Opinions Tue, 15 Jul 2014

The return of ‘Cash and Carry’?

Mahama under Siege!

When President John Mahama described his turbulent first hundred days in office as a real baptism of fire, he had no clue he had probably seen his best days yet!

Today, after a bout of fuel shortage, demonstration by middle class protestors calling for better governance, saga of a moribund Black Stars management and team, striking Polytechnic lecturers, threatening to strike University lecturers, persistent ‘dumsoric’ incursions, brouhaha in Parliament over reshuffled Ministers speaking to issues in their new Ministries while still at post in their old Ministries, and finally, a return to payment at the point of service delivery aka ‘cash and carry’ for at least thirty percent of health care seekers attended to by the Christian Health Association of Ghana (CHAG), he must be revising his notes!

The last point bites deepest. Sickness has no political colors. It touches people personally and if they cannot afford healthcare at the point of need, they will hardly tolerate excuses! Surely, none would be warm to the return of fee for service at the point of care. The lessons of history ought to be imbibed. The decisions and actions of today will to a large extent, define John Mahama’s Presidency and legacy. They will predict whether this would become the time when courageous and decisive leadership positively changed the very fundamentals of the society or when business-as-usual politics created another missed golden opportunity.

But government appears to have answers for critics in what would appear to be a well- crafted statement listing somewhat quantifiable achievements in the following sectors – Supply of Potable Water, Education, Health, National Health Insurance Scheme (NHIS), Supply of Electricity, Road network and Communications.

In due course, I do intend to take the Deputy Minister’s statement sector by sector, and match the listed achievements against promises made by the party in its 2012 manifesto. As it turns out, some governments (and I don’t necessarily refer to this one) operate without regard to its own manifesto once elected into office. Held hostage by power, they allow whatever development is in the offing to reach them passively, which they then subsequently trumpet as key achievements although they themselves had no such intentions. This is the reason why I will be watching the extent to which the achievements listed by the government measure against the ambitiously promised. Where government is on course, it will be worth keeping an eye on the pace of delivery.

Today, I focus on health where the government is touting a lot of achievements in infrastructural developments, the supply of critical equipment and innovations in the NHIS.

“Government has a program of providing modern hospital equipment to enhance healthcare delivery. Christened National Hospital Equipment Replacement Program, this initiative has ensured the construction and equipping of New MRI and CT Scan Centres in; the Komfo Anokye and Tamale Teaching Hospitals. The Korle Bu Teaching Hospital alone benefited from a $57 Million project to replace and rehabilitate obsolete equipment and theatres. Twelve operating theatres for Pediatric and General Surgery (which had been closed for nearly eight years), the Neo-natal intensive care Unit and the Baby unit were refurbished. Korle Bu also took delivery of Mammography, MRI,CT Scan ,X-ray machines and Oxygen plants. Under the same scheme, procurement and installation of new X-Ray Equipment in 40 selected District Hospitals took place nationwide;…”

Granted that all the above are in place and infact in line with the manifesto pledge to build new hospitals and refurbish old ones, the question inevitably turns to cost. What happens if the good people are unable to afford these provided services? This takes us to NHIS, our funding strategy, where government talked about everything except the problem at hand – delayed and inadequate claims reimbursements. If as government says, data shows increasing utilization, what is to be said for the quality of care patients are receiving if in some cases, providers are being paid 30-40% below the market value of medical supplies?

Over time, the NHIA has clearly demonstrated its ability to roll out innovative solutions aimed at introducing efficiency into its systems. Mention can be made of the establishment of claims processing centers, introduction of electronic claims processing systems, biometric registration and instant issuance of cards etc. It is therefore time to hold the bull of the continued refusal/inability of the Ministry of Finance to release the entire National Health Insurance levy paid by the good people to the Authority, by the horns. Has the government got the political will to ring fence the National Health Insurance levy? That way, we can truly tell whether the money is enough or not and think of alternate funding means should the later prove to be the reality. Anything else will amount to insignificant tinkering leaving the core factor untouched.

If the overall goal of honoring a certified claim is ultimately bastardized, being unable to be guaranteed five-six months after the original claim submission with depreciated value etc., what are we to make of government touting coverage expansion to “…persons under l8years, pregnant women, LEAP beneficiaries, the aged, indigents, people in special homes such as the leprosaria and mental health homes …” What is the actual level of quality that is being promised and delivered by providers adapting to an unreliable funding system?

Government may argue that it has recently upwardly reviewed tariffs. Early analysis however shows that 15% of the medicines as at 1st July were below market prices. In other words, even before new tariffs could actually kick in, facilities are complaining of already running at a loss. If government finds the cost of medicines prohibitive, is a private-public partnership that sees government entering full scale production at scale and at manageable costs to meet the demand not an option?

In the interim, who is actually funding the real cost of the healthcare being provided? The refusal of CHAG to accept the NHIS card as a mode of payment may be a blessing in disguise if it forces us to consider alternative more sustainable funding approaches. What stops government technocrats from crafting a formula for automatic tariff adjustment in accordance with prevailing economic rates? Today, it is CHAG with its 180+ rural based hospitals. Who will be next?

And while we are at it, we might as well ask about the promised 1600 CHPS compounds promised in the manifesto, 600 of which should have been built by now if government were on schedule instead of the 19 mentioned which works out to about 3%.

Sodzi Sodzi-Tettey


10th July, 2014
Columnist: Sodzi-Tettey, Sodzi