Last Saturday night around midnight, I was standing in the middle of a street in Tamale, trying in vain to beg or bribe a taxi driver to stop and take a dying man to the hospital. I hadn’t seen the motorcycle collision that injured this man and one other, but the small crowd, the battered bikes, and the bloody, limp bodies told the story clearly. My makeup, blond hair (combed for once), and red dress, which correctly marked me as a foreigner on my way to a dance club—normally very desirable fare for a taxi—suddenly carried little cachet. As multiple taxis turned me down, two of the man’s friends began a futile and possibly fatal attempt to load him onto the back of the motorcycle. His neck and limbs flopped sickeningly as the motorcycle sparked to life and died repeatedly.

In the end, the only way we could convince a driver to take the man to the hospital was to have a white person accompany him. A friend of mine drove ahead of the taxi on his own motorcycle, carrying one of the man’s friends. We paid the driver four times the going rate. As they drove away, a woman watching the scene remarked to me, “Of course the taxi driver can’t take the man. When he gets to the hospital, they will hold him responsible and make him pay if the man can’t.”

Welcome to a world where individuals have the liberty not to have health coverage, and face the consequences for how they exercise that liberty. In Ghana, you don’t get treatment—sometimes even life-saving treatment—until you prove you can pay for it. Doctors will sit and watch you bleed while your friends and family cobble together money for payment, or rush to renew your health insurance policy. I once saw a four-year-old boy delivered to a rural health clinic after he ran onto the highway and was hit by a motorcycle. There was nothing the clinic could have done to save him. His mother spent his last moments not by his side, but running desperately through the village to get his insurance card.

The issue of allowing indigent or liquidity-constrained individuals (those who could pay back their medical bills over time) to die aside, the serious economic issue here is that when the default assumption is that people cannot pay for health care, there are negative externalities that mean even those who can pay for care may not get it promptly, and as a result, may have worse outcomes.  A man with thousands of cedis in his account should be able to get a taxi to the hospital; he should not be left on the road because the drivers fear he will be turned away on the hospital steps. A child with insurance should be treated promptly; he should not be left bleeding on a clinic table while his mother runs for proof of insurance.

Those who support universal health care, or an insurance mandate, should not fail to recognize the costs, in terms of our government budget deficit, burden on the poor, and loss of economic freedom.  However, those who are opposed to it should recognize the full costs of that liberty as well.

 
 
Picture
The heavily-fortified Ivory Coast border
Some of my respondents are in Ivory Coast. They end up in our sample because they have visited health facilities in Ghana.

Why do Ivoirians come to Ghana for health care? Ghana has a very affordable national health insurance program. It’s not easy in rural areas to verify who lives where, so Ivorians in border areas occasionally sign up for health insurance, reporting that they live in a village on the Ghanaian side. Sometime they even give a typically-Ghanaian name, in place of their French-ier real one.

This is bad for Ghana’s government budget, but it’s bad for us too, because it means that we are trying to find respondents with fake names, and we don’t even know what village they come from. Our typical strategy is to go to the handful of villages near the border, ask for anyone who might have visited the Ghanaian health facility, and see if they are the person we are looking for.  You can imagine, when we walk in and essentially ask “So anyone around here defrauding Ghana Health Services?”, how many people yell “Me, me!” Surprisingly, though, we actually find people.

I spent one day serving as moto driver for one of my surveyors, Nana, in the border area. The road was rough—in many places impassable by car—and the surveyor had never been on a moto in his life.

When we first arrived at the health facility, still in Ghana, I asked the surveyor how far it was to the border, expecting it to be maybe a mile or two.  He pointed to a spot two meters to my left.

We crossed into Ivory Coast about three times that day.  Most of the borders weren’t even marked. There was one border crossing where a couple of Ivoirian border police were playing cards. They were happy to give us directions to the Ivorian village we wanted to visit.

Once across the border, not much changed, except that people in rural villages spoke French the same way they speak English in Ghana—that is to say, not much.  I was able to communicate more with my tiny bit of Twi than with my more extensive (if badly pronounced) French vocabulary.  Nana, fluent in Twi, was fine.

The day ended with several unfruitful hours looking for “Sabrina”. I felt pretty good though. On the drive home, I smugly told Nana that there were not too many PAs in IPA who would have driven these roads and asked for directions in French and Twi. He winced and rubbed his seat as we hit a bump, and I am pretty sure he wished he had been with one of those other PAs.


 
 
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Birth years of women attending ANC:  The oldest was born in 1970, the youngest in 1999.

Educational attainment of women attending ANC: Most have no school; only one had been to high school.

How women attending ANC got to the clinic: Women come by walking, tro tros, bicycle, riding on the back of motos, and canoe.  In today’s data, the extreme athletics award goes to a woman, 8 months pregnant, who walked 180 minutes to get to the clinic.

 
 
In Kusa, a mosquito bednet is called a "doomsdog".  The literal translation is "mosquito room".  The words in several other Northern Ghanaian languages are similar, translating to "mosquito room" or "mosquito house".

Apparently, this terminology can lead to some confusion. I recently heard a story about a farmer in a net distribution program. He was visited by a program officer conducting random checks to see if the net was in use.

When the program officer arrived, he found the net hanging outside, and the man sleeping in his house, netless. When he asked the farmer for an explanation, the farmer gruffly responded:

"Ahcht! These stupid salimingas don't know anything.  I hung the net and all the mosquitoes still come to me.  The mosquitoes don't go to their room at all!!"
 
 
One thing my survey sought to measure was the respondent’s perceived risk of falling ill.  We expected this to be tricky, because many of the respondents are not highly number literate, and most have no concept of probability.  This was easily the most challenging part of our survey to design.

We tried to model our question after surveys that had been done in other developing economies, as detailed in Delevande, Gine and McKenzie.  These surveys asked respondents to allocate piles of stones to different pots, depending on how likely they thought different amounts of rainfall were.  The advantage of this is that the respondent does not even need to be able to count, he or she can just compare quantities, and see that one is larger.  Also, the respondent can easily make marginal changes, moving a few stones to a different pot, if you change the conditions of the questions slightly.  We adapted our questions to ask respondents the probability they would get sick over the next month.

What sounded like a simple and elegant model turned out to be an incredible struggle.  The responses we got failed basic logic tests as often as not; for example, respondents would predict a higher risk of getting sick once in the next month than once in the next year. After rounds and rounds of piloting, and consulting everyone we could think of, we identified the major problems, and attempted to address them:

1.       People don’t like to say they will get sick, because they think it will then happen.  We addressed this by changing our question to ask about the probability someone as healthy as them would get sick over the next month.  This seemed to help.

2.       “Chance” and “likelihood” don’t translate well in Dagbani.  We did our best to write the questions in English so that they would be as simple as possible, and then carefully worked through the Dagbani to find the clearest translation.

3.       People have little concept of marginal changes in probability.  In northern Ghana, something is either certain to happen, certain not to happen, or may happen (50-50).  Our weather reports, forecasting 40% chance of rain, would make no sense here.  Conceptualizing one thing as more likely than another, or conceptualizing small changes in risk, is completely counter-intuitive.  We never completely solved this problem.

4.       People don’t like stones.  Natural objects, like stones or beans, are associated with witches’ fortune-telling, which people don’t like.  And here we were asking them to predict future sickness with stones.  We switched to bottle caps, which as a man-made object, are less threatening.  My friends in Tamale drank beer very diligently and enthusiastically in the weeks leading up to my survey in order to provide the 720 bottle tops I needed. 

As a result of continuing problems with #3, this section proved to be the most difficult in our survey.  It was only a few questions long, but the time it took to explain the concept, go through examples with the respondent, and work through the questions added up to nearly 30 minutes, almost a third of the total survey.

 
 


This week, my team will be completing our baseline survey.  This is quite a landmark achievement for us.   We pioneered a team structure my organization has not used in this region before, relying on talented temporary staff to serve as field managers overseeing survey operations in each of the four regions we worked in.  The project manager and I rotated between the locations, monitoring progress and paying surveyor salaries.  We administered a 1.5 hour survey to 1500 respondents, in at least 7 languages, using 60 surveyors.  We did it in a month, not counting our piloting and census.

During the survey, I have taken a hiatus from blogging, despite the fact that my survey has generated some material worth sharing.  For the next couple weeks, expect to see stories about my surveying experience:  the Survey Chronicles.

 
 
Last week, I managed to get an infected scratched cornea in my right eye.  I am now doing much better, and my doctors are predicting a full recovery, but the process I went through to obtain treatment offers a great deal of insight into medical care in Ghana.  Here is the story:

On Sunday evening, what I had thought was typical contact lens irritation became very red and painful, to the point where I slept with an ice pack on my eye.  By Monday morning, I realized that I likely had either a scratched cornea or an eye infection.  I took a taxi to KABSAD Scientific Hospital, which is not actually a hospital, but rather a small clinic favored by ex-pats in Tamale because it is fairly clean, admits cash-and-carry patients with relatively little paperwork, has an actual MD on staff, and will let you do your own malaria tests.  I arrived at KABSAD at 8am, and was informed that the doctor would be there any minute, and then he would decide whether they could help me, or whether to refer me to Tamale Teaching Hospital.

An hour later, the doctor had still not arrived at KABSAD, so I took a cab to Tamale Teaching Hospital.  I wandered around the hospital with one eye open until I found the eye clinic.  They informed me that I needed to get a folder from the OPD before they could help me.  I wandered around the hospital with one eye open until I found the OPD (which, by the way, I still do not know what stands for.) 

The OPD appears to be the single biggest bottleneck in the Teaching Hospital’s services.  Everyone who is there for anything must first go to the OPD.  There, they must supply personal information, including name, age, phone number, address, and religion (which sounds completely irrelevant, but as you will find out, is not.)  You must also tell them what services you will use—before you ever get a diagnosis—so you can pay for them.  Luckily for me, I knew I needed a consultation at the eye clinic.  Also luckily for me, I happened to befriend an off-duty male nurse named Awal.  Awal helped me procure my folder and pay for my eye consultation.

Awal then took me back to the eye clinic.  Before seeing the ophthalmologist, I had to first see the eye sight nurse, who made me read off letters on an eye chart, and tsk-tsked at my poor vision, apparently oblivious to the fact that my right eye was red as a tomato, barely open, and dripping tears all over her precious eye paddle.   Next I got to visit the “eye open”, which quickly became my favorite stop, because an elderly nurse, exuding competence and humming church hymns, put soothing drops in my eye that made me feel considerably more comfortable.  Finally I got to see the ophthalmologist, who looked in my eye, then sent me back to the “eye open”.  Again I got soothing drops, but this time the humming nurse betrayed me by following them up by putting a stick in my eye.  The stick must have had some type of dye on it, because after that, three nurses, Awal, and the ophthalmologist gathered around to look at my eye and make interested-sounding noises.  They then bustled me out of the “eye open” and back to the ophthalmologist’s room. 

The ophthalmologist explained that my eye was cut; that I had an ulcer in it.  I interpreted this to mean that I had a scratched cornea, which I took to be good news, because although they are painful, they usually heal quickly and without complication. “Good,” I said, “so it is not infected?” “No,” said the ophthalmologist, “it is also infected.  We will give you medicine.” 

Of course, I then had to first pay for the medicine, and then go get the medicine, and then bring it back to the “eye open.”   At the “eye open”, the humming nurse applied antibiotic drops and a soothing ointment, and then put an enormous bandage over my eye.   The bandage didn’t quite succeed at keeping my eye completely shut; I do not think the nurse was used to working with people whose noses are quite as pointy as mine.  I left feeling a bit better, but with limited vision, at 12:30pm.

I should note that, as long as these steps took, two things enabled me to care more quickly than the average Ghanaian would have.  First, I was paying cash for the services, not using health insurance, which would have entailed more paperwork and longer lines.  Second, Awal somehow managed to get me to the head of every line, from the eye sight clinic, to the “eye open”, to the ophthalmologist’s office, to the pharmacy.  I felt a little bit guilty about this, but at the time my eye hurt badly enough that I didn’t really care.  In retrospect, none of the other patients appeared to have conditions in need of immediate attention—the only person who objected to my speedy admission was a man concerned about missing the bus.   I do wonder how someone with a true eye emergency would fare: would a guy with a stick stuck in his eye have to wait in line to read an eye chart before seeing a physician?

The first day after my eye was treated was generally miserable.  I had been given pain medication, which turned out to be ibuprofen.  I had been holding out hope for codeine.  I seriously considered treating myself in the “traditional” way, and if I’d had some vodka on hand, I probably would have put away a few shots.   Fortunately, my body was being cooperative after a stressful day, and I was able to sleep through the worst of it.  The next morning, the pain had improved, the humming nurse changed my dressings at the hospital, and I shuffled back home to go back to sleep.  My friend Kris brought me some groceries, and despite my reduced depth perception, I was able to cook a fine dinner of poached guinea fowl eggs, toast, cheese, and boiled carrots with no mishaps.  .

The next morning found me sitting back in the “eye open”, as the humming nurse removed the bandages from my eye.  Again, two nurses, Awal, and the ophthalmologist peered at my eye, and made pleased-sounding noises.  However, although my eye looked better, it wasn’t doing so well at seeing.  When I closed my good eye, I found that looking through my right eye was like looking through a fogged glass—I could see light and some shapes, but little else.  I asked the ophthalmologist why my vision was blurred.  He peered at my eye, and declared I had some scarring.  I asked if it would improve, and he said that it might, as it healed.  I asked if anything could be done.  The humming nurse flipped through my chart, and noted that I was Christian.  “You can go to any church in Tamale,” she said, “and they will pray for your eye.”

I took that as my cue to go not to church, but to Accra.  (Accra has taken on mythic proportions to me living in Tamale.  In Accra, you can buy sushi, blue cheese, a new eye, and possibly baby unicorns.

Since the next-day flight to Accra was full, my boss arranged for me to drive to Accra with several of the PhD researchers who were visiting Tamale and were planning to drive back to Accra starting that afternoon.  We stayed the night in Kumasi, at a very nice hotel.  One night cost me the equivalent of one month’s rent in Tamale.  I was actually fine with that, since it was still considerably less than the cost of an airplane ticket.  However, I was a bit annoyed when the AC in my room didn’t work.  I slept fine anyway, but in retaliation, I stole the soap.

I arrived the next day in Accra.  By the time I was able to hire a taxi to take me to the well-reputed Emmanuel Eye Clinic, it was 2:30.  To my surprise, the clinic was closed, except for a receptionist who booked me an appointment for the next day: the doctors only work in the morning.  Since my eye sight had improved over the past day, I was not too concerned about the wait, but I made a note to tell my father that if he ever gets tired of being on call on holidays and weekends, he can come to Ghana, work half a day, five days a week, and drive a very swanky car.  (Note: no one has ever had fewer ambitions to drive a swanky car than my father.  Maybe a swanky bicycle.)

I returned to the clinic the next day at 10am.  Emmanuel Eye Clinic is very efficient for those who make appointments, but appointments seem to make up only a small share of the clientele.  Getting in to see the ophthalmologist, getting my eye dilated, and picking up my new medications took only a couple hours.  The news was good: the ophthalmologist said that the scarring on my eye would not obscure my vision, and that in time all of my sight should return, although I might have some permanent light sensitivity.  This news was a considerable relief.

I did have one further complication: my eye remained dilated for about 50 hours (3 to 4 is the norm).  Apparently this happens to some people, and it is more common among those with light colored eyes like mine.   Still, I wonder if the eye clinic uses a particularly strong dilator, since most of their clients have very dark eyes.

I returned home to Tamale after taking a day to relax in Accra.  My vision in my right eye is still a bit blurry, but I am continuing with my medications, and it seems to be slowly improving.  I seem to have been lucky in a number of things: the location of the scarring on my eye, the fact that I know a good deal about health care providers in Tamale as a result of my research, and not least of all, my coworkers, friends and family who provided support for me:  Jessica for getting me to Accra, Lana for checking in with me each day, Kris for bringing me food, Ryan for hosting me in Accra, and my parents for taking my calls at ungodly hours of the night.  Thanks for everything!

 
 
Today I spoke with a woman who said she did not have health insurance because she had family members who would pay for her treatment if she got sick, but those same family members would not pay for her insurance premium.  Unfortunately for the national insurance scheme, this sounds perfectly rational to me (at least from her perspective; not the family members').

Another unfortunately rational decision: not re-enrolling each year.  The way the scheme is implemented now, if you enroll once, but fail to re-enroll the next year, you get coverage immediately at any time by just paying the premiums you have missed.  Many people only re-enroll when they are sick, and the treatment cost is more than the missed premiums.  This makes perfect sense, so why would anyone do otherwise?  As long as people can do this, this poses a problem for the sustainability of the scheme-- if the only people who are enrolling and paying premiums are the people who are getting sick, the scheme will never be able to finance itself.
 
 
One of the health care providers I visited today offered to sell me his hospital.  I told him that we would not be able to run it as well as he could.

On the other hand, my organization has already acquired a monkey named George for 8 cedis (about $5), so why not add a hospital to our collection?
 
 
I am spending this week visiting health care service providers in Tamale, in order to find out more about how Ghana's national health insurance works.

Ghana's national health care scheme is supposed to be open to anyone.  The cost is low (although I am still trying to figure out the exact price; I suspect it varies by region), and some groups, including pregnant women and the very poor, get coverage for free.

My first couple of stops were at pharmacies, and what I found out about how they deal with insurance was fascinating.  Like Medicaid and Medicare in the United States, Ghana's national health insurance plan does not reimburse service providers at the same rate as private insurance, or the rate that would be charged to those with no insurance.  The national health insurance may reimburse pharmacies at perhaps 75% of the market price for many drugs.  To make up for this, pharmacies require patients to "top-off"-- to pay the difference between the market price and the insurance price.

Although this difference may only be 25 cents or so, many people cannot afford it; those who are covered for free are usually so poor that they cannot buy food. Another alternative is for the patient to accept a smaller quantity of the drug, while the original quantity is reported in the insurance claim. (I'm not an expert, but I'm pretty sure that would constitute Medicare fraud in the United States.) Finally, in some cases the pharmacist will give the patient the medicine without requiring the top-off, and the pharmacy will take a loss on that transaction.

The National Health Insurance Authority expects pharmacies to behave as health providers in the United States, and accept the prices they are given.  However, Ghanaian pharmacies are required to accept insurance, and for many, a large share of their patients use the national health insurance.  They could not survive on the prices set by the national insurance.

I have heard that the prices are too low because the price list is not updated frequently. I do not know if this is true. Raising the prices will certainly make the already-struggling insurance scheme more expensive.  It may be that a co-pay on drugs could even make sense.  However, it will not work for the poorest of the poor, and pharmacies should not be alone in bearing the cost of providing medicines to these people at below market rates.