Analysing the Impact of National Health Insurance Scheme (NHIS) on the Accessibility of Health Care in Ayigya, Kumasi, Ghana

The health sector of many developing countries has failed to address the health care needs of poor and vulnerable groups of people. As morbidity and mortality rates increase tremendously, the plight of poor and marginal groups of people remain unheard. In light of the above challenges a number of developing countries saw national health insurance as a way forward to make health care accessible to all, because most developed countries managed to expand health service and provide affordable health care through a national health insurance system. The Ghanaian population has been bearing the brunt of structural adjustment that prescribes cutting expenditures on social services and introducing a "cash and carry" system that requires on the spot payment for health care received at the point of delivery. As a result health services became accessible only to those who could afford the high cost of care, while the majority of Ghanaians resorted to traditional healers or faced financial catastrophe to cover the cost of health care. To address the health care needs of the majority of Ghanaians, a National Health Insurance Scheme (NHIS) was introduced in 2005. The literature review has discussed concepts of national health insurance schemes. Developing and developed countries experiences in implementing a national health insurance scheme were reviewed. A predominantly tax financed health care system exists in developed countries, due to the fact that a high proportion of this countries population is employed in the formal sector. While, many of the developing countries due to high informality in their economies make use of multi source financing such as the premium contribution of health insurance subscribers, taxation and donor funding. The Ghanaian NHIS adopted the German model of solidarity and decentralization to set up the system at the initial stage. The German National Health Insurance advocates for universal health coverage, portability of insurance and participation by physicians. However, in its approach towards financing the scheme, the Ghanaian NHIS is unique in the continent, because it relies principally in the internal resource of the country, unlike many developing countries where a greater proportion of the health sector is financed through donor funding. The research is an explanatory impact evaluation geared to analyse the impact of the National Health Insurance Scheme (NHIS) in Ayigya, a suburb of Kumasi in Ghana. A joint survey was conducted in 180 households initially to gather socio-economic data about the population. A total of 50 insured and non-insured individuals were randomly selected in order to analyse whether the introduction of NHIS improved the community's ability to access health care and provide financial protection against catastrophic payment. An in depth expert interview has been conducted simultaneously as well, with District Mutual Health Insurance Scheme officers and KNUST hospital personnel. The introduction of NHIS improved access to health care, patient attendance at health facilities shot up. The health facilities were overwhelmed by the sudden spike in attendance. Measures have been taken to expand services and recruit additional health workers. However, there is a big mismatch between the demand for health care and available supply, particularly in the outpatient department despite the strides to expand health services. The insured are protected from catastrophic payments compared to the non-insured who struggle to access health care due to the high cost of inpatient and outpatient care. The majority of insured received health care free of charge for inpatient and outpatient care. In terms of out of pocket at a lower range of expenditure both the insured and non-insured spent an equivalent amount of money for outpatient care, however as the amount of expenditure rises only the non-insured tended to have a higher spending for the cost of drugs. A high proportion of the Ayigian community are enrolled in the national health insurance scheme, among those non-insured the majority are an indigent group of people who can't afford the health insurance premium and elderly who can't travel to the registration offices due to old age. Identification procedures and guidelines have many weaknesses that create loopholes in the system. Poor people are overcharged, while the principle of cross subsidization is not adhered as the result, the rich are not contributing proportional to their income as envisioned in the NHIS act. The majority of the insured believe the NHIS has improved access to health care. However, physical inaccessibility of health care in terms of overcrowded health facilities and financial barriers due to high out of pocket payments for outpatient care remain issues for improvement.