University of Cape Coast—Cape Coast.

16th July, 2012

Let the word go forth from here to all corners of our country and beyond. The unthinkable is happening. The “Cash-AND-CARRY” health care system is back.
Two weeks ago, we awoke to the news that the nation’s second largest hospital, Komfo Anokye Teaching Hospital had introduced a “Development Levy” of ten and two Ghana cedis for inpatients and outpatients respectively. Under pressure from patients, NGO’s and public policy experts, the hospital “suspended” the new levy. To be fair to the Komfo Anokye authorities, they were only following the industry leader, Korle Bu Teaching Hospital, which has been charging all kinds of fees brazenly for some time right under the noses of government authorities. To apply the President’s admonition to “Dzi wo fie asem”, last week, a patient I had sent for some routine tests at the Central Regional Hospital who had NHIS called to report that he had to pay 35 Ghana cedis for some routine tests I had ordered. When I called my contact at the lab, he confirmed that they had been instructed to charge for those routine tests.

As usual, despite the significance of the Komfo Anokye Teaching Hospital incident, we talked about it excitedly for a few hours and then moved right back to what is important to us ---- arguing fruitlessly about “Judgment debts” and insulting one another!

In addition to these, most hospitals are now serving only two meals a day to patients with NHIS with the result that patients who need to eat before taking their medications sometimes have to skip those medications; that is if those medications are available. To add to this, increasingly, patients are being told that medications that should normally be covered are not available.
When the NHIS was passed in 2003 and Ghanaians, with the exception of some misguided NDC leaders, went into an orgy of self-congratulation, the celebrations were premature. Today, the resilient “Cash And Carry” system is back with a vengeance.
How come that we can win awards all over the world for banishing “Cash And Carry” when it is still with us?
First, despite all the adulation we heaped on ourselves, NHIS never completely banished “Cash And Carry”. It left significant gaps in the coverage of NHIS. For instance, despite the fact that the treatment of Diabetes is covered by NHIS, checking a patient’s sugar level, which is central to Diabetic care, is not covered. Thus if you have NHIS and get admitted with Diabetes, and your Doctor determines that your sugar needs to be checked four times a day, it will cost you 8 Ghana cedis a day. To add insult to injury, the most reliable long-term monitoring test, HBA1C, is not covered by NHIS. Two more examples should help underline the gaps in NHIS coverage as conceived. While the treatment of heart attacks is covered by NHIS, neither ECG’s nor cardiac enzymes, which are critical tests for diagnosing the disease are covered. Finally, while breast cancer treatment is covered, mammograms to screen for breast cancers are not covered. I have recounted these to show that our “Cash And Carry” problems have long and deep roots. For the avoidance of doubt, while these are significant defects in the NHIS, I believe that it is probably the most significant social policy introduced in the last quarter century and will be seen as President Kufuor’s most enduring legacy.
Second, with the introduction of the NHIS, government discontinued streams of funding that had been required even in the era of “Cash And Carry” Such funding had gone towards infrastructure and other needs. When these were discontinued, hospitals were forced to rely for the most part on NHIS for most critical expenses. To compound these problems, NHIS payments have been consistently delayed.
While these issues are important in the genesis and maintenance of the “Cash And Carry” system, the future looks even darker. Currently, the cost of HIV treatment is bourn significantly by the US government under the program launched by former US President George W. Bush to support the treatment of HIV and Malaria. When the 16 billion USD designated for sub-Saharan gets finished, I shudder to think of what will happen to our HIV patients. Furthermore, it would be recalled that in the last year of his Presidency, President Kufuor secured from the British government, funding to support free deliveries of pregnant women for the next ten years. That money too will get finished. And then, since Ghanaians intend to match the rest of the world baby for baby or better in the production of babies, there will be more “Cash And Carry”.
While the “Cash And Carry” problem is a national one, residents of Ashanti region have taken it on the chin. This has been due to the introduction of the “Capitation” system. It has been underfunded and mismanaged to the detriment of patients in that region. The choice of Ashanti region, particularly given its size was a particularly bad one. Pilots should be done on small populations or regions and then scaled up, if successful.
Another very significant contributor to the persistence and growth of “Cash And Carry” is the inefficiency of our hospitals. Tests that can be completed in hours elsewhere take days to weeks here. This means that patients’ stay in hospital is extended unnecessarily.
A final initiative that will only exacerbate “Cash And Carry” is the plan to introduce the “Single Premium” system.
The return of “Cash And Carry” is a national crisis that must be addressed in a non-partisan manner.
First, there must be a bold and visionary reconfiguration of the NHIS to refocus it on prevention as well as important diseases and critical tests that have significant impact on us.
Second, there must be more expertise in the management of NHIS so that it can be used as a lever to drive quality in our healthcare delivery system.
Third, government must commit significant resources to upgrading our infrastructure and capacity for healthcare delivery. The NHIS cannot cure all our healthcare ailments. Unfortunately, even when we decide to invest in infrastructure, our priorities are questionable. For instance, efforts are underway to provide each regional hospital with an MRI even though most of them, including the Central Regional Hospital where I work, lack mobile x-rays that are needed to take images of critically ill patients in their beds. Furthermore, it is not uncommon for a hospital to get buses that are mainly used in attending funerals and weddings when they lack basic equipment like pulse oximeters and ECG’s.
Fourth, there must be tax incentives and needed legislation to encourage the development supplementary insurance schemes.
Fifth, our hospitals must become more efficient in the use of our scarce resources. Currently, patients stay in hospital for too long and cost us too much.
Sixth, we must commit more resources to public education and environmental sanitation. Every cedi committed to this area will prevent many more cedis from being spent in curing ailments like Malaria, Typhoid, Cholera and Tuberculosis.
Next, our leaders must use our own health resources more so that they can understand the shortcomings and help to fix them.
Finally, to those who are inclined to argue that we cannot afford to fight “Cash And Carry”, my response is that if we can, over the years and across governments of different parties, pay so much judgment debt, we can pay to save the lives of the poor. It is just a matter of our commitments and priorities.
Let us work together, to banish “Cash and Carry” into the bush or into the archives.
Arthur Kobina Kennedy