This Week's News 7-11 June 2010

3

Hospitals collapsing from unpaid insurance claims
Ghana Web

07/06/2010

Let us give credit to President Mills for isolating the national health insurance for special mention in his second state of the nation address. Let us question his Excellency for failing to assure us that proposed reforms in the legal and regulatory framework of the health insurance will be the panacea to the hydra headed challenges currently facing the scheme.
After visiting four hospitals in four districts and two regions, the severe challenges of delayed reimbursement and its crippling effects on health service delivery are no longer deniable. Of the four hospitals, three have experienced varying periods of delayed reimbursement ranging from four to seven months. Their ability to maintain minimal quality of care is seriously compromised. In some cases, thanks mainly to the policy of cash and carry which continues in mortuary services, there is hope from the dead. These hospitals are now relying heavily on the dead for survival.
Hospital administrators and medical superintendents are tense, sitting on tenter hooks as suppliers are reportedly moving away from supplying the hospitals “because they don’t pay and all our capital is locked up. The mark ups we put on the prices of the drugs do not even compensate for the outrageous delay.” Some suppliers therefore have opted to supply private hospitals on a purely cash and carry basis.
In other hospitals, allowances due health workers have been outstanding for over eight months seriously raising industrial tensions to unbearable limits. “Morale is very low currently, from the highest person in the hospital to the lowest. Infact nothing is being done about it. It is very bad,” confided a doctor. A labour leader confessed, “Some of our members even took loans against some of these allowances. Can you imagine what is happening over these seven months that they haven’t been paid?” While administrators plead for patience from labor leaders, they draw attention to the peculiar challenges faced by hospitals that have a sizable portion of the staff being paid from the hospital’s internally generated funds.
“Last year by this time the Scheme owed us 4 billion old cedis. Today, they owe us 7 billion cedis. Can this be called an improvement in the system?” lamented one administrator. But perhaps, it is the impact on the medical supplies and the quality of health care delivery that are most troubling. “These days, we have to go shopping for drugs and infusions as we can’t buy our full supplies. Just last week, I was in Kumasi where after copious begging, I managed to secure a few infusions to bring here. There was nothing.” An administrator in the Brong Ahafo Region complained bitterly.
A frustrated medical superintendent blurted out, “It is all work work work. No money! The insurance is not paying us. We can’t purchase drugs. What we are doing is that after seeing the patient, we write a prescription for them to go and buy the drugs from the street. It is very bad.” Another hospital was owed 9 billion cedis but seemed to be managing well. Their secret? “We have a well resourced credit union from which we borrow money when the situation becomes unbearable. Can you believe that last year around December 2009 after we borrowed the money, a sister hospital in turn borrowed 17, 000 GH¢ from us to pay the salaries of their non-mechanized staff and to solve other financial problems they were facing? I am really disappointed in the management of the scheme. I thought things were going to improve, instead it continues to deteriorate.”
This issue of patients now being issued prescriptions in the absence of drugs is certainly gaining popularity if a reader’s letter in the Daily Graphic from the Sunyani government hospital is anything to go by.
Meanwhile, a student’s dissertation conducted in two districts in the Upper East region in 2008 clearly establishes a yawning gap between the total reimbursement rate and the total timely reimbursement rate. While the total reimbursement rate which measured the total reimbursement paid by the end of 2008 was in excess of 80%, the timely reimbursement rate which measured the rate at which claims submitted on time were paid on time was less than 40%. The main issue appears to be the significant observed increment in the amount of claims reimbursed by the schemes to the facilities on the adoption of the diagnostic related groupings as a method of billing. This is compounded by the bureaucratic processes involved in securing additional funds from NHIA after a scheme suffers financial distress. Other issues pertain to the capacity of staff submitting and processing claims, impaired ability to use computer software for processing claims, challenges with record keeping etc.
Amidst these known facts, it appears government’s efforts have thus far simply focused on centralizing authority within the NHIA through an amendment of the NHIS Act. The Authority itself has concerned itself with clinical audits, exposure of alleged fraud and attempts to discipline apparently erring scheme and service providers. As laudable as these measures are, let none kid themselves into believing that fraud is solely or mainly what is accounting for all the challenges in the system. It is also not correct to think that many of the hospitals that are owed huge amounts don’t deserve it. Since May 2008 when a new billing method was adopted by the NHIA, the study conducted in the Upper East region has for example revealed a fourfold increment in the claims made by hospitals even after vetting and subsequent deductions by the claims managers.
Where it has been proven after clinical audits that service has been rendered, it is imperative that the NHIS pays up in the absence of its ability to prove fraud and soon too if the facilities are not to collapse. It is crucial also to be guided by the legislative instrument that enjoins the scheme to reimburse submitted bills within four weeks of their submission whatever the auditing processes are. It is also crucial at this point judging from the newspaper rejoinder jointly issued by five hospitals in the Ketu North and Ketu South districts to probe the details of the clinical auditing processes. As these hospitals allege, are audits being conducted and sanctions being applied without giving service providers the opportunity to respond to audit findings? This if true certainly runs against administrative and auditing principles not to mention the grain of natural justice.
Add to these the 59 mainly rural-based health facilities under the Christian Health Association of Ghana (CHAG) that are owed a total of one hundred and forty billion, four hundred and sixty six million, two hundred and ninety five thousand in old cedis (GH¢14,046,629.50) in four-five months of arrears. The clearly outlined sequelae include bank overdrafts, increased costs of service provision and “an acute critical shortage of drugs, medical and surgical supplies for service delivery…” Additionally there is the stark reminder that if the payment of salaries were solely based on insurance reimbursements, the entire health system would have ground to a halt by now.
This is ample warning if nothing at all that all is not well with the current funding system. By all means, amend the law if necessary and conduct clinical audits but to what end really if not to improve service delivery? In the Ketu North district today, the only hospital in the whole district is currently out of the scheme for reasons that may be considered justified or not depending on one’s perspective. It is either the hospital that has withdrawn from the scheme or the NHIA that has sanctioned it. While the scheme and the providers squabble, what happens to the thousands of people in the Ketu North and South Districts who only yesterday relied heavily on health insurance to meet their health care costs? By suspending the five facilities in both districts, is the NHIA calling into question its own claims vetting team that has for years built a harmonious working relationship between claims officers, district health officials and service providers?
The current impending implosion characterized by difficulties in acquiring basic drugs and infusions cannot be the way forward and the sooner something definite and concrete happened to reverse the trend, the better it would be. It is possible to adopt these definite measures devoid of perceived intimidation and threats. If urgent steps are not taken to reverse the despondency and utter helplessness that seems to have engulfed many hospitals and healthcare workers, service delivery may actually grind to a halt way before government’s one time premium payment becomes a reality.
Perhaps, the painful words of one hospital administrator best sum up the despondency. “Everyday, I am promised again that money is coming. I am hoping for the best but from experience, I have leant to expect the worst”

4

Eric Bloch:Reversing the brain drain
Zimbabwe Independent

03/06/2010

PRIME Minister Morgan Tsvangirai’s office has issued a Government Work Programme (GWP), stated as having been approved by cabinet. It sets out stated governmental intents, and critical targets, to be addressed and attained in order to achieve economic recovery, and focusing upon attendant and allied sociological issues.
Although the GWP is said to have been approved by cabinet, recent statements by the president in respect of the mining industry, including threats to dissociate from the Kimberley Process in respect of diamonds, and scathingly attacking foreign investors in that sector, and equally confrontational statements by Indigenisation minister Saviour Kasukuwere and by Justice minister Patrick Chinamasa, and others, casts doubt upon the credibility of that cabinet approval.
Be that as it may be, the GWP is very commendable, and if pursued with conviction, would be significant in bringing about a very long-awaited Zimbabwean metamorphosis. The programme extensively identifies the prevailing economic constraints, and recognises the policies and measures needing special and urgent attention for that transformation to occur.
Of the innumerable issues that the GWP prescribed for urgent attention is that Zimbabwe desperately needs to reverse the intense brain drain that has persisted for more than a decade. The programme notes that “many qualified professionals left for the diaspora because of the rapid and radical erosion of their salaries. However, economic revival is a pre-condition for the attraction of experts and professionals. To this end, the GWP makes provision for providing incentives and opportunities for the return and relocation of skilled and professional staff. It is essential that the country attracts and retains qualified staff in the service professions as well as the rest of the public service. Thus the GWP will seek to offer incentives and other favourable conditions of service for the return and retention of skilled personnel in the diaspora.”
In reality, the attraction and retention of the skilled is a two-way issue. Economic recovery and stability is a prerequisite for that to occur, but similarly it is a prerequisite for achievement of that recovery and stability that such skills be a component of bringing that about (which comes first, the chicken or the egg?). There needs to be a progressive growth in the availability of the skilled, with the development of economic well-being accelerating as that growth intensifies, and as that availability grows, so too will the economic recovery.
The hard fact is that no economy can be viable and resilient without a constant and consistent foundation of the economically skilled. Those skills must be very varied, including technological, marketing and merchandising, product development, administration and management, ICT, quality control, and much, much else. Moreover, they must be supplemented and supported by skilled sociological services to the economically skilled, their employees, their families, and the population as a whole. The very limited present availability of those diversified skills in Zimbabwe today is one of the major contributors to the prevailing distraught state of the economy.
Although absolute statistics do not exist as to the magnitude of the brain drain that has afflicted Zimbabwe and its economy, authoritative estimates assess that approximately four million Zimbabweans live beyond its borders, representing more than a quarter of its population, and at least a third (if not more!) of the employable population.
Of course, not each and every one that has departed was economically skilled, but undoubtedly a majority of them were. They ranged from experienced agricultural workers, to trained and experienced artisans, managers, accountants, engineers, architects, pharmacists, healthcare providers, educationists, and many, many more.
With extremely rare exception, almost all departed Zimbabwe because of the deteriorating economic circumstances, and the massively escalating decline in the sociological environment.

Almost all sought livelihoods elsewhere, in order to support not only themselves, but their families and dependents back home, and to assure themselves of access to education and healthcare for themselves and their families.

Equally, almost all had the declared, genuine intent to return to Zimbabwe once the country had full restoration of economic wellbeing and sociological services. But, as time went by, most have sunk new roots. They have experienced career development and advancement, married, had children, and gained much else, with a result that, despite their patriotic love for their home country, they will never return, other than on brief visits. In the main, only those who are unemployed, those who are victims of xenophobic attacks, and those deported due to non-legal presence in the countries to which they had departed, will return.

Therefore, to reverse the brain drain, Zimbabwe’s course of action requires:

l Rapid creation of an environment of economic growth and stability to an extent that will deter continuation of exodus of the skilled and retention of the limited number of the skilled still in Zimbabwe. This must be strongly reinforced by rapid restoration of primary, secondary and tertiary education, and of health services, to meet the needs of the skilled and their families;
l Urgent and emphatic attention to

remedying and reversing the immense infrastructural deficiencies in Zimbabwe, with especial emphasis upon assured, continuous availability of electricity, water and telecommunications, for the recurrent lack thereof is a discomfort of such magnitude as to be a major motivant to seek to live in alternative surrounds;

l Realignment of Zimbabwean direct and indirect taxation to levels consistent with, or below, that prevailing in other countries in the region, for the magnitude of Zimbabwean taxation is yet another contributing

reason for many to seek livelihoods elsewhere;

l Restoration, unequivocally, of absolute law and order, inclusive of total respect for human and property rights, and of complete adherence to the principles and practices of democratic rule, for these are all environmental

prerequisites of most, the absence of which

being an immense inducement to live elsewhere;

l Major concessions on indirect taxation on imports of personal possessions (including motor vehicles, electrical goods, furniture, and the like) by returning Zimbabweans;

l Extensive recourse to expatriate services until such time as a new and sufficient Zimbabwean skills’ base has been developed, and to such services in order to accelerate the training of Zimbabweans to acquire the skills presently desperately needed.

If the GWP pursues such courses of action, dynamically and unreservedly, then progressively the brain drain will be reversed.

5

Capping doctors’ fees will cause a headache
Money Web, SA

03/06/2010

Government should not be involved in the determination of prices in the private sector, writes Jasson Urbach.

According to recent media reports, Health Minister Aaron Motsoaledi is proposing a cap on the fees doctors and hospitals in the private healthcare sector can charge their patients. If Dr Motsoaledi has been consulting specialists in the private healthcare sector, unfortunately he has been knocking on the wrong specialists' doors. In this case, the specialists he needs to be consulting are economists, not healthcare providers. Healthcare providers specialise in fixing people and economists in explaining why governments should not fix prices.

It is laudable that the Minister is concerned about the nation's health and that he is taking the issue seriously, but the cure that he is proposing will be more harmful than the problem he is trying to address. There is an obvious way to decrease prices in the private sector. Increase competition. But this would require the Minister to put an end to the "old boys club" that dominates the medical fraternity by dissolving the government created monopoly responsible for training doctors in SA. The Health Professions Council of South Africa (HPCSA) determines the number of places available for trainee doctors and has limited them to approximately 1,400 positions each year. A number that has remained relatively unchanged since the 1970's despite the fact that the demand for these positions increases every year. In 2006, it was estimated that 15,794 prospective students applied for these coveted positions.

Everyone is aware of the dramatically increased burden of disease since the 1970's, driven largely by the onslaught of the HIV/AIDS virus. Moreover, South Africa's population has increased from about 24.28 million in the mid-seventies to the current estimate of 49.32 million, an increase of 25.04 million people. Add to this our ageing population, which will require more treatments for chronic ailments in the future and one cannot fail to see that the current shortage of doctors is going to get even worse. It is also exacerbated by a poorly performing public healthcare system that is driving our doctors away. Among the common reasons cited for the mass exodus of skilled healthcare personnel from the public sector are poor salaries, high workloads, poor work environments and few opportunities for advancement.

These push factors result in many healthcare workers choosing either to exit the public sector in the hope of finding employment within the private sector or leaving South Africa to seek job opportunities abroad. According to HPCSA, despite the fact that medical schools produced approximately 19,500 graduates between 1990 and 2005, their records show only 9,304 new registrations during this period. This implies that a significant number of individuals, after graduating, instead of practising in South Africa, are leaving the country. This shortage of skilled healthcare personnel reduces the quality of care for all South Africans.

Fees charged by private hospitals could be reduced if government cuts some of the red tape that prevents private facilities from being established or operating efficiently and effectively. For example, a licence or Certificate of Need (CON) is required before a private hospital can be erected or expanded or even new high value equipment introduced. The intended purpose of the CON purports to be to control the kind of services that may be offered in any particular area. In other words, it is an attempt to match health services offered with the needs of the population on a geographical basis, something that is neither feasible nor economically justifiable.

Certificates of Need are granted for a maximum of twenty years and there is no guarantee that they will be renewed. Because of the time and expense involved in obtaining a CON for medical personnel and facilities, and other long, complicated bureaucratic procedures that delay the introduction of new medical technologies and stifle competition, the cost of healthcare is driven up. The only way these costs can be recovered is from patients. Thus bureaucracy, red tape and a conflicting mix of social, political and budget objectives drive up the cost of healthcare.

Dr Motsoaledi's response of capping the fees doctors and hospitals charge in the private sector will not reduce prices in the long run. A long-term strategy to alleviate the chronic staff shortages requires the government to relax the controls on tertiary education facilities, make entrance to these facilities less restrictive, and allow the private sector to provide a large percentage of tertiary medical education for doctors. Private education facilities could operate on either a for-profit or non-profit basis and would relieve a significant part of the burden currently faced by the public sector.

An unintended consequence of capping private hospitals fees will be capital deterioration of buildings and equipment. Another will be preventing hospitals from expanding in order to meet the growing demand for healthcare. Ultimately, it is the patients who will suffer.

If the Department of Health genuinely has all SA's citizens' interests at heart, it would increase competition in the market by removing the barriers currently constraining the efficient functioning of the private provision of healthcare services. Increased competition in the market will lead to decreased costs and improve the overall healthcare options of the nation. Government should concentrate on fixing the public health sector and leave the private sector alone. Let people decide how and where they want to spend their money.

Dr Motsoaledi told Business Day, "Health is not an ordinary commodity. It's not like if I go to buy a suit and I can negotiate with the person who's selling. If you are sick and your regular doctor says you need an op and it will cost you R2,000, it will be very difficult for you to challenge him, because you may not understand what he is talking about and all you know is that you want to live".

According to this line of reasoning, the fact that healthcare is essential to survival makes it different from other goods and services and therefore necessary for government to intervene. But to the consumer, healthcare is a commodity to be purchased just as other life-sustaining goods and services are. Food is essential for survival and is provided perfectly by the market. And everyone knows that a price cap on a certain food will make that particular food disappear.

Government should not be involved in the determination of prices in the private sector. All healthcare prices, including insurance, medical schemes, medicines, hospital fees and doctors' fees, should be determined by the value judgements of consumers in a competitive market free of barriers to entry.

Apart from the shortages that will result from the introduction of price caps, it is probable that further government interventions will be introduced to respond to all the other unintended consequences of previous interventions. If price controls on doctors' fees are introduced, apart from exacerbating the brain drain, I predict that in order to keep doctors from leaving, government will force our remaining doctors to be enslaved in the public sector for longer periods under the guise of community service or, to put it more accurately, servitude.

Author: Jasson Urbach is a director of the Health Policy Unit (a division of the Free Market Foundation). This article may be republished without prior consent but with acknowledgement to the author. The views expressed in the article are the author's and are not necessarily shared by the members of the Foundation.

6

Scrap Maternity Fees, Midwives Urge Govt
The Herald, Zimbabwe

08/06/2010

Harare — Midwives have urged the Government to scrap maternity fees and intensify training of experts in this field to minimise the number of expectant mothers and babies that die during labour.
According to reports, most public health institutions in the country have an 80 percent staff deficit, which was a cause of concern for professionals in the sector.
In its petition to Government during belated commemorations of the International Day of the Midwife in Harare last Friday, the Zimbabwe Confederation of Midwives called for a review of the hospital user fee policy.
This, they said, would allow many expectant mothers to access maternal health care and expert service during delivery.
The midwives called for increased intake to midwifery training to beef up staff at public health institutions. They demanded that Government provide adequate learning and teaching materials and implement good working conditions, fair incentives and remuneration for midwives.
"Without urgent efforts to address the serious shortage of midwives, women and their babies will continue to die needlessly.
"This would hold back efforts to provide quality maternal services, reduce maternal mortality, avoid morbidity, which may impoverish their health and increase their economic vulnerability for the rest of their lives," reads the petition in part.
Statistics indicate that maternal mortality ratio (MMR) tripled in the last decade.
The current MMR indicates that 725 deaths were recorded per 100 000 live births in 1997. The figure translates to about 2 500 women dying every year of pregnancy related complications.
In response, Health and Child Welfare Minister Henry Madzorera, urged the professionals to be patient as Government looked into their concerns