Dedicated at first, discouraged later

Ask Tony Fiakpu about his workplace and he points to his orange 2003 Opel Kadett. Tony is a taxi driver in Accra, the Ghanaian capital with an estimated population of five million people. Everyone in his family contributed to buying the car, he says, but in February last year he nearly had to sell it again. Fiakpu broke his ankle when playing football. He had to be hospitalised. “It was a complicated break,” he says. “Our savings would have never been enough for the treatment.”

Fiakpu kept the car nonetheless. He was lucky enough to be covered by a health microinsurance scheme that had set up shop in his neighbourhood. The insurance paid for his entire treatment. For quite some time, he has been driving his orange-coloured taxi around Accra again. “Initially, I wanted to save the money,” he says, “but now I'm happy I paid the insurance premiums instead.”

Fiakpu was fortunate in misfortune, says Andreas Grüb of the Centre for International Migration and Development (CIM), a German aid agency. Grüb has been involved in Ghanaian healthcare issues for 23 years. He first worked for the GTZ and now for the CIM. He knows of other cases, with less happy endings. All too often, he says, young men fail to understand why they should spend money on a health insurance. “They’re still young and healthy, and they believe that nothing will happen to them. But if something does happen, they’re forced to sell things they need to survive, like cattle or arable land.” Or the recently bought taxi.

There are many such stories in Africa, since only very few health insurance schemes operate south of the Sahara. Just two percent of Africans are covered by a health insurance, which, of course, should be an indispensable protection from poverty. The double-whammy of poverty plus illness destroys millions of people’s livelihoods in developing countries. Those who have tough work but suffer from malnutrition and live in unsanitary conditions are especially at risk. The costs of medical treatment, moreover, often plunge people who struggled hard to get out of poverty right back into it.

Remarkable story

Ghana is a politically stable country in the midst of unstable West African neighbours. It is also ahead in terms of healthcare. A national health insurance scheme was started in 2004; premiums are affordable; the catalogue of services measures up to Western standards.

The country’s history in this regard is remarkable too. Healthcare was funded by the government and free for everyone after independence. In 1983, however, the International Monetary Fund (IMF) and World Bank pressured Ghana in 2003 into introducing fees for health services, and healthcare became unaffordable for many people.

The first self-help groups started forming in the 1990s. Members pooled the little money they could spare and used those funds to pay for treatments. This was the birth of health microinsurance schemes. By the turn of the century, 47 such programmes were operating around the country.

It did not take long for state officials to find out about the schemes’ success. In 2004, the health ministry adopted the concept of the self-help groups and expanded it into a countrywide system of state-funded health insurance. Various microinsurance schemes were bundled into national programmes. They would no longer just help local residents in one place but cover all 145 districts of the country.

The government, moreover, established a microinsurance programme of its own in places where there were no self-help groups. By 2009, more than 61 % of Ghanaians had health insurance coverage – a breathtaking rate by African standards.

Grüb says the policy has been a remarkable success. “We never thought that we might develop a successful model for a nationwide healthcare system from small self-help groups,” he says. But he fears for the future. “The system’s long-term solvency is at risk,” he adds. “The government has already had to intervene on a broad basis. Three-quarters of the budget comes from taxes. A mere 38 % of the members pays premiums, and many are covered by other persons’ policies at no charge, for instance children or the completely destitute.” The risk pools of small self-help groups are too small to shoulder such costs. Their revenue tends to lag behind their expenses.

In 2008, several of the health microinsurance schemes ran into financial difficulties at the district level for the first time. Nonetheless, Grüb reports, plans are still afoot to further expand the already substantial services covered by the insurances (Grüb, 2007). Poor understanding of how commercial insurances operate – not so much among the self-help groups as in the government – is undermining the schemes, he warns.

The Lack of qualified staff

Like in most African countries, a core problem of Ghana’s healthcare system is the lack of qualified staff. Not only hospitals in remote regions are affected, but so are many microinsurance schemes. Young people who have invested in expensive vocational training are turned off by the isolation of rural life. They seek their fortune in Accra instead, where they hope some day to pay off the debt they incurred for training. There are well-educated but jobless doctors and teachers who while the day away in Accra doing nothing.

A professional health microinsurance scheme depends on qualified staff, whereas a self-help group survives and thrives on the commitment of its members. At the outset, Ghana’s self-help groups were self-sufficient, and so were their insurance schemes. Members found a way to protect themselves against the consequences of illnesses that threatened their livelihoods. They ran the organisations themselves, and negotiated contracts with hospitals and healthcare providers.

State intervention ended this freedom in the past decade. Now uniform conditions apply all over the country. At the same time, the sense of personal commitment to one’s self-help group dissipated. The schemes now need qualified employees, but in Ghana’s more remote regions, it is next to impossible to hire such people.

The non-grassroots health microinsurances, which the government established at the village level, face similar problems too – and others on top of them. Where people had shown no interest in taking their fate into their own hands, the government unsurprisingly failed to spur their personal engagement. Clients merely demand services in exchange for the premiums paid.

Helpless self-help groups

“When the government took charge it stripped away many members’ motivation to stay involved with their groups,” says Gerald Leppert who studies cooperatives at the University of Cologne and has coordinated research on African self-help groups. Leppert argues that the health ministry showed too little interest in group dynamics: “No officer asked: ‘What is it that makes self-help groups tick?’” This was what a research project of Cologne University studied. Several African partner universities were involved, and one of them was the University of Ghana.

The scholars also engaged in capacity development. “The goal of our ‘Pro Micro Health Insurance Africa’ project was to help all participants – the heads of the many microinsurance firms on the ground as well as the government agencies – and to provide them with the necessary expertise,” says Leppert, who coordinated the project. The focus was on providing basic insurance know-how while taking into account the characteristics of self-help groups. Participants were issued a document certifying their qualification to run a health microinsurance scheme. “The interest was huge,” Leppert reports, “our brochures were really hot items at workshops.”

The project, which got € 500,000 of EU support, ended in April 2010. Was the effort worth it? Leppert says that will only become clear in the long run, depending how the Ghanaian healthcare system develops over the years.

CIM expert Grüb equally advises for patience. All too often, the promises top government officials make cause doubt among foreign specialists: “Take the current health minister, Benjamin Kunbour,” Grüb says. “He’s a technocrat, he’s invested a lot of money in a satellite-based system that is supposed to make data stored on insurance cards available around the country in a flash.” The snag, however, is that officials have completely fallen behind with the distribution of the cards. “We lack a flawless accounting system; we can’t say who has paid their premiums and who has not,” Grüb says. “What does Ghana need an expensive satellite-based system for?” In his view, the success of a promising project is being put in jeopardy.

In the last election campaign, President John Atta-Mills – who took office in January 2009 – said he would introduce a single premium. Whoever paid it once would be insured for a lifetime. It sounds too good to be true – and it gives people like Grüb or Leppert a headache. “If this single premium isn’t calculated with great precision and responsibility,” Leppert warns, “the entire system may be bankrupt in a few years.” Here’s hoping that at least a proper accounting system will be in place by then.