….Through intramural services in public hospitals
A concerned health worker has raised questions about the growing use of intramural services in Ghana’s public health facilities, warning that financial incentives could lead to a situation in which patients who can pay extra receive faster access to treatment than those who rely solely on the regular public healthcare system.
In an open letter titled “Open Letter On How Health Workers Profit From The Patients Through Intramural Services,” the writer argued that the growing culture of intramural practice within some public health institutions, especially the Korle-Bu Teaching Hospital, required urgent scrutiny by the Ministry of Health and Parliament.
The writer stressed that public healthcare institutions exist primarily to protect lives and should provide treatment based on the urgency and severity of a patient’s condition rather than on their ability to pay.
“Yet concerns are growing about the expanding culture of intramural services within some public health facilities in Ghana,” the writer, who pleaded anonymity, said in the write-up sent to The Herald last week, Thursday, 28, August, 2026.
More Read
According to the concerned worker, intramural practice could provide legitimate opportunities for specialists and other health professionals to offer services beyond their normal schedules.
However, the writer argued that an important public-interest question arose when the financial incentives associated with such services could influence which patients received care first.
The writer said there was a growing perception among patients and their families that those who were able and willing to pay for special or intramural services received faster consultations, earlier procedures, and preferential access to specialists.
Meanwhile, ordinary patients, including those who depended entirely on the National Health Insurance Scheme and those with limited financial resources, could face lengthy waits for appointments and medical procedures, the letter claimed.
The concerned worker argued that such perceptions alone could damage public confidence in the healthcare system.
“Healthcare should never become a system in which one queue moves because money is available while another stagnates because the patient cannot afford an additional payment,” the writer said.
“The principle must be simple: clinical need should determine priority.”
The open letter also raised concerns about the possibility of conflicts of interest arising where the same health professionals, departments and public resources served both regular patients and those paying for intramural services.
The writer said it would be wrong to accuse individual healthcare workers or departments of deliberately delaying treatment without evidence.
However, the letter argued that the possibility of a conflict of interest should be openly examined.
“If the same institution, department, specialist, theatre, or equipment serves both regular public patients and fee-paying intramural patients, what safeguards exist to ensure the ordinary service is not disadvantaged?” the writer asked.
The letter raised further questions about whether appointment slots could become unnecessarily scarce, whether patients could face prolonged waiting times while faster alternatives became available to those able to pay, and whether difficulties experienced by patients under the regular system could suddenly be resolved once they entered a fee-paying arrangement.
“These are not questions of hostility towards healthcare professionals,” the writer said. “They are questions of accountability, transparency and institutional integrity.”
The concerned worker also raised concerns about what was described as the paradox of patients being told that no beds, theatres or other resources were available while services appeared to be more accessible through special or intramural arrangements.
Ghanaians, the writer said, were familiar with situations in which patients were told that “there is no bed”, while emergency patients and their families moved from one health facility to another in search of space.
The letter said an uncomfortable public-interest question arose when patients and families believed that the same resources said to be unavailable under the regular system appeared to be accessible through fee-paying arrangements.
“There may be legitimate explanations,” the writer acknowledged, noting that intramural services might operate outside normal schedules or under separate administrative arrangements.
However, the concerned worker insisted that such arrangements should be transparent and subject to strict safeguards.
“A public hospital cannot allow a poor patient to be told to wait indefinitely for lack of capacity while the same public infrastructure is perceived to be facilitating faster access for those with greater financial means,” the letter said.
The writer warned that the perception of “no bed for the poor but a pathway for the paying patient” could undermine confidence in the moral foundations of public healthcare.
The open letter further raised concerns about potential conflicts of interest in which health professionals or institutions stood to benefit financially from patients moving from the regular public healthcare pathway to paid alternatives.
The writer stressed that Ghana’s health workers deserved appropriate remuneration for their expertise and sacrifice and that the concerns raised were not an argument against healthcare professionals earning additional income.
Rather, the letter argued that strong safeguards were necessary to ensure that opportunities for additional income did not influence clinical access, appointment scheduling, waiting times or the use of public resources.
The concerned worker called for clear rules separating clinical prioritization from financial considerations.
The letter also proposed that appointment systems be auditable, waiting lists be transparent, and the use of theatres, beds, diagnostic equipment, and other public resources be closely monitored to ensure that intramural services did not undermine care for patients who depended on the regular system.
The writer expressed concern that intramural practice was becoming increasingly entrenched within major public health institutions, including Korle Bu Teaching Hospital and potentially other facilities.
Departments such as Surgery, Anaesthesia, Urology and Orthopaedics, where specialised procedures and limited resources could result in long waiting lists, required particular scrutiny, the letter said.
The concerned worker stressed that the letter was not an allegation that every health professional or department was acting improperly.
The writer acknowledged that many healthcare workers continued to provide exceptional services under difficult conditions but argued that systems could create incentives that placed otherwise well-intentioned professionals in ethically challenging situations.
“A system that allows private financial interests to operate alongside public responsibilities without strong safeguards may eventually compromise even the best intentions,” the writer said.
The letter called on the Ministry of Health to take a more active role in supervising how intramural services were operated and regulated within public health facilities.
Among the questions raised were what national policy governed intramural services in public hospitals, how patients were protected from financial discrimination and what mechanisms existed to prevent fee-paying patients from receiving unfair priority over those using the regular system.
The writer also questioned how public beds, theatres, equipment, medicines, and staff time were accounted for and whether hospital waiting lists were independently audited.
The Ministry of Health, the letter argued, must ensure that patients who could not afford intramural services were not disadvantaged in the timeliness or quality of the healthcare they received.
“A healthcare system cannot claim to be universal if speed and access increasingly depend on one’s ability to pay beyond the ordinary system,” the writer said.
The concerned worker also called on Parliament to exercise greater oversight over intramural services within public health institutions.
Relevant parliamentary committees, the writer argued, should investigate patient waiting times, appointment systems, resource allocation, fees, institutional revenue, professional incentives, and measures to prevent conflicts of interest.
“Parliament must ask a fundamental question: are we gradually creating a two-tier system within public hospitals, one for those who can pay more, and another for everyone else?” the writer asked.
“If the answer is even partly yes, urgent reforms are necessary.”
The letter stressed that healthcare was not an ordinary marketplace and that patients seeking surgery, anaesthesia, orthopaedic treatment and other essential services were often in vulnerable situations.
According to the writer, delayed medical procedures could result in worsening illnesses, disability, financial hardship and preventable suffering.
The concerned worker therefore urged the government to ensure that intramural services, where permitted, did not become a mechanism through which patients could purchase priority in institutions built and sustained with public resources.
“This debate is not against doctors, nurses, medical laboratory scientists, anaesthetists, surgeons, or any other health professional,” the writer said.
“It is about protecting both patients and professionals through systems that are transparent, ethical and fair.”
The letter called on the Ministry of Health to strengthen its supervisory role, hospital management to ensure transparent and impartial systems, Parliament to exercise meaningful oversight and health professionals to continue placing patients’ welfare above personal financial interests.
“Public hospitals belong to the people,” the concerned worker concluded. “Their beds, theatres, equipment and human resources must first serve the public interest because, in the end, life must always come before personal financial gain.”
Below is the full write-up On How Health Workers Profit From The Patients Through Intramural Services
When access to timely healthcare depends on a patient’s ability to pay, the line between public service and private profit becomes dangerously blurred.
Public healthcare institutions exist first and foremost to protect life. Their mandate rests on a simple principle of equity: the sick should receive care according to the urgency and severity of their condition, not the size of their wallet.
Yet concerns are growing about the expanding culture of intramural services within some public health facilities in Ghana. Intramural practice may offer legitimate avenues for specialists and health professionals to provide services beyond their normal schedules. But a fundamental public-interest question cannot be ignored: what happens when the financial incentives attached to these services begin to influence who receives care first? This question deserves urgent national attention.
When the Ability to Pay Determines Priority
There is a growing perception among patients and families that those able and willing to pay for special or intramural services receive faster consultations, earlier procedures, and preferential access to specialists. Meanwhile, ordinary patients, many of whom depend entirely on the National Health Insurance Scheme or limited personal resources, may wait weeks or months for appointments and procedures.
Such perceptions alone are damaging to public confidence. Where practices, incentives, or administrative arrangements actually create unequal access, the consequences are more serious still. Healthcare should never become a system in which one queue moves because money is available while another stagnates because the patient cannot afford an additional payment. The principle must be simple: clinical need should determine priority.
The Question of Artificially Delayed Appointments
Perhaps the most troubling question surrounding the expansion of intramural services is whether financial incentives can unintentionally or deliberately create conditions in which routine appointments and procedures are delayed.
It would be wrong to accuse individual healthcare workers or departments without evidence. But the possibility of a conflict of interest must be openly examined. If the same institution, department, specialist, theatre, or equipment serves both regular public patients and fee-paying intramural patients, what safeguards exist to ensure the ordinary service is not disadvantaged?
Could appointment slots become unnecessarily scarce? Could patients face prolonged waits while faster alternatives open up for those who can pay? Could inefficiencies that appear unavoidable in the regular system suddenly become solvable once a patient enters a fee-paying arrangement?
These are not questions of hostility toward healthcare professionals. They are questions of accountability, transparency, and institutional integrity. A public health system must not only be fair it must be demonstrably fair.
The Paradox of “No Bed” and Available Services
Ghanaians are painfully familiar with the phrase “there is no bed.” Families move from facility to facility searching for space. Emergency patients wait anxiously. Elective procedures are postponed because beds, theatres, staff, or other resources are said to be unavailable.
Yet concerns arise when patients and families observe that services appear more accessible through special or intramural arrangements. This raises an uncomfortable public-interest question: if resources are genuinely insufficient for the ordinary patient, how are those same resources being allocated for additional fee-paying services?
There may be legitimate explanations intramural services may operate outside normal schedules or under separate administrative arrangements. But those arrangements must be transparent and subject to strict safeguards. A public hospital cannot allow a poor patient to be told to wait indefinitely for lack of capacity while the same public infrastructure is perceived to be facilitating faster access for those with greater financial means. The perception of “no bed for the poor but a pathway for the paying patient” is corrosive to the moral foundation of public healthcare.
Conflict of Interest in a Public Hospital
The issue goes beyond money it is fundamentally about conflict of interest and impartiality in healthcare. Health professionals have a duty to place patients’ welfare above personal financial interest.
This does not mean they should not be fairly compensated; Ghana’s health workers deserve appropriate remuneration for their expertise and sacrifice.
However, a conflict of interest can arise when a professional or institution benefits financially from directing, encouraging, or allowing patients to move from a regular public pathway into a paid alternative. The question is not whether health professionals should earn additional income, but whether the opportunity to do so can influence clinical access, appointment scheduling, waiting times, or the use of public resources. Where that possibility exists, strong institutional safeguards are required.
Public facilities must establish clear rules separating clinical prioritization from financial considerations. Appointment systems should be auditable, waiting lists transparent, and the use of theatres, beds, diagnostic equipment, and other public resources monitored, so that intramural services do not undermine care for patients who depend on the regular system.
A Growing Culture in Public Facilities
There is concern that this practice is becoming increasingly rooted within major public health institutions, including Korle Bu Teaching Hospital and potentially others. Departments such as Surgery, Anaesthesia,Urology and Orthopaedics where specialised procedures and limited resources create long waiting lists deserve particular scrutiny.
This is not an allegation that every professional or department is acting improperly; many dedicated healthcare workers continue to provide exceptional service under extremely difficult conditions. Rather, it is a call to examine the system. Systems can create incentives that place good people in ethically difficult situations, and a system that allows private financial interests to operate alongside public responsibilities without strong safeguards may eventually compromise even the best intentions. The more intramural practice becomes normalized, the greater the need for independent oversight.
Where Is the Ministry of Health?
The Ministry of Health cannot remain a distant observer while major changes occur in how public healthcare is accessed and financed. As the government’s principal steward of health policy and public healthcare institutions, the Ministry must answer key questions:
What national policy governs intramural services in public hospitals?
How are patients protected from financial discrimination?
What mechanisms prevent paid services from receiving unfair priority over ordinary patients?
How are public beds, theatres, equipment, medicines, and staff time accounted for?
Are waiting lists independently audited?
Can a patient who cannot afford intramural services be assured this will not affect the timeliness or quality of care they receive?
The Ministry’s supervisory responsibility must extend beyond issuing policies it must actively monitor whether public institutions are living up to the principles of equity and universal access. A healthcare system cannot claim to be universal if speed and access increasingly depend on one’s ability to pay beyond the ordinary system.
Parliament Must Also Ask Questions
Parliament also carries an important constitutional and public-interest responsibility. Its oversight should not wait for a major scandal before examining practices that may gradually reshape access to public healthcare. Relevant parliamentary committees should investigate the governance and impact of intramural services in public facilities including patient waiting times, appointment systems, resource allocation, fees, institutional revenue, professional incentives, and mechanisms for preventing conflicts of interest.
Parliament must ask a fundamental question: are we gradually creating a two-tier system within public hospitals one for those who can pay more, and another for everyone else? If the answer is even partly yes, urgent reforms are necessary.
Life Before Profit
Healthcare is not an ordinary marketplace. A patient seeking surgery, anaesthesia, orthopaedic treatment, or any other essential service is often in a vulnerable position. Illness does not negotiate. Pain does not wait for a convenient appointment. A delayed procedure can mean worsening disease, disability, financial hardship, and preventable suffering. For this reason, public healthcare must be governed by a higher standard.
Ghana must ensure that intramural services, where permitted, do not become a backdoor mechanism for purchasing priority in institutions built and sustained with public resources. The right to timely and appropriate care should not become a privilege reserved for those who can afford to pay extra.
This debate is not against doctors, nurses, medical laboratory scientists, anaesthetists, surgeons, or any other health professional. It is about protecting both patients and professionals through systems that are transparent, ethical, and fair. The ultimate test of any health policy is simple: does it save lives equitably? When financial gain begins to compete with clinical priority, the health system must pause and correct course.
The Ministry of Health must strengthen its supervisory role. Hospital management must ensure transparent and impartial systems. Parliament must exercise meaningful oversight. And healthcare professionals must continue to uphold the ethical principle that has always been at the heart of medicine: the patient’s welfare comes first.
Public hospitals belong to the people. Their beds, theatres, equipment, and human resources must first serve the public interest because, in the end, life must always come before personal financial gain.
