Free Primary Health Care Has The Potential To Abolish The Nhis

The NDC Manifesto and Primary Health Care (PHC)

The 2020 National Democratic Congress (NDC) Manifesto is emphasizing social protection policies such as free primary health care. 7.1 Paragraph 5 of the manifesto reads “As part of our social contract with Ghanaians, the NDC plans to employ more health workers, introduce and implement an efficient and well-funded free PHC program to benefit all Ghanaians.” The concept of primary health care has been defined as the provision of ambulatory or first-level personal health care services. The main role of primary health care is to provide continuous and comprehensive care to the patients, including diagnosis and treatment of a health condition, and support in managing long-term healthcare, including chronic conditions like diabetes and hypertension. Free primary health care would be provided at CHPS Compounds, health centers, polyclinics and district hospitals.

The ultimate goal of primary healthcare

According to the World Health Organization (WHO), the ultimate goal of primary healthcare is the attainment of better health services for all and has identified five key elements to achieving this goal:

• reducing exclusion and social disparities in health (universal coverage reforms);
• organizing health services around people's needs and expectations (service delivery reforms);
• integrating health into all sectors (public policy reforms);
• pursuing collaborative models of policy dialogue (leadership reforms); and
• increasing stakeholder participation.

Funding for primary health care since independence

Primary health care has been a major component of the Ghana Health System. At independence in 1957, free health care policy was implemented until nominal fees were introduced in the 1970s. The PNDC government introduced the “Cash & Carry” policy in 1985 and this policy excluded many Ghanaians from access to healthcare, leading to high out-of-pocket (OOP) expenditures on health and low utilization of health services. The first Rawlings NDC government continued with this policy until the Kufuor NPP government introduced the National Health Insurance Scheme in 2003 and implementation began in 2005.

Primary health care provision

Primary health care is already provided by Ghana Health Service (GHS) and private providers, and a free primary health care would use the same primary level providers. The past 17 years, Ghana has followed a path of government strengthening the health system by providing what the providers need in order to provide quality services, the Ministry of Health plays its oversight role, and NHIS providing a financing mechanism that reimburses providers for services (private sector), supplies, medicines and consumables.

Delay in provider reimbursement, out of pocket (OOP) expenditures, OPD attendance

The NDC’s reasons behind the free primary health care proposal is, NHIS has become irrelevant, thus making primary health care services not accessible, affordable and available. The NDC again claim a lot of Ghanaians cannot afford the already low NHIS premium and rising out-of-pocket (OOP) payments at points of service. The World Health Organization (WHO) defines OOP payments as “direct payments made by individuals to health care providers at the time of service use.” Some relevant health financing facts from 2005 through 2018:

• 2005 – the year implementation of NHIS began, out-of-pocket expenditures reached 51.38% of total health expenditures because of “Cash and Carry”.

• 2005 – 2009: Implementation of NHIS reduced out-of-pocket expenditures from 51.38% to 33.9%.
• 2009 – 2017: out-of-pocket expenditures increased from 33.9% to 45.05%.
• 2009 - The Kufuor government left about GHC350 million in the NHIS Fund.
• 2012 – 2016: Delay in NHIS provider reimbursement reached 18 to 24 months, thus lowering member confidence in the NHIS.
• 2014 – 2016: OPD attendance at government hospitals and clinics reduced by 4.33% and the NHIS insured among OPD attendees reduced from 83.5% to 82.1% (GHS Annual Report, 2016).
• 2016 – 2018: OPD attendance increased by 3.6% (GHS Annual Report 2018).
• 2017 – 2018: OOP expenditures reduced from 45% to 26%, (Okoro, J et al, 2020).
• 2017 - When NDC left office, NHIS was indebted to the tune of GHC1.4 billion; NHIA settles debt.
• 2020 - Provider Reimbursement averaging about three months after receipt of claims from the provider.

From the facts listed above, NHIS and health financing faced challenges when former president John Mahama was either vice president or president. Therefore, the NDC should not be proposing free primary health care to replace NHIS because of the very challenges NDC government created.

Risk Pooling, members profile and NHIS Benefit Package

The NHIS was built on the concepts of Cross Subsidization, where the rich pays for the poor; and Risk Equalization, where the healthy pays for the sick. Pre-existing conditions do not disqualify residents of Ghana from joining the NHIS.

The passage of Act 852 made NHIS membership compulsory for all residents of Ghana. With NHIS membership being compulsory, good and bad risks are pooled, with each individual member expecting to receive- -the medical care which is needed in return for a contribution borne by oneself or government. The larger the degree of risk pooling in a health financing system, the less people will have to bear the financial consequences of their own health risks, and the more they are likely to have access to the care they need.

The informal sector, which accounts for about thirty-two percent (32%) of NHIS membership, pays the already low premiums, which averages about GHC20 per person per year. These contributions together account for less than 5% of the inflows needed to finance the NHIS. About sixty-eight percent (68%) of the population, including children and the aged 70 years and over, are exempted from paying the registration premium to join NHIS. NHIS covers about ninety-five (95%) of disease conditions in Ghana. Medicines on the NHIS Medicines List are free. In effect, there should be no payment at a point of service for medicines and covered conditions. Judging from the profile of the non-paying NHIS members and the fact those who cannot afford to register can qualify to register as Livelihood Empowerment Against Poverty (LEAP) recipients or indigents, one cannot say the NHIS is not affordable.

Inequality in geographical access already exists in certain parts of the country and free primary health care won’t be able to change this phenomenon overnight. However, NPP government has “given the assurance that the government would build hospitals in all districts that lacked one and regional hospitals in the new regions and equip them with full complement of health staff to provide quality health care to the people.” That should be the focus of a government - building infrastructure and ensuring human resources for health gaps are addressed, and the NHIS focusing on providing financial risk protection of residents of Ghana. Considering all the services under the proposed primary health care program are already covered under the NHIS, why is the NDC proposing a new program using the same providers that provide primary health care under the NHIS?

Contributions of the NHIS to health financing in Ghana

Within health systems, the significant barriers to the delivery of PHC tend to be (a) inefficient provider payment mechanisms (PPMs), (b) inadequate and inconsistent capacity to deliver the basic package of PHC services, and (c) fragmented administration and referrals. The NHIS however, has achieved all three by: (i) operating on a Benefits Package which is consistent with the Standard Treatment Guidelines and Essential Medicines List of Ghana; (ii) negotiating and agreeing on payment mechanisms and tariffs with providers, and (iii) operating on a “Gatekeeper System” which guides referrals, thus minimizing fragmentation.

Article 40 (2) (d) of the NHIS Act 852 allows the use of monies from the Health Insurance Fund to create and improve upon geographical access where needed health care services are provided. The same provision in the law supports “making health services available by supporting sufficient supply and appropriate stock of health workers, with the competencies and skill‐mix to match the health needs of the population.”

Several researchers have concluded that the government’s objective to increase access to the formal healthcare sector has been achieved with the introduction of the NHIS. Researchers have also found that on average, individuals enrolled in the NHIS were significantly more likely to visit clinics and seek formal health care when sick, and obtain prescriptions (Blanchet et al, 2012).

PHC has the potential to abolish the NHIS

An NDC administration is likely to abolish the NHIS and replace it with a free PHC. Item 6.11.2.1 (b) of the 2020 NDC Manifesto promises to exempt all cocoa farmers from NHIS premium payment for secondary and tertiary care. Contributing NHIS members pay one premium for all levels of care (primary, secondary, and tertiary). There is nothing like a premium for only secondary and tertiary services. This suggests that all primary level services which the NDC intends to place under the free primary health care program would be excluded from what would remain of the NHIS, which is, coverage for services at the secondary and tertiary levels.

Primary health care accounts for about ninety-five percent (95%) of NHIS utilization, while secondary and tertiary services account for five percent (5%). Primary health care services account for sixty-six percent (66%) of NHIS total claims cost, while secondary and tertiary account for 34%. Considering that all the services under the proposed primary health care program are currently covered under the NHIS, it would be a duplication to run the free primary health care program alongside the current NHIS. This, obviously, would be a highly inefficient use of public funds. Secondly, since the NHIS has faced sustainability challenges (inflows being less than outflows) since 2009, it would be extremely difficult for any government to fund the NHIS as we know it, alongside a free PHC program.

Private providers and NHIS workers under free primary health care

The NDC-proposed primary health care services and medicines would be provided at government facilities only -- CHPS compounds, health centers, polyclinics, and district hospitals. Since the government pays the salaries and other benefits of health workers, a global budget provider payment mechanism appears to be the most appropriate to use to purchase consumables and medicines. The WHO defines global budget as “providing a fixed amount of funding for a fixed period of time (typically one year) for a specified population, rather than fixed rates for individual services or cases.” Under global budget arrangement, Ghana Health Service would disseminate the global budget according to the population of the catchment area that the health provider serves. To include private providers in the proposed primary health care, an administrative system should be in place to negotiate their tariffs and to receive and process their claims.

According to former president John Mahama, the NDC projects to spend GHC1.4 billion on free primary health care in 2021. However, analysis of NHIS claims data, using average of 2.8 OPD visits per person per year, suggests that it will cost the government at least, GHC1.6 billion in 2021 to run the free PHC for the entire population. This amount does not include the cost of effective preventive and promotive media campaigns which usually come with typical primary health care programs.

Private providers account for 24% of NHIS utilization and 27% of NHIS claims cost. As indicated earlier, if the private sector is excluded because of reimbursement challenges, the private sector (chemical shops, pharmacies, clinics, hospitals) is projected to lose about GHC384 million under a free primary health care provided by public providers. The effect on families and economies of the communities in which these facilities operate [due to closures and lay-offs] could be devastating.

If global budget through GHS is likely to be used for the program, the current workforce of the NHIS would be operating at only secondary and tertiary levels, which account for a mere 5% of the current NHIS utilization! What happens to the NHIS workforce? So far, the NDC has been quiet on the operations of the free primary health care and Ghanaians need to know before the go to the polls.

Free PHC as Free Health Care (FHC)

A devastating effect of free primary health care is healthcare not reaching the poor and other vulnerable populations. The WHO proposes that without proper targeting and monitoring, better-off population groups tend to benefit from Free Health Care (FHC) policies more than vulnerable population groups. On the supply side, the availability of health services is usually better in wealthier areas. On the demand-side, barriers can be limited geographical access to facilities, transportation to facilities, etc. The WHO, therefore, proposes that: “preparatory and complementary measures are needed for free health care policies to be successful. There should be enough financial resources for the desired increase in the use of services. Provider payment methods and effective allocation channels must be in place before an FHC policy like free primary health care comes into effect.”

Free Health Care (FHC) and quality of care

Free primary health care, like many free health care programs, cause people to overuse health care resources because of moral hazard, thus putting pressures on health workers and resources, and affecting the quality of care in a country with the following staff availability ratios: CHPS Compounds - 68.7%; health centers - 52 .0%; polyclinics - 79.1%; district primary hospitals - 55.1%; (Avoka 2017). Physician patient ratios range from anywhere between 1 doctor for 3,582 patients to as high as 1 doctor for 25,878 patients in some areas in the country, and 4.2 nurses and midwives attending to 1,000 patients (WB, 2018).

Poor quality may deter the utilization of beneficial primary health care services. Healthcare may end up being rationed -- quality and availability of disease screening and treatment may reduce, and certain disease treatment outcomes could worsen.

Universal Health Coverage (UHC) by way of Social Health Insurance

In recent years, an increasing number of countries have initiated health financing policy reforms and actions to address concerns over high levels of government spending on health and OOP expenditures. Although there is no magic bullet, available information illustrates that an increasing number of countries have moved away from free healthcare and are using national health insurance to move their countries towards UHC.

Even countries with higher GDP per capita than Ghana’s ($1,916) are using social health insurance to move their countries towards universal health coverage (UHC). Qatar ($65,062); Taiwan ($26,309); Estonia ($24,043); Chile ($16,914); Thailand ($7,624); Colombia ($7,089); and Philippines ($3,320) are examples. Sub-Saharan countries, including Nigeria ($2,297) and Kenya ($1,834) have moved away from the often inefficiently run government free healthcare towards health insurance (financial risk protection) models to move towards UHC. South Africa ($6,908) plans to achieve UHC enabled by National Health Insurance.

Strategic reforms to improve efficiency within NHIS

The NHIA has been undertaking reforms to improve efficiency in operations and contain cost within NHIS. Among such reforms are: Mobile Membership Renewal Service and the generation of e-Receipts to track payments. Seventeen (17) years after the passing of the Act 650 that established the NHIS, the NDC manifesto should not be planning to replace the NHIS with free PHC which has the potential of sending Ghana back to "Cash and Carry", which incidentally, was implemented by a previous NDC government.

The focus rather should be on strengthening the NHIS to improve financial protection for all residents of Ghana; deepening equitable distribution of health care, particularly primary health care services; and use of appropriate technology even in the remotest parts of the country [in healthcare delivery] that are accessible, affordable, feasible and culturally acceptable, among others.

OB Acheampong

Health Financing Specialist