Karima Saleh – författare

Ghana is one of only several African countries to enact legislation and earmark financing for universal health insurance coverage for its entire population. Seven years into its implementation the Ghana National Health Insurance Scheme (NHIS) has made significant progress in transitioning to universal coverage, but faces significant fiscal and coverage challenges. This study reviews Ghana's health financing system with a special emphasis on its National Health Insurance Scheme. Such an assessment is important because Ghana is often considered a global 'good practice' in terms of earmarking significant amounts of its general revenues for health insurance coverage, providing formal coverage to its vulnerable population groups, and extending coverage by transitioning its existing community health insurance schemes into a national health insurance program. In addition to the global interest in the Ghana 'model', this review is timely in view of recent critiques of the system and questions about its financial sustainability. The study is also unique in terms of evaluating Ghana's NHIS in terms of basic health system goals of health outcomes, financial protection, consumer satisfaction, equity, efficiency, and financial sustainability. The strengths and weaknesses of Ghana's health financing system are assessed on the basis of these performance goals to provide the current health policy reform baseline. The assessment is also based on several new and updated sources of information on: total health spending, inputs, outcomes, household spending, and the macro economy. It also undertakes for the first time an extensive international benchmarking analysis; assesses the financial protection/equity of the system at both macro and micro levels; and, contains an extensive fiscal space analysis based on Ghana's new macroeconomic realities (i.e., the revaluation of Ghana's Gross Domestic Product (GDP) upward by some 60 percent in November 2010, making Ghana a lower middle income country). The study concludes with an assessment of potential structural and operational reform options to assure NHISs long-term efficacy and sustainability in the context of its future available fiscal space.

Ghana’s demographic profile is changing, and demographic, epidemiological, and nutrition transitions are well underway. However, several of Ghana’s health outcome performances, especially in terms of child health and maternal health, are worse than the levels found in other comparable lower middle income and health spending countries. The volume is timely, given the stage of the Ghana's development. It briefly discusses some of the debates in Ghana’s health sector: decentralization and governance, private sector partnership, strengthening health systems, and health financing. It brings together several elements of health system development and challenges and links it to health financing and delivery performance. The volume reviews the situation among human resources for health and pharmaceuticals. The private sector is growing and attention is required on its development. The volume benefits from health service delivery assessments in the public and private sectors, and finds large variations in distribution and weak incentives to improve productivity and performance. It also reviews the demand side financing reform, its coverage of the population and its effect on service use and the financial sustainability of the National Health Insurance Scheme. There is fragmentation in financing of public health, and inefficiency in health spending, and there is need to improve spending in areas that provide a higher value for money. Data overall has been a constraint, however, the study benefits from various household level surveys to disaggregate the analysis by income quintiles. It also reviews the household’s vulnerability to health shocks and their financial protection against illness costs. There is inequity in health access, health service use, and health outcomes. The Northern regions have poorer results. Finally, the volume highlights the range of policy options needed to improve health system performance and health outcomes. At this stage of the country’s development, and taking the agenda for reform to the next level, the Government of Ghana could embark on significant reforms in the areas of (a) decentralization and governance, (b) health service delivery, (c) public health, and (d) health financing. Further it should set up a holistic and accountable health reform process as it transitions to universal coverage along with its concomitant service delivery, public health, and governance reforms.