CINDY SHINER, 25 APRIL 2013

Mosquitoes.

A question had been nagging at Ghanaian researcher Alexander Nartey.

Since Ghana’s government had made health insurance available to the country’s poor to ease the burden of health care, why were so many people still paying cash, including those seeking basic treatment for malaria?

The Ghanaian government in 2003 introduced its National Health Insurance Scheme (NHIS), which Nartey called a “pro-poor policy” to help those less likely to be able to pay for health care. The British charity Oxfam in a 2011 report found a number of problems with the scheme, calling it “severely flawed”, but Nartey was focusing on one key question: why weren’t more poor using it when the premium was less than U.S.$10 per year?

With the support of the Dodowa Health Research Centre in Ghana, Nartey set out to find the answer. Because of his research, theAmerican Society of Tropical Medicine and Hygiene (ASTMH) included him in its Young Investigator Awards last year, giving him international recognition by his peers and a $250 cash award.

What Nartey discovered was what he said was a problem within Ghana’s health system - namely a delay in care. Those who used health insurance generally waited longer to receive treatment - standing in line or sitting on a bench until their turn came - but if they paid out of pocket they were treated much quicker.

This, Nartey said, particularly made a difference when people were seeking treatment for malaria. In a 2010 report, Ghana’s Ministry of Health attributed the illness to 33 percent of deaths among children under five and nine percent of maternal deaths - two groups that are especially vulnerable to the parasite.

Most people initially self-treat for malaria and can’t afford high-quality medications, Nartey said. They will go to a “chemical shop” or pharmacy and buy medication, but it probably won’t be the more effective artemisinin-combination therapy (ACT) that is recommended. The Ghanaian government last year began subsidizing the cost of ACTs but, Nartey said, stock-outs often prevent access to them.

“Most of the poor people use these cheaper, generic drugs and the disease comes back more intense,” he said. “Because it is quite intense they are ready to pay any amount and they pay the highest” when they go to the public hospital for treatment. Those who are willing to pay cash are taken care of first.

Nartey said public hospital staff generally prefer out-of-pocket payments to payment through health insurance. They rely on the cash to run the hospital, including buying medicine and other supplies. Part of the problem, he said, is that the government releases money to the hospitals each quarter, and there is often a funding shortfall until those payments become available.

When patients arrive at the hospital, there are two lines: one for those paying cash and one for those with health insurance. The longer that poor people have to wait to be treated, the longer they could be missing out on work, time away from their vending stall or other job trying to earn much-needed cash. Sometimes they will sell an asset, such as a farm animal or textiles, to acquire cash to pay for medical treatment.

Nartey said the average Ghanaian in the rural district where he conducted his research is likely to have malaria four times a year, equaling nearly $50 per year spent on malaria treatment.

“It’s really a big challenge,” he said.

In Ghana the minimum wage is less than $100 per month. In Nartey’s district there is an average of five people per household, and he said it is likely that four of the household members will come down with malaria three to four times a year, costing that household about $200 annually.

“Treatment of malaria alone is going to take 30-35 percent of household income per year,” Nartey said. “That’s a huge burden on the poor.”

He said the challenge is for the government to strengthen the health system in Ghana. One positive step, he said, would be to make ACTs consistently available, including at the private, local chemical shops.

“If they leave the health system the way it is now it is not pro poor,” he said.