1. health and fitness

SHIELD WORKPACKAGE 1 REPORT
Critical Analysis of Ghana’s Health System
With a focus on equity challenges and the National Health Insurance
John Gyapong, Bertha Garshong, James Akazili, Moses Aikins, Irene Agyepong, Frank
Nyonator
April 2007
Table of contents
List of Figures ...............................................................................................iii
List of Tables.................................................................................................iii
List of boxes..................................................................................................iv
Acronyms .......................................................................................................v
Acronyms .......................................................................................................v
Acronyms .......................................................................................................v
Executive Summary.....................................................................................vii
1. INTRODUCTION .........................................................................................1
1.1 Background and purpose .......................................................................1
1.1 Specific objectives and report structure: .............................................2
2. METHODS ...................................................................................................3
2.1 Document review....................................................................................3
3. CONTEXT....................................................................................................4
3.1 Geography..............................................................................................4
3.2 The Macro-Economy ..............................................................................4
3.3 Political and administrative organisation ................................................5
3.4 Demography...........................................................................................6
3.5 Health status of Ghanaians ....................................................................8
3.5.1 Health status indicators....................................................................8
3.5.2 Institutional Maternal Mortality .......................................................10
3.5.3 Disease Burden .............................................................................11
4. OVERVIEW OF THE HEALTH SYSTEM AND CHALLENGES ................13
4.1 Introduction...........................................................................................13
4.1 Health sector reform.............................................................................13
4.1.1 Organisation and Management......................................................14
4.2 Health service provision, health facilities and human resources in
Ghana ........................................................................................................16
4.2.1 Health services provision (Public Sector).......................................16
4.2.1.1 The CHPS strategy ........................................................................... 18
4.2.1.2 Access to services............................................................................. 20
4.2.1.3 Service delivery efficiency ................................................................. 21
4.2.1.4 Priority public health programmes..................................................... 21
4.2.2 Health service provision (private sector) ........................................22
4.2.3 Health facilities...............................................................................22
4.2.4 Human Resources .........................................................................24
4.3 History of health care financing in Ghana.............................................28
4.4 The National Health Accounts ..............................................................29
4.5 Trends in health sector financing: GoG, donor funds and Internally
Generated Funds .......................................................................................33
4.5.1 Cash management issues .............................................................36
4.5.2 Resource allocation between levels of the health system..............37
4.5.3 Resource allocation between regions ............................................38
4.5.4 Changing sources of revenue for the health sector .......................39
4.5.5 Other financing sources: HIPC funds.............................................40
4.5.6 The National Health Insurance Scheme ........................................41
4.5.6.1 Exempt categories-NHIS................................................................... 43
4.5.6.2 Sustainability of financing.................................................................. 45
4.5.6.3 Future role of the NHIS ..................................................................... 48
4.5.6.4 Recent Studies on Health Insurance in Ghana: Key findings............ 53
4.5.6.5 Research agenda to support health financing (including National
Health Insurance) policy and programme development and implementation in
Ghana............................................................................................................ 56
5. FINANCING AND BENEFIT INCIDENCE ISSUES ...................................66
5.1 Introduction...........................................................................................66
5.2 Financing incidence..............................................................................67
5.2.1 General tax ....................................................................................67
5.2.1.1 Direct tax ........................................................................................... 67
5.2.1.2 Indirect taxes ..................................................................................... 68
5.2.2 Non-tax incidence analysis ............................................................70
5.3 Benefit incidence ..................................................................................70
6. CONCLUSIONS ........................................................................................72
REFERENCES ..............................................................................................75
ii
List of Figures
Figure 1: Poverty incidence by region in 1991/92 and 1998/99 (poverty line=900,000
cedis per annum) ........................................................................................................ 5
Figure 2 : Regional Distribution of Population (2000 Census) .................................... 7
Figure 3: The Ten Administrative Regions of Ghana .................................................. 8
Figure 4: Infant mortality and Under five mortality by region 2006.............................. 9
Figure 5: Infant and under 5 mortality by expenditure quintile (MICS 2006)............. 10
Figure 6: Institutional Maternal Mortality by Region 2004 ......................................... 11
Figure 7: Relationship of the MoH to the various sectors and organisations ............ 16
Figure 8: Organizational structure of Ghana health services delivery....................... 17
Figure 9: Per capita OPD visits 1995-2004............................................................... 21
Figure 10: Health Care Expenditure in Ghana, 2002 (NHA 2006 using 2002 data) . 32
Figure 11: Percentage share of total Government (GoG + IGF + Donors + HIPC)
budget for 2006 ......................................................................................................... 36
Figure 12: Flow of funds to the public health sector (2001 % of expenditure) .......... 37
Figure 13: Distribution of resources between health services levels 2002 MTEF..... 38
Figure 14: Trends in real per capita resources between regions (% below or above
national average) ...................................................................................................... 39
List of Tables
Table 1: Health Status indicators .....................................................................8
Table 2: Top ten diseases reported at outpatient departments 2002 .............12
Table 3: Regional Distribution of Health Facilities-2004 and relation to
population distribution ....................................................................................22
Table 4: Distribution of Hospital beds by Region and Ownership - 2004 in
relation to population distribution ...................................................................23
Table 5: Health Staff Population ratios...........................................................24
Table 6: Selected Health Staff: Population Ratio (both public and private)
2005...............................................................................................................25
Table 7: Distribution of health Professionals by Region 2004........................26
Table 8: Migration and Destination of Ghanaian Nurses................................27
Table 9: Summary of Health Care Financing Sources and Agents, 2002 in
billion of Cedis (US$1 =8500 Cedis) ..............................................................31
Table 10: Summary of expenditure on services, 2006 ...................................33
Table 11: Financial sector-wide indicators .....................................................34
Table 12: Shares of Government budget for 2006 (¢ million) ........................35
Table 13: NHIS coverage, by region, 2006 ....................................................42
Table 14: Breakdown of NHIS membership: 2006 .........................................43
Table 15: Issues from 2005 and 2007 stakeholder meetings on priority issues
for research put into a modification of Kutzin’s framework of functions of the
health care financing system .........................................................................57
Table 16: Summary of tax health care payment, incidence, data source and
proposed method of measurement ................................................................69
Table 17: Distribution of Total Health Subsidies by location and Quintile 1989
and 1992........................................................................................................71
iii
List of boxes
Box 1: Vision 2020 priority areas ...................................................................13
Box 2: MTHS and PoW priority areas ...........................................................14
Box 3: The implementation of CHPS requires the completion of six
"milestones" in an identified health zone........................................................19
Box 4:Ghana NHIS Minimum Health Care Benefits .......................................44
Box 5: Ghana NHIS Excluded Benefits..........................................................45
Box 6: Constraints to growth of income from premiums include: ...................46
iv
Acronyms
AAK…….
ADHA……
AIDS………
AR…………
BAR………
BOR………
BMC………
CHAG…….
CHO………
CHPS……..
CR………..
CWIQ…….
DANIDA….
DCE………
DFID………
DMHIS……
DPF………
EDL………
ER…………
GAR……….
GDP……….
GHS……….
GLSS………
GoG………
GPRS……..
GSS……….
HIPC………
HIV…….…
HWF……..
IGF………..
ILO………..
IMCI………
ISSER…….
Abura Asebu Kwamankese
Additional Duty Hours Allowance
Acquired Immunodeficiency Disease Syndrome
Ashanti Region
Brong Ahafo Region
Bed Occupancy Rate
Budget Management Centre
Christian Health Association of Ghana
Community Health Officer
Community-based Health Planning and Services
Central Region
Core Welfare Indicator Questionnaire Survey
Danish Development Agency
District Chief Executive
Department for International Development
District Mutual Health Insurance Scheme
Donor Pooled Fund
Essential Drug List
Eastern Region
Greater Accra Region
Gross Domestic Product
Ghana Health Service
Ghana Living Standard Survey
Government of Ghana
Ghana Poverty Reduction Strategy
Ghana Statistical Service
Highly Indebted Poor Country
Human Immunodeficiency Virus
Health Workers Fund
Internally Generated Funds
International Labour Organisation
Integrated Management of Childhood Illnesses
Institute of Social, Statistics and Economic Research
ITNs………. Insecticide-Treated Nets
Acronyms
Km…………
LI………….
MDAs………
MDBS………
MDG……
MoFEP……
MoH…….
MTEF…….
NGO………
NHA………
NHI……….
NHIC……..
NHIF……..
NHIS……..
NPG………
NR………..
Kilometres
Legislative Instrument
Ministries, Departments and Agencies
Multi-donor Budget Support
Millennium Development Goals
Ministry of Finance and Economic Planning
Ministry of Health
Medium Term Expenditure Framework
Non-Governmental Organisation
National Health Accounts
National Health Insurance
National Health Insurance Council
National Health Insurance Fund
National Health Insurance Scheme
Non-government Providers
Northern Region
v
OOP………
OPD………
PIT……….
POW……..
RNE………
SHIELD…..
SPA………
SSNIT……
SWAP……
TB………..
UER……..
UK……….
UNICEF…..
USA……….
UWR…….
VAT……..
VCT……..
VR………
WHO …….
Out-of-pocket
Out-patients Department
Personal Income Tax
Programme of Work
Royal Netherlands Embassy
Strategies for Health Insurance for Equity in Less Developed countries
Service Provision Assessment
Social Security and National Insurance Trust
Sector-wide Approach Programme
Tuberculosis
Upper East Region
United Kingdom
United Nation International Children and Education Fund
United States of America
Upper West Region
Value Added Tax
Voluntary Counselling and Treatment
Volta Region
World Health Organisation
vi
Executive Summary
Ghana has committed to achieving the Millennium Development Goals (MDGs) by 2015.
However, Ghana and other developing countries have seen little progress towards achieving
the MDGs and there are doubts as to whether most of the developing countries including
Ghana can achieve these goals, and in particular the health related MDGs of maternal and
child health and HIV/AIDS. Among the myriad problems militating against the achievement
of the MDGs in the health sector are the inequities in the health care financing, and delivery
of health care in Ghana.
The SHIELD project is set out to critically evaluate existing inequities in health in South
Africa, Tanzania and Ghana and the extent to which health insurance mechanisms could
address equity challenges. The purpose of this report is to critically assess the inequities in
the health care system, particularly the financing and delivery of health care in the country
through a review of relevant documents.
Equity challenges in the health system
Results of the document review revealed both geographical and financial inequities in terms
of resource distribution and service provision. The Northern sector of the country is more
deprived than the Southern sector. The health system indicates that after more than 50
years of independence, the health status of the country is that of a developing country at the
onset of a health transition, with predominance of communicable disease conditions,
malnutrition, high infant mortality and generally poor reproductive health with the emergence
of non-communicable diseases, such as, diabetes and cardiovascular diseases.
These
conditions are largely exacerbated by poor access to health services. Despite progress
made over the years, geographic and financial access to health care remains a challenge.
Ghana currently faces inadequate numbers of qualified human resources due to the low
production levels of medical personnel which fall short of annual requirements. The human
resource problem is compounded by a high rate of internal and external attrition. The public
sector is loosing large numbers of its health workers primarily to the private-for-profit sector
and mission facilities.
The health personnel-population ratios illustrate both a wide
geographical disparity and a difference between cadres of personnel.
There are inequities in the distribution of the health facilities in the country. There are more
beds and other health facilities in proportional terms in Ashanti, Eastern, Volta, Western and
vii
the Greater Accra Regions than the rest of the country. Even though there has been a
general increase in the health facilities in the country, the three Northern Regions, the
poorest in the country, have not seen any increases.
Further review focusing on health care financing in Ghana indicates that fee-paying is not
new in Ghana. Hospital fee system has been operational since the first colonial hospital was
built in 1868. As part of health sector reforms in 1980s, user fees known as the ‘cash and
carry’ was introduced as means of sustaining the health services, which adversely affected
utilization. The exemption policy was introduced to address the burden of user fees on the
poor and certain vulnerable groups in the society. Even though the government allocation to
health has seen some level of improvement over the years, health care financing still
remains a major challenge in the country. In the 2006 budget, the health sector share
increased to from 12% to about 19%.
To increase access to health care for the population, various small scale pilot health
insurance schemes emerged. To test the feasibility and acceptability of a pre-paid, riskpooling financial arrangement at the community levels, studies on health insurance were
carried out to support government implementation of the National Health Insurance Scheme
(NHIS) meant to replace the ‘cash and carry’ as an alternative health care financing
mechanism in the country. The findings of the studies showed that there were challenges
ranging from perception of providers, premium payment mechanism, benefit package,
resource mobilisation, and scheme administration and management. Apart from the health
insurance studies, two key stakeholder meetings were held in 2005 and 2007, to inform
research areas for policy and programme development in health insurance implementation.
In all these, the pertinent question is “what is the burden of health care financing and benefit
incidence in the country?”
The SHIELD project’s aim is to critically evaluate existing
inequities in health care in Ghana, and the extent to which health insurance mechanisms
could address existing equity challenges.
This work was carried out with the aid of a grant from the International Development
Research Centre, Ottawa, Canada and financial support received from the European
Community's Sixth Framework Programme.
viii
1. INTRODUCTION
1.1 Background and purpose
Like many other developing countries, Ghana has committed itself to achieving the
Millennium Development Goals (MDGs) by 2015. However, Ghana and most of
developing countries have seen little progress towards achieving the MDGs. There
are doubts as to whether most of the developing countries including Ghana can
achieve these goals (World Bank 2004), particularly health related goals such as,
maternal and child health and HIV/AIDS.
Among the factors influencing the
achievement of the MDGs in the health sector are the inequities in the health care
financing and delivery of health care. Access to effective health interventions is low,
particularly for the poorest, resulting in unnecessary high morbidity and mortality.
Currently there is increasing interest and debate about the need to promote equity in
the health system, so that the poor and vulnerable groups, who tend to have the
highest disease burden and the least ability to pay for health care services, are
adequately catered for.
Of particular interest are the geographical and financial
inequities in the health system and the extent that those who live in rural areas are
often discriminated against in terms of health services provision. Another dimension
in the current health system debate is the pluralistic mix of public/private sector
financing and how this affects the delivery of health care.
In the 1980s, promoting the growth of private health care financing and provision was
a key element of the Ghana health sector reform. This was justified by the inability of
the public health sector to provide quality and efficient health care to the growing
population in the face of deteriorating economic conditions. The private health sector
today thus remains an important player in the financing and delivery of health care.
Of increasing concern however, are the geographical and physical service provision
inequities in the health system, which need to be identified and addressed.
Any meaningful intervention on inequity requires a preliminary map of existing
inequities in the general health system. The purpose of this report (which is part of
the SHIELD1 project) is to critically evaluate the inequities in financing and delivery of
health care in the country through a review of policy and non-policy documents. This
1
Strategies for Health Insurance for Equity in Less Developed countries
1
report is the product of work package 1 as outlined in the proposal
(http://www.idrc.ca/fr/ev-102522-201-1-DO_TOPIC.html).
The SHIELD project is
overall, tasked with critically evaluating existing inequities in health in South Africa,
Tanzania and Ghana, focussing on the extent to which health insurance mechanisms
could address equity challenges.
1.1 Specific objectives and report structure:
1. To describe the inequities in the health system.
2. Identify those perceived to be disadvantaged by the health system.
The report is divided into six sections. Section One provides a general introduction
and outlines the objectives of the report. Section Two examines the methods, which
includes a document review of published and unpublished literature. Section Three
outlines the context: the geography and people, the socio-economic, political and
health status, including the profile of the disease burden facing the country.
A
detailed description of the health system and its challenges are presented in Section
Four, as well as factors affecting the financing and delivery of health services.
Section Five examines issues of financing and benefit incidence and how the Ghana
SHIELD programme of work will develop the comprehensive analysis of the financing
and benefit studies in work packages (WP) 2 and 3. Finally, Section Six draws some
conclusions and highlights the key equity challenges facing the health system in
general.
2
2. METHODS
2.1 Document review
A critical review and synthesis of existing relevant documents was carried out. The
research team undertook an extensive search for relevant documents from the
various ministries and university libraries. The team also searched through websites
of institutions such as the Policy, Planning, Monitoring and Evaluation (PPME) of the
Ghana Health Service.
The type of information that was sought included the
distribution of health facilities and personnel, health care financing and financial
management and health service provision.
The preliminary results of the document review were also presented and discussed
at the SHIELD workshop in Johannesburg in October 2006.
3
3. CONTEXT
3.1 Geography
Ghana is located on the West coast of Africa, about 750km North of the
equator on the Gulf of Guinea, between the latitudes of 4º -11.5º north. The
capital, Accra, is on the Greenwich meridian (zero line of longitude). The
country has a total land area of 238,305 km² and shares boundaries with
Burkina Faso, to the North Cote d’Ivoire to the west and Togo on the east.
Ghana has a tropical climate, characterised most of the year by moderate
temperatures (generally 21-32ºC (70-90ºF)), constant breezes and sunshine
(Ghana Statistical Service 2005). There are two main rainy seasons, from
March to July and from September to October. Annual rainfall in the South
averages 2,030mm but varies greatly throughout the country, with the
heaviest rainfall in the western region and the lowest in the north.
3.2 The Macro-Economy
Ghana is well endowed with natural resources, and has roughly twice the per capita
output of the poorer countries in West Africa. Even so, Ghana with a GDP of about
US$400, remains heavily dependent on international financial and technical
assistance (World Bank, 2004).
Gold, timber, and cocoa production are major
sources of foreign exchange. The domestic economy continues to revolve around
subsistence agriculture, which accounts for 35% of GDP and employs 60% of the
work force, mainly small landholders (World Bank 2004). Policy priorities include
tighter monetary and fiscal policies, accelerated privatisation, and improvement of
social services. Inflation (about 10% in 2006) has eased recently, but still remains a
major internal problem (Ghana Health Equity Assessment, 2006).
At 5.8%, in 2004, the growth rate of the economy fell short of the Government of
Ghana’s (GoG) projections2. With budget deficits consistently higher than planned,
the GoG borrowed heavily on the domestic market to fill the gap, diminishing
available credit for private investment (although most bank lending is to the
Government or large businesses and institutions).
Ghana joined the Heavily
Indebted Poor Country (HIPC) initiative 2002, and a total of $700 million in debt writeoff at the end of 2004 was obtained (Ghana Statistical Service 2005). However,
2
http://www.alacratore.com/country_snapshot/Ghana (accessed on 03/04/07)
4
slippage occurred in the first year of the International Monetary Fund agreement,
which ended in late November 2002 (World Bank 2004). Since then, some progress
has been made (petroleum pricing liberalisation is the most noteworthy) in
addressing crucial national issues. Not withstanding this, the economic gap between
the rich and the poor is still a major challenge. A study in 2002 by the Ghana Centre
for Democratic Development, found a frightening picture of mass unemployment and
underemployment and a perceived widening of the gap between the rich and the
poor (20% of the poorest enjoy only 8.4% of the national income, whilst the richest
20% enjoyed as much as 41.7%).
Wide regional variations of poverty are also
observed (see Figure 1). From the Ghana Living Standard Survey 4 (GLSS 4),
published in Aim et al. 2001, poverty levels reduced in all regions except in Central,
Northern and Upper East regions where there was a rise in poverty incidence. Upper
East region was revealed as being the most deprived of all the regions, closely
followed by the Upper West and Northern Regions.
Figure 1: Poverty incidence by region in 1991/92 and 1998/99 (poverty
100
90
80
70
60
50
40
30
20
10
0
1991/92
To
ta
l
A
sh
an
ti
B
.A
ha
fo
N
or
th
er
n
U
.W
es
t
U
.E
as
t
V
ol
ta
1998/99
C
en
tra
l
G
.A
cc
ra
E
as
te
rn
W
es
te
rn
Percentage
line=900,000 cedis per annum)
Region
Source:GLSS 4 (unpublished), Atim et al. 2001
3.3 Political and administrative organisation
Ghana is a democratic parliamentary democracy. There is an elected Government
with a President, a Cabinet, a Parliament and an independent judiciary. The country
is divided into 10 regions (see Figure 3) and 138 decentralised districts. The districts
are administered by the District Assemblies and headed by a District Chief Executive
5
(DCE), who is nominated by the President and endorsed by the district elected
representatives.
Ghana continues to enjoy a stable political environment despite increasing instability
in the region and sub-region.
The deteriorating situation in neighbouring Cote
d’Ivoire is a cause for serious concern. To date, the numbers of returning Ghanaians
and foreign refugees have been manageable (Ghana Statistical Service, 2005).
However, Ghana is not equipped to handle large refugee flows and could easily be
overwhelmed if the situation worsens. On the domestic front, there are chieftaincy
disputes from one end of Ghana to the other (Ghana Health Equity Assessment,
2006)
Although basic reforms are in place for the acceleration of decentralisation and
delegation of responsibility for provision of many social services to district
governments, commitment at the national level is missing (Ghana Statistical Service,
2005).
Key ministries, such as health and education, have yet to relinquish
centralised control and function to the districts, and planned levels of resources are
not yet available to District Assemblies and local authorities (Ghana Statistical
Service, 2005).
3.4 Demography
Ghana’s population was estimated at 18.4 million in the 2000 Population and
Housing Census.
Its population structure is typical of a developing country with
about half of the total population below 15 years of age.
Ghana is no longer 20% urban and 80% rural as traditionally quoted. Increasingly
more and more of the population of Ghana live in urban areas. The results of the
2000 population and housing census showed that approximately forty four percent
(44%) of the population of Ghana live in urban localities.
The rural /urban
classification of localities in the census is population based, with a locality population
size of 5,000 or more being classified as urban and less than 5000 classified as
being rural. Apart from the Accra and the Kumasi Metropolis with populations of
1,658,937 and 1,170,270 respectively, the population of localities defined as urban
based on the population in the 2000 census ranged from a small rural town such as
Essam in the Western region with a population of 5,019, to Tamale with a population
of 202,317. Despite the wide range of population density in the localities defined as
urban, when the population of localities currently classified as urban is compared for
6
the 3 census periods of 1970, 1984 and 2000 that there is a clear trend towards more
and more Ghanaians migrating from low density population rural localities to live in
higher density urban localities. The extent of urbanisation in the country varies by
region from a high of 88% urban in the Greater Accra region, to a low of 16% urban
in the Upper East region. This is illustrated in figure 2
Figure 2 : Regional Distribution of Population (2000 Census)
90
87.7
80
70
60
51.3
50
43.8
40 36.3 37.5
37.4
34.6
30
27
26.6
19.1
20
15.7 17.5
15.4
11.1
10.2
9.6 9.6
10
8.6
8.4
3.2 2.1 4.4 1.9 1.4 3.4 2.5 2.8 4.91.1 3 1.7 2.7
0
W C GA V E Ash BA N UE UW All
Share of population Proportionurban Intercensal growthrate
Source: Ghana Statistical Service
Slightly over one third of the population of Ghana (34.5%) live in the two most highly
urbanised regions of Ashanti (19.1%), and Greater Accra (15.4%). These are also
the two regions, which are growing most rapidly, with an intercensal growth rate of
4.4% in Greater Accra, and 3.4% in Ashanti.
In terms of religion, Christianity is predominant in the country with Islam and
traditional religions also practised. There are many local languages but the official
language is English.
7
Figure 3: The Ten Administrative Regions of Ghana
3.5 Health status of Ghanaians
3.5.1 Health status indicators
The health indicators of Ghana, illustrated in Table 1, show a general improvement in
most of the indicators over a fifteen year period from 1988-2003. However, during
the same time period, infant, under-five mortality and neonatal mortality rates have
worsened. This is a very worrying development, given the Ghana Health Sector’s
efforts under the Ghana Poverty Reduction Strategy (GPRS) to achieve the health
related Millennium Developments Goals by 2015.
Table 1: Health Status indicators
Indicator
1988
1993
1998
2003
Infant Mortality Rate (per 1000 live births)
77
66
57
64
Under 5 Mortality Rate (per 1000 live births)
155
119
108
111
Neonatal Mortality Rate (per 1000 live births)
44
41
30
43
Post-Neonatal Mortality Rate (per 1000 live births)
33
26
27
21
Crude Birth Rate (per 1000)
47
44
39
33
Crude Death Rate (per 1000)
17
12.5
10
10
Life Expectancy at birth (in years)
54
55.7
57
58
Total Fertility Rate
6.4
5.5
4.6
4.4
Source: 2005 Review of Ghana Health Sector Programme of Work
8
Mortality rates of children in rural communities have been consistently higher than for
urban residents.
Regionally, differences in mortality are quite marked.
Western
Region has the lowest of 45 IMR per 1000 live births with 114 for Upper West (Figure
4). Under five mortality in Upper West (191) is three times that of Western Region
(66). In 2003 Ghana Demographic Health Survey (GDHS), the Upper East Region,
one of the poorest in Ghana, recorded a decrease in child mortality, whilst nearby
regions with similar socio-economic conditions recorded increases. A team of health
experts assessed factors that contributed to the sharp decline in child mortality in the
Upper East region. Their main findings showed significant improvements attributable
to the implementation of Accelerated Child Survival and Development activities,
increased resources for the health system and extensive support for community
based health activities (UNICEF Ghana 2006).
In 2006, UNICEF Ghana also
undertook the Multiple Indicator Cluster Survey (MICS) which looked at IMR and
U5MR indicators in particular.
Figure 4 further shows there is no marked
improvement as under-five mortality is still the same at 111 per 1000 live births, and
IMR in fact, worsened from 64 in 2003, to 71 in 2006.
Figure 4: Infant mortality and under five mortality by region 2006
Total
Upper West
Upper East
U5MR
Northern
Ahanti
IMR
Brong Ahafo
Eastern
Volta
Greater Accra
Central
Western
200
191
180
160
142
140
133
120
114
113
111
106
102
100
92 86 93
88 83
80
72
71
68
66 69 60
57 61
60
45
40
20
0
Source: Ghana MICS 2006
It is generally observed that poorer people have higher under-five and infant mortality
than their richer counterparts. The difference in Under 5 mortality between the poor
and the rich is striking, as illustrated in Figure 5 below.
9
Figure 5: Infant and under 5 mortality by expenditure quintile (MICS 2006)
140
126
118
120
80
101
100
100
75
100
79
65
65
64
Middle
Fourth
Richest
60
40
20
0
Poorest
Second
IMR
U5MR
Source: MICS 2006
3.5.2 Institutional Maternal Mortality
In 2004, a total of 824 institutional maternal deaths were reported out of a total of
453,096 deliveries (Health Sector Review 2006). The national institutional maternal
mortality rate was thus calculated as 186 deaths per 100,000 live births. Although
this is still high, it shows some progress, and a reduction of 214 deaths per 100,000
live births in 2001, to 204 deaths per 100,000 live births in 2003. Even though the
institutional maternal mortality rates are not considered reliable due to the ineffective
data gathering and storage, they are quite useful pointers. The regional distribution
shows that the Eastern (ER) and Volta (VR) Regions had the highest maternal
deaths in 2004 with the Upper West Region (UWR) showing the lowest (see Figure
6). This is another source of concern if Ghana is to meet the reduction in maternal
mortality as required by the MDGs (Health Sector Review 2006).
10
Figure 6: Institutional Maternal Mortality by Region 2004
300
250
200
150
100
50
0
WR
CR
GAR
VR
ER
AS
BA
NR
UE
UW
NAT
Region
Source: Ghana Health Sector Review 2006
3.5.3 Disease Burden
After 50 years of independence, the health status of the country is that of a
developing country at the onset of a health transition with a predominance of
communicable disease conditions, malnutrition, high infant mortality, and generally
poor reproductive health, with only recently emerging importance of noncommunicable diseases, such as, diabetes and cardiovascular diseases.
Most diseases are preventable and easily treatable.
Over time, the pattern of
diseases in the population has not shown any significant changes. Malaria still tops
the list of diseases managed at the outpatient departments of clinics and hospitals
(44%), followed by upper respiratory tract infections (6.8%), diseases of the skin
(4.3%) and diarrhoeal diseases (4.2%). Hypertension, a disease commonly found in
adults, also falls within the top 10 causes of outpatient visits in Ghana (at 2.8 %).
The high prevalence of hypertensive diseases and other chronic conditions is
reflected in the aging population (Ghana Statistical Service, 2005).
communicable diseases are increasing with lifestyle changes.
The non-
Hypertension,
diabetes, chronic renal diseases, cancer and mental diseases are increasing and
there is a rise in alcohol and tobacco use, and substance abuse.
Road traffic
accidents are now responsible for approximately 1,300 deaths and 10,000 injuries
per year (WHO, 2006).
11
Table 2: Top ten diseases reported at outpatient departments 2002
Disease
Male
Female
Total
%
Malaria
1,523,807
1,835,384
3,359,191 43.94
Acute Respiratory Infection
246,693
272,959
519,652
6.80
Skin Disease and ulcers
157,754
167,508
325,262
4.25
Diarrhoeal Diseases
154,473
167,931
322,404
4.22
Hypertension
78,918
133,436
212,354
2.78
Home/Occupational accidents
103,491
84,452
187,943
2.46
Acute Eye Infection
92,357
94,877
187,234
2.45
Pregnancy & related
_
150,613
150,613
1.97
Intestinal worm Infestation
70,985
80,345
151,330
1.98
Rheumatism & Joint pains
66,098
80,454
146,552
1.92
complications
Source: GHS Annual Report 2003
Table 2, shows that malaria and acute respiratory infection, skin diseases and
diarrhoeal diseases are major health challenges in the country though all of these are
preventable.
Another major challenge are complications arising from pregnancy.
This is particularly worrying because even though it only affects women of childbearing age, it still stands out as one of the top ten conditions in the country.
According to HIV sentinel survey data, the national median prevalence has declined
for a second time from 3.1% in 2004 to 2.7% in 2005 (WHO, 2006). The commercial
sex workers in Accra and Kumasi had respective rates of 76% and 82% in 2001,
which reduced to 54% in 2002 in Accra (WHO, 2006).
Guinea worm disease
particularly, affects fifteen districts in the Northern, Brong Ahafo and Volta Regions
and results in significant suffering and reduction in food production.
12
4. OVERVIEW OF THE HEALTH SYSTEM AND CHALLENGES
4.1 Introduction
In spite of the attention given to the health sector over the years, geographic and
financial access to health care still remains a challenge3. This section reviews the
health system in the country. The section is structured as follows:
•
Health sector reform, including its strategic plans and objectives;
•
Health service provision, health facilities and human resources;
•
The history of health care financing in Ghana, and
•
The financing of the health sector including the sources of financing, the
distributions and expenditure.
4.1 Health sector reform
Many changes have taken place in the health sector in the past decades. Before and
after independence the MoH assumed the role of sole provider of health care
services in the country with collaboration from the missions and para-government
agencies (the military, police and the mines) (Service Provision Assessment Survey
2002). These services were oriented towards curative, rather than preventive care
and involved programmes that were largely supported by donors.
The Government long-term vision for growth and development was formulated in
1996 and called “Ghana Vision 2020”. This Vision is aimed at propelling Ghana from
a low-income country, to a middle-income country by 2020. The Vision documents
define the nation’s areas for priority attention in the medium and long terms as
contained in Box 1 below
Box 1: Vision 2020 priority areas
•
Maximising the healthy and productive lives of Ghanaians
•
Fair distribution of the benefits of development
•
attainment of a national economic growth rate of 8%
•
Reduction of the population growth rate from 3% to 2.75%
•
The promotion of science and improved technology as tools for growth
and development
The annual report of the Ghana Health Service (2003) clearly indicates that there are still
people living beyond 8km radius to a health facility, though the WHO recommended distance
is 5km, which affects access to health care services, especially among the poor and other
vulnerable groups who can not access health care
3
13
The Medium-Term Health Strategy (MTHS) and a five-year Programme of Work
(PoW) was also developed for 1997 to 2001 by the MoH, also aimed at guiding the
development of health in Ghana. The second five-year PoW known as PoW II was
also developed for 2002 to 2006. The objectives of the MTHS and the first PoW are
outlined in Box 2.
Box 2: MTHS and PoW priority areas
•
Increase geographical and financial access to basic services
•
Better quality of care in all facilities and during outreaches
•
Improve efficiency in the health sector
•
Closer collaboration and partnership between the health sector and
communities, other sectors, and private providers both allopathic and
traditional
•
Increased overall resources in the health sector, equitably and
efficiently distributed
Indeed, the mission statement of the MoH summarises the focus and direction of the
health sector and is as follows:
“As one of the critical sectors in the growth and development of the Ghanaian
economy, the mission of the health Ministries, Departments and Agencies is
to improve the health status of all people living in Ghana through the
development and promotion of proactive policies for good health and
longevity; the provision of universal access to basic health service and
provision of quality health services which are affordable and accessible.
These services will be delivered in a humane, efficient, and effective manner
by well trained friendly, highly motivated, and client oriented personnel”
4.1.1 Organisation and Management
Before the reforms of the health sector, the MoH developed its own policies,
implemented and regulated them, evaluated its own performance and developed the
human resources needed for the health sector. This was deemed to be inefficient
and so the need was felt to decentralise roles and responsibilities. This resulted in
the passage of the 525 Act, establishing the Ghana Health Service (GHS) in 1996 as
the implementing body for public sector services, and thereby leaving the policy and
14
regulatory duties to the MoH. The operationalisation of the MoH is thus guided by
the Civil Service Act. The separation of functions between the MoH and the main
service provision agencies - Ghana Health Service and the teaching hospitals is
expounded in Act 525.
Another important service provider is the private sector which includes the NGOs and
traditional health systems (Figure 7). With regards to regulation, the bodies set up
include the Medical and Dental Council, Food and Drug Board, Pharmacy Council,
and Nurses and Midwives Council. The reorganisation of the health sector is part of
reforms being undertaken to improve efficiency in the health system. Other aspects
of the reforms include a decentralised planning and budgeting system, strengthening
of financial management, and a performance monitoring system. Strengthening of
existing regulatory bodies and existing laws as well as the Sector-Wide Approach
(SWAP) are all an integral part of the health sector reforms.
The health sector is organised along a five-tier system: national, regional, district,
sub-district and community levels. The Minister is the head of the health sector. The
MoH is responsible for policy formulation, planning, and donor coordination and
resource mobilisation.
The GHS under the authority of a Director-General is
responsible for service delivery.
A Ghana Health Service Council is in place to
oversee the activities of the Ghana Health Service. The teaching hospitals i.e. KorleBu and Komfo Anokye are autonomous bodies, complete with management boards.
15
Figure 7: Relationship of the MoH to the various sectors and organisations
Ministry of Health (MoH)
Public Sector
Private sector
GHS
Private-for-profit
Teaching
Mission-Based
Providers
Traditional
Other sectors
Education
Traditional
Medicine
Providers
Quasigovernment
institutions
Other Private
Alternative
Medicine
Statutory Bodies
Civil Society
Organisation
Faith Healers
Food and Agric.
Works and
Housing
Local Gov’t and
Rural Dev’t
Environment,
Science and
Tech.
Source: Ghana Service Provision Assessment (2002)
4.2 Health service provision, health facilities and human resources in Ghana
4.2.1 Health services provision (Public Sector)
At the regional level, curative services are delivered at the regional hospitals and
public health services are delivered by the District Health Management Team
(DHMT), as well the public health division of the regional hospital (Ghana Service
Provision assessment 2002). The Regional Health Administration (RHA) provides
supervision and management support to the districts and sub-districts within each
region. At the district level curative care is provided by district hospitals, many of
which are mission based. District Health Administration (DHA) provides supervision
and management support to the sub-districts.
At the sub district level both preventive and curative services are provided by the
health centres (Figure 8). They also provided outreach services to the communities
16
within their catchment areas. Basic preventive and curative services for minor
ailments are being addressed at the community and household level with the
introduction of the Community-based Health Planning and Services (CHPS)4.
National attention is drawn to the role of traditional birth attendant and traditional
healers.
Figure 8: Organisational structure of Ghana health services delivery
National (MoH/Ghana Health
Service providing policy and
strategic direction)
Tertiary
(apex of the
referral system)
Regional (provides
specialised clinical and diagnostic
care etc)
Districts (a district hospital provides
support to sub-districts in various respects
including referral and emergencies and
training etc)
Sub-districts (a health centre services a geographical area
with 15 000 to 30 000 population. It provides basic curative care,
disease prevention services and maternity services (primary health
care).
Community (health delivered through community health nurses, outreach
programmes, resident or itinerant herbalists, traditional birth attendants and/or
retail drug peddlers)
4
Further explanation of CHPS is provided
17
4.2.1.1 The CHPS strategy
A study known as the Community Health and Family Planning Project (CHFP)5 in the
mid-1990s in the Kassena-Nankana district of Ghana showed that providing close-toclient services reduced mortality and fertility (Debpuur et al., 2002). In particular, the
study found that a single nurse (called a Community Health Officer) equipped with a
motorbike and relocated to a village health centre, could outperform an entire subdistrict health centre, increasing the volume of health service encounters in study
areas eight-fold, and improving immunisation and family planning coverage (Bosu et
al., 2004).
The Ghana Health Service began to explore how to translate the research findings
into policy for improved health service delivery in 1999.
With support from
development partners, managerial structures were established, training modules
developed and staff training undertaken to start CHPS in ten lead districts, one from
each region.
Since then, CHPS has been seen as the key strategy to provide
equitable and pro-poor health services in line with the objective of the GPRS and the
health sector’s PoW I and II.
Operationally, CHPS is defined as a “strategy for the health care delivery system to
provide cost-effective and adequate quality basic primary health services to
individuals and households in the communities where they live through engaging the
community in the planning and delivery of services”. As part of the initial piloting of
the Navrongo experiment in more generalisable GHS settings, investment was made
to rapidly implement the experiment in the Nkwanta district in the Volta Region, in
what has come to be known as the Nkwanta Replication Project Experience.
Implementing CHPS in this district, as well as in the Abura Asebu Asamankese
(AAK) district in the Central Region, and the Birim North district in the Eastern
Region, in particular, have helped in promoting the GHS ownership of the CHPS
process (Nyonator et al., 2003; Nyonator, 2004; Bosu et al., 2004)
The CHPS approach includes the following elements, aimed at improving the
efficiency of the district health system:
• Establishing CHPS in all districts;
• Strengthening the sub-district health systems to support CHPS; and
5
Also known as the Navrongo Experiment
18
• Re-orienting district hospitals to provide the referral support for the sub-district
health systems.
Successful implementation requires a number of factors, which are illustrated in Box
3.
Box 3: The implementation of CHPS requires the completion of six
"milestones" in an identified health zone
1.
Health service work areas or zones have been delineated for primary
health
care outreach activities
2.
Community leaders are oriented and involved in the health programme
3.
A Community Health Compound has been established where a resident
nurse provides health services,
4.
Community Health Officers have been selected, trained and relocated to
community locations
5.
Equipment for transportation has been mobilised
6.
Volunteer health organisers have been trained and deployed to support the
Programme
Source: Bosu et al., 2004
Potential benefits of CHPS as a pro-poor health strategy
The key benefits of the CHPS model, particularly for the poor, include:
•
Direct service delivery to the community could foster provider-consumer
interaction. As one woman in her community remarked to the former Director of
Medical Services, “Now, if the nurse tells me something and I forget, I can ask
her about it when we meet at the market place”;
•
The CHO is potentially on call for 24 hours every day of the week;
•
When combined with community-based health insurance and the health sector’s
exemption policy, CHPS provides a unique mechanism to provide service to the
poor who will otherwise be constrained by physical and financial access;
•
Improved service outputs could hasten the achievement of GPRS and MDG
targets; and
•
CHPS provides an opportunity to deliver a wide range of preventive, promotive
and curative health services including interventions, which may be considered a
19
priority from the perspective of the poor, such as, TB, malaria, HIV, guinea worm
control and community integrated Management of Childhood Illnesses (IMCI).
The Challenges of CHPS
Even though CHPS is seen as a well tested initiative in reducing inequities and
promoting geographical access to basic health care, it has a number of challenges
(Nyonator 2005), that does not make it one-size fit all strategy. The challenges
include:
•
Nurses who are the key players in the CHPS concept are worried about transfers
to communities that do not have basic social amenities;
•
Supervisors and managers are worried about constrains in fuel, equipment,
drugs, facilities, and manpower resources;
•
The government’s capacities to expand CHPS, conduct operations research,
monitor and evaluate the program, and disseminate lessons learned are other
constrains; and
•
Above all, the enormous resource required to roll out CHPS to all parts of the
country is a major constrain.
4.2.1.2 Access to services
Attendance is an indicator of service delivery and thus provides an indication of
accessibility (geographical, financial, cultural etc), Outpatient Patient Department
(OPD) visits in general have remained the same, though with significant regional
variations. Encouragingly, outpatient visits per capita have increased minimally but
steadily over the last five years (see Figure 9).
20
Figure 9: Per capita OPD visits 1995-2004
No of OPD Visits per ca
0.6
0.49
0.5
0.4
0.49
0.5
0.52
0.45
0.32
0.34
0.37
0.38
0.4
0.3
OPD VISITS
0.2
0.1
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
4.2.1.3 Service delivery efficiency
The best sector-wide efficiency measure available until recently was bed occupancy
rates (BOR). This only applies to the use of hospital facilities for inpatient care and is
incomplete. Without either turnover rates or Average Lengths of Stay (ALOS) it is not
possible to interpret this indicator with certainty.
The national data suggest that
BORs declined from 62.7% to 58.4% over the year and there has been a steady
decline since 2001 (GHS 2006).
There are wide variations. Teaching hospitals
record BORs above 90%, but some district hospitals has BOR as low as 40%. This
implies that many hospitals are technically inefficient and may suggest that patients
prefer to by-pass some hospitals in order to seek care in teaching hospital.
4.2.1.4 Priority public health programmes
As noted in the 2002, 2003 and 2004 Health Sector Reviews, there has been overall
stagnation in most public health service outputs between 2002-5, and most targets
set by the MoH have not been met (GHS 2006). Some of the priority interventions
that have a major impact on mortality include:
•
Maternal and child heath;
•
Reproductive health services;
•
Supervised delivery
21
•
Essential Obstetric Care (EOC); and
•
Nutrition for child survival and development.
4.2.2 Health service provision (private sector)
Currently, the private sector contributes 35% of health services in the country.
Government support is targeted to raise this to 65% in the next 10 years. The private
sector, however, provides basic curative health services and very few preventive
services. Modalities for the supervision and monitoring of services of NGOs and the
private sector are under development.
4.2.3 Health facilities
In Ghana, health facilities are public, private not-for-profit e.g. the Christian Health
Association of Ghana (CHAG), and private self financing. Public facilities include the
teaching hospitals and all GHS facilities (hospitals, polyclinics, health centres, health
posts, CHPS compounds, small clinics), including the 10 regional hospitals. Private
facilities include hospitals, maternity homes, clinics, and chemical sellers. Chemical
sellers are more wide-spread in rural communities and usually the first point of call.
In the private sector, Greater Accra Region has almost a quarter (24.8%) of all
private health facilities, with Ashanti following with 20%.
Upper East Region
recorded the least, 1.6% of all private health facilities in the country. There are more
health facilities (over 60%) and beds (over 70%) in Ashanti, Eastern, Volta, Western,
and Greater Accra regions than the rest of the Regions in the country (see Table 3
and 4).
This is understandable given the large population sizes in these areas.
Comparing the population size and the health facilities, these Regions appear to
have more pressure on their health facilities than Regions like Upper East and Upper
West. This trend is similar to the distribution of beds. In terms of ownership of beds,
government facilities have more than 50% of the bed capacity in the country (see
Table 4).
Table 3: Regional Distribution of Health Facilities-2004 and relation to
population distribution
Region
Western (WR)
Central (CR)
Greater Accra (GAR)
Volta (VR)
Population
2000
1,924,577
1,593,823
2,905,726
1,635,421
Teaching
Hospital
0
0
1
0
22
Regional
hospitals
1
1
1
1
Other
facilities
310
263
308
338
Total
311
264
310
339
Eastern(ER)
2,106,696
0
1
389
390
Ashanti (AR)
3,612,950
1
0
445
446
Brong Ahafo (BAR)
1,815,408
0
1
250
251
Northern (NR)
1,820,806
0
1
193
194
Upper East (UER)
920,089
0
1
132
133
Upper West (UWR)
576,583
0
1
101
102
Total
18,912,079
2
9
2,729
2,740
Source: GHS 2005 Policy Planning Monitoring & Evaluation Division (PPME)-
Table 4: Distribution of Hospital beds by Region and Ownership - 2004 in
relation to population distribution
Region
Population
Government Mission
2000
Quasi-
Private Total
Government
Western
1,924.577
1,050
480
308
0
1,838
Central
1,593,823
1,130
366
54
0
1,550
G.Accra
2,905,726
2,871
0
759
593
4,223
Volta
1,635,421
1,260
967
47
0
2,274
Eastern
2,106,696
1,410
929
174
0
2,513
Ashanti
3,612,950
1,769
1196
256
594
3,815
B.Ahafo
1,815,408
384
1011
44
9
1,448
Northern
1,820,806
722
339
0
0
1,061
U.East
920,089
469
253
0
0
722
U.West
576,583
346
336
0
0
682
18,912,079
11,411
5,877
1,642
Total
1,196 20,126
Source: GHS 2005Policy Planning Monitoring & Evaluation Division (PPME)
Available evidence (Ghana Statistical Service, 2005) shows that there is a general
increase in the number of health facilities in both the public and private sectors. The
number of hospitals in the public sector increased from 251 in 1991 to 333 in 2001.
For Greater Accra Region, the number of hospitals almost doubled within the period,
while the number of hospitals in Ashanti Region increased by a third. On the other
hand, the number of hospitals in the Northern, Central, Volta, and Upper East
Regions remained almost the same over the period. With regard to health centres,
significant increases in the numbers occurred in all regions.
23
4.2.4 Human Resources
The provision of human resources in adequate quantity, and with appropriate competence to provide health care services is critical in improving equity in access to
health care services. Ghana is currently severely short of qualified human resources
for health (GHS, 2003), targets for 2010 are shown in Table 5. According to the
health sector review in 2006, the health sector has a work force of about 43,000
people. The public sector employs about 41,000 of which 4.8% are medical doctors,
34.7% are nurses (including midwives), 3.3% are pharmacists and 57.2% are nonclinical staff. The main issue is the large number of non-clinical staff compared with
numbers of clinical staff in the health sector.
Table 5: Health Staff Population ratios
Category of staff
Current
Target for 2010
Doctors
1: 10,000
1: 5,000
Nurses
1: 1,587
1: 1,000
Pharmacists
1: 14,286
1: 10,000
Source: GHS (2005) Review of Ghana Health Sector Programme of Work
The low numbers can be attributed partly to the low production levels of medical
personnel from the available training institutions, which always fall short of annual
requirements. In 2002, for instance, the medical training schools in Ghana produced
only 159 physicians, as against a potential demand of over 1,000. This situation is
also exacerbated by the high rates of emigration of trained doctors, inequitable
distribution of staff and great disparities between the urban southern regions and the
more rural northern ones. This has resulted in a very low level of medical personnelto-population ratios, that can barely support the optimal running of the present health
system, let alone any scaled-up health system. For instance, the Ghana Service
Provision Assessment (SPA, 2002) estimated for the year 2002 one doctor to a
population of about 1: 8,554. A review of the health sector in 2006 showed a marked
and wide geographical disparity across the country. Whilst Greater Accra has 3
doctors to 10,000 people, Northern region has 1 doctor to 100,000 people (see Table
6). Greater Accra has already reached the 2010 target staff: population ratios for
doctors, nurses and pharmacists (see Table 6).
However, a visit to any health
institution including Korle-Bu teaching hospital reveals a woefully inadequate number
of staff on duty taking care of both outpatients and inpatients.
24
Table 6: Selected Health Staff: Population Ratio (both public and private) 2005
Doctors/10000
Nurse/10000 pop
Pharmacists/10000
Regions
pop
Western
0.5
4.4
0.2
Central
0.4
5.9
0.2
3
12
2.6
Volta
0.4
6.3
0.1
Eastern
0.5
6.6
0.2
Ashanti
1
4.1
0.6
Brong Ahafo
0.4
3.4
0.1
Northern
0.1
3.4
0.1
Upper East
0.4
7.1
0.1
Upper West
0.2
5.6
0.03
Greater Accra
pop
Source: Health Sector Review 2006
An aspect of the supply of health personnel relates to spatial distribution (see Table 7
for detail breakdown). While doctors are mainly stationed in hospitals, the regional
share of doctors suggests a substantial mismatch between the number of hospitals
and the number of doctors actually employed. For instance, Greater Accra Region
and Ashanti Region have a little over half (55%) of the hospitals (both public and
private) in Ghana but have 69% of doctors. On the other hand, Volta with 8.9% of
hospitals has 4.7% of doctors, and the three northern regions with 7.6% of hospitals
have only 5.1% of doctors.
25
Table 7: Distribution of health Professionals by Region 2004
Profession
Medical Officers
Dental Surgeons
Pharmacists
Medical Assistants
Professional Nurses
Auxiliary Nurses
Physiotherapists
Health Service Administrators
Health Educators
Biologists/Entomologists
Accountants/Accounts Officers
Dispensing Technicians/ Assistants
Estate Officers
Human Resource Managers
Dental Technologists/Therapists
Biostatistics Officers
Catering Officers/Cooks
Dieticians
Nutrition Officers
Technical Officers
Administration Staff
Medical Laboratory Technologists
Other Professional Staff
Other technical staff
Artisans/Tradesmen
Security/Guards/Watchmen
Other Staff
Grand Total
Ashanti
308
4
64
69
1,278
669
4
26
6
13
162
250
7
2
4
5
80
3
2
206
28
12
7
152
91
183
2,017
5,652
B. Ahafo
55
1
15
42
552
433
3
11
10
5
144
101
4
4
1
3
28
1
3
156
29
5
7
107
67
141
1,275
3,203
Central
47
2
12
36
578
523
0
11
2
1
75
86
3
2
0
1
70
1
1
88
22
3
4
62
72
118
1,163
2,983
C.Admin
35
1
15
1
20
0
0
9
9
13
4
0
5
5
0
3
2
0
7
53
50
4
32
22
66
31
291
678
Eastern
75
1
20
38
895
956
2
15
0
2
141
122
2
2
0
4
70
1
0
141
21
12
3
119
81
81
1,630
4,434
26
G. Accra
480
11
81
57
2,295
1,249
9
14
1
8
282
133
6
3
6
3
152
7
2
227
38
31
8
117
110
123
1,819
7,272
Northern
24
1
8
41
543
435
2
10
1
3
54
52
6
1
1
1
39
1
4
79
14
6
1
75
42
62
767
2,273
U.East
29
0
7
34
387
302
0
5
1
2
56
36
3
1
4
36
1
3
67
6
3
13
47
40
91
401
1,575
U.West
9
0
4
16
336
115
1
5
1
1
57
22
2
1
0
1
17
0
2
44
14
3
3
51
24
68
487
1,283
Volta
49
0
12
26
763
668
3
12
1
3
106
75
3
1
1
1
82
0
2
93
43
6
3
77
135
123
1,745
4,033
Western
57
1
16
41
494
480
1
7
1
4
79
50
4
1
0
1
58
0
3
99
15
5
3
56
55
69
1,029
2,629
Total
1,168
22
254
401
8,141
5,830
25
124
33
55
1,160
927
45
23
17
23
634
15
29
1,253
280
90
84
885
783
1,090
12,624
36,015
Of late, the human resource problems seem to be compounded by a high rate of
internal and external attrition. The public sector is losing large numbers of its health
workers primarily to the private-for-profit sector and to mission health institutions. The
more serious threat seems to emanate from external attrition. The situation is no
different with other health workers such as nurses, pharmacists and laboratory
technicians. The State of the Ghanaian Economy Report for 2002 (ISSER 2003)
notes that 68% of medical officers, trained between 1993 and 2000, have left the
country. The major beneficiaries of Ghana’s loss of medical personnel include the
United States of America (USA), United Kingdom (UK), Germany and Canada. The
USA, for instance, is estimated to be employing 1,200 physicians of Ghanaian origin;
whilst United Kingdom has about 300 doctors, South Africa 150 and Canada 50
(ISSER 2003). Ironically, there seem to be more Ghanaian doctors working outside
the country than inside Ghana.
Ghana is also losing nurses in high numbers.
The attrition of nurses however,
reached alarming proportions during the past 5 years (see Table 8). It is estimated
that Ghana has lost about 50% of its professional nurses to UK, USA and Canada in
the last 10 years. The available records show that about 1,209 nurses left Ghana in
2002 compared to 387 in 1999.
Table 8: Migration and Destination of Ghanaian Nurses
1998
1999
2000
USA
50
42
44
UK
97
265
646
Canada
12
13
26
South
Africa
9
4
3
Others
4
4
8
Total
172
328
727
Source: Health Sector Review 2006
2001
129
738
46
2002
81
405
33
2003
80
317
10
Total
426
2468
140
2
8
923
6
5
530
407
24
29
3087
The increasing outflow of medical personnel has worsened the already precarious
human resource situation and created a human resource gap in the health sector.
This does not auger well for equitable access and sustainability of the health system
and also negates economic growth and poverty reduction, since wealth is linked to
health.
27
4.3 History of health care financing in Ghana
Ghana has a fragmented history of health care financing.
Before Ghana’s
independence in 1957, user charges were instituted in all public health facilities and
so health care has historically, been financed through taxation, user fees and donor
support. After independence in 1957, health services became free to the public and
were financed through general tax and donor support. Nevertheless, sustaining the
quality and delivery of health services became problematic.
Following the general reforms perpetuated by the World Bank and the International
Monetary Fund (IMF) in 1985, the Ghana Ministry of Health (MOH) introduced
significant client out-of-pocket payments (user fees) at points-of-service in the public
health facilities. The aim was to recover at least 15% of recurrent operating costs.
Though user fees for clients had existed earlier, the amounts paid were minimal and
more of a token. The objective of recovering at least 15% of recurrent costs was met
by only a few countries (Crease 1991). However, access and utilisation studies
showed a significant reduction in the use of health services especially in rural areas
(Crease 1991; Asenso-Okyere and Dzator 1997; Atim 1998) after the introduction of
user fees. User fees, commonly called the ‘cash and carry’ system in Ghana, have
undoubtedly contributed to inequitable health service access and utilisation between
different socio-economic groups and between poor rural and richer urban dwellers
(Waddington and Enyimayew 1990; Nyonator and Kutzin 1999).
In the late 1980s, the MOH began to consider the feasibility of health insurance as an
alternative to user fees. A number of pilot schemes were put in place to test the
viability and feasibility of this alternative health care financing scheme. Some of the
pilot schemes that were set up have led to some increases in utilization and access,
promoting equity and efficiency in the areas in which these schemes existed (Atim et
al. 2001).
In addition to the Government initiated pilot schemes, a number of
community-based pre-payment schemes sprang up and by 2002, there were more
than 159 mutual health organisations covering just about 1% (220,000) of the
population of the country (Atim et al. 2001).
These schemes operated on a pre-payment basis, and most were owned and
operated by health care providers (e.g., Nkoranza Health Insurance scheme-NKHIS),
with a few having strong community involvement (e.g., Dangwe West Health
Insurance Scheme (DWHIS) and Okwahuman Health Insurance scheme-(OHIS).
28
Despite the many community based health insurance schemes, user fees are still a
major part of health care financing and this is because the insurance schemes cover
a relatively small population. Although user fees are an important source of funding
for health services in Ghana (Nyonator and Kutzin 1999), it is also well documented
in the literature that it has negative implications for health service utilisation
especially among the poor (Arhin 2001; Wagstaff and van Doorslaer 2003).
Due to the inherent inequities associated with user fees, there was strong political
support in 2001 when the Government announced the introduction of a National
Health Insurance (NHI) scheme to replace ‘cash and carry’ or user fees at the point
of service. This policy was translated into legislation in 2003. The NHI encompasses
multiple schemes, with a mandatory health insurance scheme for those working in
the formal sector, a district mutual health insurance (DMHI) scheme in each of the
country’s 138 districts, private mutual health insurance schemes and private
commercial insurance schemes, in order to afford all Ghanaians the opportunity to
join a health insurance scheme of their choice (Government of Ghana 2003). The
NHI is aimed at offering members access to health care without having to pay at the
point of access and to offer affordable and sustainable medical care in the longer
term.
Ghana has thus implemented most of the known health care financing mechanisms:
general tax, out-of-pocket (OOP), donor funding and health insurance (community
based and the national health insurance). The next section summarises the sources
of financing, financing intermediaries, and the expenditure patterns as contained in
the National Health Accounts (NHA).
4.4 The National Health Accounts
The National Health Accounts (NHA) seeks to trace all the health resources that flow
through the health system.
In other words, they constitute a systematic,
comprehensive, and consistent monitoring of resource flows in the country’s health
system. The NHA was specifically designed to inform the health policy process,
including policy design and implementation, policy dialogue, and the monitoring and
evaluation of health care interventions. Ghana conducted its first NHA in 2006 using
2002 data. Preliminary results of the NHA show that out-of-pocket (OOP) constitutes
24% of the total health expenditure in 2002 and expenditure from MoH and
local/municipal government (district assemblies) constitute 20% each. The rest of
29
the financing agents were insignificant (see Table 9). It is however, not surprising
that contributions from private insurance was insignificant, as private insurance in
Ghana is virtually non-existent (see Table 9). The table also reveals that donor
funding as a source of health care financing was significant. The percentage of
donor funding is 20%. With regards to financing flow, figure 10 provides an overview
of the flow of funds between key financing intermediaries (i.e. direct purchasers of
health services) and health care providers. Over 60% of total health care funds in
Ghana flow via public sector financing intermediaries (primarily the national, regional
municipal district health authorities). According to the NHA, about 24% of the total
health care funds flow through households (as OOP) (see Figure 10). Table 10
shows that over 60% of the total health care expenditure go to curative care. These
preliminary results are still being reviewed.
30
Table 9: Summary of Health Care Financing Sources and Agents, 2002 in billion of Cedis (US$1 =8500 Cedis)
Financing agents
General
Tax
HPIC
savings
fund
Parastatal
employer
fund
Ministry of Health (MoH) & SWAp
186
Ministry of Education (MoE)
49
Ministry of Local Gov’t & Rural
143
Development (MLG & RD)
Regional Government
110
Local/Municipal Government
297
(Districts Assemblies)
Social security funds
Parastatals (quasi Gov’t)
151
Private employee insurance
program
Private Insurance Enterprise
(other than social insurance)
Private household out-of-pocket
NPISH (implementing agencies)
Private firms and corporations
(other than health insurance)
Rest of the World (Donors)
Not specified by any kind
736
49
151
Sub Total (Total Health
Expenditure-THE)
Financing agents spending on
21
health related items
Total
757
49
151
Total (%)
31%
2%
6%
Source: National Health Accounts GHS 2006 (unpublished)
Private
employer
funds
Households
Other
private
funds
HCF as a %
of THE
78
Rest of the Total
world
Donor/NGO
214
478
49
143
33
70
33
94
176
461
7.5%
19.6%
151
0
0.0%
6.4%
0.0%
0
20.4%
2.1%
6.1%
0.0%
570
133
570
134
161
24.3%
5.7%
6.8%
27
26
501
2,349
1.1%
0.0%
-
161
161
751
161
7%
31
3
0.441
6
30
-
754
32%
0.441
0%
507
21%
2,379
-
100%
Figure 10: Health Care Expenditure in Ghana, 2002 (NHA 2006 using 2002 data)
Ministry of Local
Gov’t & Rural Dev’t
143b
MoH &
SWAp
478b
Donors
26b
Local/Munic
ipal District
461b
Private
Household, Outof-pocket
payment 570b
NPISH
implementin
g agencies
134b
Ministry of
Educ 49b
Parastatal
(quasi gov’t)
151b
Regio
nal
Gov’t
176b
Tertiar
y
Hospit
als
177b
Private
hosp. for
profit
359b
Region
al
Hospit
als
137b
Districts
Hospitals
350b
Public
Health
centres
145b
>50billion cedis
Other
admin
160b
Gov’t
admin of
health
425b
Alternative or
Traditional
practice 5b
*
Private firms &
corporation
(other than
health insurance)
161b
Offices of
physician’s
private clinics
293b
<50billion cedis
* Source: National Health Accounts (NHA) 2006 using 2002 data
32
Gov’t
assisted notfor-profit
hosp 50b
Offices of
dentists 4b
Dispensing
chemists
157b
Providers not
specified by
any kind 2b
All other
ambulances
health care
services 37b
Provision and
admin of public
health prog. 34b
Table 10: Summary of expenditure on services, 2006
Services
Curative care
Prevention and public health
programmes
Pharmaceuticals and other nondurables
Health administration
Capital formation
Other
Total
Source: GHS 2006 (unpublished)
As a %age of total expenditure on
health
66.3% (inpatient: 19.9% and outpatient:
46.4%)
8.4%
6.7%
18.6%
0.0%
0.0%
100
4.5 Trends in health sector financing: GoG, donor funds and Internally
Generated Funds
Based on the limited data available, the government budgetary commitment and
actual spending on health, as a proportion of total government spending have
increased significantly over the years (see Table 11). For instance, GoG recurrent
spending on health has consistently increased from 10.2% in 2001 to 14.5% in 2005.
Total government spending in 2002 was around 41 percent higher than budgeted,
largely due to the increase in the personal emolument (Item 1). It is estimated that
expenditure on health care in 2002 was about ¢1,100 billion. Comparing data for the
first two quarters of 2001 and 2002, there was a 9% increase in real per capita
expenditure on personnel emoluments (Item 1) and a 4.5% decrease in real per
capita non-salary expenditure (Items 2-4).
A trend in the last few years has been the growth in spending on personal
emoluments and other salary adjustments due partly to the Additional Duty Hours
Allowance (ADHA), which was extended to most health staff. The Budget-MTEF
therefore imposes neither a hard fiscal constraint on the sector as a whole, nor on
control of individual items. The Budget for 2003 for instance, allocated only 16% of
the government health budget to non-salary items. It is expected that important nonstaff expenditure will be put under increasing pressure in future years.
33
Table 11: Financial sector-wide indicators
MOH
2001
baseline
- (19992000)
5.9%
9.1%
2002
2002
Budget actual
2003
2003
Budget actual
% GOG budget
10.3% 11.1% 11.5%
spent on health
system
% GOG recurrent
11.0%
10.2% 10.5% 11.0% 12.0%
budget spent for
health
12.9% 30.2% 17.8% 16.1%
% GOG recurrent
health spending on
non-salary items (2
&3)
% of
63.0%
NA
earmarked/direct
donor funds to total
donor fund
% IGF from
NA
NA
prepayment
schemes
% spending on
48.5% 33.3% 40.9% 47.8%
district and below
(6
(items 2 & 3)
mths)
Total % spending on
41.0%
24.6%
district from DPF &
GOG3
Total exemptions for
14.36
regions (based on 6
regions6)
% of exemptions
37.6%
spent on ANC
% of exemptions
16.9%
spent on aged
% of exemptions
43.3%
spent on under-5
years
% of exemptions
1.6%
spent on the poor
Source: Programme of Work, 2002; Ghana Statistical Service 2005.
8.0%
2004
actual
12.9%
12.0% 14.0%
43%
43.0%
50.0% 45%
5.0%
10.0%
The large increase in salary requirements has altered the balance of funding
between government and non-government sources. In the period 1998 and 2002 the
proportion of funding from GoG sources increased to around 70%. The composition
of GoG and donor funding has changed significantly over the last five years. The
6
. Northern, Ashanti, Greater Accra, Central, Brong Ahafo and Upper East.
34
proportion of the GoG budget spent on personal emolument has increased since
1998 from around 55% to more than 80%.
The reasons for the increases in overall GoG spending on health could be
attributable to the generally positive macroeconomic climate, including real GDP
growth of 5-6% per annum over 2003-2005. Inflation rates also declined although
they are still above 10%. Tax revenue also increased from 17% of GDP in 2001 to
22% in 2005 (Government of Ghana 2005)
The GoG budgets for 2006 include projections for donor funding and internally
generated revenue (IGF, or user fees). The health share of the national cake as
indicated in Table 12 shows that the share of GoG spending on health is second
only to education (19% of the total and its share of the HIPC spending is also
relatively high (15%). The health sector is third to economic affairs and education in
terms of total share of government spending in the 2006 Budget (Figure 11). How is
management of the funding system in the health sector? The next section describes
cash management system in the MoH with illustration of the flow of funds in the
health sector.
Table 12: Shares of Government budget for 2006 (¢ million)
GoG
Share
(GoG)
Public
services
1,460,546.7
8%
Defence
879,079.5
5%
Health
3,465,062.3
19%
Public order
1,043,100.6
6%
Economic
Affairs
2,422,444.0
14%
Environment
66,392.4
0%
Housing
1,478,825.8
8%
Recreation
151,194.4
1%
Education
6,812,333.9
38%
Social
protection
112,191.3
1%
Total
17,891,170.9 100%
Source: Ministry of Health 2006
IGF
+ donors
Share
(IGF/donors)
HIPC
Share (HIPC)
401,943.7
0.0
1,202,979.3
75,420.8
5%
0%
14%
1%
179,700
0
200,000
25000
13%
0%
15%
2%
4,928,729.8
36,026.1
1,305,065.9
59,559.1
659,570.0
57%
0%
15%
1%
8%
405,000
0
197,000
25,000
300,000
30%
0%
14%
2%
22%
0%
35,000
100% 1,366,700
3%
100%
5,706.7
8,675,001.4
35
Figure 11: Percentage share of total Government (GoG + IGF + Donors + HIPC)
budget for 2006
Education
28%
Social protection
1%
Public services
7%
Defence
3%
Health
17%
Recreation
1%
Public order
4%
Housing
11%
Economic Affairs
28%
Environment
0%
Source: Ministry of Health 2006
4.5.1 Cash management issues
Funding for the health sector is allocated through multiple channels (see Figure 12).
The Ministry of Health has control of three main accounts: the health account
(actually two accounts in Cedis and US Dollars), which is used flexibly mainly to
finance service and investment items, a Cedi account for the service budget
allocated by the Ministry of Health, and the Aid Pool Account, which is used to hold
funding for earmarked programmes financed by donors. Funding for administration
(Item 2) is allocated to Budget Management Centres (BMCs) by the Ministry of
Finance through the district treasuries, while funding for personnel is paid directly
through the commercial banking system to health staff (see Figure 13). Funding for
investment is allocated directly by the Ministry of Finance, based on procurement
plans and orders developed by the Ministry of Health. Some donors also finance
programmes directly and (should) report spending to the Ministry of Health based on
agreed programmes of work (Ensor and McIntyre 2004).
36
Figure 12: Flow of funds to the public health sector (2001 % of expenditure)7
Service
(item 3)
Ministry of Finance
Development
Partners
Ministry of Health
Controller General
Service account
1.7%
Investment
(item 4)
Health Account
2.2%
Capital
procurement
Aid pool
6.4%
13.4%
15.8%
Pooled
earmarked funds
5.5%
Direct
earmarked
funds
Regions
Regional & district
Treasuries
7.2%
2.2%
12.4%
5.4%
11.3%
Administration
(item 2)
41.8%
BMCs
4%
IGF
Commercial
banking system
Payroll
(item1)
14.6%
Staff
Source: Ministry of Health audited Financial Statements, 2001 in Ensor and McIntyre
2004.
4.5.2 Resource allocation between levels of the health system
The existing distribution of staff is an important factor driving the resource allocation
between levels of the health system (Ghana Health Service 2003). This is due to the
fact that personnel emoluments account for the vast majority of health care
expenditure. A key target driving consideration of redistribution between levels is the
GPRS health sector target of devoting 50% of recurrent expenditure to districts and
below by 2004 (although the POW II target for this indicator is only 42%) (Ensor and
McIntyre 2004). Expenditure on headquarters (MoH and GHS), was slightly lower
than budgeted, while expenditure at teaching and psychiatric hospitals (24% of total
expenditure), was considerably above the MTEF allocation (19%). Part of the reason
for this is the greater proportion of Government of Ghana (GoG) and Donor Pool
Fund (DPF) disbursements, relative to budgets is given to these facilities, rather than
to the district levels and below. (See Figure 13).
7
Rounding errors may mean percentages don’t add to 100%.
37
Figure 13: Distribution of resources between health services levels 2002 MTEF
50
45
40
% share
35
30
25
20
15
10
5
0
TH
PH
RHS
DHS
MoH HQ
GHS HQ
Levels of health services
Source: 2002 MTEF and Ministry of Health Financial Report for June 2002 in Ensor
and McIntyre 2004
4.5.3 Resource allocation between regions
An analysis of the decision-making process for allocating resources between
individual regional offices, regional hospitals, district offices and district health
facilities was undertaken in 2001 (Ghana Health Services 2003: Ensor and McIntyre
2004). This report indicated that the formula used relied heavily on equal allocations
for facilities within the same level and on indicators of utilisation rather than need for
health services (e.g. 30% of the funds for regional hospitals are allocated equally per
facility and the other 70% on the basis of workload) (Ensor and McIntyre 2004). The
report stressed that in order to promote greater equity, it was essential to allocate
resources between regions and districts on the basis of the relative need for health
services in each area (e.g. size of the population, demographic composition, level of
deprivation, mortality rates, etc.).
The 2002 PoW commits to “refining resource
allocation criteria to address health inequities” while the overall PoW II more explicitly
states that the “resource allocation formulae [should be] revised to include health
needs, poverty and gender issues”. Only minor changes have been made to the
resource allocation formula to date and no needs-based indicators have been
included. However, considerable efforts have been made to redistribute resources to
some of the most deprived regions through taking a ‘top-slice’ from the GHS budget
38
for targeting to these regions before the other allocations are made (Ensor and
McIntyre 2004) (see Figure 14).
Figure 14: Trends in real per capita resources between regions (% below or
above national average)
100
80
60
40
2000
20
2002
0
Ashanti
-20
Brong
Ahafo
Central Eastern Greater Northern Upper
Region
Accra
East
Upper
West
Volta
Western
-40
-60
Sources: Ensor and McIntyre 2004
4.5.4 Changing sources of revenue for the health sector
During the health system review, it was also observed that the health sector sources
of funding are changing. This change would be dramatic if the NHI scheme gathers
momentum and health partners shift their funds to budget support. The other main
changes affecting resource inflows are the shift to multi-donor budget support
(MDBS) by some of the main donors to the health sector and the relative growth of
the earmarked funding. In 2005, the EU shifted its support to MDBS, the World
Bank, DFID and the Royal Netherlands Embassy (RNE) are currently debating the
modalities of shifting their support for 2007 (MOH 2006).
These are the largest
contributors to the health fund. According to the September 2005 financial statement,
the World Bank provided 45.7% of all donor assistance for the year; DFID 14.5%;
RNE 13.2% and DANIDA 10.6%. For 2006, the main funders of health care are the
RNE (18.7% of total aid to the sector); DFID (13%); and DANIDA (10%). The Danish
government has set an upper limit of 25% of its aid which can be channelled through
budget support, but faces the prospect of being the only donor to the Health Fund in
39
2007. The shift to MDBS, which is consistent with the Paris Declaration on Aid
Effectiveness 2005, and the Ghana Partnership Strategy (MOH 2006) poses a
potential threat to the health sector budget which must be managed carefully. Major
concerns include whether:
•
GoG resources to health will fall if partners shift support to MDBS;
•
The MoFEP disbursement procedures will be more cumbersome or less
flexible and predictable than the current Health Fund arrangements; and
•
There will be a loss of sectoral dialogue with donors, which could feed into
‘lost profile’ within MDGS and result in potential reductions in allocation and
spending from the current health partners.
Despite overall increases in GoG budget allocations to the health sector over the
years, much needed salary increases and the other allowances have exerted severe
financial pressure. At the same time, Government and donors have embarked on a
number of initiatives to increase the flow of funds into the system such as the Heavily
Indebted Poor Countries (HIPC) initiative, Global Funds for AIDS, TB and Malaria
and promoting health insurance.
4.5.5 Other financing sources: HIPC funds
One potential source of some additional financing for the health sector relates to debt
relief resources. Under the enhanced HIPC initiative, Ghana will have reduced debtservicing payments (Ensor and McIntyre 2004).
Debt relief does not increase
government revenue, unless there are related grants and credits. It simply allows the
Government to increase the share and value of the discretionary budget by reducing
the statutory payment budget component (which includes debt repayment
allocations).
According to the 2003 Budget Statement, debt relief savings amounted to
approximately $275 million in 2002, $183 million through traditional debt relief and
$92.5 million as additional relief from HIPC. The majority of HIPC poverty reduction
funds disbursed were made available to District Assemblies (DAs) (each of the 103
District Assemblies received ¢1 billion), Municipal Assemblies (each received ¢1.5
billion) and Metropolitan Assemblies (each received about ¢2.75 billion) (Ensor and
McIntyre 2004: Ghana Statistical Service 2005). The only condition attached to this
40
funding was that it had to be spent on education, health, water and/or sanitation
(Ensor and McIntyre 2004).
The concern is whether there was equity in the allocation of these HIPC funds. A
macro-economic policy analysis commented prior to these HIPC allocations that it
appeared as if “the Government is intent on spreading [poverty reduction] resources
evenly across regions and districts”. This assessment seems accurate, based on the
actual 2002 allocations and some would question whether this approach is equitable.
Figure 4 shows that population size differences translate into the average per capita
HIPC allocations being above the national average in districts in deprived regions
(i.e. Northern, Upper East and Upper West Regions) and below average in districts
located in less deprived regions (i.e. Greater Accra). However, if one also takes into
account the distribution of poverty between areas, with very high levels in the three
northern regions and extremely low levels in Greater Accra region, the allocation of
HIPC funds per poor person is extremely inequitable, (Ensor and McIntyre 2004).
The argument that can be made is that fairness could be promoted, and a more
dramatic impact on poverty reduction achieved, by taking inter-regional poverty
incidence levels into account when determining future allocations to local, municipal
and metropolitan districts.
4.5.6 The National Health Insurance Scheme
Another potential source of funds is Health Insurance.
International evidence
however suggests that voluntary insurance schemes do not add much to the health
sector’s resources, compared with that of user fees (Musau 1999; Ensor 1999; Ensor
2001; Dong et al 2003; Ekman 2004; McIntyre et al 2005; Baltussen et al 2006;
Aikins and Arhinful 2006). Their main benefit is to smoothen expenditure on health
care, a major advantage for the poor if they are willing and able to contribute (Atim
1999; Atim 2001; Aikins 2003; Dong et al 2003).
Compulsory health insurance
scheme act like a hypothecated tax and may generate additional resources for the
health sector (McIntyre et al 2005). However, there should be no expectation that
even the full implementation of the National Health Insurance (NHI) programme will
close the financing gap if the intention is to fund universal and comprehensive health
care.
Results of the NHI implementation to date indicate slow enrolment levels, especially
from the informal sector. The premium levels benefit package and exemptions are
41
issues of concern that would need to be examined if the NHI is to achieve its
objectives8. Enrolments are still low and many members have not obtained their ID
cards, even after several months following registration.
According to the 2006 health sector review, a total of 120 district mutual health
insurance schemes (DMHIS) are operating, with an overall coverage of 22% of the
population. Coverage, however, does not equate to membership numbers.(Health
Sector Review 2006). The membership varies significantly by region, with the highest
proportion by far being in Brong Ahafo (nearly 27% coverage), where there were
many independent schemes before the establishment of the NHI scheme. Overall,
the average is just under 16% nationally (see Table 13). However, these members
are not entitled to benefit from services until 6 months (mandatory waiting period)
after they have paid their premium, which is a source of concern. The number of ID
card-holders (those who are entitled to receive free services) is much smaller: 6.8%
nationally. The prediction (by the NHI Council) that coverage will reach 50% in 2006
(Health Sector Review 2006) has not been achieved.
Table 13: NHIS coverage, by region, 2006
% of pop.
%
of
ID card
Estimated
Membership pop.
ID holders
holders
population
members
963,448
67,995
7.1%
34,159
3.6%
U.East
561,866
52,870
9.4%
21,564
3.8%
U.West
1,790,417
270,451
15.1%
82,244
4.6%
Northern
1,968,205
525,252
26.7%
432,075
22.0%
B.Ahafo
3,924,925
592,449
15.1%
201,840
5.1%
Ashanti
2,042,753
284,863
14.0%
74,711
3.7%
Western
1,687,311
234,449
13.9%
47,597
2.8%
Central
3,576,312
597,768
16.7%
106,803
3.0%
G.Accra
2,274,453
385,577
17.0%
318,706
14.0%
Eastern
1,636,462
211,680
12.9%
68,963
4.2%
Volta
TOTAL 20,426,152
3,223,354
15.8% 1,388,662
6.8%
Source: Health Sector Review 2006
Region
8
Within the next five years, every resident of Ghana shall belong to a health insurance
scheme that adequately covers him or her against the need to pay out-of-pocket at the point
of service use in order to obtain access to a defined package of acceptable, quality health
services.” (National Health Insurance Policy Framework for Ghana, 2004)
42
4.5.6.1 Exempt categories-NHIS
A major threat to the sustainability of the NHIS is the large proportion of members
that fall within exempt categories (see Table 14). Only 12% of current members are
formal sector workers, and a further 16% are informal sector workers. Thus, a full
72% of members do not pay for the services which they receive (the largest
proportion being children, though only children of two paid up parents are eligible for
this ‘exemption’). There is also anecdotal evidence that premium collectors, (who are
already paid a 10% commission to enrol members), may also be taking bribes to
register people as indigents (Health Sector Review 2006). This will increase the
proportion of non-paying members even more. The District Mutual Health Insurance
Schemes (DHMIS) also have an incentive to enrol the exempt, as they are paid a
premium of ¢ 80,000 per person per annum from the National Health Insurance
Council9 (NHIC), which is higher in many cases than the premium informal sector
workers are charged (¢ 72,000) (Health Sector Reform 2006).
Boxes 4 & 5 show the benefit package including the excluded package for the NHIS.
Table 14: Breakdown of NHIS membership: 2006
Membership coverage
Formal sector
Informal sector
Paying members
Pensioners
Children
70+
Indigent
Overall exempt
Total
Source: Health Sector Review 2006
Number
468,092
615,450
1,083,542
43,208
1,751,175
266,421
790,078
2,850,882
3,934,424
Proportion of
members
11.9%
15.6%
27.5%
1.1%
44.5%
6.8%
20.1%
72.5%
100.0%
The National Health Insurance Council is the governing body that regulates, registers,
licenses accredits and supervises the operations of Health Insurance Schemes.
9
43
Box 4:Ghana NHIS Minimum Health Care Benefits
Outpatient Services
Consultations including reviews: these include both general and specialist consultations.
Requested investigations (including laboratory investigations, x-rays, ultrasound etc) for general and specialist
out-patients services.
Medication (prescription drugs on National Health Insurance Scheme Drugs List, traditional medicines approved
by Food and Drugs Board and prescribed by accredited practitioners).
Out-patients/Day Surgical Operations.
(e.g. hernia repair, incision and drainage etc)
Out-Patient Physiotherapy.
Inpatient Services
General and Specialist In-patient care
Requested investigations (including laboratory investigations, x-rays, ultrasound scanning etc) for in-patient care
Medication (Prescription drugs on National Health Insurance Scheme Drug List, blood and blood products)
Cervical and Breast Cancer treatment
Surgical Operations
In-Patient Physiotherapy
Accommodation (General Ward)
Feeding (where available).
Other Specific Services
Oral Health Services
Pain Relief (e.g. incision and drainage, tooth extraction, temporary relief)
Dental Restoration (simple Amalgam filling, Temporary Dressing)
Eye Care Services
Refraction
Visual Fields
A-Scan
Keratometry
Cataract removal
Eye Lid Surgery
Maternity Care
Antenatal Care
Deliveries (normal and assisted)
Caesarean Section
Postnatal Care
Emergencies
All emergencies shall be covered. These refer to crisis health situations that demand urgent intervention. They
shall include:
Medical emergencies
Surgical emergencies (including brain surgery due to accidents)
Paediatric emergencies
Obstetric and Gynaecological emergencies (including Caesarean Section)
Road Traffic Accidents
Dialysis for acute renal failure
Public Health Services funded under special programme
Some services are already being provided free of charge by Government through its public health programs.
Under the National Health Insurance Scheme government will continue to provide these services free of charge.
These include:
Immunization
Family planning
In-patient and Out-patient treatment of mental illness
Treatment of Tuberculosis, Onchocerciasis, Buruli Ulcer, Trachoma
Confirmatory HIV test for AIDS Patients
44
Box 5: Ghana NHIS Excluded Benefits
The NHIS is intended to cover basic healthcare treatment. As such, certain services will not be
covered under the National Health Insurance Scheme. District health insurance schemes have the
discretion to decide whether or not they will offer the following services as additional benefits to
their members.
Rehabilitation other than physiotherapy
Appliances and prostheses (optical aids, hearing aids, orthopaedic aids, dentures etc)
Cosmetic surgeries and aesthetic treatments
HIV retroviral drugs (symptomatic treatment of opportunistic infections and other AIDS related
diseases will be covered).
Assisted reproduction (e.g. artificial insemination) and gynaecological hormone replacement therapy
Echocardiography
Photography
Angiography
Orthopaedics
Dialysis for chronic renal failure
Organ transplantation
All drugs that are not listed on the NHIS drugs list
Heart and brain surgery (other than those resulting from accidents) and cancer treatment (other than
breast and cervical)
Mortuary services
Diagnosis and treatment abroad
Medical examinations for purposes other than treatment in accredited health facilities (e.g. visa
application, educational, institutional, driving license etc)
VIP ward (accommodation)
Source: MOH 2004, NHI Policy Framework for Ghana: Revised version.
At present, 3.87% of the total population have been registered as indigents under the
NHIS, which is higher than the original budget estimate of 0.5%, but lower than the
estimated 27% of the population which are classified as ‘very poor’. The process for
identifying indigents, carried out by the DHMIS with community involvement, is
currently vague and open to abuse. It is not clear if ceilings are set for the proportion
of indigents which can be enrolled by a DHMIS, and if so, whether this ceiling is
uniform or related to poverty rates in the district.
4.5.6.2 Sustainability of financing
The revenue for the NHIS currently comes from a 2.5% levy on VAT; mandatory
payroll deductions of 2.5% of the 17.5% Social Security and National Insurance
45
Trust10 (SSNIT) contributions for formal sector workers; and graduated premiums for
the informal sector.11 Box 6 outlines some of the constraints to growth.
Box 6: Constraints to growth of income from premiums include:
•
The large informal sector (80% are working in the private informal sector,
according to the 2000 census (Ghana Statistical Service 2002)), for which is
hard to enforce membership (membership is currently voluntary for this group,
but the plan is to move towards compulsory membership);
•
The large size of the groups which are eligible for exemption (for example,
children under 18 constitute 41.3% of the population);
•
The low premiums, which are currently being paid12. Any increase in these
would reduce the scheme’s attraction to the informal sector and stretch
willingness and ability to pay;
•
The fact that most of the formal sector is already covered now (it will never be
fully enrolled; there is a right to opt for private insurance cover).
Source: Health Sector Review 2006
Financial viability is also potentially threatened by the comprehensive nature of the
benefits package, as currently designed (it covers all services, with only a few
restrictions on prosthetics, cosmetic surgery etc.)13.
There are no co-payments,
including drugs, and as both clients and providers have an interest in increasing the
number and quality of services offered, the insurance schemes will have to develop
systems for controlling cost escalation. Monitoring data collected in Brong Ahafo and
Eastern Region by DANIDA in 2005, show that costs per OPD and per admission are
higher for insured than for non-insured clients, which is probably due to a
Employees contribute 5% and employers contribute 12.5% making a total of 17.5%. This is
meant to act as a retirement benefit to employees. With the NHIS, 2.5% of the 17.5 % is
deducted as part of the National Health Insurance Fund. Because of this deduction, formal
employees are exempted from paying premiums to become members of the National Health
Insurance Scheme.
11
The levy on VAT (expected to yield ¢ 1.34 billion in 2006 and currently providing about twothirds of the NHIS revenue at national level) is not related to the size of coverage, so there is
a curious perverse incentive for the NHIS to not extend coverage too high - higher coverage
will lead to higher claims, but without significantly increasing revenue as the premia are low
and the majority of members are exempt, if current patterns continue (MOH 2006)
12
Premia are meant to be graduated, from ¢72,000 to ¢ 480,000, according to income.
However, it is not possible to make assessments of income so in practice virtually all are
paying the bottom tariff. The regional report for Eastern Region for 2005, for example, quotes
rates as ranging from ¢72,000 to 80,000 per adult. The average per paying adult is ¢74,000.
13
Schemes prior to the NHIS tended to offer more limited packages – commonly outpatient
care was excluded (Whitaker & Walford 2003).
10
46
combination of supply-induced demand and/or moral hazard14. Another study of the
Nkoranza scheme in 2005 showed a high rate of caesarean delivery (15%), whereas
universal indications for this surgical procedure range from 5-10%. Restrictions on
self-referrals to secondary and tertiary care will also be an important way of curbing
costs in future, as the unit costs of care rise steeply at higher levels in the health
system.
The level of overheads being carried by the NHI Fund15 (NHIF) is also of concern. By
March 2006, ¢114 billion had been disbursed by the NHIC, of which 33% was spent
on administration. The NHIC employs 22 people at national level, but in each district
it pays for a staff of five and allowances to a board of 15 local members. While
higher set-up costs are to be expected at the start of a scheme, this proportion
should fall as the scheme grows and should be monitored to ensure that it does not
remain higher than the stipulated limit of 20%16.
Of most immediate concern is the possibility that the fund, or at last district funds, will
run out of cash. This is to be expected as insurance schemes enrol members but
need to pay for services before the fund has been fully funded by accumulated
premiums. To date, the NHIF has benefited from the build up of formal sector worker
contributions before the scheme was launched; the failure to sign contracts with
tertiary institutions (which are now getting under way); and the lag time between
joining and being eligible to benefit from services. As these financially advantageous
circumstances fade, some of the schemes may face cash flow deficits. This could be
potentially catastrophic. The NHIF would be unable to pay providers and confidence
would be lost. Providers might then be reluctant to exempt members from charges
so that consumers’ confidence in the scheme would be eroded.
Generally, this
means that young insurance schemes need to be capitalised during their first few
years if operation. The problem may be avoided in the case of the NHIF by the
continued inflow of revenues from VAT and SSNIT, but it would be better to be
certain.
It has been agreed to build some cash flow scenarios under different
14
Moral hazard is the tendency to abuse the scheme by clients, providers or both. On the part
of clients, this is commonly done by consumption of unneeded services because they no
longer have to pay out of pocket and the service appears free. On the part of providers, this
is commonly done by provision of unnecessary services and over billing in order to earn more
revenue. (Ghana Health Service 2004)
15
The NHIF is a fund set up by Government where funds accrued from various sources are
deposited for disbursement to District Health Insurance Schemes.
16
District Assemblies (DAs) have also assisted with set-up costs, such as office equipment
and computers, as have interested donors such as DANIDA.
47
revenue and cost assumptions to test the robustness of the NHIF’s future cash flow
position.
One of the objectives of the insurance scheme was to reduce financial barriers and
so increase utilisation. This is now being reported in areas where the schemes are
operational and may be an indicator of success, rather than ‘frivolous use’ of services
as is generally assumed.
Although increased health service activity is of prime importance, utilisation rates
should be monitored, preferably by region and socio-economic group, as there is a
risk that increased usage by the insured actually reduces access for the poor. The
highest risk is that those with good access to facilities are more likely to join and to
increase their demand for services. This will eat up a greater share of the public
budget too, as the NHIS currently only covers the user fee component of costs (less
than a fifth of full costs).
The growth in utilisation also poses a challenge to quality of services, given the
limited capacity and staffing in many areas. Accreditation of private providers, quality
assurance of existing public and mission facilities (which has yet to be carried out),
and the creation of an incentive for health workers, are all equally important to ensure
that quality does not deteriorate.
At present, provider facilities are paid on a fee-for-service basis, which is the familiar
system, but it is prone to supply-induced demand.
The NHIC initially drew up
national tariffs for drugs and services, but they were found to be higher than the
prices charged by facilities. As a result, in most cases, facilities charge the NHIF at
IGF rates for both drugs and services. There are alternative charging arrangements
that might have advantages in containing costs and increasing the incentives
providers have to be efficient. For example, the mission sector has standardised fees
for different cases, irrespective of the number of consultations or admission days,
and it would not be difficult to do the same in the government sector.
4.5.6.3 Future role of the NHIS
Although the NHIS aims to replace IGF income, it offers the potential to shift
purchasing of all, or parts, of curative care from the MoH to the NHIS (Health Sector
48
Review 2006). This would leave the GHS BMCs as the purchasers of public health
services (‘non-personal’ services).
However, it is important to separate this discussion from another important one:
whether the NHIS might eventually be a more efficient mechanism for purchasing
care from providers and its potential as a fund-raising mechanism. In light of the
points made above, the NHIS should be seen primarily as a way of smoothing health
care costs for households, rather than adding to the sector budget as a whole.
Although it has brought in additional funds in the form of the VAT levy, the MoFEP is
able to offset that against other sources, so its overall resource mobilisation effect
may be neutral.
There are already plans for a new phase of reforms to the system from within the
NHIC, which is currently both the regulator of schemes and also the manager and
conduit for funds (Health Sector Reform 2006).
The plan is to separate those
functions and also to cut costs and increase the size of the risk pool by creating a
unified scheme, with zonal offices (rather than the current system of independent
mutual schemes at district level). This would make benefits ‘portable’ without the
need for schemes to compensate each other. The NHIC would also like employers
to make a contribution equal to that of employees (2.5% of SSNIT). Also under
discussion is the creation of a uniform price (at a higher level) for informal sector
workers and the option of offering two packages – a basic one, and one with higher
quality (non-clinical) features, such as food and accommodation. While many of
these suggestions make sense from a business point of view, they would increase
the cost to employers and members, and may have labour market consequences
that may not prove acceptable.
The implementation of the NHIS in Ghana proceeded with various forms of insurance
schemes some of which never went beyond the planning stage. Table 15 provides
an overview of the various forms of schemes including the current NHIS which has
grown to replace all existing schemes.
49
Table15: Overview of health insurance in Ghana
Name
Features
Stated
objectives
Provision of
free medical
care for civil
servants and
some
beneficiaries
Civil servant
Health Care
Schemes
(i.e. Ashanti
& Upper
West
Regions)
Existing
Public
Sector
Health Care
Schemes
“Centralized
National
Health
Insurance
Company”*
Earlier
Public
Sector
Initiatives
To
mainstream
compulsory
Social
Insurance
Scheme for
SSNIT
employees
and
registered
cocoa farmers
Forty-seven
MHOs
nationwide
functional in
2001
Community
initiatives
To improve
financial
access to
health care
Revenue
collection
- Past 4 years,
Government annual
allocation of ¢3.5
billion (June 2000)
- Channelled
through the
Regional Health
Administration for
all MDAs
- Formal sector
contributes 5% of
salary;
- Registered cocoa
farmers contributes
7.19% of producer
price
- Pilot rural-based
communityfinanced schemes
for non-formal
sector
- Annual
contribution by
members
- Schemes
collection
premiums
Pooling of funds
Purchasing
Provision
Free medical care for
76,703 civil servants,
their spouse & 4 children
- Comprehensive services (primary care &
hospital services)
- Fee for service
- Mainly
public
providers
- All SSNIT contributors
- Registered cocoa
farmers
Comprehensive services (primary care &
hospital services)
Enrolees
register with
single
preferred
provider
- 86,822 total members
-Low risk-equalization
between insurers
- Mainly outpatient services at primary
health care
- Public &
Mission
facilities
depending on
the
originators of
the Scheme
50
Name
Features
Nationwide
Mutual
Medical
Insurance –
1993 under
the auspices
of the
Society of
Private
Medical
Practitioners
Private
Sector
Initiative
Metropolitan
Health
Insurance
Plan –
Metcare
Private
Sector
Initiative
Ghana
Healthcare
Private
Sector
Stated
objectives
Revenue
collection
- Annual
contribution by
members
- Premium
collection by
Insurance company
Pooling of funds
Social
responsibility
Metropolitan
Insurance
Company
- Based on commercial &
industrial medical Aid
Society of Zimbabwe
- 15,000 members on full
coverage
- 25,000 members on
partial coverage
Access to
basic facilities
SSNIT
Established by SSNIT in
1999
51
Purchasing
a) Classic package:
- ¢2 million per annum for out-patient care;
- ¢5 million per annum for In-patient care;
b) Premier package:
- ¢3 million per annum for out-patient care;
- ¢8 million per annum for In-patient care;
c) Executive package:
- ¢5 million per annum for out-patient care;
- ¢10 million per annum for In-patient care;
d) Prestige package:
- Most comprehensive package;
e) Sankofa package:
Design for those living aboard who wants
to buy package for relatives living in
Ghana
a) General Care Policy for basic health
care at ¢20,000;
Provision
Registered
members of
the Society of
Private
Medical
Practitioners.
In 1997,
Scheme ran
into technical
solvency with
National
Insurance
Commission.
`
Both
government
and private
facilities
200 private
hospitals &
Name
Features
Company
Initiative
Stated
objectives
at affordable
contribution
Revenue
collection
- Annual
To improve
District-wide Current
contribution by
Public
financial
Health
members
Initiatives
access by
Insurance
- Schemes
replacing the
Schemes in
existing “Cash collection
all 138
premiums
and carry”
district
- NHI
system
functional to
some decree
Framework of analysis adapted from (Kutzin, 2001)
Pooling of funds
Purchasing
Provision
- 180,000 employees
b) Premier Care Policy for basic and
private health care at ¢40,000;
c) Super Care Policy most comprehensive
at ¢80,000
Comprehensive services (primary care &
hospital services)
clinics&
pharmacies
- 22% of total population
but only 6.8% currently
have IDs to enable them
access services
*This scheme never took off
52
Public,
mission
facilities in
the districts
and some
private
facilities
4.5.6.4 Recent Studies on Health Insurance in Ghana: Key findings
The Ghana-Dutch Collaboration for Research and Development which was
established in the year 2000, has sponsored most recent research in the health
sector. Research conducted on health insurance can be classified into four main
areas: 1) Design and implementation; 2) Community views and perceptions; 3)
Evaluation; and 4) Provider perspective. In all, details of seven studies have been
summarised in Table 16.
The findings of the studies range from perception of
providers, premium payment mechanism, benefit package, resource mobilization,
and scheme challenges.
53
Table16: Summary of recent studies on Health Insurance in Ghana
Topic
Evaluation of
informal
mutual health
organisations
in the
southern and
northern
sector of
Ghana (Baku
et. al.,
Unpublished)
Main Objectives
To evaluate existing informal
mutual health financing schemes
and identify best practices,
nagging problems, to inform policy
decision on workable options for
health financing in the formal
sector.
Key Findings
ƒ
Most scheme members were illiterate.
ƒ
Schemes studied employ a flat rate
premium system.
ƒ
Quality of service is motivation for joining a
scheme.
ƒ
Payment of premiums was by cash.
ƒ
Varied benefit packages.
ƒ
Resource mobilisation, major problem.
Financing
Health
through
community
Health
Insurance,
what the
community
thinks (Galley
& Afenyaadu,
Unpublished).
To explore the views of rural
communities in the Juabeso-Bia
district on Mutual Health
Organisations.
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Community
Satisfaction,
Equity in
coverage and
implications
for the
sustainability
of the
Dangme West
Health
Insurance
Scheme
(Bruce et al.,
Unpublished)
Perception
and Demand
for Mutual
Health
Insurance in
To describe community
perceptions of, experience and
satisfaction with the Dangme West
Health Insurance Scheme
(Dangme Hewaminami Kpee or
DHK); ability of scheme to
equitably reach all households;
and the potential influence of
these on the sustainability of the
scheme
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
To provide relevant information
that would lead to informed
decision-making in the design and
implementation of mutual health
insurance schemes in the
ƒ
ƒ
ƒ
Many not involved in decisions making.
Many prefer health insurance to cash and
carry.
Many prefer monthly contribution of
premium.
Premium payment influenced by ability to
pay.
Want the health insurance to be owned
and managed by community members.
Choice of treatment was based on quality
of care, proximity, and cost.
Contributors are contributing for free,
quick, quality health services.
Sources of set-up funds: Royalties from
chiefs, SSNIT and HIPC fund.
Other means of pre-financing: Deducting a
percentage from the sale of cocoa beans
from farmers.
Wide expression of dissatisfaction.
Less poor households registering in
disproportionately higher numbers.
Insured clients were made to wait longer
than uninsured clients.
Disapproval by providers when insured
clients made multiple clinic visits.
Reasons for refusal to renew: not having
money, large household size, poor
reception; quality of drugs given.
Reasons for not registering: no money, no
enough information and did not understand
it etc.
Existence of risk sharing groups like
farmers groups etc.
Some members prefer cash payments on
instalment basis.
Forcing the sick to pay before receiving
54
Topic
the KassenaNankana
district of
northern
Ghana.
(Akazili et al.,
Unpublished)
Main Objectives
Kassena- Nankana District and
other districts of similar socioeconomic and cultural values.
Key Findings
health care identified as the main setback.
ƒ
Members expect more fairness, some
respect from health personnel etc.
ƒ
Age and area of residence influences
one’s willingness to contribute to a MHIS.
What are the
staff saying”?
Providers’
perspective of
the National
Health
Insurance in
Ghana (Cofie
et al.,
Unpublished).
Evaluating the
effects of the
National
Health
Insurance Act
in GhanaBaseline
report
September
2005
(Sulzbach et
al.,
Unpublished)
17
.
To examine the health workers
knowledge, perceptions and
concerns and assess their
readiness towards the
implementation of the health
insurance
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Major problems identified:
Shortages of staff.
Lack of transportation.
Work pressures.
Inadequate water supplies.
Improper record keeping.
Inadequate supervision.
ƒ
The insured more likely to seek formal
health care than uninsured.
Insured inpatients were significantly more
likely than uninsured patients to receive an
x-ray.
Insured patients were largely able to afford
their care.
Uninsured patients did not have sufficient
cash reserves to pay their bills.
Insured women were significantly more
likely to deliver by caesarean.
Insured paid significantly less for delivery
care than did uninsured women.
Wealth was a significant factor in the
outcome of interest.
Mutual Health
Organizations
(MHOs) in
Ghana and
Implications
for Improving
the Success
of Health
Insurance
(Bruce &
Bultussen,
Unpublished).
To make an inventory of risk
mechanisms and other technical
features of Mutual Health
Schemes and its effect on
economic sustainability of
schemes.
17
•
•
To provide the GHS with
timely information on the
implementation of the
National Health Insurance
Scheme at the district level.
To monitor the effects of the
implementation on providers
at the district level.
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Private and public schemes had few
measures in place to : (1) Control moral
hazard and reduce adverse selection; and
(2) Most schemes were managed by paid
staff.
Very few public schemes and slightly more
private schemes use actuarial methods to
set premiums and define benefit packages.
Financial performance indicators varied
widely between schemes.
Both public and private MHIS make only
limited use of risk management techniques
This study was funded by PHRplus
55
4.5.6.5 Research agenda to support health financing (including National Health
Insurance) policy and programme development and implementation in Ghana
Apart from the health insurance studies listed above, key stakeholders have held two
meetings, in 2005 and 2007 as part of work financed by the Netherlands
Organisation for Scientific Research.
The main goal was to inform selection of
research areas (see Table 17) to make sure that research on health financing and
community health insurance in Ghana contributes to contribute to useful and
meaningful information to input into policy and programme development and
implementation (GHS 2007). Below is a table showing priority areas for research in
health financing in Ghana, as discussed by the key stakeholders, using Kutzin’s
framework (Agyepong, et al. 2007).
56
Table 15: Issues from 2005 and 2007 stakeholder meetings on priority issues for research put into a modification of Kutzin’s framework of
functions of the health care financing system
Function
Sources of
revenue to
support the
scheme
and
methods of
collection
/fund
mobilisatio
n
ƒ
ƒ
Cross Cutting
Research Issues
and impact
questions
How
to
increase
overall ƒ Impact of
premium
coverage of NHIS: Increasing
payments on
voluntary enrolment in the
equity (are
district mutual health insurance
different socioschemes and therefore the size
economic groups
of the risk pool and revenue
registering
generated from premiums (preequally and
paid resources)
therefore equally
o Who enrolls?
benefit from the
o What makes people to
general
enroll or not (issues of
trust
and
solidarity,
government tax
revenue
willingness to pay, ability
subsidies to the
to pay, expectations,
NHIS)
socio-economic
o Who
background, literacy)
benefits
o Impact
solutions
as
o What
spread payments???
impact on
o Costs
of
increasing
health
enrolment
status
Sustainability of the current
o What
benefit package and groups of
impact on
exempt in relation to the
out of
premiums, amounts generated
pocket
by the National Health Insurance
Currently available research information
Priority policy questions
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Samuel Prah (2006) Factors contributing to low registration of the NHIS in
Kassena Nankana district. MPH thesis, UG-SPH
Robert Adatsi (2006) Factors affecting enrollment in the NHIS – A Study
from the Ho Municipality. MPH thesis, UG-SPH
Agyepong I.A., Bruce E.S., Narh-Bana S., Ansah E., Gyapong M. (2006)
Making health insurance and equitable and pro-poor financing mechanism
in Ghana: some reflections. Medical Education Resources Africa (MERA).
January 2006. Issue 21. Ghana Edition. Pages 5 – 14
Arhinful Daniel Kojo (2003) The Solidarity of Self-Interest. Social and
Cultural feasibility of rural health insurance in Ghana. University of
Amsterdam. Doctoral thesis.
Asenso-Okyere WK, Osei-Akoto I, Anum A, Appiah EN ( 1997) Willingness
to pay for health insurance in a developing economy. A pilot study of the
informal sector of Ghana using contingent valuation. Health Policy.
Dec;42(3):223-37
Atim C. (1999) Social movements and health insurance: a critical
evaluation of voluntary, non-profit insurance schemes with case studies
from Ghana and Cameroon. Soc Sci Med.;48(7):881-96
Daniel Kojo Arhinful August 2005Evaluation of Danida Supported Health
Insurance Schemes Operating From 2001- 2003: Okwawuman Health
Insurance Scheme Eastern Region Unpublished work
Dr. Moses Aikins September 2003 Emerging Community Health Insurance
Schemes/Mutual Health Organizations in Ghana: Danida’s Achievements
and Challenges Unpublished work
Supervised by Ib Bygbjerg Health Insurance Schemes In Northern Ghana:
57
Function
ƒ
ƒ
ƒ
ƒ
Cross Cutting
Research Issues
and impact
questions
payments
Levy and supported provided by
o What
other government tax revenue
impact on
How to mobilize funds to cover
reduction
exempt groups too poor to pay.
of
Premiums
catastroph
o Basis
for
setting
ic health
premiums
expenditur
o Is there a need to
e
standardize premiums or
leave it open to the ƒ Impact of
decentralization
schemes
o Willingness to pay and ƒ Public-private
partnerships
ability to pay premiums
o Use
of
non
cash ƒ Community
mobilisation/
payments especially in
participation in
rural
subsistence
governance,
economies with little
social support
cash flow
networks)
o Implementation
of
exemptions /subsidies
o Should there be copayments?
o If
co-payments
introduced:
Optimal level of co-payments
with
health
insurance
(deductibles, ceilings)
Currently available research information
Priority policy questions
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
A case study of Salamba Women’s Health Insurance Scheme November
2003. Unpublished work
Dr Moses Aikins Jaman South Health Insurance Scheme, Brong-Ahafo
Region. External Evaluation, 2004 Unpublished work (Study)
Moses Aikens (2004) Tano Health Insurance Scheme External Evaluation.
Unpublished work
George Y. Segnitome September, 2005 The District Mutual Health
Insurance Scheme In Bosomtwe-Atwima-Kwanwoma. The Expectations Of
The Community. Student thesis
Patience Fakornam Doe September, 2005Community Perceptions Of
Asuogyaman Health Insurance Scheme: A Case Study Of The AdjenaGyakiti Sub-District. A Dissertation
Richard Fosu 1999 Community Based Health Insurance Scheme In
Nkoranza District – Design, Implementation, Management And Patronage
A Dissertation
George Abraham, 2003. Evaluation Of The Susu Health Insurance
Scheme In Manhyia Hospital, Kumasi (Ashanti Region). Student
dissertation
Dr. Francis Boakye Takyi August, 2002 Community Health Financing: The
Wayforward In Agogo Sub District. A Dissertation
Adjei Adjeisah George June, 1999 Demand For Health Insurance: A
Survey Of Formal Sector Employees In The Birim South District Of The
Eastern Region, Ghana. A Thesis
Amoako, Kwame August, 2001Factors Affecting The Feasibility Of A
Community Health Insurance Scheme At Poyentanga In The Wa District.
Student dissertation
C. Lawuo Mulbah-Gwesa September, 2002 The Dangme West
Community Health Insurance Scheme: How Affordable is the Premium?
Student dissertation
58
Function
Priority policy questions
Currently available research information
Cross Cutting
Research Issues
and impact
questions
ƒ
Pooling of
health care
revenues
Allocation
of
resources
ƒ
ƒ
Where and how to pool funds:
o Is the current
arrangement of
independent fund holding
by district level MHO
adequate
o Should we consider
regional level fund
pooling
ƒ
ƒ
ƒ
ƒ
How to allocate financial
resources between central/subƒ
national/community levels or
between levels/types of services
(public health interventions, PHC ƒ
and hospital sector)
o What are roles of central
and local government (in
lieu of decentralisation)
with regards to financing
service provision
(essential package of
services) and/or
o With regards to reaching
poor/vulnerable –
removing or decreasing
Henry Dako Offei-Akoto (2002) Factors Affecting Feasibility Of A
Community Health Insurance Scheme In Funsi Area Of Wa District.
Student dissertation
Impact on equity
and access
Impact of
decentralisation
Public-private
partnerships
Impact on equity
and access
Impact of
decentralisation
Public-private
partnerships
59
Function
Priority policy questions
ƒ
ƒ
ƒ
ƒ
ƒ
Cross Cutting
Research Issues
and impact
questions
Currently available research information
financial access barriers
Costs and cost-benefits of
various interventions
Economic evaluation and costeffectiveness of resource
allocation and alternative use of
resources.
How much is being spent on
administration versus payment
of benefits and entitlements
What is the cost of running the
national health insurance council
versus the costs of running the
district mutual health insurances
schemes i.e. how much money
stays at the central level versus
how much goes to the
implementation levels?
How to compose/revise benefit
package to be covered by
insurance
o Basis for package
o Cost effectiveness of
package
o Cost analysis
(affordability for the
scheme)
o Coverage of essential
services for the
60
Function
Priority policy questions
Currently available research information
Cross Cutting
Research Issues
and impact
questions
population
Possibility of
standardisation, based
on cost analysis and
objectives of the NHIS
Is the insurance scheme
financially sustainable under
current arrangements
o Costs of running
schemes versus revenue
o Effectiveness of risk
equalisation
o Impact of NHIS on
uptake of services and
cost of care
o Methods of minimising
abuse by schemes,
providers and clients
o
ƒ
Purchasing
and
provider
payment
arrangeme
nts and
behavior
ƒ
How effective are the current
contracting arrangements and
performance agreements for
various types of services and
service providers
o Inpatient care
o Outpatient care
o Public sector
o Private not-for-profit
o Private self financing (for
ƒ
ƒ
ƒ
ƒ
Impact on equity
and access
Provider
autonomy
Public-private
partnerships
Impact on quality
of care
o How is
provider
ƒ
ƒ
ƒ
Asenso-Okyere, W. K., Osei-Akoto, Isaac, Anum, Adote & Adukonu,
Augustina
(1999)
The behavior of health workers in an era of cost sharing: Ghana's drug
cash and carry system. Tropical Medicine & International Health 4 (8), 586593..1999.
Daniel Kojo Arhinful August 2005Evaluation of Danida Supported Health
Insurance Schemes Operating From 2001- 2003: Okwawuman Health
Insurance Scheme Eastern Region Unpublished work
Dr. Moses Aikins September 2003 Emerging Community Health Insurance
Schemes/Mutual Health Organizations in Ghana: Danida’s Achievements
61
Function
Priority policy questions
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
profit)
What are the most appropriate
provider payment forms
/mechanisms by levels and type
of care
o Public health
interventions
o Primary health care
o Hospital care
Contractual arrangements with
providers
Claims administration
Efficiency of gatekeeper system
(including client acceptability)
Costing of services
Incentives/motivations of
payment mechanisms
o On providers
o On quality of care
o On consumers
What are the effects of the
provider payment and
contractual agreements on
provider financial viability
o Revenue of local health
facilities in relation to
expenditure
o Impact of NHIS on
uptake of services and
Cross Cutting
Research Issues
and impact
questions
behaviour
towards
clients in
the
context of
NHIS
o Revenue
of local
health
facilities
o Impact of
NHIS on
uptake of
services
and cost
of care
o Efficiency
of service
delivery
o Treatment
and costs
of insured
versus
non
insured
ƒ Relationships
between scheme
and providers
Currently available research information
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
and Challenges Unpublished work
Agyepong I.A., Bruce E.S., Narh-Bana S., Ansah E., Gyapong M. (2006)
Making health insurance and equitable and pro-poor financing mechanism
in Ghana: some reflections. Medical Education Resources Africa (MERA).
January 2006. Issue 21. Ghana Edition. Pages 5 – 14
Dr Moses Aikins Jaman South Health Insurance Scheme, Brong-Ahafo
Region. External Evaluation, 2004 Unpublished work (Study)
Dr Moses Aikins & Ms. Gifty Okang April 2006 Utilization and Cost of
Health Care under the District Health Insurance Schemes: A case study of
Brong-Ahafo and Eastern Regions (September - December 2005).
Unpublished work
Dr Moses Aikins & Ms. Helen Dzikunu. Utilization by and Cost of Health
Care of the Insured Poor in Saboba-Chereponi District, Northern Region
June 2006. Unpublished work
Moses Aikens (2004) Tano Health Insurance Scheme External Evaluation.
Unpublished work
Kenneth Kwablah Yao-Dablu The Effect Of The Nkoranza Community
Health Insurance Scheme On Access To Health Care, December, 2000.
Student thesis
Dan Osei (2006) Developing Unit Cost Data for health facilities to achieve
cost standardization for an Effective National Health Insurance Scheme.
Unpublished work
62
Function
Priority policy questions
o
o
Benefits
and
Entitlement
ƒ
ƒ
ƒ
General
ƒ
Currently available research information
Cross Cutting
Research Issues
and impact
questions
cost of care
Efficiency of service
delivery
Treatment and costs of
insured versus non
insured
Composition of benefit package,
what services have to be
included and for whom
Cost-sharing arrangements for
benefit package (exempted
population or services)
Designing and Implementing
exemptions: How to identify the
indigent or too poor to pay
o How to identify the poor
and vulnerable
o Individual versus
household measurement
of and identification of
‘indigent’ status
o Geographical versus
categorical targeting
o Costs of identifying the
indigent
How to manage NHIC – Scheme
ƒ
Impact on access
and equity
ƒ
Stierle F , Kaddar M., Tchicaya A., Schmidt-Ehry B. (1999) Indigence and
access to health care in sub-Saharan Africa. The International Journal of
Health Planning and Management Volume 14, Issue 2 , Pages 81 - 105
ƒ
Amoako N, F Feeley, and W Winfrey. (2002). Health Financing in Ghana:
Willingness to Pay for Normal Delivery Benefits in a Community- Based
Health Insurance Plan. Washington DC: USAID/Commercial Market
Strategies Project.
ƒ
Baltussen R., Bruce E., Rhodes G.,
Narh-Bana S.A. and Agyepong I.
63
Function
Priority policy questions
manageme
nt issues,
regulation
and
relationshi
ps between
players and
stakeholde
rs18
ƒ
ƒ
relations
o Need for networking and
experience sharing
between zones /districts
and between
implementers and
national policy makers
o Monitoring and
evaluation
How to manage scheme
provider relationships
What is an optimal management
information system
o In general, what
information should
governments and MHO
collect
o Data analysis of NHIS
database
o Development of
monitoring and
evaluation system: for
accountability and lesson
learning between
schemes
o Software (standardized)
Currently available research information
Cross Cutting
Research Issues
and impact
questions
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
(2006), Management of mutual health organizations in Ghana. Tropical
Medicine & International Health, Volume 11 Issue 5 Page 654
Daniel Kojo Arhinful August 2005Evaluation of Danida Supported Health
Insurance Schemes Operating From 2001- 2003: Okwawuman Health
Insurance Scheme Eastern Region Unpublished work
Dr. Moses Aikins September 2003 Emerging Community Health Insurance
Schemes/Mutual Health Organizations in Ghana: Danida’s Achievements
and Challenges Unpublished work
Supervised by Ib Bygbjerg Health Insurance Schemes In Northern Ghana:
A case study of Salamba Women’s Health Insurance Scheme November
2003. Unpublished work
Dr Moses Aikins Jaman South Health Insurance Scheme, Brong-Ahafo
Region. External Evaluation, 2004 Unpublished work (Study)
Moses Aikens (2004) Tano Health Insurance Scheme External Evaluation.
Unpublished work
Veronica Asafo Adjei (2004) Social Security Systems for the excluded
majority. The extension of health insurance to the informal sector in
Ghana. Student dissertation
18
Not all the issues here require research per see. At the most they may require simple operational investigations to inform design of a way forward. However
they were raised at the stakeholder meeting as unanswered issues in implementation of concern
64
Function
Priority policy questions
Cross Cutting
Research Issues
and impact
questions
Currently available research information
Process documentation
o Analysis of the policy
process of introducing
MHO
ƒ Knowledge and awareness of
implementers
o Implementation
procedures
o Knowledge of policy, NHI
framework
o Information flow:
translating national policy
to district implementation
o Need for regular
meetings
scheme/providers/clients
per scheme /district
Source: MoH/GHS 2007 Research agenda to support National Health Insurance Implementation in Ghana.
ƒ
65
5. FINANCING AND BENEFIT INCIDENCE ISSUES
5.1 Introduction
Identifying and measuring the existing health care financing and benefit mechanisms
to establish their level of progressivity, or relative burden on the poor compared with
the rich, as well as identifying and evaluating the factors19 influencing health care
financing burden are critical for achieving equity within the health system.
The
SHIELD project will define financing and benefit incidence as “the distribution of the
health care financing burden between different socio-economic groups” and “the
distribution of health care benefits emanating from the consumption of health care
services
between
different
socio-economic
groups”
respectively.
New
methodological tools have been developed to improve the measurement of equity in
health care financing and provision (van Doorslaer et al. 1993). Unfortunately, the
application has remained focused on the health care systems of developed countries
(Wagstaff and van Doorslaer 1993; Wagstaff et al. 1999), with very limited application
in developing countries, including those in Sub-Saharan Africa (Cissé et al. 2006).
The Ghana SHIELD programme of work will generate comprehensive and detail
incidence data which will be based on existing household data from the Ghana Living
Standard Survey and the Core Welfare Indicator Questionnaire Survey (GLSS V and
CWIQ) and case studies at the community and household levels.
The need for
comprehensive financing and benefit incidence data emanates from the fact that
there are very limited studies on these important indicators of the health system. For
instance, a literature search revealed only one known study related to financing
incidence by Stephen Younger on tax incidence in Ghana, carried out over tens year
ago (Younger 1996). Another literature search on benefit studies also revealed one
study by Lionel Demery on incidence of social spending in Ghana in 1995 (Demery et
al. 1995). With these limited studies, the Ghana SHIELD programme of work has the
onus responsibility of carrying out ground-breaking comprehensive financing and
benefit incidence studies for the health sector in the country.
19
Contribution rates and structure, nature of risk pooling, exemptions mechanism, subsidy,
purchasing, benefit package, provider payment mechanisms, quality of care
66
5.2 Financing incidence
In evaluating the financing incidence of the health system, it is important to analyse
the burden, or the progressivity, of each of the identified financing mechanisms. It is
also important to weight each of the financing mechanisms, establishing their
contributions to the overall progressivity of health care financing..
Currently in
Ghana, health care payment mechanisms include general tax, the national health
insurance contributions, and out-of-pocket payments.
5.2.1 General tax
5.2.1.1 Direct tax
Income taxes are deducted from the wages and salaries of the formal sector. The
vast majority of these employees work either in the civil service or in public
enterprise, even though a few large private companies also deduct tax directly from
income. This tax would appear progressive and this is supported in a study
conducted Younger in 1996 (Younger 1996).
Younger used the 1988 GLSS to
analysis the progressivity of this tax, and found that personal income tax (PIT) was
progressive. “Daily Tax”20 is also captured in Younger’s analysis.
‘Daily Tax’ is
collected mostly from small scale self-employed businesses as presumptive income
taxes. Younger found out that only 700 household (representing 23% of the sample)
paid this type of tax, reflecting the large number of households engaged in selfemployment and thus explaining the widespread use of this tax. This tax was found
to be regressive which lends support to the complaints from the small businesses
about the fairness of this tax. Another tax was corporate tax (CT). The debate about
this tax has largely been around whether increases in corporate taxation will result in
lower wages, lower retail earnings, or higher prices. Some writers assume an equal
share (50%) of burden for consumers and shareholders (mainly foreign owned in
Ghana) for CT and others assume a 10% burden on consumers and 90% burden on
shareholders of the companies (Younger 1996; Martinez-Vazquez 2004). This tax
was not calculated in the Younger study. Rather, he analysed “annual taxes and
licenses”. These are income taxes that pertain to larger family-owned enterprises,
that file an annual income tax return. Some of these enterprises may or may not be
20
This is collected mostly from small, self-employed businesses as presumption income tax.
The study revealed that 700 households, 23% of the sample paid this type of tax, reflecting
the large number of households engaged in self-employment activities and the widespread
use of this tax (Younger 1996)
67
incorporated. Few households were observed to pay these taxes and their impact
was considered progressive.
5.2.1.2 Indirect taxes
The indirect taxes analysed in the Younger study included excise tax (including taxes
on alcoholic and non-alcoholic drinks and tobacco). Petroleum tax was considered to
be the most controversial tax in the country. This tax is essentially an excise tax
whose importance has grown over the years. Calculating the incidence of this tax
across expenditure distribution is not straightforward. The tax on gasoline and motor
oil coming from households’ direct consumption of these items was found to be
highly progressive but only 49 households in the GLSS survey reported to have
consumed them and of course these are the better off in society.
Most of the
petroleum products are taxed by firms rather than by household, so understanding
the incidence requires tracing the impact through input-output tables, which is not
currently available.
However, input-output tables from other countries such as
Cameroon and Madagascar all have a coefficient of 0.2 for the value of petroleum
which can be applied to the Ghanaian context. Taxes on kerosene, by contrast, were
found to be regressive.
Consumption of kerosene is remarkably flat across
households and so the burden from this source falls disproportionately on poorer
households, whose consumption as a proportion of household income is higher..
Value Added Tax (VAT) is another indirect tax, but was not in place at the time of
Younger’s analysis.
The SHIELD project will analysis the progressivity of VAT
including the NHIL (National Health Insurance Levy) which makes up 2.5 percent of
the 15% of VAT.
From international literature however, VAT is considered a
regressive financing mechanism.
A study by Wagstaff and others (1999) found
indirect tax to be generally regressive in that the burden of these indirect taxes falls
disproportionately on the poor.
The Ghana SHIELD programme of work will
comprehensively analyse the progressivity of the relevant taxes in the country. Table
18 below summarises the various taxes that SHEILD will analyse as part of the next
phase of work. All the taxes will be combined to calculate the overall incidence in
health care financing in the country as a whole.
68
Table 16: Summary of tax health care payment, incidence, data source and
proposed method of measurement
Payments
Incidence
towards health
care
Direct Personal
Legal
tax
Income
tax
Tax (PIT)
payer
Property
Tax
Legal
tax
payer
Shareho
lders
and
consum
Other tax er
(e.g. 2.5%
of SSNIT
deduction
for NHIS
Indirect tax
VAT
NHIL
consum
Excise duty
er
Petroleum
Other tax
Corporate
Tax
Data
source
Proposed
measurement
GLSS
V
will
be
compared
with actual
tax
revenue
from
MoFEP
♦Tax tables will provide information
such as tax rates, rebates,
exemption by income bands.
♦GLSS data will used to sort out
and identify PI tax payers
♦HH will be sorted into tax/income
bands
♦Tax rates will be applied to
estimate the incidence of PIT
♦The estimate will be compared
with actual PIT revenue and if there
is different, appropriate triangulation
will be done.
♦The GLSS questionnaire contains
information on the value of the
property of HH
♦The property tax schedule will be
applied to the value of the PT of HH
and estimated
♦This will be compared to the actual
revenue collected on PT in
2000/2001 and adjustments will be
made appropriately
♦ GLSS captured information on the
values
of
shares
held
by
households and so allocation of CT
will based on shareholding (90%) of
each HH and consumers (10%)
♦ This will be compared with the
actual CT revenue collected by
MoFEP and adjustments made.
GLSS
V
will
be
compared
with
tax
revenue
from
MoFEP
GLSS will
be
compared
with
actual tax
revenue
from
MoFEP
GLSS
which will
be
compared
with
2000/2001
actual tax
revenue
from
MoFEP
method
of
♦ From HH expenditure in the
GLSS, SHEILD will identify the
amount spent by HH on specific
products
♦Indirect tax burden will then be
calculated by applying the product
specific tax rates to these amounts
♦This will be compared to actual
indirect tax revenue by MoFEP for
the period.
69
5.2.2 Non-tax incidence analysis
There is no study of the incidence of non tax health care payments such as out-ofpocket (OOP) payments and so the Ghana SHIELD programme of work will
undertake these incidences through analysis of the GLSS and case studies. Apart
from tax, health care in Ghana is also financed by SSNIT contributions, the DMHIS
premiums from the informal sector and OOP payments. Before allocating the above
health care payments to income groups by quintiles of households, it will also be
important to provide the incidence assumption as to who bears the burden of each,
since the allocation of these health care payments depends on these assumptions.
The incidence of SSNIT contributions falls on formal sector workers, that of the
DMHIS contributions fall on insured non-formal sector workers. OOP payment is also
assumed to directly affect the consumer of the service. Information on SSNIT and
DMHI contributions will be obtained from the NHI headquarters and at the DMHIS
offices. NHI has recently compiled information on the health insurance enrolment
status, socio-economic, and other characteristics of the population of the country.
Information on OOP payments will be obtained from GLSS and supplemented by
data collected through the case studies at the district level. The Ghana SHIELD
programme will analyse the incidence of all these non-tax payments.
5.3 Benefit incidence
Benefit incidence studies examine how effectively governments are able to target
their limited resources towards the needs of the poor (DFID 2002; EQUITAP 2005).
They provide a revealing analysis of how, for example, groups disaggregated by
income or gender, make varying use of primary and hospital services, in rural and
urban settings. As said earlier, the only known benefit study on the incidence of
social spending including health in Ghana was by Lionel Demery. . The study found
that that Ghana was among a few countries like Indonesia, Kenya, and Brazil that
had the weakest targeting of health spending, such that the richest gain far more
from public sector health subsidies than the poorest (Demery et al. 1995). Whilst
only 12% of poorest group benefited from public health spending, over 30% of the
richest group benefited from public sector health spending in Ghana in 1989, and this
was further worsened in 1992, such that the richest extended their benefit to 33%
(see Table 19) (Demery et al. 1995). Some studies by DFID (2002), revealed that
public health spending was progressive in 30 out of the 38 studies carried out. This
means that the poorest 20% received more public subsidies than the richest 20%
(DFID 2002). A study in South Africa on “who goes to the public sector for Voluntary
70
HIV/AIDS counselling and Testing (VCT)” also revealed that the poor access the
services more than the rich (Thiede et al. 2004). The Ghana SHIELD programme of
work will undertake a current and more comprehensive benefit study using data from
GLSS and case studies at the community levels, as in the financing study.
Table 17: Distribution of Total Health Subsidies by location and Quintile 1989
and 1992
1992
1989
Quintile
Total subsidy
Per
Column
Total subsidy
Per
Column
in cedis
capita
share
in cedis
capita
share
subsidy
subsidy
1(poorest)
2,880,692,360 1,044
22.3
6,840,891,628 2,296
11.4
2
3,097,164,616 1,122
13.1
9,133,250,125 3,065
15.5
3
4,170,340,720 1,511
17.7
11,003,644,532 3,692
18.7
4
6,250,275,304 2,265
26.5
12,599,421,137 4,228
21.4
5(richest)
7,171,896,004 2,599
30.4
19,414,621,689 6,515
32.9
Total
23,570,369,004 1,708
100
58,991,829,110 3,959
100
Urban
9,910,421,248 2,233
42.0
28,755,473,051 5,808
48.7
Rural
13,659,947,756 1,459
58.0
30,236,356,061 3,039
51.3
Source: Demery et al 1995
71
6. CONCLUSIONS
The health sector in Ghana is confronted with several equity challenges ranging from
financial and geographical access, resource allocation, funding of health services,
access to basic services, service quality, utilisation, human resources and community
involvement.
In the area of financial access, the high cost services and management of user
charges are critical. The poor are less inclined to report illness and seek treatment
than the rich. In part, this is influenced by perceptions of service quality, but it is
more related to the impact of health costs on household expenditure relative to
income. For geographical access, about 40% of the population lives more than 15
kilometres from a health facility, this clearly falls short of the Alma Mata Declaration
(1978) of ensuring that all people live a maximum of 8 kilometres from a health
facility. Rural communities are particularly affected, since facilities are predominantly
located in towns and villages along main roads and very few sub-district teams make
regular, routine, trips to remote villages.
Generally, resources are limited, and resource distribution is inadequately linked to
health sector priorities. Inefficient allocation of resources also affects all aspects of
service delivery. Financial allocations to secondary and tertiary facilities and staff
emolument are disproportionate as compared to the primary level care.
Indeed,
resources available to the health sector have been shrinking over the years relative
to the increase in population. This has had a direct impact on the ability of the
MOH/GHS to run an efficient and effective system.
The migration of health workers to the developed countries is also a major challenge
to the health system. Globalisation has facilitated the growth of a flexible and mobile
labour market.
Shortages of medical doctors and nurses in the developed and
economically better off counties, whose governments are keen to maintain adequate
health services for their people, have encouraged the migration of an already
disgruntled workforce to fill these shortages attracted by so called “pull factors”. The
great demand for nursing personnel in particular, has intensified the migration
problem. There is also movement of health workers within countries, from public to
private sectors, rural to urban, and primary care settings to tertiary care institutions.
This may be so because, the skills of these health professionals may be either under
72
utilised due to lack of modern equipment, or incentives available in the urban or
private sectors may not be available in the rural or public sectors.
Migration
exacerbates the shortage within the sector and increases the workload for the
remaining workforce.
A majority of health care services are unavailable at most health facilities especially
at the Northern sector of the country, due to staff shortages (due to attrition and
insufficient training) and skill separation between different professional staff. At the
same time, first level referrals are neither accessible nor appropriate for certain
cases. A number of people perceive the quality of health services as poor and
therefore choose alternative treatment sources.
Confidence is undermined by
frequent shortages of drugs and medical supplies, long queues, the absence of
emergency services and poor staff behaviour. This has resulted in low utilisation of
health services despite substantial investment aimed at improving access to health
services. Nationally, outpatients’ visits at public institutions have increased marginally
from 0.36 per capita in 1996 to 0.52 in 2005.
Gradually the MOH/GHS is fostering collaboration with community and NGOs to
deliver high quality services. Health care planning and delivery has been a top-down
process, in which client satisfaction has been a low priority. In the past, attempts
were made to involve communities in health care delivery system but this has not
materialised. Many community-based volunteer health workers become disillusioned
because logistical support systems fail, while the Ministry found that the supervision
and regulation of unpaid semi-skilled workers was actually more costly than
anticipated. At the same time, Village Health Committees set up to improve service
responsiveness to client needs played little role in planning and evaluation of the
health system.
In recent years, the private health sector has grown considerably. Private not-forprofit providers, for instance, are estimated to account for 35% of health care
nationally. Although their staff salaries are covered by the MOH, linkages between
the private and public sectors are weak, leading to duplication and wastage.
Contracting with the private sector has not received the necessary attention.
It is also important to recognise that many health status determinants fall outside the
mandate of the Ministry of Health. For instance, clean water and sanitation facilities
have a critical role to play in improving people’s health status, but their provision
73
rests with other government departments. Similarly, there is a close relationship
between literacy, fertility and the health of the family. To date, however, there have
been
few
opportunities
for
inter-sectoral
collaboration.
Activities
remain
compartmentalized both at the centre and at the periphery.
From the document review, it is evident that there are equity challenges in the
Ghanaian health system regarding health care provision and financing. With regards
to health care provision, CHPS, a primary health care strategy has its challenges
relating to staff, as well as the financial resources to roll it out. The NHIS also has
challenges with regards to general management and administration, the premiums,
benefit package, waiting period, exemptions and cross-subsidisation among others.
It is anticipated that the SHIELD project would provide empirical data to assist in
addressing these inequities..
74
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