Who initiated the NHIS and who made it universal? Here are the facts

Flagbearer of the National Democratic Congress (NDC) John Dramani Mahama’s assertion about the initiation of the state health insurance scheme and the subsequent reforms that made it a national scheme has been disputed.

At an engagement with the media on July 7, 2024, the NDC flagbearer and former president said the government of Jerry John Rawlings initiated the National Health Insurance Scheme.

He stated that piloting of the health policy had commenced in Nkronza and Damongo in the then Brong-Ahafo and Northern Regions respectively before the Rawlings government left office in January 2001.

“It was NDC who started the pilot in Damongo and Nkoranza for the NHIS. Implementation started under Kufuor’s time,” he stated.

According to him, “what President Kufuor introduced was a mutual health insurance scheme. And so, your NHIS card allowed you to access health services only in the district in which you were registered”.

But the current form of the scheme, which enables subscribers to access health services nationwide, he argued, was introduced by the government of his predecessor, John Evans Atta.

“Today’s national health insurance scheme was introduced by Prof. Mills. He changed it from a mutual district insurance scheme to a national health insurance scheme so that your card could access healthcare anywhere in Ghana you go,” the former president told presswomen and men.

However, in a rebuttal, the Communications Director of the Bawumia Campaign Team, Dennis Miracles Aboagye refuted Mr Mahama’s claims as false.

Miracles Aboagye argued that the Kufuor government initiated and implemented the policy and subsequently, reformed it to its current form and was in the process of giving the reform a legal backing when its tenure of office expired in January 2009.

“It’s not never true that the National Health Insurance Scheme was piloted by the NDC in Nkoranza and Damongo. They didn’t do it,” Mr Aboagye stated on the Bawumia Campaign Team’s weekly broadcast show dubbed The Next Chapter Show on July 14, 2024.

He added, “Before the Kufuor government would leave office, it brought the 145 district mutual health schemes and made them a single national scheme. The NDC government only passed the legal framework for the reforms”.

Fact-Check Ghana has verified the claims and presents the facts as follows.

Piloting the National Health Insurance Scheme

Ghana’s efforts at implementing a health insurance scheme date back to the 1970s when the State started charging user fees at the point of service through to the 80s when the ‘cash and carry system’ was introduced.

According to a USAID report published in 2013 and a research publication in 2003 by D. Arhinful at the University of Amsterdam, several studies and consultancies were undertaken in the 70s and 80s geared towards formulating an insurance policy.

Following his election in the 1992 presidential polls, Jerry John Rawlings mentioned the government’s plan to introduce such a health policy in his first sessional address presented on April 29, 1993 (page 31).

The policy was intended to bridge the cost barrier created due to the introduction of the ‘cash and carry’ system. The system required people seeking healthcare to make upfront payments before they could be attended to which blocked many citizens from accessing quality healthcare.

President Rawlings’s idea was, thus, to eliminate the cost barrier and make health services accessible to all regardless of their financial status. He reiterated the plan in his 1995 sessional address delivered on January 6 and on January 21, 1997, announced a piloting of the scheme in the Eastern Region. The results of the piloting “will be studied as well as the performance of existing rural health insurance schemes already operating in the Nkoranza and West Gonja Districts, so that problems can be identified and eliminated before implantation begins on a national scale,” Flt. Lt. Rawlings said during his 1997 sessional address in Parliament. (pg. 15-16).

The piloting began in August 1997 in 4 districts, according to Arhinful’s research, with the intention of implementing a centralized scheme.

Although reports claim the piloting failed, the government said in 2000 that it had reviewed the pilot scheme together with existing privately run insurance schemes in the previous year and “the results favoured a multi-scheme comprising of private, social and community-based health insurance schemes”. This was contained in the president’s sessional address delivered on January 13, 2000.

The address, however, fell short of indicating when the actual implementation would begin except announcing that it would support the running of the existing private schemes and the Dangbe West Community Based Health Insurance Scheme, whose implementation was to begin in 2000.

The new government led by John Agyekum Kufuor, which came into office after the 2000 elections, confirmed the review that recommended the adoption of a multi-scheme system (See 2001 Budget; point 268).

The pioneer health insurance scheme

Even before the State piloted the health insurance scheme, there existed a number of health insurance schemes in the country run by private organisations and communities.

Prominent among them was the Nkronza Community Financing Health Insurance Scheme said to be a pioneer of health schemes in Ghana.

It was a hospital-based scheme run by the Catholic Diocese of Suyani and aimed at reducing hospital admission costs and ultimately, making health accessible to all within the Nkronza District of then Brong-Ahafo Region. It was a direct response to the ‘Cash and Carry System’.

The scheme was formally launched in 1992 with funding support from Memisa, a Dutch Christian non-government organization, according to a technical report by Partnerships for Health Reforms (PHR) published in March 2000. This was after a pilot at the St. Theresa’s Hospital at Nkoranza from 1990 to 1991 (See page 1).

By the year 2000, it was essentially running on its own resources after enjoying funding support from Memisa for 3 years and had a coverage of 30 percent of the Nkoranza District population, the report found.

“It was explicitly regarded by the Catholic Secretariat as a pilot project from which other Catholic Hospitals across the country would be encouraged to draw useful lessons for the design and implementation of similar schemes for their communities,” according to a 1998 case study report by Partnerships for Health Reform (PHR), supported by USAID, the International Labour Organisation programmes and other international organization. (pg.12).

As a result, a few years after its initiation specifically in 1995, a similar scheme was birthed at Damongo known as the West Gonja Hospital insurance scheme by the Catholic Church with financial and technical backing from a German Church-related international NGO, Misereor. (pg. 12 – 13 of the report).

Subsequently, several other community and institution-initiated health insurance schemes were rolled out and by 2001, there were a total of 47 such schemes in operation, a USAID report found.

The district mutual health insurance scheme

Several reports including those published by the government suggested that the success of community and institution-initiated health insurance schemes bolstered the government’s quest to implement a similar policy and that after understudying them, it abandoned its initial plan of a centralized scheme and opted for a decentralized approach. This was evident in the 2001 Budget Statement and the 2000 Sessional Address by President Rawlings.

Thus, Act 650, the law establishing the national health insurance scheme, was formulated based on the decentralized approach.

 The Act was enacted in October 2003 and operationalized in 2004. (2005 Budget, pg. 165). It recognized two major types of health insurance schemes – the Social-type Health Insurance Scheme and the Private Commercial Health Insurance Schemes – under the National Health Insurance Scheme.

The Social-type Health Insurance Scheme was made up of the District Mutual Health Insurance Scheme (DHIS) championed by the government and the Private Mutual Health Insurance Schemes.

According to the revised NHIS policy framework published in August 2004, “every district is to establish a health insurance scheme to enable residents in that district to register as members”. (pg. 11).

The National Health Insurance Council (NHIC) was the regulatory body and oversaw the establishment of the schemes. It had an Executive Secretary, who spearheaded the day-to-day implementation of decisions taken by the Council.

At the district level, the schemes were managed by the District Health Insurance Assembly (DHIA), the Board of Directors, who rendered operational and financial accounts to the DHIA, and management staff appointed by the Board of Directors.

By 2007, 143 schemes were in operation across the country with a total subscription of 48 percent of the country’s population at the time. (2008 Budget pg. 160 and 2008 State of the Nation Address). The number of schemes was expected to rise to 148 by the end of 2007, the 2008 Budget Statement indicated.

The government also announced in the Budget Statement, the introduction of “new universal health insurance card”.

The NDC government led by Prof. J. E. Atta-Mills who came to power after the 2008 elections confirmed, in the 2009 Budget presented on March 5, 2009, that “The new universal ID cards which was to replace the expiring scheme-specific DMHIS cards begun in September 2008”.  (pg.167).

The rollout of the universal NHIS ID cards in 2008 marked the gradual phasing out of the DMHIS-specific health insurance cards and thus, the beginning of the implementation of a single state-led National Health Insurance Scheme.

However, the DMHISs were still in operation although there were discussions in 2009 about a possible dissolution of their Board of Directors.

For instance, A GNA report published on ModernGhana on September 15, 2008, indicated that the Okwawuman West Municipal Health Insurance Scheme held its second annual general meeting around the time, at which, it expressed hope of increasing the scheme coverage to 80 percent of the Municipality population by the end of 2008.

The 2011 National Health Insurance Authority report indicated the existence of the District Mutual Health Insurance Scheme and its operations as of 2011.

In March 2012, Parliament’s Committee of the Whole submitted a report to the House on a proposed formula for the distribution of subsidies to be paid to licensed district mutual health schemes for the year 2012. This further proves the existence and operation of the DMHIS post-Kufuor regime.

Dissolution of DMHIS and establishment of a single NHIS

The NHIS Act, 2012 (Act 852) passed by Parliament and assented into law on October 31, 2012, replaced the NHIS Act 2003, (Act 650).

The new Act established a single national health insurance scheme and dissolved the DMHIS set up under Act 650, bringing an end to a multi-scheme system adopted by the government.

The DMHISs became district offices of the National Health Insurance Authority.

When the NDC took over power in 2009, one of the immediate changes they made to the scheme was the introduction of the National Health Insurance Authority (NHIA) to replace the National Health Insurance Council and the appointment of a Chief Executive in place of the Council’s Executive Secretary. Act 852 gave legal backing to these changes that took effect in 2009.

From the facts adduced, it is evident that the NHIS was initiated and piloted under the Rawlings regime, the Kufuor government led its implementation and had begun reforms of introducing a single scheme nationwide before it left power. The Atta-Mills administration continued and completed the reforms with the passage of Act 852 in 2012.

Therefore, Dennis Miracles Aboagye’s claims that the Kufuor government initiated the scheme and subsequently, reformed it to its current state are false.

Also, John Mahama’s claim that the scheme was piloted in Nkoranza and Damongo is false.