Out-of-pocket Payments for Health Care Under the National Health Insurance Scheme in Ghana: What Do Clients Pay for?

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Abstract Background: The introduction of social health insurance in developing countries is an important policy to improve financial access to health care. In 2003, Ghana implemented a national health insurance scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments by insured clients is one such challenges of the scheme. This study seeks to examine the types of services that these unauthorized charges are made for, who pays these charges and how much clients pay out-of-pocket.Methods: This was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and results presented as proportions and means.Results: Of all respondents in the study 49.7% reported paying out-of-pocket for out-patient health care while 48.6% of insured clients paid out-of-pocket. 42% of the insured poorest quintile also paid out-of-pocket. Respondents suffered fever-malaria like symptoms (45.7%). Insured clients paid for consultation (75%) and drugs (68.5%) and 34.9% purchased drugs outside the health facility visited. The unavailability of the drugs (67.9%) and drugs not covered by the NHIS (20.8%) led to out-of-pocket payments. On average patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Northern region, patients living in the Ashanti region were 4.4 times more at odds to pay out-of-pocket for health care. Conclusions: Insured clients of Ghana’s NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities. These out of-pocket payments occur in disadvantaged regions, among individuals and in all health facilities. Out-of-pocket payments under NHIS leads to inequity in access to health care.

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