Stakeholders Perspectives on the Success Drivers in Ghana's National Health Insurance Scheme - Identifying Policy Translation Issues.

Adam Fusheini,Gordon Marnoch,Ann Marie Gray

doi:10.15171/ijhpm.2016.133

Abstract

Background: Ghana’s National Health Insurance Scheme (NHIS), established by an Act of Parliament (Act 650), in 2003 and since replaced by Act 852 of 2012 remains, in African terms, unprecedented in terms of growth and coverage. As a result, the scheme has received praise for its associated legal reforms, clinical audit mechanisms and for serving as a hub for knowledge sharing and learning within the context of South-South cooperation. The scheme continues to shape national health insurance thinking in Africa. While the success, especially in coverage and financial access has been highlighted by many authors, insufficient attention has been paid to critical and context-specific factors. This paper seeks to fill that gap. Methods: Based on an empirical qualitative case study of stakeholders’ views on challenges and success factors in four mutual schemes (district offices) located in two regions of Ghana, the study uses the concept of policy translation to assess whether the Ghana scheme could provide useful lessons to other African and developing countries in their quest to implement social/NHISs. Results: In the study, interviewees referred to both ‘hard and soft’ elements as driving the "success" of the Ghana scheme. The main ‘hard elements’ include bureaucratic and legal enforcement capacities; IT; financing; governance, administration and management; regulating membership of the scheme; and service provision and coverage capabilities. The ‘soft’ elements identified relate to: the background/context of the health insurance scheme; innovative ways of funding the NHIS, the hybrid nature of the Ghana scheme; political will, commitment by government, stakeholders and public cooperation; social structure of Ghana (solidarity); and ownership and participation. Conclusion: Other developing countries can expect to translate rather than re-assemble a national health insurance programme in an incomplete and highly modified form over a period of years, amounting to a process best conceived as germination as opposed to emulation. The Ghana experience illustrates that in adopting health financing systems that function well, countries need to customise systems (policy customisation) to suit their socio-economic, political and administrative settings. Home-grown health financing systems that resonate with social values will also need to be found in the process of translation

Highlights

The Ghana National Health Insurance Scheme Ghana introduced a National Health Insurance Scheme (NHIS) under Act 650 of 2003, which has since been amended by Act 852 of 2012
We examine evidence from stakeholders in the Ghana NHIS about the implementation of the scheme in different parts of the country and discern the extent to which a system shaped to fit unique contextual circumstances means that policy translation to another context may be problematic
The rationale for adopting a qualitative approach is three-fold: firstly quantitative data is unreliable as evidenced by the difficulty in reaching consensus even on figures relating to the coverage of the scheme; secondly the study of the implementation and working of the NHIS does not lend itself to straightforward statistical analysis; thirdly the design and structure of the scheme means that a range of stakeholders are involved, often with overlapping responsibilities and it was, felt that the most effective way of achieving a fuller understanding of their views was through the use of in-depth semi-structured interviews

Summary

Introduction

The Ghana National Health Insurance Scheme Ghana introduced a National Health Insurance Scheme (NHIS) under Act 650 of 2003, which has since been amended by Act 852 of 2012. In sub-Saharan Africa, the Ghana scheme remains the first nationwide health social protection scheme to include the rural and agricultural populations.[6] The Holistic Assessment of the Health Sector Programme of Work 20147 puts the coverage figure at 38% for 2014, translating to 10.3 million people. Other estimates put it below expectations - at about 34%.8. “The main issue was with the cash and carry as people were required to make deposits before medication could be given or sometimes treated ... or following emergency treatment you needed to pay before medication will continue” (Regional service provider)

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Results

Discussion

Conclusion