Challenges

Since Ghana’s NHIS was introduced in 2003, utilization of health services in Ghana has increased substantially. One study shows that signing up for NHIS results in a 26% increase in health care consumption and a 4% decrease in out-of-pocket expenses. However, Ghana’s health sector—and consequently the NHIS—are vastly underfunded. Health spending as a proportion of government spending has been decreasing steadily since 2019, and health spending as a percentage of GDP has declined since 2022. To cover the costs of care, out-of-pocket costs remain high; for example, many facilities ask clients to pay “top-ups,” or fees for health services. This exacerbates preexisting inequities in access to care.

In addition, most of the services the NHIS pays for are curative, not preventive. Funding for preventive care remains inadequate.

The NHIS is politically popular, and the number of Ghanaians it covers has increased considerably since it was introduced. As of 2020, it had 12 million active members, or about 40% of the population. However, many enrollees do not maintain their coverage—according to one study, about 30% of those who enrolled had dropped their coverage. Likewise, nearly half of the population is not enrolled in the system at all.

One potential issue is trust—one study found that in 2014, about 7.5% of uninsured men and 3.4% of uninsured women indicated they were not enrolled because they did not trust the NHIS. The same study found that about a quarter of uninsured men and women did not participate because the insurance premiums were too costly, a factor more pronounced among the young and unemployed.

Other reasons Ghanaians gave for not enrolling in the NHIS included prioritizing other household expenses, lack of an immediate need for health care, and the perception that benefits for families did not justify the annual renewal cost. Some people whose memberships had lapsed told researchers they were dissatisfied with the health system as a whole; others said the re-enrollment process is too cumbersome.

There are also persistent wealth disparities in NHIS enrollment. Research suggests that the poorest and least educated Ghanaians living in the most remote areas were the least likely to be insured.

Together, these gaps and roadblocks threaten the sustainability of the NHIS in the long term.

Like the NHIS, the Community-Based Health Planning and Services (CHPS) initiative has transformed PHC delivery in Ghana. However, financial limitations have strained its operations as well. CHPS care delivery relies heavily on community volunteers, but voluntarism has been declining; in contrast, some NGOs in Ghana pay their community health workers, which sets a precedent the CHPS cannot follow. In addition to staffing shortages, many CHPS compounds lack key equipment and supplies. When patients need more comprehensive care that is beyond the skill level of CPHS staff, there is often a shortage of transportation (such as ambulances and motorbikes) to transfer patients to larger, more sophisticated health facilities.

CHPS depends on outside funding for its support, complicating its integration into the NHIS system. Also, many of the poor patients CHPS serves are not enrolled in the NHIS; in 2021, only 17% of poor households had NHIS coverage compared with 44% of wealthier households. Patients must pay out-of-pocket for services, supplies, and even administrative fees at many CHPS compounds. Even where CHPS facilities are integrated into the NHIS system, slow reimbursements sometimes mean that facilities must charge patients to bridge the shortfall.

In general, research shows the CHPS initiative has improved geographic access to primary health services more comprehensively than the NHIS has improved financial access to those same services.

The COVID-19 pandemic and 2020 crash in oil prices hit Ghana hard—in the most substantial slowdown since 1983, its economy grew less than 1% in 2020. This compounded a debt crisis that was already spiraling out of control. Because Ghana’s tax receipts are so low, the government routinely spends much more than it collects in revenue and makes up the difference with high-interest loans.

In the mid-2000s, a global movement for debt cancellation persuaded the World Bank and the International Monetary Fund (IMF) to implement two debt relief schemes, the Heavily Indebted Poor Countries Initiative and the Multilateral Debt Relief Initiative. As a result, Ghana’s external debt fell from US$6.6 billion in 2003 to US$2.3 billion in 2006. With its loan payments vastly reduced, the government was able to spend more on services such as health care, which was associated with improvements in health outcomes nationwide. For example, skilled birth attendance increased only marginally between 1993 and 2003, from about 44% to about 46%, but by 2014 it had increased to about 76%.

However, the debt forgiveness ended and Ghana resumed its reliance on foreign lenders. By the end of 2022, interest payments on more than US$60 billion in debt comprised more than 70% of the government’s revenue. That December, the country defaulted on its payments to foreign and domestic lenders. The IMF agreed to provide a US$3 billion rescue package if Ghana’s creditors would agree to restructure its debts—Ghana’s 17th IMF loan since independence in 1957—and conversations with creditors and bondholders are ongoing. However, Ghana’s remaining debt obligations keep it tied to the extractive colonial economic system that caused the financial crisis in the first place.