PRISMA Flow diagram of literature selection.

<p>Grey and peer reviewed articles date between 2003 and 2016.</p

A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects?

<div><p>Background</p><p>The introduction of the national health insurance scheme (NHIS) in Ghana in 2003 significantly contributed to improved health services utilization and health outcomes. However, stagnating active membership, reports of poor quality health care rendered to NHIS-insured clients and cost escalations have raised concerns on the operational and financial sustainability of the scheme. This paper reviewed peer reviewed articles and grey literature on the sustainability challenges and prospects of the NHIS in Ghana.</p><p>Methods</p><p>Electronic search was done for literature published between 2003–2016 on the NHIS and its sustainability in Ghana. A total of 66 publications relevant to health insurance in Ghana and other developing countries were retrieved from <i>Cochrane</i>, <i>PubMed</i>, <i>ScienceDirect</i> and <i>Googlescholar</i> for initial screening. Out of this number, 31 eligible peer reviewed articles were selected for final review based on specific relevance to the Ghanaian context.</p><p>Results</p><p>Ability of the NHIS to continue its operations in Ghana is threatened financially and operationally by factors such as: cost escalation, possible political interference, inadequate technical capacity, spatial distribution of health facilities and health workers, inadequate monitoring mechanisms, broad benefits package, large exemption groups, inadequate client education, and limited community engagement. Moreover, poor quality care in NHIS-accredited health facilities potentially reduces clients’ trust in the scheme and consequently decreases (re)enrolment rates. These sustainability challenges were reviewed and discussed in this paper.</p><p>Conclusions</p><p>The NHIS continues to play a critical role towards attaining universal health coverage in Ghana albeit confronted by challenges that could potentially collapse the scheme. Averting this possible predicament will largely depend on concerted efforts of key stakeholders such as health insurance managers, service providers, insurance subscribers, policy makers and political actors.</p></div

Frequency of themes in retrieved articles (n = 31).

<p>Thematic areas as presented in the Fig are the synthesized themes recurrent in the peer reviewed articles.</p

Descriptive characteristics and health insurance enrolment of respondents.

<p>Descriptive characteristics and health insurance enrolment of respondents.</p

Association of never insured status on perceived quality of healthcare.

<p>Association of never insured status on perceived quality of healthcare.</p

Conceptual framework of independence of quality perception on insurance status.

<p>Conceptual framework of independence of quality perception on insurance status.</p

Effect of currently insured status on perceived quality of healthcare.

<p>Effect of currently insured status on perceived quality of healthcare.</p

Differences between the insured and uninsured in the average perception of quality of 64 health facilities.

<p>Differences between the insured and uninsured in the average perception of quality of 64 health facilities.</p

Perceptions of healthcare quality in Ghana: Does health insurance status matter?

<div><p>This study’s objective is to provide an alternative explanation for the low enrolment in health insurance in Ghana by analysing differences in perceptions between the insured and uninsured of the non-technical quality of healthcare. It further explores the association between insurance status and perception of healthcare quality to ascertain whether insurance status matters in the perception of healthcare quality. Data from a survey of 1,903 households living in the catchment area of 64 health centres were used for the analysis. Two sample independent t-tests were employed to compare the average perceptions of the insured and uninsured on seven indicators of non-technical quality of healthcare. A generalised ordered logit regression, controlling for socio-economic characteristics and clustering at the health facility level, tested the association between insurance status and perceived quality of healthcare. The perceptions of the insured were found to be significantly more negative than the uninsured and those of the previously insured were significantly more negative than the never insured. Being insured was associated with a significantly lower perception of healthcare quality. Thus, once people are insured, they tend to perceive the quality of healthcare they receive as poor compared to those without insurance. This study demonstrated that health insurance status matters in the perceptions of healthcare quality. The findings also imply that perceptions of healthcare quality may be shaped by individual experiences at the health facilities, where the insured and uninsured may be treated differently. Health insurance then becomes less attractive due to the poor perception of the healthcare quality provided to individuals with insurance, resulting in low demand for health insurance in Ghana. Policy makers in Ghana should consider redesigning, reorganizing, and reengineering the National Healthcare Insurance Scheme to ensure the provision of better quality healthcare for both the insured and uninsured.</p></div

Recommendations to improve staff motivation levels.

<p>GAR (Greater Accra Region) NR (Northern Region) FGDs (Focus Group Discussions) <b>Source</b> Field Data Greater Accra and Northern Regions (2016).</p