Earlier in September this year, the Lancet published a special series on universal health coverage (UHC) which argued from ethical, political, economic, and health perspectives why a renewed effort to achieving UHC is necessary. The articles put forward many important policy propositions for achieving UHC, particularly on the need to abolish user fees for healthcare, and putting greater emphasis on public health financing and provision.
Indeed, the way health systems are financed is an important prerequisite for achieving Universal Health Coverage as this determines whether health services are available, and whether people can afford to use them. This link between financing and UHC is one which is clearly articulated in existing health policy documents in Ghana. However, with general elections less than two months away (December 7th), and as the different political parties articulate their visions and strategies for the health sector in particular, we ask whether the current modality of health financing in Ghana – the National Health Insurance Scheme (NHIS) – is an effective model for achieving UHC.
Up until 2003, the health financing model in Ghana was based on a fully fledged user fee scheme known as the Cash and Carry. Although vulnerable groups such as the poor people, pregnant women, and children were exempted from paying user fees, the policy had limited success in removing financial barriers to health services, as the exemption package was unclearly specified and inadequately funded. The system was also riddled with managerial and operational difficulties. As a result, the user fees policy denied many poor people access to the needed healthcare.
The National Health Insurance Scheme (NHIS) was introduced as an alternative financing model in 2004 to ensure universal access to quality healthcare, provide financial protection and ultimately improve health outcomes. Membership in the NHIS is supposed to be mandatory for all Ghanaians, and covers the direct costs of healthcare services and medicines for most common diseases in Ghana. The scheme is financed from a range of revenue sources, notably, VAT revenue, payroll deductions from formal sector workers, and premium contributions from informal sector workers.
However, there are many challenges and shortcomings of the NHIS which makes it particularly ineffective for achieving universal access to healthcare.
First, the way in which the NHIS is funded is unfair. This is because it is funded mainly from revenue generated from VAT which is regressive, and imposes a high tax burden on low income households. Ironically, despite being worse affected by VAT payments, low income households find it the hardest to afford the premiums required to enrol in the NHIS in order to benefit from the healthcare services it provides. Current enrolment rates on the NHIS stand at only 34% of the population (2010 data) mainly because of these high premium rates.
The second obstacle to achieving UHC under the NHIS is the high level of out-of-pocket (OOP) payments that still dominate healthcare financing in Ghana even eight years after the launch of the NHIS. OOP payments accounted for just over a third (37%) of the total national health expenditure in 2009. Higher OOP payments at point of service have been noted to impoverish poor patients and limit access to live-saving care. In order for countries to reduce the burden of health expenditure on low income households, the WHO has recommended countries must reduce OOP payments to around 15% of total health expenditure. But Ghana’s OOP rate is about twice the recommended WHO threshold, and higher than that of other lower middle income countries.
The third challenge the NHIS faces with respect to UHC relates to the issue of sustainability. The World Bank has predicted the scheme would go bankrupt by 2013. A large part of this problem is due to the inefficiencies of the scheme arising from poor premium and membership card administration. The cost of claims administration is estimated to have increased by around 40 folds since 2004.
The above are clear indications that the NHIS maybe a long way from achieving UHC. Maternal and child deaths rates in Ghana are among the worst in lower middle-income countries, with around one in every 280 pregnant women dying during childbirth, and about one in 15 children dying before their fifth birthday. Also about three-quarters of the poorest 20% of pregnant women give birth without the presence of a skilled health worker.
However, as election day approaches, it is encouraging to see all the major political parties being committed to pursuing UHC, though there are many loopholes in the policy plans they have put forward to achieve this. These include the Convention People’s Party promising to ensure universal health coverage, but without stated specifics as to how this will be achieved, to the New Patriotic Party committing to pursuing UHC but through public-private means that could in fact, lead to further exclusion of vulnerable people. The current ruling party, the National Democratic Congress has promised to expand the benefit package and capitation system of the current NHIS system, but without specifics on how this will be achieved, and whether current system infrastructure could support its success.
In order to achieve UHC, policy propositions should be tailored to expanding access through the removal of financial barriers, while recognising the need to expand and improve health facilities. On the demand side, payment by poor households can and should be abolished, with alternative and innovative means found to tax the higher income earners in order to fund quality health services. For instance, using property tax and scaling up the communication service tax (the ‘call tax’) could provide progressive forms of revenue to fund premium removal. Another option could be to scrap the NHIS altogether and replace it with a national health service which will be funded from progressive tax revenue. Both of these options would improve coverage, and also provide efficiency savings from reduction in the cost of administering premiums.
UHC is achievable in Ghana, but only when the financing policies are adopted!
Yussif Nagumse is a health policy officer at Oxfam-GB
Sidua Hor is the National Coordinator for the Universal Access to Free Healthcare Campaign in Ghana