Inverse Care: A Setback In Achieving Universal Health Coverage In Ghana

In the 2010 World Health Report, Universal Health Coverage (UHC) is defined as providing everyone in a country with financial protection from the costs of using health care and ensuring access to the health services they need (World Health Organisation, 2010). UHC helps drive better health and development outcomes. The services rendered should be of sufficient quality to be effective. It is, therefore, in the best interest of every government to adopt strategies to ensure that there is access to health care for its populace.

In Ghana, primary health care (PHC) is the agreed pathway for achieving UHC. PHC is the first level of contact of individuals, their families and communities with the national health system.

We notice that the government has put in place the National Health Insurance Scheme (NHIS) and Community-based health planning and services (CHPS) strategies, two social protection initiatives that form the cornerstone of PHC in the country.

While Ghana may have chalked up some appreciable gains in efforts at achieving UHC, there is still some way to go to achieve the desired standards by 2030.

Past and present, it could be observed that free market health system is somewhat operative in the country; persons with the fewest resources and greatest healthcare needs are least able to access the healthcare system, resulting in even poorer health. This phenomenon “inverse care” has bedevilled healthcare delivery in Ghana and thus has been a major challenge in our quest to achieve “health for all”.

The inverse care law as propounded by Julian Tudor Hart in 1971 states that “The availability of good medical care tends to vary inversely with the need for it in the population served”. Tudor Hart argued that “this inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced”. Although Hart was largely referring to the influence of market forces on the distribution of healthcare providers to the most profitable markets, the general precept of the law holds under universal health insurance as well.

In Ghana, the inverse care law holds with greater force than in most developing countries because of gaps in available health insurance, physician maldistribution, and inequities in the provision of healthcare. All these have implications for healthcare and outcomes for vulnerable populations including low-income persons, racial and ethnic minorities, and the uninsured among others.

In a written assessment of UHC in Ghana, Garshong & Akazili (2015) note that Ghana’s National Health Insurance Scheme (NHIS) is a pro-poor policy and offers a generous benefit package to its members. Yet many poor people find it difficult to pay registration fees as well as the premiums. The Scheme also has difficulties determining the socioeconomic status of applicants: flat-rate rather than income-related premiums therefore burden poorer members disproportionately. While there have been promises by policy-makers to improve the equity of the NHIS, not much progress has been made in this regard on the ground, and proposed premium reforms remain controversial. As a consequence, the NHIS still caters more for higher-income groups, leaving many poor families without any prepaid cover, despite contributing to the VAT-funded component of the Scheme. As a result, out-of-pocket expenditure remains relatively high.

That apart, the assessment also analyses the disparities in the distribution of health facilities and health professionals to urban and rural areas. The distribution of health facilities is a reflection of colonial health care policy with most health facilities located in urban areas. Despite efforts to provide more health facilities in rural areas after independence, in line with the primary health care policy, over 60% of formal health care facilities are still based in urban areas. There are two teaching hospitals, nine regional hospitals and several district hospitals. These hospitals are less well distributed than primary care services and specialist services are heavily concentrated in the south of the country and in urban areas.

Because of the skewed distribution of public health services, most health professionals (the majority of whom work in the public sector) are also based in urban areas. This results in wide geographical disparities in health professional to population ratios across the country.

In concluding, the inverse care framework illuminates the complex challenges and obstacles to addressing the healthcare needs of medically vulnerable populations. National policy has not adequately confronted the paradox of the inverse care law. Consequently, disparities in healthcare have persisted; in some instances, they have actually worsened. We have been even more reluctant to deal with the fundamental causes of disease and early death that have continued unabated over the years despite changes in disease prevalence and risk factors. Specific problems change but basic needs remain the same. Then, as now, reshaping the healthcare system to address disparities requires innovative, adequately funded efforts above and beyond what emerges from the marketplace.

Improved insurance is necessary but not sufficient to address access gaps. And whoever is insured and whatever the level of their coverage, services should be provided without regard to ability to pay. There should be a focus on primary care, where gaps in access as well as opportunities for prevention and early intervention in the disease cycle are greatest. However, horizontal and vertical links to other parts of the healthcare system and to other social services in the community are also essential.

Efforts must be designed to meet the needs of underserved areas where providers are lacking, or they are unwilling or unable to care for low-income, uninsured, and minority patients (or those with other vulnerabilities). Enabling and psychosocial services should be included to reach out to the population in need, and to consider ways of dealing with the economic, social, and environmental causes of ill health. Care must be respectful and culturally competent, including the provision of translation/interpretation services.

Patients should be involved personally in the management of their conditions and politically in the governance of their health services.

Only by acknowledging the reasons why disparities exist and adequately supporting efforts to address them can we make real progress toward the nation’s stated goal of equal healthcare.