Jacob Novignon, Charles Lanko, Eric Arthur, Political economy and the pursuit of universal health coverage in Ghana: a case study of the National Health Insurance Scheme, Health Policy and Planning, Volume 36, Issue Supplement_1, December 2021, Pages i14–i21, https://doi.org/10.1093/heapol/czab061
Navbar Search Filter Mobile Enter search term Search Navbar Search Filter Enter search term SearchThe road to universal health coverage depends on resources committed to the health sector. In many cases, the political structure and strength of advocacy play an important role in setting budgets for health. However, this has, until recently, not been of interest to health system researchers and policymakers. In this study, we document the political path to the establishment of the Ghana National Health Insurance Scheme (NHIS) as well as continuous political interest in the scheme. To achieve our objectives, we used qualitative data from interviews with key stakeholders. These include stakeholders instrumental in the design and establishment of the NHIS. We also reviewed party manifestoes from the two main political parties in the country. Promises relating to the NHIS were extracted from the various manifestos and analysed. Other documents that account for the design and implementation of the scheme were reviewed. We found that the establishment of the NHIS was down to political commitment and effective engagement with relevant stakeholders. It was considered a solution to the political promise to remove user fees and make healthcare accessible to all. A review of the manifestos shows that in almost every election year after the NHIS was established, there has been some promise related to improving the scheme. There were several policy propositions repeated in different election years. The findings imply that advocacy to get health financing on the political agenda is crucial. This should start from the development of party manifestos. It is important to also ensure that proposed party policies are consistent with national priorities in the medium to long term.
Key messagesUniversal health coverage (UHC) has become an important public health priority in recent years. The World Health Organization (WHO) defines UHC as ‘ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship’ ( WHO, 2020). The relevance of this global health priority was reiterated by its inclusion in the Sustainable Development Goals (SDGs). The good health and well-being target under goal three of the SDGs seeks to ‘Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’ ( UNDP, 2020). This target has received global support with majority of countries signing up to the SDGs and UN resolution on UHC.
The need for financial protection for health and UHC is even more pressing in developing countries. Available estimates from Wagstaff et al. (2018) suggest that at 10% threshold, Africa has the third highest (∼10.3%) incidence of catastrophic health spending after Asia (at 12.2%), Latin America and the Caribbean (at 17.5%). Moreover, health outcomes are also relatively poor in Africa, with relatively high mortality and morbidity rates. For instance, in sub-Saharan Africa, under-five mortality was estimated to be 78 per 1000 live births in 2019, relative to a global average of 38.8 per 1000 live births ( World Bank, 2019). Similarly, life expectancy at birth was relatively lower in the region (61 years) compared to the global average of 72.38 years in the same year ( World Bank, 2019). Health infrastructure and workforce is also reported to be deficient in the region compared to other regions of the world.
Over the years, different policies have been implemented in different countries across Sub-Sahara Africa (SSA) to improve financial protection for health and UHC. These include policies that allow people to pay into a pool while healthy and access healthcare when sick. These pooled funds come from taxes or health insurance contributions with many countries mixing the two ( WHO, 2008). For instance, in countries like Ghana and Rwanda, health insurance schemes have been established to ensure that registered individuals do not face financial risk when they seek healthcare. In other countries like Kenya, Zambia and Malawi, social protection programmes (such as cash transfers) have been used to support vulnerable and poor individuals to improve their livelihoods as well as access to and utilization of healthcare. However, these are still insufficient as a significant proportion of the populations remain vulnerable to catastrophic out-of-pocket (OOP) spending on health ( Wagstaff et al., 2018).
Moreover, the success of any programme directed towards financial protection and UHC hinges on sufficient and sustainable financing. In practice, however, government budgets across these countries face large competing interests from other equally important social and economic interventions aside health. Given that resources are typically limited, the decision to channel these resources to particular sectors is important. The role of political actors in this decision process cannot be overemphasized. Indeed, resource allocation to UHC and financial protection for health has been described as an important political process ( Chemouni, 2018).
In Ghana, significant progress has been made towards improving financial protection and UHC. The country is considered one of the first to implement a tax-funded health insurance scheme aimed at improving medical care utilization and reducing OOP health spending. The National Health Insurance Scheme (NHIS) is estimated to currently cover ∼40% of the population and is touted as the largest single reform in the health sector of Ghana. It is worth noting that majority of the population remain uncovered under the scheme even though it is largely publicly funded. Empirical studies have shown some gains for those who are covered, including increased utilization ( Blanchet et al., 2012; Sekyi and Domanban, 2012; Wang et al., 2017; Abrokwah et al., 2019), equity in health financing ( Jehu-Appiah et al., 2011; Odeyemi and Nixon, 2013) and reduced OOP payments ( Okoroh et al., 2018; Dalaba et al., 2014). However, the political process towards the establishment of the scheme has been missing in the literature. In this paper, we seek to highlight the political paths towards the establishment of the NHIS in Ghana. We also assess continuous political interest in the scheme. The relevance of this lies in the fact that while the NHIS is at the heart of the healthcare system in Ghana, different political interests by different parties can affect the scheme in achieving the desired outcome.
Understanding the political economy of health policy reforms will help policymakers circumvent challenges in the reform process. Importantly, engaging these actors early ensures commitment at all stages of the reform and smoothens the process. We provide evidence from Ghana on how key political actors facilitated Ghana’s most important health financing reform and highlight lessons for future reforms in Ghana and across the developing world. We also highlight how political interest in the scheme has been sustained over the years.
Attempts to reform health financing in Ghana dates back to post-independence. Public health financing was mostly designed for expatriate civil servants during the pre-independence era. The first attempt at UHC was between 1957 and 1969 where a universal access to comprehensive health services was tried. The approach was to tax-fund public health services at the point of use as well as rapidly expanding public health infrastructure and human resources. With the country’s relatively stable economic and political situation post-independence, this policy was considered feasible and sustainable. However, after depleting the country’s economic surplus and incidence of political instability, the policy became unsustainable and was abandoned. The poor economic outlook of the country resulted in the implementation of the structural adjustment programme (SAP) in the 1970s that limited public expenditure prospects.
In line with the SAP and concerns about the sustainability of tax-financed public health system, user fees were introduced in 1985 ( Agyepong and Adjei, 2008). This was popularly known as the ‘cash and carry’ system where patients were required to pay upfront for health services before they were treated. This resulted in a large proportion of the population being denied their basic healthcare needs. Coupled with the high poverty and inequality levels, paying for healthcare out of pocket before receiving service was a major concern for the government and population at large. To ameliorate this, community-based mutual health insurance schemes were introduced in the 1990s with financial and technical support from development partners ( Agyepong and Adjei, 2008; Blanchet and Acheampong, 2013). This was designed to reduce the financial burden from seeking healthcare and to improve utilization. However, OOP payments for health persisted in the early 2000s, and utilization of health services was low.
In 2003, the NHIS was established and operationalized in 2004. The NHIS, operated by the National Health Insurance Authority (NHIA), was designed with three key objectives: (1) increase population coverage, (2) reduce user fees and cost sharing and (3) increase access to service, coverage and utilization. The scheme was established by an Act of parliament (ACT 650, Amended ACT 852). The scheme was originally designed to amalgamate district mutual health insurance schemes operating in the country at the time. The district schemes limited health access in the sense that healthcare could only be accessed within the district of operation. The NHIS was not initially designed as a mandatory scheme until 2012 when ACT 852 required that enrolment be made mandatory. However, this provision has not been strictly implemented as majority of the population are still not enrolled on the scheme, due to the large informal base of the economy. As at 2019, the scheme covered ∼12 million people, which is ∼40% of the national population ( NHIA, 2020).
A key feature of the scheme is its financing structure. The scheme is largely tax-funded through the National Health Insurance Levy (NHIL). The NHIL forms 2.5% of all value-added tax (VAT) revenue received. This is the largest source of revenue to the NHIA. Other sources of revenue include 2.5% of Social Security and National Insurance Trust (SSNIT) contributions, interest on investments and premium payments. Parliamentary allocations, grants, donations, gifts/voluntary contributions also serve as revenue sources to the scheme. 1 While the scheme does not cover all health conditions, it is reported that ∼95% of disease conditions reported at health facilities are covered in the benefit package. 2
All residents of Ghana, including non-citizens, are eligible to enrol on the NHIS scheme, even though not all of them are required to pay premiums and/or processing fees. Contributors to SSNIT do not pay premiums. Exemptions of the scheme include pregnant women, beneficiaries of the Livelihood Empowerment Against Poverty programme and indigents. These are completely exempted from paying premiums and processing fees. They, however, need to register and hold a valid NHIS card. Besides, children below the age of 18 years and the elderly above 70 years are only required to pay processing fees and not premiums ( NHIA, 2012). The informal sector constitutes the only fee-paying membership category and, as at 2019, they make up ∼34% of the membership ( NHIA, 2020).
The study follows a framework proposed by Sparkes et al. (2019) on the political economy of health financing reforms. The authors argue that successful health financing reforms require a clear understanding of the power and position of key political actors. The framework highlights key stakeholders that could influence the implementation of financing reforms. The framework identifies six important stakeholders that are considered to be key actors in health financing reforms. Engaging these actors can guide policymakers in identifying and effectively addressing challenges that may arise in the reform process. These six actors are (1) interest group politics, (2) bureaucratic politics, (3) budget politics, (4) leadership politics, (5) beneficiary politics and (6) external actor politics. Interest group politics is defined to include stakeholders with shared interests and power to influence political authorities as well as the policy process. In the context of the NHIS, these groups would include the Ghana Medical Association, Christian Health Association of Ghana, Nurses and Midwives Council as well as Trade Union Congress (TUC). These associations typically influence the health policy in Ghana. Bureaucratic politics on the other hand highlights the need to ensure proper coordination across various government agencies to ensure that proposed policies are acceptable. For instance, in many cases, health financing reforms require commitments from ministries of finance to ensure that budgetary allocations for the new reform are feasible and sustainable.
Budget politics is closely related to bureaucratic politics and emphasizes the need to recognize that budgetary allocations are important political processes. Decisions on what gets onto the budget and what share of the budget is allocated to what sector are influenced by political power. Hindriks and Myles (2013) also demonstrated that policies that are high on the political agenda will most often receive a higher preference in the budgetary process.
Leadership politics represents the commitment of political leaders. A typical feature in public policy is the acceptability of the head of state. If the political leader considers the reform important, its chances of success are usually very high. Aside the head of government, other leaders in the various arms of the government (Legislature and Judiciary) are also crucial to the success of the policy.
Beneficiary politics concerns the people and they cannot be overlooked. In some cases, if the will of the people is very strong, policies are forced onto the political agenda and become priorities. Political leaders know their mandate is determined by the people and therefore are committed to ensuring their needs are met, even if partially. Therefore, health financing reforms are likely to benefit from public mobilization that demonstrates that a particular reform is a priority to the population at large.
External actor politics is also an important part of the political process to consider. While external actors such as donors and development partners may not be obvious stakeholders in health financing reforms, their power and position make them very relevant. Sparkes et al. (2019) noted that external actors influence reform processes through their financial condition, intellectual influences and incentives. The authors also note that the extent of influence depends on the political environment of the country.
In Figure 1, we present the framework discussed above. In addition to the discussion so far, the framework also highlights the fact that these actors also interact among themselves to finally influence public policy. That is, while it is possible for the individual actors to separately influence public policy, a more practical approach allows partners to negotiate, resolve conflicts, form alliances and build consensus that jointly influences policy. This is depicted in the figure with arrows that connect the various actors.
Analytical framework of interaction across political actors.