Lamptey et al. Archives of Public Health  (2017) 75:36 
DOI 10.1186/s13690-017-0205-9
RESEARCH Open Access
National health insurance accreditation
pattern among private healthcare providers
in Ghana
Abena Agyeiwaa Lamptey1, Eric Nsiah-Boateng2, Samuel Agyei Agyemang2 and Moses Aikins2*
Abstract
Background: Healthcare providers’ accreditation is one of the standard means of assuring quality services. This
paper examines the pattern of National Health Insurance Scheme accreditation results among private healthcare
providers in Ghana.
Methods: A cross-sectional quantitative analysis of administrative data from seven National Health Insurance
Scheme healthcare provider accreditation surveys over the 2009–2012 period. Data on private healthcare providers
that applied for formal accreditation between the study period were retrieved from the NHIS accreditation database
using a checklist. Proportions were used to examine pattern of private healthcare provider accreditation results by
region, type of care provider, and grade.
Results: Overall, 1600 healthcare providers applied for accreditation over the study years, of which 1252 (78%)
passed and were accredited. Majority of healthcare providers that passed the healthcare facility assessment were in
Ashanti, Greater Accra, and Western regions, and were significantly higher than those in the other regions. Among
the healthcare providers that passed the assessment, pharmacies (22%) and clinics (18%) constituted the largest
groups, and were significantly higher than the other types of healthcare providers. Similarly, among those that
passed, majority (62%) obtained grade C and D, representing a score of 50–59% and 60–69%, respectively, and were
significantly higher than those that obtained the top three grades of A+ (90–100%), A (80–89%) and B (70–79%).
Conclusions: Majority of healthcare providers accredited to provide services to the insured are concentrated in three
regions of the country, and are mainly pharmacies and clinics. Moreover, substantial proportion of the healthcare
providers obtain average scores of the healthcare facility assessment, an indication that these care providers fall below
the National Health Insurance Scheme applicable-predetermined standards.
Keywords: Accreditation, Private healthcare providers, National health insurance scheme, Ghana
Background have also initiated accreditation programmes to assess and
Over the last decade, there has been an increased inter- monitor the quality of care delivery in their health systems
est in development of accreditation programmes or tools in response to long waiting times, high cost, favouritism,
for assessing healthcare providers and ensuring quality disrespectful behaviour on the part of some healthcare
of care delivery in the health sector. This is being pio- providers, misuse and pilferage of medicines, and irregular
neered by international bodies involved in quality of care availability of medicines, among others [4–6].
assessments to address quality of care challenges associ- In Ghana, healthcare facility accreditation is a legal
ated with increasing population and advancement in requirement for all care providers and the National Health
healthcare [1–3]. Other national governments in Africa Insurance Authority (NHIA) in collaboration with the
Health Facility Regulatory Agency (HEFRA) undertakes
this exercise [7–9]. HEFRA is mandated to register,
* Correspondence: mksaikins@ug.edu.gh
2School of Public Health, College of Health Sciences, University of Ghana, licence, and monitor all healthcare facilities in the country.
Accra, Ghana NHIA, on the other hand, credentials healthcare providers
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Lamptey et al. Archives of Public Health  (2017) 75:36 Page 2 of 7
who have obtained accreditation from HEFRA and wish and accreditation manual are issued. The manual issued
to provide services to the National Health Insurance to care providers are used to make necessary preparation
Scheme (NHIS) members. The credentialing exercise is for inspection. According to the unpublished accreditation
undertaken using applicable predetermined standard qual- manual, inspection (or direct observation) and scoring of
ity assessment tools as stipulated by the National Health facilities are conducted based on 12 assessment modules;
Insurance Act, Act 852 and Legislative Instrument, LI (i) range of service; (ii) staffing; (iii) environment and in-
1809 [10, 11]. According to the NHIA, a total of 3434 frastructure; (iv) basic equipment; (v) organisation and
healthcare providers have been accredited to provide ser- management; (vi) safety and quality management; (vii)
vices to the insured since July 2012 [12]. out-patient care; (viii) in-patient care; (ix) maternity care;
Since implementation of the NHIS policy in 2004, (x) specialised care; (xi) diagnostic services; and (xii)
considerable achievements have been made in the area pharmaceutical services. Each module is divided into sub-
of providing financial access to healthcare for majority units and all sub-units have a set of standards which
of Ghanaians [13–16]; however, geographical access and depend on the type of facility (hospital/clinic, pharmacy/
quality of care issues remain a challenge to both the in- chemical shop, maternity home) and the level of service
sured and the uninsured. Review of the literature shows provision (primary, secondary, tertiary). An example of
that there is no study on the NHIS that looked at the ac- the standards tool for assessing “range of services” and
creditation process and pattern of accreditation of “staffing” modules of clinics is shown in Additional file 1:
healthcare providers. A study on NHIS accredited pri- Appendix 3. The category to which the standard belongs
vate and public primary health facilities was limited to is indicated with the letter I (Input standard), P (Process
efficiency of these healthcare providers [17]. Another standard), H (Human capacity), O (Output/Outcome
study on the prospects and challenges of the NHIS standard) or S (Services) under the column labelled “cat-
briefly mentioned types and number of healthcare pro- egory”. The criteria for assessing the standards and the
viders accredited to provide services and how they are methods of assessment are also indicated for each stand-
reimbursed [13]. Other health quality related studies fo- ard. In order to meet the requirement of a standard and
cused extensively on clients’ perception of quality of be accredited, a healthcare provider should satisfy the
delivery under the scheme [15, 18], leaving very little in- criteria listed under the subheading “Definition”. The
formation on the performance of private healthcare pro- method of assessment is also indicated under the sub-
viders in the NHIS accreditation process. For example, heading “Methods”.
information such as the trend of results as well as factors Scoring of each of standard is done according to
associated with success and failure in the accreditation the following criteria: Score 3 if all criteria are met;
process is not available. Therefore, this study examines Score 2 if half or more are met but not all (≥½);
the pattern of NHIS accreditation results among private Score 1 if less than half are met (but not zero); Score
healthcare providers. The significance is to advance the 0 if no criterion is met; and Score “N/A” if the stand-
understanding and the necessity for accreditation as a ard is not applicable [8]. On average, a team of four
standard regulatory practice to promote high quality of observers with varied professional backgrounds in
care among all NHIA service providers. Overview of the medical and health disciplines assesses one healthcare
NHIS healthcare provider accreditation is provided in provider; however, the assessment is not blinded. Each
Additional file 1: Appendix 1. unit/module score is obtained by averaging all the
sub-unit scores. The 12 unit/module scores are then
Methods added up and the cumulative score determines the fa-
The first part of this section describes the process of cility score on which the outcome is based. All the
the NHIA healthcare provider accreditation and per- modules have the same weight for the scores. A
formance score. The later part focuses on design of healthcare provider is accredited if the facility score is
the study, the study population, and data collection 50% and above. Provisional accreditation is given
techniques used. when facility score is less than 50% but scores 50%
and above in core areas put together. Accreditation is
Healthcare provider accreditation and performance score denied when a facility scores below 50% overall and/
process or in core areas put together. Facilities which are
The healthcare provider accreditation process begins already accredited to provide service at a lower level may
with an application from interested healthcare providers reapply for accreditation for a higher level. These facilities
(see Additional file 1: Appendix 2). A completed applica- are assessed on modules based on the desired high level
tion form is submitted along with relevant documents and when successful, an upgraded accreditation is given
and applicable fees. Applications are vetted to ensure [8]. The interpretation of the assessment score is shown in
that forms are appropriately filled, after which receipt Additional file 1: Appendix 4.
Lamptey et al. Archives of Public Health  (2017) 75:36 Page 3 of 7
Study design were from Maternity homes while the least applications
This was a cross sectional quantitative study using ad- were from Scan or Diagnostic centres 3.1% (50).
ministrative data from seven NHIS accreditation surveys
covering the period, July 2009 to July 2012. Distribution of accreditation application and performance
score by region
Study population Overall, one hundred and ten (110) applications were
All private healthcare providers that applied for NHIS ac- submitted over the study period for reaccreditation
creditation between July 2009 and July 2012 were used for (renewal of accreditation), reapplication (subsequent
the study. They included pharmacies, chemical shops, ma- applicants with provisional accreditation or those who
ternity homes, laboratories, scan centres, clinics, primary failed previous assessments), upgrade to next level of care,
hospitals and secondary hospitals. Other healthcare pro- and downgrade (Table 1). Out of this number, Ashanti
vider information were location (or address of healthcare region submitted the highest of 41 applications, of which
facility), ownership, level of care, accreditation scores and 20 (32%) were reapplications, 16 (39%) reaccreditation,
accreditation status. and 5 (12%) upgrades. Twenty-nine applications came
from the Brong-Ahafo Region, of which 20 (69%) were
reapplications, 7 (24%) reaccreditations and 2 (7%) up-
Data collection and management
grades. The Upper East Region had only two reapplica-
The NHIA accreditation and performance score data
tions, (1 reapplication and 1 reaccreditation). There were
were extracted from the NHIA accreditation database
no reapplications from the Upper West Region. All appli-
using data extraction checklist. The completeness of the
cations for upgrade passed except for one failed applica-
data was assessed and healthcare providers whose data
tion from the Brong-Ahafo region. Only two healthcare
were incomplete were contacted through telephone or
providers in the Eastern region were downgraded.
by visit to obtain missing information.
Healthcare provider performance score by region
Data analysis Out of the 1600 accreditation applications assessed,
A descriptive analysis was employed to examine pattern 1252 (78%) applications passed while 348 (22%) failed.
of success (or pass) and failure among private healthcare Accreditation performance score by region showed that
providers (PHCPs), pattern of reaccreditation among Ashanti region had the highest number of healthcare
PHCPs with provisional accreditation, and pattern of providers that passed, 304 (24%; 95%CI: 21.9%–26.7%),
upgrade among PHCPs. The analysis was conducted by followed by Greater Accra region, 275 (22%; 95%CI:
region and by type of healthcare provider for all the 19.6%–24.3%) and Western region, 165 (13%; 95%CI:
seven batches of accreditation surveys using Microsoft 11.3%–15.1%) (Fig. 2). The proportion of healthcare pro-
Excel (2010 version). Successful accreditation per batch viders in Ashanti, Greater Accra, and Western regions
was estimated as proportion of accredited (passed) that passed the healthcare facility assessment were sig-
healthcare provider per accreditation batch; failure per nificantly higher than those in the other regions (CIs did
batch was calculated as proportion of failed healthcare not overlap either of the other regions). Likewise, there
provider per accreditation batch; successful reaccredita- were significant differences in the proportion of health-
tion per batch was determined as proportion of accre- care providers that passed the healthcare facility assess-
dited healthcare provider with provisional accreditation ment between Ashanti and Western, and Greater Accra
per batch; and successful upgrade per batch was estimated and Western. However, there were no significant differ-
as proportion of successful upgrade per upgrade applica- ences in the proportion of healthcare providers that
tion. Confidence intervals were also estimated for propor- passed the healthcare facility assessment in Ashanti and
tion of healthcare providers that passed the accreditation Greater Accra; Brong-Ahafo and Central; Brong-Ahafo
assessments, using Stata immediate command “cii N X, and Eastern; Eastern and Central, Northern and Eastern,
level (95)”; where cii is immediate confidence interval, N and Upper East and Upper West, as lower and upper
is sample size or number of observations, and X is num- bound limits overlapped each other, respectively.
ber of successes [19].
Healthcare provider performance score by type of facility
Results The healthcare provider performance assessment by
Distribution of the application data type showed that pharmacy recorded the highest pro-
A total of 1600 applications were received for accredit- portion that passed the assessment, 275 (22%; 95%CI:
ation between July 2009 and July 2012, of which clinics 19.6%–24.3%), followed by clinic 230 (18%; 95%CI:
constituted 356 (22.3%), pharmacies, 328 (20.5%) and 16.2%–20.6%), and chemical shop, 225 (18%; 95%CI:
chemical shops, 266 (16.6) (Fig. 1). About 16% (254) 16.2%–20.2%) (Fig. 3). The proportion of pharmacies,
Lamptey et al. Archives of Public Health  (2017) 75:36 Page 4 of 7
Fig. 1 Distribution of applications by healthcare facility type, 2009–2012
clinics and chemical shops that passed the healthcare fa- E. Likewise, the proportion of healthcare providers that
cility assessment were significantly higher than that of obtained grade E (fail) were significantly higher than those
scan centre, laboratory, primary hospital, maternity home that obtained grade A+, A, B, and provisional. However,
and other facilities. However, there were no significant dif- healthcare providers that obtained grade C and D showed
ferences in the proportion that passed between pharmacy no significant difference because the lower limit of grade C
and clinic; pharmacy and chemical shop; clinic and chem- overlapped with the upper limit of grade D.
ical shop; clinic and maternity home; and chemical shop
and maternity home, as lower and upper bound limits Discussion
overlapped each other, respectively. This study sought to examine the pattern of NHIS ac-
creditation results among private healthcare providers
Healthcare provider performance score by grade over the 2009–2012 period. The findings show that
Accreditation performance score by grade showed that pharmacies and clinics constitute the largest groups of
251 (16%) healthcare providers obtained the top three healthcare providers accredited to provide services to
grades (A+, A, B) while 1349 (84%) obtained the lowest the insured. This result was expected due to the large
four grades (C, D, Provisional or fail) (Fig. 4). Majority of number of these private healthcare providers across the
the healthcare providers, 504 (32%; 95%CI: 29.2%–33.8%) country compared to the public healthcare providers,
obtained grade C; 494 (31%; 95%CI: 28.6%–33.2%) which are exempted from the accreditation process. The
obtained grade D; and 309 (19%; 95%CI: 17.4%–21.3%) positive effect is that, majority of these accredited health-
obtained grade E (fail). The proportion of healthcare pro- care providers are found in the remote areas of the coun-
viders that obtained grade C and D were significantly try where there are limited number of public/government
higher than those that obtained A+, A, B, provisional and healthcare providers. For instance, in some areas the only
Table 1 Application and performance score by region, 2009–2012
Upgrade Downgrade Reaccreditation Reapplication
Region Pass (%) Fail (%) Pass (%) Fail (%) Pass (%) Fail (%) Pass (%) Fail (%) Total
Ashanti 5(12.2) 0(0.0) 0(0.0) 0(0.0) 13(32.0) 3(7.3) 16(39.0) 4(9.8) 41
Brong-Ahafo 1(3.5) 1(3.5) 0(0.0) 0(0.0) 3(10.4) 4(13.8) 20(67.0) 0(0.0) 29
Central 1(16.7) 0(0.0) 0(0.0) 0(0.0) 2(33.3) 0(0.0) 3(50.0) 0(0.0) 6
Eastern 1(16.7) 0(0.0) 2(33.3) 0(0.0) 0(0.0) 0(0.0) 3(50.0) 0(0.0) 6
Greater Accra 1(33.3) 0(0.0) 2(66.7) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 3
Northern 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 1(25.0) 3(75.0) 0(0.0) 4
Upper East 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 1(50.0) 1(50.0) 0(0.0) 2
Upper West 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0
Volta 0(0.0) 0(0.0) 0(0.0) 0(0.0) 1(7.7) 0(0.0) 6(46.2) 6(46.2) 13
Western 4(66.7) 0(0.0) 0(0.0) 0(0.0) 1(16.7) 0(0.0) 1(16.7) 0(0.0) 6
Lamptey et al. Archives of Public Health  (2017) 75:36 Page 5 of 7
Fig. 2 Proportion of healthcare providers with accreditation (95% CI) by region, 2009–2012
government healthcare provider that may be available Ashanti and Western region. These results are expected
is the Community-based Health Planning and Services due to the proportionally large number of private health-
(CHPS) compound. Therefore, the high proportion of care providers in these three regions in the country. The
pharmacies and clinics could help address the chal- significance of these results is that it would facilitate easy
lenge of geographical access to healthcare services, as access to healthcare provider services for the substantial
well as geographical equity in access to healthcare in number of the insured residing in these three regions.
deprived communities. Similarly, the relatively large number of accredited health-
Assessment of applications by administrative region re- care providers in the Brong-Ahafo region could help ad-
veals significant differences in the proportion of healthcare dress the challenge of geographical access to healthcare in
providers that passed. In all, Ashanti region submitted the the remote communities. However, the small number of
highest number of applications and also had the highest healthcare providers in the three deprived regions of the
proportion of healthcare providers that passed the ac- country (Northern, Upper East, Upper West) that passed
creditation assessment. This was followed by the Greater the healthcare facility assessment could pose a barrier to
Accra and Western regions. The proportion of healthcare access to health services for the insured in these regions.
providers in these three regions that passed the healthcare Results of the study also show significant differences in
facility assessment were significantly higher than those the proportion of healthcare providers that passed the
from the other seven regions. Whilst proportion of health- healthcare facility assessment by type of provider. Majority
care providers in Ashanti and Greater Accra region that of the pharmacies, clinics and chemical shops passed the
passed the healthcare facility assessment show no signifi- assessment; however, there were no significant differences
cant difference, there were significant difference between between them. On the contrary, proportion of pharmacies
Fig. 3 Proportion of healthcare providers with accreditation (95% CI) by type of facility, 2009–2012
Lamptey et al. Archives of Public Health  (2017) 75:36 Page 6 of 7
Fig. 4 Proportion of healthcare providers with accreditation by grade, 2009–2012
that passed the assessment were significant higher than meet the applicable requirements for accreditation? In
that of the other types of healthcare providers (scan the last instance, the team may favour the unqualified
centres, maternity homes, primary hospitals, and labora- facilities by given average or weak performance score, as
tories). Interestingly, the clinics also recorded the highest found in other studies [1, 5, 19, 20]. One key measure
number of failed applications, which means that most of that NHIA uses to address the issue of healthcare providers
them fall below the NHIS applicable pre-determined stan- borrowing or renting equipment and other resources in
dards for accreditation. order to gain accreditation is post accreditation monitoring,
Findings of the study also show that among the health- involving a team of experts drawn from the health sector.
care providers that passed the healthcare facility assess- However, the large number of care providers with the aver-
ment and were accordingly accredited, about two-thirds age score needs to be examined further to ensure that only
had average score of 50% to 69% (grade C and D), and providers that meet the applicable pre-determined stan-
were significantly higher than those that obtained a dards are accredited to render services to the insured.
score of 70% to 100% (grade A+, A and B). Only a lim-
ited number of healthcare providers (about one-sixth) Study limitations
obtained the top three scores of the accreditation assess- There were gaps in the data obtained especially informa-
ment. The plausible reason is that majority of the health- tion on reapplication. Thus, deductions had to be made
care providers’ facilities are below the pre-determined on which applications were for reaccreditation (or renewal)
standards. This finding supports a study by Alhassan et and which ones were reapplications from healthcare pro-
al. [17], where less than one-third of NHIS accredited viders that did not meet requirements of previous health-
private primary healthcare facilities were found to be op- care facility assessment exercises, making it a potential
timally efficient. Our finding implies that majority of the source of error. Secondly, the study used a 5-year old
healthcare facilities are not well-resourced, and this data; hence, generalisation of the findings needs to take
could result in limited access to needed resources such this into account.
as personnel and technology, as well as important ser-
vices including laboratory and imaginary. Conclusions
The large number of healthcare providers in the score The study reveals significant differences in accreditation
bracket of 50–69% also raises the question of “is it the scores between regions and between healthcare providers.
case of accreditation fraud, where healthcare providers Healthcare providers in the Ashanti, Greater Accra and
borrow or rent equipment and other resources for the Western regions recorded significantly higher assessment
purpose of satisfying the inspection team to get the scores than those in the other seven regions of the
desired level of accreditation and return them after the country. Accreditation by type of healthcare provider also
inspection? Or is it the case where healthcare providers shows that pharmacies, clinics, and chemical shops
that do not meet the pre-established standards for obtained significantly higher scores than the other types of
accreditation tend to “buy” the inspecting team, as found healthcare providers; however, they are no significant dif-
in other study [6]? Or the NHIA facility inspection team ferences in pass scores between them. The study also
applies collegial approach of accreditation to some of reveals that majority of the healthcare providers that apply
the healthcare providers especially those that do not for accreditation obtain average assessment scores, and
Lamptey et al. Archives of Public Health  (2017) 75:36 Page 7 of 7
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Ethics approval and consent to participate
The study received approval from the Ghana Health Service Ethics Review
Committee (GHS-ERC 61/03/13).
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