Top up payments at health facilities

Working in the health industry can really be worrisome as every day all kinds of problems emerge.

In the era of free medication and admission, it is common for patients to still settle fees for laboratory tests, consultation and others, depending on which department the patient found himself or herself.

Nobody goes to seek health care without parting with some money which, of course, was not receipted. This has been entrenched despite the exemption policy for expectant mothers, children under five years and the elderly.

Whilst the exemption was seen to work at least in theory, the practical reality is that the patient paid fully for all services rendered and the state reimbursed the facility fully for all the services (double dipping).

The obsession to collect money from patients has been with us far before introduction of user fees and the prevalence does not seem to ever have a halt. One would have thought that with the introduction of NHIS the craze for payment will be a thing of the past. Unfortunately, it is rather on the ascendency.

We are confronted with several reasons for this “evil manifestation” by our care givers who, sometimes, advertise their commercial intents overtly ahead of the duty or professional calling.

The NHIS card holders have often complained of payments demands from healthcare providers and it is the leading documented complaints in all NHIS office complaints registers across the country.

Health caregivers are quick to find alibi in delayed reimbursement, low tariffs, services outside of the benefit package, high cost of medicines, lack of regents, and as many other reasons as could be envisaged.

Delay in reimbursement is a major challenge to not only health care managers but threatens quality health care since providers will not be able to timely and adequately restock both medical and non-medical consumables.

Casual or temporal members of staff are paid from Internally Generated Funds (IGF). When casual labourers are not paid, we have low morale and under performance.

My personal interaction with most clinical care institutions suggests to me that departments such as the laboratory, imaging, pharmacy, blood banks mostly survive on what they generate. This suggests that when there is less financial inflows, inputs will not be available. These departments also have a lot of staff who are not on the official pay roll of the main institution hence depends on the IGF.

Medical inflation the world over-runs twice the general inflation and in developing countries, it can be over 200% higher. The introduction of NHIS in Ghana has seen a steady growth in health care utilisation and many more people access health care now than before.

This means there will be high consumption of medical and non-medical consumables. One will, therefore, not wonder the ever increasing cost of medical products, especially in Ghana, where the concept of free economy seems not to be regulated.

This has been compounded with external dictates that results in ascendency of prices. The result is that prices fixed during annual review lose their significance to market forces midway the period, hence patients required to pay the difference.

The implementation of procurement law, which was meant to prevent corruption and bring sanity into public procurement transactions, has introduced its own cost escalating ingredients. The official procurement becomes more expensive than open market purchases. Health providers often get outrageous quotations for goods and services that affect their pricing as well.

The result has been to push the frustration on the vulnerable, who is the patient, since it is about life that has no spare parts and once lost is forever lost. Patients are therefore asked to top up at every turn of care in the health facilities.

At the OPD, you top at for folder, top up for laboratory investigations, top up for your X-ray or MRI scan, top up for your medicines and top up for packing space. Recently, in one of the regions, patients were asked to pay top up for electricity and water since that was not factored in calculating the tariffs. That was not the true situation, though.

We cannot rule out the traits of unhealthy attitude by some health care providers who just want to see the patient pay money. These individuals, though in the minority, will insist on taking money from the care seeker at all cost. Some individuals have complained of being detained at hospitals because they could not settle their fees.

To overcome this fixation for top up, we need to improve on several areas, including ensuring prompt reimbursement of claims which starts with proper management of claims at the facility level and timely submission to the NHIS office. Effective and efficient vetting of claims and release of vetting report to health care providers, will impact positively to the reduction in bureaucracy at the NHIA.

The receipt of cash as the only means of financial transaction should give way to cashless payment system at all health facilities starting with the hospitals. The use of cash baits some people to demand for payment as such persons are often ready to receive the money even if it is not for their personal use.

Conscious effort to train staff on customer care with emphasis on attitudinal change is paramount. This question of poor morals should be worked on starting from training institutions for continuity at the job environment.

The emphasis on revenue generation by management of health institutions as a measure of high performance should be looked at seriously. It drives staff to focus on more income generation and sometimes leads to illegal methods of generating money.

Proper regulation of supply of medicines and non-medical consumables should be considered seriously. The Ministry of Health, in collaboration with relevant bodies, should work at standard pricing regime for health care equipment, medicines, and other logistics.