There is no doubt that the Public Health Insurance System established by the Government of Ghana has played a major role in the delivery of health care to all Ghanaians. The Act that set up Health insurance in Ghana (Act 650) proposed the establishment of two health insurance platforms: a national or public health insurance scheme supported with the national health insurance levy to offer care to “all” Ghanaians and a private health insurance scheme to provide an alternate health coverage to private individuals who could afford it. The National Health Insurance Scheme (NHIS), despite all the “issues” associated with it, has brought accessible healthcare to a lot of Ghanaians who ordinarily could not have afforded it. The myriad issues being experienced and endured by enrolees of the NHIS are well documented and in public knowledge. Radio presenters have spoken about it and articles have been written in several newspapers about the performance of the NHIS. The purpose of this article is not to re-echo these known issues, but to throw a bit of light on the Private health insurance schemes and also to suggest some ways of enhancing their operations so that as a country we can have a vibrant and functional private health insurance sector. The National Health Insurance Act governing the operations of health insurance in Ghana proposed the establishment of two types of Private Health Insurance schemes - a Private Mutual Health Insurance Scheme and a Private Commercial Health Insurance Scheme. The Private Mutual health insurance schemes (PMHIS) was supposed to be an ‘organisation – service provider’ directed scheme wherein individual organisations could go into agreement with service providers to provide health care to their members for a fee. The fee for the services provided was to be paid for at an agreed predetermined rate and in advance to the service providers by their enrolling organisations. At the end of each service period, the service providers and their partner organisations were to sit over the health care expenditure and reconcile all the figures. Gains made for less use of services were to be shared between the agreeing parties at predetermined ratios. Similarly, losses made by the service providers as a result of overuse of services were to be reimbursed at an agreed ratio. This is the basic tenet and legal basis of the mutual health schemes – well-crafted to offer security to both the service provider and the enrolling organisation. To facilitate easy administration of these schemes, the law permitted third-party organisations -- called the mutual scheme administrators -- to operate these schemes and ensure trust between the real engaging parties, the service providers and their enrolling organisations, and also to allow for the smooth running of the schemes. The mutual scheme administrators were supposed to be non-profit making organisations working in the interest of the ‘real’ engaging parties. The Private Commercial Health Insurance Schemes (PCHIS) are however to be operated as full private commercial entities and therefore profit making enterprises. PCHIS’s are financial products couched under insurance principles aimed at offering readily available quality healthcare to enrolees while generating profit for their owners and administrators. Organisations who signed onto these schemes passed on their health risks to these financial institutions after paying the actuarially determined premiums. Whatever happened after the payment of such premiums was a risk to be borne by the PCHIS’s. There is no opportunity of cost-redemption from the enrolee at the end of the agreed service period. In this light, therefore, private commercial schemes were to employ and apply all the insurance principles of risk-pooling and risk-sharing, actuarial premium determination, good administrative and management principles, as well as good investment principles, to be able to offer the quality health care sold as products to their enrolees. Again, the PCHIS’s are required to have the financial backing and wherewithal to be able to pay-off all accruing losses due to all the uncertainties with service utilisation by enrolees, as seen in all forms of insurance. The law that sets up these schemes proposed a registration fee of GH¢500,000 for all private commercial schemes. This fee was to be lodged in an ‘escrow’ account at the bank of Ghana. This money was to yield an interest that was to accrue to the account of the private commercial company as well as offer back-up for payment of medical bills if the need ever arose. Companies that are operating as PCHISs know the full implications of their business, and hence supposedly are well-equipped to operate and implement those business strategies for profit. The National Health Insurance Law since its passage has seen the establishment of about six private mutual health schemes and one private commercial health scheme. Quite recently a couple of mutual schemes have sprouted, adding to the growing number of mutual health schemes. These mutual health schemes have been a source of employment for many young and able Ghanaians and have been offering health care to a good number of Ghanaians as well. While agreeing that these PMHISs need to be encouraged to continue their immense service in the provision of health care to many Ghanaians, there are a lot of challenges with these mutual health schemes -- and addressing these challenges will go a long way to help Ghana build a great private health insurance sector. Foremost is the fact that these Private Mutual Health Insurance schemes (PMHISs) are being run by independent managers as for-profit organisations instead of their legally being recognised as not-for-profit organisations. Apart from this, the services being covered under the schemes administered by the PMHIS companies are similar if not the same as that offered under the socially subsidised NHIS. In effect, beneficiaries who are almost always already registered under the National Health Insurance Scheme (NHIS) end up paying twice for the same service they would have accessed under the NHIS. There is need for the regulatory authority to dialogue with these PMHIS’s so as to find ways of enhancing the coverage for care under the PMHISs; such that it becomes a top-up to the services offered under the NHIS. Again, service providers engaged under contract with these PMHISs have had to endure months of delayed payment for services already provided to the enrolees. Some of these delays are genuine and result from administrative procedures involved in the claims processes. Vetting of claims is currently a paper-based process for most of these PMHISs -- hence most of these companies, if not all, have to practically go through each of those millions of paper-submitted claims every month to arrive at post-vetted amounts for each service provider before payment can be made. In some situations, however, these delays are purely due to unavailability of funds for payment. The unavailability is as a result of insufficient funds in the premium pool to start off with, or due to problems with the management of the premium pool. To solve the problem of delayed claims processes, the PMHISs must move from paper-based claims submission to electronic claims submissions using a very reliable claims processing software. This will cut down the claims-processing time by about 80% as well as eradicate most of the issues such as poor handwriting, wrong calculations and wrong patient identification information as seen with the paper-based claims submissions. Another problem being faced by many of the PMHISs is that the Schemes are run by people without an adequate Health Insurance background. Currently, the National Insurance College does not run any diploma course in Health Insurance. Most managers of these schemes therefore have to transfer their knowledge from general insurance into health insurance. The two may sound similar, but the critical issues involved are not the same. In order to enhance the operations of these schemes, the NHIA and these PMHISs must engage the National Insurance College to craft a programme or course to update these managers with the critical issues needed for the smooth running of such schemes. Adequate education will also help address another major issue of correct and actuarially determined premiums facing almost all the PMHISs. Currently, most of the PMHISs charge premiums based to a very large extent on what other competitors in the market are charging for the provision of coverage for similar service packages. The competition is so fierce that within the Private Health Insurance industry there is a Red ocean of bleeding companies. Survival depends on how well a company can undercut the market. Technically therefore, and in simple terms, PMHISs are charging way below the actuarially determined premiums for almost all their service packages. Those who are charging the right premiums are losing their clients to those who are undercutting the markets. The bottom-line is that client organisations who sign unto these schemes offload their health risks to these Medium enterprise organisations (PMHIS’s), who because they charge low premiums end up subsidising the health care bills of these large enterprises. At the end of the insurance year, these large enterprises make huge health care budgetary savings while the PMHISs struggle to survive on the meagre premiums it received. Those who hope to do well must do so at the expense of reduced quality of health care to the enrolees, achieved through strategies such as use of generic-only prescriptions and use of “lower-charges, low-quality” service providers. If left to the markets alone, this competition for premium under-cutting will never end and we may end up with collapsed PMHIS organisations with huge health care debts sitting on their account books (just trying to avoid the use of the word bankruptcy). There is need for all these PMHISs to collaborate as a single unit to enhance their bargaining power regarding premium charges. They should also agree to a certain minimum charge for service coverage, below which no company should be allowed to charge the client. Despite all these, some of the enrolee organisations after having being offered low premiums also end up delaying payment of these premiums. The premiums are already determined at the beginning of the insurance year and this is spread to be paid on biannually, quarterly or monthly basis to the PMHIS. This mode of payment of premium, however flexible it is to the enrolling organisation, also deprives PMHISs of the opportunity to have all their premiums in advance so as to benefit from good investments and raise the earnings on their investment income. With the current economic climate, investing these sums do not yield very high margins; so not investing at all even worsens the plight of these companies. A way around this is to charge interest on all outstanding premiums at rates similar to what the PMHISs would have earned had they invested the money at the start of the insurance year. Some of the PMHISs are doing this to good effect. Another problem being faced by PMHISs is the issue of service over-utilisation. PMHISs have to battle with high utilisation for services by almost all their enrolees. Ghanaians in general have a notion that once a person is on any form of health insurance, he should access the health care at the least sight of ill-health. Although most of these PMHISs have annual limits of utilisation per individual, enrolees end up utilising up to about 90% of those annual limits. When put together, the schemes end up losing a lot of funds due to this over-utilisation of services. This is a key problem that may never go away unless the whole country embarks on nationwide education on what Health insurance is and how each enrolee can take responsibility for his own health care as well as that of other enrolees. Until then, PMHISs can attempt to set monthly limits of enrolee visits to service providers or enforce the Gate-Keeper system of service access. This may help to an extent. Above all these, PMHISs are competing with other major international health insurance companies like Vanbreda, GMC, Allianz Worldwide Care, AXA Assistance, BCS Insurance, BUPA, CIGNA International, SOS International, Oracle Med Health, Medaire, Euro Centre and so many others. These are the companies preferred by many expatriates who are trooping into Ghana after our oil-find. These insurance companies use the same service providers available in Ghana, though they charge their enrolees huge premiums. How do we as a country build a better Private Health insurance system to be able to provide added health care and coverage for our already struggling Public NHIS? How do our PMHISs strategise to cash in on our oil find (and the increasing number of expatriates working and living in Ghana)? How do the PMHISs compete with these invading International Insurance Companies? How do our Hospitals and other service providers benefit from the Private Health Insurances to improve their quality of service? These are critical questions that we need to ask and answer as a people. If Ghana wants to set up a vibrant private health insurance sector that will support the NHIS by offering good quality, reliable and affordable health care to its citizenry -- as well as create jobs for the many unemployed youth -- then the National Health Insurance Authority must play its oversight and regulatory role over the private health insurance market (both local and international) and help to solve all these challenges faced by our Private Mutual Health Insurance Schemes. The PMHISs must also take the bull by the horns, collaborate under one umbrella, and set the playing turf such that this zero-sum game they are currently playing can become a win-win one.