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Background: Ghana's National Health Insurance Scheme (NHIS), established by an Act of Parliament (Act 650), in 2003 and since replaced by Act 852 of 2012 remains, in African terms, unprecedented in terms of growth and coverage. As a result, the scheme has received praise for its associated legal reforms, clinical audit mechanisms and for serving as a hub for knowledge sharing and learning within the context of South-South cooperation. The scheme continues to shape national health insurance thinking in Africa. While the success, especially in coverage and financial access has been highlighted by many authors, insufficient attention has been paid to critical and context-specific factors. This paper seeks to fill that gap. Methods: Based on an empirical qualitative case study of stakeholders' views on challenges and success factors in four mutual schemes (district offices) located in two regions of Ghana, the study uses the concept of policy translation to assess whether the Ghana scheme could provide useful lessons to other African and developing countries in their quest to implement social/NHISs. Results: In the study, interviewees referred to both 'hard and soft' elements as driving the "success" of the Ghana scheme. The main 'hard elements' include bureaucratic and legal enforcement capacities; IT; financing; governance, administration and management; regulating membership of the scheme; and service provision and coverage capabilities. The 'soft' elements identified relate to: the background/context of the health insurance scheme; innovative ways of funding the NHIS, the hybrid nature of the Ghana scheme; political will, commitment by government, stakeholders and public cooperation; social structure of Ghana (solidarity); and ownership and participation. Conclusion: Other developing countries can expect to translate rather than re-assemble a national health insurance programme in an incomplete and highly modified form over a period of years, amounting to a process best conceived as germination as opposed to emulation. The Ghana experience illustrates that in adopting health financing systems that function well, countries need to customise systems (policy customisation) to suit their socio-economic, political and administrative settings. Home-grown health financing systems that resonate with social values will also need to be found in the process of translation. [ABSTRACT FROM AUTHOR]

Ghana’s National Health Insurance Scheme, introduced in 2003, aims to remove financial barriers to health-care access and bridge the inequality gaps in health care. This paper reports on a study of the implementation process in four local government areas in southern and northern Ghana. The paper profiles key institutional actors and draws on qualitative interview data from 33 in-depth interviews. Findings highlight the gaps and challenges that have emerged in the implementation process. Issues of managerial capacity, inadequate and uneven distribution of medical facilities and health-care professionals, cost escalation, fraud and abuse, and reimbursement of providers threaten the sustainability of the scheme. [ABSTRACT FROM PUBLISHER]

Background: Contracting private medical practitioners for the National Health Insurance pilot project in 2012 by the National Department of Health in South Africa was envisaged to reduce workload at referral district hospitals by reducing self-referral by clients as the perceived quality of care at the primary healthcare level improves., Aim: To describe the effect of contracting private medical practitioners at primary healthcare facilities on the self-referral rate of clients at district hospitals as a proxy for perceived quality of care in a National Health Insurance pilot district., Setting: The study was set in Tshwane National Health Insurance pilot district compared to Ekurhuleni district., Methods: We compared findings before and after implementing the National Health Insurance private medical practitioners contracting between a pilot and a non-pilot district. A quasi-experimental ecological study design was used to compare district hospital outpatient department indicators of clients follow-up, self-referral, self-referral rate and referred in the two districts from June 2012 to May 2014 using single and controlled interrupted time-series analyses., Results: Controlled interrupted time series analysis found decreases in self-referral rate (-1.8 [-2.2, -1.1] [ p < 0.0001]) and the initial trend of headcounts of self-referral (-516 [-969, -66] [ p = 0.0260]), but an increase in headcounts of referred clients (1293 [77, 2508] [ p = 0.0376]) in the pilot compared with the non-pilot district., Conclusion: We concluded that the implementation of contracting private medical practitioners in primary healthcare facilities might have resulted in an improved perceived quality of care at primary health care facilities. However, the higher number of outpatient department headcounts for follow-up and the increase in referred cases in the pilot district would need to be investigated., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2021. The Authors.)