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Opinions of Tuesday, 27 November 2012

Columnist: Sodzi-Tettey, Sodzi

Politics of Health Insurance

Sylvester Mensah & Frimpong-Boateng

Between the New Patriotic Party’s (NPP) ‘collapsing’ (black) and the National Democratic Congress’s (NDC) strengthened (white) National Health Insurance Scheme (NHIS), there appears to be no grey areas. And nowhere was this better portrayed than at last week’s political parties health platform organized by the Ghana Medical Association (GMA) at its 54th Annual General Conference held in Cape Coast in the Central Region.

The closer the election gets, the better crystallized the issues get. As it turns out, NHIS appears to be to health what free Senior High School (SHS) is to education. In the latter, it is without doubt a contest between the NPP’s promise of free SHS and the NDC’s quality/access platform. In health, the battle appears to belong to the party that does the better job convincing us that the scheme under the NDC is either collapsing or not. This depressing focus itself might not have been so unwelcome had the argument been better informed by and been fair to the current facts and had contending parties crying loudest about the collapsing scheme, done a better job outlining their own specific interventions to resuscitate same.
Indicative of the impending fire, both debaters, the NPP’s Professor Frimpong-Boateng and the NDC’s Sylvester Mensah started off exchanging light verbal jabs. While Frimpong-Boateng questioned the propriety of a head of a public institution –Chief Executive of NHIA—speaking on behalf of the ruling party, Sylvester Mensah countered by querying when the former had seen the anomaly in this given his own contest in the presidential primaries of the NPP in 2008 at a time when he was CEO of the Korle Bu Teaching Hospital. Further, while Frimpong-Boateng showed two pictures depicting worsening sanitation on the Korle Gonno beach from 1924 to 2009, Mensah countered that given the NDC’s assumption of power in 2009, worsening sanitation at the time reflected more poorly on the preceding NPP government than the NDC.
Rather than recount their presentations, I would rather reflect on some of the contentious issues that came up for discussion starting with one doctor’s passionate appeal for the NHIS not to be politicized.
As good a sound bite as this phrase “non politicization” is, to all practical intents and purposes, what does it really mean? Some social mobilization experts have argued that any social protection programme that affects more than 20% of the population immediately assumes a political dimension. Given the over 60% of the NHIS coverage, should anyone be surprised that the matter of the NHIS is front and center of the health debate and is a call for its non-politicization realistic or even necessary? Perhaps, the best one could ask for is for the NHIS debate to be critically factual and not overcome by jaundiced analysis delivered on the altar of political expediency.
Perhaps the very politicized health insurance debate might be better appreciated when viewed against the historical perspective of its conceptualization and the political womb in which it was conceived and delivered. In the 2000 election, ‘Cash and Carry’ or payment at the point of service delivery by being a barrier to access had assumed a political dimension with the NPP promising to replace it with the NHIS which it did. Further, the initiation of the free maternal care programme was something that President Kufuor took political credit for and rightly so. If today, the NDC is citing improvements in indicators and other important management interventions to buttress its claims of a non-collapsing scheme, I doubt that this should overly worry anyone. Finally, given the very politicized and unpopular nature of the ‘Cash and Carry’, why should anyone be surprised when the issue of an allegedly returning ‘Cash and Carry’ becomes a battleground issue? With the NPP claiming that ‘Cash and Carry’ has returned when the facts clearly show that the fortunes of cash and carry have admittedly been dealt a deadly blow with the revenue generated from facilities from ‘cash and carry’ dwindling from over 80% to less than 19%, it is arguable that at 19%, ‘cash and carry’ cannot be said to have ever really gone away.
So rather than convince us that ‘Cash and Carry’ is returning (when it never went away), or that it is insignificant (high 19% notwithstanding), our time will be better spent if both parties focused on their strategy, if any, for achieving universal coverage.
Perhaps, the hottest issue on the day resulting in flared emotions pertained to interpretation of figures indicative of increasing utilization of outpatient (OPD) services. Utilization of OPD services has risen from 12.5 million to 25.4 million between 2008 and 2011. While the NDC maintains that this “is evidence of the growth and expansion of the NHIS”, the NPP would have us believe that this means more people are getting sick! The latter of course begs the question: can the NPP adduce data to show that more people are now getting sick? If in 2000, we were all in unison that cost was a barrier denying access to millions of Ghanaians in need of care, how is then that when more people are utilizing OPD services now, we argue not that access is increasing but that more people are falling sick?
There is no consistency, unfortunately. When utilization improved from about 5 million to 12. 5 million between 2007 and 2008, it was very much interpreted as a sign of expanding coverage and growing access. How one indicator can be subjected to different interpretations based on political convenience is what remains baffling to many.
Amidst the throes of passionate debate with this highly contested issue, Sylvester Mensah described Prof Frimpong-Boateng’s argument of more people getting sick as “smacking of mental imbalance.” This expression was of course unacceptable to the audience as it detracted from the pure contest of ideas that this had been billed as. Sylvester Mensah subsequently withdrew the comments and the debate proceeded.
With utilization increasing, the inevitable concern about its impact on quality of care was elevated by doctors, especially given stagnating health workforce and unexpanded infrastructure, growing workload regardless. Doctors cited basic laboratory tests that were being denied patients. With the NDC planning to expand coverage of the minimum benefit package to include Mental Health, the disabled and prostate cancer while collaborating with the Ghana Health Service to roll out nationwide cancer screening programmes, doctors expressed seriously reservations about current limitations in cervical cancer care under the scheme. Covering surgery to the neglect of radiotherapy for a patient with advanced forms of the ailment raised serious quality concerns which Sylvester Mensah promised to consult further on.
Prof Frimpong-Boateng then questioned the financial sustainability of the scheme concluding with the fact that the NDC had tactically refused to repeat the difficult “One time premium” premium promise of its 2008 manifesto in the current one. In his rebuttal, Sylvester Mensah argued that effective management practices and cost containment measures were accountable for the scheme’s current survival, the NPP’s initial projections in 2005 that at current funding levels, the scheme would not be financially sustainable by 2009 notwithstanding. Consistently, the NPP has been at great pains to convince us that the scheme is collapsing. So fixated infact that asked at the first Presidential debate of the Institute of Economic Affairs to list three key issues in health worth his policy interventions, the party’s flag bearer could only come up with ‘collapsing NHIS’. So let us assume without admitting that the NHIS is indeed collapsing. Wouldn’t the natural question then be one of what each party is proposing to do about it? Given our collective keenness to move from lamentations to solutions, it is not so obvious to me at all what the NPP specifically wants to do about this allegedly ‘collapsing’ scheme beyond noticing and naming it.
Many previous health policy conflicts have been positive, creative and affirmatively disruptive leading to significant reframing and tangible improved outputs – health insurance law, free maternal care, inclusion of children, passage of mental health law etc. This current health debate is at serious risk of becoming disappointingly flat and pointless: singing about collapsing or strengthened schemes without a clear strategy for achieving universal coverage and translating improved access to better neonatal, child health and maternal outcomes and therefore improved population health.
Sodzi Sodzi-Tettey
16th November, 2012