Better living: Increasing the level of care thanks to greater vision and new initiatives

Over the past decade, the Ghanaian health care system has undergone significant reforms aimed at improving the provision of services and infrastructure, especially in rural areas. Results including the introduction of a National Health Insurance Scheme (NHIS) have been largely positive, in part due to a shift to more preventive health care. This, combined with broader demographic changes, such as rising per capita GDP, has contributed to decreased mortality rates. Funding for health initiatives is on the rise, and facilities, equipment and supplies are more accessible than ever.

However, the sector still faces a number of challenges It may be too soon to regard the NHIS as a complete success as the scheme is rapidly running out of funds and resources are being ineffectively used. Meanwhile, the gap between health care in urban and rural areas remains huge, and despite annual increases in overall financing, there is rarely enough money to cover all costs.

STRUCTURE: Two regulatory bodies are responsible for overseeing the health care industry. The Ministry of Health (MoH) is the policy-making arm of the government, and the implementation of policies and initiatives is administered by the Ghana Health Service (GHS). Private sector health care facilities, both specialist and generalist, are growing as the government, aided by a dedicated agency in the MoH, the Private Sector Unit (PSU), works to promote private investment in the sector. At the same time as this, comprehensive studies to evaluate the potential for a broader framework for health-specific public-private partnerships are also under way. Additionally, numerous religious and non-governmental organisations (NGOs) have also played very important roles in boosting the system, often with external development partner funding.

BY THE NUMBERS: The average life expectancy at birth has increased by three years per decade for the past three decades, according to the last health census conducted in 2008. Today, new-born Ghanaians have a measured life expectancy of 60, up from 57 in 1998 and 54 in 1988. This number is well above the average life expectancy of 52 for the continent, yet it still lags behind the global average of 68.

This is mainly due to the growing frequency of visits to health facilities amongst the population. Between 1999 and 2009, outpatient attendance per capita (the average number of outpatient visits per year per person) doubled from 0.4 to 0.81. Health-related infrastructure is also increasing – in 2009 Ghana boasted a total of 3217 health facilities, including 343 hospitals, 2083 clinics, 379 community health centres and 389 maternity homes.

The prevalence of smoking and alcohol use is low in the country by both regional and global standards, which has limited the rate of diseases associated with such activities. Alcohol consumption among adults was last measured at 1.57 litres per year, well below the average for Africa (4.09) and the global average (4.36), according to the World Health Organisation (WHO). Tobacco use is even less popular with just 10.2% of the male population reported as tobacco users, compared with 18.1% for Africa and 42.4% for the world.

DEVELOPMENT PROGRESS: With regards to the country’s UN Millennium Development Goals, part of the global development initiative, there have been mixed results, according to data from the WHO. Though Ghana compares favourably to the rest of Africa in areas such as improved access to drinking water, where it has already achieved its 75% target (currently standing at 82% versus the African average of 61%), it has fallen well behind in access to improved sanitation, currently standing at 13% versus the continental average of 34%. It has also made gains in reducing the proportion of underweight children under the age of five (14% vs. 22%) and under-five mortality per 1000 live births (69 vs. 119). However, in arguably the most critical category, malaria mortality per 1000 habitants, it is still slightly behind the African average (109 vs. 104).

THE CULPRITS: Malaria has long been the largest contributor to Ghana’s disease burden, and represents 44.5% of the total share of reported diseases. The presence of HIV/AIDS in Ghana is low by African standards, found only in an estimated 1.9% of the population in 2009. In terms of outpatient morbidity, malaria tops the charts, responsible for 47.4% of the total share. It is followed in distant second by upper respiratory tract infections (7.5%), skin diseases (4%), diarrhoeal diseases (3.6%) and hypertension (3%). The top five causes of death on a national level are malaria, HIV/AIDS-related conditions, anaemia, cerebro-vascular accidents and pneumonia.

It is estimated that 204 out of every 100,000 individuals is affected by tuberculosis, although a low level of case detection at 36% contributes to the disease’s 9% fatality rate. Diseases targeted for eradication include polio, trachoma, leprosy and guinea worm, and the country has successfully reduced their contraction rates in recent years.

THE PROVIDERS: Health care providers, whether public, private or non-governmental, have developed a unified front in the last decade. “Whereas there used to be animosity between the various health care providers in the country, there is now a high level of trust and confidence among partners,” Selassi Amah d’Almeida, a health economist for the WHO in Ghana, told OBG. This renewed desire to cooperate is exemplified by the MoH’s monthly sector working group meetings where public, private, non-governmental and religious organisations, can voice concerns and work together to resolve issues.

Although the role of the private sector has increased since the introduction of national health insurance, it is far outweighed by public sector hospitals and clinics. Among the number of NGOs that are active in the field, one of the most prominent players is the Christian Health Association of Ghana (CHAG). In practice, CHAG maintains a quasi-governmental status since it is the government that funds 35% of its operations, most of which goes towards staff salaries. As Gilbert Buckle, the executive director of CHAG, told OBG, “Though our 59 hospitals and 114 clinics account for less than 5% of the national total, we account for 30% of outpatient care and 22% of inpatient care.”

NATIONAL HEALTH PLAN: In 2009 the MoH introduced the Health Sector’s Medium-Term Development Plan (HSMTDP), which runs from 2010-13. The HSMTDP is the fourth of its kind, replacing the MoH’s Programme of Work 2007-11. Great strides have been made in recent years, including in maternal health care, where maternal mortality has decreased from 740 deaths per 100,000 live births in 1990 to 451 in 2007 (see analysis). Adolescent health care has also improved, especially in light of an over 50% reduction in under-five malaria case fatalities between 2002 and 2009. In addition, the Community-Based Health Planning and Services (CHPS) initiative, which has facilitated the development of community health facilities and provision, has started to have an effect in rural and low-income areas, though significant work remains.

To accelerate the implementation of universal health coverage the HSMTDP lays out five objectives: bridging the health care gap, especially for lower-income segments; improving governance and efficiency of the health care system; providing greater access for maternal and adolescent health services; intensifying efforts to expand penetration; and improving institutional care for mental health services. Funding earmarked for achieving these goals amount to GHS6.51bn ($3.9bn) for 2010-13, although a shortfall of approximately GHS605m ($358.7m), or 15% of expected costs, may arise should non-guaranteed development partners’ commitments fail to materialise or donations fall from 2010-11 levels. In such a case, the government may look to cover the gap, by means such as extending new loans.

Should this issue be resolved, the HSMTDP is expected to contribute towards a 30.8% reduction in the rate of under-five mortality, a 30.5% drop in maternal mortality and a 12% decrease in malaria mortality, among other targets.

FINANCES: In nominal terms, national budget allocations to health care have increased significantly in recent years, although the sector’s share of the national budget has decreased. In 2007 the government devoted 16.2% (GHS479m, $247m) of its national budget to the MoH: in 2008 this fell to 14.6% (GHS564m, $288m), followed by 14.9% in 2009 (GHS752m, $387m), 12.8% in 2010 (GHS922m, 475m), 11% in 2011 (GHS987m, $508m) and 10.3% in 2012 (GHS1.8bn, $926m).

One of the more significant funding concerns is over the country’s insurance programme. Despite increases in budgets, and new sources of tax and investment revenue, the cost of the government’s relatively young NHIS is beginning to surpass the amount of revenue generated for its support, and as such new sources of funding are being sought.

NHIS: The NHIS was introduced in 2003 through the National Health Insurance Act to improve citizens’ ability to access and afford health care services by providing low yearly premiums of just GHS7.50 ($4.45). In reality, since 90% of the programme’s funding comes from tax levies, the NHIS acts more as a social health care system than a traditional insurance scheme. Regardless of the implementation methods, the effect of the NHIS has been a marked improvement in complication recoveries and more people are visiting health facilities before the onset of serious problems.

The NHIS initiative has successfully built up its user base, with 66.4% of the population having already registered and 80.6% of members considered “active”. Indeed, between 2005 and 2009 claims payments from the NHIS rose from GHS18m ($10.7m) to some GHS384m ($227.7m), which was largely due to its popularity and success in making health care significantly more accessible across the country.

However, money for the programme is running dry, and calls for new sources of funding along with fiscal accountability are becoming louder and more applicable by the day as financial resources continue to dwindle. If no new funding appears, the NHIS is expected to be in the red by the end of 2013. “The NHIS is spending more than it is generating and at the current rate will collapse within a few years,” d’Almeida told OBG.

In addition to funding, and perhaps more importantly, the scheme needs to find ways of achieving better value for money and improving efficiency.” These inefficiencies include budgetary misallocation, mismanagement of investments and disorganised administration; addressing these obstacles could greatly alleviate financial pressures. Furthermore, part of the gap is due to the programme’s success, with subscriptions to the NHIS swelling each year while premiums paid by subscribers account for less than 10% of its financing.

In addition to subscriber premiums, the NHIS is funded by several sources, with the majority coming from a 2.5% value-added tax (the National Health Insurance Levy). The NHIS also receives 2.5% of the Social Security and National Insurance Trust (SSNIT) yearly budget, as well as funds allocated by parliament and returns on investments. The MoH, along with the NHIS and other government agencies, are currently looking for new sources of revenues and ways to cut down on expenditures.

COMMUNITY HEALTH: In order to better serve the country’s health care needs, especially in rural and under-populated areas, the MoH and GHS established the CHPS initiative, which, among other things, has given a boost to health care infrastructure and facilities throughout Ghana. Sylvester Anemana, the chief director of the MoH, stated, “CHPS facilities are meant to provide basic health care services focused on common ailments, maternal and preventive care, as well as offer health education to the community.” All CHPS health care providers must complete at minimum a two-year programme run by the GHS where they learn how to treat common ailments, administer vaccinations and formulate basic diagnoses to determine whether to refer a case to a district or regional hospital for more intensive care.

CHPS centres are a less expensive alternative to establishing fully fledged clinics and hospitals in remote areas and can also act as a first line of defence in those communities. As of 2009, 379 CHPS centres had been established, and the GHS and the MoH announced in early 2012 that an additional 520 would be added throughout the year.

MALARIA PREVENTION: A key function of CHPS facilities is disease prevention, an important dimension to Ghanaian public health, especially when it comes to malaria, the leading cause of death in the country. In 2009 the disease was responsible for 32.5% of all outpatient cases and 48.8% of all under-five hospital admissions in the country. Treated outpatient malaria cases increased marginally from 3.69m to 3.74m between 2009 and 2010, while overall case fatality worsened from 1.22% to 1.44%. The total number of deaths, however, declined, due to early detection and treatment.

The National Malaria Control Programme (NMCP), part of the global Roll Back Malaria initiative, aims to decrease malaria illness in Ghana by 75% by 2015, mainly through preventive measures. The use of insecticide-treated nets (ITN) has become more widespread as the first line of defence against the disease. The NMCP targets to have at least one ITN in every home and 80% of the population sleeping under one by 2015. Indoor residual spraying (IRS), or the spraying of mosquito insecticide inside homes, has also become an increasingly popular protective measure, though it is primarily used in targeted districts with high levels of malaria occurrence.

The government has also considered subsidising anti-malaria drugs to make them more affordable, and a pilot programme was launched in the first quarter of 2012 to test the effectiveness of this idea. Spending on malaria prevention and treatment far outstrips all other health-related expenditures in the country, and controlling the prevalence and severity of malaria cases is one of the government’s highest priorities. Funding for the NMCP and related initiatives comes directly from the national budget and both directly and indirectly from a variety of international organisations, which includes the WHO, UN Children’s Fund, USAID and a range of NGOs and charitable organisations. Inesfly, a Valencia-based venture, has started construction on a $13m factory in Ghana to produce an innovative house paint to curb the prevalence of mosquitoes. The paint, already licensed in over 15 countries, uses pesticides embedded in microcapsules and could be an alternative way to help fight Malaria.

PRIVATE SECTOR: The number of private sector, for-profit hospitals and clinics has grown in recent years. In 2009 the MoH reported private ownership of 156 hospitals, 732 clinics and 389 maternity homes, giving the private sector a 39.6% share of the nation’s 3217 health facilities. According to Anemana, part of the recent growth in private health care is due to the success of the NHIS, which has enabled new segments of the population to seek private sector care since the insurance programme reimburses members for visits to all accredited health care providers, whether public or private.

At present, the Private Hospitals and Maternity Home Board (PHMHB) regulates the private health care sector and is charged with overseeing accreditation and monitoring of all private facilities. This board is to be replaced by the Health Facilities Regulatory Agency under a new Health Institutions and Facilities Act, 2011, Act 829.

The National Health Insurance Authority (NHIA), the official body administering the NHIS, reformed its accreditation policy in 2009 by giving health care providers a letter grade along with a denial or approval of accreditation as means to incentivise improvements in quality. Grades range from A+ (the highest mark) to R (failure to receive accreditation), and the higher the grade, the larger the reimbursements from the NHIS. In the first round of accreditation and grading, 619 institutions were evaluated, resulting in two A+ awards, 21 As, 86 Bs, 140 Cs, 189 Ds, 89 E’s, 44 Rs and 48 provisional grades.

A 2009 study on Ghana’s private health care market conducted by the World Bank found the business environment for private health providers to be competitive with the potential for higher revenue and new markets. However, it also noted several challenges to the segment’s development, including a lack of financial accessibility, poor accounting and general management, and a fragmented market. While growing steadily, until improved funding and lower costs are introduced, the private, self-financing health care sector will likely remain accessible only to higher-income segments.

HUMAN RESOURCES DEVELOPMENT: “Much has been done to successfully reform the universal salary structure for health care workers, as well as increase (and retain) the number of working graduates entering the health care workforce each year,” Anemana told OBG. Indeed, the country has faced a shortage of doctors and nurses as the majority of the qualified medical staff choose to leave the country, and graduate numbers from local universities and teaching hospitals are relatively low. Both trends can be attributed in part to the extremely low salaries for health care providers and the lack of opportunities for career advancement.

ON THE RISE: According to Anemana, average salaries for Ghana’s doctors and nurses have gone up roughly three-fold in the past decade, with added perks such as facilitated loan access for home and car purchases. Improvements are beginning to show: the University of Ghana has seen its average graduating nurse class increase from just 200 in 2000 to 3000 in 2012, while the number of graduating doctors more than tripled from 50 to 160 in the same period. As the health care sector develops and becomes more sophisticated, there are also more opportunities for career advancement, making the industry all the more attractive.

In 2009 the MoH recorded a doctor-to-population ratio of 1:11,929, a significant improvement on the 2005 ratio of 1:17,899. The nurse-to-population ratio also improved, from 1:1508 to 1:971. However, these figures mask the huge deficits of doctors and nurses in rural areas, especially in the country’s Northern, Upper-East and Upper-West regions, where the doctor-to-population ratio balloons to 1:50,751, 1:35,010 and 1:49,392, respectively.

RURAL HEALTH CARE: Despite numerous improvements made in extending health care to rural areas, the discrepancy between services in large cities and remote areas remains vast. Often, the lack of social infrastructure, including transportation, can make simply getting to a hospital or clinic an insurmountable obstacle for many living in rural areas. The MoH’s CHPS initiative was created to address problems such as these by erecting facilities to provide basic care on the spot, as well as to coordinate transportation to district and regional hospitals when necessary. Additional resources are also being poured into providing mobile medical units to rural areas, and the MoH recently purchased 161 ambulances for this purpose in early 2012.

Nevertheless, even with proper infrastructure in place, the shortage of medical professionals and facilities remains a major obstacle. Additionally, in the three most rural regions of the country ( Northern, Upper East and Upper-West), there is a shortage of hospital beds. The population-per-bed ratio in these regions is 1643:1, 1109:1 and 842:1, respectively. This is in stark contrast to the ratio of 657:1 in the Greater Accra region.

In general, NGOs and religious organisations such as CHAG have assisted in filling some of the gaps, as these groups tend to direct their efforts to rural and lower-income communities. The government has been very willing to assist some organisations in their endeavours, such as CHAG’s partnership with the MoH, which provides 35% of the association’s funding, allowing it to expand operations in areas that are underserved.

CHALLENGES: In addition to the inequality of health care provision between rural areas and urban centres, Ghana faces numerous challenges to advancing the national health care system. Major areas of concern range from improving sanitation and transport infrastructure, to disease prevention, to public education and awareness.

However, for Buckle the greatest challenge is reforming the mentality towards health care development. “Many people still look at health care in a very narrow sense; we need to take a holistic approach towards its development, which necessarily involves greater integration between sectors.” Cooperation among health care providers has been lauded of late, but cooperation between sectors remains underwhelming in both the public and private spheres .Sanitation, transport and education-related issues are rarely examined in the context of health care development, according to Buckle, yet they are vital towards improving health conditions, connectivity and awareness among the population.

OUTLOOK: Health care coverage in Ghana is expanding and the system as a whole can be considered well ahead of many others on the continent. The NHIS has played an enormous role in increasing health care provisions and improving results, but until new sources of financing are established, the programme will remain at risk. In principal, the country’s strong economic growth amidst new sources of revenues from oil and gas projects should enable the government to provide the necessary financing. Even so, despite the strides that have been made over the past 10 years, the country has a way to go before its goal of universal health care is finally realised.