of
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the scheme's operation within the university community. Because health
insurance is a relatively new idea in Ghana, the study's findings will serve as a
reference for students and health care professionals such as nurses and physicians.
Additionally, the findings should stimulate debate among students and academia,
as well as interest in additional research on health insurance or health care, as the
case may be. The Ministry of Health (MOH) and her development partners should
be interested in recommendations and initiatives that will most effectively
improve the country's NHIS implementation. The research recommendations
would contribute to accomplishing this goal. The study's findings will contribute
to the current body of information on health insurance and to the field of health
care insurance.
1.6 Delimitation of the Study
The study was limited to the challenges of the implementation of the NHIS in the
Amansie West District. It was not possible to study the entire Ashanti Region, for
lack of resources to conduct and elaborate extensive research of this sort. The
limited scope of the study enabled the researcher to complete the study within a
specified time.
1.7 Limitations of the Study
One notable shortcoming of the research design is the type of data obtained or
collected; self-report responses may be unreliable because people may provide
socially acceptable responses. According to Nieswiadomy (1993), the ability to
generalize sample results to the population in survey research design depends on
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the sampling method. The researcher also encountered problems with retrieving
questionnaires from participants and the reluctance of some interviewees to
participate in the study. These challenges were addressed through persuasion and
encouragement of participants to complete the research process
1.8 Organization of the Study
The second chapter reviews pertinent literature. The following topics are
discussed: the insurance concept, the various types of health insurance, the
characteristics of health insurance plans, the inherent problems with health
insurance, the various types and principles of health insurance schemes in Ghana,
and a review of related literature. The third chapter discusses the research
methods employed to conduct the study. The study region, the study population,
the research design, the sample and sampling strategy or procedures, the delivery
of questionnaires and interviews, and data collection are all taken into
consideration. Chapter four contains the data analysis, while chapter five contains
the study's summary, results, and suggestions.
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CHAPTER TWO
REVIEW OF RELATED LITERATURE
2.1 Introduction
This chapter discusses the existing literature related to the topic. It addresses
issues such as the concept of insurance, types of insurance, inherent problems
with health insurance, types and principles of health insurance schemes in Ghana
and concludes with a summary of the literature review.
2.2 Conceptual Review
2.2.1 The Concept of Insurance
Insurance has been defined differently by various agencies. Nielson (1998)
defined insurance as a mechanism for spreading risk or unpredictable events
among a large number of people. Paul and Williams (2001) defined insurance as a
mechanism that takes a risk that would be too enormous for one person and
spreads it across a large number of people, transforming it into a risk that is
manageable by a large number of people. According to the Wikipedia
Encyclopedia (2008), insurance is a method of risk management used largely to
hedge against the danger of a contingent loss in law and economics. Insurance is
described as the transfer of risk, in exchange for a payment, from one entity to
another. The term "premium" refers to the fee associated with a particular
insurance coverage or the cost of an insurance policy. An insurer is a business,
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individual, or corporation that sells insurance. The insurance rate is the
determining factor in establishing the premium.
While risk management entails the processes of risk assessment and management.
Risk is a term that relates to the source of a potential loss, sometimes referred to
as a risk. Insurance could be viewed as a legal contract that protects individuals
from the financial consequences associated with death, illness, lawsuits, or
property damage. Insurance enables people and societies to deal with some of the
hazards inherent in daily living (2008, Wikipedia Encyclopedia). Paul and
Williams (2001) estimate that practically everyone who lives in a modern
industrialized country purchases insurance. For example, most nations, including
France, Germany, England, Japan, and the United States of America, require car
owners to get insurance prior to operating their vehicles on public highways.
Lender’s demand anyone who borrows money to acquire a home or a car to insure
the property. In the United States and the United Kingdom, certain states provide
social insurance, a type of mandated insurance supplied by the government when
market failures are serious enough that the private sector cannot provide adequate
coverage. In this case, the government steps in to offer comprehensive and
universal coverage for its residents.
2.2.2 Health Insurance
Health Insurance is a system in which a large number of people contribute small
amounts of money to a common pool in exchange for a specific health benefit
during a specified time period (Atim, 2000). In most health insurance schemes,
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the primary actors or stakeholders are the subscribers or contributions, the health
care or service providers, and the managing institution or firm.
Health Insurance may also refer to cases in which officials, a committee,
commission, or taskforce formally hold a basket of resources or cash comprised
of insurer payments that are utilized to fund all or a portion of the basket (CHAG,
2002). According to Kankye (2001), when a group of people band together to pay
for their health care needs, they are said to be working under the principles of a
health insurance plan. Members donate an agreed-upon amount to a communal
"pot." This technique is strikingly similar to the "susu" groupings prevalent in
certain corporate circles and vocational organizations. However, their operations
are fundamentally different.
2.2.3 Types of Insurance
Campbell and Stanley (2002) demonstrated that any quantifiable risk may be
insured. Perils are certain types of danger that may result in claims. Typically, an
insurance company will specify in detail which risks are covered and which are
not. Depending on the type of insurance, a single policy may cover one or more
risks. Disability insurance, casualty insurance, life insurance, property insurance,
liability insurance, credit insurance, and health insurance are only a few of the
types or categories of insurance. According to Nielson (1998), disability insurance
is a sort of insurance that replaces a worker's income if they are unable to work
due to an accident or illness. Benefits are typically structured to pay a percentage
of a person's real wages, typically between 40% and 60%. Short term disability
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insurance covers a period of disability of up to six months. Long term disability
insurance is coverage that extends beyond six months.
According to economists Paul and Williams (2001), life insurance is an
organization's absorption of the risk of a policyholder's death. Loss of life
insurance is an inescapable fact of life. The element of uncertainty is the time of
death. Mortality is a probability, and life insurance premiums are typically
computed using mortality data, which reveal the average number of persons who
die each year in each age and gender category. According to insurance expert
Nielson (1998), property insurance protects individuals against the loss of or
damage to property they have purchased, such as houses and expensive objects
such as appliances and jewels. Casualty insurance protects individuals from
having their property seized to reimburse others in judicial settlements. Campbell
and Stanley (2002) defined liability insurance as an individual's legal and
financial obligation to another. A person may be held accountable for causing
another person's loss or harm, or for having an unpaid obligation. Generally,
liability claims require an assessment of fault for the loss or damage, whereas
other types of casualty claims do not. When someone is injured on, in, or on the
property of another person, the property owner may be held legally accountable
for the injuries. Credit insurance, according to Campbell and Stanley (2002),
refers to transactions involving the transfer of money or other property with the
guarantee of reimbursement at a future period. As a result, the transferor becomes
a creditor and the transferee becomes a debtor; hence, credit and debt are just
terms describing the same process from opposing perspectives. Health insurance
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safeguards individuals from the financial burdens and repercussions of illness and
injury.
2.2.4 Inherent Problems with Health Insurance
Health insurance has a number of issues, including adverse selection and moral
hazard. These issues are described briefly below. Campbell and Stanley (2002),
renowned economists, recognized adverse selection and moral hazards as
common difficulties in all health insurance schemes. Adverse selection is a term
used by insurance firms to explain the tendency for only people who will profit
from the insurance to purchase it. In particular, when it comes to health insurance,
unwell people are more likely to obtain it due to the prospect of huge medical
expenditures. On the other hand, Paul and William (2001) highlighted that,
individuals who believe they are in pretty good health may believe that medical
insurance is an unnecessary investment. For example, if they visit the doctor once
a year and the cost is $250, this is far less expensive than paying monthly
insurance payments of $40. Insurance as a core idea seeks to balance costs over a
broad, random sample of persons (Nielson, 1998). Thus, an insurance business
might have a pool of 1000 randomly chosen subscribers who each pay $100 every
month. When one person becomes very ill while the others remain healthy, the
insurance company can utilize the money paid by the healthy people to cover the
expense of the sick person's treatment. Adverse selection, on the other hand, is a
higher risk when the pool is self-selecting rather than random, as is the case with
individuals wishing to purchase health insurance directly. Individuals with high
health care costs account for a disproportionate amount of health care spending.
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According to insurance expert Nielson (1998), moral risks emerge when an
insurer and a consumer enter into a contract based on symmetric knowledge, but
one party conducts action that is not contemplated in the contract, so altering the
insurance's value. A frequent example of moral risks is third-party payment,
which occurs when the parties involved in making a decision are not liable for the
decision's costs. A case in point is when physicians and insured patients consent
to additional tests that may or may not be necessary. Doctors benefit from the
avoidance of potential malpractice cases, while patients benefit from enhanced
certainty about their medical status. The insurance company bears the cost of
these additional tests, which may have had little say in the choice. Others, like as
Aikins (2005), define moral risks as situations in which covered individuals
consume services more frequently than necessary to the point of overconsumption
(Aikins, 2005). Moral hazard is a significant impediment to the viability of the
majority of Ghana's health insurance plans.
2.2.5 Health Insurance in Ghana
The evident shortcomings and inadequacies of Ghana's health institutions' "cash
and carry" cost recovery method highlighted the urgent need for an alternate
source of health care finance. This is because it is impossible to give health care
services for free. Additionally, the expense of receiving health care in Ghanaian
health facilities was growing increasingly intolerable for patients (MOH, 2002).
According to Sabi (2006), health care finance can take a variety of forms. Among
these alternatives are the following: 1. Direct out-of-pocket payment and personal
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health account at the place of service. 2. Risk sharing or pooling via taxation and
health insurance. The Mutual Health Organization appears to be gaining traction
as a possible alternative source of health care finance in the health sector (MHO).
This is a voluntary, not-for-profit insurance plan founded on mutual aid,
solidarity, and the pooling of health risks, in which members actively engage in
the scheme's management and operation (MOH, 2002). The MHO is a prevalent
method of financing health care in Ghana. The Catholic Church developed some
community-wide health insurance projects in Ghana in 1992, in Nkoranza and
Drobo in the Brong Ahafo Region, Damongo in the Northern Region, and other
parts of the country, as part of its fundraising efforts to assist health care delivery
(Stine, 2003). The Mutual Health Organization (MHO) was chosen because it is a
not-for-profit organization that is democratic and accountable to its members.
Additionally, the organization equips communities with the ability to make
informed judgments and choices when it comes to obtaining high-quality health
care services. This has undoubtedly provided an alternative to "cash and carry,"
while simultaneously contributing to the government's health budget. Health
insurance is one of numerous financing mechanisms used by the government to
fund health care in the country. According to the Ministry of Health's (2002)
Health Sector Review Report, over 80% of health finance in the public health
sector comes from taxation and donor contributions. The remaining 20% is
derived from Internally Generated Funds (IGF) via a “cash and carry” method.
Health insurance, in this structure, takes the place of the “cash and carry”
approach of payment for health services purchased. This means that tax money
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will likely continue to play a role in the health sector's overall funding plan for
some time to come. According to the research, health insurance was not designed
to replace direct out-of-pocket payment at the moment of service usage or
delivery, but rather to supplement it. According to the National Health Insurance
Policy Framework for Ghana (MOH, August 2004), the NHIS's purpose was to
enable the government to achieve its health objectives within the framework of
the Ghana Poverty Reduction Strategy (GPRS) and the Health Sectors' Five-Year
Programme of Work (POW) 2002-2006. Its purpose is to disperse the financial
risk associated with health care costs across a group of subscribers. The more
subscribers, the more likely there will be cash available to assist members in need
of health care. The aim is that consumers continue to pay for services consumed,
but in a more humanitarian manner, as they are no longer solely responsible for
health care costs. It becomes a shared obligation for all members of the
community who participate in the scheme. This demonstrates the government's
policy of requiring all residents in Ghana to join a health insurance system of their
choice. Access to health care is made easier for those who truly need it through
the Mutual Health Insurance Scheme. Nonetheless, access is determined by the
providers' location, the cost of treatment and their ability to pay, the quality of
care, and the sociocultural factors of service provision (Dzikunu, Helen, Thorup,
Hanne as cited in Stine, 2003). Financial obstacles to health care vary according
to the payment method in place at the time-of-service utilization. Paying out-ofpocket at the moment of service utilization promotes lack of access to health care.
Prepayment programs reduce or eliminate the financial barrier to health care
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access. (1990, Waddington & Enyimayew). In other words, access to health care
becomes unrelated to an individual's ability to pay for care out of pocket during
an illness. Direct out-of-pocket payments are regressive, as a greater proportion of
the poor and lower income group's income is spent on health care. Additionally,
individuals are expected to pay for services consumed during periods of illness
when they are unable to work. The long-term policy objective of implementing
health insurance was for every resident of Ghana to be covered effectively by a
health insurance plan (MOH, 2002). Thus, people would be safeguarded from the
difficulties connected with needing to raise money during times of illness in order
to obtain necessary health care.
2.5 Principles or Philosophy of the National Health Insurance Scheme
(NHIS)
Several conditions apply to the implementation of the NHIS, as stated in the
National Health Insurance Policy Framework for Ghana (MOH, 2004). For
example, every person living in Ghana is required to join a health insurance
system of some kind. This contributes to the development of a healthy and
thriving nation by reinforcing the spirit of solidarity, social responsibility, equity,
and a sense of belonging.
According to the policy framework, every Ghanaian is expected to contribute
based on their ability to pay in order to access a package of health care covering
over 95% of Ghanaians' disorders. There is a disparity in terms of contribution
between the formal and informal sectors of society. The National Health
23
Insurance Act 650 (2003) requires the formal sector to contribute 2.5 percent of
their 17.5 percent Social Security and National Insurance Trust (SSNIT)
contribution, while the informal sector is supposed to contribute at least GH7.2
each year. The contribution levels incorporate a method of cross-subsidization in
which the wealthy pay more than the less fortunate; adults pay on behalf of
children, the healthy pay for the sick, and urbanites pay more than rural residents
(GOG, Act 650, 2003). Subscribers' contribution levels have been classified
according to their socioeconomic status (GDHS, 2003). The policy provides six
distinct classification schemes. These are the core poor, the extremely poor, the
poor, the middle class, the rich, and the very rich. All of these parties shall pay in
accordance with their financial capability. The following table summarizes the
various classifications. Risk equalization under the program would ensure that
illness burden and mortality patterns are used to determine how financial
resources are allocated to the country's various geographical regions (Aikins,
2004). The cost of care varies by geographic region and disease burden. For
example, the disease load varies greatly across Ghana's northern and southern
regions. Additionally, disease burden is positively correlated with poverty. As a
result, the greater the level of poverty, the greater the disease load. A risk
equalization mechanism will be created to compensate for the cost disparity
resulting from the minimum contribution levels. According to Stine (2003), the
program was designed in such a way that donations were based on ability to pay.
This principle infused the program with the aspect of cross-subsidization. Thus,
the wealthy pay more while the poor pay less, and the program should ensure that
24
all individuals contribute, not just those at risk of being ill (adverse selection).
Thus, the wealthy would fund the poor and vulnerable, the healthy would
subsidize the sick, and economically active adults would subsidize children.
Value for money is the core premise of quality treatment. When consumers view
health and service utilization as a good value for money, their proclivity to use
health care improves (Atim, 2000). Perceived care quality is also related to health
care access, as poor care quality is a barrier to access. Thus, if all other variables
remain constant, people are more likely to use health care that they think to be
beneficial than one that they feel to be harmful. According to Aikins (2003),
solidarity is also a desired trait in social health insurance. The NHIS's objective
was to eliminate financial barriers to health care access, which have a negative
effect on the population's health state. Furthermore, our individual health statuses
are inextricably tied to the transmission of communicable diseases, which are the
leading cause of death in this country. The impoverished, children, and the elderly
are the most vulnerable demographics. These groups require the assistance of the
general public in order to gain access to health care. Efficiency in contribution
collecting and claim management is critical to the scheme's viability.
Contributions are critical for developing a sustainable fund for the country's
social-type health insurance plans. In Ghana, the issue is that the majority of
potential contributors work in the informal sector of the economy, where formal
methods of contribution collecting do not exist (GDHS, 2003). As a result, the
NHIS embraced established informal traditional systems of community
contributions, which are made on a house-to-house basis. In the case of claims
25
administration, the NHIS reimburses service providers, albeit infrequently. These
providers of health care rely heavily on Internally Generated Funds (IGF) to
supplement the government's normal budget. Due to the frequent delays in the
issuance of government budgets, the IGF is utilized to bridge the gap by acting as
a revolving fund. Ownership by the community or subscribers is critical to the
scheme's sustainability and viability. Community engagement has been a
stumbling block in Ghana's health care planning and delivery during the last
decade (Atim & Sock, 2000). Attempts to stimulate and sustain community
participation have been tried as part of the primary health care idea, but have met
with limited success. Community ownership of the plan is expected to foster
community involvement and, as a result, introduce the client's perspective on care
quality into the delivery process. The scheme would be operated in collaboration
with the government and other stakeholders to ensure its sustainability. Due to the
scheme's pro-poor nature, the government would be compelled to give central
money to bridge any shortfall between planned and actual contributions, as well
as outright payments of contributions on behalf of the poor, children under the age
of 18, and the elderly. As a general principle, reinsurance tries to provide
additional coverage or financial protection in the event of the abrupt collapse of
any type of insurance. This is particularly true in health insurance, where schemes
may face underfunding, debt, and other financial challenges as a result of
unexpected catastrophic occurrences such as epidemics, embezzlement, and
natural catastrophes. A recent media revelation about the NHIS owing service
providers in Ghana's Ashanti and Northern regions is a classic example (Mbord,
26
2007). When such occurrences occur, central funds must be reserved to
recapitalize distressed schemes. Sustaining the operations of the programs at all
levels, particularly at the district level, is critical. This is mostly about the
effectiveness with which schemes are managed, particularly in the areas of risk
management, investment, and fraud control, as well as the development of human
resource capacity, processes, and regulations to ensure the sustainability of all
schemes in the country.
2.6 Types of Health Insurance Schemes
According to Stine (2003) all insurance systems aim to increase the security of
individuals who are confronted with risks whose occurrence is unpredictable.
They achieve this by pooling the premiums of subscribers together into a common
basket. These funds or premiums are usually invested and the proceeds then help
to compensate those insured individuals who actually suffer a financial loss from
the insured event. Thus, the risk of loss of revenue after a death is covered by life
insurance, the risk of illness by sickness insurance. These insurance policies can
either be private, commercial or social and non-profit making. The primary goal
of commercial insurance is to make profit for the owners of the firm or scheme,
while that of the social or nonprofit making scheme is to extend access to good
quality health care to members of the target population or subscribers, including
its vulnerable members on the basis of solidarity among all members. The
following types of insurance schemes were identified by the National Health
Insurance Scheme (NHIS) to be operational in Ghana. (GOG, Act 650, 2003).
27
1. Social -type Health Insurance Scheme
2. District Mutual Health Insurance Scheme
3. Private Mutual Health Insurance Scheme
4. Private Commercial Health Insurance Scheme
2.7 Social -type Health Insurance Scheme (STHIS)
It is a decentralized system that incorporates members from both the formal and
informal sectors of the economy. Again, it is social in character because it is notfor-profit and annual dividends are ploughed back into the scheme to reduce
contribution levels or increase the benefits package. Thus, every district according
to the policy framework was to establish a health insurance scheme to enable
residents in that district register as members. The social-type health insurance
scheme was designed to ensure transparency, build subscriber confidence and in
particular bring health insurance to the door steps of residents. It operates in
partnership with government and therefore receives subsidy from government in
the form of risk-equalization and reinsurance for catastrophic events.
2.8 District Mutual Health Insurance Scheme (DMHIS)
The District Mutual Health Insurance Scheme (DMHIS) is a fusion of two
concepts. The Traditional Social Health Insurance Schemes, for formal sector
workers who form about 30% of the population of Ghana and the Traditional
Health Organizations for the informal sector with a district-wide ownership of the
scheme by subscribers who have paid their required contributions or premiums
(Aikins, 2003).
28
2.9 Private Mutual Health Insurance Scheme (PMHIS)
The Private Mutual Health Insurance Scheme according to Atim (1998) was for
the purpose of reducing the financial barrier in health care access and improved
quality of service. Any group of persons in Ghana may establish and operate a
Private Mutual Health Insurance Scheme which may not necessarily have a
district focus or base. It may either be community-based or occupation or faith
based. It was also social in character, but this type would not receive subsidy from
government. Examples of this type of scheme include the Damongo Mutual
Health Insurance Scheme, Nkoranza and Tano District Health Insurance Schemes,
the Kintampo Teachers Welfare Fund (Aikins, 2003).
2.10 Private Commercial Health Insurance Scheme (PCHIS)
Private Commercial Health Insurance refers to a health insurance that is operated
for profit, based on economic or market principles. Thus, premiums are based on
the calculated risks of particular groups and individuals who subscribe to it. Those
with high risk pay more (MOH, 2002). Usually, the management or ownership of
the Private Commercial Health Insurance Scheme resides with a company and
shareholders and stocks of the company can be traded on the market just like the
stocks of the producers of any other goods and services. The Private Commercial
Health Insurance Companies play the role of offering the minimum benefit
package and supplementary insurance plans as an add-on for those who desire
additional cover for themselves and can afford to pay. This means that private
29
providers willing to participate must abide by the rules and regulations of the
National Health Insurance Programme (Stine, 2003).
2.11 The Administrative Structure of the National Health Insurance Scheme
Besides the District-Wide Mutual Health Organizations (DMHOS), the National
Health Insurance Council oversees and regulates the establishment of Health
Insurance Schemes on a national scale. The Council is a regulatory body and also
has monitoring and evaluation functions. The Council is an autonomous body
established by an Act of Parliament (Act 650) and is responsible for the creation
and monitoring of an enabling environment for the development and operation of
health insurance in Ghana (MOH, 2002). The Council is headed by an Executive
Officer or Secretary who has the day-to-day responsibility of ensuring that
decisions taken by the council are well implemented. The Council reports directly
to the President of the Republic of Ghana through the Minister for Health and also
prepares annual reports to government and other stakeholders on the state of the
National Health Insurance Scheme in the country. The following units form the
structure of the National Health Insurance Scheme to ensure the effective
execution of its functions (GOG, Act 650, 2003).
1. Policy Planning Monitoring and Evaluation unit
2. Licensing and Accreditation Unit.
3. Administration, Management Support and Training Unit
4. Fund Management and Investment Unit
30
The Policy Planning Monitoring and Evaluation Unit of the NHIS is responsible
for the review and analysis of policy options and advice to the Council on the
formulation of policies related to the NHIS. The unit also ensures the
development of schemes and budgets for the execution of the Council’s decisions
and setting of tariffs for payments to accredited providers. Again, preparation of
financial analysis on the state of the scheme, research and data management of the
scheme. The Licensing and Accreditation Unit according to Aikins (2003) is
responsible for licensing and regulating all health insurance schemes in the
country. It would also have the power to revoke the license of any health
insurance scheme that fails to conform to the law. Again, the unit is responsible
for the accreditation of health care or service providers by setting quality of care
standards that need to be met by providers in order to be eligible for entering into
contracts with health insurance schemes. The unit also negotiates between service
providers, professional bodies and the council on regular basis to agree on
standard rates to be applied to medical and surgical procedures across the country.
The unit is also responsible for monitoring on regular basis the minimum
licensing requirements of the schemes as well as publishing the list of service
providers who have met the accreditation requirements.
The Administration, Management, Support and Training Unit of the council,
monitor and evaluate the operations of all health insurance schemes in the country
and ensure that their efforts are properly coordinated to bring about the ultimate
realization of the policy goals of government. It arranges and ensures that the
needed technical support and training is made available to all Mutual Health
31
Organizations and other health insurance schemes operating in the country to
assist them meet the set standards of operation and management required for legal
operation (Aikins, 2004). The National Health Insurance Fund provides support to
District Mutual Health Insurance Schemes to cover the poor and vulnerable
groups. It also plays equity and a redistributive role to ensure that equal provision
is made for equal need and unequal provision for unequal needs regardless of
socio-economic or socio-cultural status. The use of the health insurance fund is
reserved solely for the not-for-profit schemes and therefore serves as a
reinsurance for schemes that meet a certain criterion.
2.11 Theoretical Review
2.11.1 Utilitarianism
Utilitarianism suggests that the fairness of an action should be evaluated based on
how it affects the utility of an individual or society. A fair distribution, according
to this theory, is one which maximises utility (Kymlicka, 2001). There are
different views within utilitarianism as to what yields the greatest utility,
including pleasure, preference-satisfaction, and health. A utilitarian approach
focuses on the utility gains of the outcome (consequentialism) of a distribution
rather than the process. It defines the utility of society (social utility) as the sum of
individuals’ utilities; hence, resources are distributed to maximise the utility of the
individual. In applying utilitarian principles to the health sector, resources are
allocated to maximise the health gains of the individual. This means that more
resources are allocated to persons with a greater propensity to produce the highest
32
health gains (Olsen, 1997). In most cases, this is based on individuals’ health
needs. Most utilitarians define health need as the ‘capacity to benefit’, which is
the potential improvement in health that an individual might achieve from using a
particular health service (Culyer and Wagstaff, 1993). Based on this definition, it
is ‘fair’ for two individuals who suffer similar health conditions to be allocated
different amount of healthcare resources because they have differential levels of
‘capacity to benefit’.
The utilitarian allocation principle has been criticised on a number of grounds.
Sen (1973) has argued that the emphasis on maximising the sum of individual
utilities (e.g. health) diverts attention from interpersonal distribution, which leads
to inequitable distribution of healthcare and health outcomes. Also, studies have
shown that in most societies, privileged individuals have better capacity to
benefit, and therefore, if healthcare resources are distributed according to capacity
to benefit it might lead to greater resources being allocated to the rich than the
poor. However, proponents have often argued that the health maximisation
principle promotes equity because poor people have greater healthcare needs and
therefore a need-based distribution would lead to greater healthcare resources to
be allocated to the poor (Culyer, 1990). But Sassi et al. (2001) contend this to be
implausible because even though poor people have greater health needs, in most
societies they have limited potential to improve their health and therefore
healthcare resources are mostly allocated to the rich. Le Grand (1991) has also
noted that the utilitarian emphasis on health need as a basis for equitable
distribution of healthcare resources leads to the erroneous impression that all
33
disparities in health status are inequitable. According to him, an equitable
distribution should be one which is based on what individuals deserve rather than
just health need.
2.11.2 Libertarianism
Individual liberty and autonomy are emphasized as a foundation for attaining
equitable distribution in libertarianism. Entitlement theory, advocated by Robert
Nozick, is an example of libertarianism. According to this view, a fair distribution
entails the ‘just' acquisition of an object and the free exchange of that commodity
between individuals (Nozick 1974). An item is considered to have been gained
‘justly' if it was obtained through earnings, inheritance, or government
redistribution of illegally acquired items. According to Nozick, an individual's
rightful purchase of an item confers on them an exclusive property right to that
thing, which can only be transferred to another person by mutual consent.
According to the entitlement thesis, society resources should be allocated through
market transactions in order to achieve equity. It contends that the government's
function should be confined to the preservation of private property and the
promotion of market transaction. The entitlement principle is represented in the
health sector in the form of market-based solutions in healthcare delivery, in
which individuals are expected to pay for healthcare out of pocket (Pereira, 1989).
Individuals are ‘coerced' into paying financial contributions to the program
against their will, undermining their freedom of choice. Government health
programs such as national health services and SHI, which are based on required
34
public contributions to healthcare costs, are considered as unfair. According to
LeGrand (2007), market-based alternatives promote choice and competition while
reducing the advantage that affluent individuals often enjoy in public health
service delivery systems. They also encourage providers to respond to customers'
needs, particularly those of low-income groups, potentially facilitating equitable
access to high-quality healthcare services. Critics contend, however, that rigorous
market-based systems could exacerbate inequality because most poor and
vulnerable people are unlikely to be able to pay for necessary healthcare
treatments (Ruger, 2006). However, while proponents of the entitlement theory
acknowledge the importance of assisting disadvantaged populations with their
healthcare requirements, they believe that such assistance should be optional.
Enthoven (1980) proposed the decent minimum approach, which says that
individuals should have the right to a decent minimum of healthcare in view of
the shortcomings of the entitlement theory in the provision of public health
services.
According to Buchanan (1984), a decent minimum level of healthcare is required
to resolve health-related "institutional inequities" and assure the delivery of public
health services. Enthoven does not define an acceptable minimum health service,
but proposes that it should be limited to fundamental healthcare services that are
required to support people's well-being. Pereira (1989) has criticized the decent
minimum method for being too vague and subjective, and for making healthcare
fairness difficult to enforce. Due to variations in governments' abilities to provide
healthcare services, Buchanan (1984) maintains that a fixed good minimum
35
package is unattainable. Another issue with the decent minimum approach is the
wide range of healthcare demands that individuals require to maintain their health.
Despite this, the NHIS has adopted a reasonable minimum approach in the form
of a uniform benefits package to which every insured member is entitled.
2.11.3 Egalitarianism
Egalitarianism is based on the belief that equality is the foundation for achieving
equity. Individuals should be given an equal or equivalent amount of the
dispersed object, according to the extreme of egalitarianism (Barbeuf, 1796 cited
in Gospath, 2011). However, this viewpoint has been critiqued as being
realistically unworkable, inefficient, and insensitive to individual variations,
perhaps resulting in inequity (Olsen, 1997). Within egalitarian circles, there is
much discussion about what the purpose of equal distribution should be, with
potential options including resources, liberties, capabilities, and wellbeing (Sen,
1992). Dworkin (1983) argued that society should be concerned with promoting
equality of resources, such as talent, intelligence, health, and ‘primary goods,' that
are required to achieve individuals' life goals (e.g. income). This principle's
application in the health sector entails the equitable distribution of healthcare
resources in order to achieve health equity. Although Dworkin believes that equal
access to resources is important, he also believes that in some cases it is necessary
to treat individuals differently in order to compensate for constraints that they are
not personally responsible for. People with disabilities, for example, may require
more resources to operate at the same level as able-bodied people.
36
However, Dworkin's proposal has a flaw in that it does not define what "equality
of resources" actually entails. That is, whether it refers to equal access to
resources or equal resource utilization. Furthermore, it is unclear if the proposal
applies only to public resources or also to private resources (Pereira, 1989). Rawls
(1971) offers another egalitarian viewpoint, arguing that society should be more
concerned with equalizing liberty. The ability to vote and run for office; freedom
of speech and assembly; liberty of religion; freedom of personal property; and
freedom from arbitrary detention are all examples of these liberties. He also
proposed a set of "primary goods" that must be distributed equally, such as
income, wealth, leadership positions, and self-respect. These liberties and goods,
he claims, are necessary for individuals to ‘flourish.' Furthermore, Rawls
proposed the ‘maximin' principle, which states that fundamental goods should be
distributed in such a way that they improve the status of society's least advantaged
persons. Rawls' theory has been criticized by some critics for not include health in
the list of primary goods, despite the fact that excellent health is required for
human ‘flourishing' (Daniels, 1985). However, according to Arrow (1963), adding
health to the list would be too costly and prohibitive since it would require
governments to assure that everyone achieves the same degree of health as
society's healthiest person.
According to Pereira (1989), applying the maximin principle to health would
result in compensating those whose bad health or lack of access to healthcare is
the result of their own fault or decision - and hence inequitable. Nonetheless, the
maximin principle has been used to allocate more healthcare resources to
37
vulnerable and disadvantaged populations in many health policies, particularly in
low-income countries, where positive discrimination has been used to allocate
more healthcare resources to vulnerable and disadvantaged populations (Bloom,
1975). The maximin principle, for example, appears to have inspired the NHIS'
policy of excluding destitute people from premium payments. Sen (1992)
proposed another egalitarian approach, arguing for equality of skills among
individuals. Sen criticized Rawls' method for failing to consider what "basic
goods" can achieve for individuals. He claims that human beings' ability to
convert resources into beneficial outputs is fundamentally different, which
indicates that an equal allocation of resources is unlikely to create equal
outcomes.
As a result, he advocated that social policy should be centered on equating
people's "capabilities." That is, a person's ability to engage in worthwhile
'functionings' ('doings' and 'beings') in life. Physical resources as well as what the
resources are capable of doing for the individual are included in these capacities.
The capacity approach is primarily concerned with ensuring equitable opportunity
for people to undertake functions that are important to them. In the health
profession, this approach would require assuring equality in the advantages that
individuals receive from healthcare resources, rather than just the equality of the
resources themselves (Pereira, 1989). Daniels (1981) made a similar argument to
the capacities approach, arguing that through fostering good health, individuals
should be provided an equitable opportunity to seek their fair part of the typical
opportunity range. This approach places a larger emphasis on healthcare access
38
since it ensures that people are not limited by their health and may seek their fair
share of life's chances. It envisions a two-tier healthcare system, with one layer
providing primary health services and the other offering less "essential" services,
allowing people to satisfy their own healthcare needs.
Daniels (1985) later clarified in his writings that his proposal for a basic healthcare package is not a call for a universal right to a basic health-care package, but
rather a suggestion that society's resources be distributed in a way that promotes
fair equality of opportunity.
2.12 Summary of the Literature Review
The funding of health care or health systems the world over has been of a major
concern to various governments. Health insurance is one of the options adopted
by different countries to finance their health care. The concept of health insurance
has been practiced for many decades in the western world. It is somewhat a
relatively new phenomenon in Africa and the West African sub region in general.
The literature examined the concept of insurance in general. Insurance takes risks
which are too large for one person and spreads the risks around many people so
that they become small risks for a large number of people. The business of
insurance is usually undertaken by an insurer who is the individual, organization
or company selling the insurance for a fee or premium. The concept of insurance
takes different forms and these include disability insurance, casualty insurance,
life insurance, property insurance, liability insurance, credit insurance and health
insurance. The subject matter of this discussion is health insurance. This category
39
of insurance is a system whereby a large number of people contribute small
amounts of money into a common pool in order to receive a specific health
benefit within a given period of time.
After independence, Ghana went through a checkered history as regards health
care funding in the country. Different strategies such as “The Hospital UserFees”, “The Exemptions Policy” and the “Cash and Carry System” were some
policies adopted by post independent governments to finance health care in
Ghana. These strategies did not prove successful and it was against this backdrop
of unsustainable health care financing schemes that the Government of Ghana in
2003, introduced the NHIS to provide accessible, affordable and good quality
health care to Ghanaians especially the poor and vulnerable in society. The vision
of government in introducing the NHIS was to ensure equitable and universal
access for all residents of Ghana to an acceptable quality of essential health care.
This was to protect individuals against the need to pay-out of their pockets in
order to access quality health care. The government has fashioned out its unique
own health insurance strategy based on the principles of equity, risk equalization,
cross-subsidization, solidarity, quality care, efficiency in premium collection and
community participation. The scheme operates in partnership with government
and other stakeholders to ensure sustainability and also enjoy reinsurance from
central government.
Again, government in August, 2003, adopted two main types of health insurance
regimes to be operational in the country. These were the social type health
insurance scheme, made up of District Mutual Health Insurance Scheme and the
40
Private Commercial Health Insurance Scheme. The District Mutual Health
Insurance Scheme (DMHIS) was the model adopted by government to deliver
quality health care to the poor and under privileged in society. The model was a
fusion of two concepts; The Traditional Social Health Insurance Scheme for the
formal sector workers and the Traditional Mutual Health Insurance for the
informal sector of the society. Thus, the DMHIS’s were to incorporate members
from both the formal and the informal sectors. The formal sector contributes 2.5%
of their 17.5% Social Security and National Insurance Trust (SSNIT) contribution
whereas the informal sector contributes at least GH¢7.2 per annum. The
contribution levels of the people have been categorized based on their socioeconomic stratification. The policy framework proposes six main types of
categorizations. These are; core poor, very poor, poor, middle income, rich and
very rich. All these should pay in line with their ability to pay. The minimum
benefit package of the NHIS was to ensure that every citizen of this country had
access to a level of health care that provides adequate security against diseases
and injury and to promote and maintain good health.
All service providers within the public, private and mission sectors have been
mobilized to provide health care under the NHIS. They were however expected to
satisfy a certain accreditation criteria. Government also instituted by law a 2.5%
NHIS levy on goods and services. Funds accruing from this source shall be used
to subsidize the contributions of the under privileged segment of the society and
to pay for the contributions of the core poor and other vulnerable groups. The
NHIS has been regulated by the National Health Insurance Council through the
41
National Health Insurance Act 650. It also operates under units responsible for
Policy Planning Monitoring and Evaluation, Registration, Accreditation and
licensing Unit; Administration, Management Support and Training Unit, Fund
Management and Investment unit.
42
CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Introduction
This chapter deals with the methods used to carry out the study: areas given
consideration in this chapter are, the research design, the study area, and the target
population of the study. The sample and sampling procedure, as well as
description and administration of research instruments and data analysis form the
concluding part of the chapter.
3.2 Research Design
The central business of this study was to examine the challenges of the
implementation of the NHIS in the Amansie West District. It also involved
finding what pragmatic recommendations stake holders in this health sector had
on how to fine-tune the implementation and sustainability of the insurance
scheme on campus. This required the use of the descriptive survey method.
According to Amedahe (2002), the descriptive design determines and reports on
issues the way they are. In other words, it is descriptive because issues or
phenomena are seen or viewed in their natural setting and reported on as they
unfold naturally.
Again, Amedahe (2002) saw the descriptive design as primarily concerned with
collecting data in order to test hypotheses or answer research questions pertaining
to the current status of the subject of the study. Best and Khan, cited in Amedahe
43
(2002) saw the descriptive research design as concerned with conditions or
relationships that exist, such as the nature of prevailing conditions, practices,
attitudes and opinions held by people abou issues or phenomena processes that are
going on and trends that are being developed.
3.3 Research Approach
The study engaged the use of both qualitative and quantitative data to ensure an
effective synergy between the two methods. According to Patton (1990),
qualitative research focuses on gaining insight and understanding about an
individual’s perception of events and circumstances. The most commonly used
methods of data collection in qualitative research are participant observation and
semi structured interviews. Qualitative studies produce large amounts of data. The
data usually consists of words rather than numbers and may be analyzed manually
or through the use of computer programmes. The reliability and validity of
qualitative studies are determined differently than in quantitative studies.
Quantitative studies are considered valid if the findings reflect reality from the
point of view of the subject. Quantitative research is based on the concepts of
manipulation and control of phenomena and the verification of results using
empirical data gathered through the senses.
The individual’s interpretation of events or circumstances is of importance, rather
than the interpretation made by the researcher. (Nieswiadomy, 1993). The
qualitative researcher attempts to obtain rich, real and valid data, the quantitative
researcher aims for hard, replicable and reliable data. Data for qualitative research
44
is collected through unstructured interviews and participant observation. The
researcher searches for patterns and themes in the data rather than focusing on the
testing of hypothesis. The study was cross-sectional in nature considering the
relatively short period of time used to carry out the research and more so to ensure
maximum and efficient use of limited resources and logistics for the study.
According to Nieswiadomy (1993), a cross-sectional study examines subjects at
one point in time. The study data are usually gathered on subjects at one specific
time, though the data may be collected from groups of people who represent
different ages, time periods or developmental states. Again, cross-sectional
studies are conducted because they are less expensive and easier to conduct than
longitudinal studies. The method was suitable for the study as it gave an in-depth
assessment of the situation on the ground; it reported on issues as they existed
without any biases, doubts or contradictions.
3.4 Population
According to Kuranchie (2016), population refers to the target group from which
the researcher seeks information in order to draw conclusions. In light of this, the
researcher would focus on two factors: targeted and accessible populations. The
target population, according to Tuckman (1985) and Kuranchie (2016), is the total
group of individuals from which the sample could be selected. It also refers to the
complete population or set of individuals who will be regarded qualified for data
analysis, as well as the entire group or set of individuals for whom the survey
results will be used to draw conclusions.
45
3.5 Sampling and Sampling Technique
Sample and Sampling Procedure According to Siegel (1997), one is free to choose
any sample size from an identifiable group of individuals, and there is no
requirement that the sample size should be the same for each group but according
to the population of the group. Guided by this assertion, the sample sizes of the
various categories that constituted the target population were obtained based on
the total individuals in each category. The convenient sampling method was
employed in selecting respondents. This is non-probabilistic and perhaps the most
common sampling strategy for qualitative research (Patton, 1990). The method
allows the researcher to obtain his information from respondents who are readily
available and willing to participate in the study. Hence, the sample may not
necessarily be proportional to the population. The methods were used in this case
because some staff of the hospital works in three shifts and also enjoy routine off
duty periods. This would have made it difficult reaching many respondents if they
were randomly selected.
A total number of 136 people were selected to participate in the study. The
subjects were chosen from the population by non-random methods. In nonprobability sampling, certain elements of the population will not be included in
the sample. The choice of non-probability methods or techniques of sampling was
informed by the desire to use readily available subjects for the study to save time.
The said techniques are also easy to use and less expensive to the researcher as
compared to other techniques (Nieswiadomy, 1993).
46
3.6 Data Sources
Primary data was gathered through the use of interviews, questionnaires and
observation. According to Nieswiadomy (1993) questionnaires and interviews are
probably the most frequently used data collection methods in nursing or
qualitative research. Observation is also an important method of seeking answers
to research questions.
Secondary data was gathered from reviews of documents which have a direct
bearing or link with the objectives of the study. These include textbooks, journals,
newspapers, magazines, and records from the Ministry of Health, Ghana Health
Service and other materials that dealt in part or aspects of the study. The use of
both primary and secondary data gave an opportunity to cover all aspects of the
study, both documented and undocumented literature.
3.7 Data Collection Instrument
The data used was mainly obtained through questionnaires and was considered
primary data. This particular questionnaire was utilized since all of the
respondents were literate and could easily read and react to the items on the
questionnaire without assistance. The items on the questionnaire were carefully
chosen in accordance with the study's goals and objectives. The variables were
selected after conducting a thorough assessment of relevant literature and were
formulated using both closed- and open-ended responses after being checked by
the supervisor. The questionnaire was created using a five-point Likert Scale to
gauge responses. This was done in order to make response analysis more
47
straightforward. The questionnaire method of data collection was chosen because
it was deemed to be the most convenient and allows respondents to respond to the
questions at a time that is most suitable for themselves.
3.8 Data Analysis Procedure
Data collected from the field were sorted out, checked and thereafter coded. The
Statistical Product and Service Solution (SPSS) version 22.0 software was used to
key in the data after which simple frequencies and percentages were generated
and adopted for analysis of the data. As regards close-ended items, responses
from respondents were tallied based on data that was gathered from the research
questions. The tally was translated into figures and categorized. Tables were
drawn for all cases and information converted into percentages and explained or
used as basis for discussion. Percentages obtained for frequencies were also
rounded off to the nearest whole number. Responses from open-ended questions
were summarized, important themes identified and critical responses from
respondents discussed accordingly. In respect of data obtained from observation,
critical issues were also discussed in relation to information gathered from the
questionnaire and interviews of the selected key management personnel.
3.9 Data Collection Procedure
The researcher first presented an introductory letter stipulating the name and title
of the study to heads of the selected schools where the study was conducted. After
their approval and maximum assurance, the researcher proceeded to the various
teachers and introduced himself and the purpose of the study. He then sought their
48
consent to participate in the study. For the success of this research work and
maximum cooperation of the respondents, the researcher first established rapport
with all the respondents. This, in fact, made them feel deeply within them that
whatever they were going to say would be handled with care and their identity
was well secured. The researcher approached the participants in person and
introduced himself to them. The average amount of time it took to complete each
questionnaire was 35 hours.
3.10 Reliability and Validity
Trustworthiness, according to Creswell (2009), is defined as validity and
reliability, and refers to the procedures that a qualitative researcher conducts to
assure the accuracy and consistency of his or her methodologies and data analysis.
According to Anney (2014), when conducting qualitative research, the researcher
must consider the trustworthiness of the study by analyzing the credibility,
transferability, dependability, and conformability of the findings of the study. The
term "reliability" refers to the degree to which different items, measures, or
assessments are consistent with one another as well as the degree to which each
measure is free of measurement error (Leech, Barret & Morgan, 2005).
3.11 Ethical Considerations
In order to avoid invading the participants' privacy without their consent, the
researcher and research assistants administered the study instrument during a
period of teacher break. In order to adhere to the ethical ideal of anonymity in
social research, no names or other personally identifying information from
49
respondents was collected. Each respondent who agreed to participate was told
that their involvement was fully optional and that they had the right to withdraw
their offer at any time during the research process if they so desired.
50
CHAPTER FOUR
RESULTS AND DISCUSSIONS
Introduction
The study was primarily conducted to ascertain the difficulties associated with
implementing the NHIS in the Amansie West District. The difficulties
encountered by workers, community members, and hospital personnel were
examined in this research endeavor. Additionally, the study sought to make
recommendations to the NHIS authorities and other health sector stakeholders
for how to improve the NHIS's implementation. This chapter discusses the
respondents' demographic features and provides a brief analysis of the data in
connection to the study's aims. Primary data collection instruments comprised
questionnaires, interviews, and an observation guide.
Gender of Respondents
The study noted that an individual's gender may have an effect on his or her
capacity and willingness to register with the NHIS. 75 (55.1%) of the 136
responders were male, while 61 (44.9%) were female. Men utilized slightly
more health care and accessed the NHIS than women. The gender breakdown
of responders is seen in Table 1.
Gender of Respondents
Gender
Frequency
Percentage
51
Male
75
55.1
Female
61
44.9
Total
136
100
Source: Field data, 2021
Marital Status of Respondents
On the issue of marital status, 113 (83.1%) of the respondents were married
and 23(16.9%) were not married at the time of carrying out the research. This
gives an indication that most of the people were married and did have much
social responsibilities on them. Table 2 shows the marital status of
respondents.
Marital Status of Respondents
Marital Status
Frequency
Percentage
Single
23
16.9
Married
113
83.1
Total
136
100
Source: Field data, 2021
Ages of Respondents
As indicated on Table 3, majority of the respondents fell within the age
brackets of 25years and below and 26-40 years. Only 6.6% of the respondents
were over 40years. Table 5 shows the age distribution of respondents.
52
Ages of Respondents
Age
Frequency
Percentage
25yrs and below
90
66.2
26-40yrs
37
27.2
Over 40yrs
9
6.6
136
100.0
Total
Source: Field data, 2009
Level of Educational Attainment
The educational attainment of respondents is shown in Table 4. The table
indicates that the majority of respondents 113 (83.1 percent) had completed
higher education, 8 (5.9 percent) had completed senior high school, and
around 11 (8.1 percent) had completed other levels of education not specified
on the questionnaire. Only four respondents (2.9 percent) have completed only
the Junior High School level of schooling.
Level of Educational Attainment
Level
Frequency
Percentage
Junior High School
4
2.9
Senior High School
8
5.9
Tertiary
113
83.1
Others
11
8.1
Total
136
100
Source: Field data, 2021
53
Research Question One: What problems does Scheme Managers face with
regard to the Implementation of the NHIS in the Community?
The challenges faced by scheme managers are in terms of personnel, logistics and
other equipment which are essential for a smooth operation of the scheme. Table
5 gives a clear picture of the logistical constraints of the scheme.
Adequacy of Materials/Equipment
Materials/Equipment
No. Required
No. Available
No. Functioning
Computers
20
15
10
Cameras
10
6
4
Printers
2
1
1
Photocopy machine
1
1
1
Vehicles
3
1
1
Source: Field data, 2021
From Table 5, it is quite clear that logistics and equipment such as computers
and cameras were not readily available in sufficient quantities to facilitate the
processing of NHIS data. Most of the equipment were not functioning properly
or were simply non-functional.
Challenges in Terms of Personnel
Table 6 shows the various qualifications and staffing situation of the NHIS
office in the Amansie West District.
54
Adequacy of Staff
Qualifications
No. Required
No. At Post
Diploma
20
15
Degree
5
1
Masters
1
1
PhD
-
-
Source: field data, 2021
A follow-up question about the scheme managers' preparedness in terms of
individuals with the necessary abilities found that the scheme managers lacked the
required twenty personnel with the necessary competencies to handle NHIS data.
This is consistent with similar research undertaken by Sabi (2005), which found
that the majority of programs were handled by individuals lacking in managerial
and ICT skills. Obtaining the necessary people and material resources to operate
the schemes efficiently has become a formidable undertaking for the majority of
scheme managers nationwide. This may explain why certain schemes have
encountered operational issues as a result of fraud, financial mismanagement, and
mismanagement of their allocated resources.
Research Question Two: What Challenges do the community members face in
accessing Health care by means of NHIS?
Challenges of the Implementation of NHIS to Students and Staff Problems
with NHIS
55
Delays in card
processing.
Total
%
F
%
F
%
F
%
94
69.1
28
20.6
14
10.3
136
100
Clients with expired
NHIS cards pay for
their treatment in
the hospital.
100
73.5
23
16.9
13
9.6
136
100
Time spent prior to
consultation
is too long.
97
71.3
30
22.1
9
6.6
136
100
Prescribed drugs are
91
unavailable in the hospital.
66.9
32
23.6
13
9.5
136
100
NHIS card holders are 8
given preferential treatment
in the hospital.
5.9
100
73.5
28
20.6
136
100
Lack of public
awareness about the
scheme
92
67.6
31
22.8
13
9.6
136
100
Politicization of the
scheme
87
64
29
21.3
20
14.7
136
100
Source: Field data, 2021
According to Table 7, the majority of respondents 94 (69.1 percent) agreed that
registration and issue or processing of NHIS cards for new entrants were
significantly delayed. Registration and issue of a new card may take up to six
months or more. Only 28 (20.6 percent) respondents disagreed with the statement
that the NHIS authorities experienced significant delays in the registration and
processing of cards. However, the remaining 14 (10.3 percent) respondents were
56
unsure whether a delay in the processing and issuance of new NHIS cards
occurred. This means that students and staff who became ill during this time
period were responsible for their own medical expenditures while their NHIS
cards were processed and issued for usage.
Staff and students with expired NHIS cards were once again responsible for
paying their medical expenditures. The overwhelming majority of respondents
(100/73.5%) agreed with the assertion that clients, students, and staff with expired
NHIS cards were required to pay their hospital fees. Twenty-three (16.9 percent)
disagreed with the assertion, while thirteen (9.6 percent) were unsure whether
students and staff with expired NHIS cards had to pay for hospital treatment. This
reaffirms the insurance scheme's refusal to honor expired cards, as there is a price
associated with the renewal of all expired cards.
Another issue is the enormous lineups of people waiting to be seen in hospitals
and health services. Without a doubt, the NHIS has increased OPD attendance at
UCC Hospital from 26,452 (2008) to 26,740 (2010). (2009). This data was
received from the UCC Hospital's Records Unit during its mid-year performance
evaluation in 2010. This has an effect on the time required to see a doctor in a
hospital. As shown in Table 10, ninety-seven percent (71.3 percent) of
respondents agreed that the time spent prior to consultation is excessive, whereas
thirty percent (22.1 percent) of respondents disagreed.
Since the advent of the NHIS, OPD attendance and admissions to the nation's
hospitals and polyclinics have increased dramatically. Clients and NHIS
57
subscribers' increasing attendance resulted in congestion in hospital wards and
out-patient departments of the country's largest hospitals, including the Korle-bu
Teaching Hospital, the Komfo Anokye Teaching Hospital, and the other Regional
Hospitals. Additionally, greater attendance results in longer patient wait times or
general delays in seeing a doctor at the hospital, resulting in increased effort for
health workers and increased health expense.
In Ghana, delays or excessive time spent in hospitals and health institutions are
not unusual. Stine (2003) found that people declined formal or orthodox medical
care in Northern Ghana due to the delays or long wait times at such formal health
institutions. The prevailing perception was that consumers spent time at the
hospital only to get health care. These delays will be reduced if additional
workers are hired to handle the increasing client attendance.
Another issue that employees and students encountered throughout the scheme's
implementation was the hospital's inability to provide prescribed medications. 91
(66.9 percent) respondents agreed with the assertion or statement that the majority
of drugs prescribed under the NHIS were not available in the hospital, 32 (23.6
percent) respondents disagreed with the statement, and 13 (9.5 percent)
respondents were unsure about the availability or otherwise of prescribed drugs in
the hospital.
This contention was bolstered by Arhin's (as cited in Alexander and Guy 2004)
study of the Burundi government's insurance plan (CAM) in 1984. In theory,
everyone with a CAM Card who visits a government health facility should not
58
have to pay for services. Due to a lack of drugs and other inputs, CAM Card
holders, like fee-paying customers, were frequently issued prescriptions to
purchase medications on the open market. The narrative is similar to that of the
Ghanaian programs, as NHIS cardholders are frequently issued prescriptions to
purchase pharmaceuticals, either because they are not covered by the scheme or
because they are not available in health facilities. Again, a research by Stine
(2003) of health insurance programs in Northern Ghana found that some people
declined to participate in the NHIS due to a notion that hospitals lacked sufficient
drug supplies to meet their demands.
Additionally, the issue of preferential treatment for holders of NHIS cards was
evaluated. Eight (5.9 percent) respondents agreed that NHIS cardholders received
preferred or priority treatment in hospitals as a result of their NHIS subscription
status, whereas 100 (73.5 percent) respondents disagreed. However, twenty-eight
(20.6 percent) were unsure whether NHIS consumers received preferential
treatment in the hospital. Contrary to the notion that NHIS consumers receive
preferential treatment in hospitals, Aikins (2005) found that people were
unwilling to join NHISs in the Brong Ahafo Region because the schemes do not
guarantee service quality. More importantly, the scheme's terrible staff attitude
was a deterrent to prospective subscribers.
As stated in Table 10, a general lack of information regarding the NHIS's
challenges and procedures was also a barrier for some respondents. A simple
majority of respondents, 92 (67.6 percent), agreed with the statement, while 31
(22.8 percent) said public awareness was adequate. Thus, education of the public
59
about the NHIS's purpose is necessary to prevent system misuse and to ensure the
scheme's viability. The need that subscribers pay the premium and penalties
associated with renewing their expired NHIS cards is a safeguard against the
program collapsing or running into financial difficulties after a few years of
operation. Enhancing public education has been a successful approach for mutual
insurance schemes in achieving their membership drive objectives. Aikins (2005)
recognized public education as critical to the seamless and sustainable operation
of the Tano health insurance plan.
Additionally, there were evidence that the program had been politicized by some
clients or subscribers inside the academic community. A substantial proportion of
respondents 87 (64 percent) agreed with the premise that some persons interfere
with the scheme's operation. Twenty-nine (21.3%) of respondents disagreed with
the allegation, and twenty (14.7%) were unsure about the scheme's politicization
by certain staff and students. Surprisingly, some clients believed the NHIS was
part of a certain political party's policy objective and hence refused to enroll or
embrace the plan because their political views differed.
Research Question Three: In what ways can the operations of the NHIS at
Amansie West District be improved?
Table 8 shows some ways in which operations of the NHIS can be improved in
the University Hospital.
Suggested Improvements to NHIS in Amansie West District
60
Statements
Frequency
Percentage
53
38.9
and
31
22.8
public
13
9.6
39
28.7
136
100
Provide greater variety of
medicines.
Increase
number
quality of medical
personnel.
There
should
education
on
the
operations NHIS.
NHIS clients should be
given better attention.
Total
Source: Field data, 2021
A study question was posed to elicit client feedback on how to enhance the
services provided to NHIS subscribers in the hospital setting. A sizable number of
respondents 53 (38.9 percent) suggested increasing the availability of
pharmaceuticals and medicines in hospitals for clients who sought healthcare.
This could alleviate the time and cost load on subscribers who are frequently
issued prescriptions to purchase medications in town, thus undermining the
insurance scheme's stated goals and purposes.
61
This advice is closely related to the request for NHIS subscribers to be
appropriately cared for or given additional attention whenever they visit a hospital
for healthcare. This has become a significant concern as attendance has increased
as healthcare costs have been partially covered by the scheme. The increased
demand for healthcare services does not keep pace with the restricted or scarce
supply of healthcare providers and specialists available to provide these services
to subscribers. Increased patient numbers combined with a shortage of health
professionals have an effect on the quality of service provided by health
institutions.
Thirty-one (22.8 percent) of clients advocated expanding the number of doctors or
medical workers in the hospital to deal with the ever-growing number of clients
or subscribers who visit the hospital daily to get healthcare. This recommendation
is based on the fact that clients spent significant time in the hospital before being
seen by a doctor or having their needs met or resolved. It is envisaged that
increasing the hospital's health workers will significantly alleviate the delays or
drudgery that clients face when trying to receive treatment.
Public education about the insurance scheme's operation was also proposed by
several respondents. Thirteen (9.6 percent) respondents felt the NHIS message
was not clearly comprehended by residents and employees. Public education
about the scheme's benefits and customers' or subscribers' rights and
responsibilities should be bolstered.
62
CHAPTER FIVE
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
The study was conducted to ascertain the difficulties encountered by staff and
residents of Amansie West District in implementing the NHIS. Additionally,
the study was intended to give recommendations to policymakers and the
government regarding how to improve the district's insurance scheme's
operations. A descriptive research approach was used, and a total of 136
respondents completed a questionnaire as part of the study.
Summary of Findings
Respondents said that they had to wait at least six months for processing
of their new NHIS cards. The consequence is that community members
who became ill during the specified time period were responsible for their
own medical expenses while waiting for their insurance to mature.
The study discovered that consumers covered by the NHIS were
dissatisfied with the length of time spent in the hospital waiting to see a
doctor/nurse. The suggestion was that OPD attendance and hospital
admissions have increased significantly over the years, from 26,452
(2008) to 26,740 (2009), without a commensurate increase in staff
strength. This explains why patients or clients must wait longer periods of
time to see a doctor or have their needs met in a hospital.
63
An interview was done to ascertain scheme managers' readiness to
manage NHIS data in terms of staff with ICT skills. The encounter
revealed an insufficient amount of information technology workers.
Additionally, logistics and equipment such as trucks, computers, Xerox
machines, and cameras were insufficient to support NHIS data collecting
and processing.
When asked whether respondents were able to obtain medicines or drugs
prescribed for them under the NHIS, responses indicated that patients or
clients were occasionally given prescriptions to purchase drugs in town,
either because the drugs were not covered by the scheme or were simply
not available at the health facility in question.
The following were identified as some of the major challenges of the
implementation of the NHIS in the hospital:
1. There appears to be a general lack of public awareness regarding the
insurance scheme's operation. For example, the public is unaware of the
scheme's laws and regulations, as well as the benefits and duties of
clients.
2. Again, the study revealed that clients had to wait for well over six
months after registration to get their new NHIS cards processed and
ready for use.
3. The scheme does not cover all disease conditions in the country.
64
4. Additionally, certain medications are not covered under the system.
Even when drugs are covered by the system, they are not always
available in health facilities, forcing individuals to buy them
independently without receiving reimbursement from the insurance
scheme.
5. Health institutions also face a significant challenge in dealing with the
high numbers of clients that visit hospitals daily in search of treatment.
These figures much exceed the amount of health professionals available
to provide health care to all NHIS consumers.
Conclusions
The study's findings indicate that the implementation of the NHIS in the
Amansie West District has numerous hurdles, including material and human
resource constraints. It became clear that the public needed some information
and education about the scheme's functions, such as the requirement to renew
the NHIS card annually and pay the associated payments. Subscribers are
frequently perplexed or astonished to realize that the program does not cover
all illness conditions and treatments.
The increased or increasing OPD attendance and admissions reported in health
facilities following the implementation of the NHIS is solid evidence that
subscribers are using the system to treat a variety of conditions that were
previously unaffordable to them. This is, without a doubt, one of the major
issues confronting insurance programs worldwide, as noted in the literature.
This needs commitment and care on the part of service providers and other
65
stakeholders to guarantee that the scheme's survival is not jeopardized by such
moral risks.
Again, the NHIS's implementation has exacerbated congestion in our health
care facilities. As a result of the increased attendance, considerable strain is
placed on the limited health workers and facilities available to offer healthcare.
This, of course, may jeopardize or alter the quality of treatment offered by
health institutions when demand for services is not proportional to available
resources to deliver such services.
Another point worth mentioning is the length of time subscribers spend in
hospitals or health facilities during each visit for medical services. The
problem was exacerbated by the high volume of traffic at the OPD and the
lack of facilities and employees available to deal with or manage such
incidents.
Recommendations
The findings revealed some pertinent issues which need to be addressed by
government, scheme managers and other stakeholders in healthcare delivery.
On the basis of these, the following recommendations are made.
1. The government urgently needs to empower the National Commission
on Civic Education to conduct additional public education about the
NHIS's activities. This will alleviate the difficulties and tedium
associated with registering for NHIS cards. The general public should
be aware that their cards will not be activated for at least three months
66
after registration and that any episode of disease or sickness occurring
during this time period will be treated on a "cash and carry" basis.
2. The training of additional medical and paramedical personnel to staff
health facilities and enhance service delivery to NHIS subscribers and
the general public. This should alleviate congestion and stress on our
health institutions' staff and facilities. Additionally, the quality of care
will improve if adequate facilities and trained employees are available
to run health institutions. Additionally, the government could review its
policy on the present premiums paid by subscribers and propose
lowering them to make them more affordable to some segments of the
population, particularly those in the informal sector of work.
3. The researcher is convinced that a reduction in the NHIS premium will
enable the government to fulfill its goal of guaranteeing that every
Ghanaian resident is a member of a mutual health insurance scheme of
his or her choosing. This would also improve access to and
affordability of health care, as envisioned in the NHIS framework and
policy recommendations.
4. The National Health Insurance Authority should also be assigned with
the responsibility of providing sufficient logistics and equipment to
ensure that NHIS cards are processed quickly at all levels. The NHIS's
personnel or employees should be proactive in teaching subscribers
about the scheme's functions. These may include registration and
premium payment for new cards, as well as renewal and replacement
67
of lost cards. This significantly reduces unnecessary delays associated
with the processing, issuance, and renewal of NHIS cards.
5. Once again, plan administrators must evaluate all claims for payment
filed by health institutions and service providers. Claims should be
validated and reimbursements provided promptly to service providers
to ensure that subscribers receive uninterrupted service. Additionally, it
is the responsibility of all health service providers to supply their
facilities with necessary treatments and medications so that clients or
subscribers do not have to purchase these medications on the open
market and receive value for money.
Suggestion for Further Study
Healthcare financing is quite broad and the researcher would recommend
further study into other aspects of health insurance that were not covered by
this study
68
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