Mandatory community-based health insurance schemes in Ghana : prospects and challenges
Community-Based Health Insurance Schemes are new forms of health ﬁnancing that can increase resources available for a national health system. These schemes are often regarded as not feasible. Evidence from recent experiences however; show that , if they are appropriately designed and managed they can be feasible and sustainable. The successes achieved by such schemes in Ghana motivated the government to make them a mandatory system of health financing. The main objective is that every resident of Ghana shall belong to a health insurance scheme that adequately covers him or her against "cash and carry" (i.e. user fees) in order to obtain access to a deﬁned package of acceptable quality needed health services without having to pay at the point of receiving service. This study sought to undertake a critical comparative study of the performance of voluntary and mandatory community health ﬁnancing schemes in Ghana and assess their prospects and challenges in their effort to improve efficiency, equity and the schemes' sustainability. The study, a qualitative one, employed descriptive survey techniques to evaluate the ability of schemes to ﬁnance their activities from their own sources and mechanisms put in place to cater for the poor and vulnerable, i.e. to evaluate with sustainability and equity respectively. The study also considered control measures to minimize cost escalation to assess efficiency. Focus group discussions, key informant interviews and document reviews were used to examine performance of voluntary and mandatory schemes in meeting those criteria. The study found that both voluntary and mandatory schemes were not self-sustainable due to low coverage and inadequate funds mobilized by the schemes. The main reasons for the general low enrolments are poverty, poor quality health service and limited beneﬁt packages. The study showed that including out-patient (OPD) services in the beneﬁt package and quality improvements in health service improve members' acceptability of insurance hence increase membership rates which will eventually increase schemes' sustainability. Efﬁcient and effective administration of risk equalization fund will help reduce differences in districts' ability to raise revenue owing to different levels of economic activities as well as local morbidities. The study showed further that small community-based health insurance schemes (CBHIS) could be sub-district level ﬁnancial intermediaries for the District Health Insurance Schemes. It was found in this study that a practical means testing mechanism to declare one poor in order to quality for exemption from contribution should be adopted. The study also suggests that alternative reimbursement mechanisms to fee-for-service need to be considered. The study suggests further research on equity in access and means testing. Such study should consider coming up with mechanisms for identifying the very poor in the communities and to put in place workable and sustainable measure to tackle the ﬁnancial barriers to health care they face.
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