Broken gates, broken system: How Ghana’s referral policy can rescue the NHIS

Every morning, thousands of Ghanaians queue at the Korle Bu Teaching Hospital and the Komfo Anokye Teaching Hospital for conditions that could be treated at the nearest community clinic. 

The scene is familiar. Specialists are overstretched, nurses are exhausted and waiting areas spill into corridors. In some cases, lives are lost from conditions that early care could have managed.

This situation reflects a breakdown in how patients access care. It is the challenge the Ministry of Health’s Referral Policy and Guidelines (2012) sought to address.

The 2012 Ministry of Health Referral Policy introduced a structured, tiered gatekeeper system to protect the National Health Insurance Scheme (NHIS).

Years on, the system it introduced, the National Gatekeeper Implementation Programme, remains one of the country’s most important, yet least understood health governance tools.

Under the gatekeeper system, patients are expected to begin care at the primary level and move upward only when necessary.

This structured flow supports effective use of resources and improves patient outcomes.

The policy established a two-way referral system, requiring patients to start at community health centres, CHPS compounds and clinics before referral to district, regional or teaching hospitals based on clinical need.

The policy also introduced standard referral forms, a national directory of health facilities and feedback mechanisms.

These measures ensure that when a patient is stabilised at a higher-level facility, care continues at the lower level through a return referral.

The policy notes that patients bypass primary care due to limited awareness, inadequate facilities and low confidence in first-level services.

Cost, NHIS

The stakes remain high. Ghana’s National Health Insurance Scheme, which covers a significant share of the population, depends on the gatekeeper system for cost control.

When patients go directly to tertiary hospitals without referral, the scheme pays higher tariffs for cases that primary facilities could manage at lower cost. When referral procedures are not followed, claims become difficult to verify.

The policy outlines multiple scenarios, including emergencies, chronic conditions, maternal care and walk-in cases at higher-level facilities.

These provisions were designed to protect the NHIS from financial losses while ensuring access to emergency care.

Despite this, implementation has been uneven.

Evidence points to continued non-use of referral forms, delays in referrals, weak feedback between facilities and negative perceptions among patients.

Many people still prefer higher-level hospitals, while some private providers do not follow referral procedures, leading to claims that are difficult to validate.

Communication challenge

Effective communication remains central to improving compliance.

Health workers need clear guidance on referral protocols, documentation and their responsibilities. 

Patients and communities need information on where to seek care first and how the system works.

Policymakers require data on how the system affects costs and service delivery.

Communication must target these groups through appropriate channels.

Health workers need training and continuous professional development.

Communities need outreach through radio, durbars, CHPS platforms and local languages.

Policymakers need regular reports, data dashboards and policy reviews.

Way forward

At the national level, the Ministry of Health needs to strengthen dissemination of the policy and ensure all facilities understand their roles.

Regional and district health directorates must support this with training and supervision.

At the community level, efforts should focus on building trust in primary care.

Behaviour change approaches that engage local leaders, health workers and community members will help shift care-seeking patterns.

Digital tools such as USSD platforms and messaging services can support feedback and reporting from the frontline.

The country as the policy framework for an effective referral system.

The gap lies in consistent implementation and clear communication. 

The 2012 Referral Policy remains relevant.

Its success depends on how well the system is understood and followed across all levels of care.

The writers are students of the University of Media, Arts and Communication