There is a kind of “love affair” brewing between me and Asaase Radio, the media outlet owned by leading members of Ghana’s ruling party.
The station and its online outlets have taken to inventing things I didn’t say and then responding elaborately, often to suggest that I don’t know what I am talking about.
The latest installment in this saga is this response to a post I made on social media about how poorly thought through the whole Agenda 111 project is.
How I wish that Asaase was interested in genuine policy debate for the benefit of their audience. Sadly, they are not. They don’t publish my work. They don’t engage with the substance. Their preferred approach is to distort everything I say and hope that their readers are too obtuse to discern the facts.
Let us grade Asaase’s latest bumbling intrusion into the health infrastructure development policy arena together:
- The claim that district hospitals in Ghana cost between $32 million and $45 million is presented as if it is a statistical data point. It isn’t. The writer just plucked it from the air. It is true that the Ministry of Health reckons that its model design for district hospitals should cost an average of $32 million.
But this advisory is based on a very precise set of specifications. District hospitals in Ghana vary depending on the project parameters and funding sources.
2. For example, the project most similar to Agenda 111 in recent times was the initiative by the Mills government to build 7 district hospitals through a contract with NMS Infrastructure, which was funded by Barclays Bank. The total cost of that initiative, dubbed “Built to Care”, was initially pegged at $175 million and then subsequently revised to $162.9 million at the time of parliamentary approval. The average cost per project would thus have been $23 million.
3. The NMS projects had specifications that sometimes exceeded what some Agenda 111 hospitals have, making a direct comparison dubious in certain instances. For example, the standardised size of an Agenda 111 hospital is 100 beds. Some NMS projects, like the ones at Fomena and Sekyere Kumawu, were 20% bigger (i.e. there are 120-bed facilities). On a per-bed basis, the cost of the Sekyere Kumawu District Hospital built by NMS would thus come to about $191,000. Even if we accept the $17.9 million per unit price claimed for Agenda 111 hospitals, their $179,000 per bed cost would be quite close to the NMS project costing. But there are other critical factors.
4. NMS projects were commercially funded (i.e. a loan from Barclays Bank was used). The cost of capital would thus be a major factor in determining final costing. Agenda 111 was launched without a clearly identified financing package. So far, it has been funded from general taxation. Should commercial funding be sourced, the average cost will rise significantly since financing expenses would then need to be factored into the calculations.
5. Furthermore, the NMS district hospitals also included specialty modules not found in the Agenda 111 facilities we have reviewed, such as the one at Asuogyaman (Apegusu), which lack the dental and specialised pediatric modules of the aforementioned NMS facilities. Our analysis is that, complexities notwithstanding, a like-for-like comparison between the NMS district hospitals and the Agenda 111 ones would show that the latter are more expensive on a per-bed basis once all amenities are properly accounted for.
6. Disorganised project management can only increase the average cost of an Agenda 111 hospital. Take for instance the Nabdam District Hospital awarded without competitive tender (the project’s hallmark) in early 2021. By mid-2024, even the foundation level had not been completed and the project had to be re-awarded to two new contractors, yet again without tender. It is impossible to see how such a project could avoid substantial budget overruns.
7. The Agenda 111 project at Adeiso was also abandoned after handpicked contractors awarded the project without competitive tender took “mobilisation” (i.e. advanced partial payment) and then absconded. There are reports we are still looking into that a similar situation occurred at Jasikan and in several other locations. Even some of the regional hospitals, the grand jewels in the crown of Agenda 111, have not been spared this confusion. The Koforidua Hospital, a 285-bed facility that is expected to grow into a 600-bed mega-facility, for instance, mostly stalled in the years since launch until in the heat of the 2024 election campaign an attempt was made to breath some life into it. It is still very far from completion, not to talk of operationalisation.
8. In any event, if the $17.9 million average cost was to be taken at face value, it would mean that the total cost of the district hospitals in total would be $1.86 billion. Yet, after over $400 million or so spent, analysts believe that at least $2 billion more is needed to get most of the projects over the completion line. Whilst the Ministry of Health itself believes that at least $7.5 billion is required. Using the Ministry’s figure would suggest average cost per project of over $75 million. Using the lower estimate would still yield over $24 million, and that is not even factoring in all the re-awarding charade and wasted monies we have discussed above.
9. But per unit cost was hardly the main bone of contention in my social media posts that Asaase found so offensive. Rather, at the heart of this entire issue is the financial and operational planning that went into the Agenda 111 project. When it commenced, 21 major health facility projects initiated by previous governments, such as the famous La General Hospital, the Afari Military Hospital, and the Abetifi Hospital, had been abandoned for years to loud protests and petitions. It is inconceivable how any government would set out to build 111 hospitals afresh when so many uncompleted projects and deteriorating facilities are dotted all over the country. Certainly not when it took the country 12 years to raise funds to complete the much smaller NMS initiative (just 7 facilities).
10. That the government rushed into this project primarily because it wanted to dispense juicy contracts is incontrovertible. Even the total number of hospitals was being determined on the fly. Initially, 88 district hospitals were planned. Then the decision was made to increase that number to 101. The current number is 104. Plus two new psychiatric hospitals and 7 regional hospitals. Some of the districts chosen, like Garu and Tempane, even overlapped with those previously prioritised under the NMS Built-to-Care Initiative, showing clear duplication.
11. The Agenda 111 logic of ensuring that every district is given its own district hospital (likewise that every village deserves one dam) may sound smart in the shallow confabs of presidential retreats but is technically bogus. Districts differ dramatically in terms of population size, proximity to other districts with accessible services, and capacity to host advanced medical capabilities. For example, Asokore Mampong has nearly ten times the population of Sekyere Afram Plains. Whilst a district hospital at Asokore is a non-brainer, a polyclinic, at say Drobonso, may well be more suited to the needs and maintenance capacity of Sekyere Afram Plains residents. It is this kind of analytical depth that the ownership of the policy by the Health Ministry could have brought to bear.
12. Asaase quibbles with my assertion that the Health Ministry was not in the driving seat of Agenda 111, yet that point is moot as the initiative has never been captured in any strategic plan of the Ministry before it was launched and, worse, its medium-term expenditure framework does not even contemplate it.
13. Nor is hospital infrastructure in rural Ghana exclusively managed by the government. For example, in Donkorkrom, the Presbyterian Church runs a non-profit 177-bed health facility that is the effective district hospital for Kwahu Afram Plains districts. The decision to position another Agenda 111 district hospital at Tease (“Kwaku Tease”), about 20km away when the existing Presby-run health center at Tease needs to rely on corporate philanthropists like Sikkens to house personnel betrays a remarkably poor capacity for spatial planning and prioritisation. Worst of all, the Agenda 111 facility at Tease is one of those stuck in project doldrums. Scarce funds have been poured into a brand new shell even as existing facilities cry for basic amenities.
13. We have not even talked about the staffing and operational costs of the Agenda 111 facilities should they even miraculously get completed. The answer is however obvious considering the growing backlog of trained health workers that the government cannot post and the perennial piling of debts owed to existing health facilities by the National Health Insurance Authority.
14. With the administration on its way out, after failing to secure funding for between 80% and 95% of the project, after four years of trying, who now has the burden of completing these poorly conceived, crony-enriching, edifices?
15. So, what exactly is Asaase Radio cawing on about, then?