We reproduce this feature article which was published in the Tuesday, December 8, 2009 edition of The Chronicle as part of our tribute to the late Major Courage Quashigah (Rtd) Certain people who know of my friendship with Major Courage Quashigah were clearly taken aback by the stinging criticism I leveled against him concerning what I characterized as his bungled management of industrial relations between doctors and their employers leading to persisting deep seated mistrust.
Following that critical piece, some associates of the former health Minister impressed upon him to post an equally strongly-worded rejoinder. In so doing, they clearly betrayed ignorance on two core issues; the context of the article and the philosophy of Major Courage Quashigah.
Had they come to me, I could have told them up front that Quashigah would never respond to my piece and this not because he despised me or didn't care about the issues raised, but because of an uncannily deeper appreciation of the turbulent world of industrial relations/politics. It is this uncommon understanding that enabled Quashigah to put distance between his emotions and the legitimate rights of labour leaders to represent their constituency, if even vociferously.
The context was simple. By virtue of the fact that the aim of the piece was to explore how to escape the underlying mistrust between doctors and their employers for a more productive future engagement, it was inevitable that I would by extension focus on those aspects of the relationship that had contributed significantly to the mistrust.
So while people were seething with rage, Quashigah was cool, calm and collected. He understood. Had it been my aim however to cast a broader look at his legacy in the health sector, perhaps, I might have been kinder to my good friend. I may yet be; brutally kind that is!
NHIS & Healthcare Financing
Major Quashigah assumed leadership over the health ministry at a critical time. The NPP had won a second term mandate but had failed to completely replace the much vilified cash and carry system in the previous administration. Under it patients were required to pay at the point of service delivery unlike the national health insurance which had till then only seen hesitant preliminary steps to keep the promise. The reduced access to health care created by the cash and carry system therefore remained a problem.
Although after winning the elections in December 2000, the NPP government initiated a health financing task force as early as March 2001 to advice on a suitable policy and accompanying legislation and programs to replace the cash and carry system with insurance, it was not until February 2003 that the Ministry of Health allocated HIPC funds to support the creation of MHO in all un-served districts.
In September 2003, Act 650 was rammed through parliament despite unresolved technical concerns and raucous protests from organized labour groups and some political opponents. These concerns included questionable proposed premiums, over politicization of the NHIS policy process and a role conflict of sorts between political associates involved in the policy process who had metamorphosed into implementation agents.
When Major Quashigah took over in January 2005, he reportedly “suspended close political associates acting as implementation agents” and later ordered a financial audit into the affairs of the national health insurance scheme.
Also recorded in a documentation of the policy process by Prof Irene Agyepong and Dr Sam Agyei were some administrative changes effected in the management of the NHIS under the Ministry of Health's watch by appointing a CEO in line with public services commission procedure.
This was said to have followed concerns raised about procedures adopted in appointing the first Chief Executive. According to their paper, following these changes, “NHIS policy and programme development and implementation entered a stage of more caution in dispensing with public sector procedure and technical advice in the name of urgency and political expediency.”
As Minister of Health, Major Quashigah must take some credit for the remarkable success recorded by Ghana's health insurance scheme. Registration coverage recorded at 38% in 2006 had shot up to about 60% according to President Kufuor by December 2008.
The significance of Ghana's achievements is put into context by Prof Agyepong who points out that achieving universal coverage especially in low income countries is a real challenge, with countries such as Thailand who have managed to do it exceptions rather than the norm. Despite the problems, considering the rapidly rising insurance coverage and the continued survival of the NHIS, she concludes that “much has been achieved by Ghana.”
Prof A.B. Akosa, immediate past Director General of the Ghana Health Service in an address delivered in August 2007 identified the challenges of the NHIS as lack of sufficient qualified/skilled personnel in managerial positions, poor supervision of District Mutual health insurance, poor claims management leading to a delay in some cases of over six months and increasing incidence of fraudulent claims and proposed a clear separation of the fund management and regulatory functions of the NHIA.
The freshly retired Director General in the same address was very critical of the Quashigah-led administration's release of funds for the Ghana Health Service. He accused the Major of starving the GHS of funds with “most of the agencies on their knees” and stated emphatically that in his opinion “The Ministry of Health is the rate limiting step in the progress of the Ghana Health Service.”! There are those who took on Akosa for raising these concerns only after leaving the post and for not doing enough himself while in charge to positively alter the very system he was criticizing. In an interview, Dr Kofi Ahmed, immediate past chief medical officer faulted Prof Akosa's position which appeared to him to assume that “GHS was supreme” and not appreciating why for instance “monies should be released for the accident centre at KATH although this was approved in the budget” At the lecture however Prof. Akosa pointed out that various representations made on these and other matters had not been heeded by the Quashigah-led administration.
Salaries & Conditions of service
Quashigah and Akosa played various and diverse roles to create a new health sector salary structure in 2006 that saw the abolition of the Additional Duty Hour Allowance (ADHA). To the extent that this new salary structure at the time represented a mechanized marginally enhanced accumulation of the ADHA and the GUSS figures, it was commendable. This is even more so since it put a stop to chronic industrial agitations over delays in ADHA payment. Furthermore, the grapevine has it that the Honorable Minister came under a load of bashing from fellow cabinet Ministers who felt he “had collected all the money for health.”
The Minister's management of the processes of negotiation and the implementation of the new HSSS were however abysmal leading to and perhaps exacerbating an unusually fractious relationship on the health labour front between the doctors on one hand and other health professionals on the other hand.
Today, the sour fruits of that relationship still persist, muted somewhat by an expressed desire by the union leaders to patch up old differences with the National Executive Council of the GMA calling for greater collaboration.
Also unresolved under Quashigah's tenure were the thorny issues of unilaterally abrogated fuel allowance, which though he later reinstated, took little or no action to speed up its payment.
Indeed it would not be until March 2009 when on the heels of industrial unrest by Junior Doctors in Komfo Anokye Teaching Hospital, Quashigah's successor in the current administration would issue a hitherto unheard of ministerial ultimatum to all defaulting budget management centres to honor the over 18 months arrears of fuel allowance to doctors and other analogous groups. It was this that effectively addressed the problem.
The absence of a conditions of service document regulating the terms and conditions of health sector employment was a problem which he inherited and which outlived him.
The Minister's performance in the severely-challenged field of mental health care is best captured in the words of the Acting Chief Psychiatrist, Dr Akwasi Osei. “As far as I am concerned, he appeared sympathetic to mental health but his actions did not prove he was really interested; for two good years the draft mental health bill sat on his table and he had all the opportunity in the world to make a difference but he did not. I guess that summarizes my position on him in matters of mental health.”
Regenerative Health & Advocacy
Perhaps no where was the Minister more visible in his work than in the crusading advocacy and implementation roles he played in the cause of disease prevention and health promotion. In Ghana today, the concept of regenerative health and nutrition is virtually synonymous with Minister Quashigah.
The concept of creating wealth through health as his coinage of the NPP's policy of wealth creation was also distinctive. He used every opportunity to call for frequent exercise, high water consumption, plant-based diets, fruits and vegetables and rest, among others. To give practical expression to these, he ensured that bananas and groundnuts etc and not any sickly salty oily foods were served guests during his tenure in charge. He is also credited with sponsoring large numbers of health and non health workers including traditional rulers, MPs, journalists etc to Benin and Dimona in Israel, to learn about regenerative health.
His critics however fiercely maintain that the resources would have been better spent in building the capacity of the health promotion unit of the Ghana Health Service instead of leading the MOH to directly take over program implementation and thus confusing the Ministry's role of providing policy direction for all the components of the Regenerative Health programmes some of which were already being undertaken by the Health Promotion Unit of the GHS.
He was at the forefront of calls to health professionals especially doctors to become “activist” in their approach to tackling the multiple health challenges of their communities.
His speeches at the Annual General Meetings of the Ghana Medical Association were without exception both well researched and delivered.
At the 48th AGM in Ho in 2006, he would start his address with a warning “My presentation is rated 16. It contains strong and foul language and nauseating descriptions.
Listener discretion is advised.” In an unforgettable speech, he chided doctors thus: “Rightly or wrongly, society considers all doctors as natural advocates on health issues. You have been assigned this elevated status not only because of your public influence.
However, experience shows something else. Most physicians are comfortable with advocating for the needs of individual patients and, incidentally, their own conditions of service.” Stating that individual action was praiseworthy, he insisted that “collective action was the hallmark of professionalism.”
Major Quashigah then issued a clarion call for doctors to become more involved in the health of the public and to accept responsibilities which lie outside the comfort zone of clinical practice including more rigorous health advocacy in the larger public interest affecting areas in policy and resource allocation.
Aspects of his advocacy however came under a volley of criticism from technocrats like Dr Kofi Ahmed who faulted him for “making serious policy-like statements in technical areas he was not familiar with.” Typically, Minister Quashigah is quoted in Tamale in the September 5, 2005 edition of the Accra Mail as suggesting to midwives “to adopt the Ghanaian traditional squatting position for delivery” …explaining that “it is more flexible and easy for women to squat and push out a baby than lie down.”
There are those who argue that given all the above exertions, Hon Quashigah's stewardship or any other health system's performance for that matter ought to be measured with the health indicators of Ghana in mind.
On this score Quashigah himself is damning in his conclusion, delivered at the 50th Anniversary lectures of the Ghana Medical Association. Infant mortality Rate, 133 per 1000 live births in 1957 dropped significantly to 56.6 by 1998 and by the time of the 2006 Multiple Indicator Cluster survey had risen again to 77 per 1000 live births.
Over the same period of 1957-1998, under five mortality rates dropped from 147.8 per 1000 live births to 107.6 gradually worsening to 111 by 2006. These figures typifying stagnation or a decline were described as “unacceptably high” by Quashigah explaining that observed changes were “slow compared to other countries especially in East and Southern Africa and parts of Asia”
By Sodzi Sodzi-Tettey- Ghanaian Chronicle