Policy reforms and structural initiatives improve access to care in Ghana

More than ever before, Ghanaians have seen their access to health care improve, and as a result they are living longer, healthier lives. Since the roll-out of the National Health Insurance Scheme (NHIS) in 2005, 10.2m active subscribers had been added to the scheme as of end-2014, out of a total population of 25m. This has led to improvements in average life expectancy, which, in the decade leading up to 2014, rose from 57.79 years (2003) to 61.1 years (2013). The maternal mortality rate (MMR) has declined steadily as well, to 380 deaths per 100,000 live births in 2013, down 49% from 1990, though the country is still some way off from reaching the UN Millennium Development Goal of 185 deaths per 100,000 live births. The health care system is currently dealing with considerable financial challenges, but ongoing developments suggest a positive, and healthy, future for the sector.

Sector Structure

There are two regulatory agencies charged with overseeing Ghana’s health care system: the Ministry of Health (MoH), which is responsible for policy-making as well as evaluation and monitoring, and the Ghana Health Service (GHS), which is in charge of implementing and administering health care services throughout the country. The size of the health sector has continued to expand, largely due to the increasing output from the nation’s four medical schools. In 2013 there were 2615 public sector doctors, up 363 over 2012 figures, according to the MoH, with a doctor-to-population ratio of 1 per 10,170. Better yet, the nurse-to-population ratio is close to the World Health Organisation (WHO) target of 1 per 1000 and has been improving steadily over the last few years, due to a rise in intake at nursing training programmes, with a 20% year-on-year (y-o-y) increase in 2013, according to the MoH.

Since the introduction of the NHIS, which was aimed at providing universal coverage for basic health care, access has improved significantly, but it has come with its own challenges, notably ongoing funding issues. E.C. Tamaklo, managing director and CEO of Nyaho Medical Centre, told OBG, “The management of the NHIS will be key in its ability to continue providing health care. At some point, national health systems have to be run like a business.

Outpatient utilisation of the NHIS rose to 27.4m in 2013, according to the MoH, up from 16.6m in 2009, with GHS748m ($207.57m) in claims. However, service provider debts have also increased, from GHS172.1m ($47.78m) in December 2012 to GHS262.2m ($72.76m) in December 2013, according to MoH data, with a large proportion of this coming from non-payment of NHIS service bills. According to the MoH, in 2013 the average delay between claim submissions and payment was 122 days. “Most service providers are not getting the money. It can take up to 10 months for payment to come through, and this affects what services they are able to supply,” Justice Yankson, general secretary of the Ghana Medical Association, told OBG. Reports in the local press have suggested that some service providers have returned to the previous “cash and carry” system, unable to cope with the National Health Insurance Authority’s (NHIA) delays in settling claims.

Budget

The allocation of funding to the MoH has increased steadily over the last few years, and the 2015 budget saw the continuation of this, with the health sector budget rising from GHS4.28bn ($1.19bn) in 2014 to GHS6.74bn ($1.87bn) in 2015. However, much of this is still being absorbed by employee salaries and benefits, which increased following the introduction of the Single Spine Salary Structure (SSSS) in 2012, which was designed to combine the various public sector pay structures into one. Gross revenue distribution for 2013 showed 57.3% of health care expenditure went towards employee compensation, down from 63.1% in 2012, with 31.1% going to goods and services and 11.6% to assets. “We welcome the 100% increase in funding to the health sector. However, a significant proportion of this allocation will be deployed largely towards strengthening the health systems, including employee compensation, and not necessarily improving health care access and quality, a key aspect of economic transformation,” Felix Addo, country senior partner for PwC Ghana, stated in PwC’s “2015 Budget Highlights” report.

Policy Goals

Ghana’s government has continued to make significant investments in health sector infrastructure, and has laid out plans to expand Community Health Planning Services (CHPS) to reach more rural areas. It has also targeted the need to strengthen its response to Ebola, as well as improve access to radiotherapy and nuclear medicines services and enhance the regulatory environment.

To improve the NHIA and reduce delays in payments, claims processing centres (CPC) were set up in Tamale, Cape Coast and Kumasi in 2013, in addition to the one opened in Accra in 2010. A pilot electronic programme for claims submission (e-claims) was launched in April 2013 to expedite payment processes, and 43 service providers were at various stages of submitting claims electronically as of January 2015 (see analysis). The MoH has also announced plans to scale up its capitation payment system, which facilitates advanced payments for outpatient care under the NHIS. The system was piloted in the Ashanti Region starting in 2012. Capitation is seen as a way to overcome some of the issues related to spiralling health care costs and the timely payment of claims. Despite some concerns about it leading to a reduction in the quality of care due to the potential under-provision of services, the government has deemed the pilot a success and has announced plans to roll it out nationwide by the end of 2015. According to the World Bank, the NHIA ultimately plans to cover 22% of services paid under the NHIS through capitation, with serious health cases reimbursed under the Ghana Diagnosis Related Grouping payment method.

The MoH has continued to roll out free insurance for those in need. In 2014, 1.2m eligible Ghanaians were signed up for free to the NHIS, up from 393,000 in 2013. These included people under the Livelihood Empowerment Against Poverty (LEAP) programme, for those under 18 years of age as well as the elderly, pregnant women and those in mental health facilities. Meanwhile, a new National Strategy for Cancer Control was launched in February 2015, with the aim of reducing cancer mortality by 30% over the next five years through effective screening and early detection, as well as improved diagnosis and treatment. Ghana has around 16,000 new cases of cancer a year, the most common types being cervical, breast, prostate and liver cancers, with more than 2000 women in Ghana affected by breast cancer in 2015.

Infrastructure

Ghana has embarked on a series of hospital building and upgrading projects valued at more than GHS3bn ($832.5m), including work on over 17 hospitals and health centres spread across the country. There are several major hospital projects under construction, which when completed will add around 6000 new hospital beds by 2017. These include the 617-bed University of Ghana Teaching Hospital ($184m), the 420-bed Ridge Hospital Expansion Project ($250m), the 500-bed Military Hospital Project in Kumasi ($180m) and the second phase of the Tamale Teaching Hospital Expansion Project, which will double the number of existing beds to 800. The equivalent of $57m has also been channelled into the Korle Bu Teaching Hospital, to replace or rehabilitate obsolete equipment, including the revamping of 12 operating theatres, some of which have been closed for up to eight years. Provisions for modern diagnostic and treatment equipment, under the National Medical Equipment Replacement Programme, have been expanded to cover all of Ghana’s teaching and regional hospitals, as well as 125 district hospitals, 14 health centres and eight mobile clinics.

Private Sector

The private health care system in Ghana continues to grow, with a policy environment conducive to private activity and a growing middle class that is now choosing to use private health care facilities. David Pickering, director of Lister Hospital, told OBG, “The private health insurance market is still very much in a developmental stage in Ghana. Only about 18% of patients seen currently in the private sector are insured, whereas in a mature mixed health care economy, approximately 70-80% of patients who use the private sector have health insurance.”

According to data from the Private Hospitals and Maternity Homes Board (PHMHB), by mid-2014 there were 474 private clinics in Ghana, 119 private hospitals and 241 private maternity homes. “Nowadays, 55% of people in Ghana use private health care as their first port of call,” said Yankson. Licensed health care providers can also be part of the NHIS, though claim process delays have meant that some private health care providers are questioning their willingness to take NHIS patients. Speaking to local media in January 2015, the Ho municipal director of health services, Atsu Seake-Kwawu, emphasised the need for more private hospitals in order to increase access to quality health care. Tamaklo told OBG, “There is great demand for quality health care, but there are few facilities that meet international standards.”

Several private hospitals are currently under construction in Ghana, including the $52m, 300-bed Airport City Hospital and Medical Centre, which broke ground in June 2014 and which will have a 50-bed intensive care unit and a 20-cubicle emergency room and trauma centre when it opens. According to Joseph Awasi Boateng, CEO of Airport City Hospital Company, an additional component of the project is the establishment of the first private medical school in Ghana, the St Joseph School of Medicine. In 2014 US-Based Sanford Health declared it would open 300 clinics across Ghana in the next six years, adding to the five it has opened in the country since 2012. The clinics will be linked together using technology so that rural communities can have greater access to modern health care, with each of Ghana’s 10 regions having a hub that connects to 30 satellite clinics. Sanford Health aims to invest $30m over 10 years, with each clinic breaking even within two years of opening.

Some in Ghana are touting the possibilities of developing a medical tourism business. “Ghana is very attractive in the region for medical tourism,” Akumba Asamoaning, CEO of International Bilateral Trade Council, told OBG. “The medical system is not yet large enough to serve as a medical tourism destination, but many people think if it is able to develop right, it would have great potential, with people flying here rather than to London or New York,” he added.

Rural Access

The MoH has targeted further expansion of its CHPS programme, which was established in 1999 to facilitate greater access to health care in remote areas of the country. In rural areas, CHPS facilities act as a first line of defence and are staffed by health care providers with a minimum of two years of training, so that they are capable of treating common ailments and administering vaccinations, as well as providing basic diagnoses. According to a 2014 MoH report, the number of functional CHPS zones increased in 2013 from 2226 to 2316, but this was still short of the goal of 3000. In 2012 the MoH purchased 161 ambulances to act as mobile medical units to further improve rural penetration.

One of the key challenges in this area is that many doctors and nurses decline posting in rural areas due to the lack of development and the distance from cities. At present, more than 50% of all government-employed doctors in Ghana work in the Greater Accra Region. At the graduation ceremony for nurses in January 2015, Kwaku Agyemang-Mensah, the minister of health, called on some of those graduating to accept postings in deprived rural communities.

Workforce

Ghana has long struggled to keep its doctors and nurses at home in the face of more lucrative job opportunities abroad, but in recent years that has become less of a problem. “Four to six years ago the tide changed a bit regarding medical personnel wanting to leave,” said Yankson, though he warned that the trend could be re-emerging. In early 2015 the government announced that it was scrapping a decade-old ban on newly qualified nurses going oversees to work. In the past, nurses who were trained in public institutes in Ghana had to agree to spend the first five years of their careers working in the country, but the government now says that there are enough nurses to end the ban. “There are now more private schools graduating nurses and some of them can’t find jobs,” Kwesi Abir, the MoH’s deputy director of human resources, told the press in February 2015. In 2004, 700 nurses left to work in the UK, but the MoH says that number has dropped to just 300 nurses in the two years prior to the regulation change. In early 2015, 1287 nurses graduated from the Kumasi Nursing and Midwifery Training School, the Saint Patrick’s Midwifery Training School, and the Asante-Mampong Midwifery and Health Assistants Training School, as the first group of nurse trainees to graduate under a partnership between the MoH and the Kwame Nkrumah University of Science and Technology (KNUST), Ghana’s main science and technology university.

Yet issues still remain regarding the rollout of the SSSS, which has affected public sector salaries and resulted in some payment delays and strikes across the health care sector in 2013. “Some doctors still have problems with the SSSS, and several issues remain, like basic salary and pension reductions,” said Yankson. Furthermore, others have suggested that while having adequate employees is no longer the main challenge, staffing practices have yet to catch up. Pickering told OBG, “Staffing remains a challenge for both the public and private health care sectors in Ghana. The existing workforce needs to be employed on a more flexible basis so that staffing levels can be adjusted across the day, week and year to meet fluctuating workload demands.”

Outlook

Structurally, the health care system in Ghana seems strong, though efforts need to be made to expand quality coverage to rural areas and improve the management of payments under the NHIS. However, the sector should continue to see more success.