Part 3
“Mutuality is a balance between what you put in and take out to
cure the people. Mutuality is a financial box, you have to know how
to manage it”
The thrust of this article is to deliberate on the problems and challenges currently engulfing
the National Health Insurance Scheme.
Recently, the CEO of the National Health Insurance Authority stated that, the NHIS was the
best health insurance scheme in the world. To be fair, the NHIS is much better as compared
to the previous cash-and-carry system but, as to whether it is the best in the world, I am of
the opinion that, the jury is still out and only time will tell. Notwithstanding, the NHIS has
indeed improved access to health care delivery in Ghana in terms of decent, affordable and I
hesitate to say, quality health care. However, there are serious problems and challenges
currently engulfing the smooth operation of the NHIS which if not addressed comprehensively
and immediately, it could threaten the sustainability of the NHIS programme.
The centre point of designing a project or a programme hinges primarily on good planning
because, good planning encourages proactivity rather reactivity so that the implementers of
the project will steer their own ship and destiny rather than simply reacting to events. The
NHIS has several defects in areas such as design and implementation issues. Some of the
problems are so basic that, I cannot for one minute fathom why it was not anticipated. Over
the years in Ghana, laudable programmes have collapsed due to poor planning, corruption,
inadequate monitoring and evaluation, knee-jerk solutions which is often not backed by
reliable data which creates further problems than it solves, poor supervision and yet, as a
nation, we have collectively failed in finding lasting solutions to such reoccurring problems.
The National Health Insurance Authority exempts the poorest Ghanaians referred to as
indigents from having to pay premiums. The NHIA (Article 104) defines an indigent as a
“person who has no visible or adequate means of income or who has nobody to support him
or her and by the means test qualifies as an indigent.” The Minister of Health, on the advice
of the National Health Insurance Council, is supposed to impose a means test for determining
who is indigent. This is a stringent test that will qualify only the poorest of the poor.
According to Regulation 58, people cannot be classified as indigent unless they meet each of
the following four criteria: (a) they are unemployed and have no visible source of income, (b)
they do not have a fixed place of residence, (c) they do not live with a person who is
employed and who has a fixed place of residence, and (d) they do not receive any identifiable
and consistent support from another person. Furthermore, if the list of indigents submitted by
any district mutual health insurance scheme exceeds the 0.5 percent of the entire
membership of the scheme, the NHIC shall verify the list by whatever means it deems fit. All
well and good but clearly, the number of indigents in each district will be limited, which could
mean that many of the poor and needy who deserve a subsidy may be excluded. The Ministry
of Health estimates the total number of indigents at 1.74 million, or about 9 percent of the
population. This seems unreasonable in a country where 40 percent of the population is poor
and more than 25 percent is extremely poor. This gives rise to two issues. First, the state
would find collecting the premiums it envisages difficult, as many people would be unable to
pay. Second, many poor people would be uninsured and would be denied access to care.
Thus, the scheme could end up hurting the very poor people it was intended to benefit. At
the same time, if the definition of indigents is relaxed to cover more people, then the
question of how to muster additional financing crops up.
Currently, it takes on average about 3 months upon submission of application forms before
the issuance of an NHIS card to the subscriber. During the 3 month period, the legally
mandated subscriber is handicapped in accessing free medical care as an NHIS subscriber in
any hospital because, without an NHIS card, access to free medical care will not be possible.
The subscriber is at liberty to access medical care but, he or she will have to pay hard cash
before any treatment will be offered by the hospital. When a situation of such nature arises,
it can be termed as cash-and-carry. Why does it take so long to issue an NHIS card? The
processing of application forms are done manually, lack of staff, the century old lazy
attitude of Ghanaian workers and lastly, photo taking exercise. In a well known district in
Eastern Region, there is only one centre dedicated for taking photographs of subscribers and
constantly the centre is awash with people. As usual, there is only one person with one
camera working at the centre, the usual jumping of queues because of “whom you know” and the lack of seriousness and commitment on the part of the photographer. How
on earth can we have only one centre in that district dedicated to taking photographs of
subscribers and to make matters worse, there was only one camera. The sad irony is that,
such practice is replicated in several districts in Ghana which leads to huge delays in issuing
NHIS cards.
For example, if Mr X who is a subscriber of the NHIS falls ill at Suhum whilst travelling to
Accra and because, he did not have his NHIS card on him, any medical treatment accessed
by Mr X will have to be paid for and what happens if he does not have money on him? I
guess no treatment will be offered. Accident victims who are rushed into hospital and for
argument sake who may be NHIS subscribers and may have lost their cards via the
accident cannot and will not have free medical treatment. On the other hand, if medical
treatment is offered on the assumption that, the victims have NHIS membership and later
transpires that, they were not NHIS members, who reimburses the hospital? If Mr X pays for
his medical treatment at the Suhum Government Hospital, is he legally entitled to get a
reimbursement from the NHIS secretariat and if no, why not?
Another major challenge is the payment of a penalty for delays in renewing NHIS
membership. For example, if Mr X registered for NHIS membership on the 10th of January
2007 then automatically, his NHIS membership will expire on the 10th of January 2008. Due
to financial constraints, Mr X was not able to renew his membership immediately. However,
Mr X manages to renew his NHIS membership on the 12th of May 2008. Because, the NHIS
membership operates a 12 month contract, any sane person would expect his membership to
start from the 12th of May 2008 and expire on the 12th of May 2009. Unfortunately, this is
not the case with the NHIS. The penalty for the delay in renewing NHIS membership is that,
instead of his NHIS membership expiring on the 12th of May 2009, rather, his NHIS
membership will lapse on the 10th of January 2009 as per 12 months from the original expiry
date of 10th of January 2008. In effect, instead of Mr X enjoying a full 12 months NHIS
membership, he will only enjoy 8 months because, his membership will run from 12th May
2008 to 10th January 2009 instead of 12th May 2008 to 12th May 2009. This practice has led to
a drop in renewal membership in various districts across Ghana. The renewal penalty should
be removed immediately.
The NHIA has employed agents in various communities to register the citizenry for NHIS
membership. The agents take receipt of the subscriber’s application forms and fees for
onward processing at the main NHIS offices. There are several instances where agents have
bolted with monies running into millions of cedis. For example, if the agent bolts with 20
million cedis who repays this money into the central fund? Agents are also known to operate
what is called “robbing Peter to pay Paul” schemes. For example, if 10 people registered
today, he will only declare 5 people as duly registered and spend the money of the remaining
5. The next day, should 15 people register, he will declare 10 people as duly registered and
use the monies of the remaining 5 people to balance the accounts of the previous day. This
is an ongoing fraud by NHIS agents. In the Ashanti Region, an NHIS manager was able to
bolt with 98 million cedis being NHIS subscribers contribution.. Why allow NHIS managers and
agents the opportunity to handle monies whereby, a simple solution will be for NHIS
subscribers to pay their respective premiums to an NHIS accredited bank such as Ghana
Commercial Bank or Agricultural Development Bank and upon a valid receipt to the NHIS
office, the subscriber’s application is processed. Such a basic system makes it a touch harder
to steal funds and yet, no system is in place to check such an abuse. The antics of the NHIS
agents contributes to the delay in issuing NHIS cards. There are numerous examples where
individuals who are not registered members of the NHIS access free medical care by
utilising the card of an NHIS subscriber and the process is very easy. For example, Mr X who
is a registered NHIS cardholder will visit the hospital with Mr Y who is sick and not an NHIS
registered member. Mr X will complete all the necessary formalities and when he is called to
see the doctor Mr Y will sneak in and see the doctor and get the necessary treatment. The
doctor for example, may prescribe paracetemol to Mr Y and when out of the doctor’s
surgery, the prescription note will be handed over to Mr X who will collect the medication
from the dispensary and hand it over to Mr Y. At the end of the day, Mr Y has been able to
access free medical care without paying a pesewa. The doctors must physically see and
inspect NHIS card of patients before offering any treatment. When an administrator of X
hospital submits a claim for payment to the District Health Insurance Scheme for payment
for treatment offered to for example, Ama, Kofi, Kwabena, Kwame, Serwaa , Akua, and Yaw
totalling 10 million cedis, can the District NHIS manager really be sure that indeed the above
named persons had treatment at the said hospital? False and fraudulent claims are
slowly killing the system. On occasions, hospital administrators have connived with scheme
managers to pay fictitious claims which amounts to fraud.
While the Ministry of Health has declared that the scheme will be mandatory, it has not
indicated how enrolment into the scheme will be enforced. Moreover, as the NHIC has set
targets for coverage over the next 5 to 10 years, this raises questions about the compulsory
nature of the scheme and the enforceability of membership. No specific guidelines have
been provided on how this is to be achieved. While universal coverage is a long way off and
the government seems to have targeted certain milestones, specifying the groups or people
who will be covered during the first phase would have been important. Given the
concentration of health care infrastructure in urban areas and the higher percentage of
people employed in the urban formal sector, and from an ability to pay perspective, a logical
assumption is that the urban population was the first to be covered. However, this defeats
the entire purpose of making health care accessible to the poor and to rural populations, of
risk pooling, and of subsidizing the poor. The challenge lies in targeting needy groups and
setting out a plan to ensure coverage for them in the next few years.
The Ministry of Health has published a broad package covering almost all care except chronic
diseases for feed back. Such a package is too extensive to be sustainable over the long term,
and the package does not appear to have been costed or to have considered cost escalation,
especially given the expected overutilization of services. Given traditional relations between
the state and the public in Ghana, whereby government sponsored initiatives are often
exploited, this is a legitimate fear.
Part 4 will be a continuation of the challenges and problems engulfing the NHIS scheme.
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