Investment in health infrastructure improves primary care for citizens in Ghana

With a growing urban middle class that is currently underserved by health care providers, there are substantial opportunities to offer a range of diverse services in Ghana. The government has made considerable strides in a number of important areas, including the expansion of primary care coverage, infrastructure investment and the combatting of communicative diseases, particularly in terms of vaccination and epidemic control.

Nevertheless, it has yet to meet many of its development goals, and remains behind in terms of a range of health indicators. While both the government and consumers have shown themselves to be open to private health care, expenditure remains lower than in many neighbouring markets, highlighting room for expansion.

Rising Demand

A combination of demographic and economic factors ensures that demand for a broad range of health services is likely to grow over the coming years. The population is increasing at an annual rate of 2.2%, according to the World Bank.

Furthermore, the economy is gaining momentum, with GDP per capita growing by 27% between 2008 and 2017 to reach $1608, placing its GDP above many of its regional neighbours, according to the IMF. Similarly, the country has comparatively high human capital formation, underpinning strong growth fundamentals for the future.

This combination of a rising population and increased per capita income are not the only factors that are stimulating higher health care spending: World Bank figures put the dependency ratio at 73% in 2016, and according to the UN Department for Economic and Social Affairs the elderly dependency ratio stood at 12.6% in 2015 and is predicted to rise steadily over the medium to long term.

Disease Profile

The range of services required is particularly broad. Ghana has a diverse disease profile straddling that of both the developing and the developed world. Ghanaians are afflicted by both communicable diseases – associated with restricted access to care and medicine, poor sanitation and limited health awareness – and, increasingly, chronic, non-communicable diseases associated with lifestyle choices and inadequate preventative medicine.

However, the transition to a typical Western disease profile has not yet been completed. The biggest cost to the country, in terms of both the financial and mortality burden, remains communicable diseases, accounting for 51% of total deaths. Indeed, in 2016 three of the top four causes of death were communicable diseases, with the leading causes being malaria, lower respiratory infections, ischemic heart disease and HIV/AIDS, in that order.

According the UN, the adult HIV prevalence rate stood at 1.6% of the general population in 2016. These figures mark a significant decline, down from 4.2% in 2000, a shift brought about by improved public awareness regarding transmission and increased antiretroviral therapy coverage. Nevertheless, the country is considered to be suffering from a mature mixed epidemic, with a low-level generalised epidemic among the general population and a high prevalence epidemic among at-risk groups.

Furthermore, the country has a higher than average incidence of malaria, with the Ghana Health Service (GHS) reporting 4.5m confirmed malaria cases in 2016 and 1264 confirmed deaths from the disease. Nevertheless, it should be noted that the World Health Organisation (WHO) cites 4.3m confirmed cases of malaria in 2015 but estimates the true figure as 7.3m, and similarly gives the confirmed deaths figure as 2137 but estimates the actual number of fatalities as 13,000.

Taking Action

This disease burden carries a high economic cost. Malaria cost the Ghanaian economy around $6.6m in 2014 through lost productivity, while the total cost of HIV treatments and interventions is expected to range from $252m to $450m between 2014 and 2020.

The government recognises these challenges and is taking active steps to address communicable diseases. In its National Strategic Plan 2016-20, the Ghanaian AIDS Commission outlines a holistic approach to achieving, by 2020, the UN’s 90-90-90 target, which aims to have 90% of all people living with HIV aware of their HIV status, 90% of all people diagnosed with HIV receiving antiretroviral treatment, and 90% of all people receiving antiretroviral treatment experiencing viral suppression. The document proposes a combination of HIV prevention through public education, condom distribution and the expansion of antiretroviral therapy for HIV sufferers. In order to meet these targets, the government has committed to increase funding by 20% a year over a five-year period, with additional funding being provided by the Global Fund and the international and domestic private sector.

Similarly, Ghana has consistently improved in malaria control, participating in the US-led President’s Malaria Initiative to implement measures aimed at preventing the transmission of malaria and treating those who contract it. Private sector investment has played a vital role in these efforts to combat malaria: the government launched the Malaria Foundation in late 2015, a private foundation to promote buy-in from the public sector in malaria elimination, highlighting the impact of the disease on productivity levels and raising additional funds from domestic and international donors. This ongoing incidence of such communicable diseases makes demand for health care services high and risks placing major strain on the system if private sector investment does not expand.

New Challenges

The impact of communicable diseases is compounded by the increasing incidence of non-communicable diseases. As with much of the developing world, Ghana now faces a double disease burden as the population increasingly adopts a Western diet and a sedentary lifestyle. More than half of the population is now living in towns and cities, and the urban population grew at an average rate of 3.6% per year between 2010 and 2016, according to the World Bank. With these changes incidence of non-communicable diseases is rising.

According to the WHO, cardiovascular complaints accounted for 18% of total deaths in 2012, while 27.3% of the population suffered from hypertension, of which only 4.1% have the condition under control. If left unchecked this rise in heart disease could present severe repercussions for the economy. Other non-communicable diseases in Ghana include cancer, chronic respiratory diseases and diabetes, with cancer accounting for 5% of deaths each year, and diabetes and chronic respiratory diseases each accounting for a further 2% of fatalities.

Mixed Blessings

Life expectancy at birth was 61.4 years for males and 63.4 for females in 2015, according to the most recently published data from the World Bank. These figures reflect impressive gains in longevity, rising 5.2 years for men and 5.6 years for women since 2000.

However, sources differ when it comes to mortality figures. While the UN Interagency Group for Child Mortality Estimation reported a 2.6% drop in neonatal mortality in 2016, the GHS estimated an 18% increase from 5.34 deaths per 1000 live births to 6.28 for the same period, though both cite a steady long-term decrease in this indicator. Furthermore, the GHS highlight strong regional variation in these figures, with an 11% reduction in neonatal mortality in the Upper West Region and a 14% reduction in the Western Region.

According to the GHS, maternal mortality increased between 2015 and 2016, from 142 per 100,000 to 163.5, despite a longer term decline in the maternal mortality rate. Nevertheless, the GHS has recognised this issue and identified cost-effective strategies to meet this challenge, including the provision of iron and folic acid supplements for pregnant and postpartum mothers.

Furthermore, the country has made strong progress in increasing vaccinations, with the national immunisation rate increasing to 94.6% in 2016, according to the GHS. As a result of these actions 2017 was free of any large-scale outbreaks of contagious disease. While the country experienced both a measles and cholera outbreaks in 2016, both were contained and no fatalities were reported.

The authorities continue to take steps to improve health outcomes. These range from emergency responses to longer-term programmes to reduce the disease burden. In terms of the former, the government established cholera treatment centres in the Cape Coast region in the last quarter of 2016 to deal effectively with the latest outbreak of the disease. This was accompanied by a public health campaign to encourage basic hygiene practices, coupled with the development of hand washing stations and the distribution of free rubbish bags, according to local media. A number of longer term strategies and policies are also being pursued. For example, the Ministry of Health (MoH) cooperates with donor agencies and partners to reduce the incidence of preventable disease. The US Centres for Disease Control and Prevention is one of many partners investing time and money into helping combat AIDS, malaria and influenza in Ghana.

Infrastructure

While the country faces limitations in the resources necessary to dramatically improve national health outcomes, it is nevertheless taking steps to improve the situation. In recent years the government has embarked on an extensive hospital-building programme. According to the most recent data published by the WHO, the country had 0.9 hospital beds per 1000 population in 2014. This is expected to jump to 1.2 upon completion of the current hospital building programme in 2018.

The government and NMS Infrastructure, a UK construction company, have invested $175m to build six new district hospitals throughout Ghana under the Built To Care scheme. The first of these hospitals to be finished was the 120-bed facility at Dodowa, completed in June 2016. Further facilities are under construction at Formena, Kumawu, Abetifi, Garu-Tempane and Sekondi. Lastly, the Takoradi-European Hospital is being upgraded, with the construction of staff housing and an infectious disease centre. As of November 2017 these hospitals were at various stages of completion, with Formena 72% finished, Kumawu 60% complete, Abetifi 35% and the Takoradi-European Hospital upgrade 50% complete.

In addition to these above mentioned projects, two regional and six district hospitals are under construction at Wa, Sewua, Salaga, Konongo, Tepa, Nsawkaw, Atomic and Twifo Praso, and a further 15 polyclinics are being built across the country.

Filling The Gap

Ghana has long faced shortages when it comes to health care professionals, though efforts are being made to overcome this bottleneck. In 2017 the doctor-to-population ratio stood at 1:8300, a marked improvement from 1:9600 in 2010. Similarly, the midwife-and-nurse-to-population ratio improved from 1:926 in 2010 to 1:725 in 2017. The GHS plan to go further, with the aim of achieving a doctor-to-population ratio of 1:7500, and further increases in the number of nurses and midwives.

In order to meet these pressing challenges, the administration of President Nana Akufo-Addo announced in October 2017 that the nursing training allowance would be reintroduced. The grant, which has been set at a maximum of GHS400 ($95.80) per month for the 2017/18 academic year, was previously withdrawn in 2014. The allowance will cover an estimated 54,840 health care trainees from 77 public health training institutions. On reintroducing the measure, President Akufo-Addo told local media, “We believed, and still believe, that Ghana needs all the nurses and health care workers it can get, if the nation is to have a solid, world-class health care system, and we think it necessary to provide the relevant incentives to make that possible.”

Funding

The 2018 budget allocation to the MoH is GHS4.4bn ($1.1bn), a 4.6% increase from 2017. While the contribution provided by international development partners dropped by 42.5%, the contribution to the budget made by the government rose by 5.4%, from GHS2.5bn ($599m) in 2017 to GHS2.6bn ($622m) in 2018, reflecting an increased commitment on the part of the Ghanaian state to fund access to basic medical care. Furthermore, GHS232m ($56m), or 5.2% of the MoH budget allocation, is to be used to fund the re-established nurses training allowance for the 2017/18 academic year. This health care allocation makes up 31% of the social services budget for 2018, which itself makes up 21% of the total annual budget.

Taken as a share of the total budget, health care funding increased only slightly from 6.5% in 2017 to 6.6% in 2018, with both these figures falling below the 15% target agreed upon by Ghana and all other African Union states in the Abuja Declaration of 2001. However, it should be noted that Ghana has not been exceptional in this regard, as according to data published by the African Union only four African states were meeting the target in July 2016.

Despite these commitments, the country’s public health care system faces long-term financial challenges in keeping up with growing demand. Public sector expenditure is only part of the story however, with 40% of total health care expenditure in Ghana coming from the private sector in 2014, the most recent year for which figures are available. While this figure is substantial, it is nevertheless well below the average for sub-Saharan African countries, which stood at 50% in 2014. Furthermore, according to the WHO private health insurance payments make up only 2% of total private health expenditure, with out-of-pocket expenditure (OOPE) making up 67%. These figures highlight considerable growth potential for private health care investment.

NHIS

A major change in the Ghanaian health care sector occurred in 2005 with the introduction of the National Health Insurance Scheme (NHIS). Conceived of as a social intervention programme to provide Ghanaians with access to basic medical treatment, with the eventual aim of providing all residents with universal health care coverage, the programme now covers around 41% of the population.

The scheme is funded through a number of channels, including 2.5% of the Social Security and National Insurance Trust (SSNIT), a 2.5% value-added-tax contribution, and a premium levied on informal workers at a rate ranging from GHS7.20 ($1.70) to GHS48 ($11.50) depending on income. Other sources of funding include tax money allocated by the government, voluntary contributions, and returns on investments made by the National Health Insurance Fund (NHIF). However, most of these Ghanaian informal workers pay the basic GHS7.20 ($1.70) rate, while more than 60% of NHIS members are exempt from paying premiums because they are either under 18 years old or over 70 years old. Part of the challenge for the government is that recurring expenses absorb a considerable portion of the budget. Of the GHS4.4bn ($1.1bn) allocated to health care in 2018, 59.7% was allocated to wages and salaries, 32.1% to goods and services, and 8.2% to capital expenditure. As such, the budget for infrastructural development, pharmaceuticals and equipment purchases faces constraints.

The current funding model is struggling to meet costs, with the NHIS owing pharmaceutical companies approximately GHS1.2bn ($287.3m) in early 2017, according to local media reports.

“The authorities have made significant efforts to reduce the level of debt owed to medicine suppliers,” Yaw Opare-Asamoah, managing director of Dannex, told OBG. “However, adequate funding, and a robust and efficient strategy are required to ensure the sustainability of the scheme,” he added.

The current administration has committed itself to resolving this situation. In August 2017 the government agreed to settle the outstanding debts within 12 months. According to figures that have been cited by the government, GHS560m ($134.1m) of the debt was paid off by August 2017.

Government Strategy

One way in which the administration is trying to rise to this challenge is by pursuing a range of efficiency measures. These include the institution of clinical audits, the rationalisation of prescribing practices based on a revised essential medicines list, and the improvement of information and data analysis systems. Over the course of 2017 the MoH decentralised the storage of 50% of all health commodities to regional medical stores in addition to increasing the number of facilities implementing last-mile delivery. The NHIS has also moved towards the digitalisation of the submission and processing of claims.

Another approach is a renewed emphasis on the importance of prevention and health awareness. In August 2017 President Akufo-Addo told the induction ceremony of the School of Medical Sciences of the University of Cape Coast that fatal outbreaks of communicable diseases were best prevented through action within local communities, rather than subsequent hospital interventions. “It requires better sanitation, and not better medication, to deal with cholera,” he told students and local media.

Health & Planning Services

As part of this focus on prevention and education, there has been a drive to improve and expand primary health care facilities across the country. For example, the GHS has embarked on a project to build 55 new Community-based Health and Planning Services centres in the Northern and Volta regions.

This scheme, carried out in conjunction with the US Agency for International Development (USAID), is designed to improve access to health services in rural communities and support the reduction of infant and maternal mortality. It is part of a wider five-year project known as Systems for Health. This intervention, funded by USAID and running from 2014-19, seeks to improve information systems, human capital, infrastructure and financing with the stated aims of improving childhood nutrition, reducing preventable maternal and child deaths, and preventing the spread of infectious diseases.

CHAG

An important complementary contribution to the provision of primary health care is made by the Christian Health Association of Ghana (CHAG). The non-profit NGO consists of a network of 300 church-run health care facilities and training institutions located across the country. While CHAG is autonomous, it cooperates fully with the MoH and the GHS to provide health services. While it holds only 7.4% of the health infrastructure in Ghana, it provided 29% of national inpatient care and 20% of national outpatient treatment in 2016.

Accra Hospital

There have also been efforts to improve secondary and tertiary infrastructure in the public health care system. For example, in May 2017 the Greater Accra Regional Hospital opened to the public. The $250m project, which was funded by the US EXIM Bank and HSBC, is one of the most advanced hospitals in West Africa.

The 420-bed facility has an accident and emergency department, a neonatal intensive care unit, a delivery unit an imaging department, an intensive care unit, and an on-site pharmacy. “It was envisaged that the first phase of the reconstruction play a key role in efforts to especially improve maternal, neonatal, and child health care services, and enhance an effective continuum of care in the capital city and the nation as a whole,” Dr Anthony Nsiah-Asare, director-general of the GHS, told local media. The project was initiated by the previous administration, but the government of Akufo-Addo is currently engaged in establishing funds to complete the second phase, which would add a further 200 beds.

Private Sector

While the private sector is reasonably well developed in Ghana there are, nonetheless, considerable opportunities for investment. According to the latest data published by the World Bank, private health expenditure comprised 1.4% of GDP in 2014, roughly in line with the figure recorded in 2013, whereas public health expenditure was 2.1% in 2014, a fall of 1.1 percentage points from 2013.

Private sector activity varies significantly throughout the country, with the sector accounting for a larger share of provision in Greater Accra and the Eastern Region than in other less populous regions. As the country becomes more developed consumer demand for higher-quality private health care provision is also set to rise. Furthermore, smartphone ownership has increased significantly in recent years, with the mobile data penetration rate rising from 40% in July 2013 to 77.6% in July 2017.

This shift provides opportunities for pursuing innovative delivery models for health services, particularly diagnostics. Use of mobile phone technology to provide health care services is already partially established in Ghana, with the open source Mobile Technology for Community Health platform being used since 2011 to enable pregnant and postpartum mothers to digitise and track services, and receive educational training.

Nevertheless, the segment holds strong potential for growth in the future. The opportunities for private sector investment extend beyond premium care for those with higher incomes; opportunities also exist for public-private partnership investment in general health care.

Pharmaceuticals Industry

Ghana is an important producer of pharmaceuticals in sub-Saharan Africa. The Pharmaceutical Manufacturers Association of Ghana (PMAG) lists 38 registered companies in the industry, 75% of which are locally owned. The industry has seen substantial expansion, with market revenue having doubled from $200m to $400m in the three years up to 2017, according to Kwabena Asante Offei, executive secretary of PMAG.

Furthermore, there has been foreign interest in buying into the local health care market, with the private equity firm Synergy Capital Managers announcing investment in local player Darl Pharmaceuticals Company in 2015. The country therefore not only offers the potential for regional partnerships, but also a substantial pool of professional workers experienced in all aspects of the development, manufacturing and marketing of pharmaceuticals.

Obstacles

However, the industry does face a number of pressing challenges. The competitiveness of imported products presents an ongoing problem for local manufacturers. While three-quarters of pharmaceutical companies in the country are Ghanaian owned, local manufacturers supply only 30% of the domestic drug market, with the majority of the market made up of Indian and Chinese imports. “Some degree of tax incentive needs to be in place in order for pharmaceutical manufacturers to tackle international competition,” Gopal Vasu, managing director at M&G Pharmaceuticals, told OBG. “Also, infrastructure improvements can have a direct impact on the sector’s competitiveness.”

At the same time, local pharmaceutical companies continue to be adversely affected by delays in the NHIS paying for goods and services, with medicine prices continuing to place a significant cost burden on the health care system. “Resolving the outstanding debt of the NHIS is the biggest priority for the domestic pharmaceutical industry,” Yaw Opare-Asamoah, managing director for Dannex, an Accra-based pharmaceutical manufacturer, told OBG.

The government has made efforts to address both the high price of medicine and the cost burden on manufacturers that have impeded their international competitiveness. In the first quarter of 2017 the government removed the 17.5% VAT rate on a selection of essential imported medicines in order to ease the burden on the health care system. This follows moves in 2015 that implemented tax exemptions for a range of pharmaceutical inputs and active ingredients. Meanwhile, in a move welcomed by PMAG, the government banned the import of 49 medicines, assigning their production to local companies. Under these conditions the sector is expected to expand through a growing share of the domestic market. Nevertheless, assurances about quality and reliability of medicines, and improvements in transportation and delivery, will be needed for Ghana to increase its regional and international market penetration. “Ghana still needs to improve the quality of its products, and it has helped that the government has reduced costs in some areas,” Ernest Sampong, CEO of Ernest Chemists, told OBG.

Outlook

While the country’s health care system faces numerous challenges, government, NGOs and the private sector have shown themselves to be responsive, seeking solutions even when faced with limited resources. Expanded infrastructure, increased numbers of health care professionals and a renewed emphasis on sanitation and prevention appear set to improve health indicators.

Furthermore, economic development is increasing demand for health care services, from both public and private providers. Sustained economic growth and the transition to middle-income status brings drawbacks, however, with international donor aid to the public health care system set to fall. Meeting the health care requirements of Ghana’s increasingly prosperous population will prove challenging without the private sector playing a bigger role, both in terms of offering higher quality secondary and tertiary care, and through the provision of universal care through cooperation with the public sector.