World Development Perspectives 5 (2017) 47–55

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World Development Perspectives

journal homepage: www.elsevier.com/locate/wdp

Health care financing and sustainability: A study of current conceptual dialectics

in Ghana
Emmanuel Akiweley Wedam a,⇑, Francis Nangebeviel Sanyare b
a
Department of Development Studies, University for Development Studies, Wa, Ghana
b
Department of Social, Political and Historical Studies, University for Development Studies, Wa, Ghana

a r t i c l e i n f o a b s t r a c t

Article history: One major challenge in health policy and planning in third world countries is the sustainability of pub-
Received 6 November 2016 licly funded health insurance schemes. Economic renegence restricts the fiscal capacity of governments
Accepted 5 March 2017 in Ghana to allocate limited public funds to financing a public sponsored health care insurance scheme. In
the intervening time, the increasing demands within populations in the country for health care continue
to escalate amidst political campaigns to increase access in health care and to motion towards universal-
Keywords: ism. General health care demands for the population grow as cost of treatment and enrolment increase
Financing
resulting in sustainability issues; which are further perpetuated by institutional ineptitudes, limited pub-
Sustainability
Debate
lic funds and managerial lapses. This study examines the current conceptual debates in Ghana on the
Health care funding and sustainability of the National Health Insurance Scheme (NHIS). Using data from public fora,
National Health Insurance Scheme interviews, conferences, newspapers, workshops, television and radio discussions and parliamentary
Hansards and manuscripts, the study revealed that as part of the public policy making process the current
debate is generally influenced by stakeholders’ interest, power and solidarity even though there are
attempts in some quarters to make political capital out of the debate. The complex relationship among
the various stakeholders has stimulated an unabated discourse which has caused most of the stakehold-
ers to adopt staunch positions in the debate.
Ó 2017 Elsevier Ltd. All rights reserved.

1. Introduction
Since independence, Ghana has implemented several health
care funding mechanisms as part of a broader strategy to promote
financial sustainability and to increase access in health care. In the
1990s, funding from health care was from user fees charged on cli-
ents at the point of service delivery. However, this invariably
widened the disparities in access in health care within populations
in high and low income groups’ as the cost of health care was based
on the ability to pay (Ataguba & McIntyre, 2012; Evans, Whitehead,
Diderichsen, Bhuiya, & Wirth, 2001; Nyonator & Kutzin, 1999).
Today, health care in Ghana is generally financed through the
National Health Insurance Scheme (NHIS).
The NHIS was introduced in Ghana in 2003 by the government
of Ghana through the National Health Insurance Act 2003, (Act
650) and the National Health Insurance Regulation 2004 (LI
1809). This was part of a political campaign by the largest opposi-
tion political party in the run–up to the 2000 general elections in
⇑ Corresponding author.
E-mail address: ewedam@uds.edu.gh (E.A. Wedam).
Ghana, and a general concern from civil society groups and the
international community. To this extend, the consultative and pol-
icy building processes did not witness a lot of acrimony from pub-
lic and private interest groups as has been the case in most public
policies in Ghana (Abiiro, Mbera, & De Allegri, 2014; Pal, 1992).
The NHIS is expected to create a balance in equity, access and
utilization of basic health care by all especially, for people living
within the poorest bracket (NHIS Report, 2011; Jehu-Appiah,
Aryeetey, & Spaan, 2011). Over a decade of implementation, the
scheme appears to have considerably reduced financial barriers,
risk and access in health care even though some equity issues still
remain (Abbey, 2003; Owusu-Sekyere & Kanton, 2014; Schieber,
Cashin, Saleh, & Lavado, 2012). The scheme covers about 95 per-
cent of common disease burdens in Ghana and the cost of medici-
nes for most essential diseases in the country (Agyepong & Adjei,
2008; Dalinjong & Laar, 2012; OXFARM, 2013). Current data on
Ghana’s Health Insurance Scheme reveal that the number of active
members on the scheme has been phenomenal surpassing that of
many other African countries that have been operating similar
schemes. The scheme has an active membership of 10.9 million
people representing about 40 percent of the population in Ghana
(Peprah, 2015).

http://dx.doi.org/10.1016/j.wdp.2017.03.003
2452-2929/Ó 2017 Elsevier Ltd. All rights reserved.
48 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
Coverage levels (170 districts) in the country have been very
momentous and responsible for accelerating access in health care
(especially primary health care) and utilization levels. As a result,
subscriber rates have been very encouraging. Data available indi-
cates that the number of children who are under 18 years repre-
sent more than half of the active members of the scheme. Again,
premium paying subscribers/clients, thus those in the informal
sectors make up nearly 35.5 percent of the active subscribers/
members on the scheme (Ataguba, Akazili, Mtei, Goudge, &
Meheus, 2009; NHIS Report, 2012). Funds for running the scheme
come from pooled public contributions of a Value Added Tax (VAT)
of 2.5 percent, a 2.5 percent monthly salary deduction of formal
sector workers, being pension contributions to the Social Security
and National Insurance Trust (SSNIT), an health insurance levy of
2.5 percent, donor funding, contributions from informal sector
members of the scheme, investment income or interest earned
on investments (Abiiro & McIntyre, 2012; Owusu-Sekyere &
Bagah, 2014; Abiiro & McIntyre, 2012). Nearly more than 70 per-
cent of the scheme’s expenditure comes from the 2.5 percent NHIL
(Adonoo, 2016).
1.1. The need for the financial sustainability debate
In most third world countries like Ghana, public funded health
care schemes such as the NHIS are a major pecuniary challenge to
governments. Moreover, population growth and structural adjust-
ments will strongly affect Ghana’s ability to meet its future health
care financing needs. The country’s population is expected to dou-
ble in the coming years and the burden of diseases will keep on
shifting from communicable to non-communicable diseases and
injuries (Schieber et al., 2012). In the interim, the country will have
to grumble with a dual disease burden, and this will considerably
impose severe cost on the country’s health care system. Consider-
ing the hazards in revenue mobilisation in Ghana and the fact that
about 80 percent of the labour force in the country is in the infor-
mal sector alone will pose a major challenge to revenue generation
and enrolment (Blanchet, Fink, & Osei-Akoto, 2012; Schieber et al.,
2012). At the moment the, ‘‘National Health Insurance Scheme is
seriously challenged as far as finances are concerned. There is a
huge funding gap that the National Health Insurance
Scheme faces as we speak. . .. Mr. Speaker, it is no wonder that
the National Health Insurance Authority is unable to pay the claims
of most health providers as we speak” (Dr. Kwabena Twum-
Nuamah – NPP MP for Berekum East. Debates of 26 March 2015).
In 2005, the active subscriber base of the scheme was 1.3 mil-
lion, and the corresponding expenditure on claims was GHC
597,859 ($153,336 US Dollar). In 2014, the subscriber base stood
at 10.2 million, with an associated expenditure on claims being
in excess of GHC 960 million ($ 244,663,282 US Dollar), and an out-
patient utilization of 29 million. A comparative analysis of these
two cases (2005 and 2014) visibly illustrates the financial trajec-
tory of the scheme today. Additionally, in 2014, the scheme
recorded a funding gap of close to GH¢300 million ($76,457,276
US Dollar), and in 2015, the figure increased to a little more than
GH¢800 million ($ 203,886,068 US Dollar) (Dr. Kwabena Twum-
Nuamah, 2015 – NPP for Berekum East. Debates of 26 March 2015).
The NHIS funding gap is happing restrictive implications for
people accessing health care under the NHIS. Even though the gov-
ernment since 2004 has been able to sustain the NHIS in the midst
of a huge funding gap, and public outcry and complaints of poor
service delivery; what is certain is that the coming years will be
even more taxing. According to Mathew Opoku Prempeh, an oppo-
sition member of parliament (New Patriotic Party MP – 6th Parlia-
ment) in Ghana’s parliament, ‘‘if 100 per cent of NHIS money is
even given upfront like we started in 2014 or 2015, by the time
we finish 2016, there would be a claim arrears of more than half
a million Ghanaian cedis. That is the issue we have to confront”.
(Dr. Matthew O. Prempeh, NPP MP for Manhyia South. Debates of
26 March 2015). To this extent, there have been a lot of concerns
from key interest groups. For instance, ‘‘the GMA is gravely con-
cerned with the gradual re-introduction of cash and carry at the
various health care facilities across the country. It is a fact that,
the facilities are restoring to cash and carry because of prolonged
indebtedness of the NHIS to them. Indeed, some facilities have
not been paid their claims in the last quarter of 201500 (Awuni,
2016).
The problem with the NHIS fund gap is largely attributed to the
increasing numbers of active members on the scheme even though
administrative and managerial hazards cannot be ruled out. Recent
happenings show that the survival and sustainability of the
scheme is under serious threat if new financing or policy options
beyond the traditional ones are not sought. Incessant withdrawal
of services by health providers and delays in claim payments sub-
stantiate the financial challenges confronting the scheme. At the
moment, there are many health providers mostly private that have
entirely withdrawn their services from the scheme, and even for
public facilities, patients have been forced to make OOP payments
for health care services already covered under the scheme due to
non-payment of claims submitted to the scheme. Several patients
have also been turned away from accredited health facilities. Con-
sidering the rising numbers in new subscribers, treatment cost and
cost of drugs both consumables and non-consumables, it is clear,
that the cost of claim payments to health care providers will con-
tinue to heave amid an increasing demand within vulnerable pop-
ulation groups in seeking health care.
Even though there have been attempts by other studies to dis-
cuss NHIS funding and sustainability in Ghana, this present study
discusses the various arguments in the NHIS funding and sustain-
ability debate, the interest groups and the factors influencing the
debate. In doing this, the study has been sub divided into three sec-
tions. The first section contains the introduction of the study. This
deals with general discussions about health care financing. The
second section contains the methodology of the study. In this sec-
tion – methodology, the authors discussed how they collected data.
In the final section of this study, the results and discussions of the
study are presented.
2. Methodology
2.1. Data collection
In this study, the researchers collected data from community
public fora, district/municipal and metropolitan public fora, regio-
nal public fora and national public fora. In-depth interviews with
health directors, health professionals, technocrats, directors and
staff of the NHIS, members of parliament, past ministers of health,
service providers, clients and academicians were conducted as part
of a broader and nationwide stakeholder consultation on how to
finance the NHIS. The authors also collected data from stakeholder
workshops, conferences and student symposiums (see Fig. 1 for
break down). Apart from the primary data sources, other secondary
sources of data such as books, journals, media briefings and bul-
letins, radio and television discussions, newspapers, reports, par-
liamentary Hansards and manuscripts and online resources were
utilised.
Thirty-two (32) different public and private television and radio
stations where monitored across the country through the air waves
and online websites. These televisions and radio stations were
selected based on their popularity (most listened to) and wide
media space. Panel discussions and news bulletins on NHIS funding
were the main items monitored. Six (6) national daily newspapers
 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
Fig. 1. Data collection procedure and sources.
were also sampled and examined. The newspapers reviewed pro-
cess also included editorial pieces/columns. The researchers
applied triangulation in the data collected process.
2.2. Data analysis
Data was classified into germane themes based on similarities,
significance, number of occurrence within and across different
platforms, place and time of occurrence and the length of time
enjoyed. Once the classifications were completed, the researchers
proceeded to do a content analysis of the various themes by sub
dividing the discussions into pro and anti-coalition groups. The
researchers also applied policy analytical framework in the identi-
fication of stakeholder groups, interest, concerns and positions in
the NHIS public policy making process and political debate in
Ghana.
3. Results
These is a raging discourse in Ghana about the sustainability of
the NHIS and this has attracted a myriad of contributions from the
public, civil society organisations, politicians, technocrats, aca-
49
demicians’, and health professionals and public policy experts inter
alia. For instance; ‘‘a number of measures were recommended by
stakeholders at the October 2014 conference and a few of them
include streamlining the exemption policy, reviewing the premium
rates and injection of additional funds into the scheme since
inflows have become inadequate due to growing obligations”.
(Selorm Adonoo – Deputy Communications Director of the NHIA
– Interview).
At the moment, there are some major convergence in the myr-
iad of opinions on the need to find appropriate ways to finance and
sustain the NHIS, but the rather vexing theme that appears to res-
onate is precisely the question of how best to finance such a public
funded scheme amidst escalating funding gap and enrolment. Cur-
rently, a number of public policy prescriptions are being advocated
(see Table 1). In this study, the researchers identified three major
prescriptions which appear to dominate the discussions on the
best way to finance the NHIS.
3.1. Pro cost containment
The first major prescription in the NHIS sustainability debate is
cost containment. This prescription is being exposed from a tech-
50 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55

Table 1
Summary of views about NHIS financing options.

Cost containment General tax revenues Capitation Total

Pro Anti Pro Anti Pro Anti Pro and Anti
n (%) n (%) n (%) n (%) n (%) n (%) n (%)
NHIS patient clients 2 (1.0) 0 (0.0) 193 (96.5) 5 (2.5) 0 (0.0) 0 (0.0) 200 (100)
Members of parliament 73 (35.8) 0 (0.0) 54 (26.5) 6 (2,9) 9 (4.4) 62 (30.4) 204 (100)
Health professionals 3 (37.5) 1 (12.5) 4 (50) 0 (0.0) 0 (0.0) 1 (12.5) 9 (100)
Health directors 0 (0.0) 0 (0.0) 2 (18.2) 0 (0.0) 0 (0.0) 9 (81.8) 11 (100)
Technocrats/professionals 4 (50.0) 0 (0.0) 4 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 8 (100)
Service providers 0 (0.0) 0 (0.0) 3 (3.4) 0 (0.0) 0 (0.0) 86 (96.6) 89 (100)
Academicians 22 (68.8) 0 (0.0) 8 (25) 0 (0.0) 2 (6.3) 0 (0.0) 32 (100)
Directors and staff of NHIA 14 (15.1) 0 (0.0) 2 (2.2) 0 (0.0) 77 (82.7) 0 (0.0) 93 (100)
Workshops/conferences 96 (30.3) 0 (0.0) 87 (27.4) 0 (0.0) 63 (19.9) 71 (22.4) 317 (100)
Community public fora 0 (0.0) 0 (0.0) 76 (100) 0 (0.0) 0 (0.0) 0 (0.0) 76 (100)
District public fora 6 (6.8) 0 (0.0) 74 (54.1) 0 (0.0) 0 (0.0) 8 (9.1) 88 (100)
Regional public fora 32 (29.9) 0 (0.0) 52(48.6) 0 (0.0) 17 (15.9) 6 (5.6) 107 (100)
National public fora 204 (48.0) 0 (0.0) 42 (9.9) 8(1.9) 58 (13.6) 113 (26.6) 425 (100)
Student Symposiums 82 (24.3) 1(0.3) 96 (28.5) 12 (3.6) 55 (16.3) 91 (27.0) 337 (100)
Radio discussions 19 (30.6) 0 (0.0) 15 (24.2) 0 (0.0) 12 (19.4) 16 (25.8) 62 (100)
Television discussions 22 (32.4) 0 (0.0) 38 (55.9) 1 (1.5) 2 (2.9) 5 (7.4) 68 (100)
Newspapers 32 (41) 0 (0.0) 16 (20.8) 0 (0.0) 11 (14.3) 18 (23.4) 77 (100)
NGOs 6 (28.6) 0 (0.0) 13 (61.9) 0 (0.0) 2 (9.5) 0 (0.0) 21 (100)
CSO groups 4 (44.4) 0 (0.0) 4 (44.4) 0 (0.0) 0 (0.0) 1 (11.1) 9 (100)
Online/websites 95 (20.7) 0 (0.0) 137 (30) 3 (0.7) 102 (22.3) 121 (26.4) 458 (100)
Total n (%) 716 (100) 2 (100) 920 (100) 35 (100) 399 (100) 608 (100) 2691 (100)

nocrat and an academic point of view. Health services and admin-
istrative cost constitute a major part of the funding gap that is cur-
rently confronting the NHIS. Inevitable, the cost of claims, drugs,
treatment and services will continue to exert a substantial pressure
on the funding gap of the scheme. The first part of the cost contain-
ment debate is being put forward as a pro tem measure even
though a long term cost containment measure is very critical in
the future;
‘‘What I am saying is that, yes, there may be a need to find some
revenue sources but the most important urgent requirement is
cut back in expenditure which we must enforce.
[Dr. Anthony Akoto. Osei NPP MP for Old Tafo Suame. Debates of
26 March 2015]
‘‘Like my Hon Brother just said, too much of their moneys is going
into salaries and wages”.
[Dr. Matthew O. Prempeh NPP MP for Manhyia South. Debates
of 26 March 2015]
The key point in this argument is that a reduction in expendi-
ture will significantly shrink the funding gap and boost the fiscal
capacity of the NHIS to provide better services. The second part
of the cost containment debate precisely explicates how a cut back
on expenditure and cost containment ought to be done. This pre-
scription is directly focused on the need to revise the targeting
mechanism and exemption criteria;
‘‘Mr. Speaker, if we have to improve the common targeting mech-
anism, so that only those who are qualified to be declared poor
or for that matter, indigents under the mechanism, qualified for
exemptions under the NHIS, that would be a huge cost contain-
ment. Like my Hon Friend just said, there are a number of people
exempted just because of age, beggar’s belief. If you take those
below 18 years and you add those above 70 years, you are already
getting to about 60 or 62 per cent of the population. That is one of
the reasons the Scheme is suffering. So, as a group and as Parlia-
ment, we have to start thinking about how to bring cost or expen-
diture down under the NHIS”.
[Dr. Matthew O. Prempeh (NPP – Manhyia South. Debates of 26
March 2015)]
‘‘Mr. Speaker, it is important that we face the reality. National
Health Insurance in many developing countries is concentrated
on primary healthcare. What one can do for example, is that, the
indigents, the children under 18 would have the wide benefit. But
the rest of us would be having some benefits but not all. . . One
introduces inequality, because those who can pay are taking it
freely as well as those who cannot pay”.
[Alhaji Mohammed-Mubarak Muntaka (NDC – Asawase)
Debates of 26 March 2015]
As a result of poor targeting and exemption criteria, about 60 to
65 percent of the population in Ghana do not contribute to the
NHIS. Meanwhile, there is no other cost sharing or co-payments
with the NHIS, except the annual premiums paid. Therefore, there
is the need to restrict the targeting and exemption criteria to the
core poor and people at the highest risk of vulnerability of paying
for health care.
Another part of the cost containment argument is the issue of
the benefit package. Pro cost containment coalition groups believe
that in order to sustain the NHIS, the benefit package under the
NHIS must be reduced. The campaigners of this argument are
mainly health policy experts, health directors and professionals.
They argue that the benefit package of between 90 to 95 percent
under the NHIS is too big and is part of the cost build up that is
threatening the sustainability of the scheme;
‘‘At October 2014 NHIS Stakeholder Dialogue on the Scheme’s ben-
efit package, participants after considering a holistic overview of
the NHIS and its financial challenges concluded that the current
cost structure of the scheme was not sustainable. They observed
that the benefit package of the scheme right from inception was
too generous; an observation, they surmised, added to the financial
viability challenge of the NHIS”.
[Selorm Adonoo – Deputy Communications Director of the
NHIA – Interview]
‘‘The NHIS benefits package is arguably of the most generous in the
world covering over 90% of the disease burden of Ghanaians with-
out co-payment. Moreover, great percentages of the NHIS member-
ship are exempted from premium payments (over 70%) meaning”.
[Respondent – public forum]
 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
One of the leading campaigners of the benefit package argu-
ment under the cost containment debate is the Director of Claims
of the NHIS. In a press conference in Accra, Ghana’s capital, the
Director of Claims of the NHIS said one of the major challenges
of sustainability under the NHIS is the size of the benefit package;
‘‘I am not saying that is wrong, but the financing is not marching
what we want to do as a country. The fact remains that there
has to be some rationalization somewhere because we can’t afford
everything.”
[Dr. Lydia Dsane Selby. Director of Claims of the NHI –
Interview]
Another leg of the cost containment debate in the country is
centred on the cost of drugs, services and tariffs. In health services
administration, the cost of drugs remains the biggest cost driver. In
some places, the cost of health care is over-priced due to the direct
effect of the cost of drugs both consumables and non-consumables.
As a consequence, it is estimated that by reducing the cost of drugs
there will be a significant reduction in the total overhead of expen-
diture on drugs, a key component of health care cost;
‘‘The single biggest item cost under the NHIS – is the purchase of
drugs – medicines for the poor. Mr. Speaker, I do not know why
the National Health Insurance Authority (NHIA) that pays for the
medication, cannot get into a sort of arrangement with recognised
generic drug producers, so that those hospitals and service provi-
ders prescribing those drugs can get them at an approved rate from
a National Health Insurance outlet. Mr. Speaker, you cannot just
understand why all the service providers can buy drugs from any
source that they want and still bill the NHIS. We are not sure about
some of the quality of the medicines and the prices. So, we have to
start thinking about using the financial muscle of the NHIS to con-
tain prices, especially with drugs in the country”.
[Dr. Matthew O. Prempeh. – NPP MP for Manhyia South.
Debates of 26 Mar 2015]
3.2. Anti-cost containment
There is also an anti-cost containment debate. This school of
thought appears to shift the focus of the argument from a pro cost
containment view of cut in expenditure. The anti-cost containment
augment is being championed by mainly public policy experts and
health professionals; but the relevance of this debate appears to be
a caution rather than a counter augment in opposition to the pro
cost containment debate. This argument draws its strength from
the excessive bureaucracy, low resource capacity, weak public pol-
icy administration and management and the organised economic
chaos environment in Ghana;
‘‘Covering and ensuring the provision of the most cost-effective
benefits and treatments within benefit package – medicines may
require extra effort to manage because of the fragmented environ-
ment”.
[Respondent – public forum]
There is fear that there may be an additional factor cost which
will increase the current overhead of expenditure if attempts made
to cut back on expenditure are not properly implemented and
coordinated. The weak public policy environment in developing
countries like Ghana makes a cut back on expenditure a big chal-
lenge even though rational.
3.3. Pro Revenues, general tax revenues and debt financing
Perhaps, the most familiar debate so far is financing the NHIS
from general tax revenues. This argument is more re-sounding that
51
it resonates very well with a lot of people in Ghana. About 97 per-
cent of people even pro right and pro left politicians and parliamen-
tarians strongly advocate this position. Non-Governmental
Organisations (NGOs), Civil Society Organisations (CSOs), tech-
nocrats, television and radio panellist, academicians, students and
some stakeholders are already in the forefront of this campaign
and are seeking to push the government to do more in this regard;
‘‘The tax system used in financing Ghana’s National Health Insur-
ance Scheme (NHIS) is very innovative and one of the reasons other
countries want to learn from Ghana’s experience. Using the tax sys-
tem to finance health insurance, he said, had enabled far greater
resources for health coverage. He said the continued reliance on
tax financing by Ghana’s NHIS was a better practice that could
be emulated by other countries struggling to implement their
national health insurance. According to him, the tax mechanism
in healthcare financing was a reasonably fair way of providing
the healthcare needs of people”.
[Dr. Nathan J. Blanchet, 2016 – A Health Systems Expert. –
Interview]
The argument in the general tax revenue debate is an old one
and has for a long time dominated health literature. It is a tradi-
tional mechanism for funding general health care services in both
developed and developing countries. In some countries, general tax
revenue together with earmarked revenue from government forms
a greater chunk of health care funding resources. In this study, two
main augments in favour of this prescription were found. The first
part of the argument states that general tax revenues have a poten-
tial to rake in more revenue for funding health care. The second
part of the argument however raises equity issues, and sees this
mechanism as a way of balancing growth. Pro general tax revenue
groups believe that this mechanism is more progressive because
the rich pay more for the poor as a substitute for addressing the
widening inequality gap in the country;
‘‘Mr. Speaker, I also support Hon Members who said that it is high
time some companies in this country that by the application of the
law were not paying premium and were not contributing to our
health insurance, should start contributing. Mr. Speaker, why
should the mining companies not be contributing to the NHIS? It
does not happen. If their employees get accidents, they take them
to the same hospitals. The telecommunication companies, the sim
tax, the petroleum companies – we have to think innovatively
and boldly that the National Health Insurance Fund (NHIF) be so
replenished that it would not be under strains and stresses. But that
does not mean the NHIA should be given the authority to spend
money as they want”.
[Dr. Matthew O. Prempeh. NPP MP for Manhyia South. Debates
of 26 March 2015]
‘‘These additional funding sources were thus suggested and have
indeed been mentioned many times; a 1.5% increase in NHIL/VAT,
allocation of 25% of the Communications Service Tax, a transfer
of a portion of the oil and gas revenue to cater for the health needs
of the country and a few others”.
[(Selorm Adonoo – Deputy Communications Director of the
NHIA – Interview)]
The informal sector in Ghana is the part of the Ghanaian econ-
omy that is not taxed and where tax evasion is very common. The
sector is estimated to account for more than nearly 80 percent of
the Ghanaian economy and remains a key driver of the economy
(GNA, 2016; Osei-Boateng & Ampratwum, 2011). Yet, it remains
a conundrum why the contribution of the sector to government
revenue is very derisory. Pro tax revenue coalition groups in the
country are pushing and are asking government to widen the tax
net especially in the informal sector in order to raise enough rev-
52 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
enue to finance the NHIS. There is a strong campaign for equity in
tax payment and the need to exploit other tax avenues particularly
the informal sector and the black market;
‘‘Raising more revenues from the informal sector”.
[Respondent – public forum]
There is also the argument by some pro general tax groups that
service and administrative charges are low and must be increased.
The cost of premiums per annum is also considered to be very low
thus the real cost of health is under-priced. Apart from the fact that
premium cost per head per annum is very low (GH ȼ 25–$ 6.53), it
is only about 35 percent of the enrolment population who actually
contribute to the scheme through annual premium payments. The
provision of financial waivers under the exemption category for
about 65–70 percent of subscribers is not only having dire conse-
quences on the financial sustainability of the scheme but also
raises some fundamental issues of iniquitous on those who con-
tribute to the scheme – those paying for the cost of health are more
than those who are not paying;
‘‘Section 29 of the NHIS enabling law, Act 852 exempts almost 70%
of the membership of the scheme from paying premiums. Apart
from the fact that the NHIS premium has remained static despite
rising costs of medical consumables and inflation, the NHIS stake-
holders dialogue were of the view that the exemption policy as dic-
tated by the law is not equitable”.
[Selorm Adonoo – Deputy Communications Director of the
NHIA – Interview]
‘‘One of the difficulties is also, the number of exempt groups. We
have those who are under 18, above 70, pregnant women and indi-
genes. The figure in terms of population is taking a big chunk” If the
Social Security and National Insurance Trust (SSNIT) contributors
are not going to be disadvantaged at the end of their service, then
these are the people who earn income regularly and could be made
to also pay the premiums”
[Joseph Yieleh Chireh. NDC MP for Wa West, Debates of 26
March 2015]
At the same time, government bursaries and tax revenues are
not adequate to balance the shortfalls in expenditure. As a result,
there is a strong argument to introduce more or increase service
and administrative charges and premium cost in order to raise
enough revenue to finance the NHIS;
‘‘Approximately 35% of the NHIS membership pays premiums
because they work in the informal sector. Yearly premium payment
per head for enrolment appears to be one of the lowest in the world
without co-payments. Even though the costs of goods and services
have increased since implementation of the scheme in 2005, these
premiums have not increased in commensurate terms to meet the
increasing demand for healthcare”.
[Respondent – Public forum]
The health care funding debate in Ghana has attracted a myriad
of pro liberal and anti-liberal prescriptions. Pro liberal coalition
groups say a more realistic and prudent approach to funding the
NHIS will be for clients to pay a little for their health care cost
whiles government absorbs the chunk of the remaining cost. Once
co-payment for premiums is introduced and people are made to
pay part of the cost of seeking health care, cost of health care under
the NHIS will substantially decline;
‘‘When you know that you have to foot the bill every time you go to
the hospital, you would actually ask – do I really need this service?
Is there a way that I could shift this to a month or two months?”
[Chief Executive Officer (CEO) of Acacia, Dr. Daniel Amooh –
Interview]
The odds for abuse will be directly eliminated if people are
made to bare part of the cost of their health care (Graphiconline,
2016). This is part of a neo-liberal thesis which draws its strength
from a myriad of milieu. For instance, in the Rand study carried out
from 1974 to 1988 in the USA, researchers observed that people
who paid a fourth of the health care cost visited the hospital at a
rate of 3.33 times, those who were given free health care went to
the hospital 4.45 times in a year, but those who were made to
pay so much for the cost of treatment visited the hospital fewer
times and spent less on treatment (Manning et al., 1988).
There is a pro general tax revenue group who are advocating for
a more radical way of financing the NHIS through debt financing.
The want government to use debt financing instruments like bonds
to service health care under the NHIS. In this arrangement, health
care providers could be made to pre self-finance patients’ health
care cost for some time after which government raises bonds to
pay off the expenditure incurred. This coalition group is vexed
about the escalating funding gap of the scheme and is convinced
that this could be addressed through debt financing while at the
same time making service providers more competitive;
‘‘Government must find ways and means. Some people have asked
me how Government should do so. I think what Government can
do, is to do what they have been doing to pay road contractors
and other contractors. If it also requires us to get some bonds, it
should be done. If Government wants to solve this problem, it has
to do so with stakeholder consultation very strongly”.
[Joseph Yieleh Chireh. NDC MP for Wa West. Debates of 26
March 2015]
3.4. Anti-Revenues, general tax revenues and debt financing
The main anti thesis against the general tax revenues argument
is a caution on the potential problems in over reliance on general
tax revenues. The first issue is over taxation and double taxation.
The economy may shrink if business owners are unable to plough
back profit due to over taxation. The second point is the need to
address the inherent problems in revenue mobilisation such as
the small size of firms, stagnation in economic growth, reduction
in wage base taxes, retrenchment in public funds and fragmented
economic environment inter alia. Widening the tax net in develop-
ing countries like Ghana in the mist of weak tax administration
laws and management policies remains one of the biggest chal-
lenges confronting the government. Apart from the problems of
ineffectiveness and inefficiencies there is also the question of
whether the government has the political will to pursue such an
agenda? There are also serious concerns of how general tax rev-
enues meant for health care funding go unaccounted for, missing
and the diversion of public health funds through corruption.
In the same length, the anti-debt financing coalition argue that
the debt financing prescription is a misplaced point. They stress
the view that this argument is a post health care financing arrange-
ment which will have substantial implications on the quality of
health care delivery. There are also strong trepidations that debt
financing could create compounding and chain effects in health
care service deliveries. On the other hand, the argument in the
anti-debt financing debate is strongly being advocated by demo-
cratic politicians and parliamentarians; but the nexus of this argu-
ment is precautionary;
‘‘By the end of this year, 2015, if no action is taken or nothing is
done, what it is going to mean is that, we would end up having a
gap of close to a billion. I do not think we want to go for a Eurobond
to just pay this off. This will be very wrong”.
[Alhaji Mohammed Mubarak Muntaka. NDC MP for Asawase.
Debates of 26 March 2015]
 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
3.5. Pro capitation
The capitation debate is arguably the most popular debate for
funding the NHIS in Ghana today. This is because of the noise, con-
fusions, controversies, agreements and disagreements surrounding
the policy. The policy was introduced on a pilot bases in January
2012 in the Ashanti Region to streamline what the NHIS called
alleged excesses and abuse of the scheme by service providers.
Since 2012, there has been a lot of uncertainty and hullabaloo on
the concept, its meaning and its implementation;
‘‘Mr. Speaker, I want to find out whether the honourable minister
for health is sufficiently abreast of the capitation that was practised
in the Ashanti Region before recommending this as a strategy to
address the payment of claims”
[Augustine Collins Ntim. NPP MP for Offinso North, Debates of
13 November 2014]
The policy has also attracted a lot of media discussions on radio,
television, newspapers public fora, symposiums, and parliament
and even on political platforms. NHIS staff (national, regional,
metropolitan, municipal, and district staff), current and past minis-
ters of health, some parliamentarians especially from the ruling
National Democratic Congress (NDC) are the main campaigners
in the pro capitation debate. These pro capitation groups are lob-
bing government to introduce closed-ended payment mechanisms
that impose a cap at some level throughout the country;
‘‘The capitation system ensures that per capita payment is made
within the first week of the month. It allows for payment to provi-
ders to be made before services are delivered. It therefore, remains
the best mechanism for avoiding delays in payment of claims for
services rendered”.
[Dr. E.K Mensah – Former Minister of Health. Debates of 13
November 2014]
The government is by far the biggest pro capitation advocator in
the capitation debate. As part of a mechanism to deal with the
widening funding gap and to address challenges in the late dis-
bursement of claims to service providers, the government is con-
sistently and continuously attempting to divert, direct, lead and
in some cases dictate the capitation debate. Discussions from gov-
ernment communication team members, government commu-
niqués, media encounters, press briefings, statements, and
campaign messages strongly indicate the government’s commit-
ment to adopt capitation as the major funding mechanism for
the NHIS in Ghana;
‘‘Mr. Speaker, implementing a NHIS has never been easy in any
country, whether the United States of America, Britain, Germany,
or anywhere. We are not saying that the system is perfect. But
we are trying every possible means to make sure that the system
is able to operate efficiently and effectively and also it is sustain-
able. So, we are constantly reviewing. That is why now, in terms
of the claims – capitation allowance for payment is in advance
rather than in arrears – So, it ensures early payments as against
other payment methods”
[Dr. E.K Mensah – Former Minister of Health. Debates of 13
November 2014]
3.6. Anti-capitation
There are anti-capitation groups with strong roots from centre
right parliamentarians especially from the Ashanti region of Ghana
leading a coalition against capitation. This group forms the core of
the coalition against capitation at the public policy level. When a
motion was introduced in parliament in 2012/2011 by the then
53
Minister of Health seeking to introduce capitation on a pilot base
in the Ashanti region, the main opposition republican party
brought a counter motion seeking to restrain the government from
going ahead with its plans. Even though there is political interest in
the matter, it will appear however, that the views expressed by
these anti capitation parliamentarians, the former president of
Ghana and other distinguished persons from the Ashanti region
of Ghana were out of support and solidarity for the sentiments
being expressed by NHIS service providers in the region;
‘‘Why should you keep on implementing a policy when the people
who are supposed to benefit are crying and calling for its abroga-
tion”.
[President John Agyekum Kuffour. Former President of Ghana,
2013 – KESSBEN FM in Kumasi on Monday, 23th December
2013]
‘‘Mr. Speaker, after a whole year of the promise of the roll out of the
capitation, if capitation is supposed to increase a cost containment
measure, the whole of 2014, it has not been done. If the NHIA can-
not roll out by now capitation across the length and breadth of the
country, Mr. Speaker, I do not know why Ashanti Region should be
unduly suffering. It is just not right that only one-tenth of the coun-
try is undergoing capitation. When the NHIA comes to promise this
House that they are rolling it in 2014 to three other regions, they
could not do that. Why? What have the people in the Ashanti
Region done to deserve that? We have to start looking at that as
a House”.
[Dr. Matthew O. Prempeh. NPP MP for Manhyia South. Debates
of 26 March 2015]
Residents in the Ashanti region have also joined the capitation
debate, and are calling for the capitation policy to be scrapped.
Since the introduction of the policy, there have been public out-
burst, numerous demonstrations and protest against the policy
due to experiences from patients and persistent compliant from
the service providers in the region;
‘‘The decision by the NHIA to implement the pilot programme in the
region two years ago was met with stiffer opposition from health
providers and civil society groups who fought unsuccessfully to
get the NHIA to rescind the decision”.
[Alhassn, 2013]
The main anti-capitation groups is the NHIS service providers.
The group has constantly campaigned against the capitation policy
since it was introduced by the government. Their campaigns have
been carried out through press conferences, public protest, demon-
strations and press releases inter alia, and have often threatened to
withdraw their services from the NHIS if the government fails to
suspend the implementation of the capitation policy;
‘‘Ashanti Regional Chairman of the GMA, Dr. Frank Ankobea con-
firmed to Citi News that operators of private health facilities in
the region have reverted to cash and carry because of the capita-
tion system”.
[Naatogmah, 2014]
While the government seems to be firm in its position, the
health care and service providers are vexed about government’s
decision to continue with the implementation of the capitation
policy. The Coalition of NGOs’ in Health, a health advocacy group
has however described the positions taken by both the government
and the health service providers as an ‘‘unfortunate development”
stemming from the lack of consultation between the two. The
coalition is apprehensive that the low level of government consul-
tation with stakeholders will eventually undermine the cogency of
54 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
the pro and anti-capitation debate. According to the group, the best
way forward will be for the government to promote dialogue with
stakeholder groups in the health services delivery chain.
There are two major points deriving the anti-capitation move-
ment among the NHIS health care and service providers in Ghana.
First, the NHIS service providers are worried that the per capita
rate under capitation is low – this will affect their profit margins.
The second point is delays in imbursement of funds as is the case
in the current payment system is more likely to undermine quality
health care delivery;
‘‘Some service providers also complain they have been running at a
loss because the capitation grant per person is not enough to take
care of patients”.
[Alhassn, 2013]
‘‘Mr. Speaker, I am not comfortable with the capitation system as a
strategy to address. As a payment policy, capitation requires a pre-
payment system and we have a classical example in the Ashanti
Region, whereby capitated facilities have delays in the payment
between six to eight months. I would want to find out from the
Hon Minister, what new strategy he is going to adopt to ensure that
his capitation strategy is not going to bring about unnecessary
delays as is being practised in the Ashanti Region”.
[Augustine Collins Ntim. NPP MP for Offinso North, Debates of
13 November 2014]
In the anti-capitation group, there are some people; particularly
among the NHIS service providers who have no adequate under-
standing of the capitation policy and have managed to stimulate
public resentment against the policy. This on one hand may have
given the impetuous for the anti-capitation argument to thrive.
Again, there are fears that capitation may not be successful because
of previous experiences under the capitation school feeding pro-
gramme where there were excessive delays in reimbursing funds
resulting into huge accumulation of arrears and poor services.
The Ghana Medical Association (GMA) is one of the strongest
forces in the anti-capitation campaign. Since the introduction of
the capitation policy, and from experiences of capitation in the
Ashanti region, the Ghana Medical Association has vehemently
opposed and continuous to protest government’s attempt to roll-
out capitation as a mechanism for funding NHIS claims across
the country. These sentiments have been copiously expressed in
the media, through communiqués, at meetings of the association
and at National Executive Council (NEC) meetings as well. Accord-
ing to the association, the experience of capitation in the Ashanti
region vindicates their position on the matter;
‘‘The Ghana Medical Association (GMA) has kicked against govern-
ment’s attempt to rollout the capitation mode of paying the
National Health Insurance Scheme (NHIS) claims across the coun-
try”.
[Naatogmah, 2014]
‘‘The capitation system is a misplaced priority which should be
abolished to save the NHIS from total collapse. NHIS subscribers
in the Ashanti Region have since the introduction of the capitation
system been paying extra cost for health services. The NHIA has for
the past seven months not reimbursed health service providers
across the country and this has created mistrust between manage-
ment of most health facilities and their suppliers”.
[Dr. Kwabena Opoku-Adusei, President of the Ghana Medical
Association – Interview]
In a radio a discussion, a health policy expert explained that
even though the capitation policy may sound good, it will not be
very easy for the government to implement the policy nationwide
considering the institutional and resource constraints of the gov-
ernment. This point finds expression in the fact that the weak pub-
lic sector administration structure and the poor public sector
policy regime will likely undermine the effectiveness of the policy.
In the initial stages, relative success could be achieved but in the
long term the policy may not be successful in ensuring efficiency
and abuse. There is anticipation that the capitation policy in the
long run may be a counterproductive venture with dire conse-
quences on both service providers and patient clients;
‘‘Capitation requires robust monitoring to succeed”.
[Respondent – public forum]
‘‘Addressing a press conference in Kumasi earlier this week, Dr.
Kwasi Awudzi-Yeboah, Kumasi Metropolitan Health Director,
described the capitation policy as neither beneficial to the facilities
nor the patients”.
[Joy FM mid-day news. 12: 00 pm – 25 January 2016]
3.7. Capitation, tax and cost containment
The cost containment argument is as valid as the tax general tax
revenue and the capitation argument is as valid as any other. There
are a number of NGOs, civil society groups, public policy experts
who believe a multiple approach strategy to funding the NHIS
should be the exact way forward. The validity of this argument is
centred on the complementarities of the different prescriptions
that are being espoused. Pro campaigners of this argument believe
that in public policy making the weakness of one policy must be
complemented by the strength of another. Building synergy on
the basis of strengths and weakness will overcome fundamental
challenges inherent in the various arguments;
‘‘No matter the number of these measures introduced, it cannot be
substituted with the dire need for additional funding. Efficiency
measures alone cannot salvage the scheme”.
[(Selorm Adonoo – Deputy Communications Director of the
NHIA – Interview]
‘‘the tax mechanism in healthcare financing was a reasonably fair
way of providing the healthcare needs of people; However, since
there are never enough resources in any country to cover all possi-
ble illnesses and treatments, it would be prudent in the near future
for Ghana to look at what diseases and illnesses that health insur-
ance could cover to best meet Ghanaians’ health needs in a finan-
cially sustainable way”.
[Dr. Nathan J. Blanchet, 2016 – A Health Systems Expert –
interview]
4. Discussions
The health financing debate in Ghana has enjoyed a lot of public
discourse. A cursor analysis of the discussions reveals a strong
interplay of stakeholder interest, power and positions. Even though
there may be some trepidations and confusion, the lack of clarity
on the subject matter in some quarters has undoubtedly catalysed
the various positions and interest in the debate. In the wake of the
raging discourse, a myriad of groups and sub groups have subse-
quently emerged professing various thesis and anti-thesis. The
major coalition and anti-coalition groups in the debate are the gov-
ernment and NHIS service providers. These coalition groups have
managed to solicit support from other interest groups to as it were
bought into their claims. In some instances, even though the vari-
ous coalition groups are seeking to champion their own positions
and interest, their views sometimes overlap each other. The eupho-
ria surrounding the NHIS financing debate in Ghana is not one of
numbers but who wields power and who seems to be making
 E.A. Wedam, F.N. Sanyare / World Development Perspectives 5 (2017) 47–55
the most noise. The government is by far the most obstinate oppo-
nent and it thus appears that the government will not boggle in its
stands; even though trade-offs are necessary in the near future if
any concrete progress is to be made.
Pro cost containment coalitions groups believe that cost con-
tainment is at the core of the NHIS funding debate but admit that
more funding through taxes is indispensable. The NHIS currently
spends about 80 percent of its income on paying claims to service
providers under the scheme (Citifmonline, 2015); a phenomenon
which has resulted in the huge funding gap. The argument on cost
containment is one part of the NHIS funding debate that the gov-
ernment has conceded to and is taking steps to address. As a result,
‘‘the NHIA in the last five years has introduced a raft of efficiency
gain measures to ensure that the scheme keeps running. Some of
these include the institution of clinical audit functions, centraliza-
tion of claims management at zonally cited Claims Processing Cen-
tres, provider payment reforms (capitation), electronic claims
management, the biometric membership solution, etc., and these
have been immensely beneficial” (Adonoo, 2016 – Interview).
In the NHIS financing debate, pro cost containment groups have
slammed pro capitation groups over issues of abuse and efficiency.
They argue that capitation in itself is a cost containment measure
and that there is no substantial variation from capitation and cost
containment. According to them (pro cost containment), if there is
any difference at all then the difference is found in the ‘‘effect”. Pro
cost containment coalition groups believe that beyond capitation
being a cost containment measure it has the effect of negatively
affecting health care systems in the long run especially if it is not
well monitored. But main pro capitation groups like the govern-
ment are not surprised and are unperturbed at all about the vari-
ous counter arguments against capitation. In the view of the
government, ‘‘capitation has always experienced initial resistance
anywhere it is introduced due to suspicions of delay in reimburse-
ment” (Alex Segbefia, 2016. Minister for Health – Interview).
Even though the various arguments in the NHIS funding debate
clearly reiterate the fundamental issues of stakeholder’s interest,
functions, position and power. The researchers believe that for
such a public funded scheme to work there must be a combination
of approaches and strategies that attempt to fuse the various argu-
ments together. Such a coordinated effort will require consensus
building at the public policy level. Any attempt to isolate the dis-
cussion on the basis of which approach best fit will only sludge
the debate particularly due to the fact that some of the arguments
are borne out of interest, sentiments and solidarity.
5. Conclusion
This study highlights several important points in the area of
health policy in Ghana’s National Health Insurance Scheme and
especially, for countries that are also seeking to implement public
funded pro-poor health care schemes like health insurance. First,
the study attempts to identify the various discussions in the NHIS
funding debate in Ghana. The researchers have tried to identify the
convergence and divergence in the different arguments. The study
has been able to emphasize the roles and contributions of the dif-
ferent coalition groups in the debate. The latent odds to join the
debate are generally influenced by stakeholder interest and posi-
tion. The researchers concede that even though the debate may
attempt to provide useful prescriptions for funding the NHIS, the
intricate relationship within and among the different stakeholders
is not only stimulating an unabated discourse but is responsible for
the staunch and liberal positions adopted in the debate.
Even though there is political interest in the debate, the debate
is more organised along a public policy marking process, senti-
ments and solidarity and in some quarters there are attempts to
score political points. We advocate for coordination among the var-
55
ious stakeholder groups in the NHIS policy making process to
design and implement NHIS funding policies based on evidence
building. There is a lot of stakeholder interest in the debate which
is likely to undermine the validity of the arguments and the search
for a workable solution. It remains to be seen however, whether
the government’s big push for capitation will bring the needed effi-
ciency as is being advocated.
Conflict of interest
The authors declare no conflict of interest.
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