The extent. The NHIS is funded by The

The National Health
Insurance Scheme(NHIS) is simply a social intervention program, introduced by
the government of Ghana to eradicate the financial burden that comes with
accessing quality health care services in Ghana. As a matter of fact, quality
health care is expensive. Therefore, the introduction of the NHIS in Ghana seeks
to underestimate this fact to some extent. The NHIS is funded by The National
Health Insurance Levy(NHIL), which is 2.5% levy on goods and services collected
under the Value Added Tax, 2.5% points of Social Security and National
Insurance Trust (SSNIT) contributions monthly, return on National Health
Insurance Fund (NHIF) investments, premium paid by informal sector subscribers
and some government allocations. One has to be a subscriber in order to benefit
from the scheme’s services. The National Health Insurance Authority grants
accreditations to certain health care facilities, also known as service
providers, to provide services to the scheme’s subscribers. These service
providers which include polyclinics, clinics, maternity homes, health centers,
primary hospitals, secondary hospitals, tertiary hospitals, pharmacies,
licensed chemical shops, diagnostic centers just to mention a few, in return are
reimbursed by the funds generated by the National Health Insurance Scheme. As
subscribers sign up, they are given portable cards, known as the National
Health Insurance Scheme membership identification card that serves as a proof
of registration and it is submitted at the desks of any of the afore mentioned
service providers, to enjoy health care services, that is covered by the scheme.
Since its inauguration and commencement of operations in 2003 and 2004
respectively, the scheme has been of immense benefits to its subscribers. A lot
of residents of Ghana have benefited massively from the NHIS. NHIS has made
accessing maternal care easier and costless, making home maternal delivery only
something of the past. Some beneficiaries of this scheme in an eye witness
report, talked about how in one case a pregnant woman could easily access a
hospital and underwent a free successful delivery just by being a subscriber.
In another case, a mother of two who had already lost a child to malaria the
previous year due to her financial constraints, had been able to keep the
surviving child alive without paying a dime each time she takes the child to
the hospital.  These situations and many
others confirm the good tidings that the NHIS has brought into the lives of
residents of Ghana. In an article written by Anthony Gingong, titled as “The
Silo is empty, a case of the NHIS” (2015), he stated that, “High utilization
has been the norm, with 597,859 OPD (Out Patient Department) attendance in
2005, to 27,350,847 in 2013. Increasing OPD attendance is a clear indication of
high awareness and the need to seek early treatment. In 2005 the NHIS paid a
total of Gh?7,800,000, then Gh?183,000,000 in 2008, and in 2013, Gh?780,
800,000, clearly an escalation in cost. The NHIS subscriber base has seen
continuous increase from an initial membership of 1.5 million in 2005 to almost
10.2 million as at the close of 2013, with significant improvement in indigent
registration which rose from 300,000 to 1.2 million”. In general, it has given
the indigents the opportunity to access health care, people who would choose
traditional treatment over orthodox health care, eventually signed up on the

In spite of all these
wonderful accolades that could be trumpeted about the NHIS, few challenges or
demerits can be seen in its operations as well. The challenges faced by the
NHIS can be grouped into challenges from the service providers, subscribers and
the administrators.

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 A challenge seen in the National Health
Insurance Scheme has been attributed to the various payment systems used in
reimbursing service providers registered under the scheme. There are three main
payment systems that are been used in the NHIS; the itemized fee for service
payment system, the diagnoses related grouping system and the capitation
system. The itemized fee for service payment system involves the service providers
providing the NHIA with a ‘list’ of the various services rendered to the
subscribers. The diagnoses related grouping (DRG) method requires service
providers to be paid based on the diagnoses of the subscribers. In the newer
capitation system, the service providers are prepaid based on the number of subscribers
that have chosen that particular service provider as their primary service
provider. Despite using a combination of these three methods in ensuring
successful reimbursements, some service providers complain that they receive
their reimbursements in a highly untimely manner and sometimes there could be a
very long delay in receiving their payments. This has led to the service
providers denying subscribers access to cheap and quality health care and
granting non-subscribers access to quality health care services because they
are willing to pay the prices. This challenge has been attributed by many to be
as a result of the manual nature of processing of claims of the service
providers. Under the current system, service providers present the NHIA with
their claims to payments based on the cost of attending to the various
subscribers. These claims are then processed for authenticity and the various
monies distributed to the service providers. The system processing of claims in
Ghana as at now, is mainly manual and as the population of subscribers
increases, the task of processing becomes overwhelming. This leads to delays in
processing claims consequently resulting in delay in reimbursements of the
service providers. Also some service providers have issued complaints regarding
instances where their claims have been disregarded in spite of their
genuineness and this has led to many of these service providers to be reluctant
in continuing their agreement with the scheme. For example, in 2008, Korle-Bu
Teaching Hospital recorded a rejection rate of 9-22% according to the claims manager.
Some of these claims were rejected because they did not meet the time frame for
presentation of claims. Although these challenges as consequences of the
payment systems are not new to any Health Insurance Scheme anywhere in the
world, automation of claims processing and money distribution has greatly solved
this problem in many countries like the USA.

Another challenge faced by the National Health
Insurance Scheme has to do with membership. The scheme since its inception has
recorded increasing numbers of members and as time goes on more and more people
will come on board. However, the goal of making quality health care affordable
to everybody has since not been met adequately yet. The target for the poor
especially has not been met yet. Most of the subscribers on the scheme
currently, are better educated richer Ghanaians who understand the schemes
offer and avail themselves for it. The many illiterate rural Ghanaians find the
process daunting, especially the bureaucracy of the system. The registration
centres are also often too far away from their villages and the cost of registration
which is around GH? 24 still remains a little too expensive for them. These registration centres for the NHIS
always require constant electricity in order to sign subscribers up on the
scheme, because they utilize computers and other electrical machines such as
the biometric device to upload details of subscribers on the NHIS database. In view
of this, registration centres are situated in well to do areas and not the remote
ones. These areas, as previously stated are mostly far from the indigents,
making it difficult for them to sign up too. So it can be said, that the NHIS
really has not been able to serve its purpose but just to favour a few average Ghanaians
and not the indigents actually.

this idea of choosing a particular service provider for health care when needed
puts so much pressure on certain service providers as compared to others. Subscribers,
upon hear says or probably experience choose to visit a particular hospital to
treat, for example, headache since majority visit that hospital and joining
long queues, wasting the time of other patients with more severe health
problems, whiles other equally good providers can be found in the same
vicinity. So much pressure is then put on some service providers, their human
resources, facilities and medications than others.

last but not least of the problems of NHIS concerns infrastructure. One may
ask, why would the government use NHIS as bait to get its residents to stop
home treatment and make use of hospitals without actually building more quality
and well-furnished hospitals across the country which can easily be accessed by
all and sundry?

is the challenge of unfairness on the side of subscribers. In that, there are
people who have signed up for the NHIS and undergo the renewal as at when it is
needed but these people never get to be sick during the times that the card is
active. This means that anytime some people are in dire need of the card they
reach the service providers only to find out that these cards are expired. Therefore,
it would be required of them to pay physical cash even before they are attended
to. So a heartfelt question to the NHIA is, will there be other offers for
people in such category?

Funds generation has also
been a challenge to the NHIS. As the subscriber base of the scheme increases,
demand is put on the NHIA to generate more funds to pay the service providers. The
scheme itself has been lacking initiatives that would boost fund generation as
much reliance is put on the government and the government alone. As such, there
is not a linear correlation in subscriber numbers increase and increase in
funds available to pay service providers. Service providers, upon areceiving
very small amounts of money as their reimbursements, consequently do not
provide the best care for NHIS subscribers.

In view of these
challenges a few recommendations can be outlined. The processing of claims by
the NHIA should at large be made automatic, to curb the strenuous implications
that come with the manual processing of claims. By so doing processing of
claims would be made faster, service providers would be paid earlier and
quality health service would be provided at all times. Again, the NHIA should
ensure that, there are enough service providers in the various districts that
are fully furnished, including the already existing ones, in terms of
infrastructure, medicines, equipment and health workers.

In conclusion, the NHIS
has chalked so many successes so far, and of course, there is a long way to go.
The challenges faced by the scheme can be nullified for the better if the NHIA
embarks on the journey of doing so. Certainly, there are more devastating
problems involved in the scheme but a conscious effort to address these
problems will be of so much benefit to the stakeholders of the scheme,
including the Ghanaian residents.