Public Agenda (Accra)

1 April 2011

Ghana: 'Cash And Carry' Still With Us

Former Director General of the Ghana Health Service, Professor Agyemang Badu Akosa has bemoaned the continued existence, in many subtle forms, the cash and carry system of health care which the country was supposed to have gotten rid of since 2004.

He said 'cash and carry' in the health system is a great disservice to health care delivery in Ghana.

"It is fundamental that whatever it takes to get us out of the cash and carry system the better. Health financing is pivotal in strengthening health system. Inability to do that hampers everything in the health system."

"In all insurance mechanisms you pay annual premium, why do we in Ghana think that if it is health insurance it can be done?"

He stated that if Ghana is moving to one time premium then the whole bureaucracy of the National Health Insurance Authority (NHIA) scheme managers must be abolished while education goes down well to the people.

"We need to sit and dispassionately discuss the issues. I get worried when public institutions sit down and decide that they are not accountable. They can go on air to say what they like but when they are to meet civil society to discuss they don't come. This is unacceptable".

Prof. Akosa poured out his anger at a national dialogue on universal health care under the auspices of the Alliance for Reproductive Health Rights (ARHR), which representatives of the NHIA failed to attend.

"If we are not prepared to discuss, argue, debate and chart a way forward then we are not prepared to achieve a universal health care. It's sad that we hear it's also difficult to get data from them. It is an indictment. "

He said it is a mandate of the National Insurance Council to find mechanisms to increase money into health and that premiums should not prevent people from coming to hospital.

Civil Society actors are becoming the more certain about the apparent lack of interest on the part of the NHIA in dialoguing with them. When OXFAM, the Integrated Social Development Centre (ISODEC) and other non-governmental organizations launched a report recently in Accra, the NHIA was quick to, on several occasions; described the report as inaccurate and misleading.

However, Mr. Patrick Apoya, a Consultant, has argued that the report is not a research but a policy paper that was written after examining over one hundred documents of institutions such as the Ghana Health Service and the Ministry of Health.

He explained that it is a study commissioned by ISODEC, ARHR and the Essential Services Platform and sponsored by OXFAM to explore the potential for implementing universal access to health care, free at point of use in Ghana.

Presenting the report entitled, "Achieving a Shared Goal: Free Universal Health Care in Ghana", Mr. Apoya emphasized that the aforementioned organizations are advocating for free universal access to health care at point of use because the current system is ineffective, unfair, costly and inefficient.

"Coverage of the National Health Insurance Scheme (NHIS) has been hugely exaggerated and could be as low as 18%. Those excluded from the NHIS still pay user fees in the cash and carry system, and millions of citizens who cannot afford are still excluded from health care they need. Every Ghanaian pays for VAT through NHIS but as many as 82% remain excluded. We must find innovative ways of taking money from things consumed and that are not tied to health or things needed for basic survival."

Again, he said, there is lack of transparency and accountability since the NHIA is responsible for managing a large public budget as well as individual contributions of NHIS members, yet not transparent.

"Confusing institutional arrangements and unclear lines of responsibility undermine the NHIA's accountability."

The introduction of free health care for all pregnant women in 2008 was a major step forward towards achieving universal access, he notes. "As a starting point, government should move to implement its own promise of a onetime premium for all, not for some. If the introduction of cash and carry health care was stage one, the community health insurance stage two and NHIS stage three, it is now for stage four via financing reforms and rapid expansion and improvement of health services."

Government, he further noted, must commit to a clear plan to remove the requirement of annual premium payments, abolish cash and carry in the parallel cash and carry system in public facilities by 2015.

The National Insurance Fund must also be transformed into a National Health Fund to pool fragmented streams of financing for the sector.

On how much a free universal access will cost, he stated that no homegrown comprehensive costing estimate of universal and equitable coverage currently exists in Ghana.

Latest World Health Report states, though, that low-income countries will need to spend a little over $60 per capita per year by 2015 to achieve the Millennium Development Goals.

These calculations, the health consultant argues, suggest that financing universal health care in Ghana can be achieved from two sources: savings and raising additional revenue.

He recommended among other issues that if a single lifetime payment is pursued, it must be ensured that it is a nominal fee and perfectly not more than the cost of the membership card.

"We are not saying kill it now but we must guard against what we have now jealously to make sure it works."

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