 you, our online guest and everybody, panelists, keynotes, because everybody, welcome to this edition of the Conversation Africa dialogue. Indeed, this is the second in the series in recent times. The conversation or the dialogue is on the theme of universal health coverage in Ghana, gaps and opportunity. Universal health coverage in Ghana has been a major, major issue in the past two decades or a decade and a half. Ghana is one of those shining examples, at least when it comes to the issue of health finance in Ghana, national health insurance scheme, et cetera, and the kind of what Ghana has been doing in that space on the continent. So we think it is quite opportune to have this discussion at this time to see what Ghana is doing right, what Ghana can improve upon and what Ghana should stop doing in order to speed up its march to universal health coverage. Universal health coverage is a key theme all across the world and indeed it's been captured in the Sustainable Development Goal, specifically Goal 3.8, where it takes time to detail out what it expects of countries in terms of universal health coverage. This is a two hour session. We have a very distinguished panel which will be helping us discuss the matters. It is expected that by the end of today's session we would have understood where Ghana stands in universal health coverage, what gaps and opportunities exist in the country's march towards UHC and a whole lot of things. I will in due course, introduce the panel and introduce a very important personality in our midst, who is the presidential advisor on health in Ghana. He will give an introductory remark and I believe a lot of the discussion will flow from what he really has to say. In the meantime, we want to hear a word from the conversation, Africa, the team putting this together. I must also mention that this has been done in partnership with the University of Ghana, Lagoon. My name is Selom Adonis. So on this note, I welcome or I call on Adejuan Soinka who is a conversation Africa, West Africa regional editor to welcome us and to tell us a bit about the conversation Africa and why this dialogue at this particular time. So Adejuan, you may take it over. Thank you Selom and thank you everyone for joining us this morning. Welcome to everybody on the line. Those on the Zoom call and those who are following us on Facebook live. Thank you all for joining us. Selom already told you, my name is Adejuan Soinka I'm the West Africa regional editor at the Conversation Africa based in Lagos, Nigeria from the leader West Africa team with operations in Nacra, Ghana, Dakar, Senegal. Also in the room, my colleagues who have spread across the continent in Johannesburg to start with in South Africa which is where our head office is, but colleagues from Nairobi, Kenya where East Africa regional editor is based as well as of course Ghana and colleagues from Senegal like I've mentioned earlier. But that's not all. The Conversation Africa belongs to a network of global media, the TCC, the conversation across the world. And so we have our colleagues in the UK our colleagues in Australia, the United States, Canada, France, New Zealand, Indonesia just to mention some of the places where we have opportunities to spread across the world. Again, a warm welcome to the University of Ghana who are our academic partner for this dialogue today. I must also especially welcome our speakers and panelists starting of course with the health advisor to the president of Ghana, Professor Astari who has joined us this morning and also we're delivering the opening address today. And of course our other esteemed panel speakers, Dr. Pashens Asegar Bo, Dr. Apeka Kuma and Dr. Anthony Tansu Ape, all of whom you will all meet and engage with us and we'll proceed with the program at this moment. Thank you all for honoring our invitation for being here today and in fact promptly too. Thank you very much. Now the conversation for those, the Conversation Africa for those people who may not be already familiar with what we're doing is a means and analysis-based organization. We work with academics and scientists. We help them to translate and publish their research and insight into everyday language that will be shareable and will be a platform where they can share insights of their research with the rest of the world and the public as well. Our website is freely accessible. I encourage those of those who are not yet following the website to please TUSU immediately after this program. In fact, you can also subscribe to our daily newsletters and get this insight served on the web or email on daily basis. Our work and our mission is to increase the visibility of African scientists and to make sure that the world of knowledge and research that often remains only within university corridors and of course complex peer-to-peer journals is in the hands of the public and also the policy makers and policy community who can make use of this important insight and make better decisions that will make life easier or make life better for our societies across the continent and across the world. Since we launched in 2015, the Conversation Africa has published over 4,700 scientists and researchers and their combined articles have been read over lighting media times from across the world. Proving one major important factor which is the fact that, look, our communities want to hear from experts. They want to hear from people who know exactly what they are talking about. And it also proves that scientific voices really do matter in issues around the world. So why do we engage in policy dialogues on this nature as well? Really it's an extension of our mission to bridge the gap between the academic world and policy makers and the rest of the society. So policy dialogues of this nature is a platform where we want scientists to be able to share their insights and be able to bring scientists into one room as well as policy makers and the general public to get them to discuss an important issue that affects people generally. For today, this question is focused on universal healthcare coverage. Yes, of course we'll be focusing more on Ghana, but the topic we're discussing is actually important and very important across the continent. It's important that citizens have access to healthcare and that they have access not just to healthcare but to quality healthcare. And this access is not something that should just be enjoyed by only the privileged few. It should be open to everybody. And as we all know from our experiences in different parts of the continent, lots of Africans and African countries are battling to achieve this on daily basis. So it is my hope and it is our hope as the conversation of Africa that the insights and the ideas that we shared here today will not only be useful for Ghana, but for other countries on the continent and for everybody who is on the line. Once again, thank you very much and welcome you all for joining us this morning. And I look forward to a very robust dialogue between policy makers and the scientists as we proceed along with the course of our program this morning. Thank you everybody and thank you so much. I am about to begin. All right, so thank you so much. Adedu Wan So-Inka, who is the Regional Director for the Conversation Africa, West Africa region. Thank you so much for that welcome and that brief talk on the Conversation Africa. Also, I want to zoom straight into the event itself. We're privileged to have a very important personality than our midst. And if you're in Ghana, you have had to speak on many, many occasions. And now, you know, in this period of pandemic it's quite busy. It's dealing with Ghana's COVID response amongst other things. So we are very pleased that it's made time to be with us today. It's in the person of Dr. Anthony Nsiassari, who is the Presidential Advisor on Health. So Dr. Sari is a Ghanaian medical officer. He's an academic and health management expert. He has worked in the Ghanaian health sector for close to 40 years, served various management levels and was also the Director General of the Ghana Health Service. He's a politician. So he's a member of the new patriotic party and he currently advises the President of Ghana, his Excellency, Nanadu Dankwa-Kufadu on matters of health. I must say that in his previous life he's been the Chief Executive Officer of the Konfanochi Teaching Hospital, which is one of two major, major hospitals in our country. And he's done quite a number of things for himself and now he's serving the country in yet another capacity. You know, there was something somebody told me some time back that in a political system there are two people who are very important. One, the one who has the ear of the candidate or the President. And number two, the one who has the money. So I think it is safe to say that Dr. Nsiassari on matters of health has the ear of the President. So it's one of the key persons to deal with that. And I must also mention that by virtue of his position before as the Director General of the Ghana Health Service he also sat on the board of the National Health Insurance Authority. So he's very well-clothed to take us through the subject and the discussion. So Dr. Nsiassari, you are welcome to this program and we are very pleased to have you. Thank you very much Selam and good morning to all of you especially those who are online listening to us virtually. I'm very grateful and very honored for the invitation that the Conversation Africa has given to me to at least open the topic that you have put up. It's a very important topic. It's a human rights issue. Health is the human rights issue. And as for that matter, we in Ghana and the government of Ghana is very much committed to attaining the sustainable development goals. The Principles of Africa Union Agenda 263. We also committed for attaining the Global Action Plan for Healthy Lives and Well-Being Declaration of the Primary Health Care in Astana 2018 and the UAC 2030 Compat initiatives of UAC 2020 and the political declaration of UAC adopted by the UN High Level Committee in September 2019. This is at the heart of whatever we are doing is a human, as I said, principles of human rights, equity, gender and people-centered approaches. I'm very happy that the Conversation Africa has gathered together scientists, public health, practitioners and policy makers to take stock and analyze Ghana's public health system and our ability to ensure that we attain the universal health coverage. But you all agree with me that globally, access to health globally has now become a problem because of the COVID-19 pandemic which has actually added tremendous pressure on resources and Ghana has a very scarce resources in revealing gaps in public health systems in Ghana. In fact, COVID-19 has released the gaps for all of us to see and for that matter, it's excellent to see the president have also taken the bull by the horn to make sure that at least we will fill in the gap as quickly as possible. What have you done so far? What we've done is that despite COVID-19, we have put together a roadmap and I'm sure you can get hold of the roadmap. It's a policy roadmap and what... ...a lot of the national health policy which was done... Okay, if you can hear us, I think your line is breaking up a bit. You may have to... So I think we eventually lost him. I think we will try and then reconnect with him quickly so that he continues with his submission. He was making a very important point on Ghana's journey so far and he started by looking at various institutions and various... Yes, I think it's better. Yes. So as I said, that Ghana... So I think you are at the point of the policy roadmap for UAC. Yes, the policy roadmap. Yes, so come up with a policy roadmap for achieving investor health coverage and our vision is that all people in Ghana have timely access to high-quality health services irrespective of ability to pay at the point of care. And we have objectives. The objective is the investor access to better and efficient managed quality health services. We want to reduce unnecessary maternal and adolescent child health and disabilities. We also want to increase access to responsive clinical and public health emergencies. And as you are aware, we have garden principles. We have five main garden principles for our roadmap. What you want to do is that you want to target scalable, high-impact, high-multiply areas to deliver value. And the actions should... These actions should catalyze into change and scale up our access to essential nutrition, health promotion, interventions, smart, creative care, disease prevention, palliative, rehabilitative, emergency care, and maternal health services. So it's a whole compartment of services that you want to give. But we want to use the primary health care as a level of emphasis. Emphasis and systems will be put in place to enhance access to specialized care through referral system. The value proposition follows a five-point guiding principle. The first guiding principle is that you want to target. You want to focus on the poor, the vulnerable, particularly children and adolescents, women and the aged. Two, we want to have a financial risk protection. We want to eliminate all physical and financial barriers to assessing primary health services, especially those most at risk of incurring adverse health expenditure on the incidence of health. We want to have strategic partners. We want to build sustainable partnership and harmonize agenda between government, the private, the private sector, non-state artists, and development partners to upscale the services delivery and secure predictable financing for long-term results. The fourth strategic guiding principle is to effective decentralized management. We want to cement district-level services governance with district assemblies and improve sectorial collaboration to synergize resource mobilization, efficient use, and accountability, particularly in primary health care levels of service. And lastly, we want to also prioritize domestic financing to rationalize allocation and expenditure of the domestic resources to focus on primary health care and manage existing and any new co-financing requirements within a realistic budgetary allocation. So, so far, despite COVID-19, we've done a lot of things. First, we have strengthened our national health insurance or we have strengthened it since 2017 and unfortunately, the COVID came in 2020. We've strengthened our national health insurance authority. We are increasing health insurance is supposed to be for everybody. And because another, we've introduced a Ghana card. Once you have the Ghana card as an adult, about 15 years, automatically, you are supposed to be on health insurance. So that's what we are doing so that we increase the number of people who are active on health insurance. We have also done a lot of leadership and management training for senior leaders in health sector. We've gone through training for all the people in the ministry, Ghana Health Service, the executive directors of Ghana Charg and other health sector leaders. There's a secretary, which has been constituted to commence Ghana disease CDC. And we have three physical UOC set up in Ashanti, Northern region and Western region. There's quality management teams being strengthened across the country. We are implementing our national quality strategy and their network of practices of model health centers being implemented across the country. It has already commenced in Bono, Volta and other regions. The aim of this network practice is to use it to strengthen the primary health care systems in the country. Investment is also made in our emergency response system. You are aware that we have about 307 ambulances which were brought into the country to improve the pre-hospital care. We've deployed the SOMAS system and that's what we are using for COVID-19 surveillance system. We also have introduced free post-graduate training in the Ghana College of Physicians and Surgeons which is funded through the School of Secretariat. This idea is to also increase the number of specialists across the country so that we can have specialist care to support primary health care activities across the country. And we have also been strengthened the Food and Drug Authority. It has a high ISO certification. It's actually maturity level three for the WHO and even maturity level four for pharmacovigilance. And we've improved all the regulatory bodies to also regulate the people that they also see. So these are some of the things that we have put in place within the last short period. And this is all part of the roadmap for primary health care for the Achieving University Health Coverage. We've costed what we need. For example, we know that by the year 2027 Ghana will be transitioning for the Gavi Vaccine Alliance. And because of that, we've costed how much it will cost us and you are also aware recently, the government has introduced us to start a local or domestic vaccine production not only for COVID vaccines, but COVID has taught us a lesson. So we are moving into health quickly, vaccine production in country so that we will not be caught on our ways by the year 2027. And vaccine security and the health security will be also achieved in the country. We will continuously be doing all these things and we are aware that there's, there are a lot of essential services that we have to give to the people of this country. As I said, initially, we are trying to optimize the basic health, basic essential health services. We want to also look at child and adolescent-centered school health. So we are strengthening school health to make sure that children who are in school have very good health systems in place. And we are also looking at work-place-centered health care system and try as much as possible to also improve the organization of services across the country. We are depending on the community health services system. And as I said, we are going to have a network of primary health services, which will also be developed and the district hospital system will also be developed. As you are aware, we are also moving into what you call Agenda 111. Agenda 111 means that we are going to have hospital, district hospital to support all the various 260 districts. So we are putting up 101 district hospitals, which will be state-of-the-art hospitals, which will also be fit for purpose hospitals and then to serve as a first referral center for all the community service that we are having. We also realize that if you want to do this, we have to also take care of mental health services. So in Agenda 111, we are also trying to put a psychiatric hospital, which will look after all the mental cases in the middle sector in Kumasi and the northern sector also in Tamale. In addition, we also believe that we should have a secondary referral system to support what we are doing in all the districts and the communities. So we are going to make sure that the six new regions will have also well equipped, well standardized district hospitals, regional hospitals to cater for all the primary health care activities. So in all, we'll be having 111 hospitals which have started. This excellence, the president cut the store for the beginning on the 17th of August and it's all going hopefully in the next two years to two and a half years, we have all these systems in place in addition to strengthen the community health systems, the chief systems and also health center system. So these are sort of things that we are doing. We also are not looking only at facilities. We also believe that we should have an even distribution of our scarce health resources. So we are going to look at human capital development. Under this human capital development, we want to focus on investing in the way in health workforce in several disciplines, including training of doctors, nurses, community health nurses and other health professionals in the care of the critically ill and the care of the severe ill in addition to non-communicable diseases which is also in the up stage. So these are going to be things that we are going to do to support the primary health care activities. And in addition to all what we are doing, all the facilities you are putting up, we are also trying to also put accommodation in these areas so that health workers will get the place to stay and then we have deprived area allowances that are also institutionalized and then career development will also be done. And in addition to this, COVID has taught us something that we should also be doing a lot of virtual trainings. So telemedicine is something that you are going to start to support those who will be in the rural areas. And then when you do this, you then decentralize even clinical training for doctors, nurses, pharmacists to serve in the other areas. And once you have somebody who is under training, you also improve on the health services. And as I said earlier, we also venture in domestic vaccine development and production to ensure vaccines self-sufficiency and for health security. We are working towards all these things so that by the year today 27, when Gavi pulls out and Ghana has to be fully taken care of all our activities in vaccination, which you are very good at our expanded program of immunization is one of the best in the country in the world. So we want to continuously be doing this. And then we then have a system in place to make sure that nobody travels for more than 10 kilometers to assess quality health services. So this is what we are doing as a country, but I agree with you. It is not very easy, especially with COVID-19 which has made everything slow. So we are doing everything possible. We have seen from the COVID-19 that health should be prioritized. And I can assure you that in the presidency, one of the things that we discuss most is health services. It's excellent to the president chairs the National Tax Force on COVID-19. And sometimes we sit down about late in the night discussing about health. And every time that cabinet meets, health is the first thing that we discuss to make sure that the big group of this country are healthy. So this is one of the things that we have gained from maybe COVID-19. Health have been prioritized and been put as number one. And this is saying that health is worth. So we believe that going forward, we will make sure that even though we may not achieve what you're supposed to have achieved by the year 2020, we will achieve a universal health coverage if not fully, but almost full by the year 2030. And I believe that we will go strictly and finance the road map and make sure that the road map works for this country. And then by the year 2020, we achieve universal health coverage. Thank you very much. I hope at the end of the two-hour session, we in the presidency will get the blueprint of whatever you discuss. And I can assure you that I'll make it available and discuss it with the people who matter, especially even the president, to make sure that this is what the scientists, this is what health practitioners are saying, the public health people are telling us. And this is saying that if you are cutting a path, we don't know what is behind you. So those of you who are behind us will then move us and push us to achieve the universal health coverage that we are all looking for. Thank you and God bless all of you. I wish you a very successful conversation and let us know what we will conclude it and bring you our suggestions and we'll improve on the road map that you have made and make it work. Thank you and God bless all of you. All right. Thank you so much, Dr. Ansela, presidential advisor on health, Diana. Thank you so much for that detailed yet succinct presentation. From the presentation, it appears quite a lot is going on and indeed health is well done, like we say. But of course, I think we'll come back a bit later to interrogate some of the comments or the things that have been said. In the next few minutes, we'll start a panel discussion and I believe a lot of these things that Dr. Ansela Sari has spoken about will be delved into a bit deeper. So this is the policy dialogue being organized by the conversation Africa with the investing of Ghana as a strategic partner. This is the second in the series. This one focuses on Ghana, the theme is investor health, coverage in Ghana, gaps and opportunities. And as you just heard, Dr. Ansela Sari, presidential advisor on health in Ghana has given us Ghana's journey super in what we're doing to ensure that Ghana achieves or attains investor health coverage. Ghana has a deadline of December 2021 to hit investor health coverage. And I think in due course, we'll put a few questions to Dr. Ansela Sari to assist us understand properly where we are. So you can join the conversation. The hashtag to use is a TCA policy dialogue, hashtag TCA policy dialogue. And there's also the Q&A box. If you have questions for Dr. Ansela Sari or any of the panelists will be speaking with, feel free to drop those comments or those questions there. We'll be happy to read them out and put those questions or comments or contribution to them and see what they have to say. So yes, wanna head straight and look at the panel. Like I stated earlier, it's an interesting topic. Like I stated earlier, it's an interesting panel made up of very distinguished people who are in the health sector, the health and financial sector in Ghana. So the first I'll introduce is Dr. Anthony Danso Apia of the School of Public Health and is the director of the Investing of Ghana Center for Evidence Synthesis and Policy. Dr. Anthony Danso Apia has extensive experience in evidence-based approaches and health system strengthening, leading a number of commission systematic reviews and meta-analysis for the WHO and other evidence-based institutions in Europe which have informed national and global policies. Thank you so much for having you, Dr. Anthony Danso Apia. You're welcome to their conversation. Thank you. All right, so we also have Dr. Gordon Abeka in Chroma as a senior lecturer in the Department of Public Administration and Health Sciences, Health Services, Management of the Investing of Ghana Business School. Dr. Abeka and Chroma's research focuses on understanding contemporary development policy issues including health systems and health systems financing, gender and household health, poverty and inequality and lately food security governance. He holds a PhD in Development Policy and Management from the University of Manchester and M Fuel in Health Sciences Management, Health Services Management from the University of Ghana and holds a BSE in Business Administration, accounting option from the University of Ghana as well. Dr. Gordon Abeka and Chroma, good to have you. Welcome to their conversation. Thank you very much and good morning. Good morning. All right, so we have Professor Joshua Jean de Naba Abbo. He's a Professor of Finance at the University of Ghana Business School. Dr. Professor Abbo is a Financial Economist, Qualified Accountant and Professor of Finance with many, many years' expertise, mainly in Development Finance and Economics Research and with senior levels things as a practitioner policy and consulting roles. He holds a PhD in Finance from the University of Stellenbosch in Cape Town, South Africa after completing the PhD coursework that's in Financial Economics at the University, at the Department of Economics, Harvard University in the United States. I must state really that we actually have Dr. Patience Abbo and not Dr. Joshua Abbo. I mean, it happens so if you teach together with your husband in the same institution that you do similar things as far as your research interests, et cetera, are constant. So brief apologies there. Dr. Patience Abbo, you're welcome to the program. Thank you so much. Good morning, everyone. Good morning. All right, so we have our panel, Dr. Anthony Dansuapia, Dr. Gordon Abeka and Chroma and Dr. Patience Abbo. Thank you so much for joining us. I guess you all listened to the presidential advisor on health and a lot of the things you said. I will, if he's still there. Dr. Sissari, I still with us. I have just a few questions for you quickly then I'll open it up to the panel and see what they have to say about the Streisganise making in this regard. If you are there, what do you say to the deadline that December 2021 deadline, deadline that I set for itself to reach or attain University Health Carbidotansya Sissari. Do we have Dr. Sissari? All right, so I think he's just moved. Perhaps he rejoins us and then we get some answers from him in respect of his. All right, so let me just start off with you, Dr. Gordon Abeka and Chroma. You've listened to Dr. Insya Sissari. What is your initial impression about all the nice things you said Ghana is achieving? All right, thank you very much and good morning again to listeners. Yes, I must say that what he said is impressive and we all know those of us who have been following the ministry, especially after the onset of COVID-19 as the fact that the ministry has decided to move in some very bold direction with a mix of a lot of things that they want to do. So let me say, if you look at Ibn-Universa Coverage itself in terms of the WHO definition, which says that all people have access to good quality, promoted, preventive, curative, rehabilitative health services, whilst ensuring that they do not suffer hardship at the point of payment. Ghana's definition is even much bigger. Ghana is saying that all people have access to high quality services, okay, health services, irrespective of ability to pay at the point of payment. So what it means is that Ghana is even moving and not higher with respect to what the expectations of the SDGs are. And then the raft of measures that you're putting into his, which is pretty much bold. For instance, he talked about using primary health care services as the for-crum to deliver UHC, which is fantastic, but they are challenges. And I think that at this moment, those are the sort of things that we need to sort of interrogate. Now, even also when you look at the service side, which is using PhD, but if you look at the financing side, they want to use NHIS as the major purchasing vehicle to be able to purchase services. There are issues which we have to interrogate. I will try to pick a few of them because I would imagine that as we go on, we might be delving a lot into some of those issues. Now let's begin with, let's say, using primary health care services as the for-crum for delivering a PhD. Number one, the definition of primary health care starts from the chip zone, which is the community, to the sub-district where we have health centers and polyclinics to the district level, where you have district hospitals. Now, this is actually the sort of service infrastructure that is supposed to anchor PhD service delivery. But number one is the issue of mix and distribution of health care personnel. We all do understand that if you look at the cater of health staff across the different categories, most of them are concentrated either in the south or in urban centers, but most of these PhD facilities are within the rural areas. So the first thing is that you are going to be in a big challenge when it comes to even having the requisite personnel to be able to deliver the service from which PhD is supposed to be the anchor. That is number one. There have been some sort of approaches in terms of how they want to address this, but I'll leave that and we'll come to that later and see how feasible it is. Now, you talk of NHIS being the main purchasing vehicle to drive PhD. Now, the evidence shows that the resource envelope for NHIS, only 20% of that resource envelope is spent at the primary care level. What it means is that about 80% of that is spent at the secondary and tertiary levels. So the point is if you're going to do this expansion, where then you get the extra funds to be able to finance the vehicle that is your anchor for PhD. Now, there is evidence also to show that they're about when you look at the cheap zones, only 49% of them have appropriate delivery facilities. So if you're going to do that, then it means that we need massive investment. The question is, where is the money coming from? Because if we look at the outlook of our budget, where is that money actually coming from? Again, if you look at the last report, we are having working capital issues. For instance, if you look at the working capital of the primary care system, it was around, the last time it was calculated, it was around 358 million ganasigis. And out of that 358 million ganasigis, about 48% of them were actually debt owed to them by the National Health Insurance Authority. Now we are operating just around 34 to 35% of coverage. And so my point is that once you want to push this, what is going to happen is that we're going to have overload on the end-to-chairs. How do we generate enough money to be able to clear this debt for them to begin to operate? Medicines are also issues. We have currently about 40%, if you look at the PhD system, only 40% of the required tracer medicines are available. So how do you use these things to be able to drive your PhD? I think we have other colleagues here. So it is important to probably just say, these are my initial thoughts, but I think that as we go on, we can begin to interrogate all the very, but like I said earlier on, I must commend the ministry and the government. These are very, very audacious steps that the government wants to take, but there are critical issues that we've got to interrogate and address, just as the few ones that have already put on the table. And as we go on, I think that we can interrogate some of these things more. Thank you very much. Thank you so much, Johnny. We will do that. So Dr. Applicians Abbo, I'm just coming to you right away. And I must say that Dr. Applicians as Sewe Abbo is a senior lecturer at the Department of Public Administration and Health Sciences Management at the Invest Organic Business School. She's a researcher with the African Economic Research Consortium. Her research interests include healthcare governance, health service management, health policy and socioeconomic effects on health outcomes. Very interesting background there. So Dr. Abbo, the presidential advice on the health is giving us a very flowery picture or impression of what the situation looks like in Ghana in respect of the country's match stores, UHC, giving all the things you've done in the space in which you operate. Is that an accurate reflection of what's on the ground? Thank you so much, Selom. Very interesting discussion we are having. And like you earlier said, it is so timely considering the situation in which we are globally when it comes to healthcare. I, like my colleague mentioned, I think the roadmap by the government or the Ministry of Health with regards to universal health coverage. When I went through, I glanced through it just this morning. I was so, so impressed for just about two things that really caught my attention. The issue of really doing something about school health and beefing up the care we give to our children and young people of school going in ages and the measures that the roadmap seems to spell out to deal with health around those ages. I was really impressed because it's something that I have personally researched into and I've always been worried that our schools do not seem to be part of the conversation when it comes to health. You have schools that are built with their surroundings completely concrete with a lot of concrete, no plants, no playing grounds in most of, especially with the private sector. And then you see children just go to school, sit down and just learn and not have space to exercise and then have space to have very healthy, gaseous exchange if you like because all the plants have been taken off from the schools and I get worried when children go to school and they stay there for all these hours in such conditions. And so when I saw that part of the roadmap that clearly put in measures to look at how children can be kept healthy in their schools, I was so happy because I am more of a, I lean towards health promotion rather than the curative aspect of it. Unfortunately, most of our efforts seem to be focused on the curative part of healthcare. And I think that is one of the key things that is causing us a lot of pressure and a lot of unnecessary stress if you like if we were to shift our attention a little bit away from the curative part of health services and look at the preventive and the promotion of health. Maybe our health professionals will be less busy like they always come under so much pressure and it affects the quality of the services they deliver. So I am happy to see this roadmap and I'm so excited. Like I said, I see a lot of health promotion strategies in that roadmap and that makes me really happy. I believe as we go along, we will look at some of the areas that maybe the roadmap is a bit silent on. For instance, the definition of universal health coverage says all people. And I was looking at the Ghana definition that said all people in Ghana. And I'm asking myself, all people, does it include the very vulnerable? Does it include the homeless? Does all people mean that people who do not have proper accommodation, people who live in very poor neighborhoods are they all part of this all people that we are mentioning in the definition of universal health coverage? And what is the roadmap actually saying about these people? I think as we go along, we might probably find if these people are also part of this, all people that are mentioned in the definition of universal health coverage. So I believe it's a very interesting roadmap by the Ministry of Health and probably the Ghana Health Service. We will see where the holes are and what we can do to fill them as we go along. Thank you so much. Very interesting. Thanks so much, Dr. Abel. Very interesting point you made about the emphasis on curative care rather than preventive, which really should be the place you should be heading. But wouldn't you say that emphasis is as a result of the vehicle that Ghana appears to be using, which is a national health insurance scheme? Because you first have to fall sick, go to the hospital before the usefulness of the scheme will kick in. So wouldn't you say that that emphasis and the amount of resources that we've channeled to this, I mean, the earmarked levies, the snids, contribution, et cetera, appear to be given a lot of fodder to the NHIS, which in fact, and indeed is a curative system. Wouldn't you think that that is why the emphasis is on curative when really we should be looking at preventive? You are so right about that. And that is maybe when we get to the point where we are looking at whether the NHIS should go through some kind of review. Then we might want to look at the expansion of that base. I mean, what does NHIS really cover and the things it covers will it actually help us in the long run? Because if NHIS, it's just about you getting sick in the first place and then you can utilize it. Then there's a problem, like you rightly said. Can we have NHIS coverage, for instance, for people to just go for screening? Can I just walk into a facility with NHIS? Haven't paid my premium. Can I just go and check my sugar level? Can I just, and would that be catered for? Can I go for screening like breast examination because breast cancer, it's increasing in Ghana. It's no longer a Western condition anymore. It's here with us. So can women just walk into the facility with NHIS and have their breast examined? Can people have their cervical cancer vaccines, for instance? I'm not sure at the moment if it is covered under the NHIS. But these are all screening programs that will prevent people from getting ill in the first place and increasing the number of patients in our OPDs and maybe even on admission. Can we have NHIS cover screening processes, preventive health, for instance, so that people don't even get the disease because it is more expensive treating diseases than it is to prevent it? Maybe when we look at the review of the NHIS, then we'll probably look at what it covers and what it should cover if it doesn't. Yeah. All right. So Dr. Danso up here, your quick impression on Dr. Cesaris, Nines remarks on Ganesh March 2, UHC. Yes, I think first of all, I should thank our audience and then those people who are listening to us. I think this conversation is over, Diva. And then I am happy with the impressive delivery by Dr. Antony Insia. And I wish if you can find out if he's still around because what I want him to, he, we can't speak to the government now as we are here, the president, so to speak, but we can speak to his advice and you want him to not ask a report. Then later on package as a report to send to him, which never get to where it's supposed to go, but standing or sitting here with us and then hearing what we are saying so that he would take it forward because there are so many things that probably if he was around with us, what I would appreciate. I've gone to his office some time, maybe two times, he hasn't seen me before, but I went to his office when he was the digit and I didn't meet him. And this is an opportunity. So if he leaves us over here, it is a, I don't know probably if you can find out, he's still around because you want to dialogue with him as the presidential advisor as well. This is something sharing ideas. We are not going to take sizes. So we want to, if that is what I'll say, but let me take what he said. It is impressive in a sense that Trism back to history, we can see that this universal healthcare system COVID has been with us since maybe creation because everyone in your homes, everybody will want to get the best care as possible if the person is sick. But once after the world war, second world war, it has been made like fundamental human rights. So government have been mandated to take actions to make sure that the best care is delivered to their populace and that should cover everyone. And then if you look at the roadmap that he put forward, it's so interesting, but I was wondering what estimates inform the predictions that it's by 2030, we're going to get a cover UNC that is universal healthcare coverage for all people. And as my colleagues have already said, this is something that scientists, normally scientists have used this kind of fence and anytime we don't achieve. From my experience with the WHO, people think that the WHO is a special entity that when the WHO talks nobody should maybe interrogate, not true. I've been involved in so many WHO platforms and I've questioned the kind of assumptions and the models that we have used to make predictions. For example, in the area of neglected tropical diseases. Once a while, we had this transcontent for one disease called schizosomiasis. This schizosomiasis has been with us for so long. And when we had some countries coming together and made the declaration that they were going to give mass production of persecutor to countries affected by this disease, all the people came together, calculating the number of persecutors that is going to be released and then looking at the population, they said, in the next five years, latest by 10 years, we are going to eradicate the disease. I looked at them and said, what are you saying? Are you sure? But so to speak, I was the only one who was on the opposing side. I said, am I probably not seeing what they are seeing or am I talking nonsense? But I said that the estimate that you're putting in, the very present, the near presence of persecutor does not, will not translate into getting all people treated. And even they gave me 10 years. And I said that this one would take more than 60 years or 50 years and even more than 100 years. And they were laughing at me. But now the time that they thought that we were going to eradicate, since my sense was 2020, 2020 has come and gone. And even some countries I've been mapping to see that kind of prevalence or the endemicity of the countries. You showed that I'm just beginning to think that politicians and scientists alike normally come with estimates, just make projections and I don't know. And that is what probably Africa and we are lagging behind. Now, WHO is talking about implementation research. That is one of the top most priority. Why is this so? Because the WHO has seen that all the policies that we have already introduced into Africa, normally most of them have not worked. Why is this so? So they are looking at my bottlenecks. Why and how? So these are the things that they're looking for. So my part of this one is that, why and how and with what? That is what I will be interested in. As for selling the top, the selling, maybe the story about a university healthcare, I don't even want to listen to that anymore because it's something that we have. Go to history and we see the declarations. Yesterday I was going through them almost every year. But where are we now? It is up to us to now begin to rethink and to recreate. We have to know that we are different in each even countries. We have different dynamics. We have different diseases, maybe contests. And we have different dynamics in terms of prevalence. And then there are so many things happening. So that if you normally buy into what the WHO is saying, which is one size fits all, and then we just take it like that, we are not going anywhere. It is about time that capacity ourselves begin to now look at our circumstances and situations to be able to use that one to define and design what works for us, but to know that what is coming from the global maybe discussion until we begin to do that, we are not going anywhere. Because the estimate that we gave, I think are they coming from Ghana or it's something that we have taken from the WHO estimates and using for Ghana to now work for us. Most guidelines that our people are using across the country and in hospitals are something that have been imported from somewhere else. And let me use this example. It's critical. Most hospitals are using guidelines from either the UK. I'm not saying it's not good because in the absence of anything, if you don't have anything and there's something over there, it's better to use that one instead of just saying there's nothing. I've been involved in guidelines development and normally if we are talking about the guidelines developed in the UK context, so many countries are not included. We take the Europe, centroid Europe, Australia and some parts and that's all, not even America, so the evidence, the data that is generated is around the countries that have the same system as the UK. North South Africa, no low and middle income countries have been taken into consideration and you know that the delivery of healthcare is dependent on the infrastructure and the resources, the both the woman and the material infrastructure that we have. So when this guideline has been done in the UK context and you take it and bring it to Ghana and you begin to use it to say that because it's hypertension, so it's hypertension, but the context is completely different. The expertise is different. How can you use this one and think that you achieve the same as they are and which measures are you? So I'm beginning to think that it is about time for us to be able to maybe think and then recreate and begin to use what we have to meet the problems that we have. Otherwise, we are not going anywhere because you can come back and always talk about this interesting roadmap. Have we always achieved the roadmap? We didn't achieve the 2021, we are not going to achieve it. Now 2030, we give some of the terms that we give are so short because maybe whether political or something I don't know, but I don't think Dr. Insias Ali is speaking as a political leader because he is somebody who is a scientist and a medical doctor and always speaks to medicine rather than that. And I wanted him to be around so that we can discuss this and see the way forward. For example, he is saying that we are going to now develop vaccines in Ghana. It's so fascinating how and when and all this with what are we going to develop a vaccine? I think on that, I think that the president set up a vaccine production tax for Spain also that is being led by Professor Covna Frimpon-Boatin. I think recently there was some report on that. So I think they've given themselves quite some time to be able to put in place a building blocks to be able to see to the realization of that. But very great points you can make in there, but just to move the discussion point. Dr. Abakan Krumah, we're speaking about universal health coverage, health for all, et cetera, by December 2021. We are just about some three, four months away from that particular target. It appears far, you know, when you look at what the current figures are and very laudable when you look at it in certain contexts as well. As we speak, NHIA records about 41% coverage of the population, 41%. Of course, NHIA is not the only means of gaining access to healthcare. There's a private health insurance scheme, for example, which has less than 200,000 people on it. And that is very slight compared to the number on the health insurance scheme. And we have other super out-of-pocket, but the whole idea is to discourage out-of-pocket treatment because that works against universal health coverage in the sense that not everybody at the point of use is able to make that payment. So what really should the strategy be? And I know it's a matter of finance. Health is finance. Health insurance and ensuring that everybody comes into the net is an issue of financing. And I know that it is quite easy to just step out and get everybody recorded or registered on the national health insurance scheme. But it is not just about the enrollment or the registration. It is what happens when they go to the point of use. What will happen is I will have the expenditure of the NHIS or NHIA floating many times over because you don't have a lot more people having access to healthcare, to get out with the moral hazards, everything. What should be the strategy? Financing is very important. Where should they get money from? Because it appears that the Ministry of Finance, maybe at this which end, initially when Kenu Furata, the Finance Minister came, we saw that the 2.5% part was made flat which meant that some more money for the national health insurance scheme. At some point, we saw the capping of it which also meant some money being taken away from the health insurance scheme, et cetera. SNP may not be generating that much. Premium payment is not the best. So look at all the financing options the NHIS has. That's the levy, the SNP contribution, the premium, the investment, I mean the returns on investment, I doubt if they have any serious investment because we know that from 2009 where the funding gap began to show, they have since depleted a lot of their investments to pay claims, et cetera. What should the strategy of financing be? Because the NHIS has cried many times that they do not have money. And indeed, that is a fact. When you look at their books, it appears every month they incur no less than 3 million ganas to the debt to providers. In a month, you are looking at 90 million, 100 million debt to providers. Meanwhile, the revenue they get comes no close to that figure. What should be the strategy really? What should they be doing? All right, thank you very much. So, Salome, I think that when we talk about universal health coverage, I would look at it as an all health systems approach solution. Of course, for which finance is one, but finance doesn't stand alone. Finance moves with production. So we can look at it from two perspectives and then we can also look at the other health systems components which would help us deliver UHC. So now let's begin to look at it from the perspective of financing itself. There are two areas in terms of making sure that we can shore up the financing. That is the resource envelope of the NHS. The first one is what I call additionality. And then the second one is efficiency. So if we come to the additions, the current model, all of us know that that model is not sustainable. But I think that it also depends on where you come from. And Salome, let me say that my Libra and pro-market values sometimes do take the best of me. So I want to state beforehand what my biases are. I am somebody who is a Libra and I am pro-market. So the fact of the matter is that we can just eat our cake and have it. The guys just don't have the money. So it is either we may increase the tax rate and bringing a lot more money and then say that everybody gets access to it, or there could be the possibility of having some sort of a cap so that the NHS can finance up to, let's say, primary care level. And then outside of primary care, we can then have some sort of co-payment. And then those co-payments will be through some sort of a different insurance mechanism. And we can then decide to construct data that helps us to identify the vulnerable and then the states can provide what I will call the premium to pay for those who are vulnerable. But outside of primary care level, a different financing mechanism which is based on some sort of insurance will kick in. And there are examples in other countries where they have a two or three tier insurance system. So we could have that just to be able to show up. Now the second part is that there's got to be a lot of work within the NHS itself to be able to improve on the use of money. Now, if you look at the medical loss ratio of the insurance right now, it is just too high. The amount of money they commit to administrative and operational expenses is just unbelievable because at the moment, the insurance has been hovering around 35 to 36%. It went to 40% and came back. Right now it is just around 36% coverage. But the amount of money that goes into operations is just too high. So I'm asking myself, when we get to around say 70%, what is going to be the operational cost? And we need to look specifically at what they use the NHS money for. Sometimes some of the money goes into things that are not directly related to financing care. Okay, that is number one. Number two, we also need to look at the issue of preventive care. And that's what my colleague talked about. Now, if we can begin to, but you see the problem is that when you bring preventive and promotive care into the NHS, that is a lot of work for them because it is not easy for them to do these DRGs to be able to create appropriate tariff. So that's a lot of work for them. But we need to figure out how we can create a system that takes care of preventive and promotive health so as to be able to bring down the bills. Then number three, we need to go to the production centers. So now the centers are producing at such inefficiency levels and those inefficiencies are being paid for by the health insurance. So we need to look at a model that makes our production centers a lot more efficient and how to be able to deal with moral hazards and corruption within the facility levels. Now, when it comes to how to deal with efficiency, I have said over and over again that why can't we look at plowing back money that government of Ghana every day pushes into our providing centers or our production centers as salaries? I'll give you a typical example. Can we have a system say where a lot of the Ghana Health Service facilities, okay? Let's say that we can begin to look at it from the tertiary up to the secondary. We can pilot at that level. Where these facilities are no longer, they no longer belong to Ghana Health Service but they belong to what you call a state interest in business. And these entities are pure business entities who now render service and health insurance can pay the market rate for their services. And they use that money to be able to pay salaries. What it means is that all the money that goes into salaries can then go into the health insurance. That is a sure way of making sure that people are very efficient at the production centers. So I think that that is one area that we can look at. Even at the primary level, we can begin to develop incentive structures that can send private people into these spaces and make production a lot more efficient in those places. Now another area that takes a lot of money from the health insurance is medicines. And this is because our procurement system and our supply chain systems are a bit defective. Now if we can fix that problem, what is going to happen is that hospital can reduce the amount of open market purchases that they make, which is more expensive and because the health insurance owes them and they are not able to pay these supplies, also jack up the prices, which at the end of the day they send back to the health insurance for payment. So we can begin to look at some of all these things to be able to plow back a bit of money back into the insurance and look at the possibility of either raising the tax or creating a second tier insurance that caters for expenditure outside of the primary care. No, quite interesting that the point you made about the second tier insurance because I recall that prior to 2016 there was this National Health Insurance Scheme Review Committee that submitted a report to the president. I mean, that committee was chaired by Dr. Prisatin who is quite popular in this arena. And one of the things this suggested was that we should move away from the system as it is today and then do what we call the PHC and maternal care. That would be for everybody. And so by that alone, you'd have achieved the investor health coverage because now everybody will have it. So beyond the PHC and maternal care, everything else will come into the second tier. And then now you pay premiums or you pay something little, you have a card, et cetera. And then you could be attended to. It appeared at the time that it was quite a laudable idea and a lot of social inequality or equality people were happy with it, et cetera. For five years down the line, we've not really had much about that particular report. I think it was one of the questions that I was waiting for Dr. Ansya Sari to deal with. I am hopefully he joins us later to respond to that. I don't know what to make of that review. And so I'm not sure if we were going to share that review and do another review again to look at clearly what it is. Well, thank you very much, Selom. I also don't know whether we'll do another review but the fact of the matter is that truth is truth. You can do the review several times, but what is feasible and what is technically efficient at the end of the day, you'll come back to the same point. And it seems to me that, yes, I've read through that document a little bit, but it seems to me that the approach that I'm suggesting is basically what is contained in that. So let us assume that you form a new entity and I say I'm on that entity. This is a sort of idea I'm going to give which is already captured there. So like I'm saying, we just have to be truthful with ourselves. It is either we jack up the rates, but if you do that, that is politically, I would say disastrous. And I don't think there is any government that at the moment would have the strength to want to do that, okay? Now that's why I remember when they came up with the COVID levy, the 1% COVID levy. I was interviewed on Citi and I said that it's a great idea, but I don't think it should be called COVID levy. It should be called NHIS levy so that that money goes to NHIS. And then things like emergency health and all of that could now be financed through NHIS. So for me, from the financing side, at the moment, as much as I can see, it is either we pull up the rates or we go through a second tier. But the point is that if you look at PHC, PHC covers majority of the disease bedding in Ghana. So what then it means is that at that level, you would have catered for almost everybody. And once you move to the secondary level, then the second tier insurance then kicks in. The issue that people have made is about what about the vulnerable? What it means is that we need to be a lot more hardworking and begin to tackle the issue of data. The reason why we've not been able to do those things is the absence of data. But when are we going to make sure that our data systems are right? We can take advantage of this to be able to build our robust data, use means testing to be able to find out the vulnerable. And if it means government is actually paying for your premiums, that is fine. And then we tackle service delivery. We decentralize them. We let them operate like businesses and make savings from there back into the insurance system. Very well. So just to remind the community that your comments or your questions are welcome. Look at the Q&A box, drop your questions there and they will be happy to put them to our panelists. The hashtag to use on all social media communication with respect of this dialogue is hashtag TCA policy dialogue. TCA policy dialogue in the next few minutes. We will start reading out your questions to my panelists. So they share their quick thoughts on them. So Dr. Abo, it appears that Ximba is just with us or is just about hitting us, the universal health coverage. What is your thoughts about its feasibility? Is it something you think that we can achieve indeed? When, as I was speaking, he mentioned the fact that the Ghana card, which is now being universal, is being converted to the national health insurance card, which means that once you have Ghana card, you can get to the hospital and get taken care of. I didn't quite get the details of that. I don't know what your sense of that is, Dr. Abo. Selom, that makes the two of us. I actually didn't get how the Ghana card, the whole transition. I didn't quite get the two of us. I'm sure Dr. Anziyansari is still around and will probably explain better how that card is being used instead of the national health insurance card. I'm not too sure about how it works practically. But sorry, what you said, Selom. Yeah, so initially, so that's fine. So we're trying to get him back to help us appreciate those points better. But initially, you also made a point about preventive care, et cetera. And that's quite a lot of money to be sent in there. But how do you hope to deal with issues of abuse that will arise from the preventive side of things? Somebody just wakes up in the morning. He says, I feel like screening myself for this particular condition, it could be breast cancer, it could be anything. The person walks to a facility and gets screened. Somebody has to pick up the bill. And how should it be in order to deal with abuse? Yeah, definitely when it comes to human behavior, you cannot completely rule out the issue of abusing the systems when people get the opportunity. But I believe with the same idea of this whole community-based kind of healthcare, if these people are not just coming into, let me use the word, the more sophisticated health facilities, but they are just going straight to whatever facilities available to them in their communities. And in this case, before you decide to probably just walk into a community center, for instance, or a chips compound to screen for early detection of various conditions, you might, you would have already understood what could probably put you at risk of developing certain things. And then you look at yourself and then based on the information you have about your health, you think, oh, maybe around this age, looking at these factors in my life, I will probably be prone to getting this particular condition. So let me just go and check and monitor. So here before we even start embarking on that kind of strategy with health promotion, I want to say that health literacy should be on top of the whole agenda. I think there are a lot of people who are completely ignorant about even very basic issues that concerns their health in Ghana. People are educated, but they are not educated when it comes to health. So there are, our literacy rates generally might be above 70, like the statistics will say, but I don't think our health literacy levels are at those levels. And that is very dangerous. We need to understand certain basic things about our health. And with that kind of knowledge, if we are able to raise the health literacy rates within the country, then nobody will just sleep and wake up and for the fun of it, just walk into a system exam, checking my blood pressure. You might, you will have to have understood certain things about yourself with regards to your health. And then you think you are at risk of certain conditions for which reason you want to just take steps in screening and making sure that these things are detected on time and so that you don't get the disease even in the first place. So health literacy would have to go on and be increased in the whole nation before we even decide on saying that we want to increase the issue of prevention and health promotion, making sure that people don't even get ill in the first place and increase our disease burden in the long run. So health literacy, I believe, is the key vehicle here to prevent the diseases and to prevent the issue of abuse, as you rightly said. Yeah. All right, thank you so much. Interesting. Yes. Yeah. I think just a little bit of addition to what my colleague just said. All right, go ahead. Yeah. So you know, my colleague made a fantastic point about the fact that the system won't be abused, which I agree with her because we already have experience in this. There is what you call children weighing, isn't it? Salom, you sent your kids for weighing. Do you abuse weighing? Yes, yes. You don't. Okay. So we can have what you call adult weighing and it's something that Dr. Enziasari himself has been talking about a lot. So if it is adult weighing, then the adults will be given what you call times that they have to come for weighing. And people, if we have good data, people who are pre-existing conditions would be notified and information will be sent to them when they should come for weighing. It's just like when you are in the UK and you have pre-existing condition, around this time, my colleague Pat would tell you who lived in the UK would tell you that around this time, you would be receiving a text message on your phone, come for your job. So I don't think that if we do it the right way, it will be abused. It is just the initial way to build the credible data and structure this and deliver it. And especially if we decentralize it, like Pat is saying from the community level, then there is no way this will be abused. Thank you. Very well. I see. So Dr. Danso up here, very interesting conversation so far. Preventive, the financing bit, et cetera. Talking about preventive, I mean, we are in a pandemic season and a lot of things have been said in respect of this. How, or what lessons in your view, do you think that Ghana has learned from the COVID-19 pandemic and how has the pandemic affected Ghana's match to universal health care? Many have said that the pandemic threw up a lot of difficulties and challenges with Ghana's health system. Challenges that insisted that we did not know or would not take seriously. What lessons do you think we can learn from this and how has the pandemic affected our work to UHC? Thank you for this. Yes, I'll say in the first place, yes, I would comment Ghana and for that matter, the president for leadership that was shown during the pandemic. I would also say that probably this stemmed from the fact that Ghana was used by the WHO when we had this Ebola in Guinea and other places in West Africa so that we had the technical know-how already. When the pandemic occurred, I think I traveled from the UK around March to Ghana. When I was coming through the airports, there were no checks. Wherever you have traveled, whatever this and this. But when I came to Ghana, I saw long queue and a whole lot of checks that takes that away. Where have you been? Have you experienced this? Have you done this? Where even developed countries have not started? Ghana had already started. So sometimes when you, things go well, most is more likely for those people, those in the global south who have done well for the achievement to be subsummed or to be downgraded in the midst of this. But I think Ghana has done extremely very well. So that's why there's commendation for that. But that cannot be said without gaps or something that we can, lessons that we cannot maybe learn from this. And one thing I would say that the government took leadership one. Now the gaps that we have learned is that we were not really prepared for such a scale. And then we are happy that this, that the infection did not translate into the severe forms that would really require hospital, in large numbers of hospital admissions as occurred in most of the global north in the UK and other countries. If it had happened that way, then that's when you would feel the heat of the COVID. But because most of them were about to moderate, it didn't get to that point. And although we saw that our hospital beds were maybe getting filled up, we didn't get to that point. I will say that the government has learned lessons and scientists have learned lessons in the School of Public Health. Other people were asking, where are you? When it started, when we needed data, we were so slow in coming forward with the data. After that, people have set up these Johns Hopkins and other people have set up this life data updates and we were all tapping from there. We didn't. It takes us on our way because all that we have been dealing with are outbreaks. That is some of this pandemic, but epidemic outbreaks so not to that scale. So these are some of the things that now in the public health sector, in the institutions, we now know that some of these things can happen and we know those who can maybe lead this aspect. Now they have initially, we were just teaching as teachers, but now we know those who are not going to be the experts in those areas who as soon as something happens, you will call them. I know that now it has brought this professor Keno into the landline who has been dealing with outbreaks and one of them Dr. Saki to the landline and then even the Universal Hospital and those. So these are some of the things that we learned now. We have the blocks, we have the expertise in place to use when we have set outbreaks. I will say that now government has responded very well. Had it not been the COVID, these hospitals that now they are building across the country with the to now the COVID help us to assess this rate without the straight hospitals and now we have more than 100 districts. I think it is something this rate without the straight hospitals. Now government hospitals, yeah. So this is, it is through the COVID. Now government knows that if there was anything you had only Noguchi as the reference laboratory in Ghana. Now how can you transfer somebody disease with this if you get to the severe form, by the time you travel for maybe even by plane from maybe the northern side to Ghana, the person will have passed that way. So we need to now strategically set up centers across the country, which would deal with such epidemics. So this is also a way forward. And then not only that, government is now trying to sensitize and strategize that if you look at doctor and they've specialized ratio across the country those who have been trained as specialists who can provide specialist care. All of them are scattered in Accra and some of them in Kumasi. The rest, you can't find them, no people in the other towns and cities. So government is building these patches to entice them to give them, he calls something like, what is it called, the rural something, something you are familiar with that probably. I'm not expecting this way. I'm expecting evident generation and how we can translate evidence into policies. But this is cross cutting. So I have to show interest in this aspect. That's why I've decided also to take part of this one. So government has responded very well, but I think going forward, we need capacity. What I mean by that capacity that will generate evidence. And then we are not talking about just evidence. We are talking about robust evidence, evidence that is systematically synthesized. And that's the area that I specialize. Normally we base our evidence decisions on the doctoral evidence that is pick and choose or what is available to us, but there's a paradigm shift now. The global north have changed. No policy or decision is made without systematically synthesizing the evidence. And now WU2, but just about within the space of three years, five years ago has started also. It didn't start that long even with WU2. We've gonna come by into this idea and train more people in the area of generating best evidence. This is the evidence that will support sounds, decisions and policy. So that I think even a COVID, with the lessons we've learned will not go anywhere because we don't have what it takes to even mitigate this problem if another one, maybe there's another outbreak. So I feel that government should spend a lot of money training people. And then let me come back to the person quickly. He said that we are going to, yes, develop vaccine, which is great idea, innovative and appreciate that probably I didn't put my first earlier statement. Well, it is we acknowledge and we appreciate that. But now we have the expertise. When you develop the vaccine in the lab, you have to translate into the public space or clinical trial list to now begin to assess the efficacy and those all the factors associated with this. We have clinical trial list in Ghana. We have only one university, the University of Ghana School of Public Health, which has a course in clinical trial. We don't know how many people normally are enrolled. We have only about two, three, maximum five. And these are the people that enrolled on today's program. We need government to not invest into this because if you come in to develop, you have to know that yeah, we need people who will test and who will do this. Nepal is looking for people and this is not even across, even in Ghana alone, across Africa. We don't have these expertise. That is what most of the time, even trial, see, vaccines are brought over here. Those who develop the vaccine have to bring their aspects over down to roll this one up for us. So I think it's about time that we look at the capacity building in the area of trials, the building capacity in clinical trials and how we can synthesize the best evidence to inform policy and decisions. And that is my take. So Ghana has done well. You have to really applaud Ghana and the way forward, these are the lessons that we can learn to see how we can maybe strategize when epidemics break up again in the future. Thank you. Very well. Dr. Abor, it appears very little has been said in all these UHC talk generally across the border and across many fora on the place of mental health. It appears to be an area that is generally forgotten. What can we do to rub in people who may have issues in that aspect of health? What can we do to rub them into under the umbrella of UHC? So they are not left behind. Yeah. I am so excited you mentioned it but I was just thinking about it because if you remember, Dr. Nsiang Sarri's address, when he mentioned the targeted groups of the road map to universal health coverage, I listened carefully and he mentioned the categories of people that were targeted under this UHC agenda. And I didn't hear that much about people living with disability, what is in that road map for such people and then issues of mental health disorders. And you are so right. Recently, I'm sure we all have heard on the news the kind of killings, some of the killings that are going on, the criminal activities that are going on. I sat back and looking at it as a nurse. Sometimes I see most of the issues to be some mental disorders that have probably gone undetected. And so we cannot just look at it in terms of criminality. We need to look at it in terms of our mental health as a people. And I want to actually appeal that this whole road map takes another look at what aspect of this road map will actually look at the issues of mental health, awareness first of all, and then treatment for those who have one challenge or the other. We still live in a country where people are suffering from, especially after COVID-19, you will be surprised to know that there are a lot of health professionals who are suffering from depression. There are a lot of health professionals who are having anxiety attacks. People are panicking. These are even health professionals. So look at it from the perspective of the population, people who are not health professionals, the things they are going through when it comes to their mental health and what have we really done to address these challenges in the population? I think most of, like I said, most of the efforts there again are about, oh, when you have these symptoms, go to the clinic, have your temperature checked. Nobody is talking about their mind, but health includes everything, your mind, your body, and every other as your social life. It looks like we are a bit silent on that part of our healthcare when it comes to their mind. Diseases of their mind are equally part of our health and we need to pay more attention. And so communities should be empowered as much as we are doing those whole shifts compound and we are doing all this primary healthcare. I think there need to be some more efforts and measures put in place to deal with mental challenges at that level, at that very basic level, at your doorstep, so that when somebody is having a depressive episode, somebody is having an anxiety attack, somebody is really probably having their thinking processes a bit distorted, so that they don't have to go all the way to Ancafo. They don't have to go all the way to Asaland Down. They don't need to come to Panthai. Just by where they live, they can quickly just walk into a facility that deals with mental. I'm glad I think the Ghana Health Service has instituted something like that, where in most of the government hospitals these days, when you go, there are mental health clinics and units within the general hospital settings, but people don't even know about it. I'm sure there are people who go to Kolebu, for instance, and do not know that there's a mental health unit in Kolebu. You do not necessarily have to go to Panthai. You do not have to go to Asaland Down when you go to any general hospital. There's a mental health unit in there, but the awareness there again, we are a bit silent on these facilities and people do not even know. So in our bid to send universal health coverage using the primary healthcare system, let's pay some attention to our mental health because mental health is not just about somebody misbehaving. Mental health could result in criminalities. Mental health affects productivity because people go to work and because they are not sound up there, they are not able to give their best. So it is a very, very important component of our healthcare delivery. And I'm very happy you raised it. The roadmap is a bit silent on that part of the healthcare delivery. And I just jotted it down and I'm glad you mentioned it. I think the targeted groups should include people living with disability and then people who need help with mental health issues. Yeah. At the very basic level, but I can tell that they reach out there first. Very interesting. That the two cohorts or the two groups of persons you mentioned, the mental health people and the people with disabilities. It's a very important segment. The mental health, especially, very, very important aspect of our health. But it doesn't look very attractive. And the stigma around it, to the extent that somebody having depression issues works to maybe a salam down or panther, for example, somebody sees him or her in that facility. And the talk is maybe this person is going mad. And so I met him at panther, I met him at a salam down. And the stigma around that, how do we deal with that to make it easy for people who are having such challenges to be able to walk in and get help? Yeah. It looks like a huge battle that is probably you could go on and on trying to deal. Stigma is a very strong thing to deal with. But I believe we can begin somewhere. We can start some kind of awareness and like I said, health literacy. If that is part of our agenda and we are talking about educating people with regards to health and we talk about mental health as part of the package, then people will understand that the fact that somebody has depression doesn't mean like we stay. The person is mad. Depression can happen to anybody. Anybody at all can get anxiety attacks. And we begin to demystify these conditions by educating people. I think more of education, health education is needed to kind of take that whole ministry out of the fact that it is only some cares to people. It is only some very weird looking human beings who suffer from mental challenges. Anybody at all could at a point in time develop some kind of the spotter when it comes to mental health. And so I think education is key at various level, at the school level, at the workplaces. It can be part of our occupational health, for instance. So the people will know that you can get extremely so stressed that stress alone could push you off the edge. You can get so stressed at your workplace that you probably forget about your grooming, for instance. There are people who work around and they have so much pressure from their workplace that they work and talk by themselves. You are talking to yourself, probably wondering how you're going to juggle everything together to deliver at your workplace. If we make mental health issues this close to the workplace in the schools, in various organizations, and then from the health facilities, we have people who are dedicated to this course. They decide that they will go into the nearest community from the move out of the hospital, go to the nearest community and just let people understand how anybody at all could at a point in time develop a mental disorder for which reason people need to understand the various coping mechanisms and how to seek treatment. I think stigma will go down a bit. It's just a matter of educating people and demystifying the whole mental health thing. We still have these weird beliefs about mental health and that needs to go away with education. Very well. So we'll take the last round of question or discussion. And what I want to do in this round is to make it quite open so that each panelist will tell us in their view what their major, of course we discussed it in pieces. But in their view, it's a major challenge or gap that exists in our quest to reach UAC and what opportunities or what we can do in respect of that identified gap. So maybe I'll start with you, Dr. Abakan Krumah. And before even you get to that, you think it's a realistic target that we've set for ourselves to achieve universal health coverage. And after that, you can add to your view on the challenges. If there's a challenge in your view as a most pressing challenge, how do we deal with that? All right, thank you very much, Selom. And I think that before I go to that, I just wanted to add just a little bit to the mental health issue. So yes, the ministry has started looking at mental health in terms of mainstreaming it and putting it as part of its plans. But I think that it is at this point where I probably would want to agree with Dr. Tony Danso up here when he talks about sometimes we can look at our context and evolve solutions that fits our purpose. I mean, you know, we come from a society where mental health is something else, there's spiritual is something else. So I do not want to even call it mental health. Maybe we need to evolve new nomenclature for that. I probably out of my head saying, look, we can call them psychological welfare clinics or happiness clinics or something like that. And they are integrated into our main hospitals. I don't like this whole idea of having a place, okay? Just purely, yes. In Europe, they can say mental health because their situation is different. And when you talk about mental health, nobody gets offended. In Ghana, when you say, look, when I used to live in Takradi, anybody who is getting crazy, they used to have a word for them. You'll say, for a mental, you know, like this guy is mental, it means he's getting mad. So that's nomenclature itself. So we can evolve new nomenclature, that is one. Then the education my colleague talked about and then we can look at restructuring the way we provide that particular service. It's got to be integrated with our hospitals. Just like the way somebody will go to the urology clinic or go to the cardiovascular clinic, they can also go to the welfare clinic, okay? The psychological welfare clinic, which you can deal with all these issues so that people would be at ease and be willing to go there. Now back to UHC, okay? What are the challenges? What are the opportunities? I think that I'll talk about the opportunities first. I think that COVID has become a major opportunity, okay? To sort of recreate incentives for us to be able to move as quickly as possible. Trust me, without COVID, a lot of the things that we are thinking about right now probably wouldn't have been on the drawing board, okay? Nobody, for instance, wanted to talk about adding 1%. I remember that in 2017, when the new government came into power and they were looking at new resources into the NHS, this 1% issue was discussed at length, but the political will to do it wasn't there. But COVID actually pushed us to do it. So for me, if I look at COVID, COVID has created a lot of incentives for us to be able to do a whole lot of things. The will is there politically. People are willing to commit to do both things. People are beginning to think out of the box. We are beginning to have new ideas in ways that we can commercialize setting things, okay? Who was thinking about vaccine production? But now we are beginning to think about it, even if we don't get there, we started. So I think that there are opportunities for us to be able to push. Whether we get there or not is not the thing, but even the opportunity to push. But when we talk about challenges, Salem, the challenges there are many. And the challenges are around the health system. Number one is financing. We need to be able to really look at NHS first in terms of how do we restructure NHS to make it sustainable in terms of getting new sources of revenue, in terms of rearranging the package that is the benefit package and how we do strategic purchasing. That is one. Number two, we need to begin to look at service delivery. How do we make the delivery points more efficient? How do we ensure that it is providing quality service? And one of the things, Salem, is that, look, if you look at the UHC roadmap, it is counting on 100% enrollment. But the reason why the enrollment has always been around 36 to 40% is because people are not getting the services they want. So there is no reason why they have to enroll. And some time ago, that is, I think, 2015 or 2016, we were around 40%. It was because at that point, the NHS card was a major card for going to the bank, for registering, for voting. But now, in quotes with the Baumia card, nobody needs the NHS. So people are no longer even registering. So we need to be able to deal with efficiency, quality of service at the production centers to make it attractive for people to want to be on the NHS, to be able to drive enrollment. And then we need to deal with issues of procurement and then technology. Now, we can reach a lot more with a lot more technology, which they began to look at that. We need to look at that. And the last thing I want to talk about, there are a lot of things, but let me talk about this and then the issue of community participation. Community participation. If you look at our plans, all of them are supply-driven. But at the end of the day, everything we do is around the patient. But oftentimes the conversation is about the supply structures and not the demand structures. We need to be able to engage communities, to empower them so that they can actually drive the sort of efficiencies that we want in the systems. And these are things that we need to do. Okay, thank you very much. Yes, Dr. Anthony Dansuapia, your thoughts on the challenge and then your suggestion will be for the way forward. Yeah, thank you. Salute for this. Yes, as I've already said, the area that I would maybe want to let those who are involved in UC, that is the University Health Cauvery too, notice that we need to be able to inform the estimates and then the policies and decisions and even our projections with, well, that is called robust evidence. Evidence that has been distilled and that is so robust to inform the way forward. Other than that, most of the projections that we are making will always betray us, not because you don't have good intentions, but we are using something that, we are using the wrong estimate to inform what we want because it's like we talk something about statistics. It's garbage in, garbage out. If you put garbage in something, you get garbage out. You have nice graphs, nice figures that beyond them, beyond the graphs and the figures, they don't make sense in the sense that what it takes has not been put into it to generate them. So I'm thinking, and my suggestion is that once we've seen gaps in the coverage and then COVID has opened our eyes to see, now people are governments and all bodies are interested in moving forward. So I think the capacity building is the most important that we know. All along we have depended on capacity from elsewhere. We have a lot of people, so we have to know bring the incentive that will bring people back home. And even if they are not coming home, with COVID has shown us that we can talk. Now I'm talking from, currently I'm talking from the UK and somebody from South Africa, we are all connected. So this is one thing that before COVID we didn't have access to. Now we can all connect by virtual maybe meetings and other things to share ideas, scientific ideas. So let us now reach out to our people who have gone somewhere. Some of them will not come back home because of the problems that they will go through. And so we can reach out to them, bring them into the discussion table as we are doing now to help maybe inform whatever we have. And then the last one would be what I want to say about them, still about the capacity. So probably I've said it some time back. So if you want to take up because our time is running out. So thank you for that. So we have a... All right. So I realize you are a very big capacity building but I think we'll get to that. Dr. Abbo, briefly a challenge and what do you think can be done about it? Very briefly. So maybe after Dr. Abbo's questions or comments we'll now go to our Q&A box and put to our panel some questions that you have brought in or have sent to us for them to answer. Dr. Abbo? Yeah. I think Prof Danso and my colleague Abbo come from already kind of outlined most of the challenges that I see that could actually be a problem for ensuring universal health coverage. Something very little I would want to add is the issue of leadership and governance in this whole mix. After everything is said and done. After we've, I mean, we've mentioned the issue of health promotion, preventive health, capacity building, financing. At the end of the day, when all these structures are put in place and the processes are well spelled out and we know where we are going by this roadmap that Dr. Nsiang Sari just presented. When everything is said, the next thing that will actually ensure good outcomes and ensure that at the end of the day we all enjoy good healthcare is when we have good leadership and we have good governance. And in other sectors, and not just the healthcare sector, in other sectors in the banking sector and all other sectors, there's evidence to show that good governance actually brings about very good performance and good outcomes. So let's let's invite some of these business principles into the healthcare sector, make sure that the processes and the structures are well established enough based on contextual content like Dr. Professor Danso said, with all that being done, let's have the ability to influence the achievement of these goals, ability to influence. And that is leadership. And so I believe when we add that component, I wasn't too happy when Dr. Nsiang mentioned that they are looking at the issue of leadership and management at the top level. In the new thinking with healthcare delivery is that leadership should be a shared process. Leadership should be even at the peripheral levels and not just at the top. It shouldn't be a place, the training should not just be for the CEOs and the medical directors and all that. It should go to the very operational level. People should have the ability to influence the achievement of goals. And that is the only way that we can ensure that these goals beautifully spelled out in this roadmap will actually see the light of day. Good leadership and good governance. Thank you. Very well. So a few questions. This one for Professor Abakan Krumah. It says if we were to go for an insurance system structured as primary plus maternal care with optional add-ons for hospital care, what mechanisms could we put in place to ensure equitable financing of that secondary care? And is there a place for means testing in that equation? Looks like a very loaded question, but if you can answer that in a minute, I'll be very brief, Dr. Abakan Krumah. Okay, so I think that the questioner has already answered the question because the person said, is there a place for means testing? Exactly. So means testing is going to be the mechanism for ensuring equity across board because when you have a second tier, the issue that comes in is that people would have the means. That is the reason why the savings adds the production flows. And my point is that the savings from the production flows becomes at the shalty in terms of resources for the state to finance those that you call the intense, the vulnerable, the poor. And how do we identify the means testing? How do you come out means testing? We need to have reliable and credible data. We don't need the process of getting credible data. We started digitization. And this is the platform for us to push and to get credible data so we can means test. I mean, look, a lot of us use mobile phones. That can be a big basis for starting that. The mobile phones can tell us where people sleep. It can tell us where people work using a GPS. That can be used to even calculate some sort of geostation testing to be able to start that sort of process. So yes, means testing has a rule in this. I hope I've answered the question. Very well. So another one here, a question from Nanaku Fukuachi. He says, couldn't I agree more with Mr. Abo about the energizes, overly creative focus? I think we see its consequences in the high levels of untreated, undiagnosed NCDs in Ghanaian adults. So a question here. As part of efforts to expand access to preventive care, would it be useful for Ghana to consider task shifting or preventative services and management of uncomplicated NCDs to non-physician healthcare workers? And he has that, Benga would get big bit and his team are there. And why you have promising findings on this potential for management of uncomplicated attention in Ghana. But that's our system, health system in part, non-physician healthcare workers to make, to make widespread adoption feasible. So Dr. Abo, that's to you. Hello Dr. Abo. Yeah, I'm not sure I got the question. All right, so the question is, as part of efforts to expand access to preventive care, would it be useful for Ghana to consider task shifting of preventative services and management of uncomplicated, non-communicable diseases for non-physician healthcare workers? Okay, so to leave the part of dealing with these preventive healthcare delivery to people, to professionals who are not really, he said non-physicians. Wanna relieve physician healthcare workers? Yeah, I mean, when it comes, I'm sure the professionals in the allied health areas would probably be able to deal with these things. A little, some kind of certification will probably definitely be needed, even if you are not a physician, to help people to stay healthy. I'm not sure if that is the direction the question is taking, but I believe when it comes to prevention of diseases, it doesn't quite take somebody to be like a clinical professional to help others to stay healthy. I believe it's something that can be done with non-physicians. People, non-physicians can actually handle that. And if we are bent on making people stay healthy and not get sick in the first place to come for healthcare, then maybe we can even include that in the kind of insurance being provided by employers, for instance. So that employers focus more on keeping their employees healthier than just saying that when you get ill and you go to a facility and you bring your claims, we will pay. Maybe they can give something very little for people who would want to stay healthy. And that could be an incentive. Some kind of insurance package for people who would want to take the various measures, do exercise, eat well, and then stay healthy and not get sick and come and make claims from the workplace. So employers can actually give some kind of insurance to cover such preventive services. And instead of the traditional one where they wait for employees to go to the facility to seek healthcare and then come and make claims, that kind of incentive will definitely work. And I agree that non-physicians can be helpful in dealing with these preventive health care services. Very well. All right, thank you so much. Very interesting discussion we've had there. So thanks so much. Dr. Ptecian Abbo of the University of Ghana. Dr. Anthony Dhanso-Aptia of the School of Public Health and Director of the University of Ghana Center for Evidence, Synthesis, and Policy. And Dr. Godi Ndeka and Krumasina Lectura in the Department of Public Administration and Health Services Management at the University of Ghana Business School. Earlier, we were joined by Dr. Anthony Isiasair who is a presidential advisor on health, giving us Ghana's stride so far in the area of the University of Ghana. So this is how we wrap up today's discussion on this particular policy dialogue. And I want to call on... And so thank you so much, panelists, for making time to be with us. Very insightful. We hope to do this some other time again. Thank you so much. So I call on the Ghana Commission Edit of the Conversation Africa, Guffred Akoto-Boafu, to give us a vote of thanks and his closing remarks. I will come back quickly and make an announcement and then we'll call it edit. Guffred. I thank you very much, Selam. And let me just reiterate the thanks, Dr. Professor Anthony Danswapia. You've been so, so, so cooperative with us in doing this from day one. Your enthusiasm has been overwhelming. Dr. Asi, we are both same for you as well. I know the sacrifices you've had to make particularly today to make this happen. Dr. Godnambaka and Krum as well, a very enthusiastic contributor to academic communication, to scientific communication in Ghana as well. And we're hoping this is the start of a very vibrant engagement between the Conversation Africa and the Ghanaian academic community. For the past one year, we've had some significant successes, but we hope to expand on that success and engage a bit more. And a big thank you as well to all those who joined us from across the continent, from South Africa, from Kenya, from Nigeria, from Tanzania. Everywhere you joined us on the concert, thank you very much and you feel free to engage with us. A big thank you to all my colleagues as well who made this happen to Adejuan Sriyanka, the original editor to Yusufo, to Funga Nyamukachi, to Candice Bailey, to Alex Storey, to Jabula Nisikakane, the editor and also our founding editor, Caroline Soudi, who is always hiding there and supporting us from the back. So thank you very much for spending time with us and we'll be in touch and we'll do our best to make sure that we spread the word of this conversation that we've had today. Thank you very much. All right, so thank you so much, Guffrey. So I must say that we are happy to have you with us. And so let this not be the end of it. I want you to visit the conversation Africa for more content from academics on the continent discussing their research, et cetera. And the website is www.theconversation.com theconversation.com www.theconversation.com And you can also sign up for the conversation Africa's newsletter. So thank you so much for making time to be with us. My name is Selom Adejuan, it's been a pleasure moderating this. Thank you so, so, so much for having you. Have a good day. Thank you.