No more ‘Poor care for poor people’

BY: Rebecca Quaicoe Duho
Healthcare delivery in one of our hospitals
Healthcare delivery in one of our hospitals

Still look at the picture of my child and feel a sense of deep sadness. Had we been able to afford the hospital bills or the medicines, would my daughter be still alive?”

This was the sentiment expressed by a woman whose child died because she could not pay the insurance premium of GH¢15 which would have entitled her to free health care.

The crux of the matter is that Ghana needs a health policy that will adequately address the gap between the rich and the poor in terms of access to healthcare services at health facilities across the country.

This is where Universal Health Care (UHC) comes in.

The way out of this is captured in a paper titled: “Achieving a Shared Goal: Free Universal Health Care in Ghana” put together by the Alliance for Reproductive Health Rights, Essential Services Platform of Ghana, ISODEC and Oxfam.

Government’s efforts

Trumpeting the government’s success story in the implementation of UHC, the Government’s Advisor on Health, Dr Anthony Nsiah-Asare, in an interview in Accra, said the government was working to ensure that nobody travelled more than five kilometres to access health care or lacked access to health care because of financial constraints.

He said the government was using the National Health Insurance Scheme (NHIS) to help take care of the financial problems of people; Community-based Health Planning and Services (CHPS) compounds for places where the population was more than 5,000 as the basic healthcare provider in communities, health centres for the sub-districts and district hospitals as first primary healthcare referral centres.

He said it was making sure that every district had fit-for-purpose well-equipped district hospitals to ensure that people did not travel for health care or face any financial hindrances.

111 Hospitals

To that end, Dr Nsiah-Asare said, the government was also building 111 hospitals, made up of six regional hospitals for the newly created regions, 101 district hospitals, two new mental health facilities, the redevelopment of the Accra Psychiatric Hospital and an additional regional hospital for the Western Region.

Ghana’s situation

Financing health is seen as a major challenge that needs further discussion, as the UHC strategy seeks to mobilise the equivalent of at least US$7 billion over 10 years in non-wage-resources, including Gross Domestic Product (GDP) allocation.

According to the Minister of Health, Mr Kwaku Agyeman-Manu, Ghana’s definition of the UHC “implies all people living in Ghana should have timely access to high-quality health services, irrespective of ability to pay at the point of use”.

Another addition to the international definition of the UHC, as prescribed by the WHO, is “irrespective of ability to pay at the point of use”, and according to the Director of Policy Planning, Monitoring and Evaluation at the Ministry of Health, Dr Emmanuel Odame, health was a human right issue and, therefore, the Ghanaian should not be denied care because he or she could not pay, and that was why the NHIS came in.

He said the UHC document hinged on three main objectives — universal access to better and efficiently managed quality healthcare services, reduced unnecessary maternal, adolescent and child deaths and disabilities and increased access to responsive clinical and public health emergency services.

Among other things, he said, the objectives were looking at revamping primary health care, since primary care was being looked at as “poor care for poor people”.

“How do we make it smart care for everyone?” he asked.

He said that was the real question that needed to be asked, as the rich and the poor should be able to seek primary health care from CHPS compounds, health centres and district hospitals.

He said Ghana was looking at a primary healthcare service that encompassed curative, preventive, rehabilitative, palliative, promotive, emergency care and mental health and called for the recalibration of staff, which encompassed incentives to ensure that there were doctors and nurses at all levels.

Reactions

A father of five, Mr Rholand Adom, said although the NHIS currently being practised under the UHC in the country had been beneficial to him especially, as he had five young children, much could be done about it for it to benefit the masses.

According to him, although he and his family were covered by the NHIS, he still had to cough out some money when he sent his children to hospital.

A steel bender by profession, Mr Adom said recently he had to send one of his children for a laboratory test at a community hospital which accepted the NHIS card, but he still had to find ways and means to pay for the service at the laboratory, as it did not acceptthe NHIS card.

He said if there was a way that private hospitals and their laboratories could be made to accept the NHIS card, then most people would be able to access quality care and live healthier lives.

Meanwhile, he said, in all the NHIS was a blessing to him, as he was able to send his children to public hospitals for free.

A nurse by profession, Mr Edmund Doudu who is currently based in Koforidua in the Eastern Region is of the view that not enough is being done to achieve the Agenda 2030 of the Abuja Declaration under UHC.

He said the declaration states among other things that at least 15 per cent of a country's budgeting should go into health financing but Ghana was currently doing about eight per cent.

A World Health Organisation Young Leader whose main focus is into UHC and Primary Health Care, Mr Duodu also says there was still much to be done at the patients level as well as the level of medical personnel.

He said although UHC is supposed to be the main access to health care at the primary level, access is most often not available. Almost 88 districts across the country he said do not have district hospitals and, therefore, most pregnant women do not have access to scan nor laboratory services.

Health practitioners he said also lack the needed incentives especially,  those at the district levels a situation which he said was preventing them from accepting postings to local hospitals.

Another barrier to UHC he said is the situation where as medical professionals, they have to pay for their medical bills any time they fall sick and this he says needs to be addressed.

Health financing

Ghana’s UHC policy intimates that the government will work towards allocating at least an additional one per cent of GDP to primary health care and seek additional sources of financing, with emphasis placed on optimising fiscal allocation and use.

The policy also indicates that the NHIS financing framework and management will undergo reforms to improve its efficiency, as the scheme will prioritise primary health care and allocate at least 50 per cent of its resources to fund primary health care (PHC) expenditure.

The policy also states that all primary healthcare facilities will have their operational debts paid off and recapitalised using a fund-holding approach.

These funds will be considered operational credits based on signed performance agreements and ensuring long-term financial sustainability.

On donor funding, the document says the health sector has, over the years, been co-funded by development partners, and that donor finances were stable until recently when several development partners began transitioning out with the change in the development status of the country as a low middle-income country.

Grants and credits

Grants and credits will be contracted more strategically based on the development of a five-year health sector medium-term plan. Unsolicited technical assistance and assistance not directly linked to advancing the road-map agenda will be discouraged.

In aid and development partner management, the principles of the ‘Paris Declaration and the Global Action Plan for Healthy Lives and Well-being for All’ will be followed.

All development partners will sign up to a compact in which they and the government will agree a mutual framework for engagement, acceleration, alignment and accountability.

This will serve as a management arrangement and commitment note to reduce fragmentation, improve resource pooling, matching and predictability. Partners will be required to align their resources with one another and with the government through models of co-financing or parallel co-financing arrangements. The aim is to improve synergies.

There will be de-emphasis of commercial loans. A commodities, medicines, supplements and vaccine phase-in/phase-out and sustainability framework agreement will be renegotiated with relevant partners and the private sector to improve long-term sustainability.

A deliberate attempt will be made to crowd in private sector investments and capital.

Global situation

Currently, according to the WHO, at least half of the people in the world do not receive the health services they need.

It also says about 100 million people are pushed into extreme poverty each year because of out-of-pocket spending on health.

To make health for all a reality, the world health body is calling for individuals and communities to have access to high quality health services, so that they take care of their own health and the health of their families.

Skilled health workers are also urged to provide quality, people-centred care, while policy makers also commit to investing in UHC.

Universal health coverage, the WHO says, should be based on strong, people-centred PHC, adding that good health systems are rooted in the communities they serve.

It says UHC is focused not only on preventing and treating diseases and illnesses but also helping to improve well-being and quality of life.

Background

An article entitled: “Ghana’s Journey towards Universal Health Coverage: The Role of the National Health Insurance Scheme”, in the European Journal of Investigation in Health, Psychology and Education gives the history of Ghana’s health policies to include the fact that it gained political independence in 1957 and has since assumed its own public policies, including health policies.

Ghana practised ‘free health care for all’ after independence, but it was limited to public hospitals and clinics, with less involvement of private health facilities, especially private for-profit facilities.

It said the poor collaboration between public and private facilities in the provision of healthcare services was more serious in rural Ghana, where few private health facilities were licensed to provide essential healthcare services.

This situation exposed rural folks to untrained and unlicensed service providers, which affected accessibility and quality control.

Ghana’s health system at independence was highly centralised, and that also affected rural areas, as health services were far from them.

The ‘free health care for all’ was abolished during the military rule and replaced with ‘user-fees’. It was replaced with the ‘user-fees’ which started in 1969 under the Hospital Fees Decree, which was later amended to Hospital Fees Act in 1971.

Most Ghanaians and persons resident in Ghana complained about the ‘user-fees’ as unfriendly and that they did not promote equity in healthcare services; the reason being that poor and vulnerable people had limited access to healthcare services and essential drugs.

By 1985, Ghana’s health system had changed from ‘user-fees’ system to ‘cash and carry system’ (CCS). The CCS is a practice where people must pay cash before they are attended to at health facilities.

The CCS created more health inequities among various groups, rich and poor, rural and urban, workers and unemployed groups. Rich and privileged groups could pay, and thus had more access to health services than poor and vulnerable groups.