Repackaging exemptions under National Health Insurance in Ghana: how can access to care for the poor be improved?

For the past 10 years the Ghana Government has been trying to replace the old user fee system with an overall health insurance scheme, but one problem of the old system continues to bedevil the new policy: exemption of the poor. This paper presents data from empirical fieldwork and also puts forward an opinion. It discusses how past experiences of user fee exemptions for the poor can inform exemptions under the new 'National Health Insurance Scheme' (NHIS) as a means to ensuring equity in health care. Drawing on a study of exemptions in the three regions of northern Ghana, and utilizing both qualitative and quantitative methods and data, the findings show that exemptions were applied in favour of under-fives, antenatal care, the aged and public servants to the disadvantage of the poor. As a result, the poor had very little access to exemptions. Exemptions therefore failed to address equity concerns in health care, the very reason for which they were introduced. Thus, although the paper acknowledges that provision for the enrolment of the poor into the NHIS is a step in the right direction, it underscores that effective enrolment will be essential for attaining the equity goal of the policy. Informed by past experiences that undermined the equity goal of exemptions, three policy recommendations are put forward for improving exemptions for the poor under the NHIS. These are: (1) effective community education for enhancing premium paying enrolments into the NHIS alongside education on exemptions for the poor; (2) reviewing and clarifying policy guidelines for guiding local-level identification of the poor based on communities' own understanding of poverty; and (3) providing the requisite resources to enable the Department of Social Welfare to discharge its core mandate of identifying the poor for exemptions.