This week, let’s talk about health insurance; its role and challenges in Ghana.
I must first admit that I do not know a great deal about the effectiveness and responsiveness of health insurance companies, especially the National Health Insurance Scheme (NHIS), in meeting the needs of patients in the financing of their medical care in Ghana.
My comments will be based on what I have read and a review of the NHIS website, and my general knowledge of how insurance works. (I worked for two companies, in the US, which combined health insurance and direct patient care [HMO] for a combined total of eight years as Medical Director).
There are three observations that I will make. The first is that health insurance is currently the best and most equitable and effective way to finance individual and collective health care. Out of pocket payment such as the “cash and carry system” of old, is problematic and in a “poor” country like ours, it is inhumane.
My second observation is that the introduction of NHIS is the best thing that has happened to healthcare delivery in Ghana in the last decade.
My third observation is that the NHIS has the greatest potential to improve access to healthcare, the quality of medical care, and the behavior of hospitals and doctors, especially those in private practice. The maxim of “he who pays the piper…….” However, for health insurance to be able to do these things, it must be respected and attractive to both providers and enrollees. If it is inefficient, not respected and not attractive, it becomes nothing but a conduit for money from one source to a destination. It will just become an administrative arrangement and actually an obstructive bottleneck.
From what I have read about the recent challenges of the NHIS, it does not appear to be doing too well. It is getting the enrollment, albeit more from the lower income population than from every Ghanaian as it was envisaged, but the providers are not getting paid on time and reimbursement rates are, reportedly, unsatisfactory. It is also grappling with corruption.
These may be teething problems (after ten years?) or may be a reflection of suboptimal management. It is absolutely essential for the NHIS to work well. A well-functioning NHIS will increase the internally generated funds for public hospitals, which will not only help their operations, and the quality of care they provide to patients, but could lead to some level of autonomy that can allow the hospitals to refurbish equipment and buy new ones. Hospitals cannot function and the quality of medical care will drop if they are not paid for services they have rendered. The NHIS cannot afford a negative reputation over a prolonged period. That could destroy the potential that it has.
I have also been concerned about the low premiums that enrollees pay and the absence of co-pays and enrollee financial exposure outside of the low premiums. On one hand, I would understand if the reason is because most enrollees are poor and extra payments at the point of service would just be a disincentive to going to hospital in the first place; something that would defeat the purpose of the insurance. On the other hand, I am concerned about “moral hazard”. I suspect that the dissatisfaction that patients have with visiting a hospital unless they really have to, (what with the long waits, the insults etc.) act as protection against the threat of moral hazard.
If my first conclusion is right, then NHIS becomes a pure social service, in which case, it has to be well resourced through taxes, whether direct or indirect. Considering the heavy demands on the public purse, can we add another heavy burden like a pure publicly funded health insurance system? Remember healthcare costs go up inexorably, and we do not have any credible systems in place to control costs. Does that not make the NHIS vulnerable to failure that will threaten the whole public health delivery system?
Let us hear your, more informed, views and comments on health insurance in Ghana, especially the NHIS.