1Centre for Health Policy/MRC Health Policy Research Group, and School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
2Department of Health Policy, Planning and Management, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
3School of Criminology, Politics and Social Policy, Faculty of Social Sciences, University of Ulster, Jordanstown, UK
Background Ghana’s National Health Insurance Scheme (NHIS), established by an Act of Parliament (Act 650), in 2003 and since replaced by Act 852 of 2012 remains, in African terms, unprecedented in terms of growth and coverage. As a result, the scheme has received praise for its associated legal reforms, clinical audit mechanisms and for serving as a hub for knowledge sharing and learning within the context of South-South cooperation. The scheme continues to shape national health insurance thinking in Africa. While the success, especially in coverage and financial access has been highlighted by many authors, insufficient attention has been paid to critical and context-specific factors. This paper seeks to fill that gap.
Methods Based on an empirical qualitative case study of stakeholders’ views on challenges and success factors in four mutual schemes (district offices) located in two regions of Ghana, the study uses the concept of policy translation to assess whether the Ghana scheme could provide useful lessons to other African and developing countries in their quest to implement social/NHISs.
Results In the study, interviewees referred to both ‘hard and soft’ elements as driving the “success” of the Ghana scheme. The main ‘hard elements’ include bureaucratic and legal enforcement capacities; IT; financing; governance, administration and management; regulating membership of the scheme; and service provision and coverage capabilities. The ‘soft’ elements identified relate to: the background/context of the health insurance scheme; innovative ways of funding the NHIS, the hybrid nature of the Ghana scheme; political will, commitment by government, stakeholders and public cooperation; social structure of Ghana (solidarity); and ownership and participation.
Conclusion Other developing countries can expect to translate rather than re-assemble a national health insurance programme in an incomplete and highly modified form over a period of years, amounting to a process best conceived as germination as opposed to emulation. The Ghana experience illustrates that in adopting health financing systems that function well, countries need to customise systems (policy customisation) to suit their socio-economic, political and administrative settings. Home-grown health financing systems that resonate with social values will also need to be found in the process of translation.
Waddington C, Enyimayew KA. A price to pay, Part 1. "The impact of user charges in the Ashanti Akim District, Ghana. Int J Health Plann Manage. 1989;4:17-47. doi:10.1002/hpm.4740040104
Waddington C, Enyimayew KA. A price to pay,the impact of user charges in the Volta Region of Ghana. Int J Health Plann Manage. 1990;5(4):287-312. doi:10.1002/hpm.4740050405
Shaw RP, Griffin CC. Financing health care in sub-Saharan Africa through user fees and insurance. World Bank; 1995.
Oppong JR. Structural Adjustment and the Health Care System. In: Konadu-Agyemang K, ed. IMF and World Bank Sponsored Structural Adjustment Programs in Africa: Ghana’s Experience, 1983-1999. Ashgate: Aldershot; 2001:357-370.
Mensah J, Oppong JR, Schmidt CM. Ghana's National Health Insurance Scheme in the context of the health MDGs: An empirical evaluation using propensity score matching. Health Econ. 2010;19(S1):95-106. doi:10.1002/hec.1633
World Health Organization (WHO). Success Stories of Health Financing Reforms for Universal Coverage Ghana. Geneva: WHO; 2011.
MoH. Holistic Assessment of the Health Sector Programme of Work 2014. Accra; 2014.
Kusi A, Enemark U, Hansen KS, Asante FA. Refusal to enrol in Ghana’s National Health Insurance Scheme: is affordability the problem? Int J Equity Health. 2015;14:2. doi:10.1186/s12939-014-0130-2
Amponsah EN. Demand for health insurance among women in Ghana: cross sectional evidence. International Research Journal of Finance and Economics. 2009;33:180-189.
Gobah FFK, Liang Z. The National Health Insurance Scheme in Ghana: prospects and challenges: a cross-sectional evidence. Glob J Health Sci. 2011;3(2):90-101. doi:10.5539/gjhs.v3n2p90
Nguyen HT, Rajkotia Y, Wang H. The financial protection effect of Ghana National Health Insurance Scheme: evidence from a study in two rural districts. Int J Equity Health. 2011;10:4. doi:10.1186/1475-9276-10-4
Doetinchem O, Bernd S, Jean-Olivier S. The benefits and challenges of social health insurance for developing and transitional countries. In: Laaser U, Radermacher R, eds. Financing Health Care: A Dialogue Between South Eastern Europe and Germany. Series International Public Health (vol 18). Lage: Jacobs; 2006.
Barimah KB, Mensah J. Ghana's National Health Insurance Scheme: insights from members, administrators and health care providers. J Health Care Poor Underserved. 2013;24(3):1378-1390.
Dixon J, Tenkorang EY, Luginaah IN, Kuuire VZ, Boateng GO. National health insurance scheme enrolment and antenatal care among women in Ghana: is there any relationship? Trop Med Int Health. 2014;19(1):98-106. doi:10.1111/tmi.12223
Dixon J. Determinants of Health Insurance Enrolment in Ghana's Upper West Region. Ontario: The University of Western Ontario; 2014.
Alhassan RK, Spieker N, van Ostenberg P, Ogink A, Nketiah-Amponsah E, de Wit T. Association between health worker motivation and healthcare quality efforts in Ghana. Hum Resour Health. 2013;11:37. doi:10.1186/1478-4491-11-37
Alhassan RK, Duku SO, Janssens W, et al. Comparison of Perceived and Technical Healthcare Quality in Primary Health Facilities: Implications for a Sustainable National Health Insurance Scheme in Ghana. PloS One. 2015;10(10):e0140109. doi:10.1371/journal.pone.0140109
Debpuur C, Dalaba MA, Chatio S, Adjuik M, Akweongo P. An exploration of moral hazard behaviors under the national health insurance scheme in Northern Ghana: a qualitative study. BMC Health Serv Res. 2015;15(1):469. doi:10.1186/s12913-015-1133-4
Fusheini A, Marnoch G, Gray AM. Implementation Challenges of the National Health Insurance Scheme in Selected Districts in Ghana: Evidence from the Field. Int J Public Adm. 2016. doi:10.1080/01900692.2015.1127963
Giovannetti G, de Haan A, Sabates-Wheeler R, Sanfilippo M. Successes in social protection: what lessons can be learned? Rev Can Etudes Dev. 2011;32(4):439-453. doi:10.1080/02255189.2011.647446
Sabates-Wheeler R, Devereux S. Transformative social protection: the currency of social justice. In: Barrientos A, Hulme D, eds. Social Protection for the Poor and Poorest. UK: Palgrave Macmillan; 2008:64-84.
Giovannetti G. Social Protection for Inclusive Development. A New Perspective in EU Cooperation with Africa. Florence: Robert Schuman Centre for Advanced Studies, European University Institute; 2010.
Ramachandra S, Hsiao W. Ghana: initiating social health insurance. Social Health Insurance for Developing Nations. 2007;434:61. doi:10.1596/978-0-8213-6949-4
Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet. 2012;380:933-943. doi:10.1016/s0140-6736(12)61147-7
Seddoh A, Sam A, Alex N. Ghana’s National Health Insurance Scheme: views on progress, observations and commentary. Accra: Center for Health and Social Services; 2011.
NHIA. National Health Insurance Authority, 2013 Annual Report. Accra: NHIA; 2013.
Schick A. A contemporary approach to public expenditure management. World Bank; 1998.
Pollitt C. Time, Policy, Management: Governing With the Past: Governing With the Past. Oxford: Oxford University Press; 2008.
Pollitt C, Bouckaert G. Continuity and Change in Public Policy and Management. Cheltenham: Edward Elgar Publishing Inc; 2009.
Pierson P. Politics in time: History, institutions, and social analysis. Princeton: Princeton University Press; 2004.
Basaza RK, O’Connell TS, Chapčáková I. Players and processes behind the national health insurance scheme: a case study of Uganda. BMC Health Serv Res. 2013;13:357. doi:10.1186/1472-6963-13-357
Fenenga CJ, Nketiah-Amponsah E, Ogink A, Arhinful DK, Poortinga W, Hutter I. Social capital and active membership in the Ghana National Health Insurance Scheme-a mixed method study. Int J Equity Health. 2015;14:118. doi:10.1186/s12939-015-0239-y
55. Jehu-Appiah C, Spaan E, de Hoop T, Agyepong I, Balthussen R. Equity aspects of the National Health Insurance Scheme in Ghana: who is enrolling, who is not and why? Soc Sci Med. 2011;72(2):157-65. doi:10.1016/j.socscimed.2010.10.025.
Witter S, Garshong B. Something old or something new? Social health insurance in Ghana. BMC Int Health Hum Rights. 2009;9:20. doi:10.1186/1472-698X-9-20
Mills A, Bennett S. Lessons on the sustainability of health care funding from low-and middle-income countries. In: Mossialos E, Dixon A, Figueras J, Kutzin J, eds. Funding Health Care: Options for Europe.Buckingham: Open University Press; 2002:206.