Chris Atim and Ama Fenny share experiences with co-production approaches to strengthen health insurance in Ghana
Ghana’s National Health Insurance Scheme (NHIS) aims to provide all residents with financial risk protection for, and equitable access to, a package of essential health services. Launched in 2003, the NHIS continues to grapple with operational and public perception challenges such as severe payment delays and allegations of fraud. [1-3] To address these challenges, in September 2015 the President of Ghana established a seven-member Technical Review Committee to recommend ways to improve the NHIS.
Building consensus around challenges, priorities, and solutions
To build evidence for NHIS reform that drew on different perspectives, the Technical Review Committee held discussions with health providers, academics, local and international experts, legislators, civil society, and hosted public fora. Members were advised by a multi-stakeholder Advisory Committee and seven technical sub-committees focused on governance; strategic purchasing; financial sustainability; epidemiology and benefit package; information technology and e-health; monitoring, evaluation and research; and pharmaceuticals. The sub-committees also investigated areas of inefficiency and cost escalation in the NHIS, identified gaps in public knowledge about the NHIS, and assessed the validity of negative public perceptions. The Technical Review Committee also spoke with staff and patients during visits to regional health facilities.
The Committee proposed evidence-based solutions to challenges across four priority areas: sustainability, efficiency, equity, and accountability and user satisfaction. A national stakeholder meeting was conducted to build consensus and endorse the Committee’s final recommendations.
Learning from the co-production experience
The co-production process encouraged the participation of diverse stakeholders to build broad consensus around the root causes of the NHIS’s challenges and the design of potential solutions relevant to the Ghanaian context. For example, many residents in Ghana lack access to high quality, primary health care (PHC). The Committee’s primary recommendation was to redesign the NHIS so that all residents would have access to a defined, costed and affordable set of PHC services without any financial hindrance. Health providers would receive, prospectively, a fixed amount per resident in their catchment areas for a defined period whether residents use the services or not. Those with less need for health care would balance out with residents who had higher utilization. The recommendations also reflected the user perspective. The Committee proposed establishing a Patient Protection Council with power to investigate user complaints and medical errors. The Council would also make recommendations to improve the patient experience. 
Beyond the publication of the Committee’s report in 2016, bringing in the diverse perspectives of people, institutions, and agencies yielded additional benefits.  The co-production approach combined academic rigor and a platform to engage a wide network of stakeholders. During NHIS review meetings, researchers, government representatives and other stakeholders built stronger relationships by sharing their different knowledge and perspectives on the NHIS. Stakeholders trusted each other more and felt freer to express both supportive and contrary opinions. They agreed on mutually beneficial outcomes where previously there had been considerable tensions and disagreements about the NHIS. They also cemented future partnerships. For example, research and other stakeholders in the 2016 NHIS review participated in subsequent reviews of other health financing documents and strategic plans, such as the review of Ghana’s Health Financing Strategy in 2019.
Despite these benefits, there were some challenges to the NHIS review experience. The co-production process was more time intensive than conventional forms of research or knowledge production due to the diverse group of stakeholders involved. Substantial staff time and commitment was needed to engage with partners and to prepare for sub-committee meetings. These regular meetings were important however for addressing the conflicting opinions of stakeholders. The discussions ensured all stakeholders had time to review the evidence, voice their concerns, especially when the evidence did not align with their own agendas, and agree a way forward.
Another challenge was the change in government soon after the publication of the 2016 report which contributed to a piecemeal uptake of the Committee’s recommendations. However, the issues raised in the report still dominated the health agenda in Ghana, and in response the new government continued a study started by the Technical Review Committee to examine the feasibility of the report’s primary recommendation to redesign the NHIS’ benefit package. The government is using the analysis to guide NHIS policy reform.  The 2016 report has also become a key part of discussions at health sector meetings on financing, as evidenced at the 2019 Ghana Health Financing Forum in 2019. 
The co-production approach for NHIS reform overcame previous tensions to strengthen co-ownership of the review process and collaboration among diverse stakeholders. As co-production approaches continue to be used within reform efforts in Ghana, the NHIS experience reinforces substantial benefits can be gained from genuine partner engagement in the co-production of knowledge. 
Read the full collection online here.
Chris Atim is a Senior Program Director at Results for Development Institute, Ghana.
Ama Pokuaa Fenny is a Research Fellow at the Institute of Statistical, Social and Economic Research, University of Ghana.
Competing interests: CA was Chair of the Presidential NHIS Technical Review Committee. AF was a member of the Monitoring and Evaluation Technical Sub-Committee of the Presidential NHIS Technical Review Committee.
This article is part of a series produced in conjunction with the WHO and the Alliance for Health Policy Systems and Research with funding from the Doris Duke Charitable Foundation. The BMJ peer reviewed, edited, and made the decision to publish.
- Alhassan RK, Nketiah-Amponsah E, Arhinful DK. A review of the National Health Insurance Scheme in Ghana: what are the sustainability threats and prospects? PLoS One 2016;11: e0165151
- Presidential NHIS Technical Review Committee. Proposed Redesign and Restructuring of the National Health Insurance Scheme. Accra, Ghana: Presidential NHIS Technical Review Committee, 2016.
- Haw NJL. Utilization of the Ghana National Health Insurance Scheme and its association with patient perceptions on healthcare quality. International Journal for Quality in Health Care. 2018. doi:10.1093/intqhc/mzy185.
- Ghanem SA, Bayer S, Stephens P, Nudo E. June 2019. Actuarial Modelling Exercise: Final Report (NHIS, Ghana), unpublished.
- Ministry of Health, 2019. Ghana Health Financing Forum 2019: Forum Report. Unpublished, MOH, Accra, Dec 1, 2019.
- The World Bank Group, 2020. Strengthening Primary Health Care Services to Attain Universal Health Coverage (UHC). https://www.globalfinancingfacility.org/ghana.