The illusion of prescription drug coverage in Ghana

I am spending this week visiting health care service providers in Tamale, in order to find out more about how Ghana's national health insurance works.

Ghana's national health care scheme is supposed to be open to anyone.  The cost is low (although I am still trying to figure out the exact price; I suspect it varies by region), and some groups, including pregnant women and the very poor, get coverage for free.

My first couple of stops were at pharmacies, and what I found out about how they deal with insurance was fascinating.  Like Medicaid and Medicare in the United States, Ghana's national health insurance plan does not reimburse service providers at the same rate as private insurance, or the rate that would be charged to those with no insurance.  The national health insurance may reimburse pharmacies at perhaps 75% of the market price for many drugs.  To make up for this, pharmacies require patients to "top-off"-- to pay the difference between the market price and the insurance price.

Although this difference may only be 25 cents or so, many people cannot afford it; those who are covered for free are usually so poor that they cannot buy food. Another alternative is for the patient to accept a smaller quantity of the drug, while the original quantity is reported in the insurance claim. (I'm not an expert, but I'm pretty sure that would constitute Medicare fraud in the United States.) Finally, in some cases the pharmacist will give the patient the medicine without requiring the top-off, and the pharmacy will take a loss on that transaction.

The National Health Insurance Authority expects pharmacies to behave as health providers in the United States, and accept the prices they are given.  However, Ghanaian pharmacies are required to accept insurance, and for many, a large share of their patients use the national health insurance.  They could not survive on the prices set by the national insurance.

I have heard that the prices are too low because the price list is not updated frequently. I do not know if this is true. Raising the prices will certainly make the already-struggling insurance scheme more expensive.  It may be that a co-pay on drugs could even make sense.  However, it will not work for the poorest of the poor, and pharmacies should not be alone in bearing the cost of providing medicines to these people at below market rates.