The introduction of structural health reforms and provision management systems over the past decade has enabled the sector to more effectively confront its persistent challenges. The refined roll-out strategy for the National Health Insurance Scheme (NHIS), along with a renewed focus on maternal health, investment in new equipment and overall infrastructural upgrades, demonstrates a positive outlook regarding health coverage and disease prevention for Ghanaians.
Ongoing challenges, however, remain all too apparent. The rate of chronic non-communicable diseases, such as hypertension, heart disease, diabetes and cancer, is on the rise as Ghana’s population becomes increasingly urbanised without adequate health facilities to address these concerns. At the same time, while rates are decreasing, diseases like malaria and HIV remain prevalent, especially in rural areas. There are also persistent concerns about maternal mortality and human waste disposal. Public debates regarding the efficacy of national programmes – including the NHIS and the Single Spine Salary Structure (SSSS), which attempted to combine the various public sector pay structures into one – continue to highlight bureaucratic inefficiencies and a tug of war over funding allocations.
Sector Structure
Health care is administered under the auspices of the Ministry of Health (MoH), which is responsible for policy-making, monitoring and evaluation, and policy implementation through the Ghana Health Service (GHS). The GHS is responsible for administering health care services across Ghana’s district system; GHS jurisdictions rank at the national, regional, district and sub-district levels.
As the national health care system becomes increasingly burdened by rising costs, the government has become keen on promoting public-private partnerships (PPPs) in the health sector. These are facilitated by the MoH’s Private Sector Unit, established in 1997 to enhance collaboration between the public and private sectors. Additionally, NGOs have a sizable footprint in Ghana’s health sector, and these play a significant role in rural areas. The Ghana Coalition of Healthcare NGOs has 300 members from across the country.
Budget
The MoH budget has increased significantly over the past several years, rising to GHS4.28bn ($1.63bn) in 2014, up from GHS3.53bn ($1.35bn) in 2013 and GHS1.8bn ($686.2m) in 2012. The government, however, still falls shy of its declared allocation of 15% of the total national budget for the health sector declaration, as high public sector salaries from the SSSS, inflation and lingering deficits each take their toll on spending. Nevertheless, Ghana has reached the 15% threshold twice since it made the declaration in 2001 at an African Union summit in Abuja, which is a success compared to other signatories. The 2014 allocation, representing 13.5% of the national budget, is the closest Ghana has been in the past six years.
Doctor Disputes
While public sector salaries are responsible for a majority of the budget, doctors have faced compensation difficulties as a result of the transition to the SSSS, which, due to tighter funding levels, has led to a reduction in doctors’ salaries and caused arrears in payments. Despite an agreement reached last year with the Ghana Medical Association (GMA) to end a doctors’ strike, payment disputes continue to play out, particularly after a ruling against paying a conversion difference to doctors who had seen their salaries reduced by the transition to the SSSS.
Policy Goals
The government’s fourth Health Sector Medium Term Development Plan (HSMTDP) 2010-13 was designed to focus the sector on attaining the health-related Millennium Development Goals (MDGs) by 2015, as well as developing more robust health care infrastructure. While Ghana remains on course to reach the first two MDG targets regarding extreme poverty and basic education, the country is more unlikely to meet targets 4-7, which include maternal and infant mortality, HIV/AIDS infections, sanitation and potable water availability, according to the MoH. The Health Institutions and Facilities Act, which intends to put into place the Health Facilities Regulatory Agency, the Mortuaries and Funeral Facilities Agency, and the Ambulance Council, has been in the works since 2011 and is now complete. The attorney general is currently reviewing the law. Furthermore, the subsequent HSMTDP 2014-17, aiming to continue the emphasis on equity gaps in access to health care, was drafted and is expected to come into effect later this year.
The establishment of the Private Sector Health Council, which aims to enhance public-private partnerships, remains under development. However, to improve quality assurance capacity, the Allied Health Professions Council, created in 2012, established guidelines for accrediting allied health training institutions and professional licensing examinations, according to the MoH. The registration of new members began in 2013. Furthermore, Ghana’s Food and Drugs Authority (FDA) drafted a National Food Safety Policy in 2012, which aims to institutionalise food safety in the country.
CHPS
So that the GHS can adequately intervene at the community level, the Community-based Health Planning and Services (CHPS) programme was established in 1999 to facilitate health care accessibility in remote areas. The programme focuses on using resident nurses to provide care as opposed to investing in facility-based infrastructure. In 2013, according to the MoH, an additional 731 functioning CHPS zones were developed, taking the total number of zones to 2314.
Indicators
Gradual progress has been made on some key indicators for mortality and life expectancy. According to the World Bank, infant mortality dropped from 53 to 49 per 1000 live births between 2009 and 2012. Moreover, the latest figures from the World Health Organisation (WHO) put Ghana’s life expectancy at 64, higher than the regional average of 56 but lower than the global average of 70.
Disease Burden
Malaria is responsible for nearly 50% of admissions for children under the age of five. The case fatality rate among children under the age of five decreased slightly from 0.87% in mid-2012 to 0.8% by June 2013, according to statistics from the ministry. The National Malaria Control Programme strategy 2008-15 calls for a reduction of 75% in malaria by 2015, with 2006 set as the baseline.
The programme combines prevention, detection and treatment programmes such as scaling up the distribution of indoor residual spraying, insecticide-treated nets and rapid diagnostic testing. A new strategy, launched in 2014, is seasonal malaria chemoprevention, which aims to provide a full course of anti-malarial treatment during the malaria season.
According to the WHO, an estimated 1.4% of Ghana’s population were living with HIV as of 2012. Between 200,000 and 270,000 people are living with the disease, approximately 28,000 of whom are children and another 120,000 of whom are women.
The prevalence of non-communicable diseases as a cause of both illness and death is rising steadily. According to the Ghana Medical Journal, hypertension, strokes, diabetes and cancer have each become among the top ten causes of death due to urbanisation and changing diets and lifestyles. While the government is committed to developing intervention and prevention programmes, there remains a structural gap in adequately addressing such diseases.
Mother & Child
While there has been a reduction in maternal mortality, the latest WHO statistics illustrate 350 deaths per 100,000 live births, well behind the 2015 MDG target of 185. However, results from a 2013 MoH survey on the Maternal Health Service Initiative, which launched in 2008 to provide free health care to mothers, pointed to a steady rise in the use of health facilities by pregnant women. Supervised delivery increased from 24.3% in 2012 to 37.5% by mid-2013 and antenatal care increased from 32.6% to 46.3%.
Statistics from the NHIS have also shown positive enrolment numbers for its programme providing free maternal care that launched in 2000. Coverage increased from 421,234 in 2008 to 754,658 in 2012. Neonatal mortality has also improved, with 2013 half-year statistics recording 2.3 per 1000 live births, compared to 5.8 per 1000 live births in 2012, according to MoH statistics. Over the same period, infant mortality improved to 2.6 per 1000 live births from 6.6 per 1000 live births.
NHIS
The National Health Insurance Act 2003 (Act 650) was established to provide universal coverage for basic health care. As of early 2014, the scheme was operating in over 155 districts with an active membership of nearly 10m users, up from 8.89m in 2012, according to the National Health Insurance Authority (NHIA). As of early 2013, 3575 health care facilities were accredited, and the NHIA has invested in pilot programmes to bolster the NHIS’s expansion.
Due to the past mismanagement of ID cards, a pilot biometric ID system is being rolled out in the Greater Accra and Central regions. This will provide digital data such as blood type and allergies for hospitals to use when a patient is admitted. The new card will generate a unique code to prevent instances of fraud. The next stage is expected to be implemented in the Ashanti and Eastern regions by the end of 2014.
Capitation
Ghana will also roll out a capitation system, whereby the NHIA will facilitate advanced payments for outpatient services in participant primary care facilities. The capitation pilot was initiated in the Ashanti region in 2012 and, while there is much debate regarding the size and allocation of payments, quality controls and the selection of hospitals, the NHIA is rolling out the second stage of capitation in the Upper West, East and Volta regions of the country in 2014. While capitation is expected to cut costs by limiting over-prescriptions, excessive testing and consultations, the programme may reduce the quality of care owing to the potential under-provision of services. “In order to mitigate the risks associated with the quality of the provision of services,” NHIA deputy-director Nii Anang Adejetey told OBG, “the capitation system will require a strict monitoring mechanism to ensure quality controls at each of the hospitals taking part in the programme.” The NHIA intends to cover 22% of the services provided by the NHIS via capitation, according to the World Bank. Adequate financing remains a concern regarding the sustainability of expanding NHIS coverage. The scheme is currently funded by a National Health Insurance Levy, which is accrued by deducting 2.5% of total value-added tax. This sum is combined with 2.5% of social security contributions and placed into the National Health Insurance Fund (NHIF). Moreover, interest and profits that build up within the NHIF are another source of financing, as well as contributions made by scheme, fees, grants and aid packages, and parliamentary allocations. The NHIS lacks adequate resources to maintain its programmes across Ghana. Total revenue collected in 2012 was GHS773.83m ($294.5m) while total expenditure was GHS788.32m ($300.5m), highlighting a net operating deficit of GHS14.49m ($5.52m), according to the latest NHIA annual report in 2012. Total claims in 2012 represented GHS616.47m ($235m), or 78.2% of the total expenditure. “The same funding formula is being used while the scheme is increasingly covering more people,” said Adejetey. “While there is always guaranteed support from government revenues, more funding is necessary in order for the scheme to grow its coverage and provide innovative programmes.”
Medical Staff
The employment of adequately trained and certified health staff is a significant impediment in the public sector. Some nurses are employed at three different hospitals at the same time due to low salaries, creating poor retention rates. “As the private sector increases its footprint in Ghana’s health system, it is important that staff salaries, nurses in particular, are raised to a level adequate to keep them at one hospital,” David Pickering, director of Lister Hospital in Accra, told OBG. The Human Resource (HR) Policy, completed by the MoH, is expected before the Cabinet by the end of 2014. The policy intends to digitalise HR information across the public sector and fine tune HR management. To focus on empowering nurses and health professionals, the 2014 budget provides more than GHS6.6m ($2.52m) for the construction of offices for the Ghana College of Nurses and Midwives, the Allied Health Professionals Council, the Health Facilities Regulator Authority and the Ghana College of Pharmacists. The MoH also expanded the Male Midwifery programme in 2013 to four Midwifery Training Schools in Pantang, Ashanti, Mampong, Nandom and Goaso.
Statistics from the Ghana Investment Promotion Agency in 2011 show that there are 9810 general nurses in Ghana’s public sector, 4035 midwives, 7596 community health nurses, 1055 medical assistants, 2609 medical officers and 540 pharmacists. In a 2012 baseline survey by the MoH, the doctor-to-patient ratio in Ghana was 1:10,452 and for nurses (including community health nurses) this was 1:1251.
Infrastructure & Equipment
The most recent data regarding overall health care infrastructure indicates that by 2009 Ghana had 3217 health facilities, which included 343 hospitals, 2083 clinics, 379 community health centres and 389 maternity homes. However, new investments and a growing health budget have contributed to many more projects since then, boosting the 2009 numbers considerably. The 2014 MoH Capital Investment Budget states that a total of GHS869m ($331.3m) is reserved for new projects, equipment, training and professional councils. In 2013 alone, a variety of district infrastructure projects received ministry funding. According to the MoH, projects include the completion of the Tarkwa District Hospital, the end of the first phase of the Tamale rehabilitation project, five new polyclinics in the Brong Ahafo Region, 37 new CHPS compounds in the Upper West Region (with support from the Japan International Cooperation Agency), the commencement of the second phase of the Bolgatanga Regional Hospital, and foundations for seven district hospitals in Dodowa, Fomena, Garu Timpane, Sekondi, Abetifi, Tarkoradi and Kumawu. Investment in new equipment was also a focus of the MoH in 2013. The National Medical Equipment Replacement Project facilitated an equipment upgrade programme for each of the three teaching hospitals in Accra, Tomale and Kumasi. According to the ministry, the hospitals all received new patient monitors, MRI scanners, X-ray machines, dental chairs, hospital beds and other important machinery. New CT scan centres were also established at the Tamale and Korle-Bu hospitals, and the National X-Ray Project enabled the distribution of X-ray machines across 16 hospitals, including Weija, Agomanya, Nadowli, Kpando, Jacobu, Duayaw-Nkwanta, Offinso, Dodi-Papasi, Adidome, Dzodze, Dormaa Ahenkro, Anfoega, Nkwanta, Lawra and Ashaiman.
Private Sector
While the public sector has dominated the health landscape, the private sector is pushing up its share to nearly half of the market, according to the World Bank. By the end of 2012 the NHIA was responsible for inspecting 4069 facilities, with 3575 accredited, of which 1423 were in the private sector. As of 2011 there were an estimated 160 private hospitals in Ghana, although new investments have pushed this number up. Demand for private care is continuing to increase steadily as the middle class continues to grow, rising numbers of expatriates seek employment and more people become insured.
As the NHIS registers new users, queues are growing longer outside public facilities, and the government is keen to promote PPPs to help shift this burden. The development of the Private Sector Health Council was announced in the MoH’s 2014 Programme of Work, which will allocate new resources toward private sector participation. PPPs have already helped supply much-needed training, equipment and infrastructure in Ghana. US multinational General Electric and the Netherlands’ Philips, for example, are using local partnerships with top public hospitals to distribute new medical equipment, while the Christian Health Association of Ghana provides services at nearly 150 health care facilities.
Outlook
As the sector continues to undergo important structural transformations, funding for the NHIS roll-out remains rather precarious, and many consider the high salaries under the SSSS detrimental to the economy. While many indicators are improving, diseases such as hypertension and diabetes are on the rise.
These important challenges notwithstanding, sector reforms including new salary regulations, pre-emptive capitation systems, biometric ID technologies and increases in insurance coverage under a universal system illustrate a desire for more progress in the sector.
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