Framing a future path for health transparency in Ghana
According to Brian Tracy, “all successful people men and women are big dreamers. They imagine what their future could be, ideal in every respect, and then they work every day toward their distant vision, that goal or purpose.” In his view, the size of your dream can be directly correlated with the extent of your achievement. I have been pondering on this over the past week whilst trying to envisage how to refocus Ghana’s health agenda in this new world where even a decade is an extremely long time.
Healthcare has in the last two decades evolved to a point where it is widely accepted that practitioners irrespective of how experienced or skilled are limited by their brainpower and that diagnosis, prognosis and quality of care all benefit from considerable decision support. These support systems rely on and are considerably underpinned by data. With our disease burden altering, data will become the new determinant of how our healthcare system progresses.
Sadly, our society has been late in coming to terms with this new reality. Starting from the individual citizen, very few of us are conversant with our basic health information. From our average blood pressure readings and any fluctuations thereof, our glycaemic status (sugar regulation) etc. to the information contained in our health records irrespective of whether it’s digital or manual. This lack of interest has led to a situation where health institutions and even the state have ignored the importance of this data to our overall wellbeing.
In the midst of all this, we have become saddled with the fact that over 60 per cent of our citizens do not access healthcare at a primary level annually. This situation though a public health concern has never become a priority. Apart from having an impact on the health and wellbeing of individuals and society at large, it minimises our ability to have accurate data on our primary healthcare. Thus, putting us at a disadvantage in the new charge in improving healthcare worldwide. Though we are all aware of the barriers that lead citizens not to access primary healthcare, the impact of this on our collective health must not be ignored. Even though the threat of heart attacks and strokes stirring us all in the face, personal motivation is not enough to ensure we surmount these barriers that hold us back.
It is therefore important that we explore other options. I will layout a few.
In the midst of all this, we have become saddled with the fact that over 60 per cent of our citizens do not access healthcare at a primary level annually.
In my opinion, the starting point should be the reinvigoration of the National Health Insurance Scheme. Laudable as this scheme is as a social intervention it has never achieved coverage of up to 50% of the population since its inception. Having achieved its highest coverage of 40% in 2015, usage of NHIS by citizens dropped to 36% in 2017 and had appreciated marginally to 36.3% by the first quarter of 2019.
Several reasons could be adduced for this. First, is the fact that most of the money the scheme receives is absorbed by recurrent expenditure leaving less than 10% to be invested. Meaning the usefulness of the scheme both to users and service providers is compromised. Another is the fact that many in the rural informal sector complain of lack of funds to pay premiums. Then there is the allegation of corruption amongst service providers and the high drug bill compounded by the relatively high cost of medicines for the management of chronic diseases.
Though all these are a reality, it cannot be disputed that in our setting, health insurance coverage is probably the essential driver to improving population health and decreasing mortality through the improvement of access and thereby ensuring early detection of chronic diseases. I believe therefore that there must be the utilization of unorthodox means never tried to increase the percentage of citizens it covers.
The first suggestion I would make is to change the current model of outpatient care with one that will be patient-led and rely on community outreach. This could be the first means of collecting patient data into a centralised digital system. This system must be designed with functionality to allow patients ownership to their health records. For me, this is where the first obstacle will be encountered. This is so because the age held misconception by many medics that any records generated in their premises are the property of the facility will have to be debunked. So, will the notion that health professionals know best and may be well placed to hold some information away from patients.
Once this is achieved, through active patient education, the motivation of patients to want to be part of a health database must be leveraged. Amongst the motivational options could be emphasising this new concept of democratisation of health record keeping and explaining how the liberalisation of ownership of their health records could lead to valuable data points for family members even unborn. It would also be important to debunk superstition and to explain clearly that many of the ailments that in the past were attributed to sorcery can be explained away through genetics and a better understanding of a family’s generational medical history.
Though all these are a reality, it cannot be disputed that in our setting, health insurance coverage is probably the essential driver to improving population health and decreasing mortality through the improvement of access and thereby ensuring early detection of chronic diseases.
Should patient and health professional buy in be achieved, the next obstacle I envisage would be the lack of interoperability amongst different health record systems. This could be circumvented in several different ways. The first will be the establishment of a national health centralised database that can be plugged into by different health providers in primary, secondary and tertiary care. Such a system though tried in countries like the United Kingdom affords itself to considerable cost and security concerns. Often, these costs would have to be recouped by the state through taxes; a situation that many objects to. In our setting, it also throws in the procurement angle and the potential for politically engineered state capture. Also, the central control and maintenance by the state have raised eyebrows in some settings. Should this option be discounted, the next will be to invite private providers to build these databases in partnership with health providers but ensure that these systems talk to each other and are not stan alone. Though from a business perspective, standalone systems will be in the best interest of service providers, it will significantly compromise the concept of continuity of care.
If these two obstacles are circumvented the other details around regulation and data protection can be ensured through already existing laws like the Data Protection Act. It will be important that regulators have an understanding of the intentions of system providers from the outset and have the capability to monitor their activity to ensure the integrity of patient identifiable data.
When this in place I see the following opportunities. A clear audit trail for all users of the National Health Insurance Scheme. A decrease in allegations of fraudulent claims made by service providers. A large database that will allow health trends and medicines procurement patterns to be monitored across the country. The potential for a generation with a patient owned comprehensive health record from the womb to the grave. A wealth of medical information that algorithms can research to improve the quality of care we receive and to improve healthcare access. But ultimately convert the nation’s health data into an enviable new fuel capable of driving the new General-Purpose Technology (GTP) that will define healthcare moving forward i.e. Artificial Intelligence (AI).
If we fail the consequences are grave and could convert us in a couple of decades into what historian Yuval Noah Harari has come to describe as the useless class. This is the aspect that scares me. To be successful at this we need to become a nation of dreamers for impossible when split up reads “I’m possible.”
By Kwame Sarpong Asiedu