Accra, Ghana - Right opposite Ghana's seat of government - the Flagstaff House - stands a giant billboard advertising the West African country's National Health Insurance Scheme. The billboard displays to Ghanaians from all walks of life the message: "Your access to healthcare," but the poor still struggle to get medical care.
One needs a special card to access healthcare for free, but it does not come easy and painlessly. Would-be beneficiaries must meet one unofficial requirement - be physically fit or forget about it. In Accra, the capital, people queue as early as 3am at the National Health Insurance offices to register.
"My legs are wobbling," 30-year-old Joyce Mintah, who was carrying a one-and-a-half-year-old baby boy on her back with another four-year-old boy, told Al Jazeera. She had spent close to eight hours in the queue at the Ablekuma Sub-Metro Mutual Health Insurance office in Accra, where the NHIS registration takes place.
Mintah, a teacher, had apparently asked for a day off to enrol her family in the 10-year-old social protection scheme, the biggest in Ghana. Looking miserable and almost at the point of giving up, she scoured her bag for her mobile phone to plead with her supervisors for an extra day off.
"It doesn't look like it will get to my turn today. I left home at 4:45am. We came with our own food, a chair and an umbrella. I can't imagine going through this stress again. I'm so tired. Besides I have to handle two children. The queue does not move and it will only take a miracle to get to our turn looking at the time."
Meanwhile, there is a commotion outside the compound where over 400 people are waiting under the rain with limited seats to register before dusk sets in. Mintah eventually had her card and those of her two children. A sharp grin quickly replaced her forlorn look. But it had been 12 long hours of uncertainty.
National Health Insurance Authority (NHIA) officials say they are aware of the registration challenges and are working around the clock to resolve them.
We came with our own food, a chair and an umbrella. I can't imagine going through this stress again. I'm so tired. Besides I have to handle two children. The queue does not move and it will only take a miracle to get to our turn looking at the time
"This is currently being addressed by the introduction of the instant identity card based on biometric data. Hitherto, it took members about three months to receive their cards after registering. However, with the new systems, subscribers get their cards instantly. The response to this has been overwhelming," Selorm Adonoo, the communications manager of the NHIA, told Al Jazeera, adding that this accounts for the huge numbers of people at the NHIS offices across the districts who want to register.
Of the nearly 25 million people in Ghana, the NHIS boasts of 10.1 million members since its inception, according to the NHIA website. It adds that close to 70 percent of all people on the scheme do not pay insurance premiums.
Children under 18 years, the elderly (70 years and above), pregnant women, the vulnerable (mentally challenged, disabled persons) and poor people are all exempt from premium payment. They get healthcare for free.
At least 1.12 million poor people were registered for free under the programme in 2013, compared to 342,000 registered in the previous year, thanks to outreach programmes by corporate bodies and religious organisations in the country.
However, there is a troubling perception about the health insurance scheme of this former British colony: The belief that prescription drugs given to beneficiaries are substandard.
"It doesn’t work," Victoria Commey, a trader at Lapaz, a suburb of Accra, said of the medicine. "When I go with the card, they give me a different set of medicines but when I forget and I pay on different occasions for the same ailment I receive different and effective medicine."
James Kumarh, a hawker at Mallam Junction in Accra, concurs, adding that cardholders receive poor medical treatment at the hospitals.
"I have heard it before and I have experienced it. Those of us with the NHIS cards spend a lot of hours queuing before seeing the doctor, but just walk in with your money ready and you'll be given express treatment."
Celine Mensah is a mother of three and has had three Caesarian sections. She only paid about half of the cost for all her surgeries thanks to the NHIS. The private hospitals charge at least $1,800 but with an NHIS card one pays about $600 for a Caesarian birth.
"It is a laudable policy. My only issue with it is that I spend about 6-8 hours in a queue before I can see my doctor. Sometimes I have no option than to go and pay for a quick consultation because it is so stressful and a shame for pregnant women to go through such trauma," Mensah said. "I don't want to talk about the medicine because I have no option."
The NHIA communications manager believes it is mere "misperception".
"This is not true... The medicines given to subscribers are medicines on the NHIS Medicines List, taken from the bigger Ghana Essential Medicines List approved by the minister for health. Besides, NHIS does not prescribe or dispense medicines. We believe our health providers are professionals," Adonoo told Al Jazeera.
This is not true... The medicines given to subscribers are medicines on the NHIS Medicines List, taken from the bigger Ghana Essential Medicines List approved by the minister for health. Besides, NHIS does not prescribe or dispense medicines. We believe our health providers are professionals
Ghana's elite, including government officials, still see public health institutions as "death traps" or no-go areas. Many who want to consult a doctor go to private institutions where quality healthcare is guaranteed. Only a few private health institutions accept the NHIS cards.
Dr Linda Van Otoo, the director of health services for the Greater Accra region, told Al Jazeera that the country's doctor-patient ratio is approximately one doctor to 15,259 patients in a year.
"Physician assistants also see about 38,000 patients in a year while midwives and nurses attend to about 6,000 and 1,400 patients respectively annually," she said. "This is very serious because the World Health Organisation’s revised standard for doctor-patient ratio is 1:600."
Ghanaians can only hope for the best as the NHIA cries for "more financial resources" to cater to the rapid growth in membership and improve service delivery.
Despite the dire difficulties it finds itself in, Ghana’s NHIS has earned global recognition. In 2010, the UN honoured the managers with a Global Award for Excellence in Geneva, Switzerland. And Nigeria, Ethiopia, Benin, Bangladesh, Mali, Senegal, Liberia, and the Democratic Republic of Congo are among the countries which have visited Ghana to learn from the "leading health financing model", as Adonoo puts it.
"The future prospects look very bright," Adonoo predicted, saying the NHIS has introduced a raft of prudent management systems such as Claims Processing Centres across the country; instant identity cards based on biometric data and the introduction of electronic system to help reduce the influence of human beings in claims management, among others.
But for the remaining 15 million of the 25 million Ghanaians who are yet to register, the NHIS' giant billboard proclaiming access to healthcare does not mean much. For them the age-old and costly "cash and carry" system seems far better.