Public health schemes: Getting it right

When Bernard Natey could not find a qualified cardiac surgeon in his native Togo to implant a pacemaker in his heart to manage an irregular heartbeat, he promptly packed his bags for a hospital stay in neighbouring Ghana.

In the capital, Accra, Mr. Natey told Africa Renewal that he planned to have the procedure at Korle-Bu Teaching Hospital, the leading public hospital in Ghana, which offers advanced and specialized care that is rarely available in other West African health care institutions.

The hospital prides itself on its ability to attract a sizeable number of its clientele from neighbouring countries such as Burkina Faso, Nigeria and Togo because of its expertise in plastic and reconstructive surgery, burn treatments, cardiothoracic and radiotherapy services and nuclear medicine, among others.

Mr. Natey’s experience is typical of people across sub-Saharan Africa who need medical care but are unable to get it in their home country because of either unavailability or prohibitive costs.

69%

of insured Ghanaians are not required to pay premiums

Almost half of people interviewed in 36 African countries told Afrobarometer, an independent pan-African research network that conducts public opinion surveys, that they had not had access to necessary medical care in either 2014 or 2015, while 4 out of 10 had found it “difficult” or “very difficult” to access needed care during that time.

Across West Africa, such is the dilemma of many seeking quality health care. Citizens of Côte d’Ivoire, Gambia, Liberia and Sierra Leone can regularly be found traveling to Ghana for treatment.

But what is it about Ghana’s health care that draws both Ghanaians and outsiders?

Guaranteed access

The answer is availability and affordability. To make health care affordable to all, Ghana was one of the earliest African countries to introduce a universal health insurance system — the National Health Insurance Scheme (NHIS).

The country is currently implementing a private-public partnership programme that allows a network of private facilities to provide health care in areas without public health services. Although it faces challenges, this programme has been applauded internationally, including by the United Nations and the World Bank, as a model for sub-Saharan Africa in addressing the challenges facing its public health systems.

The government-sponsored NHIS is funded mainly through taxation on selected goods and services. It covers treatment for the most prevalent diseases in the country, including malaria, skin diseases, stomach disorders, hypertension, diabetes, asthma, eye and ear infections, rheumatism and typhoid, and also covers dental care.

Under the law, all residents are required to enrol and, unless they are in one of the exempted groups, pay annual premiums. In return they are not expected to make additional out-of-pocket payments when they require care.

The scheme has gone through reforms since it was formally launched in 2004. In 2011 the NHIS was recognized by the UN Development Programme (UNDP) and the World Health Organization (WHO) for “improving financial access to health care services, particularly for the poor and marginalized.”

38%

of the population covered by insurance

NHIS had an active membership of more than 10 million people in 2013, estimated to be about 38% of the entire population. According to Afrobarometer’s ranking of countries by percentage of citizens without access to health care, Ghana had the fourth-lowest percentage (26%) over the past two years, just behind Algeria (25%), Cape Verde (19%) and Mauritius (2%).

Ghana’s performance may be attributed to the impact of the insurance scheme. A study on the impact of the NHIS on the use of health care, published in the Ghana Medical Journal in 2012, showed that people with health insurance were likely to obtain prescriptions, visit clinics and seek formal health care when sick. The authors said, “Ghana government’s objective to increase access to the formal health care sector through health insurance has at least partially been achieved.”

Another reason for the high use of health care is the way the government relies on the private sector to provide access. Ghana is “ahead of many other [African] countries” because it has a specific policy on the role of the private sector in health, the World Bank said in its working paper, Private Health Sector Assessment in Ghana.

For example, the government entered into partnership with the Christian Health Association of Ghana (CHAG), a network of 183 Christian faith-based care providers, to offer health services in underserved areas. Under the accord, the government provides support to the network facilities in the form of salaries, equipment and supplies. As CHAG members operate in remote areas across the country, serving underprivileged communities, their network allows the government to extend health care to areas with no public facilities.

“The public-private partnership between the ministry of health and CHAG is unique in sub-Saharan Africa and works well, allowing CHAG to act as an extension of the government, particularly in underserved rural areas,” the World Bank report concluded.

Growing pains

However, it has not been all smooth sailing for the NHIS since its launch over a decade ago. The scheme appears to be going through growing pains. According to the government’s own estimates, only a little more than 38% of the population is enrolled, while hospitals are still asking some of those insured to pay for their care out of their pockets. Health care providers have repeatedly complained about not being reimbursed fast enough.

Also, while the insurance is mandatory for all residents of Ghana and is financed by premiums from subscribers—2.5% national health insurance levy, 2.5% social security and national insurance trust, deductions from the formal sector, funds from the government, charities, and returns from investment—still experts say the scheme has been underfunded since 2009.

The National Health Insurance Authority, which administers NHIS, notes on its website that 69% of those insured are exempt from paying premiums. Those exempted include people below 18 or over 70 years, pregnant women, the needy and those who belong to specific disability categories.

26%

of Ghanaians didn’t have access to health care in 2015

The agency recognises that the cost of providing care has risen much faster than available financial resources since the scheme became operational in 2005, which has created persistent and growing annual deficits over the past several years.

As Ghana prepares for general elections in December 2016, sustainability of the health insurance scheme has become a point of contention between the main political parties. The main opposition party argues that the scheme is dead but promises to revive it if elected, while the governing party points to the countrywide drive to have members of the medical scheme renew their annual membership as a measure of the scheme’s success. Beyond the political banter, however, most Ghanaians appear to agree on the need for reforms.

In an effort to address the scheme’s sustainability, a commissioned government review has proposed reining in costs by limiting coverage to primary, maternal and child care.

“NHIS should be re-prioritized towards universal access to primary health care in the medium term, and progressive realization of universal access to higher levels of care in the long term,” the review committee recommended in April.

Even as the country grapples with its insurance scheme’s sustainability and, at times, with unreliable services in public facilities, Korle-Bu, the main public hospital in Accra, continues to attract patients from outside the country because of its reputation for advanced and innovative care.