With the aim to assess the operations and performance of PHIS in Ghana, eight (8) participants were interviewed from across four PHIS in Ghana. Table 1 shows the sociodemographic characteristics of the study participants.
Six (6) themes were generated from the data analysis to assess the operations and performance of PHIS in Ghana. These were; (1) regulations and registration processes for PHISs, (2) operations of PHISs, (3) benefit packages provided by PHISs, (4) policy subscription and payment for PHISs, (5) growth of PHISs, and (6) clientele coverage of PHISs.
Regulations and registration processes for PHISs
Regulations for PHISs represent a fundamental aspect of the PHI landscape. It encompasses the intricate set of rules and guidelines that govern the operations and conduct of PHISs within the country. These regulations are pivotal in shaping the framework within which PHISs function, ensuring they meet established standards and adhere to legal requirements. This study sheds light on the effectiveness of regulatory mechanisms, identifies potential areas for improvement, and assesses the overall health of the PHI sector in Ghana. Some statements, such as one made by P04, express an unwavering commitment to compliance.
“…we are fully authorized by the National Insurance Authority as a regulator. We are the first private health insurance company in Ghana. We are the pioneer in the industry so we don’t default.” (P04, regional manager)
The regulatory process with authorities in the PHI sector in Ghana was a multifaceted and crucial aspect of their operations. It involved several key requirements and steps that companies needed to adhere to function effectively. This process entailed obtaining licenses from the Health Facilities Regulatory Agency (HeFRA) and accreditation from the NHIA to ensure the provision of medical care to clients under medical insurance. P08 shared:
“…before we work with any health facility, there are two things involved. They should have a license by HeFRA assessment. In addition, they might also go and see NHIA for another accreditation that enables the participant to provide medical care to any client on medical insurance. Any company that hasn’t done that, we can’t operate with them.” (P08, operations manager)
Challenges with registration revealed varied perspectives and experiences among PHISs in Ghana regarding the registration process with the NHIS and the Regulatory and Development Agency (RDG). Some respondents, such as P02, indicated a smooth registration process, emphasizing that compliance is generally hassle-free when the necessary funding is in place.
“Not at all. The only time that you have a problem is when you decide to go off sheet with their instructions. Okay, yes, but for registration, we don’t have any issue.” (P02, assistant manager)
Others like P04, raised concerns about challenges related to license renewal and credentialing requirements.
“…the challenge is the renewal of the license with NHIA. I mentioned that they said as part of the requirement, every provider should be credentialed. But for some reason, they don’t do anything with NHIA, though they have HeFRA…” (P04, regional manager)
Operations of PHISs
Participants shared the operational strategies employed by their health insurance companies. PHISs proudly emphasized their nationwide coverage, reinforcing their commitment to providing extensive medical insurance services throughout Ghana. The statement below illustrates an operational policy share by P08.
“So operationally, we are across the country. That’s why we are [name of PHIS].” (P08, operations manager)
The findings revealed an array of insurance policies tailored to meet the unique needs of various clientele. PHISs have an assortment of policy types, each designed to cater to different segments of the population. These policy types include family, corporate, and group packages, reflecting a commitment to inclusivity and accessibility. P01 shared:
“We do family, cooperate, and then groups packages.” (P01, regional manager)
Notably, there is also a strategic shift towards extending coverage to the informal sector through micro-insurance, acknowledging the sector’s unique income structure as shared by P05:
“When we came into the industry, almost all the companies were focusing on the formal sector, we also wanted to do more for the informal sector. And because the informal sector doesn’t have a structured way of earning income, we decided to do a micro way of helping them pay their premiums…” (P05, chief operations officer)
Benefit packages provided by PHISs
Benefits packages are a critical aspect of PHI, encompassing a broad spectrum of healthcare services provided to policyholders. Policyholders typically receive coverage for both in-patient and out-patient services, with some variations in benefit limits depending on the specific insurance plan. The findings illustrate varying benefit coverage offerings, revealing discrepancies in the limits imposed. For instance, P07 emphasizes a yearly outpatient benefit of GHc20,000 and GHc16,000 for in-patient services.
“Our benefits cover everything at the hospital. We have in-patient and out-patient benefits. It covers both out-patient and in-patient benefits but there are limits based on the amount. For instance, for a family of 4 as I stated in my first example, the outpatient could be GHc20,000 for outpatient benefit and GHc16,000 for in-patient benefits for the whole year. The family would be expected to spend from these including ambulance services and x-rays and all scans.” (P07, operations manager)
Additionally, P03 introduces a unique plan called the “X-scan plan” focusing exclusively on medical imaging services. These differences suggest that PHISs offer diverse benefit coverage options, catering to the different healthcare needs and financial capacities of their clients.
“So, for us, we currently have a product called the X-scan plan… The X-scan plan is giving insurance cover for only medical imagining services which is a very expensive service.” (P03, sales manager)
Participants shared varying approaches for claim processing across different providers. These statements from various health insurance companies shed light on their respective claim processing procedures and waiting periods. P01 emphasizes a quick and efficient claim processing system, earning the trust and recommendations of healthcare facilities.
“We pay our claims on time so most of our referrals are from the health facilities we work with who recommend our services to people. Most of our service providers are happy with how fast we process our claims…” (P01, regional manager)
In contrast, P06 highlights a distinct advantage by offering no waiting period, ensuring immediate access to benefits.
“Okay, with some of our competitors, once you fill the form, they will give you a waiting period like say six months, one year. So, if after six months, nothing happens to you, then you can enjoy the benefits but with us, there’s no waiting period.” (P06, assistant manager)
Policy subscription and payment for PHISs
The findings show the processes and conditions involved in obtaining and maintaining a health insurance policy from these private providers. The subscription conditions for PHIS were characterized by a consistent emphasis on full disclosure from clients. Some institutions, as exemplified by P01, stressed the importance of clients honestly providing information about their medical history and conditions during enrollment.
“We expect every client to disclose as our enrollment forms even list out certain illnesses. Full disclosure is expected from anyone who enrolls in our packages. It would be better for a client to be wholly truthful so we would know if it is the premium we would have to increase or any other means to help the company and the client so that no one is on the losing end in our client forms, we allow clients to tell us of their pre-existing conditions as have a list of some of those ailments listed on our enrollment forms.” (P01, regional manager)
The payment structure among PHIS exhibited a variety of approaches. Some had a corporate package system, requiring a 50% upfront payment followed by quarterly installments until the end of the year. P07 shared:
“No, we don’t do monthly, quarterly, or mid-year renewals. However, if it is a corporate package, we expect 50% upfront payment then we spread the rest to be paid every quarter till the year ends.” (P07, operations manager)
Moreover, others offered flexible payment plans, allowing policyholders to choose between 1-month, 2-month, 3-month, or 6-month payment options. These diverse payment methods within the PHI industry highlight the range of choices available to clients, with some providers still considering the introduction of monthly subscriptions. P05 shared:
“We have a 1-month payment plan, a 2-month payment plan, a 3-month payment plan, and a 6-month payment plan. So, if you are on a one-month payment plan, it means we are giving you one month to pay your premium….” (P05, chief operations officer)
Difficulties associated with large upfront payments and the preference for more affordable monthly subscriptions were also mentioned by P02.
“…that clause has also given us some challenges because there are average Ghanaians, somebody might not get chunk money to register, somebody prefers going the monthly subscription rate which is somehow more affordable.” (P02, assistant manager)
Growth of PHISs
The growth pattern of PHISs presents a multifaceted narrative. While some institutions, like P01, experienced initial setbacks during the onset of the COVID-19 pandemic, they eventually rebounded due to the urgency of health concerns.
“We have grown since our establishment 5 years ago. In the last 3 years since the COVID-19 pandemic hit Ghana, we stumbled in the beginning but business picked up because health is a crucial issue that doesn’t give prompts and can’t wait because of economic issues. When it hits, and you need to find a solution because that is life.” (P01, regional manager)
In contrast, P06 highlighted a significant and consistent expansion in their clientele base over the years, underscoring their quality services.
“The growth has been massive because in 2004 when we started, we had few of our clientele base, but due to our quality services, we have increased the market share. Yes, there has been some remarkable growth.” (P06, assistant manager)
Contributing factors to the growth of PHISs were multifaceted and had played a crucial role in shaping their success in the past. These factors, as articulated by participants include strategic investments in profitable ventures, leveraging referrals and positive client testimonials, and the promptness of claim payments. P07 shared:
“We invest our proceeds in profitable ventures, referrals, and testimonies of clients and claim payments have been a contributory factor to your growth” (P07, operations manager)
Additionally, partnerships/collaboration between other insurance companies, have also been instrumental in expanding membership and sustaining the growth of PHISs in the Ghanaian healthcare sector as shared by P03:
“To increase membership and sustain the company, [name of institution] has partnered with [name of patterning institution] …” (P03, sales manager)
Clientele coverage of PHISs
The location concentration of clients on PHI was predominantly in urban areas. These urban centers, particularly regional capitals such as Accra, Kumasi, Takoradi, Tamale, and Sunyani, served as the primary hubs for PHI clientele. Participants suggested that their focus was on individuals and organizations within these urban zones, with an emphasis on sectors like education, notably teachers. P04 shared:
“So, our client-based typically are within Accra, Kumasi, Takoradi, Tamale, and Sunyani; mostly of the regional capitals, we only have the workers, mostly teachers…” (P04, regional manager)
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