ABSTRACT

Health is a crucial economic and social asset, particularly for the working low- and middle- income groups in developing countries. However, effective access to health care seems to be practically impossible without a well-functioning system that adequately protects users of health care services against the associated financial risks, especially, at the time they need them. The implementation and goal of the Universal Health Coverage (UHC) policy by 2030 as part of the Sustainable Development Goals (SDGs), therefore, is to mobilize resources and to ensure equitable and sustainable financing of the health sector. The goal of this study is to highlight measures being put in place by Ghana as a country in order to provide universal access to healthcare for all citizens. Measures to achieve this goal include the development of a comprehensive strategy for mobilizing resources from all sources of funds; pursuing equity in health financing with special emphasis on risk pooling, targeting resources to services for the poor and vulnerable groups, and reducing catastrophic health expenditures. The study adopted a qualitative research method in order to enable the researcher access the views of respondents in their most original state. The research was carried out in Accra, the capital of Ghana where respondents expressed their views primarily through interviews. Meanwhile, secondary data were collected from relevant stakeholders to give more meaning to the opinions expressed. In sum, the research study revealed that Ghana is on the right path in fulfilling SDG 3.8 in terms of funding, human resource development, and infrastructure among others. Also, it was obvious that the NHIS has evolved since its implementation in 2003 and could boast of excellent coverage in Ghana with increasing membership in recent years. Finally, the NHIS is making and continues to make giant strides towards achieving UHC in Ghana. Nevertheless, the main challenge facing the attainment of this goal is the issue of finance which the NHIA is putting in utmost efforts to resolve in order to deliver the quality of healthcare the country needs.

It is obvious that the issue of finance serves as the root cause of the many problems faced by the smooth implementation of the NHIS towards achieving UHC. The study recommends that leadership and relevant stakeholders must make transparency and accountability its hallmark which will automatically translate to the resolution of other problems faced by the scheme.

CHAPTER ONE RESEARCH DESIGN

        Background to the Study

Since the establishment of the MDGs in 2000, it has been cited widely as the primary criterion for judging progress in international development efforts (Karver, Kenny, & Sumner, 2012). Its aim was to implement new initiatives to combat poverty, hunger and diseases while promoting education, gender equality and environmental stability worldwide (Sachs & McArthur, 2005). However, calls for additions and modifications have been made by various scholars, stakeholders and international bodies, as it is believed that the MDGs in spite of significant disparities in many developing nations, lacked strong goals and indicators for equality within countries (Deneulin, 2009). It focused mainly on donor performance rather than development success. An attack levelled against the MDGs was that it did not capture all the necessary elements to achieve the ideals laid down in the Millennium Declaration (Kabeer, 2010). However, India and China have been recorded as countries whose poverty population has been drastically reduced as a result of the MDGs (Besley & Burgess, 2003). Sub-Saharan Africa is believed to have benefitted significantly largely through agriculture, education, health care and disease control even though many scholars are of the view that the African continent was rather behind in achieving the targets set by the MDGs (Ahmed & Cleeve, 2004).

The inability of many nations to achieve progress on the Millennium Development Goals MDGs has called for subsequent agenda which is aimed at building up progress to sustain the post 2000 goals. This has led to the implementation of the SDGs in the year 2015 also known as the Agenda 2030. The SDGs comprises seventeen (17) goals with one hundred and sixty

nine (169) targets measured by two hundred and thirty two (232) indicators which include economic, social, environmental development issues such as poverty eradication, health, energy, water and sanitation and human settlement (Beisheim, 2015).

Governments in various countries have been tasked to translate the objectives into national legislation, carve out an implementation plan, set and allocate budgets as well as seek partners. However, developed countries have been tasked to support developing countries to ensure the targets are met by 2030 (Begashaw, 2017). The WHO in the year 1948 declared health as a fundamental human right of every individual (WHO, 1948). Achieving UHC is gradually gaining its grounds among nations with the aim of providing health services particularly for the poor in society (Besley & Burgess, 2003). The SDSN report suggests that “by 2030 every country should be well positioned to ensure UHC for all citizens at every stage of life, with particular emphasis on the provision of comprehensive primary health care services delivered through a well-resourced health system” (Fried et al., 2013).

According to WHO, UHC means providing all people with access to affordable, quality health care services in order to ensure that they obtain the health services they need without suffering financial hardship when paying for them (Kieny & Evans, 2013). It basically seeks to make health care services affordable and accessible to all. The government of Ghana as part of its GPRS, has implemented a policy to provide all Ghanaians, particularly, the poor and most vulnerable in society, with the needed healthcare services. This policy was aimed at eliminating the out-of-pocket payment system which makes health care almost inaccessible by a larger proportion of the populace.

The NHIS was established under Act 650 in 2003 under the NPP Kufuor-led administration in a quest to fulfill one of his many campaign promises. The law also required the formation of the NHIA to regulate the activities of the NHIS and ensure its smooth operation. The NHIS provides a comprehensive range of outpatient and inpatient services at authorized public and private health care facilities for both the formal and informal sectors (Mills et al., 2012). The NHIS is funded largely through taxation, donor funding, government funding as well as premiums among others (Awoonor-Williams, Tindana, Dalinjong, Nartey, & Akazili, 2016). However, the poor and vulnerable in society are exempt from making contributions to the NHIS (Kanchebe Derbile & van der Geest, 2012). The government of Ghana, in its quest to achieve UHC for its citizens and the implementation of the SDGs, has put the country on its toes to enforce policies to meet these targets by the stipulated times.

        Statement of the Problem

Ghana’s effort to achieve UHC and to improve upon health care has led to the implementation of policies such as the NHIS, and free maternal health care, among others. Ghana as a developing country seeks to provide accessible and affordable health care to its citizens. As a result, the implementation of the NHIS is aimed at serving this purpose and in the long run alleviating poverty. A number of scholars such as Irene Akua Agyapong, Angela Abroso and Sylvester A. Mensah have conducted research on the scheme since its inception and its reformation to suite the evolution of the scheme. However, the implementation of the SDGs has called for further research into this area especially on what measures Ghana should put in place in meeting the target set by SDG 3.8 towards achieving UHC in the country. This means that achieving UHC in Ghana seems to be in the implementation of the NHIS. What measures are put in place towards achieving the UHC is what the study seeks to thoroughly investigate, to determine whether Ghana is on the pathway towards achieving the UHC

through the implementation of NHIS in an attempt to fulfil the SDG 3.8 or the country is far from achieving the UHC.

        Research Questions

• What mechanisms have been put in place to fulfill the SDG 3.8 in Ghana?

• What is the current state of NHIS since its implementation towards achieving UHC?

• What are the successes and challenges facing the NHIS in achieving UHC in Ghana?

        Research Objectives

• To assess the mechanisms put in place to fulfill the SDG 3.8 in Ghana.

• To examine the current state of NHIS since its implementation towards achieving UHC.
  • To analyze the successes and challenges of NHIS in achieving UHC in Ghana.

        Scope of the Study

The study looks at the existence of the NHIS from the year 2011 to 2018 in Ghana. The SDG 3 is used with specific consideration of the target 3.8 which seeks to “achieve universal  health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all (Minas, Tsutsumi, Izutsu, Goetzke, & Thornicroft, 2015).

        Rationale of the Study

This study is to identify the most effective way through which UHC can be achieved with the NHIS as a tool. It also seeks to bring to light the various challenges and successes achieved by the NHIS in its quest to achieve SDG 3.8. The study also seeks to enable government, the

UN, NGO’s, think tanks, as well as stakeholders concerned to develop structured programs aimed at achieving UHC. As the policy is still in progress and gaining its grounds, the study also seeks to add to the body of knowledge since research in this area is limited.

        Conceptual Framework

The conceptual framework considered for this study is the concept of human security. The UNHDR defines human security as “safety from chronic threats and protection from sudden hurtful disruptions on the patterns of daily life”. It can be grouped under seven (7) main elements. Namely; economic security, food security, health security, environmental security, personal or physical security, community security and political security. However, the element of health security is the most relevant to my study. “Human security is not about states and nations but about individuals and people” (Bajpai, 2000). The concept of human security means ensuring the basic center of all humans live in ways that enhance human potential and human fulfilment (Tavanti & Stachowicz-Stanusch, 2013).