Catastrophic health payments in Ghana post-National Health Insurance Scheme implementation : an analysis of service-specific health expenditures

Background: Ghana implemented several health reforms in the 1970s and 1990s. Still, several access barriers persist, including high out-of-pocket (OOP) spending, which led to the implementation of the National Health Insurance Scheme (NHIS) in 2003 to achieve Universal Health Coverage and lower OOP spending. This study evaluates the incidence and intensity of catastrophic health expenditure (CHE) among Ghanaian households post-NHIS, considering OOP health spending on different health services. Methods: Data came from the Ghana Living Standards Surveys rounds 6 (2012/2013) and 7 (2016/2017) and the Annual Household Income and Expenditure Survey 2022/2023. Key variables were OOP spending on three health service categories (medical products, outpatient and inpatient) and total expenditure. The incidence and intensity of CHE for various health service categories were calculated using service-specific thresholds. A household incurs CHE for each service when OOP health spending as a share of total expenditure exceeds the service-specific threshold. Results: Overall, at the 10% threshold, CHE headcount for total OOP health spending increased from 1.26% (95% CI 1.11% to 1.44%) to 11.45% (95% CI 10.86% to 12.07%) between 2012 and 2023. CHE gaps were also substantial for overall and service-specific OOP health spending. Medical supplies account for a large share of total OOP health spending, with CHE headcount rising from 1.34% (95% CI 1.18% to 1.53%) to 12.24% (95% CI 11.64% to 12.89%) between 2012 and 2023 at the 10% original threshold. Although the results were mixed, rural, northern and low-income households experienced substantial financial burdens. At the 20% threshold, the CHE headcount for inpatient services increased from 0.84% (95% CI 0.64% to 1.10%) to 4.38% (95% CI 3.83% to 4.99%) for northern dwellers between 2012 and 2023. Discussion/conclusions: Despite NHIS coverage, high-cost services like medical supplies, hospital stays and frequently used outpatient services substantially drive CHE in Ghana, particularly for underserved populations. Addressing them requires prioritised policy interventions to expand NHIS coverage for essential services and improve financial protection, especially for rural and low-income households.