The National HealthInsurance Scheme(NHIS) is simply a social intervention program, introduced bythe government of Ghana to eradicate the financial burden that comes withaccessing quality health care services in Ghana.
As a matter of fact, qualityhealth care is expensive. Therefore, the introduction of the NHIS in Ghana seeksto underestimate this fact to some extent. The NHIS is funded by The NationalHealth Insurance Levy(NHIL), which is 2.5% levy on goods and services collectedunder the Value Added Tax, 2.5% points of Social Security and NationalInsurance Trust (SSNIT) contributions monthly, return on National HealthInsurance Fund (NHIF) investments, premium paid by informal sector subscribersand some government allocations. One has to be a subscriber in order to benefitfrom the scheme’s services. The National Health Insurance Authority grantsaccreditations to certain health care facilities, also known as serviceproviders, to provide services to the scheme’s subscribers.
These serviceproviders which include polyclinics, clinics, maternity homes, health centers,primary hospitals, secondary hospitals, tertiary hospitals, pharmacies,licensed chemical shops, diagnostic centers just to mention a few, in return arereimbursed by the funds generated by the National Health Insurance Scheme. Assubscribers sign up, they are given portable cards, known as the NationalHealth Insurance Scheme membership identification card that serves as a proofof registration and it is submitted at the desks of any of the afore mentionedservice providers, to enjoy health care services, that is covered by the scheme.Since its inauguration and commencement of operations in 2003 and 2004respectively, the scheme has been of immense benefits to its subscribers. A lotof residents of Ghana have benefited massively from the NHIS. NHIS has madeaccessing maternal care easier and costless, making home maternal delivery onlysomething of the past. Some beneficiaries of this scheme in an eye witnessreport, talked about how in one case a pregnant woman could easily access ahospital and underwent a free successful delivery just by being a subscriber.
In another case, a mother of two who had already lost a child to malaria theprevious year due to her financial constraints, had been able to keep thesurviving child alive without paying a dime each time she takes the child tothe hospital. These situations and manyothers confirm the good tidings that the NHIS has brought into the lives ofresidents of Ghana. In an article written by Anthony Gingong, titled as “TheSilo is empty, a case of the NHIS” (2015), he stated that, “High utilizationhas been the norm, with 597,859 OPD (Out Patient Department) attendance in2005, to 27,350,847 in 2013. Increasing OPD attendance is a clear indication ofhigh awareness and the need to seek early treatment. In 2005 the NHIS paid atotal of Gh?7,800,000, then Gh?183,000,000 in 2008, and in 2013, Gh?780,800,000, clearly an escalation in cost. The NHIS subscriber base has seencontinuous increase from an initial membership of 1.
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5 million in 2005 to almost10.2 million as at the close of 2013, with significant improvement in indigentregistration which rose from 300,000 to 1.2 million”.
In general, it has giventhe indigents the opportunity to access health care, people who would choosetraditional treatment over orthodox health care, eventually signed up on theNHIS.In spite of all thesewonderful accolades that could be trumpeted about the NHIS, few challenges ordemerits can be seen in its operations as well. The challenges faced by theNHIS can be grouped into challenges from the service providers, subscribers andthe administrators. A challenge seen in the National HealthInsurance Scheme has been attributed to the various payment systems used inreimbursing service providers registered under the scheme. There are three mainpayment systems that are been used in the NHIS; the itemized fee for servicepayment system, the diagnoses related grouping system and the capitationsystem. The itemized fee for service payment system involves the service providersproviding the NHIA with a ‘list’ of the various services rendered to thesubscribers. The diagnoses related grouping (DRG) method requires serviceproviders to be paid based on the diagnoses of the subscribers.
In the newercapitation system, the service providers are prepaid based on the number of subscribersthat have chosen that particular service provider as their primary serviceprovider. Despite using a combination of these three methods in ensuringsuccessful reimbursements, some service providers complain that they receivetheir reimbursements in a highly untimely manner and sometimes there could be avery long delay in receiving their payments. This has led to the serviceproviders denying subscribers access to cheap and quality health care andgranting non-subscribers access to quality health care services because theyare willing to pay the prices. This challenge has been attributed by many to beas a result of the manual nature of processing of claims of the serviceproviders.
Under the current system, service providers present the NHIA withtheir claims to payments based on the cost of attending to the varioussubscribers. These claims are then processed for authenticity and the variousmonies distributed to the service providers. The system processing of claims inGhana as at now, is mainly manual and as the population of subscribersincreases, the task of processing becomes overwhelming. This leads to delays inprocessing claims consequently resulting in delay in reimbursements of theservice providers. Also some service providers have issued complaints regardinginstances where their claims have been disregarded in spite of theirgenuineness and this has led to many of these service providers to be reluctantin continuing their agreement with the scheme. For example, in 2008, Korle-BuTeaching Hospital recorded a rejection rate of 9-22% according to the claims manager.Some of these claims were rejected because they did not meet the time frame forpresentation of claims.
Although these challenges as consequences of thepayment systems are not new to any Health Insurance Scheme anywhere in theworld, automation of claims processing and money distribution has greatly solvedthis problem in many countries like the USA. Another challenge faced by the National HealthInsurance Scheme has to do with membership. The scheme since its inception hasrecorded increasing numbers of members and as time goes on more and more peoplewill come on board.
However, the goal of making quality health care affordableto everybody has since not been met adequately yet. The target for the poorespecially has not been met yet. Most of the subscribers on the schemecurrently, are better educated richer Ghanaians who understand the schemesoffer and avail themselves for it.
The many illiterate rural Ghanaians find theprocess daunting, especially the bureaucracy of the system. The registrationcentres are also often too far away from their villages and the cost of registrationwhich is around GH? 24 still remains a little too expensive for them. These registration centres for the NHISalways require constant electricity in order to sign subscribers up on thescheme, because they utilize computers and other electrical machines such asthe biometric device to upload details of subscribers on the NHIS database. In viewof this, registration centres are situated in well to do areas and not the remoteones.
These areas, as previously stated are mostly far from the indigents,making it difficult for them to sign up too. So it can be said, that the NHISreally has not been able to serve its purpose but just to favour a few average Ghanaiansand not the indigents actually.Furthermore,this idea of choosing a particular service provider for health care when neededputs so much pressure on certain service providers as compared to others. Subscribers,upon hear says or probably experience choose to visit a particular hospital totreat, for example, headache since majority visit that hospital and joininglong queues, wasting the time of other patients with more severe healthproblems, whiles other equally good providers can be found in the samevicinity. So much pressure is then put on some service providers, their humanresources, facilities and medications than others.Thelast but not least of the problems of NHIS concerns infrastructure. One mayask, why would the government use NHIS as bait to get its residents to stophome treatment and make use of hospitals without actually building more qualityand well-furnished hospitals across the country which can easily be accessed byall and sundry?Thereis the challenge of unfairness on the side of subscribers.
In that, there arepeople who have signed up for the NHIS and undergo the renewal as at when it isneeded but these people never get to be sick during the times that the card isactive. This means that anytime some people are in dire need of the card theyreach the service providers only to find out that these cards are expired. Therefore,it would be required of them to pay physical cash even before they are attendedto. So a heartfelt question to the NHIA is, will there be other offers forpeople in such category?Funds generation has alsobeen a challenge to the NHIS. As the subscriber base of the scheme increases,demand is put on the NHIA to generate more funds to pay the service providers.
Thescheme itself has been lacking initiatives that would boost fund generation asmuch reliance is put on the government and the government alone. As such, thereis not a linear correlation in subscriber numbers increase and increase infunds available to pay service providers. Service providers, upon areceivingvery small amounts of money as their reimbursements, consequently do notprovide the best care for NHIS subscribers.
In view of thesechallenges a few recommendations can be outlined. The processing of claims bythe NHIA should at large be made automatic, to curb the strenuous implicationsthat come with the manual processing of claims. By so doing processing ofclaims would be made faster, service providers would be paid earlier andquality health service would be provided at all times. Again, the NHIA shouldensure that, there are enough service providers in the various districts thatare fully furnished, including the already existing ones, in terms ofinfrastructure, medicines, equipment and health workers.
In conclusion, the NHIShas chalked so many successes so far, and of course, there is a long way to go.The challenges faced by the scheme can be nullified for the better if the NHIAembarks on the journey of doing so. Certainly, there are more devastatingproblems involved in the scheme but a conscious effort to address theseproblems will be of so much benefit to the stakeholders of the scheme,including the Ghanaian residents.
