Phyllis D. Osabutey
25 July 2008
opinion
"I heard the news on the television and did not hesitate to register. Now it feels so easy and better because every one can deliver at no cost at all."
These are the words of a two thirty-one year old mother of two, Charity Okine, who delivered at the Prampram Health Centre in the Dangme West district in the Greater Accra Region without any payment.
Her joy comes in the wake of President Kufuor's initiative of providing free medical care for pregnant women in the country as a means of addressing some of the challenges hindering the attainment of the fifth target of the Millennium Development Goal (MDG), which focuses on improving maternal health of women by 2015.
Charity, said six years ago when she delivered at the same health centre, she paid an amount of ¢45,000.00, which was quite a bother for her and so having delivered with no cost this time around, she finds the whole process easy and would therefore encourage other pregnant women to report to the health centre to be registered since it is now entirely free.
Already, about 50,924 pregnant women are reported to have registered throughout the country and the number is further expected to increase in the various health facilities across the country.
This intervention is critical to the attainment of the MDGs on the whole, particularly in view of the current rate by which maternal death was rising in the country, as a result of pregnancy-related problems such as hypertension, bleeding, anaemia, unsafe abortions, infections, obstructed labour among others.
State of Maternal Death
The situation is such that the Ghana Health Service envisaged that an estimated 12,000 women and 200,000 infants seem to be at risk of death while one million more will suffer disabilities if interventions are not put in place to curb the soaring numbers in time.
This, the Service says would amount to a loss of productivity to the tune of $12 million, equivalent to ¢ 108 billion due to maternal deaths while disabilities would include chronic anaemia, fistula, chronic pelvic pain, emotional depression and maternal exhaustion that would also amount to US$ 325 million.
Statistics show that the problem has been rising steadily since 1998 from 777, 813 in 1999, 851 in 2000, 954 in 2001, but saw a decrease in 2002 at 837, and went up again in 2003 at 854, decreased again in 2004 at 824 and since then has been on the rise from 912, 954 and 996 in 2005, 2006 and 2007 respectively.
The country's maternal mortality ratio currently stood at 214 per 100,000 live births and out of the number of deaths recorded last year, 148 were adolescents, representing 15.5%, while hypertension constituted 19% of the deaths, bleeding 17%, anaemia 12%, unsafe abortions 11%, infections 10%, obstructed 7% and others constituted 24%.
From the above figures, every one in thirty five women in Ghana stand the risk of dying from pregnancy in their lifetime as pointed out by the Programme Manager of the Family Health Division of the GHS, Dr. Patrick Aboagye.
These numbers are high and unacceptable because the setback it poses to the efforts at attaining set developmental goals especially the MDGs by 2015, experts have noted.
Among the many contributing factors to the problem are limited access of women to education, economic and land inheritance opportunities, participation in governance, high poverty levels, poor health-seeking behaviours, low risk perception and harmful traditional practices, as pointed out by Dr. Aboagye.
Benefits of Package
In view of this, many have lauded the Presidents intervention because it aims at reducing maternal mortality through the registration of all pregnant women, who are currently not registered under the National Health Insurance Scheme (NHIS).
Under the package, pregnant women would be exempted from payment of the NHIS premium, registering charges, and a waive of the waiting period between registration and accessing services while any woman who reports at any accredited health facility with a pregnancy-related complication resulting in, or arising from miscarriage or abortion would be entitled to the same benefits.
In addition, any woman, who happens to have delivered at home or in an unaccredited health facility with post-partum complications during the six-week post-natal period, would be registered.
On the other hand, any woman who reports in good health during the six-week post-natal period but has failed to register during the pregnancy or delivery period would be assumed to be registering just for the purpose of obtaining a free card and therefore would not be registered.
Authorities at the National Health Insurance Authority (NHIA) have indicated that the initiative was designed to increase uptake of ante-natal, delivery and post-natal care. As such, pregnant women are entitled to access all services under the NHIS benefit package as long as the services are provided by accredited health facilities.
In addition, children have been detached from the registration of their parents such that the newly born will automatically be covered by NHIS, receive a separate NHIS card at three months, and further included under the mother's cover for ninety days after delivery.
This free medical care is valid for a period of one year from the date of registration but if a client fails to renew her membership through subsequent payment of the appropriate premium, her membership would be de-activated.
Experts' thoughts/Issues to tackle
In spite of the positive impact of the initiative, it has increased the burden on many health service providers especially in the public health centres. This is due to the increasing number of pregnant women reporting to the facilities daily, an inadequate number of health professionals, infrastructure and logistics to support the system as reimbursement problems also persist.
That notwithstanding, experts such as the Head of Department of the Obstetrics and Gynaecology, Professor Yaw Kwawukume of the Korle Bu Teaching Hospital and the Health Service Administrator, Mrs. Patience Ami Mamaattah of the Tema General Hospital believe the current situation is better than having to refuse pregnant women care for lack of finance.
In their view, it is still better to have women deliver safely and even not have access to bed afterwards since the most important thing is for pregnant women to have access to services promptly. They were however quick to add that the initiative would reduce the incidence of women lying on the floor because most of them would be discharged unlike previously when they were detained for non-payment which created problems of congestion.
They further indicated that upon the start of the new initiative on July 1, this year, those who were initially detained for non-payment were discharged and in Mamaattah's words, "it was a loss to the hospital but it is government's policy so there is nothing we can do about it."
Meanwhile during a recent tour of some health facilities in the Greater Accra Region to access the level of compliance of health care providers, the Executive Director of the NHIA, Mr. Ras Boateng said the Authority was aware of the existing problems, especially that of reimbursement.
According to him, the problem was not as a result of lack of funds but rather due to the structure and manual process involved in dealing with claims. To address this, he indicated his outfit was working to build a technology platform by which claims could be made electronically to ensure a faster process of payment.
He also believes that the initiative provides a better alternative to the situation where women were turned away from health facilities or detained after delivery for lack of money, saying, "Ghana is the only country that has attained such a fast rate of NHIS implementation within three years."
"The pressure will come but should we say we have problems so we should not give free care to people?" he asked rhetorically and stressed that the health of the card bearing member is improving while pregnant women would have safe delivery as well as healthy babies.
Further, he urged all to help ensure compliance of the President's directive to ensure its sustenance and promote the health of Ghanaian women, and save them from preventable deaths, adding, "We must ensure our future health since the healthier the economy, the better the economy."
Considering the fact that sound health creates opportunities for jobs, he stressed the need to create the right environment for people to create employment opportunities, saying, "now those who previously give birth at home are going to the hospitals and so midwives will now have the opportunity to establish their own facilities to meet the rising demand."
In spite of this, Dr. Aboagye wondered why only about 92% of pregnant women visit health centres for ante-natal care, 18% are delivered by untrained traditional birth attendants, 9% are delivered by relatives and others, and 6% deliver by themselves.
He attributed problems associated with maternal deaths to delay in deciding to seek care at the household level due to lack of information and inadequate knowledge about danger signals during pregnancy and labour, cultural and traditional practices that restrict women from seeking health care as well as lack of money.
There is also delay in accessing health facilities due to distant health facilities, poor roads and communication network, poor community support mechanisms and delay in receiving health care at health facilities because of inadequate skilled attendants, equipment, supplies and drugs as well as poorly motivated staff and weak referral linkage.
Way Forward
Dr. Aboagye noted that to reverse the trend and attain the MDGs, the country must be able to reduce the current maternal mortality ratio by 75% that is 54 per 100,000 live births by 2015, which will amount to a gain of about US$140 million.
To achieve this, he said the Community-based Health Planning and Services (CHPS) strategy must be implemented in all disadvantaged districts, strengthen referral system, provide ambulance services for all essential obstetric care facilities and provide radio communication equipment to all levels.
That notwithstanding, he called for improved access to family planning services and the need to form partnerships with private health providers to improve access and improve skilled attendance as well as "improve access to high quality delivery services including improving attitude of health workers through capacity building."
In view of the fact that the problems mentioned contribute largely to the soaring and worsening state of maternal health, it is important especially for the GHS, Ministry of Health, NHIA and other relevant stakeholders to seek other forms of interventions in addition to the free medical care necessary for the attainment of MDG 5 within time and save the lives of our women and children.
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