What we can learn from the Ghanaian experience of national health insurance

Despite rumblings that Cabinet has rejected the NHI Bill, the health department is adamant that "all is well". Picture: iStock
Despite rumblings that Cabinet has rejected the NHI Bill, the health department is adamant that "all is well". Picture: iStock

It has taken political will and strategic funding to entrench universal health coverage in Ghana and despite hiccups, the scheme enjoys widespread acceptance, writes Samuel Adu-Gyamfi

Ghana is one of the few countries in Africa to have successfully implemented a form of social insurance healthcare, known locally as the National Health Insurance Scheme (NHIS).

The country’s success stems from the zealous efforts made by previous governments to pursue universal healthcare for poor and vulnerable groups.

Political leaders – from Kwame Nkrumah to Kofi Busia to John Kufuor – all pushed for some form of healthcare financing based on the belief that its implementation and financing are essential tools for social and economic development.

After independence was declared in 1957, Nkrumah, Ghana’s first president, gave the citizens hope that the country would provide universal access to healthcare.

However, mismanagement and corruption, which were especially rife in health centres and hospitals, thwarted the dream.

In 1966, a military coup saw the National Liberation Council seize power.

This further complicated the provision of healthcare. By then, Ghanaians had come to relish the idea of the free healthcare introduced by Nkrumah.

In 1969, Busia’s Progress Party replaced Nkrumah’s Convention People’s Party as the next civilian government.

It tried to introduce a nominal fee to guarantee access to healthcare. However, this was met with widespread resistance.

Read: Can SA’s reality support the NHI dream? Here are the challenges

With finance proving to be a barrier to accessing healthcare, Busia adopted a health insurance scheme to fund healthcare, where government paid a greater portion of the costs.

The type of healthcare management introduced by Nkrumah and Busia was put to the test during the 1970s and 1980s.

Amid a drastic decline in the health status of Ghanaians, and a high incidence of corruption and mismanagement at national level, the introduction of a user fee as a compulsory tool to access healthcare widened the inequality gap, especially between people in rural areas and those in the urban centres.

A return to democratisation in 1992 and with it, the ratification of the Fourth Republican Constitution – providing the basic charter for the country’s fourth attempt at republican democratic government since independence in 1957 – put the Ghanaian health system on a better path to ensuring universal healthcare for all citizens.

Ghanaians’ hope for better healthcare management resulted in the New Patriotic Party – which governed the country from 2000 to 2008 – under former president Kufuor, promising to replace the “dreadful cash and carry system” which had existed from 1970 to 2003.

It was during Kufuor’s leadership that the NHIS was introduced, in October 2003, through an act of Parliament.

Some viewed the NHIS as a privilege, while opposition parties used it for political leverage.

The NHIS in Ghana is not a neutral entity; it is mired in politics.

Notwithstanding this political expediency, understanding the continuities and discontinuities – the changes – that have accompanied the scheme, is key.

To this end, one must consider the nature of its implementation and financing strategies.


The first efforts to reintroduce the NHIS happened in 1997.

Ghana Health Company, for example, was to provide other means of financing to fund health insurance in Ghana.

Although it was not entirely successful, the existence of private insurance companies such as Vanguard Assurance and Gemini Life Insurance in urban areas enabled health insurers to provide such alternative funding.

While people in rural areas were at a disadvantage in that they had limited access to insurance companies, those living in places such as Damongo, Tano, Jaman and the Dangme West districts enjoyed support from nongovernmental organisations and religious bodies.

This showed that a health insurance which incorporated the rural populace was possible.

Today the NHIS is managed by the National Health Insurance Authority, an autonomous body.

It is regulated through the National Health Insurance Council, which oversees planning, monitoring and evaluation; registration and licensing; administration and management support; and funding and investment.

Some of the functions the NHIS performs are: registering of members for the scheme; ensuring equity in healthcare coverage; protection of the poor against financial risk; and drafting proposals to the health minister for the formulation of policies concerning health insurance.

The scheme is financed through a cost-sharing process involving participants of the NHIS and the government of Ghana.

There are two main groups that use the scheme: those working in the formal sector and those in the informal sector.

The former include employees of private entities and self-employed individuals who contribute to the Social Security and National Insurance Trust (SSNIT) fund.

Children under the age of 18; women in need of antenatal, delivery and postnatal care; people classified by the ministry for social welfare as indigent under the Livelihood Empowerment Against Poverty programme; people with mental disorders; pensioners of the SSNIT and people aged 70 and older are all entitled to the benefits that those in formal sector employment receive.

Most of them pay renewal and card-processing fees, with the exception of pregnant women, the poverty programme’s beneficiaries and people with mental disorders.

These formal groups constitute about 69% of the NHIS membership and they are not required to pay the premium.

The second group using the scheme comprise those in informal employment: 31% of the 40% of the national population covered by the NHIS are from the informal sector.

Members who are informal sector workers are required to pay a premium.

The NHIS covers about 95% of ailments treated at health facilities in Ghana.

These are enshrined in the products rendered by the hospitals and health facilities, and fall under the outpatient department services, which address medical conditions such as malaria, acute respiratory tract infection, skin diseases and ulcers, among other diseases.

The inpatient department delivers services such as laboratory investigations, the treatment of cervical and breast cancer, and surgical operations, including appendectomies.

The oral and eye-care services deal with issues of dentistry and optometry respectively, while the maternal health service deals with antenatal and postnatal care, including the delivery of babies.

The accredited centres of healthcare covered by the scheme comprise the following: community-based health planning and services health centres; clinics; polyclinics; primary hospitals, which include district hospitals and private primary hospitals; and secondary hospitals, which include regional hospitals, pharmacies, licensed chemical shops and diagnostic centres.

In Ghana, there are about 3 500 public, private and faith-based healthcare facilities. Of these, 57% are public facilities, 33% are private ones and 7% are operated by the Christian Health Association of Ghana.

One teaching hospital is private, and the rest – which include teaching, municipal, metropolitan, regional and district hospitals – are public facilities.

Adu-Gyamfi is an applied historian and the first trained social historian of medicine at the Kwame Nkrumah University of Science and Technology. This is an edited extract from the book Epidemics and the Health of African Nations published by the Mapungubwe Institute for Strategic Reflection

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