Financing universal health coverage not business as usual

Health financing is not cheap and as a country, we must confront the issue of looking after the health of all Ghanaians with boldness, creativity and innovation.

It must not be business as usual. We cannot be proud of our health service delivery by any stretch and looking through the building blocks of health systems strengthening, we seem to be struggling at every turn.

Bold step

Ghana took the bold step and initiated the National Health Insurance scheme (NHIS) but made many fundamental errors along the way.

The agreement to fund it through ad valorem tax (VAT) was a brilliant one, thanks to Dr Charles Wereko Brobby, but the expansion to involve all three layers of primary, secondary and tertiary care, bring in the private sector, and also to expand on the essential drug lists was far too ambitious and that has led to the unsustainability of the scheme.

What has equally brought the scheme even closer to its knees is the decision by the Ministry of Health to charge everything to the account as well as fraudulent claims by health staff.

Let me refresh everyone's memory. NHIS was created to replace the 15 per cent  cash and carry contribution to the health budget and not to pay for the entire service. The latter has put incredible strain on the account.

The health budget is inadequate. We are nowhere near the 15 per cent  of recurrent budget agreed on in Abuja and we must make strenuous efforts as a country to move steadily to this benchmark. Our healthcare delivery cannot compare to countries who prioritise health and make contribution of $4,000 per capita to our $100. If we cannot prioritise health as a country, then all people in government, including the first and second families, must pledge to use what we have and add whatever budget that has been allocated to seeking external health care to the local health budget. Our elected officials must also make sacrifices for the good of this country.

Growing the health insurance fund

I do not accept the concept of just adding another one per cent  of VAT for health insurance. It is too simple and does not make everybody and anybody understand why health is so important. Our burden of disease is very high and what are the contributors to this burden?

Apart from the poor environmental sanitation and waste management, and food hygiene which contribute to the still-high infectious disease load, the rest are lifestyle issues which are individual choices.

Road Traffic accidents, increased prevalence of raised blood pressure and blood sugar, cancers, alcohol and tobacco-induced diseases and kidney diseases being the greatest contributors.

So how do we leverage on these and add contributions from the wider social determinants of health (education, environment, food, housing, water and air quality, transport, clothing and all others that directly and indirectly impact on health) to arrive at the additions to the National Health Insurance fund, while explaining to Ghanaians and contributors the need to understand the causes of disease and prevention?

It may well come up to the one per cent of  VAT or more but in addition, we will carry the people along and educate them about preventive measures.

We produce nothing in Ghana so one per cent  tax on all imports that contribute to the burden of disease is where we must start from.

Vehicles and tyres: 0.1 per cent  on road construction and  one per cent on roadworthiness and vehicle insurance,  0.1 per cent as car import duty and 1.0 per cent  on new and second-hand tyres

Food: 1.0 per cent  on all processed food imports, including canned tomatoes, cereals, vegetables, meat and fish products, rice, vegetable oils, fruit juices and energy drinks, and monosodium glutamate cubes

Alcohol, tobacco and sugar tax, known popularly known as SIN tax, five per cent;  Pollutants including oil and gas 0.1 per cent;  charcoal, pesticides and herbicides 1.0 per cent , sand winning and quarries; one per cent.

Construction industry: 0.1 per cent on air conditions, fridge and freezers, home and office furniture; 0.1  per cent on lifts, Road fund; one per cent ,road accidents fund held at National Insurance Commission five per cent.
 
Sanitation court fines; five per cent, Institute health impact assessment on all major projects and contribute 0.1 per cent  of cost of project to the National Health Insurance fund.

The list is endless. The message in all this is that anything that prevents an individual from getting up and walking for health, eating fresh foods, including whole fruits, nuts and vegetables, and therefore contributes to ill health, must pay for obtaining good health. By this methodology, we grow the fund anytime we get into practices that are not beneficial to good health. We must also create systems that give persons who engage in exercises  discounts by health insurance companies. If the health of the people improve, the two most important beneficiaries will be life insurance and pension companies, and so contributions to improving the general health of the people will not be out of place as part of their corporate social responsibility.

Primary health care

Primary health care which takes place in the districts and include Community Based Health Planning and Servces (CHPS), health centres, polyclinics and district hospitals, must be the entry point to the national health insurance and must be fully funded. Referrals to the regional and teaching hospitals can only be reimbursed if they go through proper documentation. A referral does not mean perpetual service at the secondary or tertiary level. Once the referral episode is completed, the patient must be referred back to the primary level. The cost of health care must be as determined Drug list at the public institutions.

The essential drug list not the expanded version must be used, and drugs must all be generic. A branded drug can only be written as a private prescription. It is wrong for any professional group to create an impression that generic drugs are no good when the UK National Health Service relies on it.

Private participation must be considered as volume business, and the mark up trimmed drastically: It is not compulsory, so if the costings are not satisfactory, then opting out must be the preferred decision. Technology must be leveraged, fraud tackled head on and health personnel found guilty punished.

Management expenditure must be cut down through efficiency savings to a maximum of 15 per cent  and monies to members of Parliament from the fund even though it is enshrined in the law must stop. It is the legislature taking advantage of all funding mechanisms in the laws of Ghana.

The Ministry of Health must be advised to do what is expected of it and not charge anything other than service to the NHIS.

The District Health Management Team must be accountable to the District Chief Executive and the latter must play a major part in the full role out of CHPS in the district to ensure financial sustainability. The need for a health dialogue to agree and implement the suggestions is imperative.

The writer is a former Director-General of the Ghana Health Service