• Staff workload increases dramatically, with staff often already being overextended. This can contribute to declining staff morale and long waiting times for patients.
• Discontented staff may begin to charge ‘under-the-table’ or unofficial fees, which translates into patients continuing to bear the burden of out-of-pocket payments.
• There are frequently widespread drug stock-outs at public sector facilities. This means that patients will either not get the treatment they need, or will continue to incur out-of-pocket expenses due to having to purchase drugs elsewhere.

In an effort to reduce the very heavy burden of out-of-pocket payments (known as the “cash and carry” system in Ghana), the Ghana National Health Insurance (NHI) law was passed by Parliament in 2003. It requires everyone (whether from the formal or non-formal sector) to enrol in government sponsored district health insurance schemes, referred to as Mutual Health Organizations (MHO). 90-95% of the financing of the NHI is from a single pooled central fund known as the National Health Insurance Fund (NHIF). 70-75% of this fund comes from a NHI levy, which is part of Value Added Tax (VAT). Though VAT is not as progressive as an income tax, VAT is quite progressive in Ghana because of the extensive exemptions on goods consumed predominantly by the poor. A further 20 – 25% of the NHIF income comes from Social Security and National Insurance Trust (SSNIT) contributions.  These contributions are made by public and private formal sector workers, and are similar to classic social health insurance funds with employer and employee contributions proportional to income. Non-SSNIT contributors, comprising mainly those outside the formal sector but also workers in organisations like universities that have their own social security system outside SSNIT, pay premiums directly to their District MHO. These are decentralized funding pools compared to the single central NHIF. These direct premiums account for approximately 5% of the financing of the NHIS.

To ensure equity, the poorest of the poor (referred to as indigents) are exempted from premium payments. Difficulties in defining and identifying the poor have made this provision very difficult to implement, and this accounts in part for the continuing problem of lower enrolment in the NHI among poorer income groups. Minors under 18 years are also exempt from premium payments as are the elderly over 70 years. In recent years, all pregnant women are also eligible for free enrolment. These generous exemption clauses mean that over half of enrolees under the NHI are in non-premium paying categories.

Even though enrolment in the NHI is mandatory by law, it has not been possible to enforce this given Ghana’s large non-formal sector and poor citizens’ documentation.  Routine data estimates NHI membership at over 50% of the population. The 2008 Ghana Demographic and Health Survey, a nationally representative sample survey, found that 39% of women and 30% of men 15 – 49 years were members of the NHI with wide variation from a low of 20% for men in the Greater Accra region to a high of 59% for women in the Brong Ahafo region.
The benefit package of the NHI is defined by law, and covers at least 80% of the most common conditions in Ghana.  Outpatient, inpatient care and medicines are all covered, as are some dental services. Services not covered are mainly very expensive services like dialysis for chronic renal failure, certain cancer treatments and cosmetic surgery.  The services that are covered can be obtained at any health care provider that has been accredited by the National Health Insurance Authority (NHIA).  The NHIA also monitors providers’ performance and ensures that health care services rendered to NHI beneficiaries is of good quality.

Increasing enrolment in the NHIS over time has been accompanied by increasing service utilization levels.

In the early 2000s, about a quarter of all health care spending in Rwanda took the form of out-of-pocket payments. In an effort to provide financial protection and improve access to health services, the growth of mutual health insurance (MHI) schemes (called “Mutuelle de Santé”) to cover those outside the formal employment sector was encouraged. Over 100 of these schemes were created, with government support, between 2000 and 2003 and covered 27% of the population by 2004. MHIs were expanded in 2005 with external funding, which was used to provide premium subsidies for vulnerable groups and rapidly increase MHI coverage to 74% of the population by 2007. An elected village committee decides who is poor and should receive subsidised membership. In 2008, a law was introduced making health insurance membership compulsory for all citizens and introducing cross-subsidies between MHI schemes. Membership fees are about $2 per person per year for those who do not have subsidised premiums.

These schemes cover basic services (e.g. family planning, antenatal care, outpatient consultations, deliveries, generic drugs and hospital treatment for malaria). MHI members are required to make co-payments when they use health services, with a flat fee being charged for health centre visits (of US$0.4 in 2006) and 10% of the cost of services at hospitals.
Recent studies have found that the MHI schemes provide both financial protection and improved access to needed care. For example, households with MHI cover use health services twice as much as those without such cover when falling ill. In addition, catastrophic health care expenditure is almost four times as high in households without MHI cover than in those who are MHI members.

The Rwandan experience is widely regarded as very impressive and as making an important contribution to the key pillars of universal coverage. While there are clear advantages to having MHI coverage, studies report that there are still high levels of unmet need among the insured and that co-payments can still impose catastrophic payment burdens on insured households. A key lesson from the Rwandan experience is that MHI is a complement to (rather than a replacement of) government and donor funding; in 2006, MHI premiums generated about 5% of total health care expenditure in Rwanda.