Health insurance premiums in Ghana

In a recent report, Oxfam claims that enrollment figures reported by the National Health Insurance Agency (NHIA) in Ghana are exaggerated – that the figure is not 65% (apparently, the enrollment data is a cumulative one, which is clearly a wrong estimate for the numbers enrolled at a given time – refer pages 58 – 61 of this report) as reported by NHIA, but more closer to the 18%, as found by the researchers in this study. This difference looks quite extreme and the truth may be somewhere in between. But the authors are confident enough about their numbers to spar with other donors (mostly, the World Bank), accusing them of misrepresenting the programme as a great success and recommending them to other developing countries without really having a fair basis to make such claims.

The report claims that the insurance premium required for registration is a major barrier for the poor. The insurance premium varies from region to region and according to socio-economic status. They also point out that the access to insurance has been inequitable, since 64% of the richest quintile and just 29% of the poorest quintile are registered with the scheme – again, based on a 2008 government survey, which is likely to be dated. Its another story though, that almost all my Ghanaian colleagues say they would not use NHIS even if they were enrolled because the service is shoddy and they are made to wait in long queues if they wanted to avail of the insurance.

The scheme itself, as it started, was an attempt to move away from prohibitive user-fees towards a cost-sharing model, where citizens have to enroll by paying an annual premium. One can draw lessons from the research/literature on free distribution v/s cost-sharing. Research findings from field experiments by JPAL/IPA suggests that the benefits of cost-sharing on usage are at best unclear, while they do often tend to result in the a significant drop in demand for these products, leading to the exclusion of those who probably need the product/service the most. This is relevant especially for public health products that have proven positive externalities. Some of these products succeed only if they protect the entire population in a community and in that situation, a cost-sharing model which dampens demand may be an ineffective strategy (even if it increases appropriate usage among those who take-up the product). 

This report on the NHIS seems to strengthen these findings in general. If premiums are restricting coverage and are also not substantial enough to as a source of revenue, why bother? In this report, the authors recommend that these fees should be abolished in order to make the NHIS truly universal. In any case, the cost recovered from premiums collected does not make a substantial difference to the health expenditure in the country. The report also rightly calls out to the government to increase investment in health infrastructure – which is a necessary complement to any health insurance scheme, especially when  governments aim for universal coverage. 

Post-script – 

The World Bank responds here

Ishac Diwan, the World Bank’s country director for Ghana, says that Oxfam’s 18% coverage figure “is extremely surprising”. All the figures he has seen put it at around 40% to 60%. “If it was 18%, it would be terrible,” he says.

He also denies that the Bank is touting Ghana as an example for the whole of the developing world to follow. In Sierra Leone, for instance, “where some UN people have called for an insurance system, we have been against it”. But, he says, “the health system is something that is extremely defined by globalisation. When nurses and doctors are attracted abroad, adding private sector solutions is really important.” Essentially, insurance schemes which allow the private sector as well as public sector to flourish are good for middle and high income countries, he believes.


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