• Tuesday, February 27, 2024
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BD INVESTIGATIVE SERIES: Lessons for Nigeria as Ghana’s ‘successful’ health insurance flounders


Once upon a golden era in Ghana, for $1.5 (N540) premium, one could undergo a brain or heart surgery through the national health insurance, provided it was due to an accident.
Today, some Ghanaians think the scheme has been reduced to a mostly Paracetamol dispensary.

Over 40 percent of Ghanaians are covered by health insurance, while in Nigeria, less than 5 percent have health insurance coverage, with most enrolees in the formal sector, and poor coverage in the informal sector.

Ghana’s health insurance was a gold standard of sort when it launched in 2003, one year before Nigeria’s National Health Insurance Scheme (NHIS), and on several occasions, delegates were sent to understudy it in order to improve that of Nigeria.

Currently, the health insurance scheme in Ghana is failing and Nigeria has a lot to learn from it.
“Nigeria should not make the same mistake as Ghana in thinking it can support health insurance with taxes, and very low premiums,” Nancy Ampah, CEO, Nationwide Medical Insurance, a private health insurance company, said in an interview in Accra.

“I think they should determine the premiums actuarially. Healthcare is expensive. I do not know about Nigeria but in Ghana, everything is imported, which makes healthcare very expensive. This makes it difficult to sustain it. If we are able to get an industry that produces some of the drugs, that will be a different ball game,” Ampah said.

While Nigerian delegates who visited Ghana in the past may have returned with a template they copied for adaption, BusinessDay’s findings during a recent trip to the former Gold Coast indicate all is not well with the administration of health insurance in the country, and the same mistakes should be prevented in Nigeria.

Ghana’s health insurance “was not sustainable from the word go, but it looked good,” Ampah emphasised, adding, “As we went along, the faults started showing and that is where we are now.”

Ghana’s National Health Insurance Agency (NHIA) issues a biometric card to people who register and under the scheme, everyone below the age of 18, and those above 70 years of age, get completely free healthcare.

Those not in this category of ‘free healthcare’ essentially bear more of the financial burden, and funding the health insurance scheme was where the failure emanated.

Private health facilities still in the scheme attend to patients unenthusiastically, as they are unsure when the government will pay for services rendered, while many others have simply decided to pull out of the programme. Pharmacies were also part of the programme, but with the problem of default in payment, many have equally pulled out.

However, in the beginning when more health providers were enthusiastic to participate in the scheme, findings indicated enrolment was low, and coupled with initial enthusiasm, funding was not considered a challenge.

However, the means and scope of funding were not sustainable as manifesting now that almost half of the population is on the scheme.

Isaac Norteye, a 22-year-old Ghanaian shop attendant, said he registered for NHIA in 2015 because he heard hospitals could attend to people stranded without cash but in need of medical care.

Narrating his experience, however, he said, “It doesn’t cover all the medicines. For me, I would say it only covers Paracetamol and malaria drugs. At times, even when they have a particular medicine at the hospital, they will tell you to buy it outside, simply because you’re with a health insurance card. Every time I have gone, medicines were prescribed for me to purchase at a pharmacy.”

Philly Tamakloe, a nursing mother, renewed her health insurance card in 2017 when she was pregnant with her son. According to her, the health insurance reduced the amount she would have paid, even though she could not recall the exact figure. Though she prefers private hospitals, they would hardly accept her NHIA card.

“Some private hospitals don’t accept NHIA because they are losing money. Probably the government does not pay its share from treatments administered to patients, so they refuse to take more patients since they are losing. If I were the one, I would not continue treating other patients if I was losing. But with the government hospitals, they have no choice but attend to patients,” Tamakloe said.

Matilda Adusu, a businesswoman who is also nursing a baby, said even though she has registered for health insurance, she has not used it personally for medical care, except for the time she had her baby girl. She also got a reduction in her hospital bill, but explained her husband was in the best position to recall the amount.

“Health insurance works somehow. This is because, sometimes you can go to the hospital with the health insurance card, and then it won’t cover everything you expect it to cover. There are some things or drugs you will be told the health insurance does not cover so you have to pay. Although you have the health insurance card, still you need to get money so that if it doesn’t cover it, you pay,” said Obed Addo, a visual artist.

Addo once had a medical emergency involving his son at a time he was broke and had not registered for health insurance at that time. The incident, he said, pushed him to do the registration, although he still has not used it much.

Ghana’s NHIA is funded through a portion of three sources – the Social Security and National Insurance Trust (SSNIT); Value Added Tax; and Premiums. For VAT, 2.5 percent is put aside for health insurance, while in premiums, the NHIA stated on its website that premium is set from GH¢7.2 (minimum) to GH¢48.00 (maximum), equivalent to about $1.5 (N540) to $9.8 (N3,528) per annum.

The deductions from SSNIT and VAT are, however, inadequate. For SSNIT, the informal sector is largely left out. Also, VAT deductions are not adequate to complement SSNIT, considering how many people are now covered by NHIS in Ghana.

In addition, the premiums are too low to provide much buffer for the other two sources.
SSNIT is composed of 13 percent of basic salary, contributed by the employer of every worker in the formal sector, and 5.5 percent contributed by the workers themselves, a total of 18.5 percent.

According to information on SSNIT’s website, out of the 18.5 percent, the employer remits 13.5 percent within 14 days of an ensuing month to SSNIT. Five percent is remitted to the Second-Tier Mandatory Occupational Scheme. Subsequently, SSNIT gives 2.5 percent out of the 13.5 percent to the National Health Insurance Authority (NHIA) for the member’s health insurance.
Unlike their Nigerian counterparts, most Ghanaians have knowledge of health insurance, but many who are registered no longer have faith in it.

Thirty-two-year-old Ebenezer Tetteh, who manages his father’s four fishing boats at the harbour in Sekondi, said he only just enrolled for NHIA in June 2018 but has not been to the hospital since then.

He did not register earlier because he claimed he does not fall sick often, and when such happens, he takes a lot of herbal medicines.

“I believe in herbs, and I can’t remember the last time I’ve been to the hospital,” Tetteh said.
He enrolled because his father took ill sometime in 2017, and was taken to the hospital. His father also does not believe in orthodox medicines, but his condition seemed to defy the herbal treatments. He had a partial stroke and the herbs helped a lot with his recovery, but at some point, he needed to run tests in a hospital.

“We were told there are petty things we need not pay for, so we should get health insurance. Like lab tests and other things would be covered, that was why we enrolled him for health insurance and the rest of us followed suit,” he explained.

In a rare commendation of the NHIA, Freda Samson, a middle-aged woman from Ghana’s Eastern region, said she has done six surgeries since joining the NHIS about 10 years ago without paying. Her last surgery was in June 2017, but she did not disclose the nature of those surgeries. Samson said she was treated at a government hospital in the Eastern region, saying only some private hospitals accept NHIA.

“It is good that you do health insurance because if you don’t have money and you’re sick, when you go to the hospital they’ll treat you freely,” she said, opining the health insurance is effective, at least for her.

Told of bad accounts shared by other people, like getting more of Paracetamol, she said, “It is not Para matter, they will treat you well!”

However, while few exceptions like Samson exist, Ghana’s health insurance has lost the vibrancy from its early years, with government over-burdened with bills that keep accumulating.

Therefore, hospitals and pharmacies are increasingly reluctant to offer their services.
The government, it appears, did not get the funding mechanism right, and while it has good coverage for ailments, it is not sustainable, and Nigeria cannot afford to make a similar mistake.

A research by IFC/World Bank showed there are about 60 percent of people in Ghana who could actually pay for healthcare, but government was subsidising. So, that money they could have paid is locked up, not open to private or government, said Ampah, CEO at Nationwide Medical Insurance

“If 60 percent could pay, why pay for them?” she said.