Ghana’s sick National Health Insurance Scheme

I was skimming through Twitter when I saw a post that read, “The Ghanaian is just a sickness away from going bankrupt.” I thought long and hard about it and noticed the reality staring at me in the face.

That is the fate of many Ghanaians. Daily, social media is awash with designs and artworks of the sick and the dying holding unto the miracle of crowdfunding. Without it, the individual sees death laying its icy hands on the doorknob of his or her life.

It becomes a battle of life and death. In most cases, it is not because these individuals live unworthy lifestyles. It is not because they could not save money for lean times.

For most of these people, by the time they turned to crowdfunding, they would have exhausted their savings and investments and would have no choice but to fall on the compassion of family and friends and people they may not know. The cost of healthcare is overwhelming.

Over the years, Ghanaians with kidney and heart disease, leukemia, and, now, breast cancer, the leading cause of cancer mortality in Ghanaian women, court the influence of the traditional and social media for help to treat their ailments.

But will there ever be an end to the cry for help on hospital beds and the hard-to-hear “kofie ko wu” or “go home and die” statement doctors never have the courage to utter than to act it out?

A saviour that never was?

This is why I worry about Ghana’s  National Health Insurance Scheme (NHIS).

Is it not supposed to be a lifesaver when the going gets tough, when our bodies fail us and our pockets fail to keep up with the cost of healthcare?

Ghana became the first sub-Saharan African country to introduce an NHIS. It was in 2003 under former President John Agyekum Kuffuor. As usual, we took our pride of place in the roll call of the first to act.

Just like it was with being the first country in Sub-Saharan Africa to gain independence, history was made again.  It’s a history that was short-lived, or should I say has become an embarrassment.

Financial resources that are supposed to be pulled together, to remove any financial barrier for equitable access to healthcare for citizens, especially the poor and the vulnerable, have become another avenue for manna to fall into the mouths of certain characters in government.

The Health Insurance Levy

The NHIA obtains its revenue from the 2.5% the National Health Insurance Levy (NHIL) charged on Value Added Tax (VAT).

There is also 2.5% of the monthly Social Security and National Insurance Trust (SSNIT) contributions from the trust’s contributors.

In addition to that are the returns accrued from the National Health Insurance Fund (NHIF) Investments.

All these monies, including the premium subscribers pay, are meant to cushion the scheme financially. Yet, the ghost names and bloated false claims by some health institutions have become a canker eating the system away.

There have been consistent concerns about the payment of the NHIS claim reimbursement to service providers. In 2011, for instance, 30% of  the NHIS claims in the Ashanti Region were fictitious, with the Greater Accra region contributing 13% to the fictitious claims.

Not all the NHIS levies collected up in the coffers of the National Health Insurance Authority (NHIA). It hurts to know that the little money we have accrued from paying taxes and the insurance only sponsors the fraudulent lifestyle of an inefficient public worker who failed to account for the monies paid and crooked health facility owners who find fraudulent means to fleece the scheme.

In 2008, 45% of NHIA funds could not be accounted for. No lessons were learned. Moving on, the situation has become worse.

The NHIA has also not managed the funds well. There have been reports of corruption and misapplication of funds that should go into healthcare delivery. In 2019, the Auditor-General revealed that more than GHc184 million of the NHIS fund was paid to Zoomlion Ghana Limited, a private waste management company, under dubious circumstances.

In 2018, 2019, and 2022, the Private Health Facilities Association of Ghana threatened to revert to the cash-and-carry system due to delay in the disbursement of claims.

In 2018, the government cleared GH₵1billion out of a ₵1.2billion debt, which it claimed it had inherited from the previous government.

In 2016, the Akufo-Addo campaign promised to reform the health insurance scheme.

That promise was flowerily captured in the party’s manifesto in a manner that suggested that a messiah was coming to break the shackles of inefficiencies of the National Health Insurance Scheme.

The message in the 2016 manifesto was, “the NHIS has collapsed over the past 8 years under the watch of the NDC government. The next NPP government will revive the National Health Insurance Scheme to make it efficient with capacity to finance health services on a timely basis in a bid to achieve universal health coverage for all Ghanaians.”

However, one still cannot recall which of the policies under the NHIS has transformed for a better and cost-efficient healthcare delivery service.

It became another empty promise fit for manifesto pages but, as usual, ended up on dusty shelves.

As if to play back what they endured in 2016, in early 2022, the NDC minority in parliament accused the government of plundering the NHIS into “medical comatose.”

Per the National Health Insurance Act 852, section 52(1), “The Minister responsible for Finance shall, within thirty days after collection of the levy, cause the levy to be paid directly into the fund and furnish the Minister responsible for Health and the Authority with evidence of the payment.”

But due to the misapplication of funds for other government projects, the finance minister could not adhere to it. Since 2017, the finance minister could not also give biannual reports on the NHIS levy as expected of him per Section 52(2) of the NHIA Act.

The government’s decision to cap funds from the National Health Insurance Levy meant that only 20% of the entitlement go to the NHIS.

The scheme is being starved of very important resources that will make the ordinary Ghanaian feel the value of the NHIS.

As of April 2022, the government still owed health service providers ₵150million as arrears from 2017 to 2020.

The then CEO of the NHIA, Dr. Lydia Dsane Selby, attributed the delay in payment to the late submission of claims by service providers.

These gaps obviously make the scheme unsustainable, the reason patients are forced to buy drugs that the healthcare facilities should easily provide.

One still wonders why, since 2008, only 40% of the Ghanaian population are enrolled on the scheme?

It’s simple. All the missing links above have flamed out the attractiveness of the scheme to ultimately hedge their lives against the heavy expenditure that comes with medical emergencies.

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Sadly, despite the stagnation in its growth, the rise in claims continues to outstrip revenue collected, partly due to the lies cooked by some healthcare facilities, the mismanagement by the NHIA and the lack of commitment by the government to make the scheme better.

And what is the motivation for the political class to make the insurance scheme better when they constantly fly out of the country to access healthcare at the expense of the tax payer?

It is obvious that the challenges are more than we are being told and there is more to what is in the media. However, it doesn’t change the fact that the NHIS has ceased to play its expected role.

Ghana’s health insurance scheme continues to court interests across the world. Unfortunately, Ghana has not been a good example of how a nation’s NHIS should be.

South Africans are still wondering whether to roll out a similar scheme.

What is the solution?

To save the scheme from imminent collapse, I suggest the following.

Transparency and honesty on the part of the service providers could save the NHIA millions of cedis it needs to sustain the scheme. And since there are bound to be fraudulent elements in there, the NHIA should put in place systems to check, detect and punish fraudulent service providers.

There should be prompt action from the NHIA in reimbursing payment claims of health service providers.

It is high time stakeholders assessed the impact of the NHIA and reviewed it to improve the scheme. For those who can’t afford a private health insurance, a reliable public-funded one is the lifeline to their misery.

Until then, as it is today, the Ghanaian would only have to rely on a miracle for healing when sickness comes knocking. At best, one should pray never to encounter not to fall sick