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Following the announcement by the NHIA during its 20th anniversary celebrations to absorb the cost of dialysis for persons it describes as vulnerable for an initial period from June 2024 to December 2024, there have been mixed reactions. The word “free” is familiar to many Ghanaians, particularly during election season. Since its establishment in 2003, the NHIA has struggled to meet its own expectations.

According to its website, updated in 2024, some of its key functions are: ensuring access to healthcare services for the poor, ensuring equity in healthcare coverage, and receiving, processing, and paying claims for services rendered by healthcare providers. These are three of the 21 functions listed on its website. Admittedly, the authority has not satisfactorily performed these functions after 21 years of existence. This raises genuine concerns and questions about its flowery overture to absorb the cost of dialysis for six months as a temporary measure to address the rising cost of dialysis. The road to hell is paved with good intentions; it is not enough to announce the absorption of dialysis fees without stating how it intends to sustain it.

There are numerous documented complaints about the NHIA delaying payments of claims owed to healthcare providers for services rendered to members of the NHIS. Many healthcare institutions have bemoaned these recurring delays in payments, which have caused significant strain on these institutions. Evidently, the tide is rising vis-a-vis kidney diseases in the country; there is no question about that. In medicine, when you diagnose the problem correctly, the treatment becomes obvious. This commentary does not seek to delve into the apparent factors that contribute to the burden of kidney diseases. Needless to say, illegal mining, aka galamsey, is a culprit. The mountain of evidence of mercury-related kidney diseases obtained from autopsies is not dismissible. The authority quoted an amount of 4.4 million cedis as the total cost of dialysis for the six-month period. Considering the NHIA’s history— and history is very essential in medicine— its sore history of delayed payments of claims, shortage of medicines covered under the scheme, and its operations fraught with incidents of corruption, it begs the question: does the NHIA have the financial muscle to meet such a high financial demand?

The elephant in the room that the NHIA is pretending not to see is that the rising cost of dialysis primarily stems from the fact that there are simply not enough dialysis machines and centers in Ghana. There is nothing bad politics cannot make worse. The tale of how the COVID-19 crisis was handled, when politicians did not know when to vacate their seats for experts and professionals to take the steering wheel, is there for anyone who has eyes and wants to see. If that did not serve as a cautionary tale, then I don’t know what will. It is fair to say that not enough consultation and consideration went into making this decision. Why? There are many unclear terms begging for further clarification. Firstly, the NHIA says vulnerable persons below 18 and above 60 years and all persons between 18 and 59 years are covered. Did the authority come to this conclusion based on existing research data? I am afraid not, as a cursory look at the electronic health records of patients with kidney diseases needing dialysis shows that a significant number of these patients fall between 18 and 60 years. Secondly, the NHIA failed to state if the free dialysis covers patients who fall within the age bracket but suffer from acute kidney injury. These patients do not necessarily require long-term maintenance dialysis but need just one or two cycles of dialysis to reverse an acute injury, unlike patients with chronic kidney disease or end-stage renal disease, as the two are not one and the same. Thirdly, the NHIA also failed to address the inescapable long waiting periods that clients will suffer and how it seeks to surmount this challenge. The cure must not be worse than the disease.

It is important for the public to understand that dialysis is only a temporizing measure for clients with chronic kidney disease or end-stage renal disease until renal replacement is available. Is the NHIA promising free dialysis indefinitely? If not, then the intervention is dead on arrival. If yes, are there plans to enable tertiary hospitals to conduct renal replacements? It’s an all-or-none situation. The NHIA, with all due respect, must explain how it intends to disburse funds to the various hospitals selected for this exercise before committing taxpayers’ money to a frivolous, poorly thought-out project. The NHIA’s operational records are unconvincing enough to gain public trust in its ability to efficiently embark on such a capital-intensive exercise, considering the numerous bottlenecks with the NHIS. If this isn’t well thought through, the existing functional dialysis centers and machines will be inundated and buckle under the pressures of yet another careless, half-baked populist idea that only seeks to pander to the baser instincts of the impoverished Ghanaian whose life is hanging in the balance due to chronic illness. We must be careful not to, for the umpteenth time, afford individuals the opportunity to create a cash cow to milk this nation further dry.

In my opinion, this is a quintessential example of missing the forest for the trees. The NHIA, as a matter of fact, must step on the brakes of its lackluster, supposedly messianic solution to the strangulating cost of dialysis. The NHIA should accept that its response is a knee-jerk reaction and should consider the following: perhaps that may restore public confidence, repair the tenuous relationship between the public and the NHIA, and possibly present a more plausible intervention to the rising cost of dialysis that may set the NHIA on a path to redeeming its lost purpose. The government must show the political will to mitigate the problem. All regional and district hospitals should have functional dialysis centers. There should be a co-pay structure that helps share the burden, as the NHIA has not exhausted its functions.

In conclusion, I urge you to ponder over these words from Russ Roberts paraphrasing Adam Smith. It describes the theory of moral sentiments, where the leader with a scheme to remake society according to some master plan or vision is warned. Such people fall in love with their vision of the ideal society and lose the ability to imagine any deviation from that perfection. They are blind to those who are harmed by that vision or harmed by its implementation. In their zeal, the visionary, the man of the system, forgets that there are certain natural forces that may work in opposition to his plan, upsetting it, upsetting society, and creating unintended consequences.

Robertson A. Ayamga.

Resident Emergency Medicine.

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