**3.1 Ghana social health insurance Scheme**

Ghana is a middle-income country in West Africa with a total population of 28,207,000 in 2015 and gross national income per capita of \$3,880 in 2013 [51]. It is noteworthy that Ghana and Nigeria operate SHI (both known as National Health Insurance Scheme. Ghana began its SHI in 2004, just a year before Nigeria. Although Ghana has not achieved the recommended 90% UHC, it has become a success story in Africa within two decades of commencing the scheme, having covered about 64% of its total population. It has gone through different phases and challenges to reach this pedestal [6, 40]. Therefore, Nigeria can learn from Ghana how it was able to achieve this success, despite limited economic and human capital resources compared to Nigeria [11, 17]. Although, Ghana has not reached the targeted UCH goal, but it prides itself on achieving better health outcomes than Nigeria (see **Table 4**). This is not unrelated to its achievement so far with universal health coverage [33, 52]. While Nigeria's NHIS coverage stands at less than 5%, Ghana's rose exponentially from 6.5% in 2005 to 36% in 2010, then 40% at the close of 2015, and about 64% in 2018 [5, 6, 31]. In 2012, the previous National Insurance Act 2003 that established Ghana's NHIS was amended to accommodate some efficient changes, including merging all previously existing schemes into a unifying scheme under NHIS [5]. This 'umbrella' mechanism contrasts with the mostly fragmented NHIS in Nigeria, as discussed earlier.

One approach that helped Ghana to scale up coverage within a short time is the level of awareness and advocacy in the mass and electronic media [5]. Oni et al. has shown that the level of awareness of and access to NHIS has significant impact on service delivery [6]. The compulsory enrollment into NHIS by all residents of Ghana is another important reason why the scheme has been able to cover the country widely. This is in sharp contrast to Nigeria, where it is statutorily voluntary. Although Ghana's implementation of NHIS is faced with the problem of poverty like Nigeria, it has exempted the poor and other vulnerable groups from paying an insurance premium. This exemption resulted in increasing access and equity in healthcare. Although Nigeria NHIS made provision for the vulnerable group to include the physically and mentally challenged, prisoners, pregnant women, under-five children, and the aged, the reality in Nigeria is that no such exception is provided [5, 31, 52].

Moreover, enrollees of Nigeria NHIS still pay some hidden charges, co-payments and deductibles at the point of care, in contrast to Ghana, where no additional payment is required from their counterparts. Besides, there is a variable benefits package offered by Nigeria NHIS depending on the membership category. This is not the case in Ghana, where all benefit packages are uniform across the board using the diagnosis-related group (DRG). The most important factor contributing to the achievement recorded by Ghana is the fact that there has been an increase in total health expenditure as a percentage of total government expenditure to meet the 15% Abuja target. Moreover, Ghana finances 70% of its NHIS from taxation, used mainly for those exempted from paying the premium. The situation in Nigeria is the



*Source: World Bank [15]. (Adapted from Odeyemi and Nixon [52]).*
