Efforts To Achieving Universal Health Coverage By 2030: Is Ghana Paying Lip Service To The Concept?

What Is Universal Health Coverage?
In 2017, the UN Tokyo Declaration adopted the Universal Health Coverage (UHC) Concept. The essence of adopting the UHC Concept is to reduce barriers to accessing health services globally. As such, the UHC Concept has been the single most powerful concept th at public health has offered the world and it represents a landmark for global health and development.

In further detail, the UHC Concept requires that all people should be able to have an equitable access to quality health services devoid of financial, geographical, social, political, racial and other barriers. UHC is linked to the Sustainable Development Goal (SDG) 3, hence it is expected that each country will take gradual strategic steps necessary to achieve UHC by 2030. Therefore, a UHC-oriented health service must be affordably tailored to the health needs of the beneficiary population. The service must be appropriate and affordable.

Political Will Is Required To Achieve Universal Health Coverage

Regardless of how gradual the steps to achieving the UHC by 2030 may be, political-will, commitment, consistency and policy reviews will be necessary along the way. The Director General of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus reiterated that UHC is a political choice, so world leaders have given strong signals of readiness to make such a bold choice for their people. This is why governments such as the Government of Ghana must not pay lip service to the attempts required to achieve UHC for the people of Ghana, especially mindful of the stark reality that very wide healthcare accessibility gaps permeate the entire country. Over delay in the distribution of the procured constituency ambulances for example depicts weak political will for attainment of UHC no matter how far away the 2030 deadline may seem.

The year 2030 is a decade from today and to procrastinators, it is far away but to proactive minds, it is not far at all, hence the time to act swiftly with good results is now in order to achieve the UHC. In 2015, Ghana had a deferred hope in achieving the Millennium Development Goals (MDGs) 4 & 5 relating to maternal and child healthcare with special focus on reducing maternal and child deaths. In my measured view, these MDGs have been re-packaged into SGD 3 (Good Health and Well-being) and the UHC has been linked to it per the Tokyo Declaration in 2017.

The Three (3) Dimensions of Universal Health Coverage

The UHC Concept has three (3) main dimensions namely:

1. Who To Cover: This dimension of UHC refers to the type of population the health services are being provided for. The beneficiaries of the quality health services being provided must be considered right from policy formulation stages within a healthcare system. Health services are provided to people in need so a service that fails to address the expressed health problems in the community does not pass for a quality service. Again, who to cover demands that healthcare provider attitudes at the point of service delivery must not be hostile but friendly. National Health Policy Reforms are also required to determine what the populations require. Any attempt to make such policy reforms ought to be based on empirical data regarding epidemiological patterns within communities and communal attitudes towards healthcare especially in the area of socio-cultural beliefs as well as geographical factors. For example, UHC –oriented health services planned for a community like Nzulezu in the Western Region of Ghana must take into adequate consideration, the fact that the community hangs on water. Established in 1996 and now the most conspicuous agency of the Ministry of Health, the Ghana Health Service (GHS) exists to ensure among other things, an easy geographical and financial access to healthcare throughout the country. However, whether or not the GHS has done this effectively over the years is another subject worthy of debate against the background of whether or not the GHS has been given free hand to operate or it has been controlled with a political remote. Again, has the Mental Health Authority and for that matter our psychiatric hospitals been given adequate resources and on time to provide mental health services to the people? Are there plans to rehabilitate the old psychiatric hospitals and even build new ones in other parts of the country? For far too long, mental healthcare has been left largely in the hands of spiritualists and should we continue in same direction, 2030 will come and go and the story may even be worse.

2. What To Cover: This is the second dimension of the UHC Concept. What to cover simply refers to the kind of services required to be equitably provided to ensure that no segment of the population is deprived of the needed healthcare to stay healthy and productive. The services to provide must take cognizance of the communal needs within a country. Much as some of the services are demanded universally, there are community specific ones that seek to address endemics and neglected tropical diseases especially in our neck of the woods called Ghana.

Fortunately, Ghana has the National Health Insurance Scheme (NHIS) in place, which is an important vehicle for achieving. Just like the UHC Concept, the NHIS is supposed to be a pro-poor health financing arrangement. However, how effectively the NHIS vehicle will be driven in the direction of the UHC goal achievement is what matters. It is not lost on us that Ghana formulated the Free Maternal Healthcare Policy (FMHP) in July 2008 and has been implementing it with funding from the National Health Insurance Fund (NHIF) but could still not achieve the MDGs 4 & 5 in 2015. As a result, maternal and child mortalities are still great concerns for Ghana's Health System to deal with. The FMHP directly benefits the Women In Fertile Age (WIFA) population and neonates.

The NHIA's over delayed claim reimbursements to healthcare providers of various kinds especially in the public sector actually thwarts effective implementation of the FMHP. This delay in financial resource allocation at policy implementation stages therefore gives room for inimical street-level bureaucrat discretions that lead to policy failure. As such, attempts to achieve the UHC by 2030 do not call for lip service but political-will and meaningful and result-oriented actions or healthcare interventions. Government must therefore ensure that the NHIA reimburses submitted claims on time. We have just started the year 2020 and 2019 submitted NHIS claims are still in arrears. How can Ghana achieve UHC with this current attitude? NHIS has been implemented for years but there is no nationally accepted digital platform for claims management. Where is the political will towards the healthcare of the people we lead?

3. How To Reduce The Cost Of Care: This UHC dimension relates to ensuring that the required health services are offered at affordable service charges or prices. It is in view of this that Government through the Ministry of Health must re-visit its stand on the framework contract on the supply of the 54 essential medicines. The framework contract requires that government health facilities buy 54 selected essential medications only from the respective Regional Medical Stores (RMS). Shortage of those medicines at the RMS for a long time means shortage at the hospital pharmacies too hence patients must go and buy them from private pharmacies in town. Medication costs at private pharmacies are usually higher than the prices at the hospital pharmacies even though exceptions may abound. This occurrence of medication shortage at hospital pharmacies works against the UHC dimension of how to reduce cost in order to make the service affordable to the people. We must not give room for factors that work against the attainment of the UHC once we are truly committed to it as a country.

Badasu (2004) opined that declining or delayed government budget allocation is a possible impetus for health facility managers to focus on various ways of revenue mobilization rather being concerned with the patients' ability to have financial access to healthcare. Other Ghanaian scholars (Nyonator and Kuntzin, 1999; Agyepong, 1999) agreed that anytime the street-level bureaucrats (facility managers) are more concerned about revenue generation, it becomes difficult for the patients especially the poor to afford the health services because service charges are sometimes increased arbitrarily. This occurrence compels most of them to resort to unrefined herbal and self-medications that further complicate their health conditions. The pregnant women also resort to the prayer camps with its attendant challenges thereby leading to preventable maternal and neonatal deaths or stillbirths. Perhaps what is referred to as affordable health service is also debatable because what is affordable to one patient may not be affordable to the other even within the same community. Affordability is therefore relative. That is why national health system reforms must skew towards pooled funds or social health insurance policies rather than cash-and-carry (outright payment for health service out of pocket).

As it stands now, Ghana is not able to eradicate the cash-and carry health-financing method. This is because it is not all disease conditions that are covered under the NHIS. In some cases also, NHIS medications are not available due to the 54-medicine framework contract that the MOH signed with the 16 pharmaceutical companies. It may also be the case that even though the medications are available, healthcare providers are selling them only on an out-of-pocket basis due to the over delayed claim reimbursement by the NHIA.

The NHIA also makes huge deductions from the submitted claims without prompt information to the healthcare providers regarding why the deductions have been made from their submitted claims. Institutional attitudes of this nature do not constitute fertile grounds for the attainment of the UHC in 2030. Government and for that matter the MOH, NHIA and all other stakeholders must eschew lip service and move into result-oriented actions if we really want to achieve the UHC goal in line with SDG 3.

Conclusion
I think that for Ghana to achieve the Universal Health Coverage (UHC) by 2030, it is a gradual process but my caution is that 10 years from today is not too far so we should all work proactively to achieve milestones necessary. Kitty Genovese Syndrome or bystander apathy should be eschewed. Enough of the sensitization and long speeches to make the nation aware of UHC. Let us fold our sleeves and get to work so the SDG 3 and UHC so they do not become another mirage like MDGs 4 & 5.

~Asante Sana ~
Author: Philip Afeti Korto.i-okjl;l;
Email: [email protected]