Universal Health Coverage; where is Ghana?
Universal health coverage (UHC) is the most important concept public health has to offer to its citizens through the state. It is the concept of providing people with all the health services they need without suffering financial hardship in paying for it. Some school of taught says it is too costly or limits services but UHC address health from equity and human rights perspectives and when implemented effectively, delivers quality healthcare outcomes at lower costs.
Financing healthcare should be seen as an investment and not cost because the benefits of investing in health can be twenty (20) times greater than any cost incurred. At different stages of our lives, we all need health services at one point in time but not everyone has it today. The Ghanaian health system is faced with the double burden of communicable and non-communicable diseases and cost of healthcare at a time where more non-communicable diseases like Diabetes, Cancers, Cardiovascular diseases are on the rise with a new cutting cost of new treatments to avert complications
Universal health is an essential element of sustainable development. China, Mexico, Oman, Rwanda, Thailand, and Turkey are the few countries that have achieved UHC, Ghana and other countries should work towards this hallmark. Experiences from these countries can serve as lessons for countries beginning or on the journey like Ghana.
Ghana should seriously consider three dimensions of UHC if we want to achieve it thus;
- Population (what percentage of the population is covered with needed health services )
- Quality of services (what is the variety and quality of the services covered)
- Direct costs (proportion costs covered and how the services are paid for)
Who is covered/population coverage: China with 20% of the world's population is one of the best places to look for ideas and experience to cover as many people as possible. Within a few years, 172million previously uninsured people were brought into the China Health Insurance Scheme and in rural areas, coverage had increased from 10% to 97%. They invested 10.7billion USD to build 2,400 country level hospitals since 2009 and over 40,000 grassroots medical service facilities in order to provide people with more accessible, convenient and affordable healthcare. In places like Oman, a large proportion of the health budget goes to hospital care and treatment of chronic and expensive diseases. Our health centres should focus on prevention and early diagnosis. The WHO estimates that healthcare costs prevent 1billion people from seeking healthcare globally and pushes 100million people into poverty. One-third of Southeast Asia and Africa are forced to borrow money or sell assets to pay for healthcare.
Services covered and level of quality: ensuring access to quality care should be a policy objective and the NHIS should ensure a comprehensive health package to everyone to access primary health care especially the poor. There should be effective access to high-quality health services by the population. Ghana and Africa have seen in a rise, expensive diseases that require long-term treatment such as diabetes and cancers. Our insurance schemes should be expanded to meet these needs. Lives become stressful on both acute and chronic diseases without comprehensive insurance due to the financial implications and expensive nature in treating these diseases especially the chronic illnesses. Most of the population does not also have money to pay out of pocket to cater for the needs of these diseases in the long-term. Due to high costs, one-third of patients drop out of treatment or don’t even start or until it’s very late. In the last ten years, Turkey has increased coverage to 98% of its people and expanded the range of services available. In addition to hospital care, health coverage included preventive health services unlike in Ghana and most African
countries. Though our maternal and child health programs are showing impacts, we need to intensify the efforts and invest more in these areas. We need to find innovative ways of meeting expensive health needs for expensive treatments such as kidney dialysis whilst containing costs.
Direct Costs: The major challenge on the journey to UHC is how to cover the cost; the proportion of costs covered. In Rwanda, 55% of their budget is managed to the community level and progress is made against specific health targets. We should set how coverage should be measured and have people accountable to both the authorities and the population. How can we cover the insurance premiums of the poorest population? In Rwanda, the government covers the insurance premiums for the poorest constituting 25% of the population. Coverage has increased from 7% to 97% in Rwanda within the last decade and life expectancies (58years in 2006) have increased by ten years (68years in 2016), (WHO, 2018). Malaria-related mortalities have also dropped by two-thirds and neonatal mortality has been halved.
The road to UHC for all countries varies depending on her needs and there's no one-size-fits-all model for achieving UHC. Instead, countries must consider their historical antecedents, their health systems capacity, values, constraints, opportunities and ability and speed in terms of scope and coverage to move over time.
The essential ingredient in all of these is to provide basic primary health care to everyone to prevent diseases from ever starting or diagnosing them early when they are much more treatable. It's a necessary step every country can take and provide care and health services for everyone. It makes healthcare affordable and makes many more people live healthy and longer.
Annually, 100million (WHO, 2017) people are pushed to poverty because of ill health because of paying direct costs by patients or out of pocket expenditure. When a substantial amount of household expenditure is spent on healthcare, there are catastrophic outcomes. The WHO estimates that about 150million around the world face catastrophic healthcare expenditures yearly. In many instances, high out of pocket payments are as a result of low government spending on health and this means more poverty. But in countries where UHC is operational, there is equitable access; everyone is covered, affordable cost and minimum financial ruin. Three main challenges to UHC as reported by the WHO are insufficient funding, inefficiency, and reliance on out of pocket payments. Ghana has to adopt a health financing strategy to propel the level of progress towards UHC. To achieve a breakthrough, we need to relook the subsidy base of our NHIS.
Equity measures to ensure a safety net for the poor should be instituted by paying for their healthcare and providing transportation and food subsidies. This constitutes a pro-poor health financing strategy just like the NHIS is meant to be. Its main objective should be to reduce the financial barriers to health services by those living under the national poverty line (poor). When people are sick and seeking care, they are put into insecure positions because they face a double burden of losing health and money.
The efficient use of scarce resources as important as raising the needed funds for health. The WHO estimated that between 20 – 40% of all healthcare spending is wasted through inefficiencies such as irrational use of medicines, overuse of diagnostic services and medical equipment, and inappropriate hospital admissions and length of stay. Medicines account for 65% of hospital expenditure in some countries or 40% of the total health expenditure. More money for health to get healthy for more money should be the idea behind funding our health systems.
UHC can't be achieved in isolation without considering other social health determinants such as education and income. By investing in health and education, we improve the quality of lives of the beneficiaries. Ghana needs to institute a system of healthcare expenditure subsidy for family monthly checkups at health centres or hospitals and ensure their kids have at least 90% school attendance to qualify for these subsidies or grants or risk losing any health-related subsidy entitlements.
UHC is vital for economic growth, security, and social solidarity. To let the public know that achieving UHC is not a dream but a realistic goal and that there's no magic wand or pill to achieve UHC governments should have the political will and are committed, Ghana can raise sufficient funds for health, shift from co-payment, OOP (out of pocket payment) and build more efficient and equitable health financing systems that support UHC. With these, we can always wake up having a better day, productive, healthier and feeling financially secure.
UHC is 100% achievable to everyone everywhere. To make UHC a reality, we need fully funded strong health systems, soft and hardware of the health system, accountability, access to water and sanitation, adequate nutrition, and other social determinants of health such as good road network and transportation, peace and security, and civil society engagement. Health is a fundamental human right. A healthy population ensures a prosperous nation and therefore we must ensure full funding, strong health systems and fair or equitable access to achieve UHC.