Affiliated Organization : ACCA
Publication Type : Report
‘As a critical sector of the economy, the Ministry of Health seeks to improve the health status of all people living in Ghana thereby contributing to government’s vision of transforming Ghana into a middle-income country by 2015.’
The health policy is being executed through a series of Health Service Medium Term Development Plans (HSMTDPs) and Programmes of Work (POW).
A greater insight into some of the many issues affecting health policy and the provision of health care in Ghana was provided at a health conference organised recently by ACCA in Accra. The event gave politicians, health policymakers and senior ACCA members employed in the field of healthcare the opportunity to discuss some of the key health challenges facing Ghana, to debate potential solutions and then to consider the ways in which ACCA accountants can support the government in achieving its goal of creating a healthier population.
Around the year 2000, a number of health providers began to introduce health insurance schemes aimed at addressing the difficulties patients had in accessing and paying for care. Over time, as a development of this theme, Mutual Health Organisations were established. The schemes proved popular and by 2003, countrywide, there were 258 such schemes in existence–though total population coverage was just 2%.
Around the year 2000, a number of health providers began to introduce health insurance schemes aimed at addressing the difficulties patients had in accessing and paying for care. Over time, as a development of this theme
Building on the success of these insurance schemes, legislation authorising healthcare financing reform was passed in 2003 and 2004 leading to implementation of the National Health Insurance Scheme in 2005. This aimed to make free health care available to all, but particularly to the poor and disadvantaged. Three categories of health insurance were authorised.
District Mutual Health Insurance Schemes – these were public insurance schemes open to all Ghanaian residents. The schemes were to be funded predominantly from the central government national health insurance levy supplemented by annual member contributions. Responsibility for regulating the schemes, accrediting providers and managing funds was given to the National Health Insurance Authority (NHIA).
Commercial Health Insurance Schemes – these schemes were to be funded solely from member contributions.
Private Mutual Insurance Schemes – these schemes were to be set up by a collection of people, perhaps members of a church or social club, to cater for group health needs. They were to be funded solely from member contributions.
District Mutual Health Insurance Schemes (DMHIS) have the largest membership base with around 8.2m members or around 33% of the population in 2011. Members of the scheme pay an initial registration fee followed by annual premiums and in return receive a defined level of medical care provided free at the point of delivery.
For those working in the formal sector, who are enrolled in the Social Security and National Insurance Trust (SSNIT) pension scheme, the premiums are taken at source so they are required to pay only the initial registration fee ‘out of pocket’, whereas those working in the informal sector must pay both the initial registration fee and an annual premium (of between GH¢72,000 to GH¢480,000, depending on socio- economic status) out of pocket.
A large proportion of the population are, however, exempt from the charges including:
- children under the age of 18 whose parents or guardians belong to the scheme
- people aged 70 or more
- pregnant women (since July 2008)
- indigents with no consistent form of support from another person and with no visible source of income and no fixed place of residence
- SSNIT pensioners–though they are required to pay the registration fee.
The NHIS provides a generous package of benefits covering 95% of conditions and includes inpatient and outpatient services for general and specialist care, surgical operations, hospital accommodation, prescription drugs, blood products, dental care, maternity care and emergency treatment.
The NHIS provides a generous package of benefits covering 95% of conditions and includes inpatient and outpatient services for general and specialist care, surgical operations, hospital accommodation, prescription drugs, blood products, dental care, maternity care and emergency treatment
Exclusions currently include cancer services–other than cervical and breast cancer–dialysis, organ transplants and appliances, including optical and hearing aids. The government has recently announced, however, that it plans to extend the NHIS to cover cancer services.
Although the NHIS has increased overall access to health care, there are real concerns that it has not been successful in its aim of meeting the health needs of the poorest members of society. A National Development Planning Commission (NDPC 2009) survey undertaken in 2008, for example, found that fewer than 30% of those in the lowest socio-economic quintile were members of the scheme, compared with over 60% of the wealthiest. The main reason given for not belonging to the scheme was affordability (77%).
The Ghanaian NHIS has been the subject of many international studies, and although some of these have been complimentary, many have been highly critical. Alleged failings have included:
- long delays in provider reimbursement threatening the financial sustainability of hospitals
- accusations of fraud and abuse
- inaccurate record keeping
- ‘gaming’ by providers
- unclear lines of authority
- long delays in issuing patient registration cards
- duplicate registration of members to avoid payment of missed premiums.
In response to these criticisms, a new NHIA council was appointed in June 2009. Under its stewardship, the Authority is working to introduce an ambitious programme of reforms aimed at increasing membership and improving public confidence in the scheme. Amid concerns about financial sustainability, the Authority is also exploring ways of maximising revenue and containing costs, and is looking at alternative methods of funding the scheme.
Healthcare services are provided by the public sector: mainly by the Ghana Health Service (GHS) and the Christian Health Association of Ghana (CHAG), private for-profit and private not-for- profit organisations, and traditional medicine.
On paper, Ghana has a decentralised, multi-level health system:
- the Ministry of Health (MOH) with responsibility for health policy formation, regulation and strategic direction
- the GHS with responsibility for policy implementation
- regional administrations with responsibility for public health and curative services at the regional level and supervision and management of district level services
- district administrations with responsibility for providing public health and curative services at the district level
- sub-district level administrations with responsibility for the provision of preventative and curative services at health centres and community outreach posts
- community-based health planning and services (CHPS) with responsibility for providing basic preventative and curative services for minor ailments at community and household levels.
In practice, however, local organisations lack autonomy and the majority of decision making is done centrally: responsibility for setting staff establishment levels, appointing clinical and administrative staff and paying salary costs, for example, rests with the government.
Ghana’s national health policy, ‘Creating Wealth through Health’ (MOH 2007) is being executed through a series of HSMTDPs. The latest plan, covering the period 2010–13, identifies poor access to health services and the low quality of services as the most severe problems in the sector. The HSMTDP identified five priorities.
- Bridge equity gaps in access to healthcare services, ensuring sustainable financing arrangements that protect the poor.
- Strengthen governance and improve the efficiency and effectiveness of the healthcare system.
- Improve access to quality maternal, neonatal, child and adolescent healthcare services.
- Intensify prevention and control of communicable and non- communicable diseases and promote healthy lifestyles.
- Improve institutional care including mental health service provision.
Annual Programmes of Work (POWs) are developed around these five priorities and used to monitor and review the performance of the healthcare sector.
The United Nations MDG Progress report on Ghana published in 2010 (UNDP 2010) warns that Ghana was at that time not on track to achieve MDG 4. Although the national under-five mortality rate decreased by 30% from 111 deaths per 1,000 live births in 2003 to 80 deaths per 1,000 live births in 2008 these figures hide significant regional disparities. The under-five mortality rate in Upper West, for example, was nearly double the national average at 142 deaths per 1,000 live births.
The national rates for infant mortality stood at 57 deaths per 1,000 live births in 1998, increased to 64 deaths per 1,000 live births in 2003 then fell to 50 deaths per 1,000 live births in 2008. This suggests the rate is now in decline, but there are significant regional disparities and the rates in Central, Upper East and Northern, for example, all increased in 2008.
The proportion of children aged 12–23 months immunised against measles increased to 90% in 2008; to stop transmission coverage needs to be over 90%.
The majority of the deaths reported in 2010 were caused by complications such as haemorrhage (24%), abortion (11%), obstructive labour, hypertensive disorders or infection; problems that could have been treated with skilled care
The United Nations MDG Progress Report on Ghana published in 2010 (UNDP 2010) states that Ghana was not then on track to achieve MDG 5. The maternal mortality ratio decreased from 740 per 100,000 live births in 1996 to 451 per 100,000 live births in 2008. On the basis of this trend, the ratio is forecast to be 340 deaths per 100,000 live births in 2015, which is nearly twice the MDG target of 185 per 100,000 live births.
The majority of the deaths reported in 2010 were caused by complications such as haemorrhage (24%), abortion (11%), obstructive labour, hypertensive disorders or infection; problems that could have been treated with skilled care. A key factor in reducing mortality rates, therefore, is improving access to antenatal care and ensuring the presence of a trained nurse, midwife or physician at the birth.
Women in the lowest quintile were more likely to give birth at home than those in the higher quintiles. Reasons for giving birth at home rather than a healthcare facility include: thinking it unnecessary to give birth in a healthcare facility, lack of money, distance to healthcare facility, and having no transport.
Ghana appears to be on track to achieve MDG 6. HIV prevalence is estimated to have decreased from 2% in 2003 to 1.5% in 2010. Prevalence in pregnant women aged 15–24 has, however, increased slightly from 2% in 2010 to 2.1% in 2011. The total number of adults infected with HIV in 2008 was estimated to be 250,829, of which females accounted for more than half (147,958). Around 15% of those diagnosed with TB are co-infected with HIV.
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.
Mental health services in Ghana are severely under-resourced; the country has just 12 practising psychiatrists and only three psychiatric hospitals. There are many misconceptions about mental illness, for example that children of staff employed in the field of mental health often become affected by mental illness, and this tends to discourage clinical staff from specialising in mental health.
Owing to resource constraints and the stigma attached to mental illness, the majority of the population suffering with psychiatric conditions are not treated with modern medicine; instead, they are sent to spiritual churches or prayer camps where they are sometimes severely mistreated. Mental health patients may also be kept in police custody for long periods without treatment. If patients are released from care, then the stigma attached to them from their disease makes their reintegration into the community difficult.
Plans are now being put in place to expand services, possibly by adding psychiatric units to larger hospitals. Discussions are also taken place about increasing the number of specialist staff, though before this can happen steps will have to be taken to remove the stigma associated with such roles.
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.
As acknowledged by Ghana’s National Health Policy, ‘Creating Wealth through Health’ (MOH 2007), many of the key determinants of health are outside the direct scope of the healthcare sector, as the following examples illustrate.
- There is often poor access to safe water and sanitation. According to a study published by the Water and Sanitation Program (2012), 16m Ghanaians use unsanitary or shared latrines and 4.8m have no access to latrines and so defecate in the open.
- Malnutrition is thought to be the cause of around 45% of all deaths in children beyond infancy.
- There is a lack of education, particularly among females. Levels of literacy have increased significantly since the census in 2000 and in 2010 literacy rates for those aged 11 years or more stood at 80.2% for males and 68.5% for females. There are, however, huge regional variations and in three regions literacy rates are less than 50%.
- Climate variability and change threaten food security.
- There is overpopulation of urban areas.
Other key factors include poor road networks, an old and obsolete electricity system leading to frequent disruptions in power supply, and the rapid rate of urbanisation leading to the growth of urban slums, increases in numbers of street children, and sanitation problems.
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