From the 1970s onwards, Ghana implemented several health reforms in order to make healthcare more accessible, affordable, and high quality for its citizens. These reforms included:

• Primary healthcare strategy (1970s) with the aim to deliver “essential health services at the community level”
• Community-based Health Planning and Services (1990s), which decentralised the delivery of healthcare and improved “access to baisc health service provision in the country’s rural areas”

The National Health Insurance Scheme

Perhaps the most vital reform was introduced in 2003, with the dawn of the National Health Insurance Scheme, which aimed to address financial barriers to accessing healthcare. The NHIS, Ghana’s method for contributing to the achievement of Universal Health Coverage (UHC), was designed to cover all Ghanaians, “thereby reducing OOP health expenditures and ensuring equitable access to health services”.

The NHIS operates using a social insurance model, which is mostly funded through “value-added tax revenue and supported by household premiums, pension contributions and government subsidies”. As of 2021, around 16.75 million people (which constitutes around 54% of Ghana’s population) are enrolled in NHIS, which is a big win for the scheme. Not only this, but evidence from a systematic review published in 2018 suggests that “the national health insurance sheme of Ghana over the last 14 years has made some impact on reducing OOPEs” (out-of-pocket expenditures), and that the uninsured paid between 1.4 to 10 times more in OOP payments and were more likely to experience catastrophic health expenditures.

However, despite its successes, there are still several access barriers to healthcare for populations in Ghana. A recent analysis published in the BMJ Global Health, “Catastrophic health payments in Ghana post-National Health Insurance Scheme implementation: an analysis of service-specific health expenditures“, which analysed catastrophic health expenditure in Ghana between 2012 and 2023, found that, particularly among rural, low-income, and northern households, there are still significant financial burdens being faced. So we looked into that!

What did the analysis find?

Catastrophic-health-expenditure is defined at different ‘thresholds’. For example, the ‘10% threshold’ means that expenditures on health are larger than 10% of the total household expenditure or income, implying moderate hardship.

The report found that the percentage of households who’s out-of-pocket health expenditure exceeded this 10% threshold (and therefore was catastrophic-health-expenditure) increased from 1.26% to 11.45% for total health spending, and from 1.34% to 12.24% for health spending on medical supplies, between 2012 and 2023.

Not only this, but at the 20% threshold – so for expenditures on health that are larger than 20% of the total household expenditure or income, implying severe hardship, the percentage of households who experienced catastrophic-health-expenditure for for inpatient services increased from 0.84% to 4.38%, for northern dwellers between 2012 and 2023.

While the NHIS was created with the goal of decreasing the financial burden of Ghanaian families when accessing healthcare, the analysis shows that, 22 years after its inception, it is is falling short of fully protecting all households, especially rural and low-income groups

What are the reasons?

There are two prominent reasons why the NHIS is facing challenges, and it’s due to a disconnect between what it offers, and what is needed by those wishing to use it:

• Limited NHIS Coverage: While NHIS covers many services, it excludes certain treatments and medications, leading patients to pay OOP for these uncovered services. For example, spending on medical products, such as medicines and supplies, constitute the largest share of the total out-of-pocket health spending during the analysis period.
• Limited enrollment: While formal sector workers in Ghana are required to enrol in the NHIS, informal sector workers and the employed can register on a voluntary basis, and many don’t.
• Provider practices: Delays in NHIS reimbursements to healthcare providers have led some to charge insured patients directly, circumventing the insurance scheme.
• Inpatient care: Between 2016 and 2023, the number of people experiencing catastrophic health expenditure as a result of hospitalisation has risen sharply, making inpatient care, which is high-cost, one of the biggest drivers of CHE.

How can progress be achieved?

The authors of the BMJ bring many suggestions as to how household out-of-pocket health expenses can be reduced, such as expanding current NHIS coverage of certain drugs, including newer drugs and those which, despite being expensive, are cost-effective. Imprving not only the coverage of these drugs but also their accessibility will help pave the way to reducing CHE. Other suggestions by the authors include improving coverage of inpatient (and outpatient) care, particularly in those areas most impacted by CHE – namely rural and northern regions; increasing NHIS enrolment; implementing financial support programmes for low-income households; and allocating a higher amount of public resources to the public healthcare system.

How is the Elucid approach helping?

First and foremost, at Elucid, we recognise the NHIS for what it is: an ongoing commitment to Universal Health Coverage and improving the health of the citizens of Ghana. That’s why our approach does not, and would never, aim to replace the NHIS. What we do is complement the system by implementing health programs within smallholder farming communities, to ensure that healthcare is reaching those for whom it is most remote.

We facilitate NHIS enrollment for producers, workers, and their families, ensuring every household member is included and continuously covered. Our solution then takes NHIS enrollment and goes a step further, by managing renewals and collaborating with health authorities to share anonymized health data, ultimately supporting more coordinated and effective care. Where the NHIS coverage may fall short or be inconsistent, Elucid bridges the gap by subsidizing costs for essential and emergency services, including access to WHO-approved medications, maternal and newborn care, and urgent treatments in local facilities and hospitals. With backing from companies invested in supply chain sustainability, we’re ensuring that farming families can access high-quality healthcare without the financial strain that often drives them deeper into poverty.

Beyond access and affordability, we help improve the standard of care itself. We evaluate and strengthen partner health facilities using WHO guidelines: investing in infrastructure improvements, delivering staff training, and implementing quality upgrades to ensure faster, more reliable, and patient-centered healthcare. At a community level, we build health literacy through outreach campaigns, group sessions, and events, helping families understand the critical link between good health, productivity, and long-term economic well-being. And in areas where public services are too distant or under-resourced, our mobile clinics bring essential and specialized services, such as maternal care, immunizations, and vision screenings, directly to the doorstep of rural communities.

By building on the foundation of the NHIS, Elucid’s approach ensures that no farming family is left behind in Ghana’s journey toward truly equitable and universal healthcare.