A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects?
BACKGROUND
The introduction of the national health insurance scheme (NHIS) in Ghana in 2003 significantly contributed to improved health services utilization and health outcomes. However, stagnating active membership, reports of poor quality health care rendered to NHIS-insured clients and cost escalations have raised concerns on the operational and financial sustainability of the scheme. This paper reviewed peer reviewed articles and grey literature on the sustainability challenges and prospects of the NHIS in Ghana.


METHODS
Electronic search was done for literature published between 2003-2016 on the NHIS and its sustainability in Ghana. A total of 66 publications relevant to health insurance in Ghana and other developing countries were retrieved from Cochrane, PubMed, ScienceDirect and Googlescholar for initial screening. Out of this number, 31 eligible peer reviewed articles were selected for final review based on specific relevance to the Ghanaian context.


RESULTS
Ability of the NHIS to continue its operations in Ghana is threatened financially and operationally by factors such as: cost escalation, possible political interference, inadequate technical capacity, spatial distribution of health facilities and health workers, inadequate monitoring mechanisms, broad benefits package, large exemption groups, inadequate client education, and limited community engagement. Moreover, poor quality care in NHIS-accredited health facilities potentially reduces clients' trust in the scheme and consequently decreases (re)enrolment rates. These sustainability challenges were reviewed and discussed in this paper.


CONCLUSIONS
The NHIS continues to play a critical role towards attaining universal health coverage in Ghana albeit confronted by challenges that could potentially collapse the scheme. Averting this possible predicament will largely depend on concerted efforts of key stakeholders such as health insurance managers, service providers, insurance subscribers, policy makers and political actors.
Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands.|Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana.
Robert Kaba
RK
Alhassan
Department of Economics, University of Ghana, Legon, Accra, Ghana.
Edward
E
Nketiah-Amponsah
Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana.
Daniel Kojo
DK
Arhinful
D005869:Ghana; D005102:Health Expenditures; D006268:Health Facilities / Q000191:economics; D006282:Health Personnel; D006801:Humans; D009313:National Health Programs / Q000191:economics / Q000458:organization & administration; D011787:Quality of Health Care / Q000191:economics / Q000458:organization & administration; D012111:Residence Characteristics; D012959:Socioeconomic Factors