>Introduction

The government of Ghana have variously contemplated on how best to finance health care and all have tried to develop a system of financing that will reduce the financial limitations that cost of health care imposed on citizen’s access to health particularly the poor and vulnerable.

Before independence access to health care was narrowed to expatriates and the few Ghanaians working with the public service. The government of Osygyefo Dr. Kwame Nkrumah established the Ghana Health Service. The object of the service was to open health care to all Ghanaians. The service included principles of health insurance and health care was free at the point of use.

Prime Minister Abrefa Busia’s government in 1971 started charging for hospital services through the hospital fee act of 1971. The view of the government then was that the hospital fees will reduce unnecessary and health excessive use of health facilities and also raise some revenue for the facilities. This was not full cost recovery. Government still had to hugely subsidies health care.

In the 1980s it became extremely difficult for government to fund health care. Government therefore introduced the Hospital Fees Regulation of 1985. This ushered in the principle of cost recovery. For the first time Ghanaians had to pay the cost of health care at the point of use. This fee regulation it was reported resulted in a drop in attendance at health facilities particularly in rural areas. The law was amended in 1990 and the law allowed health facilities to retain 100% of the revenue and also keep a revolving fund for drugs. It is this amendment that ushered in the term CASH and CARRY. In local parlance it connoted no money, no treatment. It was a very unpopular term. Several pieces of research point to a fact that some of the advantages of user fees were not materialised. It rather created problems of equity and for most of the population services were no longer affordable.

Motivation for Health Insurance

The Hospital Fees Regulation of 1985 (cost recovery) was largely resulting from structural adjustment programmes introduced by the World Bank and the IMF to correct balance of payment deficits. The act distorted the health seeking behaviour patterns of Ghanaians. The system placed a heavy financial burden on the poor and led to inequities in access to healthcare. But government had no option than to agree to cost recovery in an effort to stabilise the economy of the country, which had taken a nosedive.

In other to mitigate the widening gap of access to health care, the government introduced an exemption policy in 1992. The essence of the policy was to exclude the poor and vulnerable from paying user fees. There were reports that that the exemption directive was hardly used. Service providers found the exemption policy cumbersome and laborious to implement. The inability of the exemption policy to work points to a known fact that all poor relief is given grudgingly and reluctantly by service providers.

The regressive nature of the cash and carry policy, coupled with the lackadaisical implementation of the exemption policy resulted in diminishing access of the population to health care. This agitated government and non-governmental organisations considerably and thus the beginning of the exploration of a more equitable system for guaranteeing financial access to health care.

The concept of health insurance in Ghana predates the establishment of the National Health Insurance Scheme (NHIS) and has its roots in community-based health insurance initiatives. Various community-based health insurance schemes (also known as mutual health insurance schemes) existed in Ghana, particularly in rural areas. These were small, localized efforts where community members pooled resources to pay for healthcare when needed.

The Catholic Church played a very critical role in the establishment of health insurance in Ghana. The first and most successful scheme was the Nkoranza Community Health Insurance Scheme based at St Michael hospital in Nkoranza. The Catholics established through the support of GTZ at Damongo the Damongo Community Health insurance scheme. These schemes which started in the early 1990s became a model for community-based insurance schemes in other parts of the country.

NDC and Health Insurance Agenda

President Rawlings in 1995 in order to mitigate the regressive nature of the cash and carry system introduced the ideal of health insurance scheme by piloting a scheme at Dodowa. He then commissioned the Ministry of Health to undertake a feasibility study on community health insurance. The main thrust of the commissioned feasibility study was to provide policy-makers with relevant data on the demand for and feasibility of health insurance schemes. It was also to assist to formulate a health insurance policy that would suit the largely rural population within the Ghana socio-economic context. The government through the MoH received from a private consultancy group an explicit proposal in late 1995.

This consultancy produced a comprehensive report on the feasibility for the establishment of a National Health Insurance in Ghana. The consultancy proposed strongly the establishment of a centralised national health insurance company for all contributors to the SSNIT and registered cocoa farmers. It also recommended pilot rural based community-financed schemes for the non-formal sector. The then government got SSNIT to establish a Subsidiary Company charged with the responsibility of piloting insurance schemes in the Eastern Region.

In its 2000 manifesto the NDC stated that Health Insurance will be a major strategy for mobilising additional resources and for ensuring financial access to health care in time of need. They highlighted that the pilot work already carried out will form the basis for a mix of insurance schemes, both public and private, national and local to cater for salaried employees, the self-employed as well as both urban and rural communities.

They further stated in the manifesto that one of the most effective ways of keeping the cost of health care to a minimum is through a Health Insurance Scheme and it is for this reason that the NDC Government conducted in-depth studies and pilot projects to facilitate the establishment of a viable Scheme when elected into power.It was also their view that the exemptions policy will also be reviewed in terms of coverage as well as disease spread and more funds will be provided to support the needy.

NPP and the Agenda

The NPP in opposition used very harsh words to describe the cost recovery programme. In its 1996 manifesto, the NPP stated that the system of cash and carry at the point of service had proved notoriously callous and inhuman. It promised that if it won elections, it would thoroughly overhaul the cash and carry system and evolve a new health financing mechanism.

The NPP strongly held the view that the system of financing health care will be thoroughly overhauled and the cash and carry system reviewed with a view to evolving a more equitable system including health insurance and other repayment schemes. They noted in the manifesto that this should provide for humane treatment of illness, including accidents and other emergencies. It was their opinion that emergencies shall be treated promptly in all public hospitals, and payment of fees, if any, will be discussed when the patient is out of danger.

The NPP took over the governance of the country in 2000. To keep faith with its manifesto and campaign promise, the NPP Government appointed a team at the ministry of health to draft a bill for the establishment of a national health insurance scheme for Ghana. The chair of the team was the Director of Programme Planning and Monitoring and Evaluation Department of the MoH. He later became the Executive Secretary of a National Health Insurance Council which was established. The team got technical support from USAID, as a result of a request made by the then Minister of Health. The NPP government in 2003 passed the NHIS ACT, ACT 650. The Scheme was launched in 2004 with District Mutual Health Insurance Scheme as the implementation mechanism.

The Political Process

There were agitations against the process that was instituted in formulating the national health insurance policy. The opposition to the process was not only by the opposition in parliament but also civil society groups. For the opposition, the process of formulating national health insurance policy was over politicised by the government and its agents. That the NPP made health insurance look like their baby and therefore they alone had the exclusive right to push it through and nurture it.

The NPP Government view on the issue of politicisation was that matters of this nature must naturally assume political dimensions because the politics kick starts the process and enables the establishment of the foundational structures for technocrats to take over. And that it is only normal for the government to engage individuals it trusts will deliver.

Government passed the bill in parliament in the absence of the minority who deemed the process an illegality. The opposition held strong exception to this process of passing of passing the bill. It was their view that government had underrated the process. They bemoaned the fact that government included the health insurance Bill, a largely routine business, in an emergency parliamentary session. They insisted that the decision to include routine business in an emergency session of parliament was wrong and a dangerous precedent and therefore should not have been countenanced even by the majority.

The opposition observed that the attitude of government, to pass the bill and to implement health insurance at all cost, legal or illegal within the shortest time possible by short-circuiting parliamentary procedures, was an affront to democracy. It was in this regard that the opposition decided that they were not ready to condone an illegality and therefore had to walkout of parliament and boycotted further participation in matters of the bill. They insisted they were not going to be part of an illegal process to legitimise an illegal act.

The Ghana Scheme

The terms national health insurance, social health insurance and mutual health insurance refer to different models of financing and organizing healthcare delivery. The difference is largely on how revenue is mobilised and ownership of the scheme.

The Ghana scheme is an amalgam of National Health insurance as in the NHS, Social health Insurance and Mutual Health Insurance.
In 2003, under the leadership of President John Agyekum Kufuor, the National Health Insurance Act, 2003 (Act 650) was passed, creating the National Health Insurance Scheme (NHIS). The goal of the NHIS was to provide universal health coverage and replace the cash-and-carry system with a more inclusive system, allowing all Ghanaians, particularly the poor, to access healthcare services without upfront payments.

In 2012, the Ghana National Health Insurance Authority ACT 852 was promulgated under the government of Prof. John Evans Atta Mills. This Act created the authority as a regulatory body responsible for implementing and managing the NHIS. Amongst its task is to also regulate private health insurance schemes.
Act 852 repealed Act 650 and expanded the scope of health insurance in Ghana.

This included Universal health insurance coverage, improved governance and enhanced benefit package. Act 852 further underlined key functions of the Authority in terms of powers, governance structure, and operational procedures.
In conclusion, It is clear from the above discussion that all governments have played critical roles in shaping Ghana's health insurance landscape and all government have been committed to providing financial access to healthcare through a sustainable mechanism. This sustainable mechanism is currently anchored on the wisdom of Act 852.