Health delivery in Ghana is faced with such a complexity of problems that instead of improving and becomingly sophisticated, it has rather become a commodity to be exploited for the benefit of a few. There are so many thousands of patients who throng our hospitals, clinics, polyclinics and sometimes health centres everyday seeking health care. The numbers are overwhelming to an extent that have made these facilities look like hopeless refugee holding centres. Unless drastic measures are taken and swiftly, we will be faced with a humanitarian disaster sooner or later. The major cause for concern in this quest for answers about health delivery in the country is not even the much talked about administrative, managerial, training and other areas of the sector. Rather, this paper seeks to focus on the forms of exploitative and profiteering schemes of service providers to the National Health Insurance scheme often at the blind side of patients.

The wayward dealings of service providers and their collaborators in the new health insurance scheme are happening almost unchecked with the exception of a few cases that were recently discovered. And there's no cohesive solution in sight because of lack of effective laws or rather the existing regulations have too many loophole. Any good measure from the public health sector regulators of the pharmaceutical trade remains to be seen or at best is inadequate. Such that we are in a situation that the pharmaceutical society itself has become an albatross. Thus it has become the regulator or referee since its members are mostly the provider owners. Besides, no one seems to notice it as a problem, a question of who regulates the regulator. The National Health Insurance Scheme after just a few years of operation have seen its resources almost sublime through fraudulent payments being made to unscrupulous service providers. Many of these providers who were just running "mama and papa shops" a few years ago are today reaping millions of Ghana cedis from expensive drugs retailing practice from their garage-style stores.

Ghana since independence seems to have graduated from one health scheme to the other without much success. In the beginning there was the emphasis on public health needs, with emphasis on community and workplace safety through preventive medical practice. There was a generation of health inspectors are long gone. In those days the health control officers (sanitary inspectors) in every part of the country who checked refuse disposal, issued fines for insanitary behaviour as well as dispensed spraying of mosquito endemic areas caused by stagnant water, be it in cities, towns or villages. Then came the decade of emphasis on primary health care, which involved bring health to the people, which led to the training of community health nurses who provided pre/antenatal counselling to women. There was also support for and training of traditional birth attendants and the main streaming of herbal medicine and the practice of "wanzam”; perform the age-old ritual of circumcision on boys. They were also trained on the safe use and sterilisation of tools and supplied with safe equipment operations. Later on there was a major introduction into the country or rather a compulsion to introduce "cash-and-carry," which was entirely supported by doctors but this did not provide effective guarantees for good universal health care to citizens. Since the most vulnerable in society will become exempted from affordable health care. Allow me to say though that, the categorisation of periods in health delivery mentioned above is not tightly chronological. Then by 2007, a new programme of the National Health Insurance Scheme was started and has currently gained enormous popularity throughout the country in view of the benefits. It is not clear at this stage whether out of all this programme mentioned anything about the perfection of health delivery over the years. Therefore, at present there is a blend of everything with no clear definition of which pathway to follow. While all this uncertainty is on going, some individuals are reaping their own exploitative profits.

The Ghana medical service was and will continue to be the envy of many in countries throughout Africa because of the quality of personnel and training given to persons working in the health service. The introduction of various schemes to improve on the health of the citizenry has rather gone a long way to thwart the sacrifice that medical people made in the past. Such that today, there are a decreasing number of sympathetic practitioners, as many doctors no longer regard their profession, a Devine calling. Let’s not even go into the investments made by the country to train these personnel to warrant the demand for sacrifice. Affordable tuition and board are provided with taxpayer support. It is said that it costs the Ghana government between GHc10,000 to GHc30,000 annually to train a medical doctor but not a single Ghanaian medical student pays anything close to this amount. I can go on to name very dedicated doctors, male nurses, even female nurses; now in the majority have all brought Ghana's health delivery since independence to accepted levels in the past. Past doctors of Korle-Bu and other hospitals as well as clinics both public and private, lived a greater part of their lives for the sake of their patients, which meant they had personal interest in delivering the best possible service. Such that until now, long after they were retired, they are remembered and revered by patients. Even if the nation forgets about them, their numerous patients did not. So these patients continue to pay tribute to them and their families till this day. I believe that this is about the most wonderful aspect of being a health worker; to deliver a baby for instance as a midwife or doctor and see that baby grow into a responsible adult in society. Another is, to save a life by performing vital surgery and see the individual heal, become prosperous, and so on.

Unfortunately, two years after the introduction of the National Health Insurance Scheme (NHIS) the regulator which is the National Health Insurance Authority (NHIA) discovered a lot of irregularities, and sanctioned operators like those in the recent banning of two hospitals in Kumasi from the provision of services to the health insurance scheme. It was detected that the hospitals were double billing (over billing) the National Health Insurance Scheme and making irrational prescriptions of about four similar antibiotics to individual patients. Also, in Accra two managers of the Ga District Mutual health scheme were set aside for investigations to begin on their services. Other checks in the health sector discovered that eleven workers at the Korle-Bu hospital have embezzled a total of GHc70,000. These might just be the tips of the iceberg about the problems of the NHIS. A major obstacle to be faced by the NHIS is how to initiate a fair pricing regime for "pharma-drugs" throughout the country. Our investigations have discovered discriminatory pricing of prescription drugs to the disadvantage of urban residents a kind of "pay as you go." This phenomenon needs to be checked and sanity brought into the system considering the facts that there are large numbers of urban residents who are poor and the vulnerable. It also includes the aged whose numbers are on the rise in Accra and many cities across the country. The case where my octogenarian father who joined the NHIS since its inception and had just renewed his membership in June 2009, was issued with a temporary card but could not use it to purchase drugs from any of the pharmacies in Kore-Bu Hospital and the Polyclinic, makes nonsense of the NHIS. The reason given was that Korle-Bu has not started accepting cards bearers yet except cash. So patients who preferred the use of their cards should go to the service providers outside the hospital. There is an ardent call to expand the list of ailments covered under the NHIS especially those for the aged.

Another twist to the pricing problem is that, price of common drugs for most ailments stand inflated by NHIS service providers in Accra from between 200 to 300 percent during the 2009 survey. The common cold/flu medicines for instance form part of a long list of highly priced drugs. I would like to say that similar drugs found in the survey include the pharmaceutical market of Okaishie, the township of Abeka Lapaz, following from Kojo Thompson Road, Kwame Nkrumah Avenue, also the Kwame Nkrumah Circle’s toward Nsawam roads and many areas in Accra are selling medicine at such exorbitant prices. But as you leave the metropolitan centres in the regions to rural areas and in a recent survey in places like the Anloga and places perceived to be poor, many licensed chemical stores have been selling at reasonable prices. So it was not surprising that some women have begun to leave the cities of Accra and Kumasi to buy vital drugs away from rural areas such as Anloga. These drugs are taken back to the cities or even to neighbouring countries like Togo because it has become more profitable to do so.

The concern is how could regulators check this practice in the pharmaceutical business? Some solutions could be the use of mandated VAT (value-added-tax) receipt which consists of the national health insurance levy (NHIL). There should be insisting on itemised receipts throughout the Ghana health service. Receipts should always be given during the purchase of drugs by patients and should be enforced in such a way that will make future audit less cumbersome. Also the appropriate duties should be paid by exporters of drugs from Ghana, since some drugs are cheaper here than in most of our neighbouring countries. Apart from the above solutions, it will be proper if the NHIA employs some graduates on part-time basis to assist in the checking of receipt from service providers. In advanced countries like Japan and US health insurance has become a burden because certain physicians have been found prescribing the most expensive drugs to patients, many of whom cannot even afford a health insurance. A regretable reality in the US, that informed President Obama to push for his new health insurance bill which if accepted by Congress will enable all American families whether poor or rich to access the necessary health service. In the wake of the influx of generic drugs to developing countries from Asian countries like India, China, Bangladesh and Thailand the certification of such drugs should be rigorous in all respects under the NHIS. So that patients do not end up buying cheap drugs that only tickles the ailment because the said drugs do not contain the requisite active ingredients, might have even expired or might worsen their ailment. More support and preference should be given to Ghana-based drug manufacturers to expand the scope of their manaufacturing and partner with reputable companies in the industry, like Glaxo-Smith-Kleine, ICI and others.

We should be conscious of expired drugs that are unscrupulously sold to patients. The prescription of too many antibiotics in a single dose for instance including many other dishonest and unethical practice in the industry will only result in a drug dependent society. There will be a resultant increase in serious drug abuse cases, which cannot be sustained by any health insurance scheme. The NHIS cannot shy away from computerising and networking of all health insurance service schemes to capture all VAT receipts at the source as well as finding the appropriate ways of capturing batch numbers, expiration dates and potency of all drugs. In this respect the innovation by a Ghanaian which enables patient empowerment, by enabling checks through the use of their mobile phones is laudable and must be encouraged. The NHIA has the mandate to be more aggressive with frequent monitoring, enforcement and a need to intensify public education. This could be done in collaboration with the media, Ministry of Information and the National Council for Civic Education (NCCE), Medical Council, Pharmaceutical Association and all relevant stakeholders aimed at providing the necessary safeguards for the national health needs.

Source: Doe, James W.

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