The Association of Chartered Certified Accountants(ACCA)
The Ghanaian government’s national vision is to transform Ghana into a middle-income country by 2015. This is an ambitious target for a country where over a quarter of the population live in poverty, where disease is rife and where around half of the population have no access to basic services such as safe water or improved sanitation; along with ample resources it will require strong commitment and vision.
Ghana’s National Health Policy, entitled ‘Creating Wealth through Health’ (MOH 2007), was designed to support realisation of the national vision. The policy recognises that ill health is both a cause and a consequence of poverty and acknowledges the impact that environmental factors have on health. It proposes a sector-wide approach to improving the health of the population and to reducing inequalities of access, based on both preventative and curative care. The health policy is being executed through a series of Health Service Medium Term Development Plans (HSMTDPs) and Programmes of Work (POW).
The healthcare system in Ghana
Ghana was upgraded from a low to a lower-middle income country in July 2011. This followed a statistical rebasing of the economy undertaken in 2010 to reflect new market sectors such as oil exploration, forestation and telecommunications. These developments had resulted in the growth of the economy by 60% from $18 billion to $30 billion. The government’s national vision is for Ghana to attain middle-income status by 2015. The country’s healthcare policy is aligned to this vision and to achievement of the Millennium Development Goals (discussed below) through a series of Health Sector Medium Term Development Plans (HSMTDPs).
Over the years, Ghana’s healthcare system has seen many changes. When the country first achieved independence it was committed to providing ‘free for all’ health care. This policy remained in place until the country’s economic crisis in the 1970s and 1980s when government spending on health care dropped by 20%, leading to a shortage of supplies, demoralised staff and a halt on investment in infrastructure.
In return for support from the World Bank, the Ghanaian government agreed to impose a charge for health services, equating to 15% of recurrent expenditure. The impact of this ‘cash and carry’ system was a rapid decline in service use of more than 50% countrywide and of over 70% in rural areas. Studies have since found that residents moved away from modern medicine and turned to traditional medicine or self-medication for treatment.
In the mid-1980s payment exemptions were introduced for a limited number of health services and in 1997 these were extended to cover children under five years old, people over 70 and the poor. Application of these exemptions, however, was irregular. Difficulties included: health provider access to exemption funds, obtaining each patient’s proof of age, validation of poverty, and non-uniform application of exemptions.
The challenges facing health service provision in Ghana
The mission statement of the Ghanaian MOH is to promote ‘health and vitality through access to quality health for all people living in Ghana using motivated personnel’. Achieving this ambitious goal will be a challenge. In addition to significant disparities of service between north and south and between rich and poor, factors such as cultural and religious beliefs, poor physical infrastructure and limited resources all work to hamper the provision of equitable healthcare services, creating challenges for planners and policymakers.
Service disparities between the North and South
In Ghana there has long been a northsouth divide with those in the Northern, Upper East and Upper West regions (an area containing around 17% of the population and covering around 40% of Ghana’s land mass) having significantlyless than those in the south. Fewer than 50% of the people in the three northern regions have access to electric power supplies, for example, compared with 72% nationally.
Service disparities between rich and poor
The introduction of the NHIS was intended to eradicate inequities of service provision between rich and poor but, to date, it has not achieved this aim. In a survey undertaken to assess access to health care for people from different socio-economic groups, the poorest members of society were found to be more likely to self-treat than to visit a hospital.
There are also significant differences between the poorest and wealthiest members of the population in both the under-five mortality rate and the number of births attended by skilled health personnel. The under-five mortality rate for the poorest quintile of society, for example, was 102 deaths per 1,000 live births compared with just 60 per 1,000 live births for the wealthiest quintile.
Ghana suffers from a chronic shortage of health workers as well as inequities in both the distribution and skills mix of workers, and this severely restricts access to services and hampers achievement of national health objectives. The country has just over 11 doctors, nurses and midwives per 10,000 population, less than half the number (23 per 10,000) deemed necessary by the WHO for achievement of the health MDGs.
Rural areas, in comparison with urban areas, are particularly poorly served as regards access to health care; in 2009, for example, there was one doctor for every 5,103 people in Greater Accra, compared with one doctor for every 50,751 people in Northern Region. The government has introduced a number of schemes to try to address this problem including the Deprived Area Incentive Scheme, which offered an additional allowance of 20–35% of basic salary, though this has since been discontinued; the Health Staff Vehicle Hire Purchase Scheme; and various housing schemes, but none has proved particularly successful.
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