One of the two primary thematic areas of the 2020 National Democratic Congress (NDC) manifesto is emphasizing social protection policies such as free primary health care (PHC).
The concept of PHC has been defined as the provision of ambulatory or first-level of personal health care services. PHC services often include prevention of common diseases and injuries, basic emergencies, referrals to higher levels of care, and support in managing chronic conditions like diabetes and hypertension.
PHC is already provided by Ghana Health Service (GHS) and private providers, and a free PHC would use the same primary level providers. What is needed in the country is strengthening of the health system by providing what the providers need in order to provide quality services, while the Ministry of Health plays its oversight role.
An effective PHC program needs efficient provider payments and coordinated referrals. The NHIA (NHIS) provides both by negotiating reimbursement rates with providers for their services; and also uses the “The Gatekeeper System” to coordinate referrals and approve provider reimbursements. However, the NDC manifesto is silent on role of the NHIS in its implementation of the free PHC program.
Considering all the services under the proposed PHC program are covered under the NHIS, why a new PHC program using the same providers that provide PHC under the NHIS?
18.104.22.168 (b) of the NDC manifesto promises to exempt all cocoa farmers from NHIS premium payment for secondary and tertiary care. NHIS members (the informal sector) pay one premium for all levels of care – primary, secondary and tertiary. There is no premium for secondary and tertiary services only. Would a future NHIS under an NDC government cover only secondary and tertiary level services? Will the NDC exclude PHC services which accounts for 95% NHIS utilization and 66% NHIS cost from the NHIS? And what changes would the NDC make to the operational structure of the NHIS?
According to the NDC, many Ghanaians cannot afford the NHIS premium, thus denying them access to PHC services; and pay at point of service. The NHIS is free for all the vulnerable groups in the country: children under 18 years, the aged 70 years and over, Livelihood Empowerment Against Poverty (LEAP) recipients, SSNIT pensioners, the disabled, those classified as Indigents, and expectant mothers. Currently, over 68% of NHIS members don’t pay premium, averaging 17 – 22 cedis per person per year. The NHIS law prohibits payments for services and drugs at NHIS credentialed providers.
On free health care (FHC) policies, the World Health Organization (WHO) has observed that without proper targeting and monitoring, better-off population groups usually benefit from such policies more than vulnerable population groups. Free PHC may suffer similar fate. Also, the sense of ownership and solidarity that are demonstrated in social health insurance programs like the NHIS, will be missing in a free PHC program – unnecessary utilization can be high and providers can cut services because their compensation is not based on volume of services rendered.
South Africa, Senegal, Kenya and Nigeria are moving away from government-run free healthcare to social health insurance (financial risk protection) to move their countries towards universal health coverage (UHC). Ghana has been a leader in Africa, enjoying 17 years of NHIS with many countries visiting Ghana to learn from NHIS. Rather than strengthening the NHIS by: identifying additional funding sources, committing to improving efficiencies and implementing more cost containment strategies, the NDC is proposing free PHC that has the potential to sending Ghana back to the NDC “Cash and Carry” days.
By: OB Acheampong – Health Financing Specialist