SPEECH DELIVERED BY LADY JUSTICE GEORGINA THEODORA WOOD, CHIEF JUSTICE OF THE REPUBLIC OF GHANA AT THE 13 TH ANNUAL GENERAL & SCIENTIFIC MEETING OF THE GHANA COLLEGE OF PHYSICIANS & SURGEONS ON WEDNESDAY NOVEMBER 23, 2016
Source: judicial_service_of_ghana

SPEECH DELIVERED BY LADY JUSTICE GEORGINA THEODORA WOOD, CHIEF JUSTICE OF THE REPUBLIC OF GHANA AT THE 13 TH ANNUAL GENERAL & SCIENTIFIC MEETING OF THE GHANA COLLEGE OF PHYSICIANS & SURGEONS ON WEDNESDAY NOVEMBER 23, 2016. Theme: Financing Health Care in Ghana: The future of the National Health Insurance Scheme. I have fond memories of my visit to this auditorium nine years ago. I recall that at the time, the Ghana Medical Association was celebrating fifty years of its existence, an event at which I had the honour of sharing a few thoughts with distinguished members of the Association. The uncharacteristic good humour, with which our esteemed medical professionals laced the opening ceremony, did not undermine the thoughtfulness with which they deliberated on grave matters relating to the health status of Ghanaians. At the time, I was still learning the ropes in my new position as Chief Justice of the Republic of Ghana. It is therefore a happy coincidence that barely seven months away to the end of my tenure, providence has fortuitously placed me in a unique position to be in your midst once again, to address the 13 th Annual General and Scientific Meeting of our esteemed College on a subject as important as healthcare financing. Madam Chair, when the invitation came through, I had hoped that at the very least, you would be so kind as to invite me to speak to some matters related to the frontiers of law, perhaps restate the readiness of our Courts to adjudicate fairly and expeditiously on all 2016 election-related disputes. That would have offered me far more comfort. Instead, imagine my consternation on realizing that of all things, I was being invited to address such an august body of luminaries in the field of medical science on the future of the national health insurance scheme. Why doctors will invite my humble self to dissect matters of healthcare financing and the sustainability of a scheme that has at this point attracted heated debate and very strong divergent views is beyond me. All in all, I resisted the temptation to think that a deadly medical trap has been set for me. But if it is a trap, it is one I intend to evade, while tackling the matter head on, Madam Chair. This is because health and healthcare in Ghana, their financing mechanisms and the sustainability of the scheme affects all Ghanaians directly or indirectly, including my good self. It is perfectly right that you have decided to focus on such an important matter of national concern, which matters would ultimately afford the good people of Ghana opportunity to explore various policy options. Under the health targets for Sustainable Development Goal three (3) for instance, specific mention is made of the need to substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries. We know that a healthy nation is a wealthy nation, and so nations all over the world are in a constant struggle to navigate the delicate balance between funding the health needs of its citizens and ensuring at the same time that the funding needs of other critical sectors of the economy are clearly not jeopardised. Madam Chair, on receipt of the invitation, plain wisdom, led me to leave the details of this specialist subject matter to you, the highly knowledgeable medical professionals and technocrats. I reasoned that you have the capability, from a well-informed stand point, to do all of the following and even more; examine and digest the topic, dispassionately explore the issues arising, propose realistic reforms and achievable action plans and offer pragmatic solutions to the various challenges confronting the scheme. As Chair of the General Legal Council, which is the regulatory body responsible among other things for Legal Education in Ghana and the general professional conduct of legal practitioners in our great country, we have, many a time, bemoaned the conduct of ordinary lawyers who mount the air waves, tout themselves as legal luminaries of international renown and speak authoritatively as legal experts on specialised areas of the law. I thought to myself that the worst reputational damage I could inflict on my poor soul is to tread this dangerous path and speak on the theme as if not only were I a top notch medical specialist, but one with a sub specialty in medical insurance financing. And so while I applaud you on the choice of theme, what I propose to do in the time allotted to me, is to make a few general remarks on the subject, in the hope that this would further awaken your consciousness to the important constitutional and legal imperatives of health care financing, its causal effect on economic growth to spur you on to give the matter the urgent attention it deserves. Interestingly, this line of thinking evokes the following pertinent question: is the right to quality healthcare a fundamental human right? Some of the preliminary ideas that I intend to share with you are basic and certainly well known to you. It may be likened to preaching the gospel to the already saved. But over forty years of life in public service, has taught me that it is not too irksome to re- state or re-emphasise matters that may appear rudimentary. Instructively, it is when we have grown weary of going over the same important matters over and over again; because it appears no one seems to be listening or paying attention to what we are saying, that a reminder of some basic truisms refreshes our minds of our responsibility to God and country, and consequently galvanises us into action. And so let me start by acknowledging the debt of gratitude we as a people owe to our medical professionals, who clearly are part of the success story of whatever collectively as a nation, we have been able to achieve by way of development. Why do I say so? There certainly is a correlation between the concept of health in its broadest sense, which I have come to understand as a complete state of physical, mental and social well-being, including the absence of illnesses- and economic growth and development. Health is thus an asset, perhaps the greatest asset in life. Thus, one of the critical reform initiatives we have undertaken in the Judicial Service, is the establishment of medical facilities in Accra and Kumasi to attend to the health needs of not only judges, staff and their dependents, legal professionals, but court users who may find themselves in one medical difficulty or the other, when they attend court, a venture, which as you are acutely aware, is highly stressful. The well- furnished and re-sourced facility in the new forty- two court roomed complex as well as the annex in the Supreme Court Building in Accra, is manned by a medical doctor and a full complement of other health professionals. We thank the Ministry of Health for the support and assistance in this direction. The economic burden arising from illnesses negatively impacts economic growth in the family and by logical extension the national setting. Naturally, a healthy family is more likely to utilize income from both parents, to provide good education for their equally healthy children, whose future is thus assured. It is therefore important that nations craft and implement policies to invest in health schemes for the benefit of citizens either through private medical insurance or state sponsored insurance policies. To put things in context, let me share with you a true story I heard happened three weeks ago. A man by name Kofi, a driver by profession, had noticed two tennis ball sized swellings in his groin. His wife initially guessed that he had hernia. With religious zeal, he refused the diagnosis. But there was something more to his resistance; hernia implied a surgical repair and the repair of two hernias will attract a prohibitive cost, far beyond his means. So he simply refused the diagnosis, waiting for the day his hernia will become complicated and then at the point of care, be required to cough out the full cost of the surgery. Thankfully, good reason prevailed, and he has taken steps to register under the national health insurance scheme. Kofi, is eventually hoping to have his hernia repaired for a fraction of what it would have cost him otherwise, without insurance. And this is if he does not strangulate while waiting the mandatory one month it takes under the law to render his card eligible! This story is important because it cuts to the core of the intent of the financial risk pool that health insurance schemes the world over represent. Madam Chair, we know that the rapid expansion of public sector health services after independence led to an increase in access to health care, which was provided free at the point of use. Declining economic fortunes in the 1970s with attendant underfunding of health services led to declining quality with cost increasingly becoming a barrier to access to quality care. Health care financing then progressed through user fees (out-of-pocket payment popularly known as cash and carry) in the 1980s to the establishment of Community Health Insurance Schemes (a devolved national health insurance scheme) under Act 650 and currently to the centralised NHIS scheme under Act 852 of 2012. Madam Chair, it is worth emphasising that health service provision is a constitutional duty of the State. It derives its legal underpinnings in the 1992 Constitution of Ghana, under the Directive Principles of State Policy, Article 34, (2) which provides: “The President shall report to Parliament at least once a year all the steps taken to ensure the realization of the policy objectives contained in this Chapter; and, in particular, the realization of basic human rights, a healthy economy, the right to work, the right to good health care and the right to education. The State is further charged to safeguard the health, safety and welfare of all persons in employment, and shall establish the basis for the full deployment of the creative potential of all Ghanaians. Article 36 (10). Act 650 and later Act 852 provide specific laws on the establishment and functioning of a national health insurance system. The national health policy is based on the principles of “Health for All” and Ghana’s Primary Health Care (PHC) strategy provides a framework for achieving this. Ghana is a leading advocate of the current global drive towards Universal Health Coverage (UHC) that promotes the two-prong objective access to quality health services (Access) without being exposed to financial hardship (Financial protection). The national health insurance policy framework states that ‘Ultimately, the vision of Government in instituting a health insurance scheme in the country is to ensure equitable access for all residents of Ghana to an acceptable quality package of essential healthcare’. ‘…every resident of Ghana shall belong to a health insurance scheme that adequately covers him or her against the need to pay out of pocket at the point of service use in order to obtain access to a defined package of acceptable quality of health service’.(National Health Insurance Policy Framework for Ghana, Ministry of Health, 2002; 2004) In the light of the above legal provisions, it is commendable to see the strides taken over the years by the National Health Insurance Authority (NHIA). Madam Chair, it is not for nothing that Ghana’s National Health Insurance Scheme continues to win many global awards for its stellar accomplishments. In 2005, the number of people on the scheme was 1.3 million. Over a ten year period, the NHIS membership has increased by over 9-fold or by 850% with coverage for over 95% of reported disease conditions in the country. The NHIA’s database discloses that as of today, 40, 000 people register with the scheme every day. As far as utilization goes, 8 to 9 out of every ten attendees at a public hospital are insured card holders. Millions of Ghana cedis is paid out in claims. Further, various innovations continue to be rolled out by the scheme; an electronic claims management platform which is used for the big-ticket hospitals, instant ID card issuance system, establishment of Claims Processing Centres, biometric registration, clinical audits, and some other interventions. Madam Chair, the above successes notwithstanding, undeniable challenges persist. It would be preposterous to claim otherwise. But let us bear in mind that challenges present opportunities for creativity and success. These are most obvious in the financing of the scheme. The facts clearly show that whereas between 2005 and 2008 revenue outstripped expenditure, with increasing utilization and higher total claims reimbursed to various health facilities, expenditure continues to outstrip income especially between 2009 and 2014. Funding is therefore clearly not adequate at current disbursement rates. In addition, many facilities continue to report attendant undue delays in the prompt payment of their submitted claims beyond the 90 day lag time provided under law. These delays have in turn raised dire implications for the quality of care provided. Madam Chair, the above revenue challenges are further compounded by the following; possible overuse and misuse of the scheme by the insured, Inequities in utilisation for the uninsured, inadequate targeting of the poor and vulnerable in society, undue focus of the scheme on paying for curative services instead of preventive and promotive health services and to an extent, a certain sense of diminished local ownership and sense of mutual risk sharing with the centralization of the scheme. Madam Chair, on the way forward, I wish to advocate three positions. Firstly, we should all welcome the report of the Technical Working Group set up by government to review the National Health Insurance Scheme unto a more sustainable path. Specifically, the recommendations envisaging fundamental design reforms aimed at enhancing equity, improving access to services, and assuring financial protection should be welcome. I applaud the current attempt at corralling bipartisan support for this reform agenda which at its core, advocates for coverage for all for essential primary healthcare package, especially for maternal and child health, while raising the possibility of other payment options. Secondly, I strongly urge the National Health Insurance Authority to encourage greater participation of the private sector in the provision of private health insurance options. The combined effects of the National Health Insurance Scheme, the private commercial schemes and additionally, the private mutual schemes is what will ultimately enable the country’s quest for universal health coverage. Thirdly, may I add my voice to appeals already made to government to find additional resources in the short term to support the NHIA. These additional funds should immediately go to reimburse all those health facilities owed outstanding claims despite timely submissions on their part. Madam Chair, access to quality healthcare with guaranteed financial protection is achievable for almost all Ghanaians. However, there is the need for pragmatic steps, including vigorous sensitization and education on the dangers of abusing the system. That way, we could reduce wasteful use of funds, or plug the loopholes in waste of resources through corrupt and fraudulent practices that drain the scheme of funds, to encourage appropriate use of health services by the population and to raise additional funds. In conclusion, Madam Chair, let us do nothing to undermine public confidence in the scheme through constant negative claims of its total collapse when the facts may not be supportive of these assertions. To the contrary, I will encourage all and sundry to robustly debate the proposals for reforms while making alternate proposals and in our varying small ways helping to sustain the scheme. That would be more constructive and far more helpful to the likes of Kofi and my good self when I am on retirement, who are hopefully, not patiently waiting for their bilateral hernias to become obstructed before seeking prompt medical care. Once again, many thanks for the opportunity Prev