What is right may not always be appropriate. Utilitarianism describes an action as good if it promotes the greatest happiness for the greatest number of people. The basic principle of capitalism is: if everyone is doing it, why not me? This philosophy has been embraced to the hilt by many health service managers. Profits have displaced quality.
In free-market systems, competition births quality, while monopoly stifles it. During the COVID-19 pandemic, hospitals were incentivized to admit more sick people with COVID-19. Electronic Medical Records (EMRs) of hospitals that listed Medicare patients as COVID-19 cases in the United States received more money—and even more if those patients required mechanical ventilation.
The resulting effects were alarming: misdiagnoses, skyrocketing COVID-19 diagnoses, needless mechanical ventilation, and consequently, an increase in mortality due to ventilator-associated lung injuries and pneumonia.
This isn’t about COVID per se; however, the pandemic left much in its wake. It revealed how ethical lines can be blurred by human greed. It exposed so-called robust healthcare systems, caused the buckling of weak health service delivery systems, and redefined healthcare policy globally. It also invited policymakers to revisit the structure of healthcare delivery and financing.
Healthcare is not cheap. For decades, governments have struggled to find efficient and sustainable means to finance healthcare—and for decades, this has proven to be herculean, even for wealthy countries. As many nations aim to realize SDG 3 targets of universal health coverage, the question remains: who assumes the financial burden?
In low-middle-income countries like Ghana, the National Health Insurance Scheme (NHIS) is largely funded by a 2.5% VAT on goods and services. Recent estimates suggest that about $87 per capita is the basic minimum required to achieve 80% universal health coverage. It is an unassailable fact that there is consensus: public financing remains the most reliable means to finance healthcare systems.
In Southeast Asia, Indonesia—with a population of over 280 million—allocated 5.6% of its national budget to healthcare in 2024, amounting to $12.6 billion. This further buttresses the point that privately financed healthcare systems do not reach universal health coverage, nor does out-of-pocket health financing, which is inequitable—poor people simply do not have access to the care they need. Not only does this pose a social risk, it also inevitably presents political risk.
This is not to suggest that the private sector has no role in achieving universal health coverage. Recent data reveal that in 2017, private hospitals in Indonesia represented 48.6% of the overall market share, while public hospitals held 51.4%.
What is driving this growth in private healthcare services globally? Is it increased social mobility? Is it the overcrowding and long waiting hours in public hospitals?
Ghana, with a population of 33 million, saw its health budget increase from GHS 15.6 billion in 2023 to GHS 16.5 billion in 2024 and GHS 17.82 billion in 2025. The budget allocation to the health sector increased by 51% in 2024, attributed largely to donor support. The Government of Ghana remains the major financier of the sector, per data from the Ministry of Health. In 2024, 98.57% of the health budget was dedicated to employee compensation—leaving limited resources for supplies, infrastructure, and service delivery.
The latest condiment to this cocktail, stemming from the geopolitical impacts of the Ukraine–Russia war and COVID-19, is the dismantling of USAID support by the Trump administration, exacerbating supply chain disruptions across the region.
Some observers have posited that amidst all this lies an opportunity for African governments to put their shoulders to the wheel and usher in a paradigm of self-reliance.
What this means for low-income countries is that the share of the healthcare financing burden previously borne by foreign aid or donor support will cease to exist—governments must now fill this gap. Ghana is not immune to this development.
The Mahama administration recently announced the uncapping of the National Health Insurance Fund (NHIF). This move seeks to improve access to quality healthcare services. While this restores hope for the future, much remains to be desired in the present state of healthcare service delivery in Ghana.
One major challenge is the disbursement of funds and the reimbursement or payment of claims to hospitals. With their backs against the wall, hospital managers must find ways to navigate tight budgets. Hospitals must rely heavily on internally generated funds (IGF) to cover essential purchases and operational costs.
It is no surprise, then, that public hospitals in Ghana exhibit a unique characteristic: the “no-bed syndrome,” as many hospitals are torn between accepting the patient or accepting the money. Managers know the longer the queues, the more cash flows into IGF coffers, as many essential services rendered are paid for out-of-pocket.
While this moves the needle for hospital managers, it inflicts severe financial hardship on the vast majority of patients—mostly middle-income earners who are jealous of the upper class (less concerned about paying out-of-pocket) and resentful of the poor (mostly covered through tax and donor financing).
The long queues and overcrowded emergency rooms are indistinguishable from a typical Christmas Eve market day at Kejetia—only that the pitiful sight of frail, cachectic-looking patients on the floor reminds you it is a hospital.
Worryingly, patients have become proxies for money. In the United States, longer hospital stays attract less money from Medicaid. It is no myth that prolonged hospitalization increases patient susceptibility to hospital-acquired infections and inflates overall healthcare costs. This model incentivizes hospitals to manage inpatient care effectively and discharge patients as quickly as possible.
It goes without saying: the scourge of overcrowding and no-bed syndrome in Ghanaian hospitals poses significant social, political, and economic risks. The Mahama administration is at the cusp of charting a new path. The news of increased budgetary allocation to the health sector is a testament to this commitment.
Strengthening primary healthcare is crucial to reducing disease burden and overall healthcare costs. Government must dismantle the bureaucracy and constraints in fund disbursement, fast-track reimbursement processes, and improve infrastructure.
Dr. Ayamga Robertson
Emergency Medicine Resident.
