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Challenges with NHIS hindering quality malaria care, other basic health services

Deprived communities and vulnerable groups are contending with various challenges related to the National Health Insurance Scheme (NHIS) as they try to get access to basic health care, a situation that is undermining the country’s efforts to scale-up effective malaria case management and also accelerate Ghana’s march towards universal health coverage (UHC).

Health authorities are putting in efforts and resources to promote quality, accessible and affordable health services for various conditions such as maternal and child care, acute respiratory tract infection, malaria, diarrhoeal disease, anaemia and typhoid fever, but there is an urgent need for the strengthening of the NHIS on all fronts, to support these efforts.

For instance, as part of these efforts, managers of the country’s malaria control programme have set a target for achieving in 2020 a reduction of malaria morbidity and mortality by 75%, through proper diagnosis of all suspected malaria cases followed by prompt and effective treatment of 100% of all confirmed malaria cases.

Therefore resources are being directed at supporting health facilities to get clients tested first before treatment. This is part of the current national and global policy to provide quality malaria case management, which involves diagnosis through the laboratory or rapid diagnostic tests (RDTs) to ensure that health providers can distinguish between malarial and non-malarial fevers, for appropriate treatment.

Although a lot of the private retail drug outlets are still treating malaria presumptuously without conducting any tests, so far it appears many health facilities are doing far better in making the test before treatment policy a reality on the ground.

This should make it easy for many Ghanaians with the NHIS card to get access to free treatment for malaria with proper diagnosis, at any NHIS accredited facility.

However, getting access to this quality care is currently a huge challenge because the NHIS is not functioning as it should and it is hampering the delivery of affordable and quality health care for many other health conditions and diseases, as well.

The scheme was established to provide free access to basic healthcare services for all residents in the country and to promote equity in health care coverage while providing financial risk protection against the cost of quality health care for all residents in the country.

Challenges

At the moment, the scheme is facing various challenges. Many people are complaining about the lack of medicines or low quality medicines that is being provided under the scheme. It is a problem also for many people to get registered to benefit from the NHIS.

Members of the Tsate community are part of the large community of people who are raising several complaints against the NHIS. They are complaining of the long queues they have to join to get registered including issues of bribery and corruption, which are hindering people from accessing basic health services for various conditions including malaria.

Tsate is a small, isolated and difficult to access farming community in the South Dayi district of the Volta region. It has very few social amenities such as electricity supplies and a junior high school. This community has no hospital, clinic, pharmacy or functioning retail drugs outlets.

Residents therefore have to rely on the Tsate Community-Based Health Planning and Services (CHPS) Compound to access very basic health services for various conditions.

These CHPS compounds are scattered across the country and although they are very low-level government health facilities, they have been established to provide basic packages of critical primary health services including malaria, maternal and child care, as part of interventions aimed at dealing with inequities in the health system and also as a strategy for achieving UHC.

In October this year, a young child, who could be anything between 8 and 10 years, looking pale, was brought to the Tsate CHPS compound. After some examination by the health worker, because this facility has no laboratory, the RDTs kit was used to confirm the presence of malaria, following which the child was referred to the Peki Government hospital, because of complications including anemia.

This CHPS facility is managed by two health personnel who have to attend to between 20 and 25 clients a day. Sometimes this number can go up to over 170 clients within a single month, because the entire community relies on this one facility for health care.

The Tsate CHPS compound is therefore such a very strategic facility for members of the community, when they need to get basic health services for conditions such as malaria, which is at the top of the list of diseases handled by the facility.

The health workers at this facility therefore have to strive to ensure that clients accessing services are given the best care, including providing proper malaria case management by conducting free malaria diagnosis using test kits supplied by the district health directorate at Kpeve, the district capital of South Dayi.

It is a plus therefore that despite the many challenges facing this facility including an overworked health personnel, lack of medicines, poor equipment and other issues related to accessing services, efforts are being put in place to offer some quality health services to ease the burden of people living in this deprived community.

It is no wonder therefore that community members are not too happy with the issues surrounding the unavailability of drugs at the CHPS health facility, especially when they have the NHIS card and expect to be given quality drugs and treatment.

During a visit to Tsate, some community members complained that common drugs sometimes available at the facility include paracetamol, multivitamin and antimalarial drugs.

However, some members also stated that in some instances, when they visit the CHPS compound, it is only paracetamol that is available. They therefore have to be given prescriptions to buy all other drugs.

For majority of rural dwellers, giving out prescriptions adds to the out-of-pocket expenses in accessing health care for basic services, a situation which is very discouraging to quite a number of people.

Especially for those who are NHIS card holders, they expect to get basic health services free of charge without additional costs.

People from Tsate have to travel out of their area to purchase drugs prescribed for them since there are no drug stores and pharmacies within this community. But travelling out to other neighbouring communities to buy drugs comes with additional costs.

Not only is the road network so bad but commercial vehicles come to Tsate only thrice in a week. Coupled with this is the fact that travelling by vehicle out of the Tsate community to a nearby town costs 8 cedis in and out, while going by a motor bike raises the amount to a total of 15 cedis in and out of the community.

As a result of these challenges, resorting to traditional medicine when there’s no money to travel out to purchase drugs is very common in the area.

People from this community are used to relying on herbs such as neem trees, which is a major herbal treatment used for malaria or fever-related issues.  Other herbs they rely on include tea or lemon grass and guava leaves.

They also have other issues related to getting health care. Some of them are claiming  that clients accessing health care at the CHPS compound get better services depending on whether one has the NHIS card or not.

They expressed dissatisfaction saying a client is charged between 30 to 50 cedis, when one does not have the NHIS card and this enables these non-NHIS card holders to get more drugs because of what they are paying upfront.

This means that people with the NHIS card are rather given poor treatment and get few drugs because they have not been charged anything for accessing health care.

The community perception is that drugs which are covered by the NHIS are only meant to “reduce” the impact of illnesses whiles the “potent” ones that will treat illnesses must be bought out of pocket.

According to some of the community members due to this they have decided not to renew their NHIS subscription when it expires.

Again, for some of them even getting registered to enable them secure the NHIS card to, at least, enjoy some benefits comes with a cost.

This is because one has to travel to the district capital at Kpeve where the NHIS office is located, and then join a long queue and compete with others to get registered. This situation they complained is leading to a lot of bribery and corruption since people pay their way to get registered and secure their NHIS cards ahead of others.

For those who cannot pay any bribe, they have to wait in long queues, which means wasting the whole day at the NHIS office.  More frustrating is that sometimes after joining these long queues to register, they are told the machine to get them registered is broken down making registration so very difficult.

Not only is this bribery issue frustrating to the Tsate community members but this adds to the cost of accessing health care since it costs about 25 cedis to register under the scheme, in addition to the cost of transportation to Kpeve, which pushes the overall cost of having the NHIS card very expensive.

Other communities visited at Wegbe Kpalime and Adzokoe-Peki also in the same South Dayi district have the same issues. During interactions, some people in these two communities also complained about how the challenges surrounding the NHIS are hampering the delivery of affordable and quality health care.

Staying on track 

Since malaria is part of the top common health conditions in these area and indeed across many part of the country, the NHIS situation has implication for acceleration towards malaria control and elimination in the country, despite all the efforts and resources being put into the control efforts.

In Ghana, malaria is still ranked as one of the leading causes of morbidity and mortality among children under five years of age.

Therefore health authorities are putting in various interventions to remove the country from its current status as part of the group of eleven countries in the world carrying the highest number of malaria cases.

To improve upon this situation, especially for malaria case management, efforts are being directed at getting the best care for all patients by making sure people get tested first before receiving prompt treatment when they visit any health facility in the country.

For instance, information gathered at the Wegbe Kpalime Health Centre and the Adzokoe-Peki Health Centre, shows an adherence to the treatment policy guidelines through the use of RDTs kits to test although these areas are deprived rural communities.

In urban areas, it is also not uncommon to see government facilities such as the Achimota Hospital in Accra using both the laboratory and RDTs kits for effective malaria case management.

During a visit by the ghanabusinessnews.com, to the Christian Medical Centre and Laboratory Services located in Nungua, Accra, it came out that this facility is even being supported by health authorities to expand the proper management of malaria cases.

Although this health facility is a private one, yet the municipal health authorities at the Ledzokuku-Krowor Health Directorate of the Ministry of Health have been extending invitations to the facility any time there is a malaria training programme.

Additionally, this private hospital regularly receives free RDTs kits from the health directorate to support its efforts to provide proper diagnosis and treatment although it has its own laboratory to also manage malaria cases.

All these laudable efforts to ensure quality case management to control malaria, would however be useless if the NHIS is not functioning properly, since it is creating a barrier to people getting tested and treated free of charge with quality antimalarials.

The NHIS was established to promote access to free and quality health services, and to support the country’s UHC and primary health care (PHC) programmes, therefore until there are improvements in the NHIS, bringing conditions such as malaria under control would be an uphill task.

Last year, the state-owned news outlet, Ghana News Agency, carried a news item under the title: “Ghana receives accolades for progress in universal health coverage.”

The article stated that Ghana is actively implementing UHC by providing formal support to its vulnerable population through health insurance.

It quoted Mr. Kwaku Agyeman Manu, Ghana’s Minister of Health, as making these statements during a WHO-AFRO Regional Committee meeting in Dakar, Senegal.

During the meeting, he had said that active membership of NHIS has increased to about 11 million people, representing 38% of Ghana’s population.

He then noted that despite progress, the scheme is burdened with sustainability challenges, high utilization rates, fraud and abuse of the system by some service providers resulting in high claims cost, premiums not properly determined, administrative and operational inefficiencies as well as lack of clearly defined benefit packages.

According to the article, he gave indications that some measures are being adopted to deal with these challenges including the review of the financing model to secure additional goals, restructuring of the entire NHIS, review of benefit packages, full automation of claims processing, strengthening of quality assurance and internal audit functions in addition to amendment of laws including prosecutorial powers to punish offenders.

Clearly, the minister’s speech is an indication that all is not well with the NHIS. And until various issues are dealt with, achieving the UHC goals and controlling disease such as malaria would take some time, since a number of Ghanaians are unable to pay for the cost of health services without the NHIS.

Mr. Manu had added that the country has endorsed the framework of action for strengthening health systems for UHC and SDGs in Africa, which encourages innovative means to raise funds.

Since Ghana’s objective for the NHIS is to attain universal health insurance coverage and ensure that everyone resident in the country enjoys access to basic healthcare, then every effort must be made to get the NHIS quickly functioning effectively.

By Eunice Menka

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