HEALTH CARE FINANCING IN GHANA, 50 YEARS ON

There is no doubt that the greatest asset of every country is its citizens because their general well-being determines the overall progress and development of a national economy. An enhanced quality of life means higher productivity since very little of the country’s budget would be spent on health facilities and the treatment of diseases in general. Any country which has unhealthy population is bound to suffer in many ways towards programmes aimed at development.
Health and poverty, according to the Global Forum for Health Research (1999), are intricately linked and that poverty is often associated with ill health. Therefore various governments embark on programmes to provide good health care services to the people.
In developing countries such as Ghana, the extension and improvement of primary health care, for example, disproportionately benefited low income groups by addressing their health needs in a cost-effective way.
Despite persistent efforts, both present and past by successive governments, basic health indicators show that the health status of Ghanaians remains relatively poor with low life expectancy, infectious diseases, high maternal and infant mortality cases, among other new emerging diseases like buruli ulcer, with the poor being severely hit. This is very serious especially when about 40 per cent of the people are considered poor and 27 per cent are extremely poor.
Before the advent of colonialism, the natives used medicine prepared from herbal concoctions which were prepared by herbalists and other people who were well vexed in the spirit world. However with colonisation the British introduced orthodox medical medicine and hospitals as a very improved curative method.
Therefore, health care delivery is now pluralistic: there are private medical practitioners, mission hospitals/clinics, herbalists, and fetish priests, among many others. The private practitioners are in business to make money and are concentrated in urban areas. The missions also initially exempted the poor from their fees.
This is to say that Ghana has had a chequered history of health care financing options and as the country marks her 50th anniversary it is necessary to take a look at its health financing options. There had been certain times that health services were provided free of charge and other times that user fees were charged. Since the 1980s user fees for government services have become an accepted financing option for the health and social sectors in Ghana and many other developing countries.
Thus Ghana which had a tradition of providing health services free of charge introduced fees.
In July 1985, the government of Ghana enacted the Hospital Fees Regulation as a cost-sharing measure for the use of Ministry of Health (MOH) facilities.
Proponents of user fees stress that equity and efficiency gains can be achieved through the implementation of a cost-recovery policy package. Within this package user fees are complemented by decentralisation and combined with two targeting mechanisms favouring low income groups: exemptions, and the use of fee revenue to improve the services offered to them.
Success in protecting the poor appears to be limited and there are considerable informational, administrative, resource and socio-political constraints undermining the development of effective targeting mechanisms.
Attempts to recover some government health care expenses through user charges have produced less revenue than hoped and national health insurance was seem as an attractive alternative, but needs to include features which check cost escalation. Community involvement and traditional medicine can also help to reduce costs.
Despite improvements in public health indicators, the population of Ghana still suffers because of a poor health status, especially in rural areas. The largest provider of health services is the Ministry of Health (MOH). Although the MOH budget grew 12 per cent from 1986 to 1990, this amounted to only a 2.3 per cent real per capita increase.
Prices are specified according to service level, treatment location, age, and service. This scheme resulted in an average of less than 10 per cent cost recovery for the MOH and a drop in attendance at health facilities, especially in rural areas.
The number of mutual health organisations (MHOs) in Ghana grew from 47 in 2001 to 168 in 2003. Yet there is limited evidence on factors that predict enrolment in such schemes, and whether enrolment increases health care utilisation and ultimately health outcomes. In recognition of the potential of MHOs to eliminate user fees and increase access to health care, Ghana enacted the National Health Insurance Act in 2003, mandating the establishment of district-wide MHOs.
A study was undertaken to evaluate the effects of the National Health Insurance Scheme (NHIS) in Ghana involving six districts in Ghana: Nkoranza, Kwahu South, Ahanta West, Ajumako Enyan Essiam, Offinso, and Savelugu/Nanton. Results indicated that household head characteristics (older age, female gender, higher education, and employment) predicted insurance enrolment at the household level, whereas these factors plus household wealth increased the likelihood of enrolment of an individual. Referring to outpatient care seeking, insured respondents were more likely than uninsured to seek treatment and to do so promptly. Insurance enrolment was the most important predictor of being able to afford hospital care. Enrolment also protected respondents from being detained in hospital due to inability to pay the bill. Marginal insurance effects were found in relation to prenatal care, but insured women in Nkoranza were significantly more likely to deliver by caesarean. The combined effect of insurance enrolment and complicated delivery provided protection from high out-of-pocket payments. Comparing premiums for the MHOs in the study districts with those of the NHIS suggests that the government-established NHIS premium of 72,000 cedis per adult was within reach of most Ghanaian families, and offered a better value in that it covers primary health care in addition to inpatient care. Adverse selection is more likely to pose a problem in the near term, given the slow uptake of enrolment. Findings largely demonstrate that enrolment in insurance does offer household income protection for more serious health issues. Uninsured respondents paid 10-20 times more for inpatient care than did insured respondents. My old lady who saw the significance of the scheme remarked when I visited the village that because of n her enrolment status doctors now prescribed expensive drugs for her. Findings for maternity care payments were similar – insured women paid 3-5 times less for delivery care than did uninsured women. Future surveys will be useful to both monitor progress in the study districts and to evaluate the impact of implementing national health insurance in Ghana.
It is a fact that because the Hospital Fees Regulation legislation did not provide the necessary funds for Ghana's health care system to improve and expand, other mechanisms such as the National Health Insurance scheme (NHIS) which depend upon shared costs between insurer and insured has been introduced .
Self employed or unemployed contributors to the scheme paid annual premiums while their working counterparts who contributed to the Social Security National Insurance Trust (SSNIT) were bailed when their 2.5 per cent of their SSNIT contributions were deducted to support the scheme. But this could have settled the minds of many but has its problems such that some contributors faced problems in getting registered. I happen to be victim of this unfortunate phenomenon. There were other reported cases of frustration because insurance card holders were said to be neglected for those who paid real cash at the health delivery points. This has been so probably because of the inability of the National Health Insurance Council (NHIC) to reimburse the various delivery points. It was however, refreshing when the Council late last year was reported by the Ghana New Agency (GNA) to have paid 324 billion cedis for the settlement of all debts it owed to hospitals, clinics and pharmacy shops that provide services to scheme members.
The Executive Secretary of the NHIS, Mr Ras Boateng was said to have disclosed this in a speech read on his behalf at the second annual general meeting of the New Juaben Municipal Mutual Health Insurance Scheme in Koforidua.
He was reported as saying that Ghana had achieved the fastest rate of implementation of health insurance in the world, and that within a short time of three years of actual implementation, close to 50 per cent of the country's population was accessing free health care. Is this free health care anyway?
Various concepts such as the conflict theory with its base on economics, perceptions as a concept of human behaviour and social group influences, have been found to influence health care utilisation and especially in our part of the world where health care delivery is pluralistic requires tactfulness to ensure maximum utilisation. There should be continued public sensitisation to rake in more people to embrace the scheme . This is in spite of the flagrant refusal by some people not to patronise it on the fickle excuse that it is of no benefit to them. Those who think this way say that when they go to health centres they are not given the best of drugs. This kind of thinking has a somewhat sociological base in that patients who receive drugs of certain kinds such as tablets, injections and the colour of the drug play on the minds of the people so that when they receive the expected drug they think a certain way. Since health care users fees have become in vogue in contemporay health care administration efforts must be done to streamline them to improve on the health status of the people.