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Introduction

One core issue that continues to stir debates around the world is health care financing. For this reason, many low and middle income countries are still exploring different ways of financing their health systems. This is due to the fact that their health systems are chronically under-funded (James et al. 2006). With increasing funding gaps and diminishing known sources of funding and the drive for universal coverage, Social Health Insurance (SHI) becomes appealing. It is seen as a way of removing the impact of health expenditure on the poor, protecting health spending in the health sector and facilitating increases in health resource availability. It also holds the potential for promoting a more efficient health system (Centre for Health and Social Services 2011). Whereas the advance countries like the USA, Spain, Australia among others have a strong health care financing schemes of varied frameworks, countries in sub-Sahara Africa are yet to get out of the woes. Few examples here will suffice, In Australia, the first compulsory public insurance scheme started in the early 1970s and this covered the elderly and some poor people in the society (Deeble 1982). In Spain, more than 20 % of health care financing is accounted for by social insurance and about 21 % by private insurance companies (The World Health Report 2000), while social insurance contribution dominates health care financing in Germany and France. About 50 % of funds toward health care in Italy are dependent on social insurance, with 10 % from private insurance and patient charges (Arah et al. 2003). In the examples given, reforms had focused mainly on containing costs. In African countries, reforms have been and still being motivated by growing demand for better health care and therefore the debate revolves around ways of improving the sustainability, equity, and effectiveness of health care services (AU 2009). The health financing crisis facing Sub-Saharan Africa is particularly acute because of the magnitude of the epidemiologic, demographic, and macroeconomic challenges within the region. Schieber and Maeda (1999) indicated that developing countries accounted for 84 % of the world’s population and 93 % of the worldwide burden of disease. However, they account for only 18 % of global income and 11 % of global health spending. Most developing nations are plagued by problems of under nutrition and a host of infections.

In Africa, healthcare demands are changing, making healthcare systems to be at a turning point (The Economist Intelligent Unit 2012). Although there is a growing urban middle class willing to pay for better treatment, which has opened the door to the private sector provision of services, the vast majority of Africans are still unable to pay for healthcare delivery. The continent, already home to some of the world’s most impoverished populations, is confronting multiple epidemiological crises simultaneously. High levels of communicable and parasitic disease are being matched by growing rates of non-communicable diseases such as Hypertension and Kidney infections. Although the communicable diseases—malaria, tuberculosis, and above all HIV/AIDS—are the best known, it is the chronic conditions such as obesity and heart disease that are looming as the greatest threat. These are expected to overtake communicable diseases as Africa’s biggest health challenge by 2030 (The Economist Intelligent Unit 2012).

The major concerns of various governments and policy makers have always been the best mix of financing schemes that can make the desire socio-economic impact as many of the citizenry are operating outside the Venn diagram of formal employment. As a result, new models of healthcare financing are being sought. The reforms that governments undertake over the next decade will be crucial to cutting mortality rates and improving health outcomes on the continent. Crucially, improved health not only benefits individuals but also benefits the broader society, accelerating economic growth and development. In recognition of this, most countries in sub-Saharan Africa including Ghana, have developed and implemented several health financing polices aimed at improving their citizens’ health status (Allotey 2012). In line with the growing international interest in pursuing healthcare financing options that promote universal coverage, Ghana adopted a National Health Insurance Scheme (NHIS) in 2003 to finance healthcare delivery. A prominent expectation of the NHIS arrangement is to narrow the inequality gap by providing financial insulation to individuals and households and to ensure affordable and sustainable health care arrangement for the poor. The trump card of the NHIS, unlike the cash and carry system, is the opportunity it provides for risk pooling and cross-subsidization of healthcare expenditure of certain category of Ghanaians classified as vulnerable. These people are giving fee exemptions that allow them to benefit from healthcare services that hitherto would have been inaccessible to them. This insulates them from suffering directly the perverse impact of healthcare expenditure and low access to healthcare services.

As an evolving policy, it is still going through refinements to capture the hopes and aspirations of Ghanaians. Though the National Health Insurance Scheme is at the teething stage, it is fraught with challenges which if not addressed; the policy might not fully serve the intended purpose.

This research examines the tortuous path of health care financing policies that have been implemented in Ghana and teases out the contextual issues that are challenging the current healthcare financing policy regime. Crucial issues that are discussed are the equity implications and the major implementation challenges of the different financing mechanisms over the years. The study is organized in four main parts. The subsequent section outlines the conceptual framing, which draws on the Hsiao framework. The research further highlights the state of healthcare financing in Ghana before 2003. The Search for Sustainable Healthcare Financing received critical consideration in the third sections while the final section provides the Drawbacks of the National Health Insurance Scheme.

An Overview Hsiao’s Framework

Hsiao’s framework is explicitly more analytical than descriptive. Hsiao (2003) aimed to develop a conceptual framework that modelled the role of health financing within the systemic aspects of the health system, i.e. the major components of a health system that can explain aggregate outcomes. He describes this as a causal model whose major components (i.e. explanatory variables) could largely account for observed outcomes (i.e. dependent variables). Within such a ‘mixed health system’, where some poor people seek care from private practitioners, Hsiao listed four causal financing and delivery mechanisms that can improve access to, availability, and quality of health services (Dimovska et al. 2009). Hsiao mentions the four intermediate variables that could explain the system’s outcomes as: Access, Quality of services, Equity in Financing and Efficiency, see Fig. 9.1.

Fig. 9.1
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Relationship between financing instruments and goals. Source. Hsiao (2003)

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The central government plays a leading role in implementing some of these mechanisms, but private sector actors can also employ these mechanisms, in partnership with government. In a more practical manner, both government and the private sector can employ these mechanisms in service delivery to reduce costs, increase access, and improve quality; risk-pooling to minimize out-of-pocket payments and increase access by pooling risks across populations; self-regulation to create a branding benefit for providers and incentivize greater quality; and supply chain mechanisms to ensure access to quality medicines and enable rapid scale-up (Hanson 2004). Programmes that have been implemented within this framework cover a broad spectrum of interventions that address specific challenges common to many developing countries, including reducing the fragmentation of private providers (franchises and provider networks), changing provider incentives and improving monitoring (accreditation and licensing models and insurance or voucher programmes), and providing subsidies for targeted populations and high-impact interventions (public and private risk-pooling programmes) (Loevinsohn 2006).

The Hsiao framework focuses more on policy levers and drivers and highlights connections between the different elements. In this way, the different health financing functions are described in terms of causal links, rather than through the funds flow. While Hsiao has emphasised in other works the strong impact of the macroeconomic environment on health financing and health policy, there is less reference in this framework to contextual factors, though there is greater recognition of multiple, potentially competing, objectives and of the need to balance the impact on different objectives in policy making (Murray and Evans 2003).

In a recent series of papers examining qualitative methodology of healthcare financing (Willis et al. 2007), emphasised the importance of this theory in qualitative health research. They noted that the theory provides structured interpretations or models for investigating and understanding a social problem including healthcare financing. They explain the importance of this framework by saying that the theory provides a framework for structuring healthcare studies and plays a central role in data collection and analysis. And they argue that the use of theory in a study provides the essential link to the theoretical literature and allows researchers to assess the extent to which the results can be extended to other settings and contexts.

Similarly, McPake and Mills believes that the conceptual frameworks provides the basis for the development of hypotheses on causal links in health financing, and thus determine what data are collected and seen as relevant and how the data are subsequently analysed. This is particularly relevant to cross-country comparative research (McPake and Mills 2000). McPake and Mills (2000) argue that as international comparative research accumulates, models of the relationships between policy variables and outcomes are constructed and amended; this model facilitate comprehension of critical variables that influence policy outcomes.

In applying the theory, one should recognize that a disconnect between the means and any of the intermediate outcomes in Fig. 9.1 will negatively affect the goal of the policy. Again, the universal application of this theory could also be affected the local conditions of the implementing country (Mossialos et al. 2007).

This framework has greater relevance for understanding health financing within broader health systems, such as in systems analysis and cross-country comparisons, where common measures are needed. The Hsiao approaches provide a framework for identifying the key financing components and their place within the health system (WHO 2009). This framework adequately illustrates general principles. The current frameworks adequately define the elements and the information needs for description and analysis of health financing functions (OECD, Eurostat and WHO 2009).

Healthcare Financing in Ghana Before 2003

Health financing in Ghana Prior to independence was predominantly by out-of-pocket payments at point of service use (Arhinful 2003). Following independence and in the early days of post-colonial period, the goals of many African governments including that of Ghana, were to establish a developmental state, achieve rapid socio-economic development and defeat the trinity of ignorance, poverty and disease (ISSER 2012). In line with the socialist agenda under the First Republic, from the late 1950s up to 1966, healthcare financing in Ghana was virtually free as was education and other social services. There was recognition of linkages and synergies between economic and social policies and broad-based policies on health and other social services that were put in place (ISSER 2012). Following the overthrow of the First Republican government, healthcare financing in Ghana saw a complete ‘u-turn’. The military-cum-civilian junta made Ghanaians to pay for their healthcare needs and private sector health services continued to be paid for by out-of-pocket fees at point of service use.

The overthrow of the Government of the First Republic in 1966 set the tone for military involvement in governance and leadership which triggered a series of coup d’états leading to political instability in the country. The increasing involvement of the military in governance stagnated the country’s economic growth and led to eventual economic deterioration. The implication was that by the early 1970s, general tax revenue in Ghana could not support a tax-based health financing system. Consequently, there was a reversal in the gains made in the health sector. The result was that in 1972, out-of-pocket fees at point of service use were introduced in the public health sector to discourage frivolous use, though this was done in limited circumstances.

By the early 1980s, Ghana’s economy was in an advanced state of collapse. Per capita gross domestic product (GDP) showed negative growth throughout the 1960s and fell by 3.2 % per year from 1970 to 1981. Most important was the decline in cocoa production, which fell by half between the mid-1960s and the late 1970s, drastically reducing Ghana’s share of the world market from about one-third in the early 1970s to only one-eighth in 1982–1983 (Ghana Statistical Service 2003). At the same time, mineral production fell by 32 %; gold production declined by 47 %, diamonds by 67 %, manganese by 43 %, and bauxite by 46 %. Inflation averaged more than 50 % a year between 1976 and 1981, hitting 116.5 % in 1981. Real minimum wages dropped from an index of 75 in 1975 to one of 15.4 in 1981. Tax revenue fell from 17 % of GDP in 1973 to only 5 % in 1983, and actual imports by volume in 1982 were only 43 % of average 1975–1976 levels (Aryeetey and Codjoe 2005). Thus productivity, standard of living, and available government’s resources plummeted dramatically.

The near-collapse of the country’s economy was accompanied by a decline in the health sector. There were widespread shortages of essential medicines, supplies and equipment, and poor quality of care. In 1983, Ghana adopted the traditional IMF and World Bank economic recovery programme also known as the cash and carry system.

In 1985 the Bamako Initiative, adopted as a global policy supporting user fees, advocated for cost sharing and community participation to increase the sustainability and quality of health services. The level of fees differed from patient groups, applied to different services and charged at different levels between public and private facilities or primary level and hospital levels to cover all or part of the cost of services provided (Gilson and Raphaely 2008). The World Bank in 1987 justified the rationale for charging user fees as providing the additional revenue that could be used to improve efficiency and equity; reduce frivolous demand and encourage the use of low cost primary health care services (World Bank 1987). In the case of Ghana, the primary aim was to recover at least 15 % of recurrent expenditure for quality improvements. According to a Ministry of Health (MoH) report, the financial aims of this policy were achieved (Ministry of Health 2004). Shortages of essential medicines and some supplies improved. However, these achievements were accompanied by inequities in financial access to basic and essential clinical services.

The challenge in the 1980s to the early part of the new millennium was how to find the best combination of Government-Peoples-Partnership that would meet each other part of the way and satisfy the needs and pockets of care seekers as well the Government’s finances in the healthcare sector. Under the ‘cash and carry’ system, patients were required to pay for drugs and some medical consumables, as and when they visit healthcare facilities, while the state bore all other costs including consultation, salaries and emoluments for health workers in public facilities. ‘Cash and carry’ also provided for free medical care for the aged above 70 years, children under 5 years and pregnant women for their ante-natal care, all under an exemption programme implemented with the system. The net effect of the system was that patients went to hospital only when they were very sick and had money to readily meet their side of the bargain of paying for those stipulated expenditures. In effect, ‘cash and carry’ constrained citizens from assessing healthcare except when they were in very dire situations resulting in needless deaths.

The Search for Sustainable Healthcare Financing

The search for an alternative to ‘cash and carry’ as a means of healthcare financing in Ghana began in the mid-1990s but could not materialize for implementation though the foundation was laid with some pilot projects in the Dangme West District in the Greater Accra Region and Nkoranza District of the Brong Ahafo Region. These pilot schemes were meant to lay a firm foundation for what was eventually expected to become the National Health Insurance Scheme (NHIS). The National Health Insurance Scheme (NHIS) is a social intervention program intended to provide financial risk protection against out of pocket healthcare expenditure for all residents in Ghana. The first community health insurance (CHI) scheme in the country was the Nkoranza health insurance scheme started by the St Theresa’s Catholic Mission Hospital in 1992. It proved popular and endured the test of time (Atim et al. 2000). In the mid-1990s, a unit was created in the Ministry of Health (MoH) to establish a national health insurance as an alternative to ‘cash and carry’. The unit focused its efforts and resources on consultancies and feasibility studies for a pilot social health insurance (SHI) scheme for the formal sector and organized groups such as cocoa farmers in the Eastern region. Unfortunately, the proposed SHI pilot could not stand the test of time as it collapsed, without insuring anybody, by the end of 1999. No public acknowledgement or explanation was given for its demise. However, the pilot scheme might have collapsed partly due to lack of effective leadership, consensus and direction within the MoH as well as a failure to sufficiently appreciate the difficulties of implementing a centralized social health insurance in a low-income developing country (Arhinful 2003).

Following the demise of the Eastern region pilot, the social security and national health insurance trust (SSNIT) started planning for another centralized health insurance scheme to be run by a company called the Ghana Health Care Company. Like the Eastern region pilot, it never took off despite some public expenditure on personnel, feasibility and software. This notwithstanding, the zeal and the determination of the government of Ghana to succeed in providing some form of social protection in the health sector culminated in a lot of exploratory research on the feasibility of district-wide community health insurance (CHI) for the non-formal sector in the Dangme West (Arhin-Tenkorang 2001), a purely rural district with a subsistence economy and widespread poverty in 1993. The study had strong funding from UNICEF and enjoyed enormous support and collaboration from both the MoH and the community members. At the local level, the district health directorate and research centre, the district assembly (local government) and communities continued their collaboration and completed the design of the pilot CHI scheme. The district assembly contributed part of its UNDP poverty reduction fund to support community mobilization and household register development, and WHO, AFRO and DANIDA provided start-up funding. Registration of beneficiaries and delivery of benefits started in October 2000. Funds for the continuous implementation and evaluation were provided by the Ghana Health Service (GHS) and the MoH (Agyepong and Adjei 2008).

The success of the Dangme West District’s CHI led to the establishment of several other CHI schemes, but this time called Mutual Health Organizations (MHOs), in many other parts of the country. Their rate of development accelerated exponentially after 2001 (Baltussen and Niessen 2006). According to Atim et al. (2000), many of these CHIs were sponsored by faith-based organizations with support from development partners such as DANIDA (Danish International Development Assistance) and PHR-plus (Partnership for Health Reforms plus), an organization funded by the United States Agency for International Development (USAID). These two organizations also jointly supported the development of a training manual for administrators and governing bodies of MHO who were initially very prominent in the Brong Ahafo and Eastern regions. Also, the Christian Health Association of Ghana (CHAG), represented mainly by the Catholic Church, had many mission facilities in these regions and actively supported the growth of MHOs around its facilities. The regional and district directors of health and district assemblies also took an active interest in the development of MHOs.

In March 2001, the Minister for Health inaugurated a seven member ministerial health financing task force. Members of the taskforce included personnel from the MoH, Ghana Health Service (GHS), the Dangme West District Health Directorate and Research Centre, Trades Union Congress and the Ghana Health Care Company who were remised to have some technical knowledge on the subject. The terms of reference of the task force were to support and advise the MoH on the development of a National Health Insurance Scheme (NHIS), the building up of systems and capacity for regulation of health insurance in Ghana, the development of appropriate health insurance legislation, and the mobilization of extra resources to support national health insurance.

The development of the current National Health Insurance Scheme began with Ghana’s decision to access the highly indebted poor country (HIPC) initiative in March 2001. Among the areas where the government of Ghana was to expend the funds that would accrue from the HIPC initiative included funding of projects for poverty reduction and economic growth (Ghana 2003). Inclusive of the areas that were to benefit from the initiative was the expansion of the social protection basket of the nation with much emphasis on protection of the poor and marginalized, with special reference to women and children. To this end, the MoH in February 2003, allocated some of the HIPC funds to support the creation of government sponsored MHOs in all districts where they did not exist. By July 2003, the final version of the national health insurance bill (Act 650) was placed before the legislature for considerations and approval to be passed into law.

The bill required the formal and the in-formal sector to enroll together in government-sponsored district MHOs. After the passage of Act 650 of 2003 and Legislative Instrument 1809 of 2004, a National Health Insurance Council was established to govern the NHIS. The object of the Council was ‘to secure the implementation of a national health insurance policy that would ensure access to basic healthcare services to all residents’ (Ministry of Health, Ghana 2004). Its responsibilities included registration, licensing and regulation of health insurance schemes, and supervision of their operations. It was also responsible for granting accreditation to private healthcare providers, monitoring their performance, and ensuring that health care services rendered to beneficiaries were of good quality. A chief executive officer and supporting secretariat were to support the National Health Insurance Council in the execution of its functions.

The national health insurance scheme is financed by individual premium payments and a 2.5 % National Health Insurance Levy which is collected using the same mechanisms as the already existing 12.5 % Value Added Tax (VAT). In addition, 2.5 % of formal sector worker contributions to the Social Security and National Insurance Trust (SSNIT) towards retirement benefits were automatically transferred to the national health insurance fund on a monthly basis. The minimum benefit package covered almost all outpatient care, investigations and drugs, many dental and eye services as well as most inpatient care including the cost of a general ward and meals. All Ghanaians under 18 years are exempted from payment of premiums based on the hypothesis that there are enough adults above 18 years who would pay premiums to add to the National Health Insurance Levy and the 2.5 % SSNIT contributions to carry the financial burden of those below 18 years.

As expected, a major policy development like this will not pass without scrutiny and dissenting views from all shades of opinions including that of civil society groups, politicians, development partners and many others. The major disquiet expressed by organized labour groups over the policy was the channelling of 2.5 % of their monthly SSNIT contributions into the national health insurance fund with no clear reciprocated benefit to workers. It appeared to be assumed that their hard earned savings, through deductions for the future were being stashed away. In response to these agitations from organized labour, the legislature modified the bill so that as a benefit for giving up some of their social security funds, formal sector workers did not need to pay a premium to be covered by the district-wide mutual health insurance schemes (MHIS’). This arrangement did not however go down well with organized labour groups. They felt the deductions would affect the long-term viability of the social security fund and pension payments. These concerns were part of longstanding concerns in the formal sector over low and inadequate pension payments and poor management of pension funds. They wanted to be allowed to organize social health insurance with separate payroll deductions that would exclude their SSNIT contributions, and not lump them into district-wide MHIS’ with the informal sector.

Again, concerns were expressed about the functions of the National Health Insurance Council as being too wide and sweeping, and likely to end up creating an expensive and unwieldy bureaucracy that would not necessarily advance the cause of national health insurance in the country. There were also concerns about the implications of government subsidizing district MHIS’ regardless of their performance In the widely publicized debates and commentaries, these other concerns were overshadowed by the more dramatic row over the 2.5 % SSNIT deductions. The greatest dissenting views came from the then opposition political parties, who expressed concerns that the introduction of a 2.5 % National Health Insurance Levy represented a rise in VAT from 12.5 % to 15 % and was an excessively high tax burden. The opposition also supported organized labour’s concerns about the 2.5 % SSNIT deductions and the long-term viability of the social security fund.

Another opposition also came from the already existing MHOs who expressed concerns about being classified by Act 650 as ‘private’ and therefore ineligible for any government support or subsidy. According to them, they were unlikely to survive unless they converted from independent organizations into government-sponsored district MHIS’ though they were poorly organized, and many of their constituents were the rural poor, hardly any of whom participated in the vociferous debates that erupted around the passage of Act 650. Most of the civil society engagements in the extensive media debates were in the larger urban areas, with higher literacy levels and a bigger formal sector that had almost no MHO prior to the passage of Act 650.

Implementation of the National Health Insurance Scheme

The National Health Insurance Scheme, which was implemented in 2004, has been accepted by Ghanaians as one of the best social intervention programmes to be introduced in the country. This is because it is not one of those programmes sponsored by the Donor Community or the World Bank and the International Monetary Fund. As at the end of December, 2010, 8,163,714 people were registered with the National Health Insurance Schemes operating the country’s healthcare systems. The regional breakdown of membership is shown in Table 9.1.

Table 9.1 Active membership
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According to the National Health Insurance Authority (NHIA), the new active membership figure of 8.16 million for 2010 does not necessarily represent a drop, as there is no comparative historic data based on the new methodology of computation. While the perceived drop in active membership is largely due to the application of the new methodology for reporting, other sub-standard practices from the schemes such as the issuing of old ID cards, the granting of validity period exceeding the 3 months period mandated for temporary cards and the printing of temporary ID cards outside the NHIS’ computerized system. This might have accounted for the lower figures for the reported new active membership data in 2010. Table 9.2 shows the number of new members, renewals and active membership distribution by region.

Table 9.2 New members, renewals and active members in 2010
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The total active membership of 8,163,714 as at December 2010 represents 34 % of the total population in 2010. Similarly, outpatient utilization increased by over 28-fold from 0.6 million in 2005 to 16.9 million in the year 2010, Fig. 9.2. Inpatient utilization increased over 30-fold from 28,906 in 2005 to 973,524 in 2009 but dropped to 724,440 in 2010. The decline in utilization in 2010 could be attributed to the following reasons;

Fig. 9.2
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Outpatient utilization trend from 2005 to 2010. Source. NHIA (2011)

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  • Members are seeking early treatment and thereby reducing inpatient cases

  • Primary healthcare is becoming more efficient

  • Detentions were being billed as inpatients in prior years instead of outpatient

  • Service providers are changing their behaviour due to effective clinical audit

Claims payment is the major cost driver of the scheme. Claims payments increased from GHS7.60 million in 2005 to GHS394.27 million in 2010. The total amount of GHS394.27 million disbursed for the payment of claims represent 76.2 % of the total expenditure of the NHIA.

Drawbacks of the National Health Insurance Scheme

The NHIS has been hailed as one of the most important and successful internally initiated policies in Ghana and statistics from the NHIA supports this claim. However, the scheme is plagued with challenges which could lead to the demise of the policy, if it is not mitigated within the shortest possible time. Prominent among the challenges is the legal framework within which the National Health Insurance Act (Act 650) is situated. Act 650 created an almost autonomous District Mutual Health Insurance Schemes across the country with 145 of them operating under the companies’ code of Ghana. Section 54 of Act 650 specifically states that: “a scheme shall have a governing body which shall be responsible for the policies of the scheme and appointment of the employees”.

As per the law, each scheme in each district is completely independent of the other in the country, with independent Boards of Directors and does not pool risks together in any way. However, the National Health Insurance Authority makes mandatory financial resources available to the almost autonomous District Mutual Health Insurance Schemes across the country from the Health Insurance Fund on continuous basis as stated in section 33 of the Act. This legal entanglement has created lack of accountability on the part of scheme managers. The legal ambiguities have often times created institutional conflicts, personality clashes and low work output. This fundamental flaws in the legislative framework affects the institutional checks of the system as espoused by Hsiao (2003). This has the potential to affect the financing, organisational structure, payment mechanisms, regulation and persuasion (information provision) of the policy. It is for this reason that Hsiao suggests that in any healthcare financing policy, the legal frameworks should not be applied inflexibly but rather there should be a continual revision of the legal frameworks until the hopes and aspirations of the people for whom the legal framework was developed is achieved (WHO 2009).

Apart from the legal ambiguities, corruption has been sighted as a possible drawback to the policy. Corruption is pervasive in the entire structure of the system—from service providers to employees of the schemes. Some service providers deliberately over price service charges, provide inferior drugs and sometimes, and discriminate among NHIS card holders resulting in long queues at health centres. This they do, in connivance with some scheme employees. In 2011 for example, certain private service providers in the Kumasi Metropolitan Area were blacklisted by the Scheme for engaging in this dastardly act. This affects the quality and equity issues that are at the core of any health insurance scheme. The corrupt practices arise from lack of or limited supervision from the monitoring agencies.

Delay in claims payment is another challenge facing the NHIS. The NHI Act (Act 650) mandates the NHIA to accredit service providers before they can provide service their clients. The primary goal is to ensure that healthcare services offered to card bearing members are of good quality. Total accredited health facilities as at 31st December 2010 were 2,647. Claims payment refers to the money paid to hospitals, pharmaceutical companies and allied institutions for services rendered on behalf of the NHIA. Unfortunately, such mandatory payments are not promptly done and this often results in periodic withdrawal of services by some private service providers. In March 2013, for example, Christian Health Providers (CHP), who provide over 42 %, of the health needs of Ghanaians had to withdraw their services for 7 days for non- payment of services rendered for 7 months (Sept 2012–April 2013), which added up to over GHS50 million. Such withdrawal of services has the tendency of undermining public confidence in the insurance scheme in particular and the country’s health sector in general. For this reason WHO recommends the need for the establishment of national health account (NHA) that can provide a reliable source of health financing data (WHO 2009). NHA should be compiled according to a common agreed framework and will provide an accounting system for systematic, comprehensive and consistent measurement of financial flows in a country’s health insurance system for a given period. This can reduce the level of corruption that has plagued the system.

Besides the major challenges enumerated above, other minor challenges are weak systems, poor monitoring and evaluation, poor institutional and professional accountability, poor working conditions, the absence of clear boundaries of the market in healthcare delivery leading to unbridled and unacceptable advertisement.

Conclusion and Recommendations

Recent report from the World Bank suggests that many African countries have made tremendous gains in their forward match to economic prosperity by recording economic growth rates of around 5–6 % per annum (World Bank 2010). These positive developments are good indicators for efforts to reduce poverty and improve health on the continent. However, sub-Saharan Africa still faces a grim scenario with respect to the health of its people. The region accounts for 22 % of the total global disease burden and more than 68 % of the people living with HIV/AIDS. The region’s poor health status is reflected in crises in health financing and human resources for health. With only 2 % of the global health workforce and only 1 % of the world’s health expenditures, sub-Saharan African countries are ill-equipped to adequately address their health problems. Low per capita income, limited capacity for domestic revenue mobilization, and pervasive health system bottlenecks complicate governments’ ability to respond effectively to the health challenges in their countries. Even with substantial external assistance, large gaps remain between what resources are available and what are needed.

The history of healthcare financing in Ghana provides a good example of how governments in sub- Sahara Africa have been struggling to provide for the health needs of their populations. From a free healthcare regime, in the early days of post-colonial period, to a system of ‘cash and carry’, Ghana has seen a tremendous improvement in healthcare financing from the mid-2000s with the introduction of a National Health Insurance Scheme. The scheme has provided and continues to pay for healthcare services of many poor people in the country. However, a large number of Ghanaians (about 66 %), most of them in the rural areas, still subsist on cash and carry for their healthcare requirements as they have not registered to join the NHIS. This is one of the major challenges facing the government and management of the NHIS.

Embarking on very important programmes and policies to address some of the implementation challenges, especially identified corrupt practices by both service providers and scheme employees, and of reaching out to the many unregistered Ghanaians should be the focus of scheme managers. In looking forward, the following recommendations are made:

  1. (a)

    The National Health Insurance Authority should establish a centralized computerized claims processing system so that the massive fraud associated with the current claims management of the schemes could be reduced.

  2. (b)

    The legal ambiguity that has characterized the current legal regime should be to completely streamlined and overhauled. A new legal framework resulting in the creation of a single scheme under the complete control of the National Health Insurance Authority, which would be the implementer of the scheme, should be promulgated to save the scheme from collapsing.

  3. (c)

    In order to check the increasing level of fraud and corruption that has characterized the scheme, there is the need to have a strong and well resourced internal Audit and Fraud Control Directorate in the regions and across the country to ensure financial discipline of funds made available to the various schemes. This will also ensure that all claims that are submitted for payment by service providers are for actual services which are rendered to subscribers by accredited healthcare service providers to minimize to the barest minimum, if not totally eliminated, the fraud that is associated with claims processing in the past.

Whereas health financing reforms may be a good thing, the way the reforms are managed should rather engage the attention of policy makers. It is the view of the researchers that countries that are looking to emulate Ghana’s current healthcare financing scheme should be guided by Ghana’s challenges, if they are to succeed.