Universal challenge: Infrastructure upgrades and enhanced staff development to boost coverage

The continuing implementation of expansive reforms, including the Single Spine Salary Structure (SSSS) and updates to the National Health Insurance Scheme (NHIS) aimed at providing universal health care to its citizens, made 2012 a turbulent year for Ghana’s health sector. Despite sharp budget increases to the Ministry of Health (MoH) over the past several years, growing pains within the SSSS – implemented in 2010 and designed to reduce long-term wage bills – led to strikes across the health care sector in 2013, while the future of the NHIS is clouded, with long-term funding options looking increasingly insufficient. However, government plans to invest heavily in infrastructure and training in 2013, and across-the-board salary increases, should help the sector retain talent and reduce corruption. At the same time, more investment from the private sector could help navigate the path towards expanding health care provision.

SYSTEM: There are two regulatory agencies responsible for overseeing the health care system: the MoH, which creates policy, and the Ghana Health Service (GHS), which implements policy and oversees regional and district operations. The MoH’s private health agency, the private sector unit that oversees private health facilities, and a number of NGOs help the sector improve its indicators and boost services, particularly in poorer, isolated areas. The MoH’s budget saw a massive rise in 2013, driven largely by the implementation of the SSSS and its accompanying wage increases, which have seen salaries grow by 135% since 2010. The SSSS is designed to reduce the public sector wage bill over the long term by putting in place a more cohesive and uniform pay scale, but implementation costs are expected to be high. The MoH received GHS3.53bn ($1.81bn), a 96% increase from GHS1.8bn ($925.3m) in 2012. However, Emmanuel Owusu-Ansah, head of policy analysis at the MoH, said even if the budget has increased, programme spending has not necessarily kept up. “About 94% of the budget is used for workers’ salaries, so we are left with very little money to work with, especially in a service area like health where you need drugs, supplies and equipment,” Owusu-Ansah told OBG.

Although salary increases are viewed as one way to attract and retain the best staff, a labour dispute broke out when members of the Ghana Medical Association (GMA) migrated from the health sector salary scale to the SSSS in April 2013. When doctors were moved onto the SSSS, the basic salary allocated was actually lower than what they had earned under the previously. That development, coupled with an alleged backlog of arrears owed to GMA staff, caused a monthlong doctors’ strike that ended when an agreement was reached between the GMA and Ghana’s Fair Wages and Salaries Commission.

SPENDING: Overall, health care spending increased from 10.3% of the total budget in 2012 to 15.5% in 2013. Of the government’s total $2.29bn in loans secured in 2012, 13% was allocated to health care, equating to roughly $297.57m. Health expenditure per capita has shown strong growth in recent years, rising from $47.20 in 2006 to $75 in 2011, according to World Bank figures.

INFRASTRUCTURE: Investments in infrastructure increased throughout the 2000s, and by 2009 Ghana had 3217 health facilities, including 343 hospitals, 2083 clinics, 379 community health centres and 389 maternity homes. In 2012 the government completed a number of infrastructure projects in health, including construction of five polyclinics in the Upper West Region, located in the far north-west of the country; an office complex for the Food and Drugs Authority; rehabilitation and upgrading of the Tamale Teaching Hospital; construction of an eye centre at Komfo Anokye Teaching Hospital; and the installation of new MRI and CT scan equipment in Korle-Bu, Komfo Anokye and Tamale Teaching Hospitals. In addition, the children’s ward, neurosurgery and kidney transplant theatres at the Korle-Bu were also upgraded.

In 2013 the government will boost investment in infrastructure, with plans to construct five polyclinics in the Brong Ahafo region, a trauma and acute pain centre at Korle-Bu, seven district hospitals (in Abetifi, Fomena, Dodowa, Garu Timpane, Takoradi Metropolitan, Kumawu and Sekondi), a district hospital in Tarkwa, and maternity and children’s blocks at the Tema General and Komfo Anokye Teaching Hospitals. Ambulance services were rolled out in Ghana in 2011/12, and 161 new ambulances were procured in 2012, with 28 ambulance stations built across the country in 2013, bringing the total to 52.

The government announced in November 2012 it had obtained a loan of $217m from the Israeli government to construct a 600-bed teaching hospital at the University of Ghana in Legon. The project will be equipped with modern facilities including a heliport, surgery theatre, obstetrics and gynaecology, paediatrics, cardiology, heart surgery, and medicinal imaging when construction is complete.

GUIDING POLICY: The country’s Health Sector Medium-Term Development Plan is due to expire in 2013, although a number of new acts were passed in 2011 and 2012, namely for establishing a health facilities regulatory authority, ambulance agency and mental health authority. According to the 2013 budget statement, the MoH is currently starting the process of developing legislative instruments for these acts.

INDICATORS: New expenditure should help the sector to improve its service delivery and capacity, as basic health indicators have shown mixed progress in recent years. The population climbed from 22.9m in 2008 to 24.7m in 2010, and is expected to reach 26.1m in 2013, suggesting improved health indicators have boosted population growth, with some 43% of the country under the age of 15 and over 65 owing to higher fertility rates and reduced mortality. The World Bank estimated in 2011 that up until 2020, the number of children aged under 15 will remain virtually constant at 8m, while the 15-to-64 demographic will nearly double, to 18m.

Ghana maintained its ranking in the 2013 Human Development Index released by the UN Development Programme in March, placing 135th out 186 countries. The country’s life expectancy at birth rose to 64.6 years overall, a slight increase on 64.2 years recorded in 2011. While this number is well above the average life expectancy of 56 years across Africa, it still lags behind the global average of 70 years, according to the World Health Organisation.

DISEASES: Compared with other African nations, HIV prevalence in Ghana is low. The infection rate currently stands at 1.37%, a reduction on 1.5% posted in 2011, according to the 2012 HIV Sentinel Survey. The report estimated that 235,982 Ghanaians, of which 27,734 (11.8%) are children, are living with HIV and AIDS in the country.

Disease prevention has received strong government attention in recent years, and incidence of the country’s number one killer – malaria – has been declining. According to the 2011 Multiple Indicator Cluster Survey, malaria accounts for 34% of all deaths in children under five, 38% of all outpatient illnesses, and 35% of in-patient admissions in Ghana. The National Malaria Control Programme seeks a 75% reduction in malaria mortality by 2015, achieved through a number of interventional strategies including use of insecticide treated nets and indoor residual spraying (IRS).

In its 2011 annual report, the GHS reported that it had successfully attained its goal of reducing the malaria fatality rate in children under five years old, from 1.9 in 2010 to 1.8 in 2011. The GHS also implemented IRS projects in 85% of its target structures in 2011, another positive step towards addressing the challenges of malaria.

MATERNAL MORTALITY: However, it is unlikely that Ghana will meet its Millennium Development Goal to reduce maternal mortality to 185 per 100,000 live births. The most recent statistics available show maternal mortality at 350 per 100,000 live births in 2010, and the MoH reports that institutional maternal mortality (occurring in non-teaching hospitals and health care facilities across the country) has increased sharply No. of institutional maternal deaths, 2008-12* in recent years. In 2011 the MoH reported 524 institutional deaths, but in the first half of 2012, that number had already reached 834. It is still a significant drop from 2008’s 2556 institutional maternal deaths, but much work remains to be done. “We know the problems and solutions to put in place, but we are constrained by resources,” said Owusu-Ansah.

STAFFING: The most common cause of maternal death in Ghana is eclampsia – seizures – according to the GHS. Gloria Quansah Asare, director of the GHS’s family health division, told local media in 2012 that while antenatal care is nearing universal coverage, skilled attendance at delivery, post-natal care, nutrition services and appropriate nutrition needed to be addressed. A major obstacle facing health care delivery in Ghana is the lack of trained and certified staff. Retaining doctors and nurses is a challenge, but so is human resources (HR). “HR is a huge challenge, particularly in the medical sector and especially in terms of wages,” Florian Zagel from the West African Rescue Association told OBG. The government is moving to increase staff numbers across the board. The MoH reported that Ghana’s Nurses and Midwives Council had 5811 staff members as of June 2012, including 1906 clinical health assistants, 1712 community health nurses, and 1267 general nurses. According to the GHS 2011 annual report, the patient-to-nurse ratio decreased from 1489:1 in 2009 to 1240:1 in 2011. Similarly, the patient-to-doctor ratio improved from 10,483:1 in 2010 to 10,032:1 in 2011. Since 2007, a total of 115 physicians and 173 surgeons have graduated from the Ghana College of Physicians and Surgeons. In the first six months of 2012, a total of 62 new students enrolled in the college’s specialist programme, with eight new physicians and 11 new surgeons graduating. In 2013 the MoH also plans to increase access to antenatal and post-natal care by providing 2000 community health nurses and 10 midwives in each district with a new training package on long-term family planning methods. According to the 2013 budget statement, minor refurbishment will also be completed on 150 hospitals in 2013 to improve antenatal care.

RURAL COVERAGE: Disparity remains between urban and rural health care provision. The MoH and GHS launched a Community-based Health Planning Services (CHPS) in 1999, with an initial focus on deprived and remote areas of rural districts. CHPS is meant to transform the primary health care system and shift to mobile, community-based care provided by a resident nurse, rather than a conventional facility-based outreach service. The government target for scaling up CHPS in 2012 was the establishment of 500 new functional zones, according to the MoH, which reported that 209 new zones were created that year.

NHIS: The NHIS was introduced in Ghana in 2003/04 as a result of poor accessibility to health care under the cash and carry system of health care financing for the majority of Ghanaians. The scheme includes both public and private providers, and is far-reaching in coverage, with 98% of disease burden addressed by services covered. The NHIS currently has about 22m registered members and 8.6m active users, with a significant increase of 12m new members added between 2010 and 2012, according to the National Health Insurance Authority (NHIA). However, the NHIS faces serious challenges in implementation, claims disbursement and future financing. Levies from the NHIS amounted to GHS576.1m ($296.2m) in 2012 and are projected to hit GHS753.62 ($387.44m) in 2013.

A 2012 World Bank report titled “Health Financing in Ghana” found that with current plans for expenditure and expansion, the NHIS is not financially viable, and projected the scheme could be insolvent as early as 2013. Despite a new influx of oil revenues in the country, the report asserted that the scheme is too inefficient to absorb much-needed resources, and called for major reforms led by the MoH and central government, rather than within the NHIS itself. OwusuAnsah said part of the issue lies in the broad scope of the NHIS. He argued that if 98% of the disease burden is covered by the scheme, sustainable funding would always be in doubt. “In Western countries, even under universal health care, you still have to pay for some things, such as an ambulance or for the dentist. We need to take a critical look, put politics aside, and say ‘Look, if I am going to receive eye care treatment or spinal treatment, there should be some costsharing involved,’” he said.

MURKY WATERS: Allegations of financial mismanagement within the NHIS have also been made. Send Foundation, a local NGO, released a report on the NHIS in 2010, which outlined widespread abuses including cheating, over-invoicing, fraud and unnecessary prescriptions between 2004 and 2008, that led to massive financial losses for the scheme.

The government has recognised the challenges of financial mismanagement, and moved forward with plans aimed at improving accountability and monitoring. A consolidated premium account was established in 2012 to collect premiums across the country, with the NHIA expectant that establishing the account will allow for funds to be properly accounted for, reported, monitored and controlled, according to the MoH’s 2012 half-year report. The ministry’s clinical audit programme was also scaled up in 2012, as a measure to contain cost by reducing leakage. Electronic claims processing began in Ghana in November 2012 as another cost-containment measure. Aiming to enforce prescribing and dispensing levels, as well as linking treatment and diagnosis procedures, the government’s e-claims solution will have a significant potential for containing costs, according to the GHS.

In April 2013, the NHIA also announced it would begin a biometric verification programme for NHIS claims. The new system will capture the biometric data of NHIS cardholders and generate a claim code the moment the cardholder visits any health facility, according to the NHIA.

PRIVATE SECTOR: The private sector offers many opportunities for Ghana to move forward in addressing its health care challenges. Private services represent between 33% and 50% of the total in Ghana, and more than likely at least half of all out-of-pocket spending, according to a 2011 World Bank report titled “Private Health Sector Assessment Ghana”.

The Private Hospitals and Maternity Homes Board (PHMHB) reported it had accredited a total of 479 private facilities, including 55 hospitals, 290 clinics and 134 maternity homes by 2009. However, this is likely an underestimate of the total number of self-financed providers. As of 2008, the NHIA had accredited 395 private hospitals and clinics and 237 private maternity homes, 25% more facilities than the number officially registered with PHMHB. Most recently, the MoH reported 156 private hospitals, 688 private clinics and 379 private maternity homes as of 2007.

Ghana already has an agreement between the public and private sector for health care provision, with the non-profit NGO, the Christian Health Association of Ghana (CHAG), providing services at 58 hospitals, 76 clinics, 19 health centres, 15 primary health care programmes, 10 training institutions and three specialist facilities. The country is ahead of many other African countries with its Private Health Sector Policy (PHSP), adopted in 2003. The World Bank found that the PHSP was largely unimplemented seven years after its adoption, however, a new private sector policy was finalised in the first half of 2012.

Apart from the partnership with CHAG, few expansive public-private partnerships exist. At Accra’s Lister Hospital, one of Ghana’s premier private hospitals, director David Pickering said private development holds untapped potential for the health care sector, as the rising middle class and new expatriate workers are poised to make a visible impact on all sectors of the economy. “Private medicine is growing generally because more people can afford to pay. In any developed, mixed health care economy, the ratio settles at 80% of the population having insurance, and 20% self-paid. This is the case in the US, UK and Europe. Here, it is 80:20 the other way,” Pickering told OBG.

Lister is constructing a new 125-bed hospital addition, which will bring its total number of beds to 150. The new facilities will offer a host of services including MRI and CT scans, cardiology, a neonatal intensive care unit, and an endoscopy unit. Scheduled to open in 2014, Pickering believes the new hospital proves that investment in Ghana’s health care sector is worthwhile. “The private sector has a huge role to play. As the health sector in Ghana matures, it will follow the same evolution as in any developed country. Even without the new hospital, we are predicting an 11% growth in profits in 2013,” he said.

OUTLOOK: After enduring the growing pains of a number of new health policies and reforms, Ghana’s health sector is set to move forward after a trying year. Controversy over the SSSS created trouble in early 2013, but salary increases should assist in recruiting and retaining quality staff and personnel. Although the NHIS faces a number of challenges, new measures aimed at improving efficiency, financial management and patient monitoring could keep the scheme sustainable in the medium term.

The MoH has seen its budget swell as the government attempts to address deficiencies within the sector, and remains committed to delivering universal health care through infrastructure upgrades and enhanced staff development. Although some indicators have been declining, the overall health of Ghanaians has improved in recent years, and seems set to continue on an upward trajectory into 2014.