Update: A graceful apology from the CGD here.: ‘I deeply apologize to Oxfam and its partners and to our readers for the tone of my post. I should have dialed way back on the snark. Mea culpa.’ Kudos to Amanda Glassman for that. She doesn’t give on inch on the issues, so there will doubtless be disagreements in the future, but at least now we can have the argument without the stupid stuff.
I hope regular readers will agree that I generally don’t do shrill – I prefer respectful discussion to puerile mud slinging. But I have the occasional lapse, and this post is one of them, written more in anger than sorrow. I’m a big fan of the work of the Center for Global Development (CGD), as Monday’s glowing review of Charles Kenny’s new book shows, but their health team seems to have been taken over by the policy equivalent of shock jocks – shock wonks? – who on occasion prefer abuse to debate, and ideology to evidence.
What prompts this whinge? CGD’s Amanda Glassman’s post ‘Really Oxfam? Really?’, pouring scorn on a new paper co-published a number of Ghanaian thinktanks and NGOs, along with Oxfam. This comes on top of previous attacks on our health work.
I’d like to take CGD to task on three areas: tone, process and content
Snark sells in the blogosphere (hell, I’m not immune to clicking on a good Easterly-Sachs style punch-up), but at what cost? Firstly of course, if you dish out abuse, you have to expect to get some back, but the downside is bigger than that. It’s a bit like the mud-slinging in the British Parliament (something at which it excels) – people love a row, and it doubtless boosts the blog traffic, but in the long term, it dumbs down complex debates and erodes confidence and trust. Not clever, especially coming from a think-tank like CGD.
Amanda slags off the ‘Oxfam report’ – cue abuse of ‘an international NGO judging a developing country government’s
efforts to provide health care and financial protection to its population in such pejorative and unscientific terms’. Did she fail to notice all the other (Ghanaian) organizations and researchers involved in the publication? (Helpful hint, look at the four logos on the cover, or the author credits on the back page). She did apologise when one of the organizations she ignored pointed this out, but the apology was buried in the comments and went up 5 days after the post – an eternity in blog terms, since most hits occur in the first couple of days.
Actually, I recommend the comments section on the post, which is full of robust defence of the paper, and criticism of CGD from a number of serious commentators, both Ghanaian, such as report co-author Patrick Apoya, and beyond, e.g. a pretty unrestrained post by my predecessor at Oxfam, Kevin Watkins). But the sad truth is that only the determined read the comments, while the rest of us browse and move on, thinking ‘ha! Oxfam screwed up on that one’ (witness this gleeful post from Aid Thoughts). In retrospect we should have insisted on a right to reply post, rather than a comment (I trust CGD would have accepted, and if they want one to this post, they are more than welcome, subject to quality control, of course…..)
CGD accuses ‘Oxfam’ of ‘ignoring or dismissing’ publicly available survey data and research. Actually, that criticism seems to apply rather better to CGD, in that they appear to have skim-read the report at best, before opting to condemn it. I’m not a health or Ghana specialist, but the authors of the report – Patrick Apoya and Anna Marriott – are, and the crux of the disagreement between them and CGD seems to come down to numbers – how many people are actually able to benefit from the scheme? The government says 68% of the population are enrolled, but actually, to benefit from the scheme, you need to renew your card every year, and only 3 out of every 10 do that, so the real number is 18%. The report clarifies that 18% is an estimate and sets out in detail the methodology to arrive at it, before challenging the government to come back with more accurate figures. So far it has not.
For more detail, here’s the rebuttal on the CGD comments section from Leonard Shang Quartey, Convenor of the Essential Services Platform, one of the Ghanaian civil society organizations that published the report:
‘The paper is clear that the NHIA (National Health Insurance Authority) was a welcome and progressive step towards improving access and ‘recognised the detrimental impact of user fees and the fundamental role of public financing in the achievement of universal health care’. The paper was also clear that for its members the NHIS (National Health Insurance Scheme) has brought benefits. Benefits include a higher rate of attendance; better financial protection, as well as the very positive impact on health outcomes for pregnant women in the study to which you refer. Do note however that the benefits you cite for pregnant women are thanks to the government decision in 2008 to make their membership to the NHIS automatic and free.
On the other hand NHIS coverage has been hugely exaggerated and the majority of citizens are not enjoying these benefits despite paying for the NHIS with their taxes. The NHIA has conceded in the latest independent review of the health sector and in their own annual report that their coverage data is an accumulation of all those ever registered with the scheme – not those with a valid membership card at any one point in time. You seem to have missed the clear explanation of why the 2008 household survey cannot be relied upon – not due to poor methodology but due to the fact that at the time it was impossible to distinguish between a valid and an expired membership card. We are transparent about the methodology we have used to arrive at the 18% coverage estimation and welcome the NHIA challenging this estimate with evidence based figures.
Your response appears to condone the status quo while ignoring many of the problems with the current system including unsustainable cost escalation, inefficiency, poor transparency, fragmentation but most importantly the fact that the majority of Ghanaians excluded from the scheme cannot afford to pay the insurance premium on top of the taxes they already pay. In this context your call to the government to enrol more members seems a little simplistic.
You assume that Ghana does not have the fiscal resources to extend access and perhaps you also missed this point in our paper. With efficiency savings, an improvement in the quality of aid, but primarily through improved progressive taxation of Ghana’s own resources we have estimated that per capita health spending could increase by 200% by 2015. Thank you for your suggestion but Ghanaian civil society is not willing to settle for a reduced benefits package when our government can afford to deliver a comprehensive benefits package to all.
In the paper we congratulated rather than condemn the Government of Ghana for their commitment to health but say that much bolder steps are now required to implement their own commitment to deliver free health care for all. We are optimistic that our engagement with the government going forward will be productive in pushing through the necessary changes to achieve our shared national goal of universal health care.’
CGD also misses the key point that Ghana’s health system is actually financed 75 percent by VAT and that this means every Ghanaian is paying for a health system only accessed by the minority who have a valid insurance card.
Do the CGD attacks matter? Not that much – the main issue is the paper’s impact in Ghana, where it has prompted an initially angry and defensive response from the NHIA to what it saw as an attack on the whole scheme (Leonard explained why that is to misunderstand the report). Click here for the NHIA response, and here for our five page, point by point response to the NHIA. Subsequent discussions in Ghana have been more constructive, with radio debates between civil society organizations and the NHIA, and a planned round table to try and get to the bottom of the numbers. So the report seems to have catalysed a useful discussion, at least in Accra.
Beyond Ghana, one reason for the CGD attack is the heated debate over the best way to provide healthcare to poor people – universal free services, or more market-driven approaches? Oxfam and CGD are clearly on opposite sides of that argument. It’s a really important debate, and it’s much better if cases like Ghana’s NHIS are not misrepresented by either side. On the basis of its blog, at least, I reckon CGD is more guilty of that than Oxfam and its Ghanaian partners
Final word to Kwame, another commenter on the CGD blog:
‘Sadly it does seem to me that point scoring was the main intent of your blog, from the title onwards, and that your subsequent rebuttals don’t really add up as [report author] Mr Apoya shows. CGD is widely read and respected, and this blog was to me a real step down from your usual quality.’
Sorry for the length of this post – annoyance is fatal for brevity.