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Prospects and Challenges of Implementing a Sustainable National Health Insurance Scheme: The Case of the Cape Coast Metropolis, Ghana

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Abstract

Accessibility to health services is a major development problem facing sub-Saharan African countries. The prevalence of poverty and unemployment is a major hindrance to making health services accessible to the population especially the poor. Many development theories have been on how to make basic services affordable and accessible to the poor. The World Development Report 2004 focuses on making services work for the poor. The government of Ghana introduced nationwide National Health Insurance Scheme (NHIS) with the aim of providing health insurance and making health services accessible and affordable to the average Ghanaian. The 'cash and carry system' that existed before the introduction of the National Health Insurance Scheme made health services quite inaccessible to the poor. The 'cash and carry system' compelled patients to pay for the cost of health services before they were given the desired medication. The poor resorted to self-medication with its accompanied complications and problems. The overall objective of the study was to assess the contribution of the NHIS to health care delivery in the country and examine the sustainability challenges of the scheme. The study revealed that the NHIS has assisted in increasing Out-Patients-Department (OPD) attendance, reduction of self medication and made health services more assessable to the poor. It was however, observed that for a sustainable national health insurance scheme to be achieved, issues such as maintaining and expanding the client base, regular payment of the services providers and ensuring the requisite institutional capacity should be given the deserved attention.

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... According to Transparency International quoted in Kamorudeen and Bidemi (2012, p. 101), corruption in the health sector includes "bribery of health professionals, regulators and public officials; unethical research; diversion/ theft of medicines and medical supplies; fraudulent or overbilling for health services; absenteeism; informal payments; embezzlement; and corruption in health procurement". According to Agyemang, Adu-Gyamfi and Afrakoma (2013) and Fusheini (2016), corruption was equally common in the Ghanaian NHIS. Corruption can affect the success of UHC by reducing investment in the health sector, demoralizing workers, reducing the quality of health care service, reducing trust of both workers and clients in the health system and discouraging participation of people in the UHC scheme, etc. ...
... For example, in respect of corruption, one of the participants stated this: "Corruption is a major issue in healthcare delivery especially with respect with universal health coverage. ---because of corruption, resources that are meant for programmes easily disappear and even when they are being utilized you will discover that not more than 10% to 30% of the resources meant for such programme are normally spent on that programme, so corruption is major factor"( PM-MoH10).Other authors also found corruption to be a major problem in the implementation of UHC (Aregbeshola, 2017;Fusheini, 2016 andAgyemang, Adu-Gyamfi andAfrakoma, 2011)). ...
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Background: Financial risk protection for healthcare is deficient in Enugu state, Southeast Nigeria and the worst affected are the rural dwellers and the poorest, thus creating both socioeconomic and geographic inequity in access and use of services. The study aimed at eliciting the level of awareness and use of pre-payment mechanisms, and more importantly, determining the economic and political factors that facilitate or constrain achievement of Universal Health Coverage in Enugu state, Southeast Nigeria. Methods: Study was conducted in two purposively chosen urban and rural local government areas(LGA) of Enugu state with mixed method study design. Cross-sectional household questionnaire survey was conducted on 802 sample size from the two LGAs and 12 key informants participated in In-depth interviews (IDIs). The quantitative data was analysed with STATA using descriptive statistics while the qualitative IDI data was organized into nodes and sub-nodes using Nvivo: political and economic factors, corruption, communication/Awareness, capacity development / Infrastructure, policy development, leadership and referral system. Later, findings were thematically analysed. Results: The survey results showed that 84% of the study sample have secondary school education and 83% are engaged in employment or petty business. About 56% are aware of prepayment mechanism for healthcare bills but only 10% of them have used prepayment mechanisms. Out of pocket payment (85%) is the main source of payment at health facilities. Major political constraining factors to UHC revealed by the IDI include lack of political will backed with financial commitment from the political leaders, lack of legislative framework for UHC, lack of trust on the political leaders/government by the citizenry and inactive civil society organizations. Also, the poor fiscal space for health and the poverty level in the populace are big threats to sustainable UHC in Enugu state. Other economic challenges include corruption, poor health capacity development and poorly paid healthcare workers leading to poor quality of health care delivery. There is need for comprehensive health system development in the state to accommodate UHC. Conclusions: Establishment of sustainable UHC in Enugu state faces considerable political and economic challenges. There is need for increased government budgetary allocation for UHC to ensure coverage for the poor and vulnerable members. The lack of legislative framework for UHC could be resolved by legislative arm of the government. The government should invest in health system development to improve the quality of health care services to compliment the FRP component of UHC.
... 6 While health insurance schemes seek to achieve these, researchers have also drawn attention to the challenges of implementation developing countries face. 7 In the literature, three major challenges including: collection of revenue, financial risk management, and spending of resources on service providers have been identified. 8 Within the context of Sub-Saharan Africa, five broad challenges: (i) lack of clear legislative and regulatory framework; (ii) low enrolment rates; (iii) insufficient risk management measures; (iv) weak managerial capacity; and (v) high overhead costs 6 have been noted. ...
... 6 Other challenges include weak institutional capacity for effective management, ineffective or unenforced regulatory mechanisms, rigid administrative procedures, and entrenched customs and practices that are difficult to change. 7 Furthermore, there is increasing body of literature on the technical challenges of implementing health insurance in LMICs. [9][10][11][12] In a study of national health insurance (NHI) policy implementation challenges in Nepal, for instance, financial viability has been mentioned as one major factor to achieving a more comprehensive NHI system. 4 In the specific context of Ghana, while much has been achieved in relation to dealing with the implementation challenges there has been failure to recognize and deal effectively with the political 12 and economic challenges in the implementation of the scheme. ...
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Background: National/social health insurance schemes have increasingly been seen in many low- and middle-income countries (LMICs) as a vehicle to universal health coverage (UHC) and a viable alternative funding mechanism for the health sector. Several countries, including Ghana, have thus introduced and implemented mandatory national health insurance schemes (NHIS) as part of reform efforts towards increasing access to health services. Ghana passed mandatory national health insurance (NHI) legislation (ACT 650) in 2003 and commenced nationwide implementation in 2004. Several peer review studies and other research reports have since assessed the performance of the scheme with positive rating while challenges also noted. This paper contributes to the literature on economic and political implementation challenges based on empirical evidence from the perspectives of the different category of actors and institutions involved in the process. Methods: Qualitative in-depth interviews were held with 33 different category of participants in four selected district mutual health insurance schemes in Southern (two) and Northern (two) Ghana. This was to ascertain their views regarding the main challenges in the implementation process. The participants were selected through purposeful sampling, stakeholder mapping, and snowballing. Data was analysed using thematic grouping procedure. Results: Participants identified political issues of over politicisation and political interference as main challenges. The main economic issues participants identified included low premiums or contributions; broad exemptions, poor gatekeeper enforcement system; and culture of curative and hospital-centric care. Conclusion: The study establishes that political and economic factors have influenced the implementation process and the degree to which the policy has been implemented as intended. Thus, we conclude that there is a synergy between implementation and politics; and achieving UHC under the NHIS requires political stewardship. Political leadership has the responsibility to build trust and confidence in the system by providing the necessary resources and backing with minimal interference in the operations. For sustainability of the scheme, authorities need to review the exemption policy, rate of contributions, especially, from informal sector employees and recruitment criteria of scheme workers, explore additional sources of funding and re-examine training needs of employees to strengthen their competences among others.
... The United Nations development goals consider the health of citizens an important issue in achieving the sustainable goals. Well-being is one indicator of good health and the rising emphasis on the promotion and enhancement of health is mainly due to highlights of such by the United Nations goals (Agyemang et al., 2013). However, according to Murray and Lopez (2013) one developmental problematic issue facing countries in Africa is non accessibility to good service in part due to lack of employment as well as poverty. ...
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Universal coverage of health is one of the goals of the United Nations and one which every African country, Nigeria inclusive strives to achieve. Referred to as NHIS, the study was motivated by a desire to review a policy with so much importance and set out to appraise the scheme's objectives and assess the level of achievement across sectors including the Small and Medium Scale enterprises popularly known as the SMEs. Research design using the cross sectional approach was employed along with the use of convenience and random sampling, a sample of employees (150) from ten Lagos resident health maintenance organisations (HMOs) with National accreditation were used. Data was collected with the aid of a structured questionnaire and the study relied on regression analysis to derive results. The results showed that the relationship between objectives of the NHIS were significant to the predictor variables (FWA=facility well assessed, RPS=restricted to public sector, ASN=adequate subscription and HAW=high awareness), thus accepting the alternative hypothesis. However, the relationship with the SMEs was only marginal. The study, based on its findings, concludes the scheme is yet to fully achieve its intended objectives and therefore recommend that the scheme's management put effort to expand the coverage across all sectors through enlightenment, improved assess to facilities whilst also collaborating with relevant stakeholders to assuage the people's needs with regards to good quality and affordable healthcare service.
... 62,63 The access and financial protection provided by the scheme have improved health-seeking behaviors and reduced risky health behaviors such as self-medication among Ghanaians. 64 Though some studies 42,65 reported a positive attitude of providers towards service delivery, others 10 reported poor attitudes of providers. Use of traditional medicine was high amongst both insured and uninsured but had no association with insurance status. ...
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Background: South Africa is having difficulties in rolling out the National Health Insurance(NHI) policy. There are ongoing arguments on whether the NHI will provide access to quality and equitable healthcare it is intended to and whether South Africa is ready to implement the policy. Many stakeholders believe the country needs more preparation if the policy will be successful. Ghana, on the other hand, has successfully implemented the National Health Insurance Scheme(NHIS) for over 15 years. Objective: This paper sought to explore the implementation of the NHIS in Ghana and the lessons South Africa and other low- and middle-income countries can learn from such a process. Methods: A scoping review was conducted using the Joanna Brigs Institute's System for the Unified Management, Assessment and Review of Information (SUMARI) and Mendeley reference manager to manage the review process. Journal articles published on the NHIS in Ghana from January 2003 to December 2018 were searched from Science Direct, PubMed, Scopus, CINAHL, and Medline using the keywords: Ghana, Health, and Insurance. Results: The implementation of the NHIS has provided access to healthcare for the Ghanaian population, especially to poor and vulnerable . Despite the successful implementation of the NHIS in Ghana, the scheme is challenged with poor coverage; poor quality of care; corruption and ineffective governance; poor stakeholder participation; lack of clarity on concepts in the policy; intense political influence; and poor financing. Conclusion: The marked inequity in the South African health system makes the implementation of the NHI inevitable. The challenges experienced in the implementation of the NHIS in Ghana are not new to the South African healthcare system. South Africa must learn from the experiences of Ghana,a context that shares common socio-cultural and economic factors and disease burden,in order to successfully implement the NHI.
... Therefore, health insurers should prioritise timely payment to service providers with minimal bureaucracy to avert frustration of health service providers. [29] This study concludes that health insurance services and its benefits are skewed in favor of the civil servants and those of high social class at the detriment of the low social class. However, CD was not significantly overutilised by the health-insured when it is not medically indicated. ...
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Background: Although out-of-pocket (OOP) payment for health services is common, information on the experience in maternal health services especially caesarean delivery (CD) is limited. Aim: To compare the pregnancy events and financial transactions for CD among OOP and health-insured clients. Materials and methods: A comparative (retrospective) study of 200 women who had CD as OOP (100 participants) or health-insured clients (100 participants) over 30 months at Anchormed Hospital, Ilorin, using multistage sampling was conducted. The data were analysed using Chi-square, t-test and regression analysis; P < 0.05 was considered statistically significant. Results: Of 1246 deliveries, 410 (32.9%) had CD; of these, 186 (45.4%) were health-insured and 224 (54.6%) were OOP payers. The health-insured were mostly civil servants (60.0% vs. 40.0%; P = 0.009) of high social class (48.0% vs. 29.0%; P = 0.001). The payment for CD was higher among OOP (P = 0.001), whereas duration from hospital discharge to payment of hospital bill was higher for the health-insured (P = 0.001). On regression, social class (odds ratio [OR]: 0.23, 95% confidence interval [CI]: -0.0891252-0.112799; P = 0.048), amount paid (OR: 48.52, 95% CI: -7.14-6.68; P = 0.001) and duration from discharge to payment (OR: 28.68, 95% CI: 51.7816-70.788; P = 0.001) were statistically significant among participants. The amount paid was lower (P = 0.001), whereas time interval before payment was longer (P = 0.001) for the public-insured compared to private-insured clients. Conclusion: OOP payers are prone to catastrophic spending on health. The waiting time before reimbursement to health-care providers was significantly prolonged; private insurers offered earlier and higher reimbursement compared to public insurers. The referral and transportation of health-insured clients during emergencies is suboptimal and deserve attention.
... The challenges regarding implementation an insurance scheme depends on various factors among the presence of sufficient logistic, payments of premiums on a regular basis, membership board and also regular payment to service providers is very crucial (Agyemang 2013). The designing of a scheme is very crucial; in order to achieve a proper balance between efficiency and equity, it is essential to design scheme with attractive benefit packages is necessary (Purohit 2014). ...
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Background Implementation of a mandatory insurance scheme depends on several issues, and among them are regulation, management, and program design which are very crucial. Sometimes a well-designed insurance scheme cannot attract an adequate number of people toward the scheme. Therefore, this study is aimed to explore the implementation challenges of Sajida Foundation’s health insurance scheme. Methods An exploratory qualitative research design has been applied to explore the challenges that normally exist in regular implementation process. The study population was both field and official level employees who are directly involved in the implementation process of Nirapotta scheme in Karanigoni branch. Results Successful implementation of the health insurance scheme of Sajida Foundation is getting constraints by several factors, and among them are lack of dedicated staff for this program, less involvement with community people, inadequate program knowledge dissemination to the people, and not providing incentive for work of Nirapotta are considered as the major challenges of implementation of Nirapotta Scheme. Challenges faced by policy-makers include incoordination with Microfinance Regulatory Authority and not having the latest software for perfect monitoring and evaluation of the Nirapotta program. Apart from this, there are some challenges in implementation which are normally faced in program; some of the most noteworthy findings are incoordination between employees especially in branch level, transient position of Sajida bondhu in the Nirapotta program, and low payment scale compared to other organizations. Conclusions Implementation of Nirapotta scheme is getting constraints by multiple factors which can easily be overcome by involving all necessary stakeholders and taking their valuable concern for further development of the scheme to ensure long-term sustainability of the program.
Thesis
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This thesis is about promoting a sustainable National Health Insurance Scheme (NHIS) in Ghana through improved client-centred quality care and effective community engagement in quality care assessment. The thesis comprises of two main parts. Part one reports on findings from baseline surveys conducted in 2012 among 324 health workers in 64 primary health facilities in the Greater Accra and Western regions of Ghana. Moreover, baseline household surveys were conducted in 1,903 households in the two regions. Baseline surveys explored health worker motivation levels and associations with healthcare quality efforts, efficiency in health service delivery, and comparison of perceived and technical quality healthcare. Part two of the thesis comprises of impact evaluation studies conducted in 2014, after implementing community engagement interventions in 2013. The interventions were designed to promote a more client-centred healthcare and insurance services. Positive impact of the interventions was observed on clinic staff motivation levels, perceptions on the NHIS, and efforts toward patient safety and risk reduction. The thesis concludes that client and community engagement in healthcare quality improvement efforts could augment existing quality improvement strategies of the Ministry of Health and National Health Insurance Authority. This innovative approach will help increase trust in the NHIS and the healthcare system, needed to attain universal health coverage.
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Although largely controlled by government, Ghana's health delivery system has witnessed dramatic growth in private sector participation. This growth is important for consumers of health care as it provides a wide range of choices, while informing health providers, through consumer feedback, of the quality indicators relevant for improving their services. For consumers of health care, measuring and monitoring quality based on health provider characteristics is crucial to making appropriate choices, especially as these have implications for morbidity, mortality and longevity. There is limited research in sub-Saharan Africa, and Ghana in particular, that examines how health provider characteristics associate with choice of health facility. Using recently collected data from the Ghana Demographic and Health Survey and employing random-intercept models, we fill this research void. Results showed that Ghanaian men and women who were satisfied with wait-time at the health facility were significantly more likely to have visited private health facilities, compared to public health facilities. Similarly, Ghanaian women who appeared satisfied with conditions at the health facility and accessibility of the health facility were significantly more likely to have visited private hospitals compared to public hospitals. This study provides important evidence to policy makers and major stakeholders in the public health sector of the need for quality adjustments and the relevance of improving healthcare delivery in the public health facilities.
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