Primary healthcare as defined at the Alma Ata declaration in 1978 is the essential care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self- reliance and determination. Universal healthcare on other hand is also defined as ensuring that all people have access to needed healthcare (including treatment, prevention, promotion, rehabilitation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial difficulties. Presently in Ghana, the aim of the government for the health sector is to strengthen primary healthcare by attaining universal health coverage.
Why Universal Health Coverage?
The convention at Alma Ata, where primary healthcare was born, looked far beyond the customary boundaries of curative and preventive medicine and tried to address the underlying social causes of poverty, hunger and poor health. However, primary healthcare(PHC) suffered serious assaults shortly after its implementation. Campaigns were launched against PHC to strip it of the comprehensive and potential revolutionary components and reduce it to a narrow approach with which the national and global power structures could feel more comfortable. That was why there was the introduction of universal health coverage which had primary healthcare’s basic objectives of curative, preventive, promotive and rehabilitative healthcare. Universal Health Coverage means providing all people with access to quality health services while ensuring that these services does not cause financial hardship.
Universal Health Coverage in Ghana
Over the past two decades, Ghana has committed to increasing both access to health services and financial protection in the pursuit of UHC through targeted health service delivery and financing reforms. In 2005, the national government developed a close- to-client health care delivery system called the Community-based Health Planning and Services Strategy(CHPS) to minimize geographic barriers and reach remote populations with primary healthcare. Around the same time, the government implemented a national health insurance scheme to boost financial protection.
The National Health Insurance Scheme(NHIS)
The government established the National Health Insurance Scheme (NHIS) in 2003 as a step toward UHC and unified the risk pool in 2012 to eliminate fragmentation. The NHIS provides a generous package of benefits covering 95% of conditions and includes inpatient and outpatient services for general and specialist care, surgical operations, hospital accommodation, prescription drugs, blood products, dental care, maternity care and emergency treatment.
Exclusions currently include cancer services–other than cervical and breast cancer–dialysis, organ transplants and appliances, including optical and hearing aids. The government has
recently announced, however, that it plans to extend the NHIS to cover cancer services. The NHIS is financed primarily through tax revenues, through a value-added tax, which is unique. The National Health Insurance levy, provides 74% of the NHIS revenue, Social Security and National Insurance Trust (SSNIT) deductions provide another 20%, and premiums provide 3%.
Deficiencies of the NHIS
As of 2014, the NHIS covered 10.5 million people, or 40% of Ghana’s population, falling short of the goal of 70% coverage. Participation is mandatory, but enrollment is not automatic. There is no consequence for failing to enroll. Some studies indicate that premium cost hinders NHIS registration, especially for the informal sector, which may help explain why coverage is still low.
Even those who are eligible for fully subsidized premium payments must still enroll, so many who are eligible still may not have coverage. The NHIS also has low renewal levels. A National Development Planning Commission (NDPC 2009) survey undertaken in 2008, for example, found that fewer than 30% of those in the lowest socio-economic quintile were members of the scheme, compared with over 60% of the wealthiest. The main reason given for not belonging to the scheme was affordability (77%). NHIS members pay no out-of-pocket costs for services or medicines included in the benefits. Because there is no cost sharing beyond premiums, members pay no copayments, coinsurance, or deductibles, and there are no
annual or lifetime limits. Despite that, over one-third of those covered by the NHIS still paid out of pocket for medicines and services. Those who are not covered by the NHIS pay a fee for service for both public and private providers. Together, this may explain why the out-of-pocket expenditure, at 27 percent, is so high. A recent study found that the NHIS prioritizes curative services which does not serve the purposes of promoting key principles underlining UHC and PHC, and that including services such as family planning and health education would be beneficial.
The Community-based Health Planning Services Strategy
To promote equity in access to health services, the CHPS initiative targets remote areas of high need to deliver cost-effective and quality primary care services to individuals and households, while also engaging the community in the planning and delivery of services. Each CHPS compound is designed to serve a population of 5,000. A dedicated community health nurse serves as the first point of contact and offers limited preventive and curative health care services. While the initiative reduces travel time and distance within high-need rural and impoverished areas.
Deficiencies of CHPS
Though the CHPS concept is a good one for achieving universal health coverage, its implementation has become rather cumbersome mainly because of one challenge, the cost to implement the program country-wide. Because of this reason, people in the rural areas still do not have accessibility to proper medical care and hence most fall on traditional medicines for their health needs. The has contributed to a high prevalence of some diseases like malaria in the rural areas and there is the problem of high maternal and infant mortality rate still existent in some of these rural areas.
I strongly believe that if the government should diligently concentrate on investing in the health its human resources by strengthening the policies for universal health coverage, the rate of productivity will increase to compliment the economy of the nation.
Written By:
Emmanuel Precious Ephraim
BSc. Physician Assistant Studies
University of Cape Coast
Level 200
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