How can Ghana boost access to health care and pharmaceutical manufacturing?

Ghana’s health sector has made significant progress over the last two decades, with access and insurance coverage growing since the introduction of the National Health Insurance Scheme (NHIS). The Covid-19 pandemic exposed some long-standing weaknesses in the system, most notably the lack of hospitals and larger medical centres outside big cities. However, new government infrastructure plans, such as the Agenda 111 hospital project announced in 2021, are expected to improve accessibility to health care as well as boost the number of medical staff across the country.

Oversight & Sector Policies

The Ministry of Health (MoH) produces national health care policy and provides strategic direction for the annual budget allocated to the sector. The autonomous Ghana Health Service, established in 1996, supports the implementation of MoH policy across the health care sector, overseeing the management of resources, and providing comprehensive health services at the national, regional, district and sub-district levels.

In 2020 the MoH revised the National Health Policy, which aims to address key issues in the health system and build resilience to respond effectively to public health emergencies such as the Covid-19 pandemic. The Ghana National Health Care Quality Strategy 2017-21, meanwhile, seeks to improve the health and well-being of Ghanaians by developing a better coordinated health system. There has been criticism over the lack of national coordination in Ghana’s health care system, most notably in the urban-rural divide, with a need for improved health care infrastructure across rural areas and greater technological advancements to enhance communication among medical centres and to facilitate access to patient information.

Budget & Covid-19

The 2022 budget allocated GHS6.7bn ($1.1bn) to health, down from GHS8.5bn ($1.5bn) in 2021 but up on GHS4.7bn ($803.7m) in 2020. Following criticism of the country’s lack of preparedness for the Covid-19 pandemic, President Nana Akufo-Addo promised significant improvements in the health sector. The rise in the 2021 budget allocation reflected the introduction of new health programmes and infrastructure investments, as well as the response to increased costs relating to the Covid-19 pandemic.

Ghana was the first country to receive vaccines through the UN-backed COVAX Facility programme, under which governments around the world donated vaccines to developing countries. The country commenced its mass Covid-19 vaccination rollout in March 2021. However, implementation was slow due to funding gaps, meaning that there were not enough trained staff or centres to support the programme. To help address this issue, in June 2021 the World Bank approved $200m in funding through an Emergency Preparedness and Response Project Second Additional Financing programme with the government of Ghana. As of early January 2022, approximately 19% of the Ghanaian population had received at least one dose of a vaccine, according to Our World in Data, above the African continent average of 13.3%. However, this was well below the country’s goal to vaccinate 20m people, or about 66% of its population, by the end of 2021.

General Indicators

Several of Ghana’s health indicators have improved over the last decade, demonstrating the overall progress made across the health care sector. For instance, life expectancy rose from 56.9 years in 1999 to 64.1 years in 2019. Ghana has also made significant strides in reproductive health. Mater- nal mortality, for example, has dropped progressively over the last decade, from 516 per 100,000 live births in 2007 to 334 in 2017. Likewise, the infant mortality rate per 1000 live births decreased from 48.8 in 2009 to 33.9 in 2019. The Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition Strategic Plan 2020-25 aims to continue to improve on reproductive health indicators, which still fall below international averages. This will be supported by the Health Aging and Nutrition programme, as well as investments in reproductive medical training, public education and procuring equipment for health facilities.

Staff

In 2017 there were 0.09 physicians and 2.34 nurses and midwives for every 1000 people in Ghana. This is lower than the sub-Saharan Africa average of 0.21 doctors per 1000 people that year but higher than the continent’s average of one nurse and midwife per 1000 people. Nevertheless, the number of medical staff per 1000 people in Ghana has been growing, reaching 0.1 physicians and 2.7 nurses and midwives in 2019. This is primarily due to President Akufo-Addo’s initiative to hire 100,000 health care staff during his first term in office, from 2017 to 2020. In 2021 he pledged to hire more medical staff in line with the planned construction of new hospitals and medical centres across the country.

There are five regional teaching hospitals, all working closely with universities to run undergraduate and graduate programmes in medicine, nursing and nutrition: Tamale, Korle-Bu, Cape Coast, Ho and Komfo Anokye. More training opportunities in Ghana have meant that local doctors, rather than physicians visiting from Europe, now provide the most critical medical care for Ghanaians. At the same time, a high level of emigration of trained physicians remains, especially by those from rural areas. Due to better medical education available overseas, many specialist-trained doctors leave Ghana, leading to shortages of highly trained health care staff in the country.

Disease Burden

While the percentage of the Ghanaian population dying from communicable diseases has decreased substantially over the last two decades, from 64.1% in 2000 to 45.2% in 2019, the percentage of deaths stemming from non-communicable diseases (NCDs) has increased, from 29.3% in 2000 to 45.4% in 2019. Health issues associated with being overweight and obese, including diabetes and hypertension, are on the rise, largely due to the change in lifestyle of Ghana’s growing middle class. The percentage of overweight and obese adults and children is steadily increasing year-on-year. According to the International Diabetes Foundation, there is a 1.8% prevalence of diabetes among Ghanaian adults, equating to around 281,100 individuals. Furthermore, it is estimated that approximately one in four adults have hypertension, a leading cause of death in the country.

Meanwhile, the fall in the percentage of underweight children, from 19% of kids under the age of five in 2003 to 12.6% in 2017, suggests that access to nutritious food and food education has improved. Indeed, the prevalence of undernourishment dropped from 15% in 2001 to 6.5% in 2018. This progress is set to continue thanks to initiatives such as the Food Safety Emergency Response Plan, which was adopted by the Food and Drugs Authority (FDA) in June 2021. With support from the World Health Organisation (WHO), the programme seeks to reduce the impact of food-borne disease outbreaks.

In 2012 Ghana approved a national NCD policy aimed at improving prevention, early detection, training across health services and the provision of treatment. However, over the last decade there has been criticism over the implementation of the policy, with a number of studies suggesting that there is little knowledge or practice of the strategy in poorer regions of Ghana, where there is a higher prevalence of NCDs among the population. A lack of funding has also hindered policy implementation. Nevertheless, in a 2020 report the WHO cited Ghana’s strong efforts to continue to deliver regular health care services, including the provision of sexual and reproductive care, and the ongoing treatment of NCDs and other illnesses.

Sanitation conditions continue to pose a challenge in Ghana, as only 10.4% of the population had access to basic sanitation facilities in 2020 and 41.4% had access to safely managed drinking water – although a further 44.4% had access to basic drinking water. Nonetheless, these figures have improved over the past two decades, with financial help from several international development organisations such as the US Agency for International Development.

There have also been improvements in the rates of malaria and several tropical diseases. The incidence of malaria fell from 333.7 per 1000 people at risk in 2008 to 224.3 in 2018, although Ghana remains one of the top-10 most malaria-burdened countries in the world. In March 2021 President Akufo-Addo launched a $238m Global Fund grant to support the country’s fight to end HIV/AIDS, tuberculosis and malaria, bringing the total amount of funds awarded to Ghana through this project to $1bn. The country is also working to eliminate 14 neglected tropical diseases through a number of national organisations such as Buruli Ulcer Control and Yaws Eradication, Leprosy Control and Neglected Tropical Diseases Control.

Public Care

The rollout of the NHIS in 2004, overseen by the National Health Insurance Authority (NHIA), marked the start of Ghana’s journey towards sustainable universal coverage. The NHIS is financed by the National Health Insurance Fund, of which around 70% is funded by a 2.5% share of value-added tax revenue; approximately 20% by a 2.5% share of contributions to the Social Security and National Insurance Trust; and the remainder by income-adjusted premium. The NHIS has improved access to primary health care for vulnerable populations, including children, pregnant women, individuals living in poverty, elderly people, and those with physical or mental disabilities, with these demographics exempt from paying premium.

Enrolment in the NHIS has increased in recent years, rising from around 10.8m in 2018 to more than 12m in 2019. The highest recorded enrolment figures came from the Ashanti Region, with approximately 2.2m active members in the scheme. Ghana’s Roadmap for Attaining Universal Health Coverage 2020-30 aims to boost NHIS coverage significantly, with the goal of “increased access to quality essential health care and population-based services for all by 2030”.

The Covid-19 pandemic drew attention to several weaknesses within the public health sector, most notably the lack of adequate medical infrastructure in non-urban areas. As the health system became overburdened with the rise of infections, it exposed the lack of intensive care unit (ICU) beds across the country; Ghana has a total of 113 adult and 36 paediatric ICU beds for a population of 31.1m. Of Ghana’s 16 administrative regions, 10 – covering a combined population of around 10m people – had no access to an ICU bed at the beginning of the pandemic. Many rural regions have no access to a hospital and in which to find primary care. Measures to prevent the spread of the virus meant that primary health services, such as the Community-based Health Planning and Services (CHPS) initiative, which provides door-to-door services to underserved populations, were restricted. Additionally, few people living in rural areas have access to telemedicine services due to high internet costs, unstable electricity and extreme poverty.

To address these shortcomings, President Akufo-Addo pledged to build 101 district hospitals, seven regional hospitals, and two specialised hospitals in the middle and northern belts, as well as renovate the Effia Nkwanta Regional Hospital, under the Agenda 111 hospital project. The facilities are also expected to provide accommodation for health workers. The government secured $100m in funding for the project, which broke ground in August 2021 and will be carried out by local architecture group Adjaye Associates.

The NHIA has made strides in the digitalisation of its health care services, celebrating its achievements towards a digital revolution on NHIA Data Day on November 18, 2021. That year the NHIA saw 80% of NHIS members renew their membership using the new renewal mobile platform. The authority has also made advances in the digitalisation of medical records, with over 15m records being transferred from the National Identification Authority to the NHIA. This technological progress towards a paperless health care sector demonstrates the start of Ghana’s digitalisation drive.

Private Care

Domestic private health expenditure, including out-of-pocket spending, accounted for 48.7% of total health care spending in 2018, according to the latest data available. Out-of-pocket expenditure continues to make up a substantial proportion of Ghana’s health care spending, although this has steadily decreased since the introduction of the NHIS, falling from 55.9% of total health spending in 2000 to 37.7% in 2018. Many out-of-pocket payments contribute towards medicine and treatment through the NHIS. In fact, 42% of the poorest demographic registered with the NHIS reported making out-of-pocket payments.

The NHIA is the regulator of private health insurance schemes and oversees 11 official private health insurance organisations. There were 928 private health care facilities across the country as of May 2020. The private sector consists of faith-based organisations, and private for-profit and private not-for-profit institutions.

Medical Research & Education

The University of Ghana’s semi-autonomous Noguchi Memorial Institute for Medical Research plays a key role in the country’s medical research. As Ghana’s leading biomedical research facility, it has carried out extensive studies in the areas of malaria, schistosomiasis, lymphatic filariasis, HIV/AIDS, rotavirus, influenzas, neglected tropical diseases and mycobacterial infections.

Alongside modern medicine, Ghana continues to treat illnesses using traditional medicine, supported by studies from the Centre for Plant Medicine Research (CPMR), an MoH agency. The CPMR focuses on product development, formulating plant-based medicines for the treatment of hypertension, diabetes, malaria and other diseases. Approximately 70% of patients in Ghana continue to use herbal medicine, with many seeking medical advice from traditional healers instead of or as well as modern medical institutions. The government has plans to include herbal medicines in its national Essential Medicines List as part of a national insurance scheme to reimburse patients seeking these treatment options. Yet, the majority of herbal medicines available in Ghana, as well as traditional medicine practice, continue to be largely unregulated.

Pharmaceuticals

The pharmaceutical industry is working towards increasing local production, which currently meets 30% of domestic needs. In September 2020 plans were announced for a $321m, 60-ha pharmaceutical park to be built in the Dawa Industrial Zone in the Greater Accra region, with the goal of producing between 60% and 80% of the country’s pharmaceutical needs. Increased local production will help to reduce Ghana’s import bill; drug imports reached an estimated $263m in 2019, greatly outweighing the country’s drug exports of $3.8m. Ghana is the only country in sub-Saharan Africa to produce active pharmaceutical ingredients, placing it in a good position to establish itself as a leader in the region’s generic drugs market. According to Fitch Solutions, in 2020 pharmaceutical sales hit GHS2.7bn ($461.7m), with expected sales of GHS2.9bn ($496m) in 2021. This figure could reach GHS4bn ($684m) by 2025 if the pharmaceutical manufacturing sector expands as planned.

The FDA, established in 1997, manages the regulation of food, drugs, food supplements, herbal and homoeopathic medicines, veterinary medicines, cosmetics, medical devices, household chemical substances and tobacco products. In May 2020 the WHO awarded Ghana’s FDA maturity level 3 status – out of a possible four – for its achievements as a regulatory body. It is one of only two countries in Africa, alongside Tanzania, to have received the award.

Outlook

Ghana’s health system has made strides in the past decades, notably in terms of improving health insurance coverage and general indicators, and reducing certain diseases. More recently, in part in response to the Covid-19 pandemic, Ghana has forged ahead with digitalisation efforts, improving online access to medical services and digitalising records. With the construction of health facilities in the pipeline, including the 60-ha pharmaceutical park, the sector is poised for further growth in the long term.