By Wulifan K.
Joseph,
University for Development Studies, Dep’t of
Administration & Management, Wa Campus, Ghana.
Increasing
the access of African populations to health care is one of the biggest challenge
facing Africa and the global community. At independence,
when most African economies were strong, with abundant resources to cater for
relatively smaller population sizes, it was possible to provide health care
services free of charge, without compromising quality, though geographical
accessibility was more limited as compared to today. Rapid population growth,
decline of the economies and severe financial constraints in later years have
placed great limitations on the capacity of subsequent regimes to continue to
support and subsidize or expand health care services. Environmental health
risks and the tragedy of disease like AIDS have come to place an even greater
stress on African fragile health care systems. As resources dwindled, investment in the health sector also fell
considerably. This and other circumstances such as high cost to the user
of access to care of acceptable quality, as well as external pressure and
conditional ties, services of low quality, ill-equipped facilities and poorly
maintained equipment, abuse by the narrow segment of society, frequent
shortages of drugs and other consumables made implementing cost recovery
systems favorable” (Atim
1998)
Health
care financing is under severe strain all over the world and particularly
Africa and other developing Countries where health care cost is ever
increasing. For over 30 years ago, calls have been made for communities in
developing Countries to plan, finance, organize and operate health care
services. The question that often arises is how and how much should the poor
from poor Countries contribute towards this. The Alma Ata declaration meant
community participation was a pre-requisite to the achievement of health for
all
The Primary Health Care
(PHC) initiative in Bamako aimed at making health care
universally accessible through Community financing and management but the
question remains as to whether people in rural poor Countries can and should be
expected to contribute towards health care. More so, there is strong evidence
that, neither purely statutory social health insurance nor commercial health
insurance schemes alone can sufficiently contribute to increase coverage and
thereby the access to health care to the poor ( as stated by Arkin-Tenkorang) because
in the environment of rural and remote areas unit transaction cost of contracts
are too high leading to market failure (Jutting,2001).
Consequently, in low-income Countries the majority of the population remains
uncovered against the risk of illness.
In
Tanzania the community Health Fund (CHF)
strategy for financing rural health services was piloted in Igunga District in
1996 and by 1999, it was initiated in nine other Districts and later on step by
step rolled out to the rest of the districts in the country. This initiative
like other community based health insurance schemes are potential to
realization of the goal of universal health coverage in developing counties if
they get strong political support and are well implemented.
The health
sector is central to Ghana Government’s developmental agenda. While improving
health is intrinsically desirable, it is broadly recognized that health is a
necessary pre-requisite for socio-economic development. Improving health will
improve human capital, productivity and wealth (Ghana MOH, 2007-2011
strategic plan). Many health care financing options have
been explored and experimented by the government of Ghana since independence
till date. Among them include the “cash and carry” which existed since the
1980’s to Health Insurance which was
piloted in 2001 and finally enacted into law in 2003 (NHI Act 650 of 2003).
Health
Care Financing in Ghana has gone through a chequered history. Immediately after
independence health care provided to the people was “free” in the public health
facilities. Financing of health in the public sector was, therefore, entirely
through tax revenue. The sustainability of this form of financing became
questionable as the economy began to show signs of decline and there were
competing demand on the same source. The world economic recession in the early
1980’s led to heavy pressure on provision of social amenities. This led to
drastic reduction in government’s expenditure on health care. This mid 1980’s
therefore witnessed a withdrawal of health care subsidies.
What is
important to note was that the general tax revenue did not allow for a
percentage earmarked for health as we now have in the case of VAT funds
earmarked for education.
In Ghana, the Provisional National Defense Council (PNDC)
government in August 1985 revoked the Hospital Fee Regulation, 1963,
(Legislative Instrument L.I.1277) and replaced it with the Hospital Fee
Regulation, 1985(L.I 1313) mandating fees to be charged for consultation,
laboratory and other diagnostic procedures, medical, surgical and dental
services, medical examination and hospital accommodation ) termed as the “cash
and carry”, this was a way of
raising additional funds from the public to supplement shortfalls in
government’s budgetary allocation to the health sector. Though the system has
been successful at raising additional revenue, and improving the quality of
services, other difficulties were created. Financial constraints led to people
either staying at home when they were sick, or going to health facilities so
late that not much could be done for them. Some of those who were admitted
absconded when they felt a little better.
The policy of cost
recovery (cash and carry) led to increasing concerns about equity and access
for the poor. Hence charges under the user fee exempted certain specified
communicable diseases and people termed as the vulnerable groups from
out-of-pocket payments. This policy however was saddled with several
institutional and managerial problems. Definition and identification of
paupers was difficult because basic
data on ages and births, income levels of people were not properly documented.
Other problems included, unclear
and non-existent guidelines on how to implement the policy, including
reimbursement procedures, uneven implementation leading to considerable
variations between regions on the impact of the exemptions to target groups and
health facilities, inadequate supervision and monitoring, institutions claiming
different amounts for similar services leading to differential average cost of
the exemptions to the MOH, frequent complain that the budgetary allocations for
exemption is inadequate, lack of adequate information to the public about the
exemption policy. It is however encouraging that, policy makers are
increasingly recognizing that converting revenue gains into productive service
quality and access requires some accompanying, or even prior changes in
managerial and institutional capacity.
This
situation continued until 1985 when the Government introduced the user fees for
all medical conditions except certain specified communicable diseases. The free
health care policy was badly implemented in that although communicable diseases
were supposed to have been exempted; in practice no one enjoyed this facility.
Also a guideline for implementing was not provided and no conscious system was designed
to prevent possible financial leakages. In the ensuing years the standard of
health care provision fell drastically. There was acute shortage of essential
drugs in all the public health facilities. Most importantly, the introduction
of the user fees resulted in the first observed decline in utilization of
health services in the country. In spite of this the government went ahead to
institute full cost recovery for drugs as a way of generating revenue to
address the shortage of drugs. The payment mechanism put in place was termed
“Cash and Carry”. The implementation of the “Cash and Carry” compounded the
utilization problem by creating a financial barrier to health care access
especially for the poor. It is estimated that out of the 18% of the population
who require health care at any given time, only 20% are able to access it.
Implying that about 80% of Ghanaians who need health care cannot afford it.
Hospitals at the time became death traps due to the ‘cash and carry’ system
introduced.
The
government noting the problems associated with the “Cash and Carry” system
initiated action to replace this out-of-pocket payment for health care at the
point of service. The implementation of the programme to replace the “Cash and
Carry” was in phases. This approach took cognizance of the fact that uptake of
health insurance is dependent on various factors including level of confidence,
perceived quality of care, willingness of individuals to subscribe to it and
the attractiveness of the benefit package.
Given the high latent demand for health care services of a good quality,
and the strong criticism of alternative forms of health care financing and cost
recovery strategies like user fees, coupled with the extreme under utilization
of health services in several countries, it has been hoped that District-wide
Mutual Health Insurance schemes (DWMHISs) may improve access to health care of
acceptable quality. The option of insurance therefore seems a promising
alternative as it is a possibility to pool risk transferring unforeseeable
health care costs to fixed premiums Partly as a response to this lack of social
security, to the negative side effect of user fees and to persistent problems
with health care financing, non-profit voluntary insurance schemes for urban
and rural self-employed and informal sector workers have emerged. These schemes
are characterized by an ethic of mutual aid, solidarity and the collective
pooling of health risks). The
system of upfront payment at service delivery posed a financial barrier to health
care access. By 2001 the government initiated a policy to deliver accessible,
affordable and good quality health care to all Ghanaians especially the poor
and vulnerable in society. The policy objective of this insurance was that,
within the next five years (2003 – 2008), every resident Ghanaian should belong
to a health insurance scheme that adequately covers him or her against the need
to pay ‘out of pocket’ at point of service delivery (Ghana
National Health Policy). While
this seems laudable, systemic and managerial problems exist.
The Government is
currently financing the DWMHISs through a 2.5% out of the 17.5% Social Security
National Insurance Trust (SSNIT) workers contribution, a 2.5% National Health
Insurance Levy (NHIL) placed on Value Added Tax (VAT) commodities, Donor
support etc. Adult Ghanaian residents aged between 18-70year in the informal
sector (non SSNIT Contributors) as well as non SSNIT pensioners pay a yearly
minimum of GH¢ 8.00 (Eight Ghana Cedis which is approximately $4.00) and a
maximum of GH¢48.00 or Approximately $24.00 according to the categories of
ability to pay and economics status.
According to Ghana National health
policy and National HealthInsurance Scheme the
categories of persons exempted from the payment of contributions under the
Scheme include:
(a) A
child under eighteen years of age;
(b) A
person in need of ante-natal, delivery and neo-natal healthcare services;
(c) A
person with acute mental disorder;
(d) A
person classified by the Minister responsible for Social Welfare as an
indigent, and
(e) Categories
of differently-abled persons determined by the Minister responsible
for Social Welfare using a means test
prescribed by the Minister in
consultation with the Minister responsible
for Social Welfare and the Minister
responsible for Local Government;
(f) Pensioners
of the Social Security and National Insurance Trust;
(g) Contributors
to the Social Security and National Insurance Trust; and
(h) Other
categories prescribed by the Minister.
It is
significant to acknowledge that, the National Health Insurance System in Ghana
may not be the panacea to the Health Care financing problems. It is currently
not without challenges. The challenges range from general problems of Health Insurance
Markets (Risks) such as Moral hazards, adverse selection, Cost escalation to
fraud and abuse. Financial Management of the Schemes as well as Existence of
Health care facilities and behavior of Health care providers are key to the
sustainability of the Scheme and will be discussed later in the next article.
