Over the years, it has been the practice in most public hospitals in Ghana that patients, especially those being treated on OPD basis are made to pay for nature’s call (either to urinate or to go to toilet). The toilet and urinal charges at the public hospitals are collected regardless of the number of times one person uses the facilities per visit. Suffice to say that if the OPD patient urinates ten times at the hospital per visit, he or she will pay ten times. In this article, I will delve into the matter from two different perspectives, namely the patients’ perspective and the hospital managers’ perspective. As much as possible, I will try not to take sides and I will not say the practice is good or bad. In the article, public hospital will be a generic name for any public health facility providing curative care. The chief question which we all need to answer is that is it right for public hospital managers to make patients pay toilet and urinal user fees after those patients had paid consultation fees and bought medications as well as paid for diagnostic services such as laboratory tests and medical imaging? I will equally pose some rhetorical questions to help you form your opinion.
Arguments For Patients
Patients who visit public hospitals for treatment especially on an Out Patient Department (OPD) basis are made to pay all manner of charges. As if that is not enough, they are compelled to pay for using hospital toilets and urinals provided for them by the hospital managers.
One would think logically that it behooves public hospital managers to provide privacy for the patients they treat and this privacy accorded the patients should have been inclusive of toilet and urinal facilities placed freely at the disposal and comfort of the patients.
Just as the private hospitals, the hotels, the malls, the public universities and many other organizations do, the public hospitals should have provided their core services jointly with places of convenience for their patients. From the patients’ perspective, hospital managers should not have been charging toilet and urinal fees separately.
Or is it an ethical dilemma for the public hospital managers to charge or not to charge the toilet and urinal facility user fees? Time and again, the topic has come up for discussion with the patient-oriented school of thought that hospital mangers ought to know that the delivery of social services naturally call for the provision of toilet and urinal facilities at the organizational premises for use by customers at no extra cost. In other jurisdictions, public hospitals do not charge separately for toilet and urinal utilization by the patients they treat.
In May 2015, atinkaonline.com brought the matter up again for public discussion and it was carried by www.modernghana.com under the caption, Government Hospitals Charge Patients For Using Washrooms. It was disclosed in that news item that each patient pays GH₵1.00 in a public hospital in Accra for using hospital toilets and urinals meant for the public. In advancing its submissions on the matter however, Atinka News made a mendacious assertion. It stated, “All though the hospitals are supplied with necessary logistics by the government to run these facilities, it is still unclear why these hospitals charge patients for washrooms instead of providing the services free.”
Here, Atinka News got it wrong because the public hospitals are primarily financed with Internally Generated Funds (IGFs). The public hospitals do not get free logistics from government and they do not receive any national budgetary allocations. This is why it becomes very difficult for the public hospital managers to run affairs in times that the National Health Insurance Authority (NHIA) drags its feet in the reimbursement of claims to healthcare providers including the public hospitals.
From the patients’ perspective however, it is argued that it is unethical for the public hospitals to charge the patients extra fees for using the toilet and urinal facilities. The situation becomes extremely difficult for pregnant women and other patients who suffer from urinary incontinence. Urinary incontinence means loss of bladder control or one’s inability to control urination. About five types of urinary incontinence can be identified. They are listed and briefly explained below.
- Stress incontinence: Urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy.
- Urge incontinence: You have a sudden, intense urge to urinate followed by an involuntary loss of urine. You may need to urinate often, including throughout the night. Urge incontinence may be caused by a minor condition, such as infection, or a more-severe condition such as a neurologic disorder or diabetes. If this is the case and the public hospitals treat diabetics, then why must the former charge the latter for washroom utilization?
- Overflow incontinence: You experience frequent or constant dribbling of urine due to a bladder that does not empty completely.
- Functional incontinence: A physical or mental impairment keeps you from making it to the toilet in time. For example, if you have severe arthritis, you may not be able to unbutton your pants quickly enough.
- Mixed incontinence. You experience more than one type of urinary incontinence.
Arguments For Public Hospital Managers
As indicated earlier, the public hospitals are financed with revenue that they generate internally. Central government does not finance the overhead expenses of the public hospitals. As if that is not worse enough, the NHIA usually owes the public hospitals and the debts sometimes accrue for over a year. The public hospitals tend to owe so many hospital commodity suppliers as a result, and this sometimes leads to bad blood between the two transactional parties. Unfortunate situations like this coerce the hospital managers to attempt to make extra revenue from non-core business ventures such as collection of toilet and urinal user fees in order to run the hospitals effectively on a day-to-day basis.
The general public looks up to the public hospital managers for quality healthcare delivery yet the required resources to deliver the services are woefully inadequate. The hospital managers therefore tend to improvise in so many ways to ensure that the hospitals are not shut down.
In 2015, Atinka News reported that Mr. Charles Banafo, a Senior Health Service Administrator of Ridge Hospital provided the following justifications for the Hospital’s collection of toilet and urinal fees from patients. Mr. Banafo said,
- The fees are collected to enable the hospital managers keep the washrooms clean.
- Non- patients such as hawkers also come to use the hospital washrooms as if they are public or community toilets.
- Some of the users of the washrooms do take the T-rolls away and also leave the places in a mess.
- The Ridge Hospital Management’s decision to collect the washroom user fees emanated from the foregoing.
It is clear from the foregoing that the public hospital managers do not just charge the lavatory user fees for fun or just to extort money from the patients. Rather, the prevailing difficult situations compel them to do so. The audi alteram partem principle of natural justice demands that both parties in a case must be given a fair hearing before judgment is given. Similarly, with the two perspectives advanced in this discussion, one may ask the following dozen of rhetorical questions to help the reader arrive at fair conclusions.
- Why must government not ensure that the NHIA pays the public hospitals promptly for services rendered to health-insured clients?
- Why do the patients fail to protest against the payment of the washroom charges if they find those charges unacceptable?
- Why don’t the hospital managers charge in-patients separately for the use of washrooms but they charge OPD patients?
- Is free washroom facility not a mandatory provision for patients by public hospitals?
- Hospital labs take stool and urine samples for various tests so why must the patients pay separately for using the washrooms to submit those samples?
- Are the incontinent patients given special dispensations in the payment of the washroom charges?
- Can’t the hospitals charge for the washrooms indirectly or they are being honest with their patients?
- If the toilet and urinal charges are meant to keep the public hospital washrooms clean, have these places of convenience been clean always at our public hospitals?
- How come private hospitals and the malls in the country do not charge clients for washroom use yet those lavatories are clean all the time?
- Will public hospital managers be fine if they lodge in a hotel or they visit a tourist site and the facility managers charge them separately for washrooms?
- Again, will it be ethical for an airline to collect extra fees from passengers who use toilet facilities aboard the flights or that airport managers will charge fees for washroom use?
- Central government itself charges road tolls yet our roads are bad. Government also collects public toilet user fees so why shouldn’t the public hospitals do same?
Whereas some people think that it is unethical for public hospital managers to charge their patients separately for toilet and urinal use, others submit that it is the right thing to do to keep the hospital lavatories clean all the time. Whether it is ethical or unethical for public hospitals to collect such charges, I am not able to say.
Perhaps the rhetorical questions above should guide public hospital managers to rethink their position on the matter and re-strategize accordingly if they want to continue to charge for patients’ use of hospital washrooms or not.
To this end, I leave the debate and the judgement therefrom in the hands of readers to submit their views. Please do not just read the article but submit your views online in the comment section. Your submissions will enrich the debate.
~ Asante Sana ~
Author: Philip Afeti Korto
Email: [email protected]