THE NATIONAL HEALTH INSURANCE SCHEME: Separating service provider from regulator


The National Health Insurance Scheme was set up by an Act of parliament in 2003 as a means to fulfil Universal Health Coverage (UHC). This means that all individuals and communities receive the health services they need without suffering financial hardship.

Insurance in general within our jurisdiction lacks public trust and confidence. This is a result of previous and current experiences of some sections of the people when it comes to, especially, claims payment.

There was a hope that the National Health Insurance would at least shed some light on the seemingly gloomy insurance industry. The National Health Insurance Scheme, NHIS, takes a different trajectory though, and is eventually approaching asymptotic to the known insurance challenges already being handled.

What is the problem?

  • Low uptake and renewal of health insurance subscription upon expiry

The initial idea of general health insurance for the populace was great to strive for. The objective that the scheme is to provide quality and ‘free’ health care that can be accessed by all was something very worthy and welcome. Over a decade after its implementation, the District Public Mutual Health Insurance Scheme (DPMHIS) has lost the citizenry’s interest. The initial perception that the scheme was going to be beneficial upon subscription has met the rather not too good reality of its usage. Thus, directives as to the need to renew a subscription, replace an ID card or roll onto the scheme entirely give Ghanaians cold feet.

Studies have revealed that this shortfall can be attributed to the unavailability of well-equipped health facilities in some localities, the cost and trouble of accessing the nearest health facility, access to NHIS offices for renewals, and most likely the low level of education and sensitisation on the policy are some of the reasons why the scheme is not as popular as envisaged at inception.

Also, the low quality of service provided under the scheme as compared to private or the former cash and carry method accounts for the policy’s low patronage/appreciation.

Given the option to choose between private health service and public health service, under the scope of quality, a majority will choose the former. However, given the situation that health care, as crucial as it is, is also very costly under cash constraints, persons are rather obliged to take what is offered or face the ultimate crisis of their illness.

Quality is not cheap, aside from all the successes the scheme has chalked up since its inception, the quality of services under the scheme should be given a critical look. Long waiting time in queues, unpleasant reception of some health facility staff, drug shortages among others render the NHIS rather unattractive and ultimately defeats the purpose for which it was established.

Case Study from other Jurisdictions

The United Kingdom is known to run one of the most functioning and successful National Health Insurance Schemes. The culture of quality improvement initiatives conducted under several indicators according to numerous studies accounts for the sustainability and effectiveness of the scheme.

One predominant quality improvement initiative is a patient survey to test the quality of service in terms of access and effectiveness. In this survey, patients are allowed to assess and rate the care they receive at their various general practices. The result of these surveys informs the distribution of resources to various general practitioners. According to Campell et al, 2009 results from patients’ surveys from different general practitioners are used as a measure of payments for various GPs – with higher payments being made to GPs whose patients report a higher level of care. Public and user involvement in the NHS is the central plank of the UK government policy (Harrison et al, 2002)

A recent study has revealed that money remains the fundamental issue of NHS UK. However, a quarterly monitoring report in the 2013/2014 financial year recorded the sum needed from the central budget and a reserve from the Department of Health and NHS England to assist the NHS in averting the financial difficulty it was facing at the time.

All the above account for a successful sustenance of the NHS in the UK.

Another jurisdiction worth considering is the French health care system. Though similar to the United States system of predominantly private health care, France practices a public/private health care system. The French health insurance scheme provides universal health coverage with high-level services to its population.

The coverage, like that of the United States, ensures no queues, no tertiary hospital services and, remarkably, no patient-dumping as a result of financial barriers to receiving health care. (REF)

The French system is however distinguished by the following:

  • Office-based private practice for ambulatory care
  • A mix of public and private hospitals
  • Cost-sharing
  • Direct payment from patients to doctor
  • Financing derived from payroll taxes

The success of French universal coverage can however be attributed predominantly to the management of a national network of public hospitals, public health programmes and publicly financed health centres.

All the above which are unique to France are sourced from the three principles which guide universal coverage. These are solidarity, liberalism and pluralism.

Solutions for Ghana

  • The scheme should collate the views of its subscribers and figure out why they are not renewing their subscriptions. To be fair, both the working and non-working populace directly or indirectly contribute to the fund – whether they decide to leverage on benefit or not. The norm is that, even with the NHIS, citizens resort to private health insurance or at worse the ‘cash and carry’ system – which the scheme is supposed to do away with.
  • There should be a policy direction to shift power from professionals and government to citizens and patients when it comes to health care.
  • The enforcement of Act 650 of 2000 mandates all citizens to enrol in some form of health insurance coverage, be it private, public or both. Studies have shown that most people prefer private health insurance or cash and carry to the public ‘free’ health insurance coverage. Government should make provisions in the national budget to further equip and run routine maintenance at our public health facilities; especially the intensive care unit, maternity and neonatal care units.
  • We could also discuss having different levels or tiers of the scheme with different benefits and premiums. People who can afford it might pay to access wider coverage service.
  • Health professionals should be motivated and given periodic training on work ethics to keep them up to date on the job. 


The National Health Insurance Authority (NHIA) was commissioned to secure the implementation of a national health insurance policy that ensures access to basic healthcare services for all residents. Can a discussion be started on who regulates activities of the health insurance provider? Is it appropriate for a service provider to regulate itself?

The writer is a Chartered Insurer and an Associate of the Chartered Insurance Institute of United Kingdom and also Ghana (ACII-UK, ACIIG),Co-writer and editor: Lydia Ama TOKU.

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