Ghana's National Health Insurance Research Articles

Examining Ghana's National Health Insurance Act, 2003 (Act 650) to Improve Accessibility of Artificial Intelligence Therapies and Address Compensation Issues in Cases of Medical Negligence

Objective: Examine Ghana’s National Health Insurance Act (Act 650) to identify coverage gaps limiting artificial intelligence (AI) therapy access and address medical negligence liability issues surrounding automated healthcare systems. 
 Methods: Legal and regulatory analysis of Act 650 were conducted, review of academic literature on global uptake of AI interventions and medical negligence principles were elucidated, examination of case studies implementing pilot AI therapy programs under insurance schemes were considered.
 Results & Conclusions: Act 650 lacks clear provisions for funding innovative AI treatments with proven efficacy and undefined negligence determination guidelines involving AI systems, contributing to accessibility and accountability issues. Proposed amendments to reimburse certain AI therapies through the National Health Insurance Scheme, expand certified provider eligibility, and institute transparent negligence compensation formulas.
 Recommendations: Reform Act 650 to support increased appropriate use of AI healthcare services, protect patients undergoing automated diagnosis/treatment, and clarify liability rules for medical negligence incidents relating to AI.
 Novelty & Significance: First extensive analysis focused on opportunities for Ghana’s health insurance framework to catalyze equitable diffusion of advanced AI therapeutics and address emerging legal challenges and safety risks as automated medicine advances.

'Digitising health protection schemes in Ghana': An enquiry into factors associated with the use of a mobile phone-based health insurance contribution payment system among tertiary students.

In 2018, Ghana's National Health Insurance Scheme (NHIS) introduced a mobile money payment system for membership renewal and premium payments to enhance enrolment and retention rates. However, the adoption of such innovations depends on various factors, including personal traits and public perceptions. This study aims to explore the determinants of NHIS membership renewal and premium payment via the mobile renewal system. Conducted at Kwame Nkrumah University of Science and Technology (KNUST) in Kumasi, Ghana, the study used a survey design to gather data from 951 KNUST students. Employing logistic regression analysis, the study identified key factors influencing the use of the NHIS mobile renewal service. The findings revealed that individuals aged 19-21, 25-27 or above 27, without mobile money accounts, and those with no history of online purchases were less likely to adopt the mobile renewal system (P < .05). Conversely, those perceiving the system as useful and easy to use were more likely to utilise it for NHIS membership renewal (P < .05). In conclusion, policymakers should prioritise system quality, accessibility, perceived ease of use, and usefulness to facilitate the adoption and usage of the NHIS mobile payment system. These findings contribute valuable insights for enhancing the effectiveness of health insurance innovations.

Economic inequalities in health insurance subscription renewal: Evidence from Ghana's National Health Insurance Scheme

Ghana's national health insurance scheme (NHIS) is considered a major step towards achieving Universal Health Coverage (UHC) in the country. However, over the years the scheme has faced challenges, including subscription non-renewal, that threaten its sustenance. In this study, we estimate and analyse the nature of economic inequalities in NHIS subscription renewal and determine factors that contribute to the observed inequality. Data from the seventh round of the Ghana Living Standard Survey (GLSS) was used for the study. A sample of 40,170 ever insured individuals was included in the analysis comprising 18,066 males and 22,104 females. We computed concentration indices (CIs) and used linear regression techniques to decompose the CIs. The results show that NHIS renewal is pro-rich [CI = 0.126; P < 0.01] and favored males [CI = 0.110; P < 0.01] and urban dwellers [CI = 0.066; p < 0.01]. Major contributors to the observed inequality in subscription renewal include premium and processing fees payment, access to information, and economic wellbeing. The observed rural-urban and male-female differences in subscription renewal were explained by differences in premium and processing fee payments, education outcomes, employment status and access to information. The findings suggest that interventions that reduce cost barriers to NHIS subscription for the poor, improve physical access to healthcare and improve sensitization efforts should be encouraged.

Heterogeneous effects of national health insurance scheme on healthcare utilisation: evidence from Ghana

PurposeThis paper aims to evaluate Ghana's National Health Insurance Scheme (NHIS) on healthcare utilisation by exploring its heterogeneous effects based on residential status and wealth.Design/methodology/approachThe study used the Ghana Socioeconomic Panel Survey (GSPS) datasets. An instrumental variable strategy, specifically the two-stage residual inclusion (2SRI), was employed to control endogenous NHIS membership.FindingsGenerally, the results show that NHIS improves healthcare utilisation (i.e. visits to a health facility and formal care). Concerning the heterogeneous effects of health insurance on healthcare utilisation, the results revealed that NHIS members are more likely to seek care, irrespective of their residence status. The results further indicate that the probability of visiting a health facility and utilising formal care increases for the poorest NHIS participants. Based on these, the authors conclude that NHIS provides equitable healthcare access and utilisation for its vulnerable populations, who are beneficiaries.Originality/valueTo the best of the authors' knowledge, this paper is the first to explore the heterogeneous effects of NHIS on healthcare utilisation across residential and income subpopulations. Splitting the dataset by residential status to examine healthcare utilisation inequality is worthwhile. In addition, analysing utilisation in terms of health care type would show whether Ghana's NHIS may be viewed as welfare-enhancing through increased formal health care utilisation.Peer reviewThe peer review history for this article is available at: https://publons.com/publon/10.1108/IJSE-05-2023-0330

Contribution of the Ghana National Health Insurance Scheme to Inequality in Healthcare Utilisation

Inequality in healthcare utilisation contributes to socio-economic disparities in health outcomes. The government of Ghana rolled out the Ghana National Health Insurance Scheme (NHIS) as a pro-poor health policy to reduce the financial barrier to accessing healthcare to increase healthcare utilisation, especially among the poor. Evidence showed a pro-rich utilisation inequality in Ghana prior to the nationwide start of the NHIS in 2005. This article applied the concentration index and decomposition methods to the round six of the Ghana Living Standard Survey data to investigate the contribution of the NHIS to utilisation inequality. The results showed the rich to benefit more than the poor from the NHIS and the NHIS contributed to about half of the pro-rich utilisation inequality. The NHIS increased utilisation but more so for the rich than the poor. A policy implication of the article is that pro-poorness of the NHIS might require separate NHIS schemes for the poor and non-poor to enable different policies implemented in the schemes to increase the distributional disparity of health subsidies in favour of the poor.

Whose public, whose goods? Generations of patients and visions of fairness in Ghanaian health.

Since Ghana's independence in 1957, the country has seen an ebb and flow of reforms intended to expand and fund state healthcare, informed by diverse notions of affordability and adequate provision. Cycles of attempted health reforms have emerged from disparate political and economic ideologies, themselves a product of broader global histories and specific national experiences. Based on group interviews with people across most administrative regions of Ghana, this paper examines how the formative historical experiences of different generations gives rise to a multiplicity of understandings of what constitutes a 'fair' distribution of national health resources. It discusses the forms and contents of arguments that people of different ages raised in both rural and urban settings in the course of the study - with particular reference to the operation of Ghana's current National Health Insurance Scheme, and in light of their perceptions of the justice or injustice of present day healthcare in relation to earlier periods.

Billing the Insured: An Assessment of Out-of-Pocket Payment by Insured Patients in Ghana

The Ghana National Health Insurance Scheme was introduced in 2003 to provide financial protection to the population. While the Scheme has made strides in improving access to healthcare there have been a few challenges including out of pocket charges to insured patients with weak client power. The study investigated the catastrophic nature of the out-of-pocket charges, the factors affecting the charges and the client power. We used primary data collected in 3 administrative regions: Greater Accra, Ashanti and the Northern regions, within the period April and June 2022 to compute catastrophic expenditure of the out-of-pocket healthcare expenditure on household expenditure on food and non-food. In addition, multivariate logistic regressions and a linear regression were run to examine the incidence of the practice and client power. The results showed that on average the insured paid out-of-pocket charges with a probability of 66%. The probability was highest (80%) in the Greater Accra, followed by Ashanti region (66.6%) and (52.9%) in the Northern region. The out-of-pocket charges were found to be catastrophic with incidence rate between 48.2% and 26.1% for the 5% and 20% thresholds; the overshoots ranged between 34.1% and 26.9% for the thresholds; the poor were more disadvantaged than the rich. Patients reported the out-of-pocket charges to the NHIA with probability of 1.9%, but the NHIA did not respond to 81% of the reported cases. Knowledge of the benefit list is likely to motivate the insured to report out-of-pocket charges, while cordial relationship between the NHIA staff and the insured deters providers from charging out-of-pocket. The out-of-pocket charges occur extensively across health facilities and is impoverishing. A close collaboration between the NHIA and the insured is needed to reduce the incidence and hold providers accountable.

The effect of the price of time on healthcare provider choice in Ghana

The existing literature confirms that the cost of treatment affects the choice of a particular healthcare provider. The Ghana National Health Insurance Scheme was established in 2003 to reduce the cost of healthcare provision and increase access to healthcare. However, we find that that even when the price is assumed to be “zero”, there remain some economic costs for choosing a particular healthcare provider over the other. This is called the price of time or opportunity cost. The study uses data from the seventh round of the Ghana Living Standards Survey (GLSS 7) conducted in 2016/2017 and employs multinomial probit regression as the technique for the analysis. The study finds that travel time and waiting time have significant effects on the choice of healthcare provider. If travel time and waiting time increase by 1 h, it will decrease the probability of seeking healthcare by 12% and 17%, respectively. Travel cost was not found to have a significant effect. The recommendations are that policymakers should make the effort to decrease travel time and waiting time at the health facilities in the country to improve healthcare delivery.

The Role of Effective Communication on Organization Performance: A Case study of Ghana's National Health Insurance Scheme

The Role of Effective Communication on Organization Performance: A Case study of Ghana's National Health Insurance Scheme

Spatiotemporal patterns of diarrhea incidence in Ghana and the impact of meteorological and socio-demographic factors.

Diarrhea remains a significant public health problem and poses a considerable financial burden on Ghana's health insurance scheme. In order to prioritize district-level hotspots of diarrhea incidence for effective targeted interventions, it is important to understand the potential drivers of spatiotemporal patterns of diarrhea. We aimed to identify the spatiotemporal heterogeneity of diarrhea incidence in Ghana and explore how meteorological and socio-demographic factors influence the patterns. We used monthly district-level clinically diagnosed diarrhea data between 2012 and 2018 obtained from the Centre for Health Information and Management of the Ghana Health Services. We utilized a hierarchical Bayesian spatiotemporal modeling framework to evaluate potential associations between district-level monthly diarrhea incidence and meteorological variables (mean temperature, diurnal temperature range, surface water presence) and socio-demographic factors (population density, Gini index, District League Table score) in Ghana. In addition, we investigated whether these associations were consistent across the four agro-ecological zones. There was considerable spatial heterogeneity in diarrhea patterns across the districts, with clusters of high diarrhea risk areas mostly found in the transition and savannah zones. The average monthly temporal patterns of diarrhea revealed a weak biannual seasonality with major and minor peaks in June and October, respectively, coinciding with the major and minor rainy seasons. We found a significant association between both meteorological and socio-demographic factors and diarrhea risk, but the strength and direction of associations differed across the four agro-ecological zones. Surface water presence demonstrated consistently positive, while diurnal temperature range and population density demonstrated consistently negative associations with diarrhea both overall and across the agro-ecological zones. Although overall diarrhea incidence is declining in Ghana, our results revealed high-risk districts that could benefit from district-specific tailored intervention strategies to improve control efforts. Ghana health sector policy-makers can use these results to assess the effectiveness of ongoing interventions at the district level and prioritize resource allocation for diarrhea control.

An Analysis of Catastrophic Out-of-Pocket Health Expenditures in Ghana.

Ghana implemented a universal health coverage scheme aimed at attaining financial risk protection against catastrophic out-of-pocket health expenditures. The effort has yielded mixed benefits for the different socio-economic profiles of the population. The present study estimates the incidence of catastrophic payments among Ghanaian households. The study analyzed the round seven dataset of the Ghana Living Standards Survey collected between 2016 and 2017. We estimated the incidence and intensity of catastrophic payments for total household consumption and non-food consumption for a range of thresholds. The analysis further weighted the measures of catastrophic payments to determine the distribution sensitivity. As the threshold increased from 10 to 25% of total household consumption, the incidence of catastrophic payments dropped from 1.0 to 0.1%. At the 40% threshold of non-food consumption, the estimated incidence was 0.2%. For both total household consumption and non-food consumption, the concentration indices were negative at all the thresholds. The results were indicative of a higher concentration of financial catastrophe among the poorest households and significant inequalities in the incidence between the poorest and richest households. The study confirmed the declining trend in the general incidence of catastrophic health expenditures in Ghana. However, the incidence and risk of financial catastrophe remained disproportionately higher among the poorest households, which is instructive of gaps in financial risk protection coverage. The Ghana National Health Insurance Scheme must therefore strengthen its targeting and enrolment of this sub-population group to reduce their vulnerability to catastrophic payments.

Equity in the Perceived Quality of Care Received by Malaria Patients Under National Health Insurance Scheme in Ghana.

The Ghana National Health Insurance Scheme (NHIS) seeks to provide access to quality healthcare to its members regardless of the health facility in which they receive care. However, it is unclear if all members of the Scheme receive quality care. The objective of the study is to examine the equity of perceived healthcare quality received by NHIS members depending on the type of facility in which care was provided. The study purposively sampled 2000 NHIS members who sought malaria treatment in the study areas. Only patients who had visited the health facilities at least twice not more than 12 months, before the data collection, were sampled. The SERVQUAL model was used to examine perceived quality of healthcare services in 5 quality dimensions: Reliability, Assurance, Tangibility, Empathy, and Responsiveness. These quality dimensions were compared in health facilities according to ownership (public, private, and faith-based facilities), capacity (hospital vs health centers), and finally location (urban vs rural health facilities). Instrumental variable estimation method was used to analyze data to address health facility selection bias problem. The results showed that faith-based health facilities scored the highest in all 5 perceived quality dimensions followed by public and private. Hospitals had higher score in perceived quality than health centers just as urban facilities scored higher in quality than rural facilities. These results represent high inequality in the perceived quality of care received by NHIS members.

Political economy and the pursuit of universal health coverage in Ghana: a case study of the National Health Insurance Scheme.

The road to universal health coverage depends on resources committed to the health sector. In many cases, the political structure and strength of advocacy play an important role in setting budgets for health. However, this has, until recently, not been of interest to health system researchers and policymakers. In this study, we document the political path to the establishment of the Ghana National Health Insurance Scheme (NHIS) as well as continuous political interest in the scheme. To achieve our objectives, we used qualitative data from interviews with key stakeholders. These include stakeholders instrumental in the design and establishment of the NHIS. We also reviewed party manifestoes from the two main political parties in the country. Promises relating to the NHIS were extracted from the various manifestos and analysed. Other documents that account for the design and implementation of the scheme were reviewed. We found that the establishment of the NHIS was down to political commitment and effective engagement with relevant stakeholders. It was considered a solution to the political promise to remove user fees and make healthcare accessible to all. A review of the manifestos shows that in almost every election year after the NHIS was established, there has been some promise related to improving the scheme. There were several policy propositions repeated in different election years. The findings imply that advocacy to get health financing on the political agenda is crucial. This should start from the development of party manifestos. It is important to also ensure that proposed party policies are consistent with national priorities in the medium to long term.

Effect of the Ghana National Health Insurance Scheme on exit time from catastrophic healthcare expenditure

AbstractCatastrophic healthcare expenditure (CHE) can plunge households into poverty. Faced with CHE, the question that becomes relevant is how long it will take the household to exit CHE. This paper examines the effect of the Ghana National Health Insurance Scheme (NHIS) on exit time from CHE. The paper uses the Cox proportional hazard model for the analysis, with data sourced from round six of the Ghana Living Standard Survey and World Development Indicators. The results show that households that spend 40% (20%) of their non‐food incomes on healthcare, on average, exit CHE after 10 months and 4 days (13 months and 24 days) being in CHE and those with NHIS coverage exit CHE 19 days (30 days) earlier than those without NHIS coverage. Policy implications arising from this paper include the need to expand NHIS enrolment to mitigate impoverishment due to out‐of‐pocket healthcare payments. Households with higher risks of severe CHE and longer exit time from CHE should be identified and provided with comprehensive NHIS coverage than those with lower risks.

Prevalence and quality of antihypertensive therapy among hypertension patients enrolled in the Ghana National Health Insurance Scheme

Hypertension is a leading cause of morbidity in Ghana. However, there is insufficient data on the prevalence and quality of antihypertensive therapy. To describe the prevalence of use and quality of antihypertensive therapy. A cross-sectional study design was used to analyze the 2015 Ghana National Health Insurance Scheme (NHIS) electronic claims data. Hypertension diagnosis was defined using ICD-10 codes. The primary outcomes assessed were the prevalence of use and quality of antihypertensive therapy. Quality of antihypertensive therapy was defined as the use of antihypertensive agents recommended for treating hypertension patients with comorbid heart failure, myocardial Infarction/Coronary Artery Disease, diabetes, chronic kidney disease or stroke. We used multivariable logistic regression models to identify predictors of antihypertensive use and quality of therapy. Antihypertensive medication use was very high (86%) among the 161 873 hypertension patients covered under the Ghana NHIS. Only a third (32%) of hypertension patients received guideline-concordant therapy. Angiotensin receptor blockers were consumed at the highest dosages of 120 (Interquartile Range [IQR]: 60, 180) daily defined doses over a year. Males (odds ratio [OR]=0.60; 95% Confidence Interval [CI]:0.58, 0.61) and those with comorbid stroke (OR=0.91, 95% CI:0.84, 0.99), diabetes (OR=0.72; 95% CI:0.69, 0.74) and stroke (OR=0.74, 95%CI:0.68, 0.80) were less likely to use antihypertensives, all other predictors were associated with higher use. Antihypertensive medication use was very high among hypertension patients covered under the Ghana NHIS. However, there was indication of suboptimal quality of the antihypertensive therapy provided.

Socioeconomic and demographic correlates of nonenrolment onto the national health insurance scheme among children in Ghana: Insight from the 2017/18 Multiple Indicator Cluster Survey.

The goal of Ghana's health insurance scheme is to achieve universal coverage. Despite NHIS' benefits to children, not all children in Ghana are covered. This study investigates the sociodemographic covariates of nonenrolment onto the national health insurance scheme among children in Ghana. We used the child dataset of the 2017/18 Ghana Multiple Indicator Cluster Survey (G-MICS). We used STATA version 14 for the data analyses. We described each study variable using frequency and percentages. We used Poisson regression to estimate crude and adjusted prevalence ratios of the relationship between the covariates and the outcome variable. Approximately 57% of children were covered with health insurance in Ghana. In the adjusted multivariable model, male children, children within the ages of 10-14 or 15-17years, and children who have some form of functional disability and those with no information on their functional disability status, children of mothers with lower than post-secondary education, and children residing in households of less than the fifth quantile on the household wealth index were associated with a higher likelihood of nonenrolment onto the national health insurance scheme. Finally, compared to the children in greater Accra, children in the other nine regions were associated with a lower likelihood of nonenrolment onto the national health insurance scheme. Given the results, improvement in health insurance coverage should be done, taking into consideration variations across the socio-demographic characteristics of the child, mother, and households.

Does Ghana's National Health Insurance Scheme provide financial protection to tuberculosis patients and their households?

Financial barriers are a key limitation to accessing health services, such as tuberculosis (TB) care in resource-poor settings. In Ghana, the National Health Insurance Scheme (NHIS), established in 2003, officially offers free TB care to those enrolled. Using data from the first Ghana's national TB patient cost survey, we address two key questions 1) what are the key determinants of costs and affordability for TB-affected households, and 2) what would be the impact on costs for TB-affected households of expanding NHIS to all TB patients?We reported the level of direct and indirect costs, the proportion of TB-affected households experiencing catastrophic costs (defined as total TB-related costs, i.e., direct and indirect, exceeding 20% of their estimated pre-diagnosis annual household income), and potential determinants of costs, stratified by insurance status. Regression models were used to determine drivers of costs and affordability. The effect of enrolment into NHIS on costs was investigated through Inverse Probability of Treatment Weighting Analysis.Higher levels of education and income, a bigger household size and an multi-drug resistant TB diagnosis were associated with higher direct costs. Being in a low wealth quintile, living in an urban setting, losing one's job and having MDR-TB increased the odds of experiencing catastrophic costs. There was no evidence to suggest that enrolment in NHIS defrayed medical, non-medical, or total costs, nor mitigated income loss. Even if we expanded NHIS to all TB patients, the analyses suggest no evidence for any impact of insurance on medical cost, income loss, or total cost.An expansion of the NHIS programme will not relieve the financial burden for TB-affected households. Social protection schemes require enhancement if they are to protect TB patients from financial catastrophe.

Why Do Women Delay in Seeking Prenatal Care? A Discrete-Time Survival Analysis

This paper evaluates the effect of access to the Ghana national health insurance on the timing of the first prenatal care visit for pregnant women after controlling for other factors. Due to the voluntary nature of the national health insurance program, insurance status is likely endogenous, this paper therefore uses the Multilevel Multiprocess (MLMP) model and the Mixed Proportional Hazard (MPH) model estimation techniques, which controls for endogeneity in survival data analysis. Results from the estimation shows that access to insurance reduces the delays in receiving prenatal care, and increases the probability of seeking prenatal care.

The Social Value of Health Insurance: Results from Ghana

We use the roll-out of the national health insurance in Ghana to assess the cushioning effect of coverage on the financial consequences of health shocks and resulting changes in coping behaviors. We find a strong reduction in medical expenditures, preventing households from cutting non-food consumption and causing a decrease in the volume of received remittances as well as labor supply of healthy adult household members. Moreover, we present evidence that the insurance scheme reduced the likelihood that households experiencing a health shock pulled their children out of school in order to put them to work. Avoidance of such costly coping mechanisms is potentially an important part of the social value of formal health insurance.

Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children.

IntroductionGhana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana.MethodsWe performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE.ResultsOf the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55).ConclusionsNHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children.