The New Patriotic Party (NPP) launched its 2012 manifesto themed “Transforming lives, Transforming Ghana.” Unable to interrogate the party’s flag bearer following my regrettable nonappearance at the Institute of Economic Affairs’ presidential encounter, it is only fair that I take a peek at the party’s health platform, if nothing at all, to appease my friends at the IEA.
Broadly, the party’s situational analysis recognizes poor access, high mortality, deteriorating National Health Insurance Scheme (NHIS) and a fake 30% of drugs that enter Ghana’s markets. Very important is the plan to increase “training and placement of midwives nationwide”, given acute current shortages especially in some of the areas recording high maternal mortalities.
Fake drugs in Ghana; 30% or less than one percent?
The NPP’s plans to reduce the deleterious impact of the malaria burden are laudable and I assume the how is through rigorous implementation of their sanitation policy coupled with the plan to establish a bioequivalence center that is expected to spur research and certification in the manufacture of quality anti-malarial and other medicines in Ghana.
Some technocrats at the Food and Drugs Board (FBD) however vehemently dispute the 30% fake drugs quoted, pointing out that “Those statistics were allegedly for Africa and South East Asia in general. As far as Ghana is concerned the supply chain is adequately monitored albeit with some constraints and limitations. Our main problem is substandard medicines which could be attributed to manufacturing errors and improper storage. Surveillance activities so far conducted by the Food & Drugs Board in collaboration with USP on quality of antimalarials and analgesics in 2011 showed that of 544 samples , four were substandard and one fake (less than 1%). Out of 400 analyzed so far in 2012, three were substandard and one fake (less than 1%).”
Will the party’s initiatives significantly reduce the current burden of malaria? It would appear that public health experts working in malaria have clearly prioritized increasing access through ensuring that all pregnant women are on intermittent preventive treatment, more people sleep under ITNs, all health facilities provide prompt and effective treatment using Artemisinin based combination therapies, all communities (100%) have effective community-based treatment for uncomplicated malaria and also 90% of symptomatic children receive treatment within 24 hours. Viewed against the above objectives, the NPP’s proposal to simply tackle “the causes of this”, do not sound very convincing in so far as significantly reducing the malaria burden is concerned.
While commending the plan to establish bioequivalence centers given Ghana’s heavy reliance on generic medicines, pharmacy experts point to other critical interventions. “Bioequivalence centers are one of the crucial interventions needed for quality, but I can’t say they are the most crucial intervention. Our inspections show that other interventions such as capital to put up good manufacturing practices (GMP) - compliant facilities, state of the art equipment, acquiring the needed expertise, development of appropriate documentation like dossiers, maintenance of equipment and perhaps some tariff reliefs to give local manufacturers a competitive edge in the import market are equally important.”
Mismanaged collapsing NHIS?
“The NHIS scheme we proposed and implemented in 2003 cannot be allowed to fail…it faces collapse with a perilous lack of care and poor management.”
Between 2007 and 2011, outpatient utilization under the National Health Insurance Scheme improved by about 400% from its baseline utilization of less than five million. In other words, the number of visits by NHIS subscribers is increasing. With the establishment of the NHIS Claims Processing Centre in 2010 – processing claims from all the Teaching Hospitals, regional hospitals and selected district hospitals— the facts show that the proportion of claims rejected has reduced from about 19% of claims submitted to less than 8% in 2012. The amount of claims paid to providers has risen consistently from less than 100 million GH? in 2007 to over 500 million GH? in 2011. Payment of cash by patients at the point of service delivery, popularly known as cash-and-carry, which used to constitute about 80% of the revenue of healthcare facilities in 2006, has now reduced to about 19%.This suggests a consistent significant reduction in the fortunes of cash-and-carry.
All the above notwithstanding, the NPP manifesto, for unspecified reasons totally unsupported by the facts, is emphatic that the NHIS is collapsing under poor management! How credible and relevant are proposed policy initiatives that are based on a flawed assessment of the current situation? There is an unmistakable disconnect between the facts on the ground and the conclusions drawn by the NPP which must make us question whether the party is really ready to take us to the next level as far as achieving universal coverage is concerned.
Is it my contention that the NHIS is free of any challenges?
Of course not!
With reimbursements to health facilities for April/May 2012 being released in September 2012, two months behind the target 60-day schedule, it may appear that the system is re-setting to its 2008 delays of 6-12 months. This of course puts health facilities under a lot of stress and in some cases compromises their ability to procure essential drugs. Further, providers remain bitter about unrealistic tariffs while scheme managers continue to fret about high levels of polypharmacy – thus raising doubts about quality of care. Uncertainty about the one time premium proposal remains.
But, the NHIS is not collapsing. Sowhat about the charge of mismanagement? At which point do you conclude that an organisation is being mismanaged?
Here is an organization that started submitting itself to internal audit processes followed by auditing of all 145 schemes effective 2009; strengthened its human resource base through its new HR department; is implementing a medium term strategy supported by rigorous data-driven monitoring and evaluation wings; commenced clinical audit in 2010 in partnership with providers to abate error and abuse; and is currently designing a process to electronically link treatment to the various diagnoses; not forgetting the recently launched 18-hour NHIS call center to assist subscribers.
How is it that it is rather after the introduction of these interventions and not before, that the charge of mismanagement is leveled? This is truly baffling. In fact, in terms of accountability, the first published annual report of the NHIA was in 2010, which was the annual report for 2009. On what basis then does the NPP manifesto reach the conclusion that the scheme is poorly managed? Or perhaps, it is a sad case of politics as usual?
Clearly, our political parties need to take urgent steps to move into the era of evidence-based or at least evidence-influenced policy making so that at any time, Ghanaians can be fairly certain that real and not phantom challenges are being addressed. What is the use of proposing solutions to problems that do not exist while other concrete challenges that could very much lend themselves to continuous quality improvement stay unaddressed?
Free maternal care policy
The NPP manifesto pledges to “revive the implementation of the original Kufuor policy of free maternal healthcare …” This of course implies that the policy is moribund in the post Kufuor years. My checks do not support this assertion. The free maternal care programme is apparently still very much alive and being accessed by our pregnant women today. Perhaps expanding its coverage to include blood transfusion services would have been a better performance target rather than pledging to revive an active intervention.
Private sector participation
The NPP talks about “encouraging other health insurance schemes and private sector participation.” Given that the current NHIS law already makes provision for the establishment of three different kinds of schemes— namely private mutual, private commercials and the social health insurance schemes— and given that we do already have private insurance schemes operating, a little more detail on how the party intended to execute this pledge would have been helpful. In the absence of any unique strategy, I am tempted to conclude that the NPP is only proposing to do something that is already being done which of course reflects rather poorly on how progressive and transformational it might wish to brand its policy initiatives.
The initiative to boost capacity in mental health through “encouraging the training of more psychiatrists, clinical and social psychologists, and other mental health professionals” is truly laudable. According to Ghana’s chief psychiatrist however, though more are needed, the country now has fourteen psychiatrists and not the five indicated in the manifesto. Given the passage of the mental health law in May 2012, perhaps, it would have been more beneficial for the party to have situated its policy initiatives within improving life beyond the mental health act.
Non communicable Diseases
The manifesto’s complete silence on non-communicable diseases (NCDs) is disturbing if not disappointing given that NCDs now account for almost a third of total deaths in sub Saharan Africa. According to the British Medical Journal, Africa in 2008 had the highest age standardized mortality rate for NCDs for males and females and by 2030, it is expected that leading NCDs are expected to “become the main cause of disability adjusted life years lost in sub Saharan Africa.” By lacking concrete policy initiatives to confront this future, the NPP’s health platform has failed to adequately position itself as truly progressive and transformational.
12th September, 2012