Two major landmark points in the life of Oman Ghana were celebrated last week. Both dealing with the physical health and well-being of every Ghanaian living everywhere. The National Health Insurance Scheme (NHIS) attained the age of 10 while the Korle Bu Teaching Hospital cut its 90th birthday cake.
As with all birthdays, these two events provide excuses for both merrymaking and reflections about how far we have come and what prospects the future holds for us.
Commemorating (hint of mortification) the birthdays of Korle Bu and the NHIS has come at a most awkward time. Our physical health is deteriorating every day because those who govern in our name (and their twins waiting to get their turn) seem only interested in alleviating their own personal poverties instead of working to increase our collective well-being. Our plight is being worsened by the visibly crumbling of the twin pillars that prop up the edifice and that are meant to stop us from an early rendezvous with our Maker.
Ten years ago, Ghana’s Parliament passed the National Health Insurance Bill (Act 650) into law and paved the way for the abolishment of the “Cash and Carry” system in the public health sector. The NHIS did not actually come into being till December 2004, but who cares. It is only in Ghana that we count age from the day of conception, instead of the normal nine.
As with many of the policies of our founding father, Dr Kwame Nkrumah, Public Health Provision in Ghana was founded on the basis of ‘free health care’ for the people. However, as the country’s economic challenges mounted, free health care became increasingly unsustainable, leading to the introduction of token fees in 1972, which became a full-fledged user fee system in 1985, called “Cash and Carry”.
Under “Cash and Carry,” all those who sought treatment in public health institutions were required to make a cash deposit before they would be attended to. The requirement to deposit cash applied even in situations when patients had been brought to the hospital as emergency cases.
The consequence of not having “ready cash” could be sometimes literally fatal, with premature death leading to corpses being carried away in ambulances for burial after a living human being had been raced in a horn-tooting taxi to the hospital. Then as now, the receiving hospital was the Korle Bu Teaching hospital.
The conception and birth of the NHIS was dogged by partisan fights about its true paternity. First the NDC claimed to be the father on account of a few test tube experiments. The gynaecologist turned politician, Edward Mahama, also laid claim to fatherhood. Then the practising doctor brother of my partner, Fred, the prolific F. W. K. Akuffo, also chipped in his claim. Even yours truly put in a bid under “SHIKEENA”. Finally, the DNA paternity test (Act) established the Gentle Giant as the true father of the NHIS.
Happily it has now become fashionable. We have adopted the all-inclusive approach to the NHIS, have stopped the “who is the father” fights and agreed that the NHIS is our collective baby, which has become the envy of the world over the past 10 years. The NHIS has survived and remained largely intact for 10 years, even as it has been beset by and continues to face a number of major challenges.
The objective of the NHIS is to offer every Ghanaian the opportunity to contribute to a fund so that in the event of illness, their treatment would be paid for from the fund instead of having to pay “ready cash”. Although the NHIS is intended to provide universal coverage, unlike “Obamacare”, subscription to the scheme is by voluntary personal choice, although the sources of its funding and provisions under the law, such as SSNIT contributions, means that a substantial majority of Ghanaians are covered by the NHIS.
A decade after its establishment, the NHIS is considered by every Ghanaian living everywhere as one of the finest pieces of social engineering policies in our history. The partisan jockeying, which bedeviled the development of the scheme, has given way to a consensus that has reduced political debate to “who can manage it best and who is destroying it most.”
Unfortunately, the celebration of a decade of the NHIS has coincided with major challenges which threaten to derail the scheme and return us to the dreadful and weary days of “Cash and Carry”. The NHIS is being starved to death as statutory deductions and contributions earmarked for it are being diverted into filling the looting pockets of the governors.
As he launched the 10th anniversary programme, the current Chief Executive, Mr Sylvester Mensah, said “it is a good time to take stock and re-strategise for the future and improve on the achievement of the scheme”. He described the landmark as a commemoration (stock-taking) rather than a celebration (excuse for partying).
Why is the NHIS coverage today only at 35 per cent of the population? What proportion of those who join re-register after only one year? How many private clinics have pulled out of the National Insurance Scheme and why? What is capitation and what is it intended to achieve? Why is it that only one region has been singled out for its introduction?
The NHIS law calls for investment in the health sector itself. What proportion of funds per year go into efforts to develop the sector? How can the NHIS complain about financial challenges that stop it from paying its service providers when it has built a spanking HQ edifice and several district offices?
Already, many of the service providers, including public hospitals, have returned to “Cash and Carry” operations. Private doctors are crying foul about the levels of incentives to enable their full participation. People who join the scheme are tired of having to wait for nearly a year from the day of paying premium to full enrolment. Many are so chastened by their experience that they abandon their subscriptions after only one year.
We say “ayekoo” to the NHIS @ 10, but the overriding question exercising the minds of most Ghanaians is: will the NHIS still be alive 10 years from now or will it have become another casualty of our high infant mortality rate? In its own words, the NHIS estimates that by the end of this year, its deficit will have reached GH¢ 307 million, and rise to GH¢ 507 million at the end of 2015.
The ghosts of “cash and carry” are being resurrected each and every passing day as our rapidly emptying pockets are being picked by those purportedly acting in our name and on our behalf. Where will we find the money to pay for the treatment of our rapidly failing health when the ghost of pay cash or be carried away in a taxi returns to haunt our children and our children’s children.
As for Korle Bu, it is beginning to show its age and imminent exit despite the millions of cedis injected into keeping it propped up with the latest gadgets that pretend there is still useful life in the crotchety edifice. The money expended could have spawned many more new Korle Bus to improve the opportunities for keeping us healthy to attain 90 years also.
By attempting to sneak gargantuan user fees onto its patients while Parliament had gone to sleep shows the flagship service provider in our NHIS, Korle Bu, has already given up on the scheme on its dying bed. This cannot be a good sign or reason for us to Say Cheers to the NHIS @ 10 or to mark the 90th year on earth of the terminally ill Korle–Bu Teaching Hospital.
The author, Dr Charles Wereko-Brobby aka Tarzan is the Chief Policy Analyst, Ghana Institute for Public Policy Options (GIPPO)