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Tuesday, September 8, 2009

Improving the National Health Insurance Scheme (NHIS)

Author, Dr Arthur Kennedy
Author, Dr Arthur Kennedy
By Kobina Arthur Kennedy

Last week, the Ho Regional Hospital announced that it was no longer providing services to patients with NHIS cards. According to Dr. Kofi Gafatse Normanyo, the decision had been necessitated by the failure of the Scheme to re-imburse the hospital for services. When we were Medical students more than two decades ago, Dr. Normanyo was an activist student who was generally very supportive of the poor and having to make the announcement on the suspension of services must have been rather painful for him.

To be fair, the problems that hospitals have had with getting paid by the NHIS for services predated the Mills administration. Despite repeated assertions by former CEO Ras Boateng and recently by the Mills team that the NHIS had significant cash reserves, it has been unable to pay hospitals on time for services since its inception.

When I visited the Agogo Hospital in the Ashanti region in late 2008 while conducting a survey, they revealed that they were on the verge of defaulting on their debts and that not even the intervention of late Finance Minister Baah-Wiredu had succeeded in persuading the NHIS to pay the hospital what was owed in full.

Make no mistake about it. The NHIS is without doubt the most significant pro-poor program introduced in Ghana in the last 25 years. It will be hailed by historians as President Kufuor’s most enduring legacy.

But it was born with significant shortcomings. This situation was compounded by the partisan rancour that occurred at that time. When it was passed, the NDC should have joined in passing it. Today, the NPP must join the NDC in strengthening it.

The Scheme had significant obstacles right from the beginning.

First, a health care system is about more than an insurance scheme. It is about public health. It is about an emergency care system. It is about hospitals with adequate capacity to absorb the increased number of patients brought out by increased access. It is about staffing the healthcare system, with Doctors, Nurses, Pharmacists, Orderlies and Cleaners. And there are deficiencies on all fronts.

While the NHIS increased outpatient attendance by about 50% and doubled in-patients for many hospitals, there were no corresponding increases in staff. The result is that the capacity of most hospitals, already strained before NHIS, is now at breaking point.

These are the real problems that should have been discussed during the election campaign of last year and these are the challenges we must discuss now.

The loud discussions on single premium during the campaign were a red herring. Here is why. Already, 62% of the beneficiaries pay no premium and that was before the idea of presumptive eligibility for children was accepted. Furthermore, tax receipts already cover 85% of the cost. Furthermore, before leaving office, President Kufuor obtained a grant of about 45 million dollars from the British government that will underwrite free maternal care for the next decade. According to then CEO Ras Boateng, the scheme had large financial reserves which mean that the problem of the scheme now should not be cash-flow.

Unfortunately, last week, even while Dr. Normanyo was announcing that daily OPD visits to the Ho hospital had dropped from about 300 per day to 200 and was dropping further, policy-makers met in the same region and talked right past the problem. Addressing a meeting in connection with the NHIS in the Volta Region, Dr. Benjamin Kumbour announced that plans were on course to implement the single premium plan promised during the 2008 campaign by the NDC. When he took his turn at the podium, Mr. Sylvester Mensah, the CEO of the NHIS announced that “By the end of 2010, the NHIS would have a fully portable and sustainable scheme driven by robust ICT solution.” On his part, Mr. Doe Adjaho, Council Chair for the NHIS Scheme pledged to review the NHIS legislation and to support a “forensic audit” into the operation of the NHIS including the 145 schemes in the country.

Aside from the fact that the portability problem was significantly addressed by the NPP administration, it is not of little import to the man in Ho to learn that his card can be accepted in Accra when his local hospital is refusing to provide him with care because the NHIS is not paying for services.

We must stop the politics and start dealing with the real problems of the NHIS.

First, the NHIS must pay hospitals and pharmacies on time for services provided. If the scheme cannot pay for services in this initial period when it must have excess revenue, what is going to happen when it reaches saturation point? The government, through an executive order or in the proposed legislation must require the scheme to pay 50% of claims submitted within three months and all claims that are not disputed within six months. Without resolving this problem, the hospitals and the public will lose confidence in the Scheme and this will affect the viability of the scheme.

Second, the government must make significant investments in the construction of new hospitals and the provision of existing ones with basic equipment. It does not matter how much insurance there is if over ten percent of our hospitals lack stand-by generators and a majority of those who do have generators have manual rather than automatic generators. While on the topic of equipment, indeed many of the hospitals as well as the Ministry of health did not have a standard list of the equipment required by hospitals.

As a result of unreliable water supply, most of our hospitals provide care in very insanitary conditions and this must change. Providing care in an unclean environment endangers the health of both patients and staff.

In terms of services offered to patients, there are hospitals that do not even offer meals to patients on admission. How can you heal the sick when they are starving?

Third, we must deal with staff issues.

We must train more Doctors, Nurses and Medical Assistants while improving opportunities for continuing education and training in emergency care.

Around the world, there is a shortage of Doctors and Nurses virtually everywhere and we must train more of them while strategically exploiting the “brain-drain” and turning it into a “brain-gain”. For decades, droves of Indian physicians headed for the West in search of greener pastures but today, many of them have returned to become the backbone of the Indian “Medical tourism” industry.

Two years ago, that industry, involving the provision of care to patients from the West at cheaper cost generated about 2.5 billion USD for the Indian economy. We can, with good planning and investment, have a “Medical tourism” industry that can be the envy of Africa.

While we mobilize the resources to train more Doctors and nurses, we must make it easier for our Doctors and Nurses in the Diaspora, to practice at home, either on a temporary basis or permanently. While I have heard many stories of health professionals from abroad having difficulties in practicing, my own experience dramatically confirmed this to me.

At the beginning of this year, I decided to practice in Ghana. With a vacancy rate of at least 25%, I thought as a board-certified Family Physician in America, this would be easy. After six months of cooling my heels and waiting for the Ghana Health Services bureaucracy, I gave up and returned to North America. I got a job offer within two days and was at work in two weeks! It is tragic that a Ghanaian physician should find it easier to work in the US than Ghana when Cuban physicians, some of whom are not as qualified as he is and cannot speak the language can get to work easily.

Fourth, we must check corruption in the NHIS and the health system in general. There have been disturbing stories of people without cards on admission having back-dated cards made for them and of bills submitted to the NHIS for services not rendered. While these must be checked, the reflexive resort to “forensic audits” must be resisted. The nation has audit requirements that must be followed.

While portability for the NHIS is important, we must not put too much onus on ICT. As my Technology Course instructor never tired of reminding my class, “if you computerize a bad system, all that you get is a bad computerized system”.

I remember walking out of Bechem hospital after a visit last year. Right at the entrance was a taxi driver, a woman and her newborn baby, all covered with blood. The driver had helped the mother to deliver the baby on the way to the hospital. All three were in good shape. When I asked the taxi driver how much he had charged, he said “How can I ask for money when somebody’s life is at stake.” That is the reality of the care most people get.

Finally, healthcare is not an NPP issue or an NDC issue. It is a Ghanaian issue. Death comes to NPP and NDC members in equal measure. Too often, the rich and powerful think that when they get sick, they can get care abroad. The reality is that in an accident or sudden sickness, we are all at the mercy of our local health system, for better or for worse. Let us work together, to build a healthier nation and move our nation forward.

Arthur Kobina Kennedy
Email: arkoke@aol.com

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