Authors: Cherri Zhang, Md. Shafiur Rahman, Md. Mizanur Rahman, Alfred E. Yawson, Kenji Shibuya
Publication Site : PLOS ONE
Publication Type : Research Article
Date of publication : 2019
Universal Health Coverage (UHC) is a concept in which all people receive the quality, essential services they need without experiencing financial hardship. The First Global Monitoring Report formulated by the World Health Organizations (WHO) and World Bank identified three dimensions: population, health services, and financing through risk pooling mechanism to track UHC progress. Since its integration into the recently adopted Sustainable Development Goal (SDG) 3, member countries of the United Nations (UN) have committed to achieve UHC by 2030.
This commitment consists of two targets: a minimum of 80% essential health service coverage for all people, regardless of socioeconomic status, and 100% financial risk protection from out-of-pocket (OOP) payments for health care. UHC is a key mechanism to ensure affordability and equity as well as to guarantee resilient health system, which many countries have embraced in order to achieve better health for all.
This commitment consists of two targets: a minimum of 80% essential health service coverage for all people, regardless of socioeconomic status, and 100% financial risk protection from out-of-pocket (OOP) payments for health care.
Achieving UHC in Sub-Saharan Africa should be of utmost priority as countries in this region trail significantly behind in achieving health outcomes especially the Millennium Development Goals (MDGs) formulated by the WHO. Moreover, millions of Africans fall into poverty annually due to OOP payment as a result of lack of health insurance in health financing system. Ghana, being one of the few Sub-Saharan African countries advocating for UHC, implemented the National Health Insurance Scheme (NHIS) in 2003, in an attempt to remove financial barriers, protect Ghanaians from catastrophic expenditure, and improve access for everyone.
NHIS is mainly funded by three sources: 70% of National Health Insurance Levy (NHIL), 17.4% of Social Security and National Insurance Trust (SSNIT), and 4.5% of premium payments. NHIL is a 2.5% tax on selected goods and services; SSNIT is a 2.5% contribution paid by those in the formal sectors, and premium is set at an annual flat rate of $4.8 USD to $32 USD depending on districts for those in the informal sectors. Pregnant women and those under the age of 18 years or over 70 years of age are exempt from premium and make up 60% of the enrollees.
Ghana, being one of the few Sub-Saharan African countries advocating for UHC, implemented the National Health Insurance Scheme (NHIS) in 2003, in an attempt to remove financial barriers, protect Ghanaians from catastrophic expenditure, and improve access for everyone
Services covered under the insurance include outpatient and in patient care, oral health, eye care, maternity care, and emergencies with no copayment upon receipt of services. It excludes cosmetic services, HIV antiretroviral drugs, orthopedics, and organ transplant etc. Despite enrollment into NHIS being mandatory, overall enrollment remains low at 40% as of 2016 since majority of the population belongs to the informal sector, and there is a lack of formal tracking regulations.
Although Ghana made significant stride towards health financing in recent years; however, Gross Domestic Product (GDP) spending on health and total government expenditure allocated to health has dropped since 2010 to 3.6% and 6.8%, respectively in 2014.
Furthermore, other challenges such as funding and sustainability persist as overall enrollment has decreased in recent years and many citizens find paying for premiums difficult. In addition, as the incidence of poverty is around 25% with some regions such as Upper East and Upper West experiencing more than 70% incidence of poverty, inequality remains a prominent issue especially across regions. Inadequate funding for health can lead to unstable health insurance scheme and an increase in OOP payments, pushing people further into poverty and worsen health outcomes.
In addition, as the incidence of poverty is around 25% with some regions such as Upper East and Upper West experiencing more than 70% incidence of poverty, inequality remains a prominent issue especially across regions
Based on future projections, most prevention service indicators are estimated to have more than 90% probability of achieving the target except need for family planning satisfied, adequate sanitation, and non-use of tobacco. Amongst the treatment indicators, care seeking for pneumonia among children has the lowest probability of reaching the target at 5.1% while access to institutional delivery and use of skilled birth attendance will have more than 85% probability.
A notable achievement is the national coverage of the four childhood vaccinations (BCG, measles, three doses of DPT and polio vaccination) which had already reached the target in 2015. In addition, coverage for maternal postnatal care increased from 10.6% in 2005 to 79.9% in 2015. The lowest coverage among the poorest quintile was observed in adequate sanitation at 6.5% in 2015.
This is followed by need for family planning demand satisfied at 38.1% and access to skilled birth attendance at 38.9%. It is expected that all quintiles will fail to achieve the 80% coverage target for family planning demand satisfied and care seeking for pneumonia. Besides the two aforementioned indicators, the richest quintile is highly likely to reach the target for most indicators except polio vaccination and insecticide treated bed nets use by children under five.
Overall, absolute inequalities have drastically decreased across most indicators except for use of skilled birth attendance, institutional delivery, and adequate sanitation in which SII only slightly decreased for skilled birth attendance (SBA) and even increased and is predicted to remain so for institutional delivery and adequate sanitation.
These three indicators have the biggest inequalities in 2015 and will likely to prevail up to 2030. Adequate sanitation has a SII of 87.7, followed by institutional delivery at 87.4 and skilled birth attendance at 69.9. These numbers signify that the richest quintile had 69.9 to 87.7 percentage points higher coverage compared to the poor.
Although inequalities in indicators related to maternal care such as antenatal and post- natal care have decreased, but persistent inequalities are predicted up to 2030. Similar to absolute inequalities, decreasing trends are also seen and predicted for relative inequalities, represented by RII values, to a lesser degree.
The greatest achievement is the childhood immunization coverage with all vaccinations already reaching the 80% coverage target in 2015. The government made a strong commitment to finance immunization paying 100% for childhood vaccines
However, inequalities still exist for both UHC components throughout the nation. Similarly, subnational disparities were apparent as well with some regions faring better than others.
The greatest achievement is the childhood immunization coverage with all vaccinations already reaching the 80% coverage target in 2015. The government made a strong commitment to finance immunization paying 100% for childhood vaccines. The Expanded Programme on Immunization (EPI) began in 1978 in an attempt to reduce overall poverty by reducing infant and child mortality caused by vaccine preventable diseases. Through community-based strategies, home visits and outreaches, it has evolved to become one of the most successful and cost effective programmes implemented in Ghana.
On the contrary, family planning demand satisfied showed the least likelihood of reaching its target. The low uptake of family planning can be explained by many facets such as misconception, stigma, lack of knowledge, religious abhorrence, spousal disapproval, and inaccessibility. Health concerns including fear of side effects remain one of the biggest reasons and a similar finding was reported in Ethiopia as well. Proper teaching is critical and Community Health Workers (CHWs) can greatly improve the use of contraceptives by providing adequate education on its usage and health safety concerns.
It should be integrated into existing health education programmes to increase awareness, access, and utilization. Additional interventions include empowering women, improving female education through the free universal secondary school policy, involving male partners, and making contraceptives readily available and affordable.
It is imperative to increase people’s knowledge of childhood illnesses and perhaps the Ministry of Health and Ghana Health Service need to strengthen the health pro- motion unit to provide structured and targeted community educational programmes by adequately training CHPS Community Health Workers (CHWs)
Similarly, care seeking for the treatment of pneumonia also had a low coverage and unlikely to reach the target because a past study conducted in rural Ghana found significant knowledge deficit among residents regarding pneumonia. In that study, only one-third of the studied population ever heard of the disease name and among those, only half sought treatment for their children.
It is imperative to increase people’s knowledge of childhood illnesses and perhaps the Ministry of Health and Ghana Health Service need to strengthen the health pro- motion unit to provide structured and targeted community educational programmes by adequately training CHPS Community Health Workers (CHWs). As an additional effort, the EPI in Ghana currently have vaccines against all common causes of pneumonia in children. Enrolling into NHIS can also potentially improve treatment-seeking behavior since parents who are enrolled are more likely to seek curative and preventive care for their children.
We also found that utilization of institutional delivery and access to SBA were among the top three indicators with the biggest absolute and relative inequalities in 2015. Our raw data showed that during the 2000s, coverage in these two services decreased for the poorest quintile; thus, widening the inequality gap. This finding is confirmed by a previous study conducted on young Ghanaian women with childbirth history which showed an increased inequality in the use of SBA between 2008 and 2014.
A separate study that examined spatial inequalities of institutional birth revealed that women belonging to poorer households are less likely to give birth in institutions. Financial determinants, physical barriers, conceptions about the quality of services, availability of human resources, and social barriers can all have an impact on the use of institutional delivery and SBA. Several studies have found that wealthier and more educated women are more likely to enroll into the NHIS and seek maternal care services. Many uneducated women from poor households lack the basic knowledge about maternal health.
A previous study conducted by Ganle et al revealed that increasing women’s general level of education can also promote the use of maternal health services; there- fore, the government should invest in schooling of young women. Ghana is in the right direction to achieving universal health care as there is a quest to provide free education from basic to secondary school level by the national government.
Keeping girls in school for longer is one key way to enhance maternal health and promote safe motherhood. The CHPS concept can boost access to reproductive health services especially for the rural poor as CHWs who work at the CHPS level have proven to be effective in improving health care access and overall health status.
Financial catastrophe due to healthcare spending decreased by almost eight-fold from 1995 to 2015 and impoverishment witnessed a four-fold decrease. From our data, it is evident that expenditure on non-food items drastically increased. The number of non-food items in Ghana Living Standard Surveys conducted in 2012–2013 tripled compared to the survey conducted in 1991–1992; therefore, health expenditure as a percentage of non-food expenditure decreased over the years, lowering the proportion of household suffering catastrophic expenditure.
Although inequality gaps have narrowed as difference in the incidence of financial catastrophe between the rich and the poor groups reduced, the poor is still suffering more CHE as a result of OOP health payment. This finding is in congruence with previous studies from other Sub- Saharan African countries. At a threshold of 25% non-food expenditure, incidence of CHE was 1.8% in 2015 and 0.4% of households were pushed into poverty. These results were worse compared to earlier studies done in South Africa and Tanzania in which impoverish- ment were only 0.045% and 0.37%, respectively in 2008. On a positive note, Ghana’s progress was shown to be better than Rwanda and Nigeria.
Ghana with its strenuous efforts in making health care more equitable and affordable has made tremendous improvements in health service coverage along with reducing OOP payment. Rigorous health policy implementation, attempts in achieving the MDGs, and the establishment of the NHIS resulted in significant improvement in maternal and child health indicators.
Ghana with its strenuous efforts in making health care more equitable and affordable has made tremendous improvements in health service coverage along with reducing OOP payment
However, apparent inequalities were evident at the national and subnational level since the poor were suffering more catastrophic health expenditure (CHE) and had less access to health services. These inequalities were observed in many studies conducted in Ghana thus far. Policy makers need to make stronger commitments in achieving equity as many health care interventions, aimed at the poor, do not reach them. Poverty, unavailability of services, inadequate infrastructure, insufficient human resources, social norms, and limited education and health knowledge are potential contributing factors to inequities.
Several options to be considered are equitably distribute funds to regions according to needs, administrative re-organization of some regions, increase enrollment unto NIHS, scale up of the CHPS programme to improve access to hard-to-reach population along with raising the quality of care, increase the capacity of human resources, and improve health infrastructure. Ghana serves as an example for other Sub-Saharan African countries in implementing a universal health insurance.
Its achievement in improving health care utilization for its citizens and reducing financial burdens is praiseworthy. This study recommends a multi-sectoral approach to address economic, social, and political barriers through partnership between the Ministry of Health and its agencies including Ghana Health Service and other service delivery agencies and development partners. By doing so, UHC will no longer be a distant dream.
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