How to Save Health Insurance in Ghana

1. Ghana has what it purports to be a social insurance scheme.

2.  This means that it is a scheme designed to cover as many people as possible and not necessarily make profit.

3. In this scheme, public money (taxation, development aid and direct subventions etc.) makes up about 95% of all revenues into the scheme. Essentially, the government pays up 95% of the money used to run the program.

4. Only about 30% of the users of this “insurance” program contribute anything at all, and their contributions make up less than 5% of the insurance scheme’s revenue. Take that in slowly. DOES THIS RESEMBLE IN ANY FORM ANY INSURANCE SYSTEM YOU’VE HEARD OF?

5.There are regular announcements of Ministries and local government agencies providing ‘free registration’ to indigents who will thereafter be exempt from paying premiums. So what we have is one part of government using public money to, wait for it, REGISTER people onto a scheme when these people are too poor to ever contribute to the scheme. Which makes you wonder, if these people are so poor that they can’t even afford to pay a few Ghana Cedis to register for the service, what then are they doing in an *insurance* program??? And if the government is going to be paying for their access to the actual service after the registration anyway, then why not simply scrap the registration fee?

6. In fact, why not create two completely separate programs: a Universal Health Care Fund, that is free for all poor and vulnerable people (using a combination of geographical indicators of poverty – i.e. some districts are nearly universally poor – and means-testing in the towns), and is free to register for? And then create a separate, ACTUAL, insurance scheme that BEHAVES like a proper insurance scheme, where premium contributions actually work to pool risk, cross-subsidise the sick with the contributions of the healthy, and invest the contributions in high-yielding financial products?

7. That way, the government can ensure that insurance fund can properly function as such, growing the investment base of the system to pay service providers on time, thus enabling them to invest in infrastructure, reverse outbound medical tourism and retain the money that would have flowed out in this country, and enhance the value chain of health in Ghana on top of it all. Surplus income may then be generated to reduce the government’s direct payments to the Universal Healthcare Fund (UHCF). Equally critically, we will then transparently see that growing the numbers of those dependent on the UHCF is nothing to be proud of, as it will demonstrate growing poverty and dependency.

8. Currently, the confusing setup of the NHIS mean that we rightly celebrate the growing subscriber base without pausing to reflect whether this mean that more and more Ghanaians are unable to make any financial contribution to their own healthcare, a metric that can by no means be celebrated by any sane society.

9. Why carry on a charade of an insurance scheme that is at one and the same time a ‘single-payer (government) universal health program’ and a ‘social health insurance program’? It is a mess, and that is why all studies show that the scheme will go bankrupt at the current rate of expenditure (even at the same time that it is struggling to pay its bills!)

10. Can’t every one see that by mixing this mess in one pot. we have made the whole thing fully unsustainable and unlikely to ever succeed in driving outcomes? It is lost on the leadership that a scheme that by evolution is now designed primarily to distribute free healthcare cannot incentivise its management to prioritise premiums mobilisation and the attraction of paying members. The skillsets and attitudes needed for the two competing goals are so different as to warrant a contradiction in terms. No wonder there are many people who can afford to contribute to the health insurance scheme but do not because they are never targeted as potential customers by the Scheme. The current setup of the system encourages the mass enrollment of non-paying beneficiaries and discourages the development of a customer-centric model capable of attracting mid-income earning Ghanaians capable of paying their share of premiums.

11. The only alternative to radical surgery to create two separate agencies with different mandates so that one of them can focus on premiums growth is to increase taxation across the board in order to plug the mounting deficits being witnessed by the scheme.


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