World Development Perspectives 5 (2017) 47–55

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World Development Perspectives

j o u r n a l h o m e p a g e : w w w . e l s ev i e r . c o m / l o c a t e / w d p

Health care financing and sustainability: A study of current conceptual dialectics in Ghana

⇑
Emmanuel Akiweley Wedam a, , Francis Nangebeviel Sanyare b
a
Department of Development Studies, University for Development Studies, Wa, Ghana
b Department of Social, Political and Historical Studies, University for Development Studies, Wa, Ghana

article info abstract

Article history: One major challenge in health policy and planning in third world countries is the sustainability of pub-licly funded health
Received 6 November 2016 insurance schemes. Economic renegence restricts the fiscal capacity of governments in Ghana to allocate limited public funds
Accepted 5 March 2017 to financing a public sponsored health care insurance scheme. In the intervening time, the increasing demands within
populations in the country for health care continue to escalate amidst political campaigns to increase access in health care and
to motion towards universal-ism. General health care demands for the population grow as cost of treatment and enrolment
Keywords: increase resulting in sustainability issues; which are further perpetuated by institutional ineptitudes, limited pub-lic funds and
Financing
managerial lapses. This study examines the current conceptual debates in Ghana on the funding and sustainability of the
Sustainability
Debate
National Health Insurance Scheme (NHIS). Using data from public fora, interviews, conferences, newspapers, workshops,
Health care television and radio discussions and parliamentary Hansards and manuscripts, the study revealed that as part of the public
National Health Insurance Scheme policy making process the current debate is generally influenced by stakeholders’ interest, power and solidarity even though
there are attempts in some quarters to make political capital out of the debate. The complex relationship among the various
stakeholders has stimulated an unabated discourse which has caused most of the stakehold-ers to adopt staunch positions in the
debate.

2017 Elsevier Ltd. All rights reserved.

1. Introduction
Since independence, Ghana has implemented several health care funding
mechanisms as part of a broader strategy to promote financial sustainability
and to increase access in health care. In the 1990s, funding from health care
was from user fees charged on cli-ents at the point of service delivery.
However, this invariably widened the disparities in access in health care
within populations in high and low income groups’ as the cost of health care
was based on the ability to pay (Ataguba & McIntyre, 2012; Evans,
Whitehead, Diderichsen, Bhuiya, & Wirth, 2001; Nyonator & Kutzin, 1999).
Today, health care in Ghana is generally financed through the National Health
Insurance Scheme (NHIS).
The NHIS was introduced in Ghana in 2003 by the government of Ghana
through the National Health Insurance Act 2003, (Act
650) and the National Health Insurance Regulation 2004 (LI
1809). This was part of a political campaign by the largest opposi-tion
political party in the run–up to the 2000 general elections in
⇑ Corresponding author.
E-mail address: ewedam@uds.edu.gh (E.A. Wedam).
Ghana, and a general concern from civil society groups and the international
community. To this extend, the consultative and pol-icy building processes
did not witness a lot of acrimony from pub-lic and private interest groups as
has been the case in most public policies in Ghana (Abiiro, Mbera, & De
Allegri, 2014; Pal, 1992).
The NHIS is expected to create a balance in equity, access and utilization
of basic health care by all especially, for people living within the poorest
bracket (NHIS Report, 2011; Jehu-Appiah, Aryeetey, & Spaan, 2011). Over a
decade of implementation, the scheme appears to have considerably reduced
financial barriers, risk and access in health care even though some equity
issues still remain (Abbey, 2003; Owusu-Sekyere & Kanton, 2014; Schieber,
Cashin, Saleh, & Lavado, 2012). The scheme covers about 95 per-cent of
common disease burdens in Ghana and the cost of medici-nes for most
essential diseases in the country (Agyepong & Adjei, 2008; Dalinjong & Laar,
2012; OXFARM, 2013). Current data on Ghana’s Health Insurance Scheme
reveal that the number of active members on the scheme has been
phenomenal surpassing that of many other African countries that have been
operating similar schemes. The scheme has an active membership of 10.9
million people representing about 40 percent of the population in Ghana
(Peprah, 2015).

http://dx.doi.org/10.1016/j.wdp.2017.03.003
2452-2929/ 2017 Elsevier Ltd. All rights reserved.
48 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
Coverage levels (170 districts) in the country have been very momentous
and responsible for accelerating access in health care (especially primary
health care) and utilization levels. As a result, subscriber rates have been very
encouraging. Data available indi-cates that the number of children who are
under 18 years repre-sent more than half of the active members of the scheme.
Again, premium paying subscribers/clients, thus those in the informal sectors
make up nearly 35.5 percent of the active subscribers/ members on the
scheme (Ataguba, Akazili, Mtei, Goudge, & Meheus, 2009; NHIS Report,
2012). Funds for running the scheme come from pooled public contributions
of a Value Added Tax (VAT) of 2.5 percent, a 2.5 percent monthly salary
deduction of formal sector workers, being pension contributions to the Social
Security and National Insurance Trust (SSNIT), an health insurance levy of
2.5 percent, donor funding, contributions from informal sector members of
the scheme, investment income or interest earned on investments (Abiiro &
McIntyre, 2012; Owusu-Sekyere & Bagah, 2014; Abiiro & McIntyre, 2012).
Nearly more than 70 per-cent of the scheme’s expenditure comes from the 2.5
percent NHIL (Adonoo, 2016).
1.1. The need for the financial sustainability debate
In most third world countries like Ghana, public funded health care
schemes such as the NHIS are a major pecuniary challenge to governments.
Moreover, population growth and structural adjust-ments will strongly affect
Ghana’s ability to meet its future health care financing needs. The country’s
population is expected to dou-ble in the coming years and the burden of
diseases will keep on shifting from communicable to non-communicable
diseases and injuries (Schieber et al., 2012). In the interim, the country will
have to grumble with a dual disease burden, and this will considerably impose
severe cost on the country’s health care system. Consider-ing the hazards in
revenue mobilisation in Ghana and the fact that about 80 percent of the labour
force in the country is in the infor-mal sector alone will pose a major
challenge to revenue generation and enrolment (Blanchet, Fink, & Osei-
Akoto, 2012; Schieber et al., 2012). At the moment the, ‘‘National Health
Insurance Scheme is seriously challenged as far as finances are concerned.
There is a huge funding gap that the National Health Insurance Scheme faces
as we speak. . .. Mr. Speaker, it is no wonder that the National Health
Insurance Authority is unable to pay the claims of most health providers as
we speak” (Dr. Kwabena Twum-Nuamah – NPP MP for Berekum East.
Debates of 26 March 2015).
In 2005, the active subscriber base of the scheme was 1.3 mil-lion, and the
corresponding expenditure on claims was GHC 597,859 ($153,336 US
Dollar). In 2014, the subscriber base stood at 10.2 million, with an associated
expenditure on claims being in excess of GHC 960 million ($ 244,663,282
US Dollar), and an out-patient utilization of 29 million. A comparative
analysis of these two cases (2005 and 2014) visibly illustrates the financial
trajec-tory of the scheme today. Additionally, in 2014, the scheme recorded a
funding gap of close to GH¢300 million ($76,457,276 US Dollar), and in
2015, the figure increased to a little more than GH¢800 million
($ 203,886,068 US Dollar) (Dr. Kwabena Twum-Nuamah, 2015 – NPP for
Berekum East. Debates of 26 March 2015).
The NHIS funding gap is happing restrictive implications for people
accessing health care under the NHIS. Even though the gov-ernment since
2004 has been able to sustain the NHIS in the midst of a huge funding gap,
and public outcry and complaints of poor service delivery; what is certain is
that the coming years will be even more taxing. According to Mathew Opoku
Prempeh, an oppo-sition member of parliament (New Patriotic Party MP –
6th Parlia-ment) in Ghana’s parliament, ‘‘if 100 per cent of NHIS money is
even given upfront like we started in 2014 or 2015, by the time we finish
2016, there would be a claim arrears of more than half
a million Ghanaian cedis. That is the issue we have to confront”. (Dr.
Matthew O. Prempeh, NPP MP for Manhyia South. Debates of 26 March
2015). To this extent, there have been a lot of concerns from key interest
groups. For instance, ‘‘the GMA is gravely con-cerned with the gradual re-
introduction of cash and carry at the various health care facilities across the
country. It is a fact that, the facilities are restoring to cash and carry because
of prolonged indebtedness of the NHIS to them. Indeed, some facilities have
not been paid their claims in the last quarter of 2015 00 (Awuni, 2016).
The problem with the NHIS fund gap is largely attributed to the increasing
numbers of active members on the scheme even though administrative and
managerial hazards cannot be ruled out. Recent happenings show that the
survival and sustainability of the scheme is under serious threat if new
financing or policy options beyond the traditional ones are not sought.
Incessant withdrawal of services by health providers and delays in claim
payments sub-stantiate the financial challenges confronting the scheme. At
the moment, there are many health providers mostly private that have entirely
withdrawn their services from the scheme, and even for public facilities,
patients have been forced to make OOP payments for health care services
already covered under the scheme due to non-payment of claims submitted to
the scheme. Several patients have also been turned away from accredited
health facilities. Con-sidering the rising numbers in new subscribers,
treatment cost and cost of drugs both consumables and non-consumables, it is
clear, that the cost of claim payments to health care providers will con-tinue
to heave amid an increasing demand within vulnerable pop-ulation groups in
seeking health care.
Even though there have been attempts by other studies to dis-cuss NHIS
funding and sustainability in Ghana, this present study discusses the various
arguments in the NHIS funding and sustain-ability debate, the interest groups
and the factors influencing the debate. In doing this, the study has been sub
divided into three sec-tions. The first section contains the introduction of the
study. This deals with general discussions about health care financing. The
second section contains the methodology of the study. In this sec-tion –
methodology, the authors discussed how they collected data. In the final
section of this study, the results and discussions of the study are presented.
2. Methodology
2.1. Data collection
In this study, the researchers collected data from community public fora,
district/municipal and metropolitan public fora, regio-nal public fora and
national public fora. In-depth interviews with health directors, health
professionals, technocrats, directors and staff of the NHIS, members of
parliament, past ministers of health, service providers, clients and
academicians were conducted as part of a broader and nationwide stakeholder
consultation on how to finance the NHIS. The authors also collected data
from stakeholder workshops, conferences and student symposiums (see Fig. 1
for break down). Apart from the primary data sources, other secondary
sources of data such as books, journals, media briefings and bul-letins, radio
and television discussions, newspapers, reports, par-liamentary Hansards and
manuscripts and online resources were utilised.
Thirty-two (32) different public and private television and radio stations
where monitored across the country through the air waves and online websites.
These televisions and radio stations were selected based on their popularity
(most listened to) and wide media space. Panel discussions and news bulletins
on NHIS funding were the main items monitored. Six (6) national daily
newspapers
 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
Fig. 1. Data collection procedure and sources.
were also sampled and examined. The newspapers reviewed pro-cess also
included editorial pieces/columns. The researchers applied triangulation in the
data collected process.
2.2. Data analysis
Data was classified into germane themes based on similarities,
significance, number of occurrence within and across different platforms,
place and time of occurrence and the length of time enjoyed. Once the
classifications were completed, the researchers proceeded to do a content
analysis of the various themes by sub dividing the discussions into pro and
anti-coalition groups. The researchers also applied policy analytical
framework in the identi-fication of stakeholder groups, interest, concerns and
positions in the NHIS public policy making process and political debate in
Ghana.
3. Results
These is a raging discourse in Ghana about the sustainability of the NHIS
and this has attracted a myriad of contributions from the public, civil society
organisations, politicians, technocrats, aca-
49
demicians’, and health professionals and public policy experts inter alia. For
instance; ‘‘a number of measures were recommended by stakeholders at the
October 2014 conference and a few of them include streamlining the
exemption policy, reviewing the premium rates and injection of additional
funds into the scheme since inflows have become inadequate due to growing
obligations”. (Selorm Adonoo – Deputy Communications Director of the
NHIA – Interview).
At the moment, there are some major convergence in the myr-iad of
opinions on the need to find appropriate ways to finance and sustain the NHIS,
but the rather vexing theme that appears to res-onate is precisely the question
of how best to finance such a public funded scheme amidst escalating funding
gap and enrolment. Cur-rently, a number of public policy prescriptions are
being advocated (see Table 1). In this study, the researchers identified three
major prescriptions which appear to dominate the discussions on the best way
to finance the NHIS.
3.1. Pro cost containment
The first major prescription in the NHIS sustainability debate is cost
containment. This prescription is being exposed from a tech-
50 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55

Table 1
Summary of views about NHIS financing options.

Cost containment General tax revenues Capitation Total

Pro Anti Pro Anti Pro Anti Pro and Anti

n (%) n (%) n (%) n (%) n (%) n (%) n (%)
NHIS patient clients 2 (1.0) 0 (0.0) 193 (96.5) 5 (2.5) 0 (0.0) 0 (0.0) 200 (100)
Members of parliament 73 (35.8) 0 (0.0) 54 (26.5) 6 (2,9) 9 (4.4) 62 (30.4) 204 (100)
Health professionals 3 (37.5) 1 (12.5) 4 (50) 0 (0.0) 0 (0.0) 1 (12.5) 9 (100)
Health directors 0 (0.0) 0 (0.0) 2 (18.2) 0 (0.0) 0 (0.0) 9 (81.8) 11 (100)
Technocrats/professionals 4 (50.0) 0 (0.0) 4 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 8 (100)
Service providers 0 (0.0) 0 (0.0) 3 (3.4) 0 (0.0) 0 (0.0) 86 (96.6) 89 (100)
Academicians 22 (68.8) 0 (0.0) 8 (25) 0 (0.0) 2 (6.3) 0 (0.0) 32 (100)
Directors and staff of NHIA 14 (15.1) 0 (0.0) 2 (2.2) 0 (0.0) 77 (82.7) 0 (0.0) 93 (100)
Workshops/conferences 96 (30.3) 0 (0.0) 87 (27.4) 0 (0.0) 63 (19.9) 71 (22.4) 317 (100)
Community public fora 0 (0.0) 0 (0.0) 76 (100) 0 (0.0) 0 (0.0) 0 (0.0) 76 (100)
District public fora 6 (6.8) 0 (0.0) 74 (54.1) 0 (0.0) 0 (0.0) 8 (9.1) 88 (100)
Regional public fora 32 (29.9) 0 (0.0) 52(48.6) 0 (0.0) 17 (15.9) 6 (5.6) 107 (100)
National public fora 204 (48.0) 0 (0.0) 42 (9.9) 8(1.9) 58 (13.6) 113 (26.6) 425 (100)
Student Symposiums 82 (24.3) 1(0.3) 96 (28.5) 12 (3.6) 55 (16.3) 91 (27.0) 337 (100)
Radio discussions 19 (30.6) 0 (0.0) 15 (24.2) 0 (0.0) 12 (19.4) 16 (25.8) 62 (100)
Television discussions 22 (32.4) 0 (0.0) 38 (55.9) 1 (1.5) 2 (2.9) 5 (7.4) 68 (100)
Newspapers 32 (41) 0 (0.0) 16 (20.8) 0 (0.0) 11 (14.3) 18 (23.4) 77 (100)
NGOs 6 (28.6) 0 (0.0) 13 (61.9) 0 (0.0) 2 (9.5) 0 (0.0) 21 (100)
CSO groups 4 (44.4) 0 (0.0) 4 (44.4) 0 (0.0) 0 (0.0) 1 (11.1) 9 (100)
Online/websites 95 (20.7) 0 (0.0) 137 (30) 3 (0.7) 102 (22.3) 121 (26.4) 458 (100)
Total n (%) 716 (100) 2 (100) 920 (100) 35 (100) 399 (100) 608 (100) 2691 (100)

nocrat and an academic point of view. Health services and admin-istrative
cost constitute a major part of the funding gap that is cur-rently confronting
the NHIS. Inevitable, the cost of claims, drugs, treatment and services will
continue to exert a substantial pressure on the funding gap of the scheme. The
first part of the cost contain-ment debate is being put forward as a pro tem
measure even though a long term cost containment measure is very critical in
the future;
‘‘What I am saying is that, yes, there may be a need to find some revenue
sources but the most important urgent requirement is cut back in
expenditure which we must enforce.
[Dr. Anthony Akoto. Osei NPP MP for Old Tafo Suame. Debates of 26
March 2015]
‘‘Like my Hon Brother just said, too much of their moneys is going into
salaries and wages”.
[Dr. Matthew O. Prempeh NPP MP for Manhyia South. Debates of 26
March 2015]
The key point in this argument is that a reduction in expendi-ture will
significantly shrink the funding gap and boost the fiscal capacity of the NHIS
to provide better services. The second part of the cost containment debate
precisely explicates how a cut back on expenditure and cost containment
ought to be done. This pre-scription is directly focused on the need to revise
the targeting mechanism and exemption criteria;
‘‘Mr. Speaker, if we have to improve the common targeting mech-anism,
so that only those who are qualified to be declared poor or for that matter,
indigents under the mechanism, qualified for exemptions under the NHIS,
that would be a huge cost contain-ment. Like my Hon Friend just said,
there are a number of people exempted just because of age, beggar’s belief.
If you take those below 18 years and you add those above 70 years, you
are already getting to about 60 or 62 per cent of the population. That is one
of the reasons the Scheme is suffering. So, as a group and as Parlia-ment,
we have to start thinking about how to bring cost or expen-diture down
under the NHIS”.
[Dr. Matthew O. Prempeh (NPP – Manhyia South. Debates of 26 March
2015)]
‘‘Mr. Speaker, it is important that we face the reality. National Health
Insurance in many developing countries is concentrated on primary
healthcare. What one can do for example, is that, the indigents, the
children under 18 would have the wide benefit. But the rest of us would be
having some benefits but not all. . . One introduces inequality, because
those who can pay are taking it freely as well as those who cannot pay”.
[Alhaji Mohammed-Mubarak Muntaka (NDC – Asawase) Debates
of 26 March 2015]
As a result of poor targeting and exemption criteria, about 60 to 65
percent of the population in Ghana do not contribute to the NHIS. Meanwhile,
there is no other cost sharing or co-payments with the NHIS, except the
annual premiums paid. Therefore, there is the need to restrict the targeting
and exemption criteria to the core poor and people at the highest risk of
vulnerability of paying for health care.
Another part of the cost containment argument is the issue of the benefit
package. Pro cost containment coalition groups believe that in order to sustain
the NHIS, the benefit package under the NHIS must be reduced. The
campaigners of this argument are mainly health policy experts, health
directors and professionals. They argue that the benefit package of between
90 to 95 percent under the NHIS is too big and is part of the cost build up that
is threatening the sustainability of the scheme;
‘‘At October 2014 NHIS Stakeholder Dialogue on the Scheme’s ben-efit
package, participants after considering a holistic overview of the NHIS
and its financial challenges concluded that the current cost structure of the
scheme was not sustainable. They observed that the benefit package of the
scheme right from inception was too generous; an observation, they
surmised, added to the financial viability challenge of the NHIS”.
[Selorm Adonoo – Deputy Communications Director of the NHIA –
Interview]
‘‘The NHIS benefits package is arguably of the most generous in the
world covering over 90% of the disease burden of Ghanaians with-out co-
payment. Moreover, great percentages of the NHIS member-ship are
exempted from premium payments (over 70%) meaning”. [Respondent –
public forum]
 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
One of the leading campaigners of the benefit package argu-ment under
the cost containment debate is the Director of Claims of the NHIS. In a press
conference in Accra, Ghana’s capital, the Director of Claims of the NHIS said
one of the major challenges of sustainability under the NHIS is the size of the
benefit package;
‘‘I am not saying that is wrong, but the financing is not marching what we
want to do as a country. The fact remains that there has to be some
rationalization somewhere because we can’t afford everything.”
[Dr. Lydia Dsane Selby. Director of Claims of the NHI –
Interview]
Another leg of the cost containment debate in the country is centred on the
cost of drugs, services and tariffs. In health services administration, the cost
of drugs remains the biggest cost driver. In some places, the cost of health
care is over-priced due to the direct effect of the cost of drugs both
consumables and non-consumables. As a consequence, it is estimated that by
reducing the cost of drugs there will be a significant reduction in the total
overhead of expen-diture on drugs, a key component of health care cost;
‘‘The single biggest item cost under the NHIS – is the purchase of drugs –
medicines for the poor. Mr. Speaker, I do not know why the National
Health Insurance Authority (NHIA) that pays for the medication, cannot
get into a sort of arrangement with recognised generic drug producers, so
that those hospitals and service provi-ders prescribing those drugs can get
them at an approved rate from a National Health Insurance outlet. Mr.
Speaker, you cannot just understand why all the service providers can buy
drugs from any source that they want and still bill the NHIS. We are not
sure about some of the quality of the medicines and the prices. So, we
have to start thinking about using the financial muscle of the NHIS to con-
tain prices, especially with drugs in the country”.
[Dr. Matthew O. Prempeh. – NPP MP for Manhyia South. Debates
of 26 Mar 2015]
3.2. Anti-cost containment
There is also an anti-cost containment debate. This school of thought
appears to shift the focus of the argument from a pro cost containment view
of cut in expenditure. The anti-cost containment augment is being
championed by mainly public policy experts and health professionals; but the
relevance of this debate appears to be a caution rather than a counter augment
in opposition to the pro cost containment debate. This argument draws its
strength from the excessive bureaucracy, low resource capacity, weak public
pol-icy administration and management and the organised economic chaos
environment in Ghana;
‘‘Covering and ensuring the provision of the most cost-effective benefits
and treatments within benefit package – medicines may require extra
effort to manage because of the fragmented environ-ment”.
[Respondent – public forum]
There is fear that there may be an additional factor cost which will
increase the current overhead of expenditure if attempts made to cut back on
expenditure are not properly implemented and coordinated. The weak public
policy environment in developing countries like Ghana makes a cut back on
expenditure a big chal-lenge even though rational.
3.3. Pro Revenues, general tax revenues and debt financing
Perhaps, the most familiar debate so far is financing the NHIS from
general tax revenues. This argument is more re-sounding that
51
it resonates very well with a lot of people in Ghana. About 97 per-cent of
people even pro right and pro left politicians and parliamen-tarians strongly
advocate this position. Non-Governmental Organisations (NGOs), Civil
Society Organisations (CSOs), tech-nocrats, television and radio panellist,
academicians, students and some stakeholders are already in the forefront of
this campaign and are seeking to push the government to do more in this
regard;
‘‘The tax system used in financing Ghana’s National Health Insur-ance
Scheme (NHIS) is very innovative and one of the reasons other countries
want to learn from Ghana’s experience. Using the tax sys-tem to finance
health insurance, he said, had enabled far greater resources for health
coverage. He said the continued reliance on tax financing by Ghana’s
NHIS was a better practice that could be emulated by other countries
struggling to implement their national health insurance. According to him,
the tax mechanism in healthcare financing was a reasonably fair way of
providing the healthcare needs of people”.
[Dr. Nathan J. Blanchet, 2016 – A Health Systems Expert. –
Interview]
The argument in the general tax revenue debate is an old one and has for a
long time dominated health literature. It is a tradi-tional mechanism for
funding general health care services in both developed and developing
countries. In some countries, general tax revenue together with earmarked
revenue from government forms a greater chunk of health care funding
resources. In this study, two main augments in favour of this prescription
were found. The first part of the argument states that general tax revenues
have a poten-tial to rake in more revenue for funding health care. The second
part of the argument however raises equity issues, and sees this mechanism as
a way of balancing growth. Pro general tax revenue groups believe that this
mechanism is more progressive because the rich pay more for the poor as a
substitute for addressing the widening inequality gap in the country;
‘‘Mr. Speaker, I also support Hon Members who said that it is high time
some companies in this country that by the application of the law were not
paying premium and were not contributing to our health insurance, should
start contributing. Mr. Speaker, why should the mining companies not be
contributing to the NHIS? It does not happen. If their employees get
accidents, they take them to the same hospitals. The telecommunication
companies, the sim tax, the petroleum companies – we have to think
innovatively and boldly that the National Health Insurance Fund (NHIF)
be so replenished that it would not be under strains and stresses. But that
does not mean the NHIA should be given the authority to spend money as
they want”.
[Dr. Matthew O. Prempeh. NPP MP for Manhyia South. Debates of 26
March 2015]
‘‘These additional funding sources were thus suggested and have indeed
been mentioned many times; a 1.5% increase in NHIL/VAT, allocation of
25% of the Communications Service Tax, a transfer of a portion of the oil
and gas revenue to cater for the health needs of the country and a few
others”.
[(Selorm Adonoo – Deputy Communications Director of the NHIA –
Interview)]
The informal sector in Ghana is the part of the Ghanaian econ-omy that is
not taxed and where tax evasion is very common. The sector is estimated to
account for more than nearly 80 percent of the Ghanaian economy and
remains a key driver of the economy (GNA, 2016; Osei-Boateng &
Ampratwum, 2011). Yet, it remains a conundrum why the contribution of the
sector to government revenue is very derisory. Pro tax revenue coalition
groups in the country are pushing and are asking government to widen the tax
net especially in the informal sector in order to raise enough rev-
52 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
enue to finance the NHIS. There is a strong campaign for equity in tax
payment and the need to exploit other tax avenues particularly the informal
sector and the black market;
‘‘Raising more revenues from the informal sector”.
[Respondent – public forum]
There is also the argument by some pro general tax groups that service
and administrative charges are low and must be increased. The cost of
premiums per annum is also considered to be very low thus the real cost of
health is under-priced. Apart from the fact that premium cost per head per
annum is very low (GH ȼ 25–$ 6.53), it is only about 35 percent of the
enrolment population who actually contribute to the scheme through annual
premium payments. The provision of financial waivers under the exemption
category for about 65–70 percent of subscribers is not only having dire conse-
quences on the financial sustainability of the scheme but also raises some
fundamental issues of iniquitous on those who con-tribute to the scheme –
those paying for the cost of health are more than those who are not paying;
‘‘Section 29 of the NHIS enabling law, Act 852 exempts almost 70% of
the membership of the scheme from paying premiums. Apart from the fact
that the NHIS premium has remained static despite rising costs of medical
consumables and inflation, the NHIS stake-holders dialogue were of the
view that the exemption policy as dic-tated by the law is not equitable”.
[Selorm Adonoo – Deputy Communications Director of the NHIA –
Interview]
‘‘One of the difficulties is also, the number of exempt groups. We have
those who are under 18, above 70, pregnant women and indi-genes. The
figure in terms of population is taking a big chunk” If the Social Security
and National Insurance Trust (SSNIT) contributors are not going to be
disadvantaged at the end of their service, then these are the people who
earn income regularly and could be made to also pay the premiums”
[Joseph Yieleh Chireh. NDC MP for Wa West, Debates of 26 March
2015]
At the same time, government bursaries and tax revenues are not adequate
to balance the shortfalls in expenditure. As a result, there is a strong argument
to introduce more or increase service and administrative charges and premium
cost in order to raise enough revenue to finance the NHIS;
‘‘Approximately 35% of the NHIS membership pays premiums because
they work in the informal sector. Yearly premium payment per head for
enrolment appears to be one of the lowest in the world without co-
payments. Even though the costs of goods and services have increased
since implementation of the scheme in 2005, these premiums have not
increased in commensurate terms to meet the increasing demand for
healthcare”.
[Respondent – Public forum]
The health care funding debate in Ghana has attracted a myriad of pro
liberal and anti-liberal prescriptions. Pro liberal coalition groups say a more
realistic and prudent approach to funding the NHIS will be for clients to pay a
little for their health care cost whiles government absorbs the chunk of the
remaining cost. Once co-payment for premiums is introduced and people are
made to pay part of the cost of seeking health care, cost of health care under
the NHIS will substantially decline;
‘‘When you know that you have to foot the bill every time you go to the
hospital, you would actually ask – do I really need this service? Is there a
way that I could shift this to a month or two months?” [Chief Executive
Officer (CEO) of Acacia, Dr. Daniel Amooh – Interview]
The odds for abuse will be directly eliminated if people are made to bare
part of the cost of their health care (Graphiconline, 2016). This is part of a
neo-liberal thesis which draws its strength from a myriad of milieu. For
instance, in the Rand study carried out from 1974 to 1988 in the USA,
researchers observed that people who paid a fourth of the health care cost
visited the hospital at a rate of 3.33 times, those who were given free health
care went to the hospital 4.45 times in a year, but those who were made to pay
so much for the cost of treatment visited the hospital fewer times and spent
less on treatment (Manning et al., 1988).
There is a pro general tax revenue group who are advocating for a more
radical way of financing the NHIS through debt financing. The want
government to use debt financing instruments like bonds to service health
care under the NHIS. In this arrangement, health care providers could be
made to pre self-finance patients’ health care cost for some time after which
government raises bonds to pay off the expenditure incurred. This coalition
group is vexed about the escalating funding gap of the scheme and is
convinced that this could be addressed through debt financing while at the
same time making service providers more competitive;
‘‘Government must find ways and means. Some people have asked me
how Government should do so. I think what Government can do, is to do
what they have been doing to pay road contractors and other contractors.
If it also requires us to get some bonds, it should be done. If Government
wants to solve this problem, it has to do so with stakeholder consultation
very strongly”.
[Joseph Yieleh Chireh. NDC MP for Wa West. Debates of 26 March
2015]
3.4. Anti-Revenues, general tax revenues and debt financing
The main anti thesis against the general tax revenues argument is a
caution on the potential problems in over reliance on general tax revenues.
The first issue is over taxation and double taxation. The economy may shrink
if business owners are unable to plough back profit due to over taxation. The
second point is the need to address the inherent problems in revenue
mobilisation such as the small size of firms, stagnation in economic growth,
reduction in wage base taxes, retrenchment in public funds and fragmented
economic environment inter alia. Widening the tax net in develop-ing
countries like Ghana in the mist of weak tax administration laws and
management policies remains one of the biggest chal-lenges confronting the
government. Apart from the problems of ineffectiveness and inefficiencies
there is also the question of whether the government has the political will to
pursue such an agenda? There are also serious concerns of how general tax
rev-enues meant for health care funding go unaccounted for, missing and the
diversion of public health funds through corruption.
In the same length, the anti-debt financing coalition argue that the debt
financing prescription is a misplaced point. They stress the view that this
argument is a post health care financing arrange-ment which will have
substantial implications on the quality of health care delivery. There are also
strong trepidations that debt financing could create compounding and chain
effects in health care service deliveries. On the other hand, the argument in
the anti-debt financing debate is strongly being advocated by demo-cratic
politicians and parliamentarians; but the nexus of this argu-ment is
precautionary;
‘‘By the end of this year, 2015, if no action is taken or nothing is done,
what it is going to mean is that, we would end up having a gap of close to
a billion. I do not think we want to go for a Eurobond to just pay this off.
This will be very wrong”.
[Alhaji Mohammed Mubarak Muntaka. NDC MP for Asawase. Debates
of 26 March 2015]
 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
3.5. Pro capitation
The capitation debate is arguably the most popular debate for funding the
NHIS in Ghana today. This is because of the noise, con-fusions, controversies,
agreements and disagreements surrounding the policy. The policy was
introduced on a pilot bases in January 2012 in the Ashanti Region to
streamline what the NHIS called alleged excesses and abuse of the scheme by
service providers. Since 2012, there has been a lot of uncertainty and
hullabaloo on the concept, its meaning and its implementation;
‘‘Mr. Speaker, I want to find out whether the honourable minister for
health is sufficiently abreast of the capitation that was practised in the
Ashanti Region before recommending this as a strategy to address the
payment of claims”
[Augustine Collins Ntim. NPP MP for Offinso North, Debates of 13
November 2014]
The policy has also attracted a lot of media discussions on radio,
television, newspapers public fora, symposiums, and parliament and even on
political platforms. NHIS staff (national, regional, metropolitan, municipal,
and district staff), current and past minis-ters of health, some parliamentarians
especially from the ruling National Democratic Congress (NDC) are the main
campaigners in the pro capitation debate. These pro capitation groups are lob-
bing government to introduce closed-ended payment mechanisms that impose
a cap at some level throughout the country;
‘‘The capitation system ensures that per capita payment is made within the
first week of the month. It allows for payment to provi-ders to be made
before services are delivered. It therefore, remains the best mechanism for
avoiding delays in payment of claims for services rendered”.
[Dr. E.K Mensah – Former Minister of Health. Debates of 13
November 2014]
The government is by far the biggest pro capitation advocator in the
capitation debate. As part of a mechanism to deal with the widening funding
gap and to address challenges in the late dis-bursement of claims to service
providers, the government is con-sistently and continuously attempting to
divert, direct, lead and in some cases dictate the capitation debate.
Discussions from gov-ernment communication team members, government
commu-niqués, media encounters, press briefings, statements, and campaign
messages strongly indicate the government’s commit-ment to adopt capitation
as the major funding mechanism for the NHIS in Ghana;
‘‘Mr. Speaker, implementing a NHIS has never been easy in any country,
whether the United States of America, Britain, Germany, or anywhere. We
are not saying that the system is perfect. But we are trying every possible
means to make sure that the system is able to operate efficiently and
effectively and also it is sustain-able. So, we are constantly reviewing.
That is why now, in terms of the claims – capitation allowance for
payment is in advance rather than in arrears – So, it ensures early
payments as against other payment methods”
[Dr. E.K Mensah – Former Minister of Health. Debates of 13
November 2014]
3.6. Anti-capitation
There are anti-capitation groups with strong roots from centre right
parliamentarians especially from the Ashanti region of Ghana leading a
coalition against capitation. This group forms the core of the coalition against
capitation at the public policy level. When a motion was introduced in
parliament in 2012/2011 by the then
53
Minister of Health seeking to introduce capitation on a pilot base in the
Ashanti region, the main opposition republican party brought a counter
motion seeking to restrain the government from going ahead with its plans.
Even though there is political interest in the matter, it will appear however,
that the views expressed by these anti capitation parliamentarians, the former
president of Ghana and other distinguished persons from the Ashanti region
of Ghana were out of support and solidarity for the sentiments being
expressed by NHIS service providers in the region;
‘‘Why should you keep on implementing a policy when the people who
are supposed to benefit are crying and calling for its abroga-tion”.
[President John Agyekum Kuffour. Former President of Ghana, 2013 –
KESSBEN FM in Kumasi on Monday, 23th December 2013]
‘‘Mr. Speaker, after a whole year of the promise of the roll out of the
capitation, if capitation is supposed to increase a cost containment
measure, the whole of 2014, it has not been done. If the NHIA can-not roll
out by now capitation across the length and breadth of the country, Mr.
Speaker, I do not know why Ashanti Region should be unduly suffering. It
is just not right that only one-tenth of the coun-try is undergoing capitation.
When the NHIA comes to promise this House that they are rolling it in
2014 to three other regions, they could not do that. Why? What have the
people in the Ashanti Region done to deserve that? We have to start
looking at that as a House”.
[Dr. Matthew O. Prempeh. NPP MP for Manhyia South. Debates of 26
March 2015]
Residents in the Ashanti region have also joined the capitation debate, and
are calling for the capitation policy to be scrapped. Since the introduction of
the policy, there have been public out-burst, numerous demonstrations and
protest against the policy due to experiences from patients and persistent
compliant from the service providers in the region;
‘‘The decision by the NHIA to implement the pilot programme in the
region two years ago was met with stiffer opposition from health providers
and civil society groups who fought unsuccessfully to get the NHIA to
rescind the decision”.
[Alhassn, 2013]
The main anti-capitation groups is the NHIS service providers. The group
has constantly campaigned against the capitation policy since it was
introduced by the government. Their campaigns have been carried out
through press conferences, public protest, demon-strations and press releases
inter alia, and have often threatened to withdraw their services from the NHIS
if the government fails to suspend the implementation of the capitation policy;
‘‘Ashanti Regional Chairman of the GMA, Dr. Frank Ankobea con-firmed
to Citi News that operators of private health facilities in the region have
reverted to cash and carry because of the capita-tion system”.
[Naatogmah, 2014]
While the government seems to be firm in its position, the health care and
service providers are vexed about government’s decision to continue with the
implementation of the capitation policy. The Coalition of NGOs’ in Health, a
health advocacy group has however described the positions taken by both the
government and the health service providers as an ‘‘unfortunate development”
stemming from the lack of consultation between the two. The coalition is
apprehensive that the low level of government consul-tation with stakeholders
will eventually undermine the cogency of
54 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
the pro and anti-capitation debate. According to the group, the best way
forward will be for the government to promote dialogue with stakeholder
groups in the health services delivery chain.
There are two major points deriving the anti-capitation move-ment among
the NHIS health care and service providers in Ghana. First, the NHIS service
providers are worried that the per capita rate under capitation is low – this
will affect their profit margins. The second point is delays in imbursement of
funds as is the case in the current payment system is more likely to undermine
quality health care delivery;
‘‘Some service providers also complain they have been running at a loss
because the capitation grant per person is not enough to take care of
patients”.
[Alhassn, 2013]
‘‘Mr. Speaker, I am not comfortable with the capitation system as a
strategy to address. As a payment policy, capitation requires a pre-
payment system and we have a classical example in the Ashanti Region,
whereby capitated facilities have delays in the payment between six to
eight months. I would want to find out from the Hon Minister, what new
strategy he is going to adopt to ensure that his capitation strategy is not
going to bring about unnecessary delays as is being practised in the
Ashanti Region”.
[Augustine Collins Ntim. NPP MP for Offinso North, Debates of 13
November 2014]
In the anti-capitation group, there are some people; particularly among the
NHIS service providers who have no adequate under-standing of the
capitation policy and have managed to stimulate public resentment against the
policy. This on one hand may have given the impetuous for the anti-capitation
argument to thrive. Again, there are fears that capitation may not be
successful because of previous experiences under the capitation school
feeding pro-gramme where there were excessive delays in reimbursing funds
resulting into huge accumulation of arrears and poor services.
The Ghana Medical Association (GMA) is one of the strongest forces in
the anti-capitation campaign. Since the introduction of the capitation policy,
and from experiences of capitation in the Ashanti region, the Ghana Medical
Association has vehemently opposed and continuous to protest government’s
attempt to roll-out capitation as a mechanism for funding NHIS claims across
the country. These sentiments have been copiously expressed in the media,
through communiqués, at meetings of the association and at National
Executive Council (NEC) meetings as well. Accord-ing to the association, the
experience of capitation in the Ashanti region vindicates their position on the
matter;
‘‘The Ghana Medical Association (GMA) has kicked against govern-
ment’s attempt to rollout the capitation mode of paying the National
Health Insurance Scheme (NHIS) claims across the coun-try”.
[Naatogmah, 2014]
‘‘The capitation system is a misplaced priority which should be abolished
to save the NHIS from total collapse. NHIS subscribers in the Ashanti
Region have since the introduction of the capitation system been paying
extra cost for health services. The NHIA has for the past seven months not
reimbursed health service providers across the country and this has created
mistrust between manage-ment of most health facilities and their
suppliers”.
[Dr. Kwabena Opoku-Adusei, President of the Ghana Medical
Association – Interview]
In a radio a discussion, a health policy expert explained that even though
the capitation policy may sound good, it will not be very easy for the
government to implement the policy nationwide considering the institutional
and resource constraints of the gov-
ernment. This point finds expression in the fact that the weak pub-lic sector
administration structure and the poor public sector policy regime will likely
undermine the effectiveness of the policy. In the initial stages, relative success
could be achieved but in the long term the policy may not be successful in
ensuring efficiency and abuse. There is anticipation that the capitation policy
in the long run may be a counterproductive venture with dire conse-quences
on both service providers and patient clients;
‘‘Capitation requires robust monitoring to succeed”.
[Respondent – public forum]
‘‘Addressing a press conference in Kumasi earlier this week, Dr. Kwasi
Awudzi-Yeboah, Kumasi Metropolitan Health Director, described the
capitation policy as neither beneficial to the facilities nor the patients”.
[Joy FM mid-day news. 12: 00 pm – 25 January 2016]
3.7. Capitation, tax and cost containment
The cost containment argument is as valid as the tax general tax revenue
and the capitation argument is as valid as any other. There are a number of
NGOs, civil society groups, public policy experts who believe a multiple
approach strategy to funding the NHIS should be the exact way forward. The
validity of this argument is centred on the complementarities of the different
prescriptions that are being espoused. Pro campaigners of this argument
believe that in public policy making the weakness of one policy must be
complemented by the strength of another. Building synergy on the basis of
strengths and weakness will overcome fundamental challenges inherent in the
various arguments;
‘‘No matter the number of these measures introduced, it cannot be
substituted with the dire need for additional funding. Efficiency measures
alone cannot salvage the scheme”.
[(Selorm Adonoo – Deputy Communications Director of the NHIA –
Interview]
‘‘the tax mechanism in healthcare financing was a reasonably fair way of
providing the healthcare needs of people; However, since there are never
enough resources in any country to cover all possi-ble illnesses and
treatments, it would be prudent in the near future for Ghana to look at
what diseases and illnesses that health insur-ance could cover to best meet
Ghanaians’ health needs in a finan-cially sustainable way”.
[Dr. Nathan J. Blanchet, 2016 – A Health Systems Expert –
interview]
4. Discussions
The health financing debate in Ghana has enjoyed a lot of public discourse.
A cursor analysis of the discussions reveals a strong interplay of stakeholder
interest, power and positions. Even though there may be some trepidations
and confusion, the lack of clarity on the subject matter in some quarters has
undoubtedly catalysed the various positions and interest in the debate. In the
wake of the raging discourse, a myriad of groups and sub groups have subse-
quently emerged professing various thesis and anti-thesis. The major coalition
and anti-coalition groups in the debate are the gov-ernment and NHIS service
providers. These coalition groups have managed to solicit support from other
interest groups to as it were bought into their claims. In some instances, even
though the vari-ous coalition groups are seeking to champion their own
positions and interest, their views sometimes overlap each other. The eupho-
ria surrounding the NHIS financing debate in Ghana is not one of numbers
but who wields power and who seems to be making
 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
the most noise. The government is by far the most obstinate oppo-nent and it
thus appears that the government will not boggle in its stands; even though
trade-offs are necessary in the near future if any concrete progress is to be
made.
Pro cost containment coalitions groups believe that cost con-tainment is at
the core of the NHIS funding debate but admit that more funding through
taxes is indispensable. The NHIS currently spends about 80 percent of its
income on paying claims to service providers under the scheme (Citifmonline,
2015); a phenomenon which has resulted in the huge funding gap. The
argument on cost containment is one part of the NHIS funding debate that the
gov-ernment has conceded to and is taking steps to address. As a result, ‘‘the
NHIA in the last five years has introduced a raft of efficiency gain measures
to ensure that the scheme keeps running. Some of these include the institution
of clinical audit functions, centraliza-tion of claims management at zonally
cited Claims Processing Cen-tres, provider payment reforms (capitation),
electronic claims management, the biometric membership solution, etc., and
these have been immensely beneficial” (Adonoo, 2016 – Interview).
In the NHIS financing debate, pro cost containment groups have slammed
pro capitation groups over issues of abuse and efficiency. They argue that
capitation in itself is a cost containment measure and that there is no
substantial variation from capitation and cost containment. According to them
(pro cost containment), if there is any difference at all then the difference is
found in the ‘‘effect”. Pro cost containment coalition groups believe that
beyond capitation being a cost containment measure it has the effect of
negatively affecting health care systems in the long run especially if it is not
well monitored. But main pro capitation groups like the govern-ment are not
surprised and are unperturbed at all about the vari-ous counter arguments
against capitation. In the view of the government, ‘‘capitation has always
experienced initial resistance anywhere it is introduced due to suspicions of
delay in reimburse-ment” (Alex Segbefia, 2016. Minister for Health –
Interview).
Even though the various arguments in the NHIS funding debate clearly
reiterate the fundamental issues of stakeholder’s interest, functions, position
and power. The researchers believe that for such a public funded scheme to
work there must be a combination of approaches and strategies that attempt to
fuse the various argu-ments together. Such a coordinated effort will require
consensus building at the public policy level. Any attempt to isolate the dis-
cussion on the basis of which approach best fit will only sludge the debate
particularly due to the fact that some of the arguments are borne out of
interest, sentiments and solidarity.
5. Conclusion
This study highlights several important points in the area of health policy
in Ghana’s National Health Insurance Scheme and especially, for countries
that are also seeking to implement public funded pro-poor health care
schemes like health insurance. First, the study attempts to identify the various
discussions in the NHIS funding debate in Ghana. The researchers have tried
to identify the convergence and divergence in the different arguments. The
study has been able to emphasize the roles and contributions of the dif-ferent
coalition groups in the debate. The latent odds to join the debate are generally
influenced by stakeholder interest and posi-tion. The researchers concede that
even though the debate may attempt to provide useful prescriptions for
funding the NHIS, the intricate relationship within and among the different
stakeholders is not only stimulating an unabated discourse but is responsible
for the staunch and liberal positions adopted in the debate.
Even though there is political interest in the debate, the debate is more
organised along a public policy marking process, senti-ments and solidarity
and in some quarters there are attempts to score political points. We advocate
for coordination among the var-
55
ious stakeholder groups in the NHIS policy making process to design and
implement NHIS funding policies based on evidence building. There is a lot
of stakeholder interest in the debate which is likely to undermine the validity
of the arguments and the search for a workable solution. It remains to be seen
however, whether the government’s big push for capitation will bring the
needed effi-ciency as is being advocated.
Conflict of interest
The authors declare no conflict of interest.
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