The National Health Insurance Scheme was set up by an Act of parliament in 2003 as a means to fulfill the Universal Health Coverage (UHC). This means that all individuals and communities receive the health services they need without suffering financial hardship.
Insurance in general within our jurisdiction lacks public trust and confidence. This is a result of previous and current experiences from some section of the people when it comes to especially claims payment.
There was a hope that the National Health Insurance would at least shed some light on the seemly gloomy insurance industry. The National Health Insurance Scheme NHIS though takes a different trajectory, is eventually approaching asymptotic to the known insurance challenges already being handled.
What is the problem?
- Low uptake and renewal of health insurance subscription upon expiry
The initial idea of general health insurance for the populace was great to jump up to. The objective that the scheme is to provide quality and ‘free’ health care that can be accessed by all, was something very worthy and welcoming. Over a decade after its implementation, the District Public Mutual Health Insurance Scheme (DPMHIS) has lost the interest of the citizenry. The initial perception that the scheme was going to be beneficial upon subscription has met the rather not too good reality of its usage. Thus, the judgement as to the need to renew a subscription, replace an ID card or roll onto the scheme entirely gives Ghanaians cold feet.
Studies have revealed that this shortfall can be attributed to the unavailability of well-equipped health facilities in some localities, the cost and trouble of accessing the nearest health facility, access to NHIS offices for renewals and most possibly the low level of education and sensitisation on the policy are some of the reasons why the scheme is not as popular as envisaged at inception.
Also, the low quality of the service provided under the scheme as compared to private or the former cash and carry method accounts for the low patronage and appreciation of the policy.
Given the option to choose between private health service and public health service, under the scope of quality, the majority will choose the former. However, given the situation that health care as crucial as it is, is also very costly, under cash constraints, persons are rather obliged to take what is offered or face the ultimate crisis of their illness. Quality is not cheap, aside from all the successes the scheme has chalked since its inception, the quality of the service under the scheme should be given a critical look. Long waiting time in queues, unpleasant reception of some health facility staff, drug shortages among others renders the NHIS rather unattractive and ultimately defeating the purpose for which it was established.
Case Study from other Jurisdictions
The United Kingdom is known to run one of the most functioning and successful National Health Insurance Scheme. The culture of quality improvement initiatives conducted under several indicators according to numerous studies accounts for the sustainability and effectiveness of the scheme.
One predominant quality improvement initiative is a patient survey to test the quality of service in terms of access and effectiveness. In this survey, patients are allowed to assess and rate the care they receive at their various general practices. The result of these surveys informs the distribution of resources to various general practitioners. According to Campell et al, 2009 results from patients’ surveys from different general practitioners are used as a measure of payments for various GPs. With higher payments being made to GPs whose patients report a higher level of care.
Public and user involvement in the NHS is the central plank of the UK government policy (Harrison et al, 2002)
A recent study has revealed that money remains the fundamental issue of NHS UK. However, a quarterly monitoring report in the 2013/2014 financial year recorded the sum from the central budget and a reserve from the Department of Health and NHS England to assist the NHS in averting the financial difficulty it was facing at the time.
All the above accounts for the successful sustenance of the NHS in the UK.
Another jurisdiction worth considering is the French health care system. Though similar to the United States system of predominantly private health care, French practices a public/private health care system. The French health insurance provides universal health coverage at high-level services to her population.
The coverage, like that of the United State, ensures no queues, no tertiary hospital services and remarkably, no patient dumping as a result of the financial barrier to receiving health care. (REF)
The French system is however distinguished by the following;
- Office-based private practice for ambulatory care
- A mix of public and private hospitals
- Direct payment from patients to doctor
- Financing derived from payroll taxes
The success of the French universal coverage can however be attributed predominantly to the management of a national network of public hospitals, public health programs and publicly financed health centers.
All the above which are unique to French is sourced from the three principles that guide universal coverage. These are; solidarity, liberalism and pluralism.
Solutions for Ghana
- The scheme should collate the views of its subscribers and figure out why they are not renewing their subscriptions. To be fair, both the working and non-working populace directly or indirectly contribute to the fund whether they decide to leverage on benefit or not. The norm is even with the NHIS, citizens resort to private health insurance or at worse the “cash and carry” system which the scheme is supposed to do away with.
- There should be a policy direction to shift power from professionals and government to citizens and patients when it comes to health care.
- The enforcement Act 650 of 2000 mandates all citizens to enroll in some form of health insurance coverage, be it private, the public or both. Studies have shown that most people prefer private health insurance or cash and carry to the public ‘free” health insurance coverage. Government should make provision in the national budget to further equip and run routine maintenance at our public health facility. Especially the intensive care unit, maternity and neonatal care units.
- We could also discuss having different levels or tier of the scheme with different benefits and premiums. People who could afford might pay to access wider coverage service.
- Health professionals should be motivated and given periodic training on work ethics to keep them up to date on the job.
National Health Insurance Authority (NHIA) was commissioned to secure the implementation of a national health insurance policy that ensures access to basic healthcare services to all residents. Could a discussion be started on who regulates the activities of the health Insurance provider? Is it appropriate for a service provider to regulate itself?
Written by: Justice Peprah AGYEI.
The writer is a Chartered Insurer and an Associate of the Chartered Insurance Institute of United Kingdom and also Ghana (ACII-UK, ACIIG), and holds MPhil in Enterprise Risk Management and Business Consulting from Kwame Nkrumah University of Science and Technology. Attained Bachelor’s degree from University of Ghana, Legon and have Applied Insurance studies, Diploma and Advanced Diploma (AAIS & AIS) from Ghana Insurance College / Malta Insurance Training Institute.
Co-writer and editor: Lydia Ama TOKU.
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- Health Systems 20/20: Mutual health insurance, scaling-up and the expansion of health insurance in Africa. Bethesda, MD: USAID; 2010. http://www. healthsystems2020.org/content/resource/detail/2523/.
- World Bank: Ghana & Rwanda set the example on scaling up health insurance in Africa; 2009. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/ EXTHEALTHNUTRITIONANDPOPULATION/EXTHSD/0,,contentMDK:22383215~ menuPK:376799~pagePK:64020865~piPK:149114~theSitePK:376793,00.html.
- World Health Organisation: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(UHC)