Mutual Aid in Paying Medical Fees : Acceptance of the National Health Insurance Scheme in Southern Ghana

<p>In 2004, the National Health Insurance Scheme (NHIS) was introduced in Ghana, and the scheme has since become widely used. The people concerned can now select a new way of paying medical fees. This paper discusses how the new way of paying medical fees is related to face-to-face mutual aid. Previous studies suggest that insurance has undermined face-to-face mutual aid, replacing it with anonymous mutual aid and individualistic preparation. Additionally, in Sub-Saharan Africa, since structural adjustment, paying medical fees has been one of the activities that most activates face-to-face mutual aid. In that context, we can speculate that NHIS in Ghana has replaced face-to-face mutual aid in the payment of medical fees through anonymous mutual aid and individualistic preparation. However, by examining both (a) institutional features and the diffusion process of NHIS and (b) experiences taking out insurance, this paper illustrates that NHIS is not necessarily undermining face-to-face mutual aid, but is producing a new domain for face-to-face mutual aid. This study focuses on the Kwaebibirim District Mutual Health Insurance Scheme (KbMHIS) and town "A" in the western part of the Eastern Region of Ghana, where I conducted fieldwork for a period of 18 months. Approximately 2,000 people over the age of 18 live in town "A," where cacao, oranges, palm, timber and bauxite are the main products. In Kwaebibirim district, about 62 percent of the population is registered with KbMHIS. Generally, whether insurance has features of anonymous mutual aid or individualistic preparation depends on the "fine print," such as regulations about premium burdens or policy coverage. NHIS has three features: (1) it presumes all the insured persons have the same risks, (2) it exempts aged people and children under 18, and (3) it is supplemented financially by the national budget. For those reasons, NHIS is an institution of anonymous mutual aid rather than individualistic preparation. However, this anonymous mutual aid is primarily at the district level, and its participants are limited to the insured. The annual premium for KbMHIS is 120,000 cedi. This amount is not exorbitantly expensive, yet not easily affordable for everyone. Many people living in town "A" can afford the premium through the saving practice known as susu. There are three types of susu in Southern Ghana: (1) Rotating Savings and Credit Associations (ROSCA), (2) susu collectors, and (3) bank susu. As ROSCA are based on social networks such as kinship and friends, those who use susu collectors and bank susu do so to avoid the associated obligations of those networks. If an uninsured person incurs a high medical bill, she can resort to face-to-face mutual aid, such as with family members or friends. However, it is rare that someone resorts to it for insurance. Also, users of susu are able to avoid contributing to another person's medical bill. Because of that, it can be said that the existence of health insurance tends to weaken face-to-face mutual aid when medical fees are paid. Yet, the importance of face-to-face mutual aid is preserved in other domains. Health insurance also has gambling-like qualities. Those insured can receive medical services and pharmaceuticals free of charge, but they cannot get a refund if they do not become sick. On the latter point, most people discuss it in terms of an extension of concrete mutual aid, instead of as addressing the risk of high medical fees. There are minute differences in attitude towards insurance between accounts that emphasize mutual aid and those that emphasize the dangers of high medical fees. Accounts that emphasize the danger of high medical fees are predicated on a sustained period of subscription, because the danger of becoming seriously ill is certainly not limited to when one is subscribing. In contrast, in the case of accounts focusing</p><p>(View PDF for the rest of the abstract.)</p>