The national health insurance scheme in Ghana : policy, equity, community and healthcare

Africa has made great progress through the Millennium Development Goals (MDGs), however, it still faces challenges like high disease burdens, poverty, health inequalities and weak healthcare finances and systems. Improving health and well-being through the post-2015 development agenda cannot be an end but a means to addressing the causes of these health determinants and problems. The study uses the work of the Commission on Social Determinants of Health (2008) to expand healthcare financing in Ghana with the principles of equity, human rights and health needs. It places social determinants of health and health promotion in a historical, economic and social context. 

The first stage involved a desk assessment to extract data from literature and policy documents. The assessment revealed that transportation, income, education, food security and nutrition, health status, assets, gender, age, employment and social position are the main determinants of NHIS. A second qualitative phase of study followed; gathering data from the field. Informed by social constructionism, nine focus group discussions were conducted in nine different communities within the Agogo Ashanti Akim North District of Ghana with seventy-two respondents. Nine key informants, including policy makers, heads of institutions and civil servants were also interviewed. The sampling approach tried to gain maximum variation so that a broad based understanding of NHIS could be obtained. The qualitative data of focus groups and the interviews of key informants were analysed using AttrideStirling’s (2001) thematic network framework. The qualitative data revealed that membership selection of the NHIS depends on ability to pay both the fees of the NHIS card and the premiums. However, an individual may also become a member of the scheme free of charge if exempted from payment on the grounds of age or through being accepted as core poor (indigent). The focus groups present a different perspective to inform policy makers in Ghana that the current official criteria for classifying the core poor are not appropriate. Despite the NHIS policy allowing free indigent registration, priority was also not given to reaching out to the indigents within the scheme's authority.Another key theme that emerged indicates that the poor struggles to manage the NHIS by sacrificing basic needs such as clothing and food or having to borrow to pay for health services out of pocket (OOP). There is therefore a gap between NHIS policy and real life.Insured and non-insured still pay OOP despite the generous benefits package. The FGDs find that the NHIS is progressive for formal sector employees, whose payments were by direct taxes and payments but regressive for the informal sector workers, whose payments were by premiums and other indirect payments.The results further noted lack of voice and lack of understanding as features limiting people from accessing the NHIS facilities. Understanding of equity as a key theme revealed: first, lack of stakeholder engagement and a lack of consultation or participation in the NHIS decision making process.Second, the NHIS displayed an overreliance on healthcare and an emphasis on a biomedical approach. Third, it was established that while the policy indicated a will to include all the core poor patients for an equitable NHIS, there is lack of willingness to implement this aim fully. Finally, health and local authorities are not sharing responsibility for tackling the unfairness inherent in the NHIS contributions. 

The thesis argues that much more needs to be done to address the social determinants of NHIS by advancing concrete and meaningful Health Equity in All Policies for the post -2015 development agenda in Ghana. This entails improving the health of Ghanaians by coordinating action across health and non-health sectors to bridge the policy implementation gaps, increase access and reduce inequities that are not only unnecessary and avoidable but unfair. In conclusion, the research’s contribution to knowledge recommends clear directional philosophies that can help facilitate continued progress to improve health in the post-MDGs agenda and beyond.