Does the National Health Insurance Scheme provide financial protection to households in Ghana?

Kusi et al. BMC Health Services Research (2015) 15:331 DOI 10.1186/s12913-015-0996-8 RESEARCH ARTICLE Open Access Does the National Health Insurance Scheme provide financial protection to households in Ghana? Anthony Kusi1,3*, Kristian Schultz Hansen2, Felix A Asante3 and Ulrika Enemark1 Abstract Background: Excessive healthcare payments can impede access to health services and also disrupt the welfare of households with no financial protection. Health insurance is expected to offer financial protection against health shocks. Ghana began the implementation of its National Health Insurance Scheme (NHIS) in 2004. The NHIS is aimed at removing the financial barrier to healthcare by limiting direct out-of-pocket health expenditures (OOPHE). The study examines the effect of the NHIS on OOPHE and how it protects households against catastrophic health expenditures. Methods: Data was obtained from a cross-sectional representative household survey involving 2,430 households from three districts across Ghana. All OOPHE associated with treatment seeking for reported illness in the household in the last 4 weeks preceding the survey were analysed and compared between insured and uninsured persons. The incidence and intensity of catastrophic health expenditures (CHE) among households were measured by the catastrophic health payment method. The relative effect of NHIS on the incidence of CHE in the household was estimated by multiple logistic regression analysis. Results: About 36% of households reported at least one illness during the 4 weeks period. Insured patients had significantly lower direct OOPHE for out-patient and in-patient care compared to the uninsured. On financial protection, the incidence of CHE was lower among insured households (2.9%) compared to the partially insured (3.7%) and the uninsured (4.0%) at the 40% threshold. The incidence of CHE was however significantly lower among fully insured households (6.0%) which sought healthcare from NHIS accredited health facilities compared to the partially insured (10.1%) and the uninsured households (23.2%). The likelihood of a household incurring CHE was 4.2 times less likely for fully insured and 2.9 times less likely for partially insured households relative to being uninsured. The NHIS has however not completely eliminated OOPHE for the insured and their households. Conclusion: The NHIS has significant effect in reducing OOPHE and offers financial protection against CHE for insured individuals and their households though they still made some out-of-pocket payments. Efforts should aim at eliminating OOPHE for the insured if the objective for establishing the NHIS is to be achieved. * Correspondence: 1 Section for Health Promotion and Health Services Research, Department of Public Health, Aarhus University, Vennelyst Boulevard 6, 8000 Århus C, Denmark 3 Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, P.O. Box LG 74, Legon, Accra, Ghana Full list of author information is available at the end of the article © 2015 Kusi et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kusi et al. BMC Health Services Research (2015) 15:331 Background In 2000, the World Health Organisation (WHO) recognised fairness in health finance as one of its three core health system goals [1]. Fairness in health financing and protection against financial risk suggest that accessing healthcare should not impose untold hardship on affected households [2]. Promoting fairness through health system financing arrangements therefore has a wider social value as its implication goes beyond improving health status [3]. It is estimated that globally, about 150 million people face catastrophic healthcare expenditures (CHE) annually because of direct payments for healthcare while about 100 million are driven into poverty [4]. This is mainly because such people lack prepayment schemes and have to pay for healthcare at the point of service. A well-functioning prepayment arrangement which facilitates effective risk-pooling and risk-sharing among the population including the poor has been identified as having a strong potential to improve financial protection against illness [4–6]. Some studies have however found partial or no impact of health insurance on out-ofpocket health expenditures (OOPHE) and catastrophic health expenditures depending on the structure and services offered by the scheme [7–11]. In Ghana, the introduction of user fees in the health sector in the 1980s and 1990s impeded access to health services, imposed a heavy financial burden on households and often led to worse health outcomes for majority of the population [12–15]. As a response to address these adverse effects, the National Health Insurance Scheme (NHIS) was introduced in 2004 following the passage of the National Health Insurance (NHI) Act (Act 650) in 2003 [16]. According to the NHI Act 650, Ghana was to establish a national health insurance policy that ‘ensures access to basic healthcare services to all residents’ [17]. The NHIS is therefore aimed at removing the financial barrier to health services by limiting OOPHE [18]. Membership in the NHIS is mandatory for all residents of the country including foreign nationals legally resident in Ghana [17]. To become a valid card holding member of the NHIS, it is necessary to actively register and pay a registration fee. Formal sector employees who contribute to the Social Security and National Insurance Trust (SSNIT), a mandatory 2.5% deduction is made on their social security contributions as their premium [16]. Adults (18–69 years) in the informal sector pay an annual premium of between 7.2 Ghana Cedis (US$4.8 in March, 2011) and Gh¢ 48.0 (US$32.0) depending on the district of registration [19]. Children under 18 years, pregnant women, elderly (≥70 years), SSNIT pensioners and indigents are exempted from paying the premium [17]. The NHIS has a comprehensive benefit package that covers about 95% of the country’s disease conditions Page 2 of 12 [20]. The benefit package covers outpatient services, inpatient care and maternity care among others. The NHIS has an exclusion list of health problems which include cancer treatment other than breast and cervical cancers, HIV retroviral drugs, dialysis for chronic renal failure, among other tertiary services. Formal health care services in Ghana are delivered through an integrated and multilevel health system comprising of a (...truncated)