Universal health coverage in Ghana: how can we really make progress?

In Ghana, universal health coverage (UHC) is not a new concept.

As far back as the 1970s, Ghana committed to the ‘Health for All’ movement and adopted the Ghana Primary Health Care Strategy in the late 70s and early 80s. We introduced District Health Systems in the 1990s, and more recently (in 2003), the National Health Insurance Scheme (NHIS) was introduced to provide equitable access and financial coverage for basic health care services to Ghanaian citizens. Community-Based Health Planning and Services (CHPS) has also been set up to deliver essential community-based health services.

So, you might think that, as a country, we’re on the right track… But despite the near-universal acceptance of the UHC concept among most stakeholders in the health sector, there remains little consensus over what needs to be done by Ghana to make real progress towards UHC, nor are there any clear national goals and targets. Here’s an overview of the current status of UHC in Ghana.

We are not investing enough domestic resources in health  

Public financing of health is the most equitable and sustainable way of achieving UHC. There are two targets around minimum public expenditure for health, neither of which Ghana is meeting:

• 4-5 per cent of GDP is proposed as a minimum target by WHO
• The Abuja Declaration, signed by heads of state of African Union countries in 2001, pledged to allocate at least 15 per cent of annual budgets to improve the health sector

The government’s health sector spending is actually decreasing – from 10 per cent of the total budget in 2010, to seven per cent in 2017. And according to data from 2015, the government spend on health (as a percentage of GDP) was only two per cent.

We are not reaching the people who need health care the most

At the heart of UHC is equity. A key question any country must ask when making roadmaps for UHC is who to include first? The priority needs to be the people who struggle the most to access even the most basic services, who will be pushed even further into poverty by trying to meet a basic need. But with decreasing public health financing, these are the people who are excluded.

Ghana’s key health indicators improved steadily during the period of the implementation of the Millennium Development Goals and were applauded as a success on several platforms. But even during that period, huge inequalities in health persisted beneath the strong overall performance. The NHIS was introduced to curb high user fees and their effect on the poorest people in rural and working environments. After more than a decade of implementation, it is estimated that less than two per cent of the poor are covered, and people with disabilities – many of whom are among the poorest of the poor – do not have any special provisions under the scheme. It is not surprising that about 36 per cent of current health expenditure is out-of-pocket payment.

The current flagship project of the government, CHPS, is a laudable and has great potential, but funding continues to be a challenge – many CHPS compounds are unable to provide quality services to meet the health care needs of the people in their communities.

We have reasons to be optimistic

“By 2030, all Ghanaians should be able to access high quality services that are included in the UHC Package of Care.” (The overview of the draft UHC Roadmap Document contains a milestone of improving NHIS coverage from 35 per cent to 50 per cent by 2020.)

In July 2019, the Civil Society Engagement Mechanism for UHC2030 supported a national level consultation in Ghana on the national roadmap towards UHC. This was supported by Alliance for Reproductive Health Rights and conducted in preparation for the UN’s High-Level Meeting on UHC which will take place in New York on 23 September 2019.

I attended the two-day national consultation, which brought together practitioners from preventive and curative health care, as well as civil society, including representatives of persons with disabilities and the government. During the event, the bare bones of a UHC Roadmap for Ghana was presented and discussed.

The development of this roadmap is extremely welcome – it demonstrates that the Ministry of Health is committed to delivering UHC. As the roadmap is finalised, we need to really think about the actions that are needed for sustainable progress towards UHC to be made.

These actions should include:

• Maximising the potential of the NHIS – but prioritise reaching the furthest behind
• Adopting a health systems approach to ensure that gains made are sustainable
• Increasing public funding for health by engaging the broader government (especially the Ministry of Finance) and politicians sooner rather than later – their buy-in and commitment in is fundamental
• Ensuring data is disaggregated – this is critical to monitoring the equity gaps in health status and access to services
• Including disabled people’s organisations (DPOs) in civil society engagement and multi-stakeholder partnerships

While there’s still a long way to go in achieving UHC in Ghana, the newly-developed roadmap offers a vital opportunity for progress. The key now is to make sure this ambitious plan turns into concrete action, leading to real and lasting change.

Grace Antwi-Atsu
Grace is Sightsavers’ Advocacy Adviser for the West Africa Region, based in Ghana.