Aligning Health Financing with PHC in Ghana

Ghana’s National Health Insurance Scheme (NHIS) has been praised globally as an example of how government can implement UHC in low- and middle-income countries. But the system has not been without challenges.

Ghana’s Community-based Health Planning and Services (CHPS) – a successful primary health care program that relocates health workers into communities to deliver preventive and promotive services, as well as treatment of minor ailments – encountered a significant bottleneck. There was no provision for reimbursement of community-based care in Ghana’s NHIS, which was largely designed to protect Ghanaians from catastrophic health expenditures and improve access to curative care in clinic settings. 

As a founding member of the network and a key participant in the JLN’s PHC technical initiative, JLN Ghana suspected that Ghana’s health financing approaches did not always support the country’s primary health care goals, so they joined other JLN members in creating a tool to assess for misalignment. The JLN Ghana team applied the initiative’s co-produced UHC Primary Health Care Self-Assessment Tool in collaboration with the NHIS and its Regional Health Directorate in the Upper East Region of the country in late 2014.

Dr. Koku Awoonor-Williams, a JLN representative from the Regional Health Administration Upper East Region in Ghana who piloted the tool, reflected, “The pilot provided us with a lot of new knowledge. We identified key areas of misalignment that work against the very foundation of universal health coverage. For example, delays in reimbursements of claims for services provided by health care providers at the PHC level, which serves as a disincentive to support the NHIS; inadequate coordination among stakeholders in PHC delivery; inadequate funding for PHC; and non-reimbursement by NHIA for preventive and promotive services.”

“What this means is that, despite the progress that we have made since we first established CHPS, and later NHIS, in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. There is no better time to address these gaps than now, and this tool was important to unearth these gaps,” Dr. Awoonor-Williams concluded.

Since completing the UHC-PHC self-assessment analysis, a strong consensus emerged among stakeholders that primary health care should serve as a foundation for Ghana’s universal health coverage goals. A presidential-level technical review of the NHIS in 2016 concluded that the insurance scheme should be revamped to focus on ensuring access to primary health care services for all Ghanaians – with a new PHC-oriented benefits package, provider payment mechanisms that incentivize preventive and promotive care, and automatic enrollment based on residence rather than voluntary enrollment based on premium payment or exemptions. 

Applying the UHC Primary Health Care Self-Assessment Tool provided health service providers and stakeholders in Ghana’s Upper East Region an opportunity to communicate their key concerns with the implementation of the NHIS. This led to further integration of Ghana’s health financing and primary health care. The lead authors of the application of the self-assessment tool have also expressed a desire to extend its application to other regions and nationally – and as the new government sets its course for health system strengthening, the timing is ideal to do so.

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