Ghana's National Health Insurance Scheme: Insights ...

Ghana’s National Health Insurance Scheme: Insights from Members, Administrators and Health Care Providers Kofi Bobi Barimah, Joseph Mensah

Journal of Health Care for the Poor and Underserved, Volume 24, Number 3, August 2013, pp. 1378-1390 (Article) Published by The Johns Hopkins University Press

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ORIGINAL PAPERS

Ghana’s National Health Insurance Scheme: Insights from Members, Administrators and Health Care Providers Kofi Bobi Barimah, PhD Joseph Mensah, PhD Abstract: The Ghana National Health Insurance Scheme (NHIS) was established as part of a poverty reduction strategy to make health care more affordable to Ghanaians. It is envisaged that it will eventually replace the existing cash-and-carry system. This paper examines the views of NHIS administrators, members/enrollees, and health care providers on how the Scheme operates in practice. It is part of a larger evaluation project on Ghana’s NHIS, sponsored by the Bill and Melinda Gates Foundation and the Global Development Network as part of a two-year global research. We rely primarily on qualitative data from focus group discussion in the Brong Ahafo and the Upper East regions respectively. Our findings suggest that the NHIS has improved access to affordable health care services and prescription drugs to many people in Ghana. However, there are concerns about fraud and corruption that must be addressed if the Scheme is to be financially viable. Key words: Ghana, national health insurance, qualitative research, health coverage, health financing.

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he under-funding of health care is a growing problem the world over. However, the situation is worse than average in sub-Saharan African countries, where the dearth of financial resources remains an enduring problem. In the immediate postindependence era, Ghana had a health care system that, in theory, provided free medical services to all citizens. However, by the early 1980s, persistent budgetary constraints had compelled the government to implement a cost recovery regime, or cash-and-carry system, as part of its IMF- and World Bank-sponsored Structural Adjustment Programs [SAPs].1,2 Research shows that the cash-and-carry system has undermined access to health services in the country, with many low-income households regularly postponing medical treatment, resorting to self-treatment, or relying on traditional medicine provided by unregulated healers, spiritualists, and itinerant drug vendors.3 It is against this background that, in 2003, the government established a National Health Insurance Scheme (NHIS), with the hope of making health care affordable to Ghanaians. Notwithstanding the financial protection offered by the NHIS against catastrophic health KOFI BOBI BARIMAH, Faculty of Public Health & Allied Sciences, Catholic University College of Ghana-Fiapre, P.O. Box 363, Sunyani, Ghana, Tel. (233) 208132190. E-mail: [email protected]. JOSEPH MENSAH, International Development Studies, York University, Toronto Ontario, Canada. E-mail: [email protected].

© Meharry Medical College Journal of Health Care for the Poor and Underserved 24 (2013): 1378–1390.

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care payments, some Ghanaians are hesitant to enroll in the Scheme for a variety of reasons, not the least of which is cost.2 While several studies have assessed Ghana’s NHIS using large-sample quantitative data,4,5,6,7 only a handful have examined the Scheme with the aid of narratives couched in qualitative methodology—a notable exception here is the work of Afers.8 Furthermore, even though many previous studies4,9,10 have examined how NHIS members are faring, relative to non-members, few, if any, have incorporated the perspectives of NHIS administrators and health care providers into their evaluation of the Scheme. As with most insurance programs, the National Health Insurance Act (Act 650) itemizes the benefits of the Scheme, allowing for some variations here and there for the different Districts. Thus, one can easily ascertain what the Scheme does, or does not, cover by reviewing Act 650 and other relevant NHIS documents. Still, the question remains: How do health care providers, hospital administrators, and NHIS official and ordinary members interpret these documents from their respective perspectives? Do NHIS members really get the benefits they are supposed to per these documents? What is the extent of discretion involved in the determination of benefits by NHIS officials and health care providers? What are the discrepancies or disjuncture, if any, between what the NHIS Act stipulates and what actually happens? Writing on environmental perception decades ago, Brookefield noted that “decision makers operating in an environment base their decision on the environment as they see it, and not as it is. The action resulting from their decision, on the other hand, is played out in the real environment.”10[p.53] Analogously, it is reasonable to assert that the health care decisions of NHIS stakeholders, including members, administrators, and health care providers, have a lot to do with how they perceive the Scheme, and not necessarily with how the Scheme is officially set-up or planned in any objective sense. And as the now-famous Thomas’s rule in Sociology stipulates, “When people define situations as real, they become real in their consequences.” 11[p.628] Thus, the need to understand stakeholders’ views, perceptions, and interpretations regarding the Scheme’s operation on the ground cannot be gainsaid. Indeed, in this case, we can hardly ignore the difficulties, challenges, and prospects of the Scheme from the standpoint of its stakeholders, and expect to get a deeper grasp of the role of the Scheme in the provision of health care in Ghana. In the next sections, we profile Ghana’s NHIS, and then review some of the major studies on the Scheme. Following this, we outline our research approach, and finally discuss our findings. We bring the paper to a close with few remarks on how to improve the Scheme.

The Ghana National Health Insurance Scheme Upon assuming office in 2000, the National Patriotic Party (NPP) sought to replace the existing cash-and-carry system with the NHIS. A Ministerial Task Force on Health care Financing was established to conduct further studies and recommend an appropriate Scheme for Ghana. A report submitted to parliament in 2003, culminated in the passing of the National Health Insurance Act of 2003 (Act 650), and the official birth of the NHIS that same year.12 The stated mission of Ghana’s NHIS is “to ensure equitable universal access for all residents of Ghana to an acceptable quality of essential health

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Insights into Ghana’s National Health Insurance

services without out-of-pocket payment being required at the point of service use.”13[p.2] Act 650 identifies three major types of health insurance in the country. These include: (a) District (Mutual) Health Insurance Schemes; (b) Private Mutual Health Insurance Schemes; and (c) Private Commercial Health Insurance Schemes. All these Schemes must register with the government to be able to operate legally in the country. However, the government provides direct financial support only to the District Health Insurance Schemes, as part of its ongoing Poverty Reduction Strategy. Ghana’s NHIS is regulated by the National Health Insurance Council (NHIC) in Accra. Regional and District offices of the NHIC are set up to decentralize the operations of the Scheme. NHIC manages the National Health Insurance Fund (NHIF) through the collection of revenue, investment, disbursement, and administration of the Scheme. The Council manages and oversees broad guidelines for the purchasing and providing of health through the licensing, regulation, and accreditation of health care providers. Premiums for NHIS are generally based on members’ ability to pay. District Health Insurance Committees identify and categorize residents into four main social groups (i.e., core poor or the indigent; the poor and very poor; the middle class; and the rich and very rich) and calibrate their contributions accordingly. Following guidelines set by the national government, the core poor (or, the indigent), together with people who are 70 years of age, or former Social Security and National Insurance Trust (SSNIT) contributors on retirement are exempted from paying any premiums. While premiums vary slightly from District to District, members pay no less than GH¢7.2 (US$8.00*) per annum. For members in the formal sector, 2.5% of their contribution to SSNIT is deducted monthly as their health insurance premium. Workers in the formal sector are automatic members of the NHIS, but they still have to register with their respective District Mutual Health Insurance Schemes. Those in the informal sector, as well as the self-employed, pay between GH¢7.2 and GH¢48.0, depending on their income. All contributors’ premiums cover their children and dependents who are below 18 years of age. Thus, NHIS registrations of children are linked to those of at least one of the parents. In 2004, the government introduced a 2.5% sales tax (i.e., Health Insurance Levy) on selected goods and services for the funding of the NHIS. Other notable sources of funding for the Scheme include money from the government’s budget and donor contributions.4 The benefits package of the NHIS includes general out-patient services, in-patient services, oral health care, eye care, emergencies and maternity care (such as prenatal care, normal delivery, and some complicated deliveries). Diseases covered, among others, include malaria, diarrhea, upper respiratory track infections, skin diseases, hypertension, asthma, and diabetes. About 95% of all common health problems in Ghana are covered12,14 with specified minimum benefit packages to members. Some services (such as HIV antiretroviral drugs, hearing aids, dentures, and VIP accommodations) are excluded from the health benefit package. As of December 2009, some 14.1 million Ghanaians, or 60.1% of the total national population of 23.4 million, had registered for *In 2007, Ghana changed its currency from the old cedi (¢) to New GH Cedi (¢). One New GH¢ = 1000 old Ghana ¢. The exchange rate to the US$ is now about US$1=New GH¢0.93.

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Table 1. AGGREGATE NHIS SUBSCRIBERS BY CATEGORY 2009 AND 2010

y Informal SSNIT Contributors SSNIT Pensioners Under 18 years Pregnant women 70 years and above Indigents Total

Number of Registrants as at Dec. 2009

Percent of Total Registrants

Number of Registrants as at Dec. 2010

Percent of Total Registrants

4,266,051 884,666 76,974 7,175,085 804,450 967,401 337,150 14,511,777

29.4% 6.1% 0.5% 49.4% 5.5% 6.7% 2.3% 100.0%

5,282,258 1,036,882 89,639 8,709,389 1,394,445 1,140,549 378,204 18,031,366

29.3% 5.8% 0.5% 48.3% 7.7% 6.3% 2.1% 100.0%

the NHIS. The largest rates of enrolments were in Upper West (87.7%), Brong Ahafo Region (73.9%); Eastern Region (69.25%) with the Greater Accra Region, coming in dead last out of the ten with a mere 39.39%.15 Table 1 shows NHIS subscribers by category for 2009 and 2010.

Previous Studies on the Ghana NHIS Several studies have been conducted on Ghana’s NHIS, with the very first sustained studies by Sabi who examined its history, legislative instruments, and the design [Sabi W. Ghana National Health Insurance Scheme. Unpublished MA Thesis, Department of Public Health, University of Cape Town, South Africa, 2005.] Another study has also evaluated the effectiveness the NHIS using 1,318 respondents from six districts, including Nkoranza, Kwahu South, Ahanta West, Ajumako Enyan Essiam, Offinso, and Savelugu/Nanton.7 The latter authors used both bivariate and multivariate statistical tools to explain respondents’ enrolment status, their utilization of health care, and their out-of-pocket health expenditures. On the whole, they found that some characteristics of household heads (older age, being female, and having higher education and employment) were major predictors of enrollment at the household level, while these factor plus household wealth increased the propensity to enroll among individuals. In a follow-up study, Chankova and his colleagues used data from a 2007 household survey to also evaluate the impact of the NHIS.8 With the aid of multiple regression analysis, they found that the likelihood of NHIS enrolment among respondents increased with education of the head of household and with wealth. Additionally, children and the elderly (over 70 years) were more likely to be enrolled, just as enrollment was more likely if the individual was a female with a chronic illness. Witter and Garshong also combined secondary data with primary in-depth interview data from key informants to assess the performance of the NHIS.16 Among other find-

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ings, they noted that the Scheme derives 70 to 75% of its revenue from tax funding. However, they noted that only about a third of the enrollees actually contributed to the Scheme financially with the bulk relying on exemptions. Under the leadership of Diane McIntyre, the SHIELD* project is one of the most comprehensive international research endeavor involving Ghana’s NHIS (together with health insurance schemes in South Africa and Tanzania). With country teams documenting the situation in their respective nations, the Ghana team profiled the nation’s health care system and its health accounts, and discussed the evolution, design, and implementation of the NHIS. Another SHIELD-related project, compared the level of fragmentation implicated in the move towards universal coverage in South Africa, Ghana, and Tanzania, using this triad of theoretical constructs: revenue collection, pooling, and purchasing. They noted that Ghana “appears to be pursuing a universal coverage policy in a more coherent way”5[p.871] than South African and Tanzania. In another study, qualitative data from focus group discussions and in-depth interviews were used to assess the barriers facing Ghanaian female informal workers in accessing the NHIS.8 Her findings indicate that female informal workers generally support the NHIS, with many acknowledging that the Scheme has enhanced their access to health care. However, the latter notes that while most of the women are aware of the Scheme, many are still confused about some of its details, especially as they pertain to its premium/cost, prompting the author to call for public education among the people in the informal sector.8 With the sponsorship of the Gates Foundation and the Global Development Network, some researchers4,13 evaluated the Ghana NHIS as part of a two-year global research (from 2007–2009) on Promoting Innovative Programs from the Developing World: Towards Realizing the Health MGDs in Africa and Asia. Using the quasi-experimental technique of propensity score matching, the authors matched relevant background characteristics of women who were enrolled in the NHIS with those of non-members, and compared their health outcomes. On the whole, the findings suggest that the NHIS has yielded positive outcomes: women who are enrolled are more likely to give birth in hospitals, to have their births attended by trained health professionals, to receive prenatal care, to have fewer birth complications, and to experience fewer infant deaths. We must reiterate that the present study forms part of the work of Mensah and his colleagues.4,13 Given Ghana’s relative success towards universal health coverage, it is hardly surprising that Ghana’s NHIS has received that much research attention. What is surprising is the lack of qualitative studies from the perspectives of stakeholders, and it is this gap that the present study seeks to help fill.

Methods As noted in the introduction, the present paper is part of a larger project that evaluated the Ghana NHIS in the context of the health-related Millennium Development Goals (MDGs). The evaluation used a survey dataset collected from two of the 10 administration Regions of Ghana, namely the Brong Ahafo Region (from the Sunyani *SHIELD stands for Strategies for Health Insurance for Equity in Less Developed Countries.

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Table 2. PARTICIPANTS OF THE FOCUS GROUP DISCUSSION Participants

Gender

Region

NHIS Stakeholder Category

1 2 3 4 5 6 7 8 9 10 11

Female Male Male Male Female Male Female Female Male Male Female

Upper East Brong Ahafo Brong Ahafo Upper East Brong Ahafo Upper East Brong Ahafo Upper East Brong Ahafo Upper East Brong Ahafo

Hospital Administrator NHIS Municipal Scheme Manager NHIS Public Relations Officer NHIS Registration Agent NHIS Registration Agent Hospital Administrator NHIS Service Provider NHIS Member NHIS Member NHIS non-Member NHIS non-Member

and Nkoranza districts) and the Upper East Region (Bolgatanga and Talensi-Nandom districts). These two particular regions were selected for a number of reasons, including the fact that both have District Mutual Health Insurance schemes that have longer periods of operation than those in other regions of the country. Located at the geographic center of the country, the Brong Ahafo region has people of diverse ethno-cultural background, and thus it acts as a transitional zone for both the physical and human geographies of Ghana. The Upper East region, like any of the other two Regions of northern Ghana, is deeply depressed economically, and its inclusion provides insight into how poor women interacted with the NHIS. The present paper deals with the qualitative dataset collected as part of the evaluation, by means of focus group discussion (FGD), among a carefully selected group of 11 key informants, including NHIS members, non-members, health providers, and NHIS personnel from the two regions (Table 2). Conducted at the Catholic University College of Ghana in Sunyani, and facilitated by the two co-authors, this FGD dealt with several pertinent issues concerning the NHIS; these included matter of NHIS premiums, benefit package, and exemptions. Other themes concern NHIS protocols on prescriptions, maternal care benefits and general problems. Carefully selected is emphasized to hint at the attention we paid to power dynamics and issues of positionality in bringing such a wide range of people together for our FGD. With the permission of our participants, the deliberations at our FGD (that lasted for two hours) were tape-recorded.

Results Insights into the operations of the NHIS in practice. In this section we synthesize the results of our FGD, paying particular attention to how the Scheme operates in practice, with insights into the challenges and ambiguities implicated in the process. On premiums, benefits, and exemptions. Asked about the amount of premium charged

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by the various Schemes, the answers we heard from our discussants were not much different from what we ascertained through our review of various NHIS documents. The premiums for the Sunyani Municipal Scheme, for instance, was found to be a flat GH¢20 per annum, while the Nkoranza District Scheme (also in the Brong Ahafo Region as Sunyani) charged GH¢8, per annum. Each of the two Upper East District Schemes charged GH¢7.2 per annum—the lowest possible premium set by the NHIA. On NHIS benefits and exemptions, our discussants confirmed that out-patient department (OPD) services, including reviews and consultations, are covered by the NHIS, as are requested medical investigations, including laboratory investigations, x-rays, and ultra sound scanning for generalized and specialist out-patient services. We also noted that in-patient physiotherapy and accommodation in general ward (not special ward) are covered, so are out-patient medical visits, as well as dental treatments for pain relief, incisions, drainage, extraction, and filling. When it came to HIV/AIDs, there were some confusion, but the emergent consensus—which was latter upheld by available government documents—was that HIV/AIDS per se is not covered by the NHIS, but symptomatic treatment for opportunistic diseases associated with HIV/AIDS are covered. We learned that there are special government programs for HIV/AIDS, hence its exclusion from the NHIS. The same exemption applies to tuberculosis and mental illness, both of which have their own prevention and treatment programs. On ambiguities surrounding NHIS benefits, one of our discussants had this to say: Orthopedic treatments are not covered per se, but what the NHIS legislation says is that road traffic accidents are covered. Now, the problem is when somebody gets a road traffic accident which most of the time comes with orthopedic problems, then what happens to the person? Clearly, there are some grey areas in all these specifications.

Additionally, we learned from the discussion that even though emergency situations are covered, the related transportation cost, in terms of ambulance services, is not. One health care provider noted that the situation with emergency has not really changed much even with the NHIS. In her words: It has always been the case, even under cash-and-carry, that you look after the patient in emergency situation first, and talk about payments later. So the health provider is not allowed to seek payment in emergency situation.

Another discussant confirmed this in the following words: In critical situations, you don’t ask about insurance until the person is stabilized. Evidently, the system relies great deal on the good judgment and discretion of agents and health care providers in these instances.

The issue of what the NHIS covers, or does not cover, is undoubtedly complicated, and nowhere is this complication more profound than in the area of maternal care.17 At the time of our FGD, we were aware of an article reporting that “Despite new health scheme, newborn babies [are] detained in hospital pending payments.”18[p.1] The hospital

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implicated in the alleged detention of babies, for mothers’ inability to pay for delivery cost, was the nation’s premier health care center—the Korle Bu Teaching Hospital in Accra. The article talks of a 28-year-old woman who, like 27 other women at the time, had her newborn detained because she owed New GH¢340 for the caesarean section she underwent at the hospital. What complicates this particular case is the fact that not only is maternal care officially free of charge for all Ghanaian women under the government’s exemption policy of September 2003,19 but also normal delivery and even some complicated deliveries are covered by the NHIS benefit package in many Districts.1 Upon more investigation by the authors of the article, it surfaced that even though deliveries are covered by the NHIS and by the national exemption policy, the unwritten rule seems to offer these benefits only at the District hospitals, where the cost is not that exorbitant, and not at the Korle Bu Teaching Hospital, where the cost tends to be very high.18 The matter of whether or not maternal care is covered by the NHIS received considerable deliberation in our FGD. After some confusion among our discussants, one hospital administrator noted quite authoritatively that the NHIS covers maternal care as follows: When we say maternity care is free, there used to be a period in our history when old people and those needing maternal and child health care were exempted from paying for health care and the government took over their bills. Now with the NHIS coming in, all these things have been scrapped to encourage people to insure themselves; thus, if you do not go for insurance, it means you have accepted that you have the funds to be able to pay when you have any illness. Now, if you go to the hospital and you do not have health insurance, it means that you are willing to pay out of your pocket and those are the instances that catch people by surprise. The bottom line is that maternity services, such as antenatal, delivery, both normal and assisted or C-Section and post-natal care are all covered by the NHIS. [hospital administrator]

Another administrator expressed his disenchantment with those who expect maternal care to be free of charge at the hospital without insurance in these words: I don’t sympathize with these people, because maternity is not an emergency; you just don’t wake up one morning and decide to deliver. There is a gestation period for nine months and so if you really want to pay your bill you can make an effort to pay your NHIS bill. So I do not sympathize with people who give birth at the hospital with no insurance. No! I don’t. Once you don’t subscribe to health insurance, it means that you want to tell everybody that you can afford it; you should pay. [hospital administrator]

Upon a visit to a hospital. On the issue of NHIS procedures, we learned that when an NHIS member goes to any designated health care center, s/he is required to present his/her NHIS card for verification, before moving on to the consulting room to procure the necessary health care. To reduce fraud, this verification is taken rather seriously by health care providers, scrutinizing the pictures on the card to make sure it matches the face, age, and gender of the cardholder. In most hospitals/clinics, there are different queues for NHIS members and non-members to facilitate this process. Because NHIS

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card holders are often separated from the uninsured, and because the queue for the former often moves more slowly than that for the latter due to the verification process and the related paperwork, there is a growing misconception that some hospitals prefer to treat the uninsured, who pay cash, rather than the insured. When the client comes to the hospital, you know, because of cheating these days, you have to look at the NHIS ID card. You look at the picture and also look at the client to check if he or she is the person for the card, because sometimes they collect other people’s ID cards and use it in the hospital. After confirming that the card belongs to that person, you direct the person to the appropriate place. This causes delays which some use against the Scheme with the misperception that hospitals now prefer to look after those who can pay ready cash to those who bring in the NHIS ID cards. [hospital administrator]

On prescription drugs. When our participants were asked to discuss what they knew about the procedures for the procurement of prescription drugs within the NHIS, a number of interesting facts surfaced, some of which were fairly straightforward and not unexpected, while other were a bit surprising and of an uncertain status. We learned that each District Scheme has its “designated drug list,” based on which it pays for prescription medicine. The question then becomes: What happens if a prescription is on the drug list, but the hospital or clinic does not have it in stock? Many discussants indicated that some Schemes allow their members to procure the prescription from contracted private pharmacies, which then present the invoice for reimbursement by NHIS. In fact, some Schemes even reimburse the patient directly, when the patient provides the receipt. It came to light that the NHIS drug list is usually made up of generic medications, rather than brand name ones. As one NHIS Manager elaborated: When you are writing prescription, it has to be of generic name which is on the drug list. Thus, if, for instance, paracetamol is on the list, but the care giver does not write paracetamol, but writes another brand, the Scheme will not accept that drug. [manager of municipal NHIS]

Still, there seems to be some flexibility, depending on the District, as well as on the health care provider involved: Notwithstanding the drug list, it all depends on the particular NHIS or District, even though they are all government insurance, there are some which are a little bit flexible than others. Some insurance Schemes are very strict on the list—and when a medication is not on it they will never pay for it or supply it, others are flexible and prepared to go with comparable substitutes that are not on the list, especially when the price is right. We must also remember that most of the time, some of the drugs which are rare are not on the insurance list. I remember in the Sunyani Scheme, for instance, there is a TB drug, Nilon, which is not on the insurance list, but our pharmacist made the case to the Scheme administrators that many people do not react well to the one on the list so some people should be allowed to go for the Nilon, which may work better for them, and the Scheme accepted it; but there are other instances

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where the Scheme will not accept any substitution. So it all depends on the people you are dealing with. [hospital administrator]

Another participant described a situation where she had to pay a private designated pharmacist the difference between the price of the medication she was actually prescribed and the substitute she ended up getting, as the prescribed medication was unavailable. Asked to indicate what stood in their minds about access to prescription drugs visà-vis the NHIS, the recurrent themes that emerged related to the different practices of the private or contracted pharmacy shops and the pharmacy departments of the hospitals. For instance, they were concerned that some of the private pharmacy shops were charging more than they had already agreed to with the NHIS. Some participants even alleged that some pharmacists intentionally offer higher-priced substitute and compel client to pay out-of-pocket, as they have little choice under conditions of indisposition or severe illness. This allegation is particularly poignant, deserving further investigation, as the whole purpose of a health insurance is to eschew payments in such dire circumstances. In the words of one NHIS member: OK, so you see the pharmacist’s clarification is that he does not have the prescribed medication, but the alternative is B, and B is 50% higher in price; so what do I do? . . . Meanwhile, I was sick, and needed the medication badly. [NHIS member]

Indeed, there were even allegations to the effect that in an attempt to charge higher prices, some of the private pharmacists create the impression that the drugs on the NHIS drug lists are not good. This is how one discussant cast this particular assertion: I think that something different is also happening. These pharmacists are in the market for profit and they want to sell their medications, so they push it on you. Probably, it is even close to expiry date, and they will still push it on you. Also, they will say we don’t have this particular one; or they will say even though this one is on the insurance list, it is not good. So if you want to get better then you have to buy this one instead. They give people the wrong impression that the drugs on the insurance list are not good, just because they want to sell their drugs and they don’t want to sell the generics. You know, the generics are cheaper and they don’t make much profit from them compared to the branded drugs; they end up discrediting the insurance, so that they can sell their branded drugs. [hospital administrator]

On Challenges facing the NHIS. The leading problem facing the NHIS is money— more specifically, the financial viability of the Scheme. Many were those discussants who insisted that the premiums are simply too small, and thereby making the system unsustainable. To others, the main problem has to do with the fact that the health insurance is fairly new to Ghanaians and that many are hesitant to pay for something for which they may, or may not, get anything in return. Additionally, funding for the exempt groups (e.g., the elderly, children, and the indigent) comes from the government, but we learned that this often delays to the point of undermining the operation of some Schemes. Another basic problem identified by some discussants relates to fraud. Depending on

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who is speaking, the culprit might be the agent who collects premiums and embezzles them; the pharmacist who presents fraudulent claims for reimbursement; or the member of the public who tries to impersonate an NHIS enrollee to procure free health care. The fact that the registration of children is tied to that of parents was also a matter of great concern to discussants. Some parents, especially father (we found), are hesitant to register, thereby restricting their children’s access to the Scheme. At first, children’s registration was tied to that of both parents, but as of the time of writing this paper, the registration of just one parent was enough to bring a child into the Scheme. That excessive red-tape undermines the smooth running of the NHIS was another concern raised by some of our discussants. Hospital administrators and pharmacists were particularly incensed by the amount of paperwork and regulations involved in reimbursement.

Discussion We used qualitative data from focus group discussion to shed light on the benefits, exceptions, procedures, and challenges of Ghana’s NHIS. Our findings indicate that more and more people are enrolling in the NHIS, and enjoying its benefits, just as they are enmeshed in its challenges. A point worthy of note is that there is no significant difference in the aggregate NHIS subscribers by category for 2009 and 2010 respectively (see Table 1).Without a doubt, many of the answers we sought in this study— especially those dealing with the NHIS procedures, benefits, and exemptions—could have very well been procured from various NHIS documents and legislative instruments. Still, with our qualitative approach we have managed to humanize the discussion with narratives and insights from the subjective views and interpretations of key NHIS stakeholders. Such humanization becomes even more attractive when set in the context of W. I. Thomas’s long-standing axiom in sociology about self-fulfilling prophecies, alluded to earlier on, viz: “When people define situations as real, they become real in their consequences.” In this case at hand, what counts are the realities in the minds of people involved in the NHIS. Such realities, be they accurate or inaccurate, end up becoming consequential in the final analysis. Our focus group discussion uncovered a host of challenges facing the NHIS, not the least of which deal with fraud, impersonation, and misrepresentation of the NHIS. Of the many policy ideas that readily come to mind in addressing these challenges, we give primacy to public educational campaigns on the NHIS. This could help not only to dispel some of the misconceptions surrounding the Scheme—most notably the idea that hospitals somehow prefer to treat the uninsured to the insured—but also to enhance people’s understanding of the value of health insurance in general. Even efforts to improve record-keeping and to reduce fraud and impersonation could be enacted through intense public education.

Acknowledgments We are very grateful to the Bill and Melinda Gates Foundation and the Global Development Network for funding a larger version of this project. We also appreciate the

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support of William Sabi and Yabuku Abubakari of the Catholic University College of Ghana-Fiapre for their involvement in the larger research project.

Notes 1.

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4.

5.

6.

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8. 9. 10.

11. 12.

13. 14. 15. 16.

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