Scaling-up health inve Scaling-up s tment for better health, economic growth and accelerated poverty reduction poverty accelerated and growth economic health, better s for

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G INITIATIVE © National Development Planning Commission, Government of , October 2005

The ideas expressed are those of the consultant and the technical team put together by the NDPC to support the process.

Design by rsdesigns.com sàrl. Printed in France. ONOM EC IC O S R A C N A D

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G INITIATIVE Scaling-up health investments for better health, economic growth and accelerated poverty reduction

Report of the Ghana Macroeconomics and Health Initiative

October 2005 Resource Mobilisation 66 GOG Domestic Resource Mobilisation 67 Table of Contents HIPC Funds 68 Establishment of Community Health Endowment Fund 69 nitiative

Reprioritisation of GPRS Allocations 69 I Transfer of the Exemption Fund under the Cash and Carry System from the Central Government 69 Foreword iv Scheme 70 Message from the Regional Director vi Donors Assistance to Financing 70 Risks and Constraints to Scaling Up Investments in Health 71 Acknowledgement vii ealth Controllable Risk 72 Members of the GMHI viii Uncontrollable Risks 73 H List of Acronyms xi Major Constraints 73 Recommendations for Minimizing the Major Risks and Addressing the Major Constraints 77

Part I. Introduction 1 and

What is the Ghana Macroeconomics and Health Initiative (GMHI)? 1 Part III. Analysis of Costs and Investment Plan 79 s Who are the members of the GMHI 2 Introduction 79 The GMHI Report 2 Health Priorities and Health Target Outcomes in Ghana 80 How is the Report to be used? 3 Health Priority Areas in Ghana and MDGs 82 Total and Incremental Costs Analysis 83 Part II. Investing in Health for Economic Growth and Poverty Reduction 5 The Costing Methodology 84 Introduction 5 Assumptions 84 The Link between Health and Development 6 Cost Components 86 Link between Poor Health and Poor Economic Growth in Ghana 8 Resource Envelope 86 Health and Poverty in Ghana 10 Total Costs and Incremental Cost of Scaling-up Health Spending 87

Poverty 11 Cost in Relation to GNP 88 acroeconomic Potential Available Resource Envelope 88 Low Female Literacy 11 M High Population Growth Rate 12 Resource Gap Analysis 90 Poor Nutrition 12 Proposed Capital Investment Plan 93 Limited Access to Water and 12 Resources Allocation by Line Item 93 Resource Allocation by Level of Service 96

A Health Profile of Ghana 13 hana Profile of Morbidity and Mortality, and Health Interventions 13 Civil Works 96 G Maternal Mortality 14 Medical Equipment 98 Child Morbidity and Mortality 19 Transport 98 The Old Agenda of Communicable 23 Absorptive Capacity Constraints 99 Threats to Gains in 28 Human Resource Constraint 99 Widening Access to Health Services 37 Bridging the Human Resource Gap 101 CHPS as the Basis of a “CTC” Health System in Ghana 38 Analysis of the Costs of Scaling-up Investment in Water and Sanitation in Ghana 106 National Health Insurance Scheme 40 Design of the Cost Estimation Model 106 Health Care System and Service Delivery in Ghana 43 Model Assumptions 107

for better health, economic growth and accelerated poverty reduction Estimating Costs of Coverage for Water and Sanitation 108

s Structure of Service Delivery 46 Policy Framework on Health 46 eport of the

Health Sector Reforms 48 Appendix A 111 R Access to and Utilisation of Health Services 48 Appendix B 131 s tment Water and Sanitation Situation in Ghana 50 Description of the Coverage and Costing Estimation Model for Water and Sanitation 131 Financing Health Care 56 Main Assumptions 131 Patterns of Health Care Finance and Expenditure 56 Scenario Building in the Model 131 Health Care Spending by Line Items 58 Population parameters 132 The Medium Term Rolling Health Expenditure Programme 60 Facility Parameters 133 Ministry of Health - Programme of Work (POW) 60 Readiness Factor 134 Financing Plan under POW II 63 Health Expenditure under the GPRS 64 References 136 Under funding of the Health Sector 65

ii • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • iii Scaling-up health inve Foreword nitiative

“Making investments for a healthy population is a necessary prerequisite for economic The release of this report is timely, as never before in history has there been so much I growth, and poverty reduction”. In recognition of Ghana’s commitment to improve the enthusiasm and political commitment from both the developed and developing worlds health status of all Ghanaians, the President HE John Agyekum Kufuor in his State of to spotlight health as a prime mover for economic well being and poverty reduction. The the Nation address at the first session of the 4th Parliament of the 4th Republic stated environment is very conducive. that” Government is sharpening its focus more by adopting a three-pronged strategy; (1) Recent announcements indicate that Ghana amongst eighteen countries is expected to ealth Vigorous Human Resource Development, (2) Private Sector Development and (3) a con- benefit from a debt relief of about $40 billion from the multilateral donors (including H tinuing emphasis on Good Governance. … [T]hese priorities will drive all programmes the World Bank, the International Monetary Fund (IMF) and the African Development and accelerate the pace of their implementation. The expertise, health and the progressive Fund). Furthermore, the recently held G-8 in June 2005 decided to grant 25 billion dollars outlook of the human capital are what will move the economy and propel the country per year to Africa to assist it to achieve the MDGs. These announcements in addition into a middle income nation in the next ten years.” and to current initiatives such as the GAVI, Global Fund, and the Millennium Challenge s It is in this light that The accepted the recommendations of the Account provide opportunities for Ghana to mobilize the additional resources to supple- report of Commission on Macroeconomics and Health (CMH) by WHO (2001) and sees ment local resources to achieve the health and health related MDGs. it as an opportunity to set the agenda for health as a resource for economic development The required investments to achieve the health related MDGs translates into US$ 21 per in Ghana. To operationalize the recommendations to the local setting, the Ghana Mac- capita per year up to 2007 and up to US$ 40 per capita from 2008 to 2015, compared to roeconomics and Health Initiative was instituted and working guidelines put in place for current total (public and private) per capita expenditure on health of US$ 13.5. This is its functioning. In November 2002 HE the President John Agyekum Kufuor launched the doable and achievable given the conducive environment. Initiative with the objective of developing a report that would detail the cost for achieving the health MDGs through the scaling up of a set of key interventions that address priority The challenge now is for our partners to keep to their promises in making the additional health conditions including water and sanitation provision in the rural areas. resources available and for a common agreement on a monitoring and evaluation frame- work that will set targets to measure resource flows and level of performance. acroeconomic The process to develop the plan has been participatory through numerous consultations M and seminars with several stakeholders and partners. In addition to the local technical We on our side are ready to play our part and also accept our stewardship role in the expertise, technical assistance was also provided by the WHO country office, WHO/ management and utilization of such resources. AFRO and Geneva.

The report consists of three parts: Introduction, Investing in health for economic growth hana

and poverty reduction, and Analysis of costs and investment plan. The report addresses G key national health priorities which are mostly poverty related including reducing the maternal, infant and child mortality rates, HIV/AIDS, TB and in addition to rural water and sanitation provision, given the close relation of poor water supply and sanitation to key endemic diseases.

Health investments primarily rely on a lot of resources, particularly human resources, Major (Rtd.) Courage Quarshigah Mr. Kwadwo Baah Wiredu equipment, technologies and medicines. These requirements call for substantial addi- Minister of Health Minister of Finance and Economic Planning tional resources which are beyond the scope of most developing countries, including for better health, economic growth and accelerated poverty reduction s Ghana. Building partnerships in and out of Ghana will be crucial in mobilising these

resources. eport of the R The report has provided valuable information and inputs for developing the following;

s tment the health component of the Ghana Poverty Reduction Strategy (GPRS), the Ministry of health annual 2006 POW, as well as the third POW 2007-2011 and the Round 5 proposals for the GFATM. Findings of the report have also been used to develop proposals for the Millennium Project as well as the US Government’s Millennium Challenge Account.

iv • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION •  Scaling-up health inve Message from the Acknowledgements nitiative

The Ghana Macroeconomics and Health Initiative (GMHI) wish to thank His Excel- I Regional Director lency, the President of Republic of Ghana Mr. John Agyekum Kufuor for his support and launching the Initiative on November 2002. The initiative also acknowledges the support received from the members of the Advisory Board comprising the Ministers for Economic Planning and Regional Cooperation: (Dr. Kwesi Nduom); for Health: (Dr. Kwaku Afriyie),

In September 2000, the largest-ever gathering of Heads of State ushered in the new mil- ealth for Finance: (Mr. Yaw Osafo Marfo) Local Government and Rural Development (.Mr.

lennium by adopting the UN Millennium Declaration. The Declaration, endorsed by 189 H countries, was then translated into a roadmap setting out goals to be reached by 2015. Kwadwo Baah Wiredu). Gratitude also goes to Prof. George Gyan Baffour and Dr. Regina Adutwum of the National Development Planning Commission (NDPC) for providing The eight MDGs build on agreements made at the United Nations conferences in the 1990s and represent commitments to reduce poverty and hunger, and to tackle ill health, the guidance and political stewardship during the early era of the GMHI. The personal gender inequality, lack of education, lack of access to clean water and environmental interest of Mr. Kwaku Agyeman Manu (Deputy Minister of Finance and Economic Plan- and s degradation. ning) in the whole GMHI process is also be acknowledged. We are also grateful to Dr. Dyna Arhin Tinkorang for her invaluable technical advice at the inception of the process The MDGs are framed as a compact, which recognizes the contribution that developed leading to the coming into being of the GMHI. The GMHI is indebted also to Prof. Alex countries can make through trade, development assistance, debt relief, access to essential Kwapong (former chairman of Council of State) and his Advisory Group for providing medicines and technology transfer. policy directions in shaping the GMHI. A lot of gratitude is owed to the members of the Three out of eight goals, eight of the 16 targets and 18 of the 48 indicators relate directly to various Technical Working Groups and the authors of the papers commissioned, particu- health. Health is also an important contributor to several other goals. The significance of larly from Ministry of Health, , Community Water and Sanitation the MDGs lies in the linkages between them: they are a mutually reinforcing framework Agency and Ministry of Local Government and Rural Development. (see below for list to improve overall human development. of members of the various technical groups)

The MDGs have set standards and challenges for us to work towards. Through the Ghana acroeconomic A lot of dedicated individuals from Ghana and elsewhere provided technical assistances in Macroeconomics and Health Initiative (GMHI), in Ghana, this has been taken seriously M by identifying the priority actions and through a very thorough and consultative process the drafting of the GMHI document. Among the many individuals who devoted especially worked out the estimates of how much it will cost to achieve the set health goals and long hours of time and energy to the preparation of the document, we would like to pay targets. many special tributes and appreciations to Dr. Kojo Appiah Kubi who served as the lead consultant in pulling together all the thematic papers and reports. We also express our

The process has yielded a lot of experience and has raised pertinent questions such as hana sincere gratitude to Messrs Edward Amanning-Ampomah, Lawrence Damnyag, Newton

fiscal space, availability of human resources and absorptive capacity given the quantum G Torvinyo, and Daniel Torvinyo (all from the University of Ghana), Dr. Chris Mwikisa, Dr. of resources required to achieve the MDGs. However, these are questions which must not only be put on the table but also need to be resolved if the MDGs are to be achieved. Benjamin Nganda (all of WHO/AFRO), Jeanette de Putter, Valerie Crowell, Jenni Kehler, Dr. Alaka Singh (WHO/HQ) and Dr. Frank Nyonator, the PPMED director of the Ghana To the development partners it is our hope that the case of what it will cost to achieve the Health Services for contributing in diverse ways to the document. The World Health MDGs has been well presented. Your support will be crucial for resource mobilization Organisation led by Dr. Sergio Spinaci, and ably supported by his team also provided vari- and allocation, monitoring of resource flow and evaluating the impact of programme ous assistances and facilitated in diverse ways the work of the GMHI. We acknowledge outcomes. the crucial importance of donations provided by the Gates Foundation, Italy, Norway I want to thank all development partners, the United Nations System (Ghana) and the and Sweden for the CMH follow-up at country level. We also wish to thank Dr. David for better health, economic growth and accelerated poverty reduction various government sectors that have worked tirelessly through the whole process. In s Nabarro who participated in the launch of the GMHI. Many special thanks go to WHO addition to facilitating the process, WHO has provided technical and financial support. Ghana Country team, especially to their able country director Dr. Melville O George and eport of the DFID also provided financial support for the process. We have no doubt that Ghana is his assistant Mr. Selassi Amah d’Almeida, without whose personal involvement, financial, R well positioned to achieve the health MDGs if given the expected support. This is our technical assistance and persuasion the document could not have been completed. Dr.

s tment chance to make a difference. Regina Adutwum of the NDPC who served as the coordinator of the GMHI skillfully managed the process to the admiration of all involved in the process.

The GMHI gratefully acknowledges the financial support provided by the World Health Organisation and the United Kingdom Department for International Development.

Dr Luis Sambo Regional Director WHO Regional Office for Africa

vi • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • vii Scaling-up health inve Technical Groups Members HEALTH

Name Organisation nitiative I of the GMHI Dr. Frank Nyonator (Leader) Ghana Health Service Dr. Nana Kwadwo Biritwum Ghana Health Service

Dr. Caroline Jehu-Appiah Ghana Health Service ealth Dr. Ken Sagoe Ghana Health Service H Mr. Dan Osei Ghana Health Service

Mr. Partrick Nomo Ministry of Health

Mr. George Dakpallah Ministry of Health and s The Core GMHI Technical Team Mr. Emmanuel Owusu-Ansah Ministry of Health Mr. Isaac Adams Ministry of Health The GHMI Technical Team is the small group pulled out of the various Technical Work- Dr. Eddie Addai Ministry of Health ing Groups to work with the Consultant, Dr. Kojo Appiah-Kubi in finalization of this Document. The Members of the GMHI Technical Team are: Dr. Sam A. Akor Ministry of Health Dr. Evelyn Awittor Ministry of Health » Dr. Regina Adutwum – Coordinator Mr. Selassi Amah d’Almeida World Health Organisation » Dr. Melville George » Dr. Frank Nyonator WATER AND SANITATION acroeconomic » Mr Selassie D’Almeida Name Organisation M » Mr. George Dakpallah Dr. N.A. Coleman Min of Local Government and Rural Development

Mr. W.M. Marfo Min of Local Government and Rural Development

Consultant Mr. Kweku Quansah Min of Local Government and Rural Development hana » Lead Consultant: Dr. Kojo Appiah-Kubi

Mr. R.K.D. Van Ess Community Water and Sanitation Agency G

» Co-investigators: Edward Amanning-Ampomah, Lawrence Damnyag, Newton Tor- Mr. Kordzo Sedegah United Nations Development Programme

vinyo, and Daniel Torvinyo Mr. Henry Noye-Nortey Sch of Public Health, Univ. of Ghana

Mr. George Laryea Adjei UNICEF

Mr. Kenneth Owusu Institute of Social Statistics and Economic Research, Univ. of Ghana

Dr. Isaac Osei-Akoto Institute of Social Statistics and Economic Research, Univ. of Ghana for better health, economic growth and accelerated poverty reduction s eport of the

ADVOCACY R Name Organisation s tment Dr. Regina O. Adutwum National Development Planning Commission

Ms. Rosemary Ardayfio Health Desk, Graphic Corporation

Ms. Yaa O. Acquah Health Desk, Ghana News Agency

Mr. K.K. Kamaluddeen United Nations Development Programme

Mr. F. Kwarteng-Amaning Ministry of Finance & Economic Planning

Ms. Sophia Twum Barima World Health Organisation

viii • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • ix Scaling-up health inve Members of the Advisory Committee » Minister of Health List of Acronyms nitiative

» Minister of Economic Planning and Regional Cooperation I

» Minister of Finance

» Minister of Local Government and Rural Development

» Minister of Works and Housing ealth

» Majority Leader of Parliament H

» Representatives of Parliamentary Select Committee on Health

» Chairman of the Council of State ACSD Accelerated Child Survival and GMHI Ghana Macroeconomics and Health and » Director General of Ghana Health Service Development Program Initiative s AFP Alpha-Fetoprotein GNP Gross National Product » Insurers Association AIDS Acquired Immune Deficiency GNP Gross National Product Syndrome » Vice Chancellor, University of Ghana GOG Government of Ghana ANC Antenatal Care GPRS Ghana Poverty Reduction Strategy » Country Representative of WHO AP Aqua Privy GSS Ghana Statistical Service ARI Acute Respiratory » Country Representative of UNDP GWCL Ghana Water Company Limited BCG Bacille Calmette-Guerin » Country Representative of UNICEF HIPC Heavily Indebted Poor Countries CHAG Christian Health Association of HIV Human Immunodeficiency Virus Ghana » Country Representative of DFID HND Higher National Diploma CHO Community Health Officer acroeconomic i.e. That is » Country Representative of the World Bank CHPS Community Health Planning and Services IDA Iron Deficiency Anemia M CMH Commission on Macroeconomics IDA International Development Agency and Health IEC Information, Education and CSM Cerebrospinal Meningitis Communication

CTC Close to Client IGF Internal Generated Fund hana

CVD Cardiovascular Diseases IMCI Integrated Management of G Childhood Illness CWSA Community Water and Sanitation Agency IMF International Monetary Fund DACF District Assemblies Common Fund IMR Rate DALY Disability Adjusted Life Years IPT Intermittent Preventive Treatment DHMT District Health Management Teams ITN Insecticide Treated Net D-MHO District Mutual Health Organization KVIP Ventilated Improved Pit latrine’ DPT Diptheria, Pertussis, M & E Monitoring and Evaluation DWST District Water and Sanitation Teams for better health, economic growth and accelerated poverty reduction

s MDA Ministries, Departments and EPI Expanded Programme on Agencies

Immunization eport of the MDG Millennium Development Goal GAVI Global Alliance for Vaccines and R Immunizations MHO Mutual Health Organization

s tment GDH Ghana Demographic and Health MLGRD Ministry of Local Government and Survey Rural Development GDHS Ghana Demographic and Health MMR Maternal Mortality Rate Survey MTEF Medium Term Expenditure GDP Gross Domestic Product Framework GFATM Global Fund to Fight AIDS, MTHS Medium Term Health Strategy , and Malaria NCD Non-communicable GLSS Ghana Living Standard Survey NCMHI National Commission on Macroeconomics and Health

 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • xi Scaling-up health inve NCWSP National Community Water and SARS Severe Acute Respiratory Syndrome Sanitation Programme SIF Social Investment Fund NCWSP National Community Water and SIP Strategic Investment Plan Sanitation Programme

SMI Safe Mother Initiative nitiative NEPAD, New Partnership for Africa Support Treatment and Anti Introduction I Development START Retroviral Therapy NGO Non-Governmental Organisation STI Sexually Transmitted Disease NGO Non-Governmental Organization SWAp Sector-wide Approach NHIF National Health Insurance Fund

TB Tuberculosis ealth NHRC Health Research Centre

TBA Trained Birth Attendant H NID Noise-Induced Deafness UNDP United Nations Development NMCP National Malaria Control Programme Programme NPV Net Present Value UNGASS United Nations General Assembly NRSC National Road Safety Commission Special Session and

OPD Outpatient Department UNICEF United Nation Cultural and 1 s Toward achieving the MDGs: Education Fund OPV0 Oral Vaccine VAD Vitamin A Deficiency A HEALTH INVESTMENT PLAN FOR GHANA PMM Prevention Maternal Mortality Programme VAST Violence, Alcohol, Substance abuse, » In Ghana, an additional US$ 5 billion will be needed over 2002-2015 to achieve national health Tobacco use PMTCT Prevention of Mother-to-Child- priorities, including the Millennium Development Goals (MDGs). This finding is part of the health Transmission VAT Value Added Tax POW Programme of Work VCT Voluntary Counselling and Testing investment plan of the Ghana Macroeconomics and Health Initiative (GMHI)’s report, “Scaling up PPP Purchasing Power Parity VIP Village Infrastructure Project and Health Investments for Better Health, Economic Growth and Poverty Reduction.” the Social Investment Fund PRSP Poverty Reduction Strategy » The report establishes a multi-year strategy to scale up a priority health package to improve Programme WATSAN Water and Sanitation Committee health outcomes and improve access for the poor. This consists of essential health interventions, RBM Roll Back Malaria WC Water Closet health systems development, close to client services, and improved access to water and sanita- ROG Republic of Ghana WHO World Health Organisation acroeconomic tion. To bridge the financing gap, the GMHI report calls for concerted international support and RTA Road Traffic Accidents WVG World Vision Ghana M proposes options to mobilize the required resources, including debt relief, increased aid and new financing mechanisms.

» The GMHI Report is aligned with completed and ongoing planning activities, such as the Ghana

Poverty Reduction Strategy, the Medium-Term Expenditure Framework and the Ministry of Health hana

Programme of Work. G

What is the GMHI? The GMHI is a participatory national health and development mechanism. It was set up in 2002 to establish the health needs of poor people, analyse the barriers to utilization of health and health-related services and identify ways to increase the efficiency of health for better health, economic growth and accelerated poverty reduction s spending. eport of the

By boosting inter-sectoral collaboration and promoting locally-developed evidence, the R GMHI serves to: s tment » Mobilize political support for enhanced investment in health and health-related sectors

» Improve priority-setting in the health sector

» Guide decisions on central and peripheral-level resource allocations to health

» Increase aid effectiveness

xii • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION •  Scaling-up health inve Who are the members of the GMHI? The GMHI brings together key players in the health sector and sectors that influence Health and development in Ghana:

health to deliberate and take a common stand on pressing health and development issues. nitiative Members include representatives from the Ministries of Health, Economic Planning and Facts and Figures I Regional Cooperation, Finance, Local Government and Rural Development and related » Only 37% of the rural Ghanaian population have access to health services; 42% have access to agencies such as the Ghana Health Services. All major health partners in Ghana par- potable water. ticipate in the GMHI, including WHO, the United Nations Development Programme » It is estimated that Ghana's low life expectancy of 57 years deprives the country of about US$ 620 (UNDP), the United Nations Children’s Fund (UNICEF), the Danish International ealth million in annual output. Development Agency (DANIDA), the United Kingdom Department for International H Development (DFID) and the World Bank. » Per capita government allocation to the health sector fell in real terms from US$ 10.16 in 1978 to below US$ 8 in 2003.

» The Ghana Poverty Reduction Strategy envisions increasing government health expenditure as and The GMHI Report: a percentage of total government expenditure to 7% in 2005 in real terms, likely to guarantee s a per capita health expenditure equivalent to about US$ 10 by 2006. This is still far below the » Presents evidence of the links between health and development in Ghana. CMH recommendation of US$ 38 per person per year to scale up a set of essential interventions.

» Analyzes the health needs of Ghana and develops a close-to-client strategy, anchored » The richest households are estimated to benefit three times more from Government expenditures at the community level, for scaling up access to essential health services. on health than the poorest.

» Recommends strengthening this strategy by paying more attention to specific health » Total debt relief to Ghana is estimated at about US$ 3.7 billion. A significant amount of resources systems requirements, in particular human resources. could thus be freed up for health. » Calls for attention to the lack of clean water and sanitation conditions, which causes

about 70% of all communicable diseases. acroeconomic

The investment plan substantiates the proposed health package by detailing resource M requirements, financing gaps, and resource allocation in line with policy priorities. The How is the Report to be used? GMHI also estimates the cost of meeting water and sanitation targets. The GMHI finds » Local and international advocacy that government allocations to the health sector have fallen in real terms since indepen- » Revision of the health component of the Ghana Poverty Reduction Strategy, and pro- dence. A major challenge will be mobilizing resources for scaling up investment according hana moting a clear link between the GPRS and the government's annual budget to the GMHI’s plan in order to achieve the MDGs and other national health targets. G » Ministry of Health planning

» District health planning Summary of Incremental Cost of Scaling-up Health Spending, 2002-2015 in US$ million, unless otherwise indicated (Part III of the GMHI Report) » Developing proposals for the Millennium Project and the US Government’s Millennium Challenge Account Time period Incremental Cost Total Cost 2002-2007 1 144 2 060 » Identifying areas for further research » More effective partnerships with donors, civil society and others for better health, economic growth and accelerated poverty reduction 2008-2015 3 837 5 602 s 2002-2015 4 981 7 662 eport of the

For further information: R Per capita health expenditure (in US$) 1. The Ag Executive Director National Development and Planning Commission, 2007 12 21 s tment Flagstaff House, P.O. Box CT 633 Cantonments-, Ghana. Tel: +233 21 773011. 2015 31 41 Fax: +233 21 773055.

2. The Chief Director, Ministry of Health. P.O. Box MB44, Accra, Ghana. Tel: +233 21 666151. Fax: +233 21 663810. www.moh-ghana.org.

3. The Representative, World Health Organisation, 29 Volta Street, P.O. Box MB142 Accra Ghana. Tel: +233 21 763918/9; 774719; 774725. Fax: +233-21-763920. www.ghanawho.org.

 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION •  Scaling-up health inve Investing in health nitiative for economic growth I and poverty reduction ealth H and

2 s Introduction Ghana like many other developing countries, in response to the demands of international development partners (particularly, the World Bank and IMF), has drawn up a new com- prehensive development policy framework document, dubbed Ghana Poverty Reduction Strategy (GPRS), for sustainable economic growth and accelerated poverty reduction. In this document improved health care as well as protection of the vulnerable within a decentralized democratic environment have been given a new impetus. Consequently the GPRS has identified policies, programmes and project that seek to realise the following

objectives: acroeconomic

» Ensuring sound economic management for accelerated growth; M

» Increasing production and promoting sustainable livelihoods;

» Enhancing direct support for human development and the provision of basic

services; hana G » Intensifying the provision of special programmes in support of the vulnerable and excluded;

» Ensuring good governance and increased capacity of the public sector; and

» Promoting the active involvement of the private sector as the main engine of growth and partner in nation building.

These objectives embody the goals as enshrined in other global strategic initiatives such

for better health, economic growth and accelerated poverty reduction as the NEPAD, CMH, MDGs, etc. Meeting these goals is regarded as an essential step s on the road to accelerated poverty reduction and economic growth. The main thrust of these initiatives is improving human development and providing basic services such as eport of the R health, potable water and good sanitation at the local level to address the underlying causes of ill-health and death. s tment In the past 40 years the Ghanaian economy grew on average below the population growth rate, resulting in a deterioration of the standards of living conditions. Many factors are responsible for this slow growth, but poor health and low levels of education can be seen to be the salient contributing factors (Schultz 1999). Estimates indicate that only 40% and 42% of the population of Ghana have access to health services and potable drinking water respectively. Even though the country can boast of having made some strides in the field of health care, it continues to be plagued by a high preponderance of communicable

SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION •  Scaling-up health inve preventable diseases, under-nutrition, and poor reproductive health. This situation is through economic losses to society arising from low years of healthy life expectancy. also compounded by the HIV/AIDS pandemic and other health threats emanating from We expect to see improvements in health to enhance workers’ productivity by increasing non-communicable diseases (, diabetes, cancers, hypertension and cardiovascular their physical capacities, such as strength and endurance, as well as their mental capaci- disease), which seem to reverse the decades of gradual gains in life expectancy. In many ties, such as cognitive functioning and reasoning ability. Evidence of this link has been nitiative contexts the burden of diseases is enormous in the light of the negative impact on pro- provided by many empirical studies at the microeconomic level (Savedoff and Schultz I ductivity, the loss of productive assets, the high treatment costs and on the break in the 2000; Schultz 1999a, 1999b, 2002; Schultz and Tansel 1992; Strauss and Thomas 1998). transfer of valuable livelihood knowledge from one generation to the next. In the face of In addition low health is said to result in a combination of depressing effects on parental the high burden of disease and mortality in Ghana, the government seems overstretched investments in children and on returns to business and infrastructure investments (WHO

with its limited resources in dealing with these problems. 2001). For instance, low individual worker productivity occur when disease conditions ealth

reduce the work output of the sick and temporary or permanently displace a worker and H These factors contribute to make the economic costs of avoidable diseases staggeringly thus reduce his/her number of productive working years. Cross-country regressions for high, particularly, for the poor in Ghana. A concerted effort to improve health care in the 1965-90 period by Gallup and Sachs (2001), for example, revealed that poor coun- Ghana, therefore, inherently constitutes a poverty reduction strategy whose benefits tries like Ghana with serious diseases conditions such as malaria grew 1.3% less per should accrue disproportionately to the poor. For this reason investments in health and

person per year, controlling for initial poverty, economic policy, tropical location, and s should merit a special pride of place in any future development path not only to meeting life expectancy among other factors. Additional losses from poor health and unsanitary the international development goals but also to achieve accelerated economic growth environment stem from reduced returns on investments in education (unhealthy chil- and poverty reduction. dren have reduced capacity to produce returns on the education they receive), and also This chapter discusses the findings and recommendations of the CMH report to provide from depressed returns to investments in business and infrastructure (high prevalence of in-country strategic options for scaling-up investments in sectors that influence the health disease undermines perceived growth potential for sectors such as agriculture, mining, status of Ghanaians, economic growth and poverty reduction. It provides analytical bases manufacturing, tourism) and hence economic growth. for investing in health and demonstrates the benefits for such investments. The negative effects of poor health on productivity and economic development in most The rest of this section is organised as follows. The sub-section two attempts to establish Sub-Sahara African countries including Ghana have also been widely documented (Cole the analytical links between health and development as well as poverty reduction, with

and Neumayer 2000, McCarthy et al. 2000, Bhargava et al. 2001). The Commission on acroeconomic particular reference to Ghana. Using empirical findings of micro-economic studies on Macroeconomics and Health, for instance links the heavy burden of disease, and its M Ghana it attempts to verify the direct and indirect links between ill-health and develop- multiple effects on productivity, demography, and education to Africa’s chronic poor ment and poverty in terms of economic losses and costs of ill-health emanating from economic performance. In its estimation the high prevalence of malaria, for instance, productivity losses, lost Disability Adjusted Life Years (DALYs) in Ghana, lost savings costs Africa about 1 percent annually in lost economic growth. Hence experts assert that and low life expectancy. After an extensive discussion of the epidemiological profile of

more than half of Africa’s growth shortfall relative to high growth countries in East Asia hana the country to ascertain the health needs of the population and the health interventions

can be attributed to its relatively high burden of diseases, demography and geography G in the country, and equity in health systems to gauge accessibility to health care, the sub- rather than traditional variables of macro-economic policy and political governance section that follows critically analyses the new close-to-client system, the national health (Bloom and Sachs 1998). Furthermore it appears that all these economic costs and losses insurance and other measures to widen access to health care services. The following of well being associated with poor population health are also underscored by macro- sub-sections discuss the water and sanitation situation in Ghana and health financing in economic evidence of a positive correlation between better health and higher economic Ghana. This part of the document concludes with a discussion on resource mobilization development (see table 2.1). Using infant mortality rate as a proxy for the health status of and probable risk analysis of any intended plan to scale up investment in health. a population, for instance, it can be seen in table 2.1 that economic growth rate seems to be higher in countries with lower infant mortality rate or higher population health status,

for better health, economic growth and accelerated poverty reduction The Link between whereas countries with poor health status tend to have slower economic growth. s eport of the

Health and Development R There is a strong positive direct and indirect association between health, economic s tment development and poverty. In the view of CMH (2001) “…good population health is a critical input into poverty reduction, economic growth and long term economic devel- opment at the scale of whole societies”. Empirically the links between health and the economy has been documented by many studies, (Schultz, 1997, 1999) which show that low population health impedes economic well-being and economic development directly

 A typical statistical estimate suggests that each 10 percent improvement in life expectancy at birth is associated with a  For a critique of this apparent virtuous circle hypothesis see David Legge (2002) Globalisation on trial: world health rise in economic growth of at least 0.3 to 0.4 percentage points per year, holding other growth factors constant (WHO warning. In: http://users.bigpond.net.au/sanguileggi/Blum#Blum (19.11.2004) 2001).

 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION •  Scaling-up health inve Table 2.1 Growth Rate of Per Capita Income, 1965-1994 that the slow agricultural growth in Ghana is partly the result of the low investments in (according to income and infant mortality rate) health and consequently unfavourable health conditions that have impacted negatively on Initial Infant Mortality Rate (IMR), the supply (flow) and productivity of agricultural (family) labour. From the whole nation’s IMR≤50 50150 perspective, considering that human capital formation is an integral part in the process of

1965 nitiative economic growth, we can thus conclude that the low rate of economic growth in Africa, and I Initial Income, 1965 Growth Rate (PPP-adjusted 1990 US dollars) for that matter, in Ghana, is partly due to the poor health conditions, low health investment and the effects of the heavy financial losses from poor health on the economy. GDP ≤ $750 - 3.7 1.0 0.1 These losses are enormous for many developing countries and Ghana, in particular. For

$750 < GDP ≤ $1,500 - 3.4 1.1 -0.7 ealth example, it is estimated that Africa loses about 6.5% of its normal earnings, two to three H $1,500 < GDP ≤ $3,000 5.9 1.8 1.1 2.5 times that of other regions, or about $360 billion annually in productivity losses due to $3,000 < GDP ≤ $6,000 2.8 1.7 0.3 - ill health. The equivalent loss for Ghana is about 6.4% of GNP (WHO 2001). There is GDP > $6,000 1.9 -0.5 - - also the cost in the form of reduced output, which emanates from low life expectancy.

It is estimated that Ghana’s low life expectance of 57 years deprives the country of and Source: WHO (2001) Macroeconomics and Health: Investing in Health for Economic Development, Report of Commission on Macro- about $620 million in annual output. In addition to that the burden of diseases such as s economics and Health, WHO, Geneva. malaria, which accounts for over 43% of all outpatients seen in Ghana’s health facili- The losses from poor population health manifest themselves quantitatively in reductions ties and 25% of under-five mortality in Ghana, is estimated to cause about 600,000 lost in market income, longevity, and psychological well being (i.e. pain and suffering) caused Disability Adjusted Life Years (DALYs) in Ghana (WHO 1999) and in costs equivalent by illness (Philipson et al 2001; Cutler et al 1997). Therefore any evaluations of economic to about $177.5 million or 3% of GDP in economic burdens (see also Gallup and Sachs development that do not take into account the direct and indirect linkages of health 1998; Leighton and Foster 1993). These high costs of poor health in developing countries status and economic well-being will tend to understate the economic benefits of good appear to be exacerbated by high inequalities in the distribution of health services and health (Nordhaus 2002). The burden of disease thus appears to stand as a stark barrier to health subsidies. Evidence available in developing countries suggests that the poorest economic growth and therefore must be addressed frontally in any comprehensive devel- 20% receives only about 12% of public subsidies and only $2 in benefits of every $100 opment strategy. However, isolating the causal effect of health on economic prosperity

spent on drugs (World Bank 2000). In Ghana the rich has been found to enjoy over-pro- acroeconomic has over the period proved to be very controversial. portionately from government subsidies on health care than the poor (Demery et al 1995; M Canagarajah and Ye 2002). The results of a benefit-incidence analysis of public spending Link between Poor Health and Poor on health by Castro-Leal and others (1999), for instance, suggest that whilst the poorest quintile (20%) benefits from about 12% of the total government subsidy to the health

Economic Growth in Ghana sector, the richest quintile received over 33%. hana

The main thrust of Ghana’s development strategy since the eighties has been to “go for These negative effects of poor health affect in one-way or the other savings of a coun- G growth” vis-à-vis poverty alleviation (Armstrong 1996). Accelerated growth was seen as try negatively, which have very important implications for the economic growth and a precondition for poverty alleviation. But the growth of the GDP averaging about 4% consumption, welfare or poverty levels of the population. Indeed there exist sufficient since 1983 appears to have been too low to appreciably reduce poverty. Moreover, the evidence that explains the boom in savings in East Asian as a combination of improved composition of growth has been quite different from the one that could support any sub- health as reflected in rising life expectancy and falling youth dependency (Bloom 2001). stantial reduction in poverty. For instance, the growth of agriculture and manufacturing, The opposite has been found in Africa where falling life expectancies are closely associ- which have strong potentials of impacting positively on poverty, has been substantially ated with declining savings and investment rates. This underscores the finding that in lower than expected and that of the services sector. Very often the slow growth of agri- general national savings rates are higher where dependency rates are low and in all for better health, economic growth and accelerated poverty reduction

s culture in Ghana, which provides subsistence to over two-thirds of the population, has such cases economic growth is rapid (Kelley and Schmidt 1996, Higgins 1998, Masson

been attributed largely to its relative neglect by the government. et al 1998). This thus establishes the link between poor health and the low savings and eport of the

investment ratio of most African countries. In Ghana, for instance, not only is the overall R However, given that public health investments constitute means of human capital forma- investment ratio relatively low, even by Sub-Sahara African standards, but investment tion, which affect the supply and/or efficiency of agricultural labour, we can then argue s tment spending on health seems to hover at a level that appears simply insufficient to engineer

 The reductions in market income can take the form of 1) costs of medical treatment; 2) the loss of labour-market income any progress (table 2.2) in health conditions and economic growth. from a episode of illness; 3) the loss of adult earning power from episodes of disease in childhood; 4) the loss of future earnings from premature mortality (WHO 2001).  This can also be seen against the background of the fact several of the great “takeoffs” in economic history – such as the rapid growth of Britain during the Industrial Revolution,; the takeoff of the US South and the rapid growth of Japan in the early 20th century; and the dynamic development of Southern Europe and East Asia beginning in the 1950s and 1960s – were supported by important breakthroughs in public health, disease control, and improved nutritional intake (Fogel 1997, 2000).  The assertion that poverty change is largely determined by economic growth has been empirically confirmed in the literature by Demery and Squire. 1996; Brunno et al 1998; Grootaert 1995; Fields 2000.

 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION •  Scaling-up health inve Table 2.2 Spending on and Selected Regions 1990s (Percent of GDP)* (education), reproductive behaviour (age at first birth, birth-spacing parity, etc.), nutri- tional status, access to antenatal care and delivery care services can all be influenced by Region/Country Total Spending Public Spending poverty levels, which may interact with unhealthy living conditions and lack of adequate Africa 5.6 2.8 sanitation and consequently increase risk of . The presence of high risk scores nitiative East Asia and Pacific 3.5 1.5 on these factors could predispose a mother to higher risk of producing miscarriage, I South Asia 4.1 0.8 congenital malformations, delivery complications, low birth weight babies, etc. Similarly , the result of poverty, may result in irreversible growth and developmental Latin America and Caribbean 7.2 3.0 disadvantages, whilst insufficient diet during adulthood may severely affect productivity

All low and middle-income Countries 5.6 2.8 and income. We discuss briefly below the situation in respect of some of these factors in ealth

Ghana 3.0 1.3 Ghana. H

* = Figures exclude donor inflows to the health sector Poverty Source: World Bank 2000, 2001 In Ghana about 40% of the total population is estimated to be living in poverty, even and Against this background the recommendation of GMHI for scaling-up health investment s though poverty incidence appears to have declined between 1991/92 and 1998/99 from is a step in the right direction. Because not only would these successive planned invest- 52% to 40%. Extreme poverty also declined from 37% to 27% over the same period. ments represent a direct big push to economic growth, but also the associated interven- However, there are significant differences in the spatial distribution of poverty incidence. tion and programmes are likely to contribute massively towards raising the performance Five out of the ten regions in Ghana had more than 40% of their population living in and level of health (and savings) of the people in Ghana. In other words the envisaged poverty in 1999, with the three North Savannah Regions (the Upper East, Upper West scaling-up of investment in health would not only boost domestic savings by way of and Northern Regions) experiencing poverty incidence rations ranging between 69% reducing the health related financial losses, but also raise capital formation that is likely and 88%. Of the ten regions the Upper East, Northern and Central Regions experienced to ensure sustainable economic growth in Ghana. Moreover, Ghana’s future lies with increases in poverty levels and extreme poverty in the 1990’s (GPRS 2003). Given that its people and thus investing in people, which the GMHI strongly seeks to facilitate, is poor health status is associated with high poverty prevalence, it is no wonder that these essential for accelerated development and poverty reduction. savannah regions with low access to health care services have high poverty incidence acroeconomic

rates. The high poverty rates in Ghana is also compounded by the fact that large majority M Health and Poverty in Ghana of the 8 million Ghanaians estimated to be in employment are mostly rural peasant farm- Ill health deepens poverty, which in turn reduces poor people’s access to health services ers and small scale traders in the informal sector with irregular income. Thus such poor or makes them less likely to seek care when they need it. Poor people often do not use people are more likely to get sick and stay sick and consequently have low productivity existing services because of the lack of means to afford the service, long distance or per- and income. hana ceived low quality or socio cultural perceptions about possible negative effects of modern G medicine. The consequence is that poor health holds back economic growth because Low Female Literacy of ill-health induced productivity losses. Such losses, as has already been pointed out, are estimated to amount to roughly $360 billion per year in developing countries (WHO In most developing countries, populations with the lowest literacy rates have the poorest 2001). Looking at the poverty data in Ghana not only do the costs of poverty induced health status. The relationship between literacy and health is particularly strong when ill-health seem to be very high, both direct and indirect costs associated with ill health female literacy is studied. A large body of research has established a strong positive cor- represent a substantial burden on the poorer households. A study in northern Ghana, for relation between female literacy and the health of a family or household since females instance, recently found that, while the cost of malaria care was just 1% of the income of notably make many decisions about the health, personal hygiene and nutritional status of for better health, economic growth and accelerated poverty reduction the family (Weiss et al 2001). These studies, focussing on the links between literacy and s the rich, it was 34% of the income of poor households (Akazili 2002). health have reported the strong links between female literacy and children’s health, here There are many factors that underscore the strong link between poverty and health and eport of the

measured in terms of infant mortality rates. Robinson and Wharrad (2000), for instance, R thus make them mutually dependent upon one another. Whilst ill-health can lead to have found that GNP and female literacy together account for about 80% of the variation poverty, poverty has a direct interdependence with the risk of becoming sick and dying s tment in infant mortality rates. from diseases. The poverty-disease cycle may start right from pregnancy of the human being, the prenatal period to shortly before death. For instance, maternal characteristics In a recent study of the impact of maternal literacy, numeracy and schooling on the pro- duction of children’s health in Ghana, using data from a recent household survey, Blunch  World Bank (2000) Can Africa Claim the 21st Century? The World Bank, Washington. D.C. and Venner (2001) found that literacy and numeracy skills have positive and statistically  For example, a study in Bangladesh Salway and Nurani (1998) have found that wrong perceptions plus significant effects on intermediate and final child health outcomes. These results are (mis)understanding by poor women that modern methods of contraception are “strong” and potentially damaging to the health, have discouraged the majority of women from adopting family planning methods soon after birth. Similarly also confirmed by the study of the immunization determinants of children aged 12 to 18 Fosu (1994) has found that the reasons for the poor outcomes of diarrhoea episodes in Ghana are due to the lack of months in the by Brugha and Kevany (1995). They also found that higher participation by poor mothers in Oral Rehydration Therapy programmes. Stephansson et al (2001), also report for Sweden that low socio-economic status is inversely associated with increased risk of stillbirth. female literacy, or perhaps more effective education of parental and under five years clinic

10 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 11 Scaling-up health inve attendees, improved economic status, and lower parity may contribute to the better use of primary health care services by mothers (see also Appiah-Kubi 2004). But in Ghana not A Health Profile of Ghana only does the country suffer from low level literacy; female literacy rates lie considerably This section describes the major health problems that affect disease burden and mortal- lower than that of their male counterparts (64% for males and 42% for females).

ity in the country so as to obtain a comprehensive assessment of the health status of nitiative Ghanaians. Each health problem is briefly described, along with its degree of burden I High Population Growth Rate in the country and the interventions designed to reduce the burden and the impact on mortality in Ghana. Rapid population growth places huge demands on health care systems. This means more

funding is required, which may be difficult to satisfy, given the competing demands on ealth

the scarce resources of the nation. Even though the population growth rate in Ghana has Profile of morbidity and mortality, and H reduced from its high level of about 3% in 1994 to about 2.3% in 2000, it continues to health interventions outstrip the provision of social services and infrastructure in health. This high fertility Available data shows that morbidity pattern or prevalence of diseases has remained rate produces a youthful population structure and a high dependency ratio. Moreover, fairly constant over the years, in spite of improvements in health care, with the country the high rapid population growth also results in poor health indicators, because of the and demonstrating a high preponderance of communicable preventable diseases, under-nutri- s difficulty of the government of Ghana to provide social services in the area of health to tion, and poor reproductive health. Adams and others (2001) report the top ten causes cater for the ever-increasing numbers of people in need. The problem of the increasing of out-patient morbidity in 2000 as 1) malaria; 2) upper respiratory tract infection; 3) demand for medical care, generated by the rapid population growth, should be recog- diarrhoea diseases; 4) skin diseases; 5) accidents; 6) pregnancy related complications; 7) nized as originating in the socioeconomic structural conditions prevailing in Ghana eye infections; 8) intestinal worms; 9) hypertension; and 10) anaemia. Other of today which determine, simultaneously, low health levels, deficiencies in the provision cerebrospinal meningitis (CSM), guinea worm, buruli ulcer, and still of health services, and rapid population growth. Where the socioeconomic level is very occur. On the other hand, although there have been improvements in the control and the low and the population growth is high the need for health care services is very severe. eradication of diseases like Oncocerciasis, polio, leprosy, small pox, etc., in recent years For instance, for the whole country whilst an estimated 47% of deliveries get supervised the emergence and/or re-emergence of diseases such as the HIV/AIDS menace, tubercu- by trained medical personnel in a health facility, the percentage for the poverty burdened losis, buruli ulcer and filariasis are increasingly threatening the gains in life expectancy. , with a high population growth rate, is below 17%. The percentages Non-communicable diseases (NCD), including cardiovascular disease, diabetes mellitus, acroeconomic for the equally poor regions in the north, Upper East (25.7%) and Upper West (33.6%) cancers, asthma, sickle cell disease, mental health disorders, substance abuse, and road M Regions are similarly low. Similarly a very high proportion of women with high fertility accidents, are also becoming major public health problems. Though data on the burden of rates in these poor regions (Upper East (71.5%) and Upper West (75.8%)) do not receive NCDs diseases is limited, health institutions are reporting of rising case loads. Currently post-natal check-up or first after 41 days. it is estimated that NCDs constitute over 20% of all cases of outpatient attendance. The age standardized prevalence of hypertension, for instance, is estimated to be 27.8%, hana G Poor Nutrition equivalent to the levels in many areas in Europe. It is generally held that nutritional well-being is a prerequisite for the attainment of the In the past various interventions have been designated in Ghana which are aimed at full social, mental and physical potential of a population. People with nutrition problems addressing these health problems. A list of selected major known diseases and the health are prone to sickness. In Ghana malnutrition is prevalent among infants, pre-school interventions aimed at addressing some major health problems is shown in table 2.3. children as well as pregnant and lactating women. Available information suggests that these groups satisfy less than 75% of their dietary requirements. The results reflect a high number of stunted (14.3% of urban and 29.7% of rural) children and wasted (6.5%

for better health, economic growth and accelerated poverty reduction of urban and 10.5% of rural) children. s eport of the

Limited Access to Water and Sanitation R

s tment Estimates indicate that only 42% of the population of Ghana have access to potable drinking water. The rest depends upon less hygienic drinking water, such as wells (34%) and natural sources (25%) which make users susceptible to infections. This situation is also compounded by the inadequacy of sanitation systems, which includes solid and liq- uid waste disposal especially in the urban centres. This would be treated in detail later.  Other epidemiological sources have also come up with different burdens of diseases for the country. In the Global Burden of Disease 2000 Report (WHO 2002), for instance, the top ten leading causes of death and burden of diseases in Ghana include HIV/AIDS (13.7% of total deaths), peri-natal conditions (8.3%), Malaria (6.9%), (6.2%), lower respiratory infections (5.7%), ischaemic heart disease (5.6%), tuberculosis (5.1%) and cerebrovascular disease (4.7%), diarrhoeal diseases (3.6%) and road traffic accidents (1.3%).

12 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 13 Scaling-up health inve Table 2.3 List of known Major Diseases, and Interventions and Programmes Figure 2.1 Major Causes of Maternal Mortality in Ghana, (percent)

Reducing Maternal Mortality Neglected Diseases Other causes Bleeding • Safemotherhood • Control 24% 17% • Filariasis Elimination nitiative

• Leishmanaisis Control I • and other helminthes Infections Control 10% • Buruli ulcer Control

Reducing Child Mortality Reducing the Burden of old Unsafe abortion • IMCI communicable diseases 11% ealth • EPI • Malaria Control H • Neonatal care • Diarrhea prevention and management • Nutrition Programme • Acute Respiratory Infection Obstructed labour • Guinea worm Eradication 7% Hypertension 19% Anaemia and

12% s Dealing with Threats to Life Expectancy gains • HIV/AIDS and STI control These avoidable maternal deaths can be attributed to inadequate maternal health ser- • TB control vices. The average antenatal care (ANC) visit is just 2.4 and well below the target of 4 • NCD programme • Accident and Emergency services visits per pregnancy. Besides, many women go to the ANC relatively late in pregnancy and only half of the women receiving antenatal services are supervised by a trained person at the time of delivery. Maternal mortality will be reduced when facilities exist to provide emergency obstetric care. Currently the network of TBAs and health posts refer cases Maternal Mortality to periphery facilities which lack the requisite personnel and facilities – beds, surgical

In Ghana the maternal mortality rate (MMR) ranges from a predicted ratio of 214 (WHO equipment, anaesthesia, oxygen and blood supplies, and vacuum extraction equipment acroeconomic etc. Many deaths therefore occur in the periphery because the necessary and prompt 1999) to about of 586 (Hill 2001) per 100,000 live births, with considerable differences M between the regions, particularly, with the deprived northern regions showing MMR treatment is not available and referral difficult. of over 800 maternal deaths per 100,000 live births. This high rate has made reduction During the eighties, alarmed by the large burden of maternal and pregnancy related in maternal mortality one of the major goals of several efforts including MDGs and deaths and suffering, international partners mobilized and committed themselves behind

GMHI. several initiatives including Safe Mother Initiative (SMI) and Prevention Maternal Mor- hana G Various studies have identified and described the risk factors for maternal mortality in tality Programme (PMM), Making Pregnancy Safer Initiative and others to bring about Ghana. The Ghana VAST Survival Study, for instance, found in 1992 that postpartum a substantial reduction in the menace. In this direction Ghana, for instance, developed haemorrhage constituted 19% and severe anaemia made up 17% of the causes of maternal in the early 1990s a reproductive health policy and a safe motherhood programme to deaths. The leading immediate causes of death were sepsis (17%), obstructed labour improve the health and well being of expecting mothers and children and especially to (11%), ante partum haemorrhage (6%) and sepsis due to suspected abortion (6%). Malaria reduce maternal morbidity and mortality. The country developed clinical management was found to be the cause of 6% of deaths and pulmonary tuberculosis also 6%. protocols for identifying and treating pregnancy-related complications at all levels of the health system. The protocols also set standards for the provision of safe motherhood Other studies including the Maternal Health Project (1997/1998) also made similar services including antenatal care, supervised delivery, postpartum care, family planning

for better health, economic growth and accelerated poverty reduction findings and identified the leading immediate causes of maternal deaths to include s and management of abortion complications (MOH 1994). sepsis (25%) and obstructed labour (24%). Structural factors that impede treatment of eport of the obstructed labour were found to be transportation (30%), cost of emergency admissions Available records on safe motherhood observations from Ghana’s Ministry of Health R (25%). Although access plays a role (10%), staff attitude and practices constitute a large suggest some improvements in maternal health (see figure 2.2), even if these achievements fall far short of the set target to reduce the maternal mortality ratio by 75%, from 214 per s tment contributory factor (35%) in impeding treatment of obstructed labour. The diagram figure 2.1 presents the proportionate maternal deaths caused by these identified factors in 100 000 live births to 54 per 100 000 births by 2015. We present below the trends in the Ghana. development of the basic components of the safe motherhood services.

 The various objectives of these initiatives can be summarised to include the following: Reduction of maternal mortality ratios by 75% from 1990 levels by 2015; the Safe Mother Initiative, for instance, had the goal to halve maternal mortality by the year 2000 (Mahler 1987; Starrs 1987); Reduction of infant mortality to below 35 per 1000 live births by the year 2015; Provision of access for all who need reproductive health services by 2015; Skilled attendants present at 80% of births, globally, by the year 2005. Where maternal mortality is very high, 40% of births should be assisted by the year 2005; by 2010, this figure should be 50% and by 2015, at least 60% (WHO 1998).

14 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 15 Scaling-up health inve Figure 2.2 Trends in safe motherhood interventions (1998–2003) Intermittent Preventive Treatment (IPT) during pregnancy has been adopted as the strategy for reducing the incidence and complications of malaria in pregnancy since

140 2003. Nevertheless the implementation of IPT is constrained by late attendance to ANC as the IPT protocol requires the administration of Sulfadoxine-Pyremethamine nitiative in the second and third trimesters. In order to sustained the improvement and ensure I 120 effective risk detection, management of complications and improvement in pregnancy output so as to achieve the millennium development goal of reducing maternal mortal- 100 ANC % ity by two thirds of the 1990 levels, there is the need to scale-up investment in this

sector. This would allow ANC to be available in all facilities and at all working days ealth 80 throughout the year as well as facilitate operational research at facility and community H levels to inform the design of pragmatic strategies to address the problem. 60 » Labour and Delivery Care: The World Health Organization (WHO) recommends that SD %

delivery should be supervised by doctors, midwives or nurses with the midwifery skills and

40 s PNC % to handle normal deliveries safely and recognize the onset of complications. However,

X X in Ghana many deliveries continue to occur at home and/or attended by traditional 20 X X X birth attendants (TBAs), with only 46% of all births being delivery in health facilities FP Acceptor Rate X (GSS 2004). But in the view of the Safe Motherhood Initiative “the level of skill among 0 1998 1999 2000 2001 2002 2003 ‘skilled birth attendants’ is lower than is ‘safe’ for safe motherhood” (Maternal and Neonatal Health Programme, 2001).

» Antenatal Care: The coverage of ANC attendance has been generally encouraging. This That notwithstanding, we must point out that skilled supervised deliveries in Ghana is partly due to the intensive education given to expecting mothers and increased avail- has experienced some increases over time under the Safe Motherhood Initiative. For ability of ANC services in health facilities under the initiative. An expert assessment of instance, it has increased from 40% in 1998 (GDHS 2000) to 47% in 2003 (GSS 2004), the health service provision (GSS et al 2003) reported in 2002 that ANC is now avail- but large geographical differences remain. Whereas 80% of all deliveries in urban areas acroeconomic able in over 88% of all health facilities in Ghana. The report also revealed that ANC are likely to receive assistance from medically trained provider, only 31% of rural births M is also available 5 days per week in about 75% of these facilities. This has raised the do get this service. In the Northern Region, for instance, only 18.3% of all pregnant level of pregnant women who attend institutional ANC at least once during pregnancy women get supervised delivery, whilst about 81.4% of these women in the Greater to over 90% of the total pregnant women. However, despite the steady increase in the Accra Region can avail themselves to supervised delivery. As reported in the Service number of registrants ANC, it must be emphasised that the rate of increase is gradu- Provision Assessment Survey 2003 (GSPA) simple skilled delivery services are available hana ally declining over the years, with Ashanti, Volta and Upper East Regions recording only in 83% of all health facilities, with only 11% offering caesarean services. Faced G absolute decreases in the number of registrants during 2003. Moreover, many women with serious logistic constraints the GSPA survey found that only 41% of the facilities attend ANC relatively late in pregnancy leading to a low average number of ANC visit offer emergency transportation for maternity emergencies. of 2.4 compared to a target of 4 (fig. 2.3). Since supervised skilled delivery is key to reducing maternal morbidity and mortality, it thus essential, in order to meet maternal MDG, to scale-up investment in this area Figure 2.3 Trend in Institutional ANC Registrants, 1999–2003 to cover basic essential and emergency obstetric care to cater for life-saving interven- 850 000 tions and preventive services provided by well-trained primary health care as well as non- providers. for better health, economic growth and accelerated poverty reduction 800 000 s » Postnatal Care: In Ghana postnatal care (PNC) refers to the care given to mothers 750 000 eport of the

and babies up to six weeks after delivery to maintain the physical and psychological R 700 000 well-being of the mother and child. However, coverage of postnatal care shows that

s tment a significant number of pregnant women who attend ante-natal clinic do not use post

Number 650 000 natal services in the country. Although there has been some improvement over the 600 000 years, PNC ranges from 88% of antenatal registrants in the to 37% of antenatal registrants in the . The low level of PNC in Ghana can 550 000 also be attributed to the low capacity of health facilities to provide PNC. The GSPA 500 000 (2003) survey, for instance, found PNC to be less available in Ghana than prenatal 1999 2000 2001 2002 2003 care. According to this survey only 70% of health facilities offer postnatal care and

Source: MoH Reproductive and Child Health Unit (2004) 2003 Annual Report, Public Health Division, GHS this lends credence to the low levels of BCG, DPT1 and OPV0 in Ghana.

16 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 17 Scaling-up health inve The essence for all women and babies to receive basic postnatal care cannot be dis- acceptor rate continue to remain relatively low (figure 2.2), with geographical dispari- puted if maternal and child mortality is to be reduced. To achieve extra resources shall ties, ranging between 6.8% and 20.0% in 2001, with the Upper West and Brong Ahafo be necessary to do the following: Regions recording the highest of 20.0% and Ashanti the lowest of 6.8%.

» Target poor and rural women for additional postnatal support (e.g. women with nitiative I complicated pregnancies or deliveries, women with their first baby, unaccompanied Child Morbidity and Mortality women and adolescent girls). In Ghana, even though, progress has be made in reducing under five mortality from 155 » Train TBAs, health care providers, midwives and families to deal with referral and in 1983-1987 to 111 per 1,000 births in 1999-2003, as table 2.4 shows, the mortality rates

follow-up of postnatal complications. in Ghana remain relatively high, and far higher than the target goal of 70 deaths per ealth

1,000 live births set to be achieved by the year 2000 by the World Summit for Children H » Equip health centres to effectively manage postnatal complications (puerperal in New York in 1990. The sluggish decline in the child mortality rates in Ghana , as can sepsis, fever, postpartum haemorrhage, perineal trauma, breast engorgement, and be seen in figure 2.4, may be attributed to the fact that the six main causes of morbidity anaemia). and mortality among children have persisted as the main threat to their health over the » Provide BCG and first polio immunizations as soon as possible after birth to every years. For instance, malnutrition still remains the number one killer among children and s infant. and acute respiratory infections (ARI), diarrhoea, anaemia, measles, malaria, and other » Prevention and Management of Safe Abortion: Morbidity and mortality emanating neonatal causes continue to be major health challenges. These health problems account from unsafe abortions contribute substantially to maternal deaths and illness. World- for about 50% of all childhood admissions and 30% of childhood deaths. wide the WHO estimates that about 19 million women experience unsafe abortions Table 2.4 Trends In Early Childhood Mortality Rates and Infant And Under-Five each year. 18.5 million or 4.2 million of these occur in developing countries in or in Mortality, Ghana, 1983 – 2003 Africa including Ghana. From all indications unsafe abortions seem to be high in Approximate Ghana. In a survey of 1,196 women in four under the Maternal Health Survey year calendar period Infant mortality (1q0) Under-five mortality (5q0) Project (1998) it was found that almost 7 out of every 10 women have had an abortion 1988 1983 – 1987 77 155 in their reproductive lives, with the majority having resorted to unsafe procedures. The law in Ghana prohibits induced abortion, but allows abortion in circumstances 1993 1989 – 1993 66 119 acroeconomic where a woman’s life is endangered by her pregnancy, the foetus is impaired, or other 1998 1994 – 1998 57 108 M circumstances determined by the law courts. Unsafe abortions are however believed 2003 1999 – 2003 64 111 to be much more frequent than documented, with young people more likely to abort than older women. From WHO records, about 59 % of all unsafe abortions in Africa Source: Ministry of Health hana are among young women aged 15-24 years. Also playing a significant role among the childhood mortality rates is the neonatal mor- G Unsafe abortion is one of the neglected problems of health care, particularly, in devel- tality (death occurring among infants aged less than 28 days). In Ghana it is estimated to oping countries and a serious concern to women during their reproductive lives. Many contribute over 50% of all infant deaths and appears to have declined less rapidly than women put their health and life at risk as a result of unsafe abortion, with an estimated other child mortality factors (see figure 2.4). This represents an estimated 21,502 neonatal 68 000 (Africa 30,000) women dying as a consequence of unsafe abortion worldwide. deaths (UN Population Division). In developing countries the risk of death is estimated at 1 in 270 unsafe abortion Figure 2.4 Child Impact Mortality Indicators in Ghana 1980 – 2003, procedures. Given that between 10% and 50% of unsafe abortion cases need medical (per 1000 live births) attention (UNDP 2004), increasing access to abortion management and post abortion 250

for better health, economic growth and accelerated poverty reduction care by scaling-up health intervention can be seen as a step in the right direction.

s 200 UFMR

» Family Planning: Family Planning is an important determinant of maternal health, eport of the 150

yet there is a high unmet need in the country. The 2003 Ghana Demographic and IMR R Health Survey (GDHS) shows that only 25% of currently married women reported 100 s tment using a family planning method at the time of the survey, with only 19% reporting the 50 use of modern methods (GSS 2004). Men reported a higher contraceptive prevalence NNMR 0 rate than women with 32% of currently married men using a modern family planning 1980 1985 1988 1993 1998 2003 method as compared to 20.4% of women. Indeed family planning programmes have UFMR = Under Five Mortality, IMR = Infant Mortality, NNMR = Neo-Natal Mortality made tremendous strides over time by focusing its activities on IEC activities, micro planning and on steps to ensure availability of commodities. That notwithstanding, Source: GHDS various series. major challenges still remain particularly with respect to refusal of male clients to be Registered and ineffective counselling due to heavy workload. For this reason, the FP

18 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 19 Scaling-up health inve Routine data from health facilities indicates that the major causes of neonatal deaths 2001). The results indicate that complete coverage by all EPI antigens reduces mortality of are asphyxia and injuries (29%), neonatal infections (32%), pre-maturity causes (24%), children between the ages 9 and 59 months by 70 percent. BCG, polio, and DPT vaccines and the rest (15%) including low birth weight, neonatal tetanus, and severe congenital without measles vaccination reduce mortality by 40 percent. The independent reduction abnormalities. During the last decade the government of Ghana has adopted specific in mortality associated with measles vaccination is 50 percent. nitiative interventions for improving child survival and development, which include Integrated I The EPI has progressed substantially in the last decade, as can be seen in table 2.5. At Management of Childhood Illnesses, Expanded Programme on Immunization and pro- present the coverage of pentavalent vaccine, for instance, is above 80% in most districts. motion of good nutrition. BCG coverage, for instance, is about 93% as at 2003. Similarly experiences from recent exercises of the polio eradication initiative have been very encouraging and created ealth Integrated Management of Childhood Illness (IMCI) opportunities for implementing a measles elimination programme. Nevertheless, there H are large geographical variations as far as coverage and impact are concerned. Logisti- The Integrated Management of Childhood Illness (IMCI) was first developed in 1992 cal difficulties, for instance, have placed limits on immunization programmes’ potential by UNICEF and the World Health Organization (WHO) as an integrated approach to impact, particularly, in rural areas and northern part of Ghana. Progress towards polio improve the quality of care provided to children under five years of age to ultimately

eradication has also stalled with the identification of wild polio cases this year after two and reduce childhood mortality. IMCI includes both preventive and curative elements that are years of polio free status in the country. s implemented by families and communities as well as by health facilities. The three main components of the strategy include: 1) to improve case management skills of health-care Table 2.5 EPI Performance in Ghana (1994 – 2003) staff; 2) to improve overall health systems; 3) improve family and community health practices. 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 BCG 61% 67% 65% 70% 77% 85% 94.5 91.3 96.6 93 In 1999 Ghana adopted the IMCI strategy and piloted it initially in four districts before expanding it to 18 districts in 2003 and further to 50 of the 138 districts in Ghana in DPT3 48% 52% 51% 56% 68% 73% 83.8 76.2 79.1 76 2004. The programme involved improving the diagnostic and management skills of health Measles 49% 51% 53% 57% 67% 71% 83.8 81.9 84.7 80 professionals, strengthening health systems to provide essential drugs and logistics for Yellow Fever 22% 25% 28% 41% 41% 64% 73.7 76 71.4 73 managing childhood diseases and improving community and household health practices. acroeconomic IMCI is supposed to integrate and provide a proven package of cost-effective interven- TT2+ (WCBA) 18% 20% 14% 17% 18% 21% 73% 61 68 66 M tions including the promotion of breastfeeding and ITNs and strengthening the health Source: EPI Unit, Ghana Health Service, using 4% of target under one year system to manage sick children using tested diagnostic and treatment algorithms for managing diseases such as malaria, diarrhoea, measles ARI and malnutrition. These problems call for a new thrust for the EPI programme, namely, to reduce inequali- ties in the coverage by reaching the hard to reach areas and communities with services

IMCI at the community level has sought to strengthen links between health facilities and and to revise the national EPI strategy to incorporate targets for the elimination of hana

communities and has gained the support of a coalition of non-governmental organiza- measles and neonatal tetanus. Moreover the high levels of routine immunization coverage G tions and private voluntary organizations. The coalition has served to update members must be sustained by reinforcing static and outreach services as well as targeted supple- on issues related to child health and nutrition and to share strategies that have involved mentary immunization activities based on evidence from micro-planning in districts. the community. However, IMCI has been moving slowly in Ghana. In order to reap the Furthermore, there is also the need to conduct nationwide NIDs and strengthen AFP full benefits of its seemingly high potential impact on reducing childhood mortality, it and measles case-based surveillance. All these measures can be implemented within a may be appropriate to scale-up the scope or coverage and impact of this intervention. framework of scaling-up of investments in the area of the EPI intervention.

Expanded Programme on Immunization (EPI)

for better health, economic growth and accelerated poverty reduction Malnutrition s In response to the worldwide call to improve child survival, the Expanded Programme In Ghana the malnutrition rate has changed very little over the years. The imbalance on Immunization (EPI) advocated by UNICEF and WHO has wholly been embraced eport of the

between body’s needs and intake of nutrients is a serious health and economic problem, R by the MoH since 1978. From this date EPI has been implemented in Ghana through a especially, and the groups most at risk are children and pregnant women. The conse- combination of routine and mass immunization exercises as one of the key child health s tment quences are that almost 30% of children aged 0-35 months are considered to suffer from interventions. As in most developing countries, immunization against the six immuniz- stunting, with about 22% and 7% suffering from underweight and wasting respectively able childhood diseases (i.e., diphtheria, measles, pertussis, poliomyelitis, tetanus, and (see table 2.6). Nationwide about 55% of mortality in children are associated with mal- tuberculosis) has been instituted as part of Ghana’s primary health care program. nutrition. There are, however, wide geographical differences. Childhood malnutrition is Over time these vaccines have proved to be efficacious in preventing disease-specific lower, for instance, in Accra than in rural areas of Ghana but is still high, and close to childhood morbidity and mortality. The evidence has been provided by a longitudinal 18% of children younger than three years of age suffer from low height-for-age. Protein study of all-cause mortality among vaccinated and unvaccinated children under 5 years energy malnutrition is the commonest nutritional disorder in children. Micronutrient of age, using data from the Navrongo Demographic Surveillance System (Nyarko et al deficiency e.g. vitamin A, iodine, and iron deficiency, is also quite common. The preva-

20 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 21 Scaling-up health inve lence of Iodine Deficiency Disorder in the country was estimated to be 33% in 1993. A Figure 2.5 Malnutrition trends limited survey in the Northern Savannah regions showed a xerophthalmia rate of 1%. Up 35 to 50% of pregnant women were reported to suffer from Iron Deficiency Anaemia. Stunted 30 Recent baseline study of vitamin A supplementation trials in the savannah area of Ghana nitiative I 25 found the prevalence of clinical vitamin A deficiency (VAD) to range from 0.7% to 1.5%, Underweight indicating that VAD was a problem of public health significance in some regions of the 20 country. Moreover, low serum retinol (< 20µg/dl) was found in 65-70% of the study % 15 children, reflecting high levels of sub-clinical VAD in the population. Most rural areas Wasted ealth reveal moderate iron deficiency anemia (IDA) (hemoglobin [Hb] <10 g/dl) to be prevalent 10 H among 25% and 10% of children 0-4 years and 5-9 years old, respectively. Prevalence 5

of anemia among women 15-29 years of age was 11%. Malarial infection may be a major 0 factor underlying anemia in the population. In a hospital population of children, anemia 1988 1993 1998 2003 10 (Hb <11 g/dl) was found in 70% of the population . and s Table 2.6 Regional Trends in Malnutrition in Ghana Source: GDHS 2003 Reducing the current trends of malnutrition (see fig. 2.5) is a necessity if the country were Region Stunting Wasted Underweight to achieve rapid increases in economic growth, improvements in health outcomes and Ghana (0-35 months) 29.9 7.1 22.1 poverty reduction. Just as malnutrition leaves scares of underweight, stunting and wast- Western 28.04 50.3 16.5 ing on human sufferers, so do these negative consequences result in reduced physical and Central 31.06 3.0 22.0 mental capacity, and productivity in the whole economy. For instance, it has been found that for every 1% reduction in adult height, the productivity of physical labour reduces Greater Accra 13.9 7.2 11.5 by 1.4%, equivalent to annual loss in terms of future economic production, of about Volta 23.3 13.9 25.7 US$297 million (GHS 2004). Reducing malnutrition in Ghana would, however, require

Eastern 27.4 6.2 17.3 substantial investments in programmes to sustain the efforts to reduce macronutrient acroeconomic

and micronutrient deficiencies. M Ashanti 29.1 6.7 20.8 Brong Ahafo 29.4 5.7 20.4 The Old Agenda of Communicable Diseases Northern 48.8 6.6 35.5

The World Health Organization (WHO) estimates that in 2001, infectious diseases hana Upper East 31.7 12.9 32.4

accounted for 26 percent of total mortality worldwide and caused 15 million deaths, many G Upper West 34.1 11.0 25.9 of which could have been prevented with drugs, vaccines, and access to uncontaminated food and water. Throughout Ghana communicable diseases are the most common cause Source: GDHS 2003 of death, disability, and illness. A number of them such as malaria, acute respiratory Following the recommendation of the International Conference on Nutrition, the Ghana infections, guinea worm and diarrhoea, continue to account for high levels of morbidity government together with a multi-sectoral task force, including various ministries, and mortality. research institutes, nongovernmental organizations (NGOs), FAO, WHO, and UNICEF The effects of these diseases transcend beyond simply a public health issue and have now initiated a National Plan for Action for Food and Nutrition in April 1993. A micronutrient become a development issue, impacting on demographic and educational development deficiency control programme was established with sub-committees for iodine, vitamin for better health, economic growth and accelerated poverty reduction s as well as ·economic growth of Ghana. In the past in order to achieve a better impact of A, and iron. These were also complemented with programmes to promote vitamin A

measures on the ground, solid partnerships have been built among key actors, – such as eport of the supplementation of pregnant and lactating mothers using existing health facilities, home the International Partnership Against AIDS in Africa, Roll Back Malaria, and Stop TB R and school gardens through production and consumption of vitamin A-rich foods, drying – which all provided excellent road maps for action. But, unfortunately, it appears the of vitamin A-rich foods at the community level using women’s groups, and legislation for s tment fight against communicable disease in Africa is still being waged on too small a scale. food fortification. NGO programmes distribute vitamin A capsules to children. For example, we know that treated bed nets can prevent malaria, yet only 2 percent of African children are protected from deadly mosquitoes. Hence the need for a massive scaling up of resources, both human and financial, in order to able to mount an effective response to communicable disease endemic.

10 See http://www.mostproject.org/Ghana.htm.

22 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 23 Scaling-up health inve Malaria Control with the private sector and the community12. It has also committed itself to the Abuja Declaration on Roll Back Malaria in Africa, which similarly seeks to achieve specific Malaria in Ghana is the single most important cause of mortality and morbidity especially targets on malaria prevention and control with time limits. among children under five years and pregnant women. In 2002, for instance, malaria

A major intervention promoted under the RBM Initiative is the use of insecticide treated nitiative

was estimated to account for 44.5% of all outpatient illnesses, 36.9% of all admissions I and 13.2% of all deaths in health facilities in Ghana. The disease is responsible for a nets (ITNs) as a key component of Ghana’s new strategic malaria control plan. The new substantial number of miscarriages and low birth weight babies among pregnant women. National Malaria Control Programme (NMCP) in Ghana also outlines the strategy for Among this group, malaria accounts for 13.8% of OPD attendance, 10.6% of admissions promoting the availability of ITNs through state-private sector partnership. The malaria and 9.4% of deaths. Around 800,000 children under the age of five die from malaria every control programme aims to reduce mortality and morbidity due to malaria by 25% by ealth year, making this disease one of the major causes of infant and juvenile mortality. The 2008 through improved case management, implementation of multiple prevention meth- H trend has remained constant over time since long (Yeboah-Antwi and Marfo 2002). ods, focused research and improved partnerships. Though ITNs have been shown to be efficacious against malaria13, their use in Ghana is still very low. Currently the national Apart from the health consequences of malaria, it puts a heavy burden on economic coverage of ITNs in children less than 5 years of age is 3.5% and coverage in pregnant development. It is estimated that a single bout of malaria costs a sum equivalent to over 10

women is 2.2%. These levels are far below the Abuja target of 60%. Tackling malaria and

working days in Africa. The cost of treatment is between US$0.08 and $US5.30 according s effectively requires substantial resources. At the Abuja Summit it was estimated that to the type of drugs prescribed as determined by local drug resistance. In 1987, the total at least US$ 1 billion is needed from a combination of increased domestic spending “cost” of malaria – health care, treatment, lost production, etc., – was estimated to be and international assistance for endemic African countries. Even though the amount US$800 million for tropical Africa and this figure is currently estimated to be more than is substantial, it is worth it, since the benefits to be derived would far exceed the socio- US$1,800 million. In terms of productivity losses malaria accounts for up to 1% loss of economic burden of malaria. annual GDP. Table 2.7 Regional Distribution of ITN Use in Ghana In Ghana malaria accounts for a significant portion of the disease burden, causing about 10.6% of lost Disability Adjusted Life Years (DALY) and costing an equivalent of about Region Children Under Five Women in Fertile Ages 3% of GDP annually in economic burdens. As has already been pointed out, it accounts Western 1.0 1.1 for over 44% of all outpatients seen in health facilities and 25% of under-five mortality. Central 0.7 1.4 acroeconomic Crude parasite rate ranges from 10 to 70% with Plasmodium falciparum accounting for Greater Accra 3.1 1.1 M 80-90%. All these add up together to reduce the level of growth and per capita income through a reduction in worker productivity, in addition to the reduced lifespan and life Volta 2.2 1.9 earnings lost to society. Hence the need for all sectors to work together to reduce the Eastern 0.3 0.0 social and economic costs of the burden of malaria11. Ashanti 1.2 0.8 hana

Intensive government efforts at controlling malaria in Ghana dates back to 1957 when a G Brong Ahafo 2.1 1.5 malaria control unit within the MOH was established in the in collaboration with WHO to train personnel in geographical reconnaissance, malariometric and ento- Northern 7.2 5.3 mological surveys, and to conduct trials of indoor residual insecticide application in the Upper East 20.7 15.1 control of adult mosquito population. Ghana followed up this in 1961 with the creation Upper West 1.9 1.9 of a National Malaria Service when the country adopted the global Malaria Eradication National 3.5 2.2 Programme, which used residual spraying and larvicides to control malaria parasites. The programme had to be discontinued in 1967 due to technical and financial reasons. In Source: GDHS 2003 for better health, economic growth and accelerated poverty reduction

s 1992, the country launched a 5-year (1993-1997) National Malaria Control Action Plan For an illustration of the benefits expected to accrue to reduction in malaria disease

with the focus on capacity building for improved disease management in health facilities. eport of the burden, let us assume conservatively that malaria accounts for an estimated 600,000 dis-

Drawing on past experiences and lessons, an accelerated malaria control programme R ability adjusted life years (DALYs) lost in 2002 in Ghana, with a population of 19.6 million piloted in 30 districts, was launched in 1997, again with a focus on case management. people. Upon the conservative assumption that each DALY value is equivalent to the per s tment Since 1998 Ghana has committed itself to the Roll Back Malaria (RBM) Initiative of capita income ($390), the total cost of malaria could then be valued at approximately WHO, which builds on the Global Malaria Strategy with a focus on Africa. The goal of 3% (=0.6/19.6) of the GNP of Ghana. Three percent of the 2002 GNP (=$5.8 billion) the Roll Back Malaria Initiative is to halve the world’s malaria burden by 2010. Con- sequently the country drew up a ‘Medium Term Strategic Plan for Malaria Control in 12 Ministry of Health 1998. Strategic Plan (June 1998), Government of Ghana. Ghana’ (1998-2002), which sought to improve the coverage of malaria control activity by 13 Evidence from randomized controlled trials have shown that ITNs can reduce the number of under-5 deaths by around adopting an inter-sectoral approach involving other government sectors and partnership one-fifth (5), saving about 6 lives for every 1000 children aged 1–59 months protected each year (Figure 2.1). The impact derives not only from a reduction in malaria deaths, but also from reductions in child deaths due to other causes that are associated with, or exacerbated by, malaria, such as acute respiratory infection, low birth weight, and malnutrition 11 GMHI, 2003 Mobilising resources for scaling-up health investments’, Technical paper no.6. (WHO/UNICEF 2003).

24 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 25 Scaling-up health inve is equivalent to about $177.5 million. This compared with the present expenditure of Guinea Worm Eradication $2.5 million for reducing malaria illness burden illustrates the considerable saving that The Guinea Worm Eradication Programme has been experiencing mixed fortunes over Ghana stands to make with the Roll Back Malaria programme. These savings increase by the years. Currently, Ghana is second to Sudan in the number of reported cases of guinea threefold, if we value each DALY at three times the per capita income, according to the nitiative

worm. After successfully reducing the number of guinea worm cases from 179,556 in I conventional estimations (Cutler et al 1997; WHO 2001). The total cost would in this case 1989, to 4877 in 1996, the number of guinea worm cases has oscillated between 5 000 rise to almost 9% of GNP (3% x 3). This observation thus lends credence to the strong and 9000 from 1997 to 2003 as shown by figure 2.6. need to seek new funding to scale up investment or at least carry the Roll Back Malaria programme through to its successful end. As in previous years the bulk of the cases (8,002 or 92%) were reported from the three

most endemic regions, namely Northern (5,999 or 72%), Brong Ahafo (492 or 6%) and ealth Diarrhoea Diseases Volta (1,511 or 18%). Sixty-two districts reported at least one case with 15 districts in H the three northern regions accounting for 95% of the cases. Currently approximately Diarrhoea is still a major cause of morbidity and mortality, particularly among children. It 13,300 communities are under surveillance. Of these 1,289 villages reported cases. Only is estimated that two million children die each year in developing countries from the dis- 4,866 (59%) of the total number of cases were contained. Further, only 47% of endemic ease, making diarrhoea the second most serious killer of children under five worldwide. and communities have potable water. s In Ghana it is reported to be currently the fourth highest cause of admission accounting for about 6% of the total admission. In a survey it was found that about 17.9% of children Figure 2.6 Incidence of Guinea Worm Disease in Ghana, 1989-2003 under 5 had suffered from diarrhoea in the last two weeks (GSS 2000, see also GHS 2004). The majority of cases are caused by unsafe water supplies, inadequate sanitation 179 556 and poor hygiene.

Oral rehydration treatment (ORT), an inexpensive but efficacious method of treating 180 000 160 000 diarrhoea, has been available in the health system since the 1980s and yet less than 50% 123 798 of children less than five years with the condition are treated with ORT. It is believed that 140 000 the country can raise the levels of prevention and transmission of diarrhoea through: 120 000 acroeconomic 100 000

1. Improved Access to Safe Drinking Water 66 697 M 80 000 2. Improved Sanitation

Number of cases 60 000 33 464 3. Hygiene and Health Education 17 918 40 000 8 894 8 921 9 027 7 402 8 290 5 432 4 877 5 473 4 699 5 611

However, all these require resources which can be made possible if investments in health 20 000 hana

are scaled-up. 0 G 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Acute Respiratory Infection The major activities under the Ghana Guinea Worm Eradication Programme have Acute respiratory infections (ARIs) are a leading cause of mortality among children, kill- included the following: ing approximately 2 million children under the age of five in developing countries in 2000. In a nationwide GDHS survey in 2003 it was reported that nearly 19% of children under 5 » House to house surveillance for guinea worm cases by village volunteers; with ARI in the two weeks prior to the survey had suffered from ARI in Ghana. Poverty, » Case management, including occlusive bandaging and worm extraction;

for better health, economic growth and accelerated poverty reduction overcrowding, air pollution, malnutrition, harmful traditional practices, and delayed and s » Filter Distribution and /or replacement: inappropriate case management account for high case fatality rates from ARI. eport of the » Abate application to treatable water sources: On the recommendation of UNICEF different approaches have been adopted to combat R ARI in Ghana, given its cross-cutting nature and the specific characteristics of the areas » Health Education; s tment of implementation. The two major integrated approaches currently adopted are the West- » Training of Volunteers and health workers (Case management, filter use) African Accelerated Child Survival and Development Program (ACSD) and the Integrated Management of Childhood Illness. The ACSD programme is an integrated, results-based » Provision of potable drinking water approach that includes the expanded programme on immunization, prevention and case Even though there are presently no empirical estimates of the socio-economic costs of management of ARI as one of the main childhood killer diseases and antenatal care. the burden of the disease, it can be said to deepen poverty of the infected people or the Furthermore, other more vertical interventions addressing specific diseases are also household for which the person caters. Other negative social and educational effects of implemented at the regional level, usually within the context of integrated approaches the disease include preventing infected people from engaging into social activities and covering nutrition, and water and sanitation. prohibit children from attending schools. As found by a longitudinal study in Nigeria

26 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 27 Scaling-up health inve by the World Bank14, guinea worms tend to cause temporary disability, leaving 58% of Figure 2.7 HIV Infection rates at Selected HSS Sentinel Survey Sites infected people unable to leave their beds for a month during and after the emergence of the worm. This usually occurs during the peak agricultural activities and labour is 0.6 Nadowii 1.3 in a great demand, this can affect the nutritional status of their children. In Sudan, Jirapa 1.8

Sunyani 2.0 nitiative

Ho 2.0 I households where more than half the adult members had suffered from Guinea worm North Tongu 2.0 Sefwi Asafo 2.4 in one year, their under 6 year children were three times as likely to be malnourished, 2.6 3.0 as indicated by wasting. Thus its eradication harbours enormous benefits for economic Wa 3.2 3.2 growth as well as poverty reduction. 3.2 3.4

Tamale 3.6 ealth For guinea worm eradication to be achieved, case containment levels need to be increased Asunafo 3.6

Obuasi 3.7 H to at least 80% and up to 90% and endemic communities should be provided with potable Takoradi 4.0 4.2 water. At the same time, guinea worm surveillance needs to be strengthened. An under- Maamobi 4.2 Korie-Bu 4.2 lying condition for success would be a multi-sectoral approach in Ghana that ensures Navrongo 4.4 Kumasi 5.0 Adabraka 5.2 improved funding for the programme. and 5.4 5.4 s Eikwe 6.1 Fanteakwa 6.6 7.6 Threats to Gains in Life Expectancy Agomanya 9.2 Ghanaians live longer, and are healthier today than at any other time in its history. Since 1950 life expectancy in Ghana has increased from about 41 years to 58 years—a gain of Source: National AIDS/STD Control Programme , “Estimating National HIV Prevalence,” Technical Report, 11/03. about 17 years. But the lingering effects of HIV/AIDS pandemic and other health threats According to the country’s National AIDS Control Programme, approximately 400,000 emanating from tuberculosis and non-communicable diseases (obesity, diabetes, hyper- adults are currently living with the HIV/AIDS virus (see table 2.8). About two-thirds of tension and cardiovascular disease) appear to reverse the decades of gradual gains in life the reported AIDS cases have been females, and the peak ages for females (15-34 years) expectancy. These epidemics undermine poverty reduction efforts by sapping economic are much younger than the peak ages for males (30-39 years). The National AIDS Control growth, thus hampering efforts to achieve the MDG and half poverty by 2015. This thus

Programme projects the average national sero-prevalence rate to increase to 4.7% by acroeconomic makes the control of these diseases a necessary condition. This condition can, however,

2005, 8.2% by 2009 and 9.5% by the year 2014 if the current trend of infection conti­ M be fulfilled only if the existing interventions are scaled-up. nues. In addition about 34,000 children under the age 15 years are estimated to be living with the HIV/AIDS virus, with about 200,000 children orphaned by it in Ghana. The HIV/AIDS distribution pattern of adult infections showed that almost 90% of the cumulative AIDS

cases were between the ages of 15-49 years and 63% of all reported HIV/AIDS cases were hana HIV/AIDS is not just a health issue. It is also a social, developmental and economical

females. The male-to-female HIV/AIDS infection ratio, which used to be 6:1 in 1987, has G issue. The impact poses not only a serious threat to health but also has huge repercussions fallen to approximately 2:1 in 2003. HIV sero-prevalence among sexually transmitted on the socio-economic development of Ghana. The pandemic adversely affect growth rate disease patients and blood donors is 17% and 4%, respectively. Among commercial sex in complex ways, not least, by killing off the most productive segments of the population workers in Accra and Kumasi, it has been found that 75.8% and 82%, respectively, are in their prime (Over 1992). Even in some worst affected countries in Africa the effects of HIV positive. Heterosexual transmission of HIV accounts for 75-80% of all HIV/AIDS the HIV/AIDS has impacted negatively on life expectancy. For example, in South Africa infections. Mother-to-child-transmission accounts for 15%. it is estimated that both women and men would survive only the ages of 37 and 38 years respectively by 2010, as against the estimated life expectancy rate of 54 years in 1999. Table 2.8 Estimates number of people living with HIV/AIDS, 2002– life expectancy is feared to fall from 57.8 years in 2003 to 55.6 by 2010, if the

for better health, economic growth and accelerated poverty reduction Best estimates: 2003 s current level of HIV/AIDS transmission continues. Since the first case of HIV/AIDS in 2002 – 2003 Low – High Range

Ghana was reported in 1986, the prevalence rate has consistently risen from 1.5% to eport of the

Estimated Adult (15-49) Prevalence 3.4 – 3.6 2.8 – 4.2 R 3.6% in 2003, with wide geographical differences (figure 2.7). Number of Infected Adults (15-49) 336 000 – 352 000 282 000 – 423 000 s tment Number of Infected Children (0-14) 23 500 – 26 000 21 000 – 31 000 Number of AIDS Deaths 26 000 – 29 000 23 500 – 35 300

Source: National AIDS/STD Control Programme, “Estimating National HIV Prevalence,” Technical Report, 11/03.

14 See http://www.who.int/ctd/dracun/disease.htm (10 October 2004)

28 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 29 Scaling-up health inve The national response to the HIV/AIDS pandemic incidence of tuberculosis cases and deaths. Currently, the annual risk of infection is estimated at between 1% and 2% putting an estimated number of expected new TB cases The Government of Ghana established a National Advisory Commission on AIDS in in 2003 at 57,194. This makes the current tuberculosis-related mortality rate equivalent 1985, followed by the National AIDS Control Programme in 1987. In September 2000, to 38 per 100,000 people (UNDP 2004). An estimated 10,000 deaths due to tuberculosis nitiative

Ghana took a significant step toward mobilizing all sectors in responding to HIV/AIDS by I occur in Ghana each year. establishing the multi-sectoral Ghana AIDS Commission. The Commission coordinates the involvement of all public and private sector stakeholders in combating the . Over the past decade the government has implemented a National Tuberculosis Pro- Specific aims are to prevent new infections among youth and other vulnerable groups; gramme, which had relied typically on training of health-care workers and provision mobilize groups to support persons living with HIV/AIDS; and establish a budget line of DOTS as the main strategy. In spite of these efforts, improvements in the control of ealth in every Ministry for HIV/AIDS activities, separate from the budget for the Commission TB have been slow, with achievements falling far below their targets. TB case detection H itself. The commission has developed HIV/AIDS Strategic Framework (2001-2005) with rate, for instance, has remained below 40% since 1995 as against a target of 75% (figure the following objectives: 2.8). The cure rate has risen only minimally from 44% to 51.4% during the 1995-2003 compared to a target of 85%. Thus the treatment success continues to linger at about » Reduce new HIV infections among the 15-49 age group and other vulnerable groups

54% compared to a target of 85%. New strategies need to be implemented to reverse the and

by 30 percent by 2005; s current low levels of both case detection and treatment success. Such strategies include » Improve service delivery and mitigate the impact of HIV/AIDS on individuals, families, increasing access to diagnostic and treatment centres, strengthening partnerships, and communities by 2005; improving diagnostic and management skills of health workers, enhanced supervision and assuring availability of efficacious drugs for treating TB. The Global Fund has cre- » Reduce individual and societal vulnerability and susceptibility to HIV/AIDS through ated opportunities for scaling-up the initial implementation of these activities. However, the creation of an enabling environment for the implementation of the national these opportunities need to be enhanced if the disease and its negative effects are to be response; and controlled or eradicated. » Establish a well-managed, multi-sectoral and multidisciplinary institutional framework for coordination and implementation of HIV/AIDS programs in Ghana. Figure 2.8 Case detection rate (1995–2003)

It has designated certain priority interventions, which include: Prevention of new infec- acroeconomic 40.00 tions through promotion of safe sex (BCC), condom promotion, and management of M STDs, blood safety, infection control and integration of VCT and PMTCT into service provision. Interventions to reduce morbidity and mortality include strengthening of the 30.00 health system to increase provision of ART and care and support for people infected

and affected by HIV/AIDS, including counselling and home-based care. For this reason hana 20.00 G guidelines (Guidelines on Anti-Retroviral Therapy and guidelines on the management ercent P of opportunistic Infections) for the management of persons living with HIV/AIDS have been prepared. In collaboration with Family Health International (FHI), a pilot project 10.00 sm+ Support Treatment and Anti Retroviral Therapy (START) was launched in 2003 in the Manya Krobo district. The project, which will eventually provide anti-retroviral drugs, has begun with provision of Voluntary Counselling and Testing (VCT) and community 1995 1996 1997 1998 1999 2000 2001 2002 2003 sensitisation towards a smooth take off of drug therapy. Lessons learnt from this will be applied to other parts of the country. For the prevention of mother-to-child transmission

for better health, economic growth and accelerated poverty reduction a programme was started in 2002 to offer treatment to mothers who have tested positive s for HIV. Non-Communicable Diseases eport of the

Programme targets are aimed at the maintenance of the prevalence of HIV/AIDS below Non-communicable diseases (NCD), including cardiovascular disease, diabetes mellitus, R 4% and reversal of the trend by December 2009. These include increasing public aware- cancers, asthma, sickle cell disease, mental health disorders and substance abuse, are s tment ness, access to and uptake of VCT and PMTCT and other HIV/AIDS related services; becoming major public health problems. Though data on the burden of NCDs diseases is increasing utilization of these services by specific population groups and improving blood limited, health institutions are reporting rising case loads. Currently it is estimated that safety programmes in public and private facilities. NCDs constitute over 20% of all cases of outpatient attendance. The age standardized prevalence of hypertension is estimated to be 27.8%. Lymphomas, leukemia and cancers of the liver are also on the increase. Between 1997 and 2003, Korle-Bu Teaching hospital Tuberculosis (TB) recorded cervical cancer ratios ranging between 26.1 – 35.7% and breast cancer between Tuberculosis, a disease once thought to be under control, has bounced back with a ven- 12.9 – 23.1% of the total number of cases per annum. Ageing and changes in lifestyle geance. Ghana has during the past several years experienced a huge upsurge in the associated with tobacco and alcohol consumption, obesity, lack of exercise and poor

30 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 31 Scaling-up health inve eating habits seem to contribute highly to the silent NCD epidemic in the country. Not egy. It is also recommended to embark upon awareness-creation on injury and violence only is diabetes is slowly becoming one of the main disablers and killers in developed prevention; to develop and implement pertinent information systems; prioritize research countries but also in the developing countries. Many of these diabetes related deaths are to bridge information gaps, provide better training and education to vehicle drivers and from cardiovascular complications. In Ghana cerebrovascular accident is the leading users. The target is to reduce the number of fatalities and injuries by 20% or more by 2010 nitiative cause of death of adults above 45 years. Most of them are premature deaths when the and the interventions will be focused on accident ‘black spots’ in urban areas and vil- I people concerned are economically contributing to society. lages, pedestrians, children, professional drivers, speeding and drunk driving. A national Ambulance service is also being set up to provide pre-hospital emergency services to The associated complications and hospitalisation are increasingly outstretching the accident victims and transport of victims to hospitals with minimum delay. resources devoted to the health sector. For instance, the high costs of diabetes care do ealth not only affect individual patient and his/her family, but overburden the health authori- H ties. Studies in India estimate that, for a low-income Indian family with an adult diabetic Neglected Diseases patient, as much as 25% of family income may be devoted to diabetes care. For families Since the World War II the world has witness a “health revolution”, which has brought in the USA with a child who has diabetes, the corresponding figure is 10%. In Ghana considerable gains in life expectancy in many parts of the world, but has left most of the

the comparative figure may ranges between 15% and 30%. In addition to the direct costs and world’s poor population behind. This is partly due to the existence of certain “neglected” (medical care, drugs, insulin and other supplies), which are borne by individual patients s diseases that do not constitute a valuable enough political and economic “market” to and their families, patients may also have to bear other personal costs, such as increased stimulate adequate political attention, and research and development of new medicines. payments for transport, pain and shortened life span. Direct costs of diabetes such as These “neglected” diseases refer to those for which governments have failed to redress hospital services, physician services, lab tests, etc., to the healthcare sector range from this market failure, largely because they affect the poor. In many developing countries 2.5% to 15% of annual health care budgets, depending on local diabetes prevalence and such diseases do not usually find adequate attention in plans and budgets of the health the sophistication of the treatment available. Such costs range from US$ 3.9 billion for sector, because they tend to be focal and limited to deprived and hard to reach areas and Brazil, US$ 0.8 billion for Argentina, for Mexico US$ 2.0 billion. Even though estimating to communities where the poor predominantly live. These so-called “neglected” diseases the cost to NCDs to society of this loss of productivity is not easy, the few cost estimates are viral, bacterial and parasitic infections (often vector borne infections) and they tend show that combining the cost estimates for 25 Latin American countries suggests that to cause or intensify poverty.

costs of lost production may be as much as five times the direct health care cost. acroeconomic In the view of Professor David Molyneux of the Liverpool School of Tropical Medicine The strategies for NCD control include basic intervention such as screening, periodic M in the UK15 the neglect of such diseases can also be attributed to the concentrated focus medical examinations, health promotion and early detection and management. There is on the three killer diseases: HIV/AIDS, tuberculosis, and malaria, as well as emerging no systematic NCD control programme of non-communicable diseases in Ghana, even diseases. And this has caused funding for neglected diseases to be overlooked with though pilot projects, such as breast and cervical cancer screening programmes, are being deleterious effects on the social and economic well being of the poorest quintile of the implemented. The way forward is to establish a programme for NCD control. hana population. G There is ample evidence to show that controlling these neglected diseases can produce Accidents enormous economic benefits to affected communities and the country as a whole. The Ghana is one of the world’s leading accident prone countries, where, for instance, road objectives of control and elimination of these disabling diseases are to break the trans- accident fatality rate per 10 000 vehicles is about 30--40 times higher than that in high- mission and to secure sustained benefits for afflicted communities with no or limited income countries (WHO 2003). In 2001 alone, 14,883 casualties from Road Traffic Acci- future resource commitment by the health system. If we are to maximise health benefits dents (RTA) were reported. Road fatalities have also risen by more than 50% of the for the whole country, then an increase in investment in proven, cost-effective inter- 1991 levels to 1,660 in 2001. This figure is likely to be higher because many of the road ventions against such neglected diseases will bring sustainable public-health benefits,

for better health, economic growth and accelerated poverty reduction accidents and injuries are not registered. More than 85% of the fatalities occur in the integrate well with and strengthen the health system, reduce disabling conditions, and s five regions Ashanti, Central, Eastern, Greater Accra and Western region. Pedestrians bring collateral benefits to the health of the poorest nations. eport of the

account for about 45% of fatalities followed by mini-bus occupants. RTAs also contribute R significantly to the country’s population of physically challenged. Trachoma s tment The increasing incidence of road accidents is a result the combination of poor road con- The prevalence of blindness is high in the country and is currently estimated to be ditions and low standard of driving in the country. It has also not been possible for the about 1% of the population. Of these 80% is avoidable and preventable. This situation is development of road infrastructure to keep up with rapid increase in vehicle population. unacceptable, given that blindness contributes considerably to poverty. Blind people are As a national response the country has established the National Road Safety Commission usually very poor and poor people are more predisposed to risks of avoidable blindness. (NRSC) as a lead agency to coordinate multisectoral efforts and plans of action with clear This disease is particularly prevalent and severe in rural populations living in poor and roles and objectives for each sector to improve road safety. It has since its establishment designed a national road safety strategy which identifies seven major public and private 15 The Lancet (p 380) 23 Jul 2004 Call for investment in prevention of ‘neglected diseases’ to improve global health. road safety stake holders who will be the mainstay for the implementation of the strat- Medical News Today. 23 July 2004. http://www.medicalnewstoday.com/medicalnews.php?newsid=11135

32 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 33 Scaling-up health inve arid areas. Trachoma is the leading cause of preventable blindness in Ghana and remains Table 2.9 Prevalence of active Buruli ulcer cases by region in Ghana, 1999 a public health concern in the Northern and Upper West Regions. An epidemiological Total no. Prevalence study carried out in the year 2000 in two districts in Upper West Region (Sissala and Wa) of active (rate per and three districts in Northern Region (-Nanton, Tamale and Tolon-Kumbungu) Region No. of males No. of females cases 100,000) nitiative I showed an active trachoma prevalence range of 0-64% and trachoma trichiasis range of Ashanti 482 475 957 30.8 1-22%. Brong Ahafo 113 110 223 12.5 Since joining the International Trachoma Initiative, dedicated to eliminating blinding Central 519 395 914 59.2 by trachoma by the year 2020, Ghana has implemented its recommended SAFE strategy ealth (Surgery, Antibiotic, Facial Cleanliness & Environmental Improvement) as a cost-effective Eastern 202 150 352 16.9 H approach for eliminating trachoma. This strategy entails delivering Community-Based Greater Accra 259 255 514 18.5 Trichiasis Surgery (CBTS) by trained staff, treatment of active cases with antibiotic, Northern 65 68 133 7.4 promoting facial cleanliness and environmental improvement. A national trachoma con- Upper East 34 63 97 10.7 trol programme has been developed and is being implemented with the support of the and International Trachoma Initiative. Through this programme, the coverage of surgery and Upper West 21 21 42 7.4 s antibiotic treatment for trachoma and trachiasis has been increasing steadily. Nonethe- Volta 78 74 152 9.6 less, a backlog of cases still exists, which can be covered if the intervention and resources Western 181 140 321 17.9 are scaled-up. Unknown 20 Filariasis Ghana 1 751 1 954 3 725 20.7

Filariasis is a parasitic disease transmitted by anopheles mosquito that affects predomi- Source: MoH nantly the poor. Approximately 50% of the Ghana’s population is at risk of contracting National Control strategies include surveillance and early case detection, capacity devel- filariasis. Currently the antigen prevalence is between 20 and 40% in the Northern part

opment in case management and strengthening of health facilities to provide the needed acroeconomic of the country and between 10 and 20% in the endemic areas in Southern Ghana. In June

services, research including the application of cultured skin in the treatment of Buruli M 2000, the Ministry of Health developed a national programme for the control of filariasis. Ulcer and advocacy for fee free services. In the short and medium term interventions are The core strategy for the control of filaraisis is mass drug administration of Ivermectin meant to include following: and Albendazole to break the transmission cycle and reduce morbidity. » Institutionalising the surgical training programme

Presently, about 50% of the population at risk of contracting filariasis has been reached hana » Continuing with the surgical training and strengthening of the treatment centres with this intervention. It is important to build on this achievement by scaling-up coverage G of the mass treatment in order to achieve total elimination of lymphatic filariasis by the » Strengthening surveillance and response year 2015. » Implementing drug treatment using pure rifampicin and streptomycin for selected lesions as alternative to surgical treatment of the disease Buruli Ulcer Buruli ulcer also continues to be a major cause of disability particularly among the poor. Schistosomiasis A national search for cases of Buruli ulcer in Ghana in 2001 identified 5,619 patients, Since Independence in 1957, many water related development projects have been con-

for better health, economic growth and accelerated poverty reduction with 6,332 clinical lesions at various stages. But the total number of active cases stands

s structed with their attendant health hazards. Several irrigation projects were also created around 3,725. As can be seen in table 2.9, even though the harbours the

to cater for all year round irrigation farming and these have greatly contributed to the eport of the greater number of active cases among the regions, the tops the list in worsened status of schistomiasis in the country. In the basin, before the dam- R terms of prevalence rate comparisons. The overall crude national prevalence rate of active ming in 1964, prevalence of urinary schistosomiasis was below 5% among communities lesions was 20.7 per 100,000, but the rate was 150.8 per 100,000 in the most disease- s tment living along the River. However, after damming, by 1971 many communities living along endemic districts. In these endemic areas up to 22 per cent of villagers are affected. The the lakeshore had prevalence rates as high as 80 – 90%. In 1989 infection rates of 76.2% case search demonstrated widespread disease and gross underreporting. Buruli ulcer for S. mansoni and 6.3% for S. haematobium were recorded. commonly affects the young, even though cases are reported in all age groups. There is therefore the need to intensify efforts targeted at the treatment and control of schistosomiasis through selective mass chemotherapy of heavily infected communities and school children. Weeds, which are known to harbour host snails need to be removed mechanically along the foreshore of endemic settlements and molluscicides use to control

34 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 35 Scaling-up health inve the host snails has to be undertaken at selected sites. All these control measures, which should be pursued with rigorous health education and improvement in sanitation, can Widening Access to Health Services be implemented rigorously under a scaled-up health intervention. Improving the health status of the poor is crucial for poverty reduction in any country,

given that ill health is a consequence and cause of poverty. However, in most developing nitiative Soil-Transmitted Helminthiasis countries like Ghana geographical access is a major barrier to health care. In Ghana I a significant proportion of the people still do not have access to health services and Soil transmitted helminthes cause malnutrition, anaemia and growth retardation, cogni- where the services are available, the cost of these services deters them from using them. tive impairment as well as lowering of resistance to other infections. Hookworm causes Access in this context, is defined as living within one hour travel time (by any available

blood loss into the gut and this results in iron deficiency anaemia. Trichuris trichiura ealth means) from the health facility. By this definition the government estimates that only

causes chronic , rectal prolapse, iron deficiency anaemia and growth retarda- H 45% of the rural population have access to health services. Nationally about 40% of the tion. Ascaris lumbricoides can cause intestinal obstruction in children and other compli- population do not have access to health facilities (UNICEF 1998). In order to overcome cations when adult worms migrate from the small intestines to other parts of the body. this, community-based care delivered at health centres, at smaller facilities or through a Global mortality due to soil transmitted helminthiasis and schistosomiasis is about penumbra of outreach services radiating out from static facilities is being advocated in and

200,000 annually. Pregnant women and school-age children are most at risk of adverse Ghana as an effective way to extend and expand services to poor people in remote areas. s effects of infection. A survey of 760 primary school children in Savulugu / Nantong This new Ghanaian strategy for empowering communities to improve health status is district in the Northern Region in the year 2001 gave prevalences of 31.7% (hookworm) a bottom-up close-to-client structure, which is anchored at community level and has a and 4.7% (Hymenolepis nana). Another survey in the Tolon – Kumbungu district also nodal district hospital with an intermediary sub-district level (see figure 2.9). This close to found 51.5% (hookworm) and 4.5% (H. nana) in 800 primary school children. In the Kas- client strategy, for bridging equity gaps in access to quality health services and removing sena-Nankana district in the gave prevalences of 68.7% (S. mansoni) non-financial constraints to health care delivery, entails the definition of the concept and 67.7% (S. haematobium). of ‘whole district health systems’. At the heart of this system will be the expansion of the community-based health planning and services (CHPS) initiative. This strategy is The main intervention to reduce the prevalence of Schistosomiasis and Soil Transmit- in line with the Government’s policy of locating ‘nurses in every hamlet’ in Ghana. The ted Helminthiasis uses an integrated approach to achieve a level where they no longer three tiers of the new ‘whole district system’, as illustrated by figure 2.9, are linked on the

constitute public health hazards or risks. acroeconomic service delivery side through bottom-top referrals and top-down supervision on the man- M agement side, with monitoring and evaluation and accountability running both ways. Leishmaniasis The CHPS approach will be oriented to deliver a specific basic package of services or Leishmaniasis is one of the major infectious diseases afflicting the poorest population in essential interventions that are effective in reaching poor populations. This will be cou- the poorest regions of the world. Cutaneous leshmaniasis forms are the most common and pled with effective government stewardship that guides the contribution of public, private hana can produce many skin ulcers on exposed skin, causing serious disability and permanent and voluntary services. The CHPS as a close-to-client system is designed to comprise of G scarring when they heal. Cutaneous leishmaniasis is said to be rare in West Africa and a set of CHPS zones within a sub-district, Sub-District health Facilities (Health Centres) for that matter in Ghana. However there has been an observed increase in incidence of providing technical backstopping for these zones and at least a district Hospital providing the disease in recent years in some districts in Ghana. These ulcers continue to spread referral services for the Sub-district structures as depicted in figure 2.9. among sub-districts in the Ho district and also to neighboring districts. For 2003 alone The CHPS requires a strong community involvement, without which any scaling up of 6,450 cases occurred in the 3 districts with Ho district accounting for 96% of the cases investment in health or effective expanded coverage of the poor is unlikely to be achieved. as depicted in the table 2.10. But a sincere community-based drive would necessitate a different strategic approach, Table 2.10 Selected Cases of Leishmaniasis additional human resources and finances, and new support and supervision of strategies. for better health, economic growth and accelerated poverty reduction s Number of cases Number of cases, previous Total number of In support of the CHPS initiative as a way of reducing geographical and service delivery

District (2003) years (before 2003) cases barriers the Technical Team on Health Service Provision of the GMHI recommended eport of the

HO 6 185 2 348 8 533 the following areas of action: R HOHOE 174 2 176 1. Increasing the physical access to care in Communities by scaling up the establishment s tment 91 76 167 of Community Health Planning and Services (CHPS). TOTAL 6 450 2 426 8 876 2. It is recommended to complement CHPS with strategies for scaling up the establishment of community-based prepayment (insurance) schemes or Mutual Health Organisations Leishmaniasis Cases in Ho, Kpando and Hohoe districts from Case Search – Dec 2003 as a process of removing financial barriers of communities’ access to health care.

3. Developing sound human resource production and management to reduce the rate of loss of health manpower. This should also lead to improving the quality and volume

36 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 37 Scaling-up health inve of services provided by government and private facilities especially at the District and the POW of the Ministry of Health to reduce health inequalities and promote equity of Sub-district level to support and complement CHPS. health outcomes.

Figure 2.9 CHPS and the New Health System Implementation of an Infrastructure to Deliver the CHPS nitiative Interventions I In implementing CHPS, it is proposed that each sub-district would be zoned into at least District level six zones. Given that each sub-district is carved to contain around a population 30,000 District Health

Management Teams District hospital people, each zone will have a population of between 500-5,000 people or 3 to 4 Unit ealth (DHMT)

Committees grouped together. Accordingly each district will theoretically be divided H into at least forty-eight zones. This proposal envisages at least 5,280 CHPS zones, which

patient referral supervision patient referral require about 5,280 Community Health Officer’s (CHO) to man the system nationally. In line with the expected roll out of CHPS strategy, about 4475 Community Health

Sub-district level and

Sub-district Health Compounds needs to be constructed at the community level (table 2.11). Working on s Management Teams (SDHMT) Health centres Health centres the assumption that each sub-district will be adequately served by a well equipped and in Sub-district in Sub-district ...... appropriately staffed, and also on the assumption that each district has an average of six Sub-Districts, a total of three hundred and forty-six -346- additional Health Centres patient referral patient referral patient referral will need to be constructed at the sub-district level. A properly located District Hospital supervision supervision supervision will be expected to provide adequate referral support for the sub-district health struc- tures and taking into consideration the existing 72 district hospitals (public and Mission CHPS CHPS CHPS CHPS Community level Institutions), an additional 67 district hospitals is needed to be constructed at the district Community Health zones with zones with zones with zones with Committees community community community community level (see figure 2.9). With the kind of Health systems outlined, each Region will need a support support support support referral hospital. The current situation will require the refurbishment of some of existing systems systems systems systems acroeconomic Regional Hospitals and the construction of a ‘Regional Hospital’, for instance, for the

...... M Ashanti region. Table 2.11 Recommended Number of Facilities to roll out CHPS in Ghana CHPS as the basis of a “CTC” health system in Ghana Additional Structures hana

The CHPS started as a new initiative of the Ghana Health Service in 1998, and as a Level Number of Facilities needed Current Situation Needed G process for translating innovations from an experimental study of the Navrongo Health 6 CHC’s X 6 Sub Research Centre (NHRC) into a national community health care programme. Indeed Community level – Districts X 139 the Navrongo experiment has demonstrated convincingly that community mobilization Community compounds Districts = 4896 47 + (374 Clinics) 4475 combined with community-based deployment of the nurse represents the most effective Sub-district Level – 6 Health Centres X 139 Districts intervention to enhance service coverage. In addition this experiment demonstrated Health Centres = 834 488 346 service strategies that can greatly improve the quantity, efficiency or quality of health District Hospitals 139 District Hospitals 62 + 10 67 and family planning care. Even though a detailed evaluation has not been carried out in Regional Hospitals 10 9 1 for better health, economic growth and accelerated poverty reduction these districts, trend analysis from shows remarkable improvements in service s provision. This is also supported by evidence from Abura-Asebu-Kwamankese District Teaching Hospitals na 2 na eport of the

in the Central Region of improvement in access to health care in communities where Completed zones will comprise communities where the following six “milestones” have R CHPS has been initiated. been accomplished: s tment Over time CHPS is supposed to become a sector-wide health system reform that aims to i. Health service work areas have been delineated for primary health care outreach provide accessible primary health care to all communities of Ghana. It seeks to enable activities, District Health Management Teams (DHMT’s) throughout Ghana to adapt and develop ii. Community leaders are oriented and involved in the health programme, approaches to community health care that are consistent with local traditions, sustain- able with available resources, and compatible with prevailing needs. The GPRS intends iii.A “Community Health Compound” has been established where a resident nurse pro- to use the CHPS as a strategy to disassociate the allocation of staff with facilities by vides health services, placing community health workers directly in the communities to deliver services rather than attaching them to health facilities (GPRS 2002). CHPS is also intended to support

38 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 39 Scaling-up health inve iv.Community Health Officers have been selected, trained and relocated to community Consequently, for many years the government of Ghana has being looking for ways of locations improving equitable universal access to health care for those excluded by many factors as well as find alternative ways of financing health care in response to declining pub- v. Where equipment for transportation has been mobilized and finally, lic health expenditures. In 2001 the government initiated a National Health Insurance nitiative vi.Where volunteer health organizers have been trained and deployed to support the Scheme as humane approach to financing health care. This is seen as one option of I programme. obtaining additional resources for the financing of health care without deterring the In the light of resource (financial and human) constraints it is proposed to implement the poor and vulnerable groups from seeking care when they need it. It is also seen as a way CHPS in Ghana in phases according to a plan. The plan proposes that annually about of improving the quality and access to health care as well as managing resources more three hundred (300) CHOs will be placed within the communities. This phased plan takes efficiently. However, the main aim of the health insurance scheme is to enable the gov- ealth into consideration districts with low populations and sparsely distributed populations. ernment to achieve its set health goal within the context of the GPRS and Health Sector H The Ghana Health Service has proposed a region by region roadmap of placing CHOs Five-Year Programme of Work, 2002-2006. The Scheme is supposed to kick off in 2005. in the communities (table 2.12). The target is that 80% of districts will be implementing It is, however, important to point out that numerous risk-sharing schemes in several

CHPS in the medium term or by the end of POW II in 2006. districts in Ghana have been piloted in the country for more than a decade, prior to and Table 2.12 Projected Placements of CHOs per Year by Region, 2002-2006 the initiation of a comprehensive scheme in 2001. These comprised a mix of different s schemes, including geographically based Mutual Health Organizations (MHOs), social Number Total Region Districts 2002 2003 2004 2005 2006 2002-2006 health insurance for the formal sector, and private health insurance. Under the new insurance regime it is compulsory for every person living in Ghana to belong to a health Upper East 6 24 30 30 30 30 144 insurance scheme. The choice of scheme to enrol with will, however, be voluntary. Upper West 5 15 15 15 15 15 75 Northern 13 50 50 50 50 50 250 Types of Health Insurance Schemes Central 12 16 30 30 30 30 136 In order to ensure sanity in the health insurance market the new Health Insurance Bill Brong (Act 650 2003) categorises all the insurance types under two main health insurance acroeconomic Ahafo 13 40 40 40 40 40 200 regimes, viz: the social-type Health Insurance Scheme made up of the District Mutual M Volta 12 30 30 30 30 30 150 Health Insurance Scheme and the Private Mutual Health Insurance Schemes and the Private Commercial Health Insurance Scheme. All these types are supposed to be reg- Ashanti 18 NA 35 35 35 35 170 istered as companies limited by liability or guarantee with governing boards to oversee Eastern 15 NA 35 35 35 35 170 management practices, governance and democracy. It is required that the design of these hana Western 11 NA 30 30 30 30 150 schemes follow the principles of equity, risk equalisation, cross-subsidisation, solidar- G Greater ity, quality care, efficiency in premium collection, community or subscriber ownership, Accra 5 25 25 25 25 25 125 partnership, reinsurance, and sustainability. Totals 110 290 320 320 320 320 1570 The District Mutual Health Insurance Schemes (DMHIs) schemes have been designed to capture all persons in both the formal and informal sectors of the economy. It can National Health Insurance Scheme thus be said to be a merger of the traditional Social Health Insurance Scheme, which accepted memberships from people working in the formal sector and the Mutual Health Financing of health care has gone through a chequered history in Ghana. After indepen- Organizations, which used to be for workers from the districts in the informal sector.

for better health, economic growth and accelerated poverty reduction dence the government provided health care freely to the people, and was wholly financed The DMHIs shall usually have the character of a not-for-profit organization, owned s through tax revenue. The sustainability of this form of financing became questionable as by members who contribute regularly to a pool with the view to sharing health risks. the economy began to show signs of distress in the light of increasing other competing eport of the

Any profit made in the operations of the firm shall be ploughed back into the scheme to R demands. In the 60s a limited number of fees for specific hospital services was introduced reduce the periodic contributions or increase benefit packages of members. However,

s tment by the then government. In 1985 the government introduced user fees for all medical it shall continue to receive assistance from the government in the form or subsidies for services except certain specified communicable diseases. It was later complemented with risk-equalisation and reinsurance for catastrophic events, as part of the government’s pro- a full cost recovery for drugs as a way of generating revenue to address the shortage of poor economic policy. Under the insurance proposal every district shall establish DMHI drugs. The payment mechanism put in place was termed “Cash and Carry”. The imple­ to register residence from every community, something which gives it a district focus. mentation of the “Cash and Carry” led to a reduction in the utilization of medical services The DMHI shall operate on certain institutional structures the most important include since it created a financial barrier to access especially for the poor. According to the the District Health Insurance Assembly, the Board of Directors, and Community Health GLSS4 report (2000) of the 18% of the population who require health care at any given Insurance Committees. The District Health Insurance Assembly shall comprise of the time, only 20% are able to access it. chairmen or secretaries of the Community Health Insurance Committee of the various

40 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 41 Scaling-up health inve communities in the district. This assembly shall provide the general policy direction of Benefit Packages of the Scheme the scheme operations, put in place a constitution and approve the Board of Directors for The minimum benefit package of health services to be provided by all the schemes shall the scheme, which would be responsible for the enforce of the constitution, approval of be defined by the National Health Insurance Council. Generally health care benefits to the budget, render operational and financial accounts to the Assembly and appointment nitiative

be offered may include general and specialist consultations, in-patient services, labora- I of management staff for the scheme. tory and ultrasound scanning services and drugs as contained in the approved NHIS The Private Mutual Insurance Scheme (PMHI) shall not have a district focus and can be drug list. community, occupational and faith-based. This type shall be operated by any group of In addition, oral health services such as tooth extraction, incision and drainage, den- persons, who may come together to share their health-risks. Unlike the DMHIs the PMHI

tal restoration such as filling and temporary dressing would be offered. Eye care ser- ealth would not receive any subsidy from the government. The Private Commercial Health vices including refraction, eyelid surgery and cataract removal, among others may be H Insurance Schemes are those that would be operated by private companies limited by offered. Other health services may include maternity care – antenatal care, normal and liability, offering the minimum benefit package and supplementary insurance plans as assisted deliveries, caesarian and postnatal care. All emergencies such as road and traffic an add-on for those who so desire and can afford to pay. accidents, industrial and workplace accidents shall also be covered under most of the and

schemes. Public health programmes of the Ministry of Health covering health services s Financing the Scheme such as immunization, family planning, in-patient and out-patient treatment of diseases The scheme shall be financed with contributions from members in the case of the social- like tuberculosis, , buruli ulcer, trachoma and confirmatory HIV test shall type and premium payment in the case of the private commercial insurance schemes. As also be free. pointed out earlier the DMHIs shall receive additional subsidies for risk-equalisation, However, healthcare services such as cosmetic surgery, heart and brain surgery, cancer and reinsurance for catastrophic events. The Insurance Bill also establishes a National treatment, organ transplantation, assisted reproduction (e.g. artificial insemination), Health Insurance Fund with the sole object of providing finance to subsidise the cost diagnosis and treatment abroad and mortuary services would not be covered by the of the provisions of healthcare services to members of district mutual health insurance NHIS. Medical examinations for purposes other than treatment, in accredited health schemes licensed by the council. To kick start the insurance scheme the government bor- facilities including visa applications, educational, institutional, driving license among rowed 2.5 percent out of a 17.5 percent levy that about 850,000 people in the formal sector others would also not be covered by the scheme. acroeconomic already pay to the National Workers’ Social Security Scheme (SSNIT). The proceeds of a M new National Health Insurance Levy will also be collected to cater for those who cannot afford to make contributions. The levy shall be calculated at a rate of 2.5% on certain Health Care System and Service delivery taxable goods and services that go through the value added taxation and is payable at the in Ghana time the goods and services are supplied or imported. The levy will go into a National hana Insurance Fund to be administered by the National Health Insurance Council, which also Health care provision in Ghana can be categorised into orthodox, tradition and spiritual G registers, licenses and regulates the Health Insurance Scheme through the accreditation systems (Appiah-Kubi 2003). The orthodox health care delivery system is clinic-based, and monitoring of healthcare providers operating under the Health Insurance Schemes. and is mainly provided by government, private practitioners and religious missions. The In addition to that about 40.6 billion cedis – nearly US$ 5 million – from the Heavily government of Ghana, which manages the health sector through the Ministry of Health Indebted Poor Countries Index (HIPC) has been hitherto used to fund the scheme at the (MOH) and the Ghana Health Services (GHS), owns about 58.4% (Appiah-Kubi 2004; district level. A similar amount has been set aside as incentives for health workers who MOH 1999) of facilities within the sector. Government health facilities in Ghana consist agree to work in deprived areas in the country. of four levels in the urban areas and five levels in the rural areas of health care providers. The divisions are based on the amenities and levels and type of personnel available in In the case of the social type the contributions shall be designed according to the ability a facility. The MOH also provides mobile health services, including immunization and for better health, economic growth and accelerated poverty reduction to pay. There is, however, a differential contribution level with regard to workers in the 16 s family planning and reproductive care to rural residents . In addition the country has a informal sector of Ghana. Workers shall be categorised into six social classes with the

network of maternal homes, which are owned by the government and private individuals eport of the

core or extreme poor paying the minimum package, whilst the very rich pays higher R (Canagarajah and Ye 2002). The government also pays a substantial share of the private contribution. For beneficiaries or members of the DMHIs in the informal sector, it is and missionary health expenses in the form of subsidies. s tment estimated that the minimum benefit package will be offered at a minimum premium contribution of ¢6,000 per adult person per month and this shall be for the group in the The second largest provider of orthodox health care services comprises the private pro- category of core poor. For those in the formal sector, who contribute to SSNIT, 2.5% viders, which also include the (quasi private) missionary providers. There is also a Coali- will be deducted from the 17½% SSNIT contribution and used as premium for formal tion of Non Governmental Organisations (NGOs) working in the health sector. However, sector contributors. whereas the majority (almost 60%) of health care centres, clinics and the tertiary levels in Ghana are owned or run by the government, most of the facilities at the general hospital

16 The latest population census (2000) estimates the share of the rural population of Ghana at about 56.2% and that of the urban population at about 43.8% (GSS 2002).

42 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 43 Scaling-up health inve levels are owned by private entities and missionaries. The missions providing health The traditional system on the other hand comprises herbalists and fetish priests, whose care in Ghana have of late grouped themselves under the umbrella Christian Health operations involve the use of herbs and invocation of ‘spiritual powers’ of a deity in diag- Association of Ghana (CHAG). It is estimated that in 1998/1999 almost half of all visits nosis and treatment of diseases. Another source of traditional medicine, which is rapidly to health facilities occurred in the private sector (GLSS 4). The distribution of health gaining currency, especially, among women, is religious spiritualism, where treatment is nitiative facilities favours mostly the more affluent regions in southern Ghana, including Greater sought through prayers and faith healing. It is estimated that over 70% of the population I Accra, Ashanti, and Volta Regions, with the Ashanti alone having about 30% of the total rely on traditional medicine, even though it still remains to be adequately integrated number of government run hospitals and the Volta Region also with a population share into the formal health sector. Self-medication or self-prescription without consultation of about 10% possessing about 26% of the total number of sub-district health centres and or any expert advice is also rapidly becoming popular. Similarly the use of drugs on the

clinics (see table 2.13). Just as with the distribution of facilities, access to modern health suggestions of a drug store operator, who might not necessarily be a pharmacist, is on the ealth

care services as reflected in population density per facility appears to favour the more increase. In both cases the patient avoids the payment of consultation fee of a medical H affluent regions, which are more or less at or below the national average of 11 persons expert and the distance costs to a health facility. per facility. Another indicator of availability as measured by population per physician The main problems of the traditional medicine sector are two fold: how to integrate shows a skewed picture. In 1998 the only two teaching hospitals of the country, located it adequately into the formal health systems; and how to ensure that the practice is and

in Accra, the national capital, and Kumasi, the regional capital of Ashanti region, for s adequately regulated and assure high quality of services. During the past couple of years instance, employed about 503 or more than 40% of the 1,204 publicly funded physicians attempts have been initiated towards putting in place mechanisms to handle the above- in Ghana (MOH 1999). mentioned problems. This has led to the establishment of, for instance, a traditional

Table 2.13 Distribution of Health Facilities by Facility, Type, and Region

Christian Ministry of Health Quasi Governmental Health Non-governmental Institutions Institutions Associations Institutions Total Institutions by Type

Private Medical acroeconomic Practitioners M tal i hana G

Regions Regional Hospital District Hospital Health Centre/Pos MCH Centre Leprosy/Psych Other Comm-Initiated Clinics Total MoH Institution University Hospital Military Hospital Police/Prisons/Hospital / Clinic Others (e.g., Mines) Hospital Clinic Planned Parenthood Association of Ghana Ghana Reg. Midwives Association Hosp Clinic Hospital A+B+E+H+I+J+L+P Health Centre/Post Clinic D+F+K+M+O+Q Total all health Institutions Percent Reg. Distribution of all Institutions A B C D E F G H I J K L M N O P Q R S T U V Ashanti 1 20 85 21 2 9 138 1 1 3 6 14 33 12 101 43 64 85 85 246 416 18.4

B. Ahafo 1 5 84 13 0 0 103 0 1 1 0 9 9 3 46 4 6 21 84 77 182 8 Central 1 6 39 14 2 26 88 1 0 2 1 3 7 6 27 4 62 19 39 143 201 8.9 Eastern 1 9 46 122 6 14 198 3 0 0 2 4 15 10 47 5 23 28 46 233 307 13.6 for better health, economic growth and accelerated poverty reduction

s Gar 1 3 29 13 2 14 62 1 2 3 4 2 3 2 87 37 142 51 29 265 345 15.3

Nr 1 6 73 9 0 9 98 0 2 0 0 3 18 2 6 0 2 12 73 46 131 5.8 eport of the R Uer 1 3 21 7 0 40 72 0 0 1 0 1 9 0 2 1 11 7 21 69 97 4.3 s tment Uwr 1 3 41 5 0 0 50 0 0 0 0 2 15 0 5 3 5 9 41 30 80 3.5 Volta 1 10 141 48 1 4 205 0 1 0 0 6 11 3 29 6 23 25 141 118 284 12.6 Western 1 10 63 10 0 12 96 6 1 2 3 4 16 4 51 11 25 35 63 121 219 9.7

Total 10 75 622 262 13 128 1,110 12 8 12 16 48 136 42 401 114 363 292 622 1,348 2,262 100 Percent 49.1 2.1 8.1 40.7

Source: GSS Ghana Statistical Service, Ministry of Health (Health Research Unit), and ORC Macro (2003) Ghana Service Provision Assessment Survey, Calverton, Maryland: Ghana Statistical Service and ORC Macro.

44 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 45 Scaling-up health inve medicine directorate and the development of a code of ethics for the practice. A draft bill » To focus on the Priority Health Interventions for the medium term which are: for alternative medicine practice has also been developed to take a closer look at other » The Expanded Programme of Immunisation (EPI)/Child Health, HIV/AIDS, Emer- considerations including the following: gency care, Tuberculosis, Reproductive and Maternal Health, Malaria Control,

» Strengthening the Traditional and Alternative Medicines directorate and establishing Guinea worm Eradication; nitiative I the Council to assist in monitoring of practitioners to improve quality of service. » Ensuring sustainable financial arrangements that protect the poor i.e. exemptions and » Training of traditional and alternative medicine practitioners other alternative health financing schemes such as the health insurance.

» Establishing model centres of Traditional and Alternative Medicines practice The programme of work also seeks of achieve the following: ealth » Facilitating dialogue between traditional, alternative and allopathic providers » To increase geographical and financial access to basic services H

» Supporting the cultivation of medicinal plants » To improve quality of care in all facilities and during outreaches

» To improve efficiency in the health sector

Structure of Service Delivery » To foster closer collaboration and partnership between the health sector and communi- and s Health care delivery in Ghana, as pointed out above, is provided by both the public ties, other sectors, and private allopathic and traditional providers and private sectors. However, the Ministry of Health exercises the overall oversight » To increase overall resources in the health sector, and achieve equitable and efficient control over the whole system as well as policy formulation, monitoring and evaluation distribution of these resources. of progress in achieving set targets. Under the public health system, the service delivery is undertaken largely by Ghana Health Service, and teaching hospitals, both of which As a policy objective, the MOH seeks to maximize the potential health life years of all constitute the bulk of the Ministry of Health Institutions. In addition to that, other quasi individuals resident in Ghana by reducing the incidence and prevalence of illness, injury government institutions and statutory bodies are also involved in health service delivery. and disability, and the prevention of premature death. This is derived from the new Under Ghana Health Service, service delivery is structured according to a three-tiered overarching vision of health sector to improve the health status and reduce inequalities system with regional, district and sub-district elements. At the regional level the regional in health outcomes of all people living in Ghana. The goal which has been set for the

hospitals deliver curative services and public health services, which is largely provided health sector drives on working together for equity and good health for all people living acroeconomic

by the DHMT. in Ghana. These give the Ministry the specific mandate to evaluate and monitor the M country’s health status, advise central government on health policies and legislation, The Regional Health Administration provides supervision and management support to formulate policies and strategies, design and coordinate programmes to address health the districts and sub-districts within each region. The districts hospitals, largely owned by problems of the country, and implement, monitor and evaluate (in collaboration with missions but supported by government, provide curative services as well as public health other related sectors and agencies) all health programmes and activities in the country. hana services. They are concerned with operational planning and implementation of service All these different roles and responsibilities have off late been decentralised to different G within the district. The DHMT at the district level also provide public health services. implementing agencies including the Ghana Health Service (GHS), tertiary institutions, Supervision and management support to the sub-districts are provided by the District specialised institutions, statutory and regulatory bodies. Thus the implementing agencies Health Administration. The health centres operate the sub-district level to provide both are now responsible for service delivery, whilst the ministry provides the policy direction preventive and curative services, as well as outreach services to their respective com- to the government. Since 1997 the Ministry of Health has adopted a sector-wide approach munities. Of late the Community-based Health Planning Services has been introduced (SWAp) to planning and funding of the health sector, which emphasises on one single as new sub-structure to provide basic preventive and curative services for minor ailments sector programme that is owned by the government, accepted and supported by develop- at the community and household levels. ment partners/donors and all stakeholders. The (SWAp) seeks to rationalise donor inputs,

for better health, economic growth and accelerated poverty reduction encourage efficiency of service delivery and at the same time promote private sector s involvement and community and household empowerment and participation.

Policy framework on Health eport of the

Presently the health policy framework of Ghana is ingrained in various strategies, poli- Over the last decade the MOH has reviewed, formulated or revised several of its policy R cies and guidelines. Of importance among them are the Medium Term Health Strategy documents, the most important of which include the following: s tment (MTHS) and the rolling five-year programme of work (I and II) that guide health devel- » Policy framework on Health Insurance in Ghana opment in Ghana. The MTHS commits the government in the medium term towards improving the health outcomes of the poor, by pursuing the following: » Private Health Sector Policy.

» A health related poverty strategy that focuses on the Community-Based Health Plan- » National Ambulance Service Policy and Implementation Plan. ning and Services (CHPS). This initiative focuses on placing health workers in com- » National Drug Policy munities that are deprived and requires that they deliver preventive and primary health » The GHS Code of Ethics and Patients Charter care including family planning services;

46 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 47 Scaling-up health inve » Accident and Emergency Care Policy and Strategy document was reviewed and ties and consequently better health indicators than the northern and rural parts of the accepted by the GHS Council. The council has recommended the development of an country. Even though it can be said from the foregoing that the health facility network implementation plan. is quite extensive in Ghana, accessibility ratios17 are relatively low compared with other developing countries. Latest available data reveal that only 80% and 37% of the urban » Guidelines have been prepared in collaboration with the National Insurance Commis- nitiative and rural population live close to a health facility (Canagarajah and Ye 2002). This I sion and Ghana Insurer’s Association to implement an Emergency Treatment Benefit compares unfavourably, for instance, to access ratios in Botswana, where about 100% of Package for Road Traffic Accident victims in accordance with the Motor Insurance urban and about 90% of rural dwellers live within a walking distance of about 30 minutes Policy. Under the package victims who report to a health institution within 48 hours to a health facility (World Bank 2001). of the event will be treated free of charge and the health institutions reimbursed up to ealth charge and the health institutions reimbursed up to ¢400,000.00 of the initial cost by Table 2.14 Levels of Sector-wide Performance indicators of the Health Sector H appropriate bodies responsible. Indicator 2001 2002 2003 2004 Health status Health Sector Reforms Infant Mortality Rate per 1000 live births 57 64 65 and

Ghana has since independence in 1957 tried to increase access of its population to quality Under five mortality Rate per 1000 live births 108 111 s health services through a host of social sector reforms and other interventions in the Maternal Mortality Ratio per 100, 000 live health sector. The latest round of reforms started in 1996 with the enactment of a new births 214 Health Service Act (525) of 1996 and the Medium Term Health Strategy (MTHS), which Under five who are malnourished 25 na 23 22 launched a restructuring of the health sector. These were followed by five year rolling HIV sero prevalence 3 3.4 3.6 3 programmes of work (POW I & II), which sought to achieve measurable improvement in Tuberculosis Cure Rates (%) 44.9 48.9 53.8 58 the nation’s health by targeting some selected health problems for eradication. Guinea worm cases 4733 5545 8290 6000 Until the enactment of Act 525 in 1996 everything concerning health was put under the Under five malaria case fatality rate 1.7 3.67 3.70 3.70 Ministry of Health. As part of the institutional reforms roles and responsibilities were Service Outputs and Health Service Performance

decentralised to different agencies. This culminated in the creation in 1997 and the offi- acroeconomic Outpatient per capita 0.49 0.48 0.50 0.6

cial launching of the Ghana Health Services (GHS) in 2003 to take over the implementa- M tion of public health services. The Act 525 also streamlined the Ministry of Health, and Hospital admission rates per 1000 population 34.9 34.1 35.9 38 separated the service delivery, policy, and regulatory components of the ministry. And Bed occupancy rates 64.6 65 64.1% 65 this made the ministry the backbone for the provision of the general government policy % FP acceptors 24.9 21.6 22.6 24

direction, resource mobilisation, monitoring and evaluation and administrative support % ANC coverage 98.4 93.7 91.2 94 hana

for the Minister. The act also paved the way for the strengthening of the regulatory bodies, G % PNC coverage 54.2 53.6 55.8 57 especially the Food and Drugs Board, the Nurses and Midwives’ Council, the Medical % Supervised deliveries 50.4 32 55 60 and Dental Council, the Traditional Medicine Board, the Funeral Homes Board, and the Private and Maternity Homes Board. EPI coverage (DPT3) 76.3 77.9 76 80 EPI coverage (measles) 82.4 83.70 79 85 In addition to that the government has formulated policies, standards and protocols to guide the delivery of health services. Health facilities at the primary health care level No. of specialized outreach services carried out 141 158 na 158 offer various health services in an integrated manner through public sector health centres Quality of Care and community outreach sites. In the case of other diseases, whose serious potential % Tracer drug availability 70 Na 85 90 for better health, economic growth and accelerated poverty reduction s impact has attained crisis proportions, such as HIV/AIDS, the Government has set up % Maternal deaths audited 10 0 – 84 85 85

an inter-ministerial commissions, under the chairmanship of the President, to coordi- eport of the AFP non polio rate 2.8 na 1.3 1.3 nate the national response to the crisis. This has led, for instance, to the adoption of a R Level and Distribution Health Resources national policy on HIV/AIDS and the design and government’s approval of strategic plan s tment of action. Doctor to Population ratios by regions 1:22,811 1:22,193 1:17,489 1:16,500 Nurse to Population ratios by regions 1:2034 1:2079 1:2598 1:2800 Access to and Utilisation of Health Services No. CHPS compounds established 19 39 55 85 % GoG budget spent on health 9.1 7.6 9.8 9 Available data indicate that there were about 292 hospitals, 1,348 clinics and about 622 % GOG recurrent budget spent on health 10.2% 10.5 12.1% 14% total health facilities in Ghana by 2003 (see table 2.13). However, it must be pointed out that the distribution of these facilities depicts wide geographical disparities. The southern 17 Health facility accessibility ratios refer to the proportion of the population who live within a 30 minute distance from a and urban parts of the country have relatively more and better-equipped health facili- nearest health facility.

48 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 49 Scaling-up health inve Proportion of non-wage recurrent budget spent Table 2.15 Sources of Drinking Water at district level 48.6 40.9 39.5 43 Source Urban (%) Rural (%) Ghana (%) % Donor funds Earmarked 62.3 na 45 40 Pipe borne 80 19 41

% IGF from pre-payment and community nitiative I insurance schemes 3 na 5 5 Well 11 47 34 % Recurrent budget from GOG and health fund Natural source 9 34 25 allocated to private sector, CSOs, NGOs and Total 100 100 100 other MDAs 1.2% na na 1.8%

% Recurrent budget spent on exemptions 3.6 3.2 na 5 Source: GSS Ghana Statistical Service (2000) Ghana Living Standard Survey. Report of the Fourth Round (GLSS4), Ghana Statistical ealth

Service, Accra. H Source: MoH, The Ghana Health Sector, Programme of Work 2005 Theme: Bridging the Inequality Gap: Addressing Emerging Challenges with Child Survival, January 2005. The poor water and sanitation situation has brought about high incidences of water and sanitation related diseases in Ghana. In 2002, for instance, it was estimated that 44% There is ample evidence that Ghana has recorded some substantial improvements in of all outpatient visits to health facilities in Ghana were the result of malaria. Malaria health outcomes, particularly, since the nineties. This can be underscored partly with and infections are, however, transmitted by mosquitoes, whose spread is caused by poor s evidence provided in table 2.14. Supervised deliveries, for instance, have increased in sanitation and drainage. On the other hand it is estimated that twelve percent of all visits recent times from 50% of annual total deliveries in 2001 to about 60% in 2004. Similarly to health facilities are due to health problems (e.g. diarrhoeal diseases, skin diseases, and the cure rates of tuberculosis have improved from 44.9% of annual total TB cases to 58%. acute eye infections, cholera and dysentery, typhoid and infectious hepatitis, trachoma There has also been an observed decline in malnutrition of children under five years as and scabies) that are consequences of poor and/or absent good drinking water. Besides well as polio cases. However, recent reports suggest of a reversal of some of the gains in these health consequences, there are other indirect economic costs connected with the infant and child mortality rates as well as guinea worm incidence recorded in the nineties. lack of potable water and poor sanitation. These economic costs come about from the The causes for the deterioration in some indicators, as observed by the GDHS in 2004 loss of significant energy and time wasted by individuals and households, particularly are not yet known. It can, however, be conjectured that part of the reasons may lie in women and children, in fetching water from distant streams. Other economic costs result the observed decline the utilization of health facilities due to the substantial increases from the treatment expenditures and loss of productivity in man hours from water and in health user fees alongside the policy of full cost recovery of prescribed drugs – ‘the acroeconomic sanitation related diseases. These wasted resources could be invested in more produc-

Cash and Carry System’ (GLSS4 2000). Arhin-Tinkorang (2000), for instance, attributes M tive activities such as childcare, farming and attending school. An accelerated provision poverty as well as long distances to health facilities as some of the major causes for of water and sanitation to increase access to these facilities will therefore improve the the observed low utilisation of health facilities, even in those areas with high average health of Ghanaians, increase productivity and reduce poverty. WaterAid and Tearfund18, incomes. On the other hand patronage of, particularly, public health services has been two international organisations working in the area of water and poverty, for instance, found to be low as a result of the low public confidence in the health system, which hana believe that global attempts to reduce poverty will fail if the issue of poor sanitation is emanates from perceived poor quality of the health services. G not urgently addressed. Water and Sanitation Situation in Ghana It is therefore no wonder that access to potable water and improved sanitation systems has been chosen as one of the vital goals of MDG, NEPAD, the GPRS, WHO and UNGASS. The health status of a nation cannot be measured with a single indicator of health Whilst NEPAD makes it obligatory for member countries to initiate actions to ensure outcome. It reflects the comparative levels of child, infant and maternal mortality, life sustainable access to safe and adequate clean water supply and sanitation, especially, for expectancy at birth, and other health outcomes. Almost all the known development the poor, MDG recommends the proportion of the population without access to potable goals including the NEPAD, MDG, GPRS, share the common zeal to reduce the levels water to be halved by 2015.

for better health, economic growth and accelerated poverty reduction of these health outcomes by a certain period of time. However, there are health related s interventions, which can be identified as critical inputs to the attainment of these health

Rural Water and Sanitation eport of the related development goals. R In Ghana the provision of water lies largely in the hands of two institutions: the Water One such important input is improvement in access to potable water and sanitation. Company and the Community Water and Sanitation Agency (CWSA). Whilst the Water s tment In Ghana it is estimated that 70% of all diseases are caused by lack of clean water and Company Limited is responsible for the provision of water in urban centres, the CWSA sanitation conditions. This is due to the fact that the majority of Ghanaians do not have takes care of the provision of potable water in the rural areas. Since its establishment in access to piped borne water. Table 2.15 shows that only 41% of Ghanaians have access 1994, the CWSA has facilitated the provision of a number of water supply facilities and to water from the pipe. Most of the people in the rural and urban areas are susceptible to diseases because of the lack of potable water and sanitation facilities. Over 34% of 18 WaterAid and Tearfund, 2002, “The Human Waste: A call for urgent action to combat the millions of deaths caused the rural people, for instance, depend on untreated water from rivers, streams and other by poor sanitation”. WaterAid is the UK’s only major charity dedicated exclusively to the provision of safe domestic natural sources for their drinking water (table 2.15). water, sanitation, and hygiene promotion to the world’s poorest people. Tearfund is one of the UK’s leading relief and development agencies, working in partnership with Christian agencies and churches around the world to tackle the causes and effects of poverty.

50 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 51 Scaling-up health inve related sanitation services in rural areas with GoG/donor financing. The CWSA links up tremendous improvements in the water and sanitation situation, particularly, in rural with the communities through the district assemblies, which assumes the responsibility Ghana. The achievement of the annual performance targets had, however, been varied for water supply in rural and small towns. The District Assembly in ensuring that water and mixed, with the attainment level in 2001, for instance, exceeding all other years. As facilities are managed in a sustainable manner entrusts this responsibility to the District table 2.16 illustrates, 2002 has been the worst performing year with sanitation and point nitiative Water and Sanitation Teams (DWST). The DWST supports, supervises and monitors sources failing to meet targets. With regard to specific systems, the rehabilitation of point I the service delivery agencies and provides day-to-day contract management assistance sources achieved a higher performance threshold, consistently exceeding set targets. to the District Assembly. It also collaborates with community-based institutions (Unit With respect to new water systems, pipe systems performed better than point sources. committees and WATSANs) in ensuring sustainability. It is, however, worthy to note that these mixed results with regard to performance of

the government’s intervention in the water sector, have contributed in decreasing the ealth Against this background the government launched in 1994 a National Community Water percentage of all rural dwellers without water supply from about 70% in 1994 to 59% as H and Sanitation Programme (NCWSP), with the assigned objective to seek sustainability at the end of 2000. This slow pace of improvement makes Ghana continue to rank poor in water supply through the adoption of community ownership and management prin- even by Sub-Sahara African standards (table 2.17) in terms of access to good drinking ciple. The NCWSP is anchored at the community level and supported by the District water of its citizens. For instance, whilst about 55% of the total population have access Assembly, which are supposed to create the enabling environment for communities to and

to improved water source in Sub-Saharan Africa, only about 40% of Ghana’s population s own and manage their water supply and sanitation facilities. The three key objectives of enjoy such a facility. Moreover, a look at the annual rate of progress in providing potable the NCWSP are: water to Ghana’s unserved population during the nineties (1.83%), as compared to 4.5% 1. Provision of basic water and sanitation services to communities that contribute towards of South Asia (table 2.17), indicates that the country would have to more than double its the capital cost and generate resources for the normal operations, maintenance and efforts in terms of investments in the water sector, if it were to achieved the water MDG repair of facilities; by 2015.

2. Ensuring sustainability of facilities through community ownership and management. In the case of improved sanitation systems, the country can be said to have achieved some The facilities are safeguarded through public sector promotion and support, com- improvements, even if it still continues to remain one of the poorest in the world (Table munity participation in their design, the active involvement of women at all stages in 2.18). Available records show that overall sanitation coverage in Ghana increased from the programme, the involvement of the private sector in the provision of goods and

about 10% to 12.6% between 1994 and 2000, thus reducing the proportion of Ghanaians acroeconomic services; and without access to sanitation from 90% to 87.4% during the same period. Compared with M 3. Maximising health benefits by integrating water, sanitation and hygiene education sanitation conditions of other developing countries, Ghana does not only seem to have interventions, including the establishment of hygiene education and latrine construc- the worst, but appears to have achieved one of the lowest average annual rate of decline tion capabilities at the village level. in the proportion of people without access to improved sanitation systems in the nineties,

about 0.43% as opposed to 2.4% for Latin America and the Caribbean. hana The targets for the NCWSP are defined in terms of population coverage: From CWSA 1992 records, only 61% and 11% Ghana’s urban and rural populations have G 1. Reducing by 50% the population without access to safe water by 2015; access to safe excreta disposal respectively. Also from Ghana Demographic and Health 2. Ensure that each person in the community served has access to no less than 20 litres Survey (GDHS), 1999 data, only 8% of Ghanaian households in 1999 have access to of water per day; flush toilets, whether shared or privately owned. However, there have been significant increases in household access to other methods of safe excreta disposal from 59% of 3. Ensure that the walking distance to a water facility does not exceed 500 metres from households in 1987 (GSS 1990) to approximately 73% in 1997 (GDHS, 1999). the furthest house in the community;

4. That each sprout of a borehole or pipe system must serve no more than 300 persons

for better health, economic growth and accelerated poverty reduction and 150 persons for a hand dug well; s

5. Delivered water facility must provide all year round potential water to community eport of the

members; R

s tment 6. For household latrines an average of 8 persons using one latrine;

7. For institutional latrines an average of 50 persons per squat hole.

In order to provide the basis for targeted interventions to achieve the objectives of the NCWSP the agency developed in 1994 a strategic investment plan (SIP), which followed up with reviews in 1998 and 2004. On the other hand the plan is meant to determine the mix of financial and other resources to be applied to deliver safe water and sanitation ser- vices to a defined target population. In the retrospect NCWSP can be said to have made

52 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 53 Scaling-up health inve Table 2.16 Selected Indicators of Water and Sanitation in Ghana, 2000-2003 Table 2.17 Access to Improved Water Source Without Without Average Average annual rate of access to access to annual rate change necessary to improved improved of change achieve goal (%) nitiative water source water source 1990-2000 I (2000-2015) 2000-2003 2000 2001 2002 2003 1990 2000 (%) All Developing 27 21 -2.5 -2.9 Countries

East Asia and ealth 30 25 -1.8 -3.4

Pacific H Latin America and 19 15 -2.4 -3 arget arget arget arget otal haracteristics Caribbean C T Actual Achievement T Actual Achievement T Actual Achievement T Actual Achievement T Middle East and Water 16 11 -3.7 -2.1 and North Africa s Boreholes 660 462 70 550 198 36 1500 685 41 1600 859 54 2204 South Asia 20 13 -4.3 -1.7 new Sub-Saharan Hand Dug 51 45 -1.3 -3.8 350 126 36 50 629 1258 240 62 27 220 185 84 1002 Africa Wells new Ghana 70 59 -1.83 Total new 1010 588 106 600 827 138 1740 747 68 1820 1044 57 3146 Water Points Source: WHO websites; CWSA Small Table 2.18 Access to Improved Sanitation Communities 40 22 55 40 92 920 20 4 25 15 2 13 120 new Average annual

rate of change acroeconomic Small Towns Without access Without access Average annual necessary to 30 39 130 10 63 630 20 30 125 48 14 29 146 M new to improved to improved rate of change achieve MDG Total new sanitation 1990 sanitation 2000 1990-2000 (%) (2000-2015) (%) 70 61 185 50 155 310 40 34 150 63 16 25 261 pipe systems All Developing 58 48 1.5 3.6 Countries

Hand Dug hana 6 >100 0 2 0 0 8 Wells rehab.

East Asia and G 62 53 1.6 3.6 Boreholes Pacific 619 619 500 606 121 140 360 190 100 97 97 1682 rehab. Latin America 28 22 2.4 3 Conversions 734 100 20 932 4660 5 0 1166 and Caribbean Middle East and Total Rehab. 619 1653 219 520 1544 297 145 409 282 100 97 97 3403 22 17 2.6 2.9 North Africa Sanitation South Asia 69 64 0.8 4.1 Household 1300 2821 217 3400 10295 303 8000 4300 53 10000 5371 54 22787 Sub-Saharan

for better health, economic growth and accelerated poverty reduction Latrines 45 45 0 4.6 s Africa Institutional eport of the Latrines 100 109 109 150 679 453 260 165 55 350 384 110 1337 Ghana 90 87.4 0.43 R (KVIP) Source: WHO, CWSA

s tment Total Latrines 1400 2930 209 3550 10974 309 8260 4419 53 10350 5755 56 24074 The case of solid waste management services has been a major problem for Ghana; with the urban centres producing currently over 1 million tones a year. Out of this, only third is collected and the remaining left to pollute the environment. In the , which is even supposed to have the best waste disposal system as at 2003, less than 20% of the residents have access to the approved solid waste disposal facility; 29% are without any facility and more than 50% use unapproved facilities/systems. Central region is the worst in terms of access to the stipulated facility. Less than 1% have access to

54 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 55 Scaling-up health inve the stipulated facilities, whilst 30% are without any facility and over 69% use unapproved Table 2.19 Health Sector Revenue (1997-2000) (in billion cedis, %) methods. 84% of households are without any facility in the Upper West Region. 1999 2000 2001 2002 2003

The toilet situation is just a bit better as at 2003. Only about 40% of urban and 15% of Amount % Amount % Amount % Amount % Amount %

rural dwellers have an acceptable domestic toilet, while 15% of urban dwellers still use nitiative Government 238.20 55.59 366.58 49.14 444.57 48.35 662.26 48.51 986.00 46.60 I pan latrines. Greater Accra ranks best in access to standardized toilet facilities yet the Financial coverage is only 32.2%. 48% are without toilet facilities and 20.2% use substandard 27.80 6.49 31.70 4.25 13.42 1.46 142.95 10.47 166.08 7.85 Credits toilets. The worst situation is in Upper West Region where over 93% of households are without toilet facilities. IGF 50.70 11.83 81.70 10.95 135.85 14.77 196.90 14.42 264.70 12.51 ealth Donors 104.90 24.48 230.40 30.89 325.64 35.42 363.07 26.60 570.30 26.95 The extent to which interventions in the water and sanitation sector can impact on the H health sector can be demonstrated on the reduction in guinea worm infestation cases. HIPC Funds 0.00 0.00 n/a 0.00 n/a 0.00 68.80 3.25 As at the end of March 1989, a total of 179,556 cases were reported. Partly as a result Others/DACF 6.90 1.61 35.60 4.77 n/a 0.00 n/a 0.00 60.00 2.84 of improvements in water and sanitation conditions in Ghana during the nineties the number of reported cases reduced to about 4,733 in 200119. This number is still very high Total 428.5 100 745.98 100 919.48 100 1 365.2 100 2115.87 100 and s

and it is believed that greater improvements in health can be achieved with scaling up of Source: MoH financial statement and 2003 annual review (main) report. investment in the water and sanitation sector. As shown in table 2.19, the GOG and IGF finance about 59% (2003) of the total health expenditures. This proportion however increases to about 78% of total recurrent expendi- Financing Health Care ture if capital expenditures, which normally accounts for 35% of total health expenditure, are excluded. The rest of about 27% comprises donor-pooled funds to finance mostly MOH Patterns of Health Care Finance and Expenditure programmes. Over the period, it appears that government budgetary allocations to the health sector has enjoyed tremendous increases in nominal terms, increasing by 115,621 Traditionally Ghana has largely relied on public resources, financial credits, internally times from ¢18.3 million in 1963 to ¢2,115.87 billion in 2003 in nominal terms. However, generated funds, foreign and donor funding and others particularly, from the District

these allocations appear to have stagnated relative to total government expenditure as acroeconomic Assemblies to finance public spending on health. Over the last two years other sources well as in real terms over the years (see also Lavy et. al 1995). As figure 2.10 shows after of funding, e.g. HIPC, have also emerged. Available data indicate that the Ministry of M rising successively in the sixties to reach a peak level of 9.13% of total government health Health recorded a total of about ¢2,115.87 billion cedis in 2003 in gross revenue for the expenditure in 1974, the government health expenditure ratio experienced downward financing of health care spending in Ghana. This represents an increase of about 55% trend to hit a low level of 4.26% in 1983 before increasing to level off at 9.80% in 2003. from ¢1,365.2 billion cedis in 2002. Out of the total available finance for the health sec-

A close look at the trends in the last two decades shows differing tendencies with respect hana tor in 2003, government budgetary allocations accounted for about 47% (see table 2.19),

to government allocations to the health sector. With the introduction of the Structural G which represents the greatest share of total amount that go to finance health care spend- Adjustment Programme in 1983, government health expenditure rose continuously to ing in Ghana. The second largest source of health care finance comes from contributions peak of at 9.74% of total government expenditure in the early 90s. It took a nose dive from donors and NGOs, which accounted for about 26.95% of total revenue for health and declined to about 4.46% in 1997. Since the start of the POW in 1997 the ratio of care spending in 2003. User fees and other internally generated funds from the sale of government health expenditure to total government expenditure has shown a continuous drugs and other charges produced about 13% of total health care finance in 2002, whilst upward trend increasing more than two fold in relative terms. These recent increases, financial credits from external sources to make up for deficits in the health budget. however, have only made good the substantial declines of the previous decades. for better health, economic growth and accelerated poverty reduction s eport of the R s tment

19 It must be pointed out that the number of reported guinea worm cases is once again on the increase, partly due to breakdown of some of the water boreholes in some of the guinea worm endemic areas.

56 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 57 Scaling-up health inve Figure 2.10 Comparison of Selected Health Indicators of over time, 1963-2003 In 2003, for instance, personnel emoluments rose by nearly 50%. This caused the rela- tive share of MOH capital expenditure to GOG capital expenditure to fall from a peak 11 150 level of 4.8% in 1997 to 0.6% in 2001. However, the year 2003 witnessed a more than 10 135 doubling of investment spending (mainly due to HIPC transfers to the health sector); but 9 120 nitiative I 8 % Total Exp. the service and administration budget, which registered a sharp decline in 2002, is yet 105 7 to recover to 2001 levels. 90 6 75 The increasing trend in the wage expenditure of the health sector is indeed a constant 5 60 dilemma. On the one hand the wages of health personnel are too low to ensure to stem 4 ealth 45 the high attrition of health staff which has afflicted the health sector in recent times or 3 H HEXP-INDEX ensure supply to meet the high demand for staff. On the other hand the wage bill is rela- 2 30 tively too high, compared to non-salary items, to allow for increases in spending for other 1 % of GDP 15 important non-wage expenditure or health infrastructure. It appears that redistribution

0 19 1 1 1 1 1 19 1 1 1 19 1 1 1 1 1 1 1 1 19 19 1 1 1 1 1 19 1 1 19 19 1 1 1 1 1 19 1 1 2000 200 2002 2003 0 962 963 964 965 966 968 969 970 972 973 974 975 976 977 978 979 982 983 984 985 986 988 989 992 993 994 995 996 998 999 71 61 67 80 81 87 90 91 97 of staff and downscaling of facilities with low utilisation could provide the leeway to and 1 increase individual wage payments without necessarily increasing the wage budget. s HEXP-Index = Health Index = Government Budgetary Health Allocations or Health Expenditure, 1993 = 100 % Total Expenditure = Ratio of Government Budgetary Health Allocations or Health Expenditure to Total Government Expenditure Table 2.20 Health care expenditures and Financing through MOH 1996-2003 ITEMS 1996 1997 1998 1999 2000 2001 2002 2003 Indeed over time it can be said that the government allocations to the health sector in Recurrent Expenditure 146.8 182.5 258.5 334.2 532.4 762.9 596.0 758.8 real terms have fallen since independence. This can be documented using a time series Capital Expenditure 149.0 142.9 101.5 63.5 111.5 80.9 59.7 73.1 deflation to measure the real value of fiscal resource allocations to the health sector, with 1993 as the base. As can be seen in figure 2.10, the real value of budgetary allocations Total 295.8 325.4 360.0 397.7 643.9 843.8 655.7 831.9 has over the period declined from an index of over 141 in 1975 to 119.80 in 2004. This Total in 1997 real prices 357.3 325.4 308.6 294.1 347.8 382.2 422.4 460.1 compounds the problem of financing the health sector. Not only is the funding of health

Percent acroeconomic sector inadequate, the available inadequate resources have indeed declined in real terms over time. This decline is also underscored by the fall in per capita government allocation Recurrent Expenditure 49.63 56.08 71.81 84.03 82.68 90.41 85.6 81.3 M to the health sector in the last two decades from $10.16 in 1978 to below $8 in 2003. In Capital Expenditure 50.37 43.92 28.19 15.97 17.32 9.59 14.4 18.7 the light of this situation it is no wonder that the claim on the total output of the nation Total 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 by the health sector lingers below two percent (see figure 2.10). INDICATORS hana

Further evidence of under funding of the health sector in Ghana is produced by Musgrove G % MOH recurrent/GOG and others (2002), through a comparison of per capita levels of total health expenditure, 7.0 8.4 8.7 9.5 11.4 11.0 10.5 12.0 recurrent (narrow) out-of-pocket spending, and total public spending to per capita income in purchasing % MOH capital/GOG power parity. In dollar purchasing power parity, they showed that Ghana spends only $63 4.6 4.8 3.2 2.1 1.9 0.6 0.8 0.8 capital per person, as compared to $411 by Namibia, $220 by Botswana and $277 by Mauritius. In their opinion such a low amount can hardly assure the availability of even a few highly % MOH total/GOG total 4.9 5.2 6.2 5.9 7.5 6.9 7.6 9.5 justified services (based on cost-effectiveness, protection from catastrophic expense, or % Recurrent/MOH total 49.6 56.0 71.7 84.0 83.0 96.5 90.9 91.21 other criteria) to the whole population. Hence the need to scale-up spending if the health % IGF / MOH Total 9.2 8.5 9.2 11.4 11.2 12.5 14.4 15.7

for better health, economic growth and accelerated poverty reduction care and poverty is to be improved by any appreciable level. s % Health Expenditure / 1.1 0.92 1.11 1.7 1.35 1.17 1.39 1.37 GDP eport of the R Health Care Spending by Line Items MOH total per capita (US$) 4.62 4.18 4.93 4.82 4.29 4.1 4.4 4.8 With regard to the utilisation of available resources for the health sector, about 49.6% s tment MOH total per capita (US$) 10.16 8.14 7.81 6.83 6.44 6.4 6.9 7.8 of the resources available to the health sector in 1996 was used to finance recurrent (incl. Foreign financing) expenditure, whilst 50.4% went to finance capital expenditure. This trend has reversed Source: Ministry of Health, Accra over time to 81.3% and 18.7% for recurrent and capital respectively in 2003 (table 2.20). It must however be pointed out that the substantial upsurge in recurrent expenditure since early 2000 is a result of large increases in personal emoluments, and this has resulted in a substantial decline in health capital expenditure.

58 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 59 Scaling-up health inve The Medium Term Rolling Health Expenditure Programme guiding the implementation of the 5-year POW, the Ministry of Health developed annual programme of work which spelt out in more detail the key priorities and activities to be Since 2000 the Ministry of Health has been preparing a three-year rolling expenditure implemented in any particular year. programme within the Medium Term Expenditure Framework (MTEF). Table 2.21 pre­ nitiative

sents the three-year rolling budgetary expenditure programme for the period between I 2003 and 2005 of the ministry. As the table illustrates, these budgetary allocations, whose projections were made against the background of the GPRS, are expected to The Strategic Objectives of the Five Year increase by about 37.34% between 2003 and 2005. This increased budgetary alloca- Programme of Work 2002 – 2006 tion during this period translates into an increase of per capita budgetary allocation » To increased geographical and financial access to basic services or to quality health services ealth

from $6.49 in 2003 to $8.05 in 2005. Comparatively this increase in per capita health H with emphasis on the four deprived regions; budgetary allocation and thus per capita expenditure would neither enable the country to achieve the expected improvement in health of Ghanaians that can have any strong » To provide better quality of care in all health facilities and during outreaches; impact on economic growth and hence poverty reduction. Nor can the increase bring » Improved efficiency in the health sector, cost effectiveness and planning; the country anywhere near to achieving the international set health targets of WHO, of and » To foster closer collaboration and partnership between the health sector and communities, other s the Millennium Declaration, NEPAD, IMF, etc. sectors and private providers both allopathic and traditional; Table 2.21 The Three-Year Rolling Budget of the Ministry of Health for 2003–2005 » Increased overall resources in the health sector, equitably and efficiently distributed; Year 2003 2004 2005 » To ensure sustainable financing arrangements that protects the deprived and vulnerable. GOG 893 413.00 1 095 967.80 1 257 223.40 Source: Ministry of Health Donor 261 205.00 286 253.40 328 741.80

NHF 210.00 239.00 65.00 During the period of the first POW I geographical access to static health services Total (million cedis) 1 154 828.00 1 382 460.20 1 586 030.20 continued to improve. Physical accessibility to health facilities witnessed tremendous

improvement A consequent resource shift to the district and sub-district levels and a acroeconomic Per Capita Budgetary Allocation 6.49 7.30 8.05 wider implementation of the exemption scheme contributed to a 25% increase (average) M Projected Exchange rate 8 900.00 9 250.00 9 450.00 utilisation of publicly financed services, with the highest increase in utilisation (95%) Projected Population (million) 20.00 20.46 20.93 being observed in the Northern (and poorer) belt of the country. Similarly the coverage of key essential public health services experienced significant improvements. Immunisation RoG, (2003) The Budget Statement and Economic Policy for the 2003 Financial Year presented to Parliament on Thursday, 27th

February 2003 Accra. against measles increased from 57% in 1997 to 85.4% in 2001, while DPT3 rose from hana

51% in 1996 to about 80% in 2001. The TT2 immunization rate went up from 37% in G A look at the indicated resource allocation to the district level and below in the past, can 1996 to 73% in 2001. Antenatal coverage increased from 84% in 1996 to 98% in 2001. be regarded as low. In 1997, for instance, the levels of care in the district and sub-district Supervised deliveries went up from 38% in 1996 to 52% in 2000 and postnatal coverage levels, where the majority of the poor resided, received only 26% of non-wage recurrent (1 visit) increased from 33% in 1996 to 50% in 2001. expenditures. This and other investment expenditures must be substantially scaled-up if the MDGs were to be achieved. It is against this background that the POW I & II pro- Drawing on the lessons and the experiences learnt from the first 5-year POW as well as posed resource shifts between the institutional levels, particularly, for non-wage spending building on its achievements a second new 5-year Programme of Work (2002-2006) was in favour of the district and sub-district levels. The POW II, for instance, proposed to raise launched in 2002. The strategic objectives (see Box 1) of this second Five-Year Programme the district’s and sub-district’s relative share of non-wage recurrent budget from 26% in of Work provided the basis for priority action in health with special emphasis on bridging the for better health, economic growth and accelerated poverty reduction s 1997 to about 43.4% in 2006. However, given the declining trend of capital expenditure, inequality gap with regard to access to quality health sectors, ensuring sustainable financing

it cannot be expected that a commensurate large proportion of it would be allocated to arrangements that protect the poor and enhancing efficiency in service delivery. eport of the the district levels and below to engineer the expected improvement in health conditions After designating a number of diseases as priority to be targeted for eradication, the R and reduction in poverty. For this reason it important to scale-up investment in the health programme defined sector wide targets for measuring progress towards the vision of the s tment sector beyond the levels planned under the existing budgetary programmes. health sector. The sector wide indicators in Programme of Work 2002-2006 (POW II) were complemented with the health targets in GPRS. The health sector targets identified Ministry of Health – Programme of Work (POW) in both POW II and GPRS include targets regarding output and outcome of the health sector (health status and health sector service) and regarding input – financial allocation In 1997, against the background of growing financial distress of the health sector, the to the health sector (see table 2.22). Even though the POW II raised the health targets to government initiated a 5-year programme of work for the Ministry of Health, which levels higher than otherwise planned, these targets nonetheless fall short of the levels set spanned the period between 1997 and 2001, with the main objective “to increase overall resources in the health sector.” In line with the Common Management Arrangements

60 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 61 Scaling-up health inve by the MDGs. Thus only the scaling-up of investment in the health sector would facilitate Financing Plan under POW II the achievement of the MDGs. The Five-Year Programme of Work was also accompanied by a comprehensive financ- Table 2.22 Sector wide indicators in POW II ing plan, based on expected receipts from GoG, External and IGF sources, developed to

Baseline Target Target nitiative support the achievement of the set health objectives. The projections operated with two I 2001 2003 2006 scenarios – a low case scenario and a high case scenario as presented in tables 2.23 and Health Status 2.24. The low and high case scenarios reflect two different views about the financing plans Infant Mortality Rate per 1000 live births 57 64 50 Under five mortality Rate per 1000 live births 108 100 95 of the Ministry of Health. In the low case the Ministry of Health takes a less optimistic view of the resource flows from potential donors, whereas in the case of the high case scenarios Maternal Mortality Ratio per 100 000 live births 214 200 150 ealth

Under five who are malnourished (underweight) 25 23 20 the ministry maintains a more optimistic expectation of the inward flows from outside. H HIV sero prevalence among reproductive age 15-19 and 20-24 (%) 3 3.6 2.6 Table 2.23 Projected Expenditure of Health Sector 5-Year Programme of Work % Supervised deliveries (skilled attendants) 50.4 55 60 (2002-2006) – Low Case Scenario – ($ million) Tuberculosis Cure Rates (%) 44.9 53.8 85 Source/ Low Case Scenario % Family Planning acceptors 24.9 25 40 and

Year s % ANC coverage 98.4 98.5 99 2002 2003 2004 2005 2006 Total % PNC coverage 54.2 55.8 60 GoG 82.3 111.4 127.5 146.7 169.8 637.7 %EPI coverage (DPT3) 76.3 80 85 External Aid 60 60 60 60 60 300 %EPI coverage (measles) 82.4 85 90 IGF 15 15 15 15 15 75 Access Total 157.3 186.4 202.5 221.7 244.8 1012.7 Number of specialized outreach services carried out 141 180 240 Projected Budget/ per Capita* 7.88 9.09 9.61 10.24 11.00 — Doctor to Population ratios 1:22 811 1:20 500 1:16 500 * Assuming a population of 18.4 in 2000 (Statistical Service 2000) and a population growth rate of 2.75% p.a. Nurse to Population ratios 1:2 034 1:2 598 1:1 500 Source: MOH (1999) Health Sector 5-Year Programme of Work -2002-2006 Outpatient Visit per capita 0.49 0.55 0.6 Hospital admission rates 34.9 35.9 40 Under the low case scenario public health care expenditure was projected to rise from Number of Community Resident Nurse (functional CHPS zones) 19 400 2 000 $7.88 per capita in 2002 to $11.0 in 2006 with the largest proportion coming from Govern- acroeconomic Quality ment of Ghana. Under the high case scenario, public per capita expenditure is expected to % Maternal audits to maternal deaths 10 20 50 rise from $8.88 per capita in 2002 to about $11.90 per capita in 2006. In both cases health M Under five malaria case fatality rate (%) 1.7 1.5 1 related expenditures, which go to other sectors such as water and sanitation, etc., are % Tracer drug availability 70 85 95 not included. The resource envelope, however, take into account the additional funding, Efficiency equivalent to about 13-15% of the initial projected total resource, made available to the

AFP non polio rate (%) 2.80 1.30 >1 hana health sector from the HIPC initiative.

Number of Guinea worm cases 4733 <1 000 0 G Bed occupancy rates (%) 64.6 64.1 80 Table 2.24 Projected Expenditure of Health Sector 5 Year Programme of Work Partnership (2002-2006) – High Case Scenario – (in $ million) % Recurrent budget from GOG and health fund used by private 1.2 1.6 2 Source/ High Case Scenario sector, CSOs, NGOs and other MDAs Year 2002 2003 2004 2005 2006 Total Financial GoG 82.3 111.4 127.5 146.7 169.8 637.7 % GoG budget spent on health 9.1 9.8 10 External Aid 80.0 80.0 80.0 80.0 80.0 400.0 %GOG recurrent budget spent on health 10.2 12.1 15 IGF 15.0 15.0 15.0 15.0 15.0 75.0 % Donor funds Earmarked 62.3 50 40 Total 177.3 206.4 222.5 241.7 264.8 1112.7 for better health, economic growth and accelerated poverty reduction %IGF from pre-payment and community insurance schemes 3 5 20 s Projected 8.88 10.06 10.56 11.16 11.90 - Non-wage recurrent expenditure at district level to total Budget/ Capita* 48.6 43 43 eport of the recurrent expenditure * Assuming a population of 18.4 in 2000 (Statistical Service 2000) and a population growth rate of 2.75% p.a. %Spent on exemptions to non wage Recurrent expenditure 3.6 5 8 R Source: Health Sector 5 Year Programme of Work II -2002-2006, revised August 2002 s tment Even though the POW II ventured into new land by raising the targets of health outcomes and resource envelope for the financing of health programmes to new higher levels, these levels nevertheless fall short of that sufficient for the achievement of the MDGs. For instance, it raises the public per capita health expenditure above the levels feasible under the government budgetary allocations from about US$8 in 2006 to between US$11-12 in 2006. These levels, however, come nowhere near the US18-21 considered necessary for the achievement of the midterm MDGs in 2007 by the CMH. This points to the need for

62 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 63 Scaling-up health inve a special programme to mobilise extra resource for scaling-up investment in the health Ratio of population per nurse in Northern: Greater Accra 4:1 3:1 sector, since the existing sources of finance are not able to provide sufficient revenue to finance health services at an appropriate level, that can appreciably reduce poverty. Ratio of population per doctor in Northern: Greater Accra 5:1 4:1 Per Capita Expenditure in US$ 6 10 nitiative I Health Expenditure under the GPRS Source: GPRS, 2003

Government’s development agenda as spelt out in the GPRS gives priority to improving The strategy therefore commits the government to increase the overall resources avail- the health status of the poor as crucial for poverty reduction. The strategy therefore out- able for health. The increased additional finance is likely to increase the ratio of health

lines interventions that put strong emphasis on promoting equity of health outcomes with expenditure to GDP from its current low level of below 2% to about 4%, which still falls far ealth

special focus on reducing geographical disparities and addressing diseases that affect below the World Bank recommended level of 12% of GDP. It envisages increasing health H the poor most, enhancing efficiency in service delivery, ensuring sustainable financial expenditure as percentage of the total government expenditure from about 5.7% in 2003 to arrangements that protect the poor and strengthening links with health-related sectors about 7% in 2005. This increase is to be achieved through increases in normal budgetary of the society. Jointly, interventions in health care and safe water and environmental allocation and additional resource transfer, particularly, from HIPC funds to the health sanitation discussed in other sections are expected to result in the achievement of the and sector as part of Medium Term Priority Programmes and Projects under the GPRS. This s following targets (see table 2.25): increase is likely to guarantee a per-capita government health expenditure equivalent to Table 2.25 Selected Indicators on Health Care Targets under the GPRS about $10 by 2005 (see table 2.25). This, however, appears too low to bring Ghana anywhere near the recommended levels of about $18-21 per capita public expenditure necessary to Item 2000 2005 cover the costs of a basic minimum package of public and curative services. Infant mortality rate 57/1000 50/1000 Under five mortality Rate per 1000 live births: Under funding of the Health Sector Total for the Country 110/1000 95/1000 It remains a basic fact, from the foregoing sections, that the health sector in Ghana is Northern 171/1000 130/1000 woefully under funded. This view is also supported by the World Bank, which sees the

Upper East 155/1000 116/1000 problem of under finding of the health sector as a major constraint to improve the health acroeconomic

status of the Ghanaian population (World Bank 2003). Because in spite of the recent GOG M Upper West 156/1000 117/1000 efforts to increase allocations to the health sector, total spending on health remains very Central 142/1000 107/1000 low by all comparable standards. The percentage of the GDP allocated to public health % children under five malnourished (underweight) 25% 20% care expenditures, for instance, decreased from its peak levels of over 2% in the mid

seventies to reach a low level of barely 0.4% in the early eighties, before rising to about hana Maternal mortality rate 200/100000 160/100000 1.40% in 1989. It declined successively to about 0.92% in 1997 before taking an upward G Reported cases of guinea worm 3678 0 trend in the wake of the introduction of the POW. A long term view of the funding trends % Total government expenditure allocated to health 5.7% 7% reveals that government health expenditures as a share of total government expenditures decreased from its peak of 9.13% in 1974 to level of around 4.46% in 1997 with a slight % Recurrent spending on districts and below 42% 44% upward trend that continued ending at 9.80% in 2003. Under the Abuja Declaration, to % Capital spending on sub-districts 7% 15% which the country is signatory, the government is expected to reach 15% by 200620. % of districts with model health centres 100 Despite these recent improvements government health spending continues to remain % of recurrent spending on three northern and Central Regions 32% 39% relatively low, estimated at below US$8 per capita. As can be seen in table 2.20 present for better health, economic growth and accelerated poverty reduction s Proportion of people consulting qualified health personnel when public health spending per capita has fallen below the levels available in the mid 1990s. 30% 50% ill This has, on the one hand, resulted in a huge out-of-pocket private spending accounting eport of the R At least 10% increase in amount budgeted for exemptions from for about US$14 or 70% of the estimated total (public and private) per capita health ¢12bn ¢13.2bn fees spending. From theoretical and empirical evidence such out-of-pocket expenditures are s tment known to be one of the least efficient and most inequitable means of financing health Per capita OPD attendance at public facilities 0.49 0.55 Uptake of antenatal care 96% 98% Post-natal care coverage 52% 58% 20 On April 27, 2001 African leaders meeting in Abuja, Nigeria, declared the battle against HIV/AIDS, tuberculosis DPT 3 coverage 75% 90% and other infectious diseases as their top priority for the first quarter of the 21st century. As they adopted the Abuja Declaration, the signatory countries pledged take all necessary measures to ensure that the needed resources Proportion of supervised deliveries 49% 55% are made available from all sources and that they are efficiently and effectively utilized. The governments further pledged to devote 15 percent of their budgets to improving the health sectors (http://www.uneca.org/adf2000/ Abuja%20Declaration.htm (10.10.2004)).

64 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 65 Scaling-up health inve care21. In Ghana the huge out-of-pocket private health spending has had a substantial GOG Domestic Resource Mobilisation negative effect on the poor, making them use public health services less often22. This has Domestic revenue mobilization already constitutes a major thrust of government’s eco- brought about a situation where the richest households in Ghana are estimated to benefit nomic development strategy and this is amply demonstrated by the wide ranging revenue three times more from government expenditures on health than the poorest (Canagarajah nitiative

mobilization initiatives in the 2003 budget. The measures introduced were expected to I and Ye 2002). yield 1% of GDP which is equivalent to an additional ¢469 billion. Even though this In terms of the health resource claim on the total output of the country it must be noted might not be sufficient to meet all the imminent financial challenges confronting the that, even though the percentage of GDP allocated to public health care expenditures has nation, it is nonetheless likely to facilitate increasing resource flow from the government increased substantially (see figure 2.10) it still hovers below 1.5% of GDP in 2004 and well to the health sector. On a longer term basis much prospects exist for increasing revenue ealth below the level of 12% recommended by the World Bank. All these present themselves of

generation in general and for that matter health care financing, particularly, if efforts H pieces of evidence that underscores the critical under funding state of the health sector could be mobilised to scale up investment in the health sector. and the necessity for a substantial scaling-up of investment in the sector so as to achieve the health MDGs and poverty reduction by 2015. However, the World Bank (2003) itself Earmarked Increase in the VAT Rate in a critical evaluation of the Ghanaian situation does not believe that the level of public and spending on health (including donor funding), in the current economic context and Similar to the GETFund it has been recommended to increase VAT rate and earmark the s competing demands on the resources of the nation, and even under the most optimistic proceeds for the health sector. It is believed that an increase in the VAT rate by another scenario, can be increased beyond US$12 per capita by 2006. On the other hand, higher 2.5 percentage points could bring about ¢400 billion or about $45 million to the health user fees, health insurance premiums or out-of-pocket private spending appear not fea- sector annually. This has been done for the education sector in the form of the Ghana sible in the current economic circumstance without exacerbating the poverty situation or Education Trust Fund which is fed with 20% of the 12.5% VAT receipts, the District inequalities. The only way to facilitate substantial improvement in health outcomes and Assemblies Common Fund (DACF) which statutorily enjoys at least 5% of all tax revenues poverty reduction therefore is a new programme that would convincingly form the basis and the Road Fund. These earmarked taxes have so far been successful and succeeded in for additional substantial resource mobilisation from other local and external sources securing additional resources to the sectors for which they are earmarked. The Education for scaling-up investment in the health sector. Trust Fund for instance yielded about ¢140 billion in 2001 and is projected to increase

to ¢329 billion in 2002. The DACF also contributed additional funding amounting to acroeconomic ¢2309.4 billion in 2001 for the development agenda of District Assemblies. Depending on Resource Mobilisation M the percentage of the VAT that will be decided on, such a policy could be a very reliable The biggest challenge in the whole exercise is mobilising resources to finance the scal- source of securing additional funding to up-scale intervention in the health sector. ing-up of investment in the health sector. The GMH Initiative Team suggests a number of options to mobilize domestic and foreign resources to support the proposed scaling-up hana of investments in health care, and water and sanitation. These options include: Introducing New Tax for the Health Sector G 1. improving GOG resource mobilisation drive for the sector; It has been advocated that in addition to the above suggested revenue mobilization from tax sources, the health sector could be made to be more solvent if new taxes are introduced 2. allocation of HIPC Funds to the Health sector, to fund the programmes and projects of the sector. Among the suggested tax types are:

3. Establishment of Community Health Endowment Fund » Sin Tax: These are taxes that could be imposed on activities and commodities, whose 4. reviewing resource allocation criteria especially under the GPRS; undertaken or consumption could be seen to generally cause health hazards to human beings. The commodities include tobacco, alcohol, etc. 5. Transfer of the Exemption fund under the cash and carry system from the Central Government » Environmental pollutants: It was agreed to identify all pollutants or economic activi- for better health, economic growth and accelerated poverty reduction s ties whose environmental unfriendliness could cause health hazards. Examples of 6. Health Insurance Scheme

such activities were identified to include vehicle usage, pollutants from mining and eport of the

7. Getting the Development partners to increase their contribution to the sector; industrial companies. R

8. etc. Vehicle usage: – An agreed percentage of car sticker revenue of the National Insur- s tment » ance Commission would be earmarked for health sector.

» Exhaust emission tax: A new vehicle exhaust emission tax as practised in certain European countries including Germany can also be introduced in Ghana, with the accruing revenue to be earmarked for the health sector.

21 That is why the WHO and CMH recommend a reduction in out-of-pocket spending on health services and the channelling of such community financing into pre-payment schemes (Frenk and Knaul 2002, WHO 2001). 22 Canagarajah and Ye (2002), for instance, report in a study that among people who reported themselves as being ill 56% in the richest quintile sought care as compared to 37% in the poorest quintile.

66 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 67 Scaling-up health inve » Tax on Mining Activities: Mining is known to cause health hazards through envi- increase in the resources devoted to health and education could thus be realized if they ronmental degradation and pollution of water and air. A tax could be imposed on were augmented by an amount equivalent to the level of assistance under the HIPC Ini­ their annual sales, which could be earmarked for the health sector. tiative over the 2002-2020 period. Furthermore, within the HIPC framework Ghana is supposed to receive programme support credits from IDA to (i) promote growth, incomes » Tax on other industrial pollutants from petrol chemical factories could be identified nitiative and employment (ii) improving service delivery for human development and (iii) improv- I and taxed. ing governance and public Sector Reform23 In February, 2003, for instance, the govern- » Earmarked Tax on petroleum products: Petroleum products certainly have negative ment received a grant from the IDA of about $57.3 million to improve the health care impact on the environment and health. Moreover, petroleum taxes are known to have system in Ghana by reducing the geographical, socioeconomic and gender inequalities in

very high revenue buoyancy. Therefore a tax on petroleum products to be earmarked health care service implement the Ministry of Health’s 2002-2006 work program24. ealth

for health would help the sector meet some of its set targets of improving health. H » Luxury Tax which will include levy on private health insurance premium, and travel and Establishment of Community Health Endowment Fund air travel tax which will be levied on everyone who uses our international airport. Under this arrangement, communities should be encouraged to establish health endow­ » Earmarked Remittance Tax: Mobilization of additional domestic revenue from 2.5% ment funds to cater for its members. Members of the community should be encouraged to and s tax on private foreign remittances, estimated to provide $15m annually, could be ear- make monthly contribution to the fund. Ghanaians in the Diaspora who belong to such marked for health and used to supplement the funding of MDAs implementing the communities could also be encouraged to support such initiatives. Ghana Macroeconomics and Health Initiative investments. » Tax on Lotto Winnings: There is also the suggestion to tax lotto winings for the health Reprioritisation of GPRS allocations sector. Such a tax could be levied on wining payments made by lotto companies. Even The GPRS has prioritised its Medium Term priority programmes and projects under the though the burden of the tax is supposed to be on the winner, payment could be made 5 main thematic areas. The cost of implementing the programmes and projects of the to be paid by the lotto company. entire GPRS is currently estimated to be $5,112.6 million. Thirteen percent of this total » Tax on Telephone Bills-A small tax on telephone bills was also recommended to be is allocated for programmes geared towards ensuring macroeconomic stability, 36% for

specifically earmarked for health financing. enhancing production and gainful employment, 42% for enhancing human resource acroeconomic

» Tax on premiums of private health insurance policies: While considering national development and the efficient and equitable provision of basic social services, 7% for M health insurance for all there may be some individuals who may for some reasons want developing special programmes for vulnerable and excluded, and 3% for pursuing and take up their own private health insurance policies with private insurance companies. supporting activities and institutional reforms that enhance good governance. Since these people can afford to pay more it may be fair to ask them to contribute more It is suggested to re-prioritise these allocations to increase the allocations to the relevant by taxing their private premiums to finance the investment needed for the scaling-up MDAs associated with the scaling-up of investments in health. hana of the health system. G Transfer of the Exemption fund under the cash and carry HIPC Funds system from the Central Government The HIPC Initiative addresses not only a key obstacle of unsustainable debt servicing There exists already an exemption fund for the aged, children and pregnant women under to economic growth and poverty reduction, but also seeks to make resources available the cash and carry system, which could also be transferred to finance the proposed extra toward improving the social sector of the Ghanaian economy including health. Ghana scaling up of investment. It was observed that most of the potential beneficiaries were is expected to derive some financial benefits under the HIPC initiative. A substantial not aware of this kind of facility. On the part of health services it appears that most of for better health, economic growth and accelerated poverty reduction portion of these benefits could be transferred to the health sector to facilitate accelerated s them have difficulty in administering the facility and so tend to ignore it. Thus it can be health investment and consequently poverty reduction. Total relief from all of Ghana’s seen not to be serving the intended purpose for which it was set up. The group therefore eport of the

creditors is estimated approximately $3.7 billion, which is equivalent to $2.18 billion in concluded that it would appropriate to transfer the fund to scale up investment in the R Net Present Value (NPV) terms, Net Present Value (NPV) of debt is the discounted sum health sector. s tment of all future debt-service obligations (interest and principal) on existing debt Under the HIPC agreement, assistance of $781 million in NPV terms committed by the World Bank will be delivered over a 20-year period. This will result in a two thirds reduction in debt service due to them. These reductions could translate into an average annual debt service reduction of around $170 million over the 2002 to 2020 period, equivalent to around 7 percent of the central government’s projected non-interest expenditures for the 2002-20 23 In June 2003, for instance, about $125 million IDA credit was granted to the country to support the Ghana Growth and Poverty Reduction Strategy. period. By comparison, the combined spending on health and education amounted to 24 World Bank 2003, Ghana: Poverty Reduction Support Grant and Credit, Date: 40 percent of central government’s non-interest expenditures in 1999-00. A significant June 24, 2003 http://web.worldbank.org/WBSITE/EXTERNAL/NEWS/ 0,,contentMDK:20116954~menuPK:34468~pagePK:40651~piPK:40653~theSitePK:4607,00.html.

68 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 69 Scaling-up health inve Health Insurance Scheme government’s programmes. In order to achieve the CMH recommended levels of funding to the health sector, not only will additional donor pledges be required, their timely dis- The proposed health insurance scheme is intended to replace the cash and carry system bursement will be very crucial to meeting the goal set forth in the CMH report. There is to improve financial access to health care in Ghana. The aim of health insurance is to also the need to rope in the non-traditional donors into the system. The present economic nitiative

spread the risks of incurring health care cost over a group of subscribers. The advantage I conditions in the country may not permit government to substantially increase health is that although the individuals will still contribute to services consumed, it will be in a financing to reach the level of $38 total health expenditure per capita per year in 2015 as humane manner as they do not have to carry the burden of health care alone. recommended by the CMH. Much will be required from our development partners. Looking at the proposed financing plan, consideration is given to the fact that about 70% of Ghanaians are in the informal sector, where collection of premium may not be easy Risks and Constraints to Scaling Up ealth and secondly, about 40% of Ghanaians live below the poverty line and may not be able H to afford higher premiums. Even though the scheme would cost a lot of money, it would Investments in Health also generate revenues for the health sector. Risk is about deviations from the expected. In other words, risk refers to the possibility

Based on a study of the 5 pilot schemes operating in the country, the likely contributions that what is expected will not be achieved. It is the quantification of the degree of devia­ and s from the non-formal sector has been estimated at ¢72,000.00. Assuming that with the tions of actual results from the expected results. Fundamental investment principles show health insurance 100% non-formal sector is covered and a contribution of ¢72,000.00 per that a direct relationship exists between risk and return. A higher return comes with a head is made, an amount of ¢360 billion can be generated annually. Also, if the formal higher risk and a lower return, usually a safer investment option, also has a lower risk. sector employees contribute about 2.5% of their salaries, this would generate additional The application of the concept of risk – return relationship to investment in health care ¢151.7 billion given a total of ¢511 billion, (an equivalent of $63,875,000.00). and the possible increase in the economic growth is therefore laudable. This is because, naturally, should very drastic and conspicuous economic growth rate be expected, then Donors Assistance to Health Care Financing more and more investment in health care would be needed. This means more money would be needed to provide food for the poor, health care for the sick, and comfort for It cannot be overemphasised that Ghana’s modest gains achieved in the health sector n the deprived. Both preventive and curative measures may need to be addressed simulta­ recent years would not have been possible without Ghana’s development partners. There neously. It could mean that the government may have to bear the total cost of health care acroeconomic is however the need for the country to explore more new international funding initiatives for many. Given this aggressive approach to health care investment, it is expected the M available to the health sector of developing countries. Initiatives such as the Global Fund many more people will be healthy and more productive. Households will probably save to fight Tuberculosis and Malaria and HIV/ AIDS, Gates Foundation should be seriously colossal amounts of out-of-pocket expenses on health care. Consequently, individuals targeted and approached to assist in the external resource mobilization effort to scale up could make savings to build some personal capital for investment in productive ventures. health interventions in Ghana. Already the Global Alliance for Vaccines and Immuniza­ The rippling effects would be an increase in economic growth of the nation, a higher hana tions (GAVI) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) return indeed. G have netted pledges of more than $1 billion and $1.3 billion world wide respectively. In addition to that other new specific and bilateral initiatives such as the GATES Foundation The above will however, go with a higher degree of risk (not being realized), since the and the Millennium Challenge Account of the US government have been set up recently to nation may not have such huge sums to invest all of a sudden. Even, if this were availa­ assist in funding serious health interventions such malaria control, better therapy manage- ble, it is also possible that enough in-depth analyses might not have been made as to ment, maternal child mortality control, improved health surveillance, poverty reduction how exactly to manage the investment of the sum. This situation could result in waste of programmes, etc. All these underscore the fact that donors could be willing to commit resources such that the perceived targets may not be achieved. This implies that there will additional resources to the health, given their recognition of the strong linkage between be deviations, which is the risk involved. Another way of looking at this is to consider that

for better health, economic growth and accelerated poverty reduction health, economic growth and poverty reduction. Ghana, for instance, stands to benefit fact that, if government needed to achieve an aggressive policy in this area of investment, s from the good groundwork done by the Global Macroeconomics and Health commission it would probably has to fall on foreign donors. This grants and loans may not come as to justify the need for more increased spending in health in the medium to long term. expected hence, targets set may not be achieved. eport of the R The common pool system of health care financing by donors in Ghana agreed upon On the contrary, the government could set very low targets, which could be achieved s tment recently in Ghana between donors and the government has given a new dimension to with domestic resources. This will go with low risk, all other things held constant. This health care financing and all efforts should be made to encourage all development part­ is because the targets would probably be achieved, since there may not be the unexpected ners to be part of this multi-donor budgetary support programme to enable government shocks such as disappointment from foreign partners, in case they fail to release funds as commit more resources to scale up investment in the health sector. expected. The effect however is that the expected results would be of minimal benefit to the total population. Many more people may not be covered in such a package, and it is One problem that has confronted the implementation of such programme has been the possible that the nation may lose a lot of people due to poor health and avoidable deaths. inability of donors to translate pledges into commitment and actual flows. In some instan- This will surely have some adverse effects on the economic performance of the nation. ces such inflows have not been disbursed on time to the disadvantage of the implementing

70 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 71 Scaling-up health inve To achieve any of the levels of return as earlier discussed, the following risks are likely Uncontrollable Risks to be significant. They are classified into controllable and uncontrollable risks. There are other risks that neither individuals nor institutions can control. This is because, most often than not, they are determined by forces that are exogenous (outside the control nitiative

Controllable Risk of key players). These are the uncontrollable factors. They include: I

» Poor target setting » Failure of donors to deliver on promises

» Improper education of the public before projects implementation (e.g. Immunization) » Emergence of unexpected epidemics and diseases not considered during the planning » Diversion of resource meant for specific projects to other non-programme uses period ealth

» Poor management of programmes » Effects of external shocks such as economic depression in major development partner H nations. All the above risks are human centred. They are likely to prevent the targets being achieved as expected. Poor target setting, for instance, is a common phenomenon in organizations The above factors are not exhaustive. These are factors that normally raise their ugly

where proper planning has not been done. The effect is that either such targets are too heads and throw otherwise beautiful plans overboard. Ghana, like many other developing and high and unachievable hence, acting as disincentive to workers, or that they are too low nations, depends heavily on donor support to finance its health budgets. This therefore s and makes the workers lazy. Either way, there is the danger of not achieving the overall makes our budgets susceptible to failure, should the donor fail to deliver on the promises. long-term goal of the organization. There is the risk that this lack of assurance concerning the dependability on foreign sources of financing, will determine the pace at which our plans would be implemented. It is also possible that in the nation’s bid to increase coverage, programmes and pro­ Whether an Accelerated Radical Strategy, Graduated Strategy or A Mixed Strategy will jects may be rushed. In this case, it is a possibility that the major stakeholders may not succeed or not, depends on the goodwill and loyalty of these external partners. be properly educated about the importance of the planned programmes. Consequently, the target recipients may not co-operate with the health workers. This happened on Another important risk that confronts Ghana in our bid to achieve any planned targets in some occasions in Ghana, where certain religious groups vehemently opposed a national health care delivery is the emergence of unforeseen epidemics. Though this is not peculiar immunization programmes. to Ghana, it is an important factor to be considered. The issue of Severe Acute Respiratory

Syndrome (SARS), which hit China and Canada, recently is a classic example. The effect acroeconomic The human factor in any organization is crucial and needs to be properly motivated and

of this is that, resources that are meant for a specific programme to achieve a planned M monitored. Resources meant for certain deprived communities might not reach them target may have to be shifted to serve as emergency fund. Targets in such instances are if there is no proper supervision and motivation for those responsible, to perform as not likely to be achieved. expected. This point ties in with the risk of poor management. There are many very competent Ghanaians who are skilled enough to run the health sector properly. However, Due to globalization, no country is completely insulated against external economic and hana the risk still exists that the sector could suffer greatly due to poor management. This political shocks from other nations. This issue of external shocks is more paramount to G may be the case due to the fact that officers, who are not satisfied with work conditions the developing world of which Ghana is a member. Many of our well-drawn programmes and/or are not properly motivated, could still be negligent. Again, the highly qualified would end up gathering dust on our shelves, just because the economies of our major individuals may not be willing to accept posting to deprived rural communities. Hence development partners are in depression. At best what a nation can due is to minimize the implementation of projects can suffer due to the lack of qualified staff on the ground the effect of the external shocks. But in a nations where almost every thing is imported to monitor the progress of work. Many good programmes in Ghana failed over the years, and our budget is heavily financed through foreign funding, one wonders how long we not because there were no competent personnel to handle them, but due to the fact that can survive on our own, should our development partners, for whatever reason, fail live the right persons might fail to take the right decision and action at the right time. up to expectation.

for better health, economic growth and accelerated poverty reduction All the above risks can be overcome and controlled since they are all human centered. s This can be achieved through proper education and training, improvement upon the Major Constraints eport of the

working conditions and work environment for the medical and paramedical staff, and Whilst risk concerns factors that make it impossible for us to achieve our set targets, con- R through greater commitment and collaborations from all stakeholders. Good health is an straint are the factor that place limits on what we can possibly do. The major constraints that s tment all-inclusive concept. It involves everyone hence, we need all hands on deck to maintain the nation faces in her drive to improve upon the health care delivery system, can be put into and improve our health delivery systems. The awareness creation about improvement in two broad categories. These are the financial constraints and non-financial constraints. personal hygiene and environmental cleanliness must therefore be and endless project. Financial Constraints The financial constraints are quite very straightforward. There are budgetary constraints or limitations on what the nation offer to the health sector. Internal revenue mobilization comes mainly from taxes. For the government to spend more, it must generate more. This

72 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 73 Scaling-up health inve calls for greater revenue to be generated from taxes. Should current tax rates be increased Emergency services are not available to many rural communities in the country. This or tax nets widened? This is a normal dilemma for governments, who may also be think- is because most of the communities do not have telephone facilities. They cannot call ing of the effect of such decisions on the standard of living of the people. for this kind of service from the nearest health centre, which might be about hundreds of kilometres away. It is therefore not an exaggeration to state that poor infrastructure Furthermore, the there is limit on what the nation can receive from donors. This implies nitiative development in the rural communities in the country has created a yawning gap between I that though the nation may have very fine plans drawn, their implementations, to a large the demand for interventions and the response for delivery. extent, lie in the hands of the suppliers of funds. This problem is compounded heavily where the nation has to constantly service her old debts. The HIPC initiative of the nation is therefore expected to at least make some funding available for the health sector. The Health Service Delivery Level ealth financial constraints call for proactive and innovative strategies to be followed in the

There a myriad of major constraints that infest health serve delivery in the country. H implementation of programmes as far as funding is concerned. Ghana is noted worldwide for training and grooming effective medical doctors, nurses and paramedical professionals. Unfortunately, however, the exodus of these professio­ The Non-financial Constraints nal to the developed world to seek greener pastures, has left the nation with a huge and unsatisfied demand for medical professionals, needed to support her drive to improving and These may be addressed at four broad levels, namely: the recipient and community level; s the existing health service delivery system. The nation is left with skeletal staff of com- health service delivery levels; the policy makers’ level, and natural and environmental petent, skilled and dedicated health professionals, who are found mainly, in the few big characteristics (Hanson et al (2001). cities of the country. This shortage and poor distribution of skilled and qualified staff, to a large extent, hampers effective and efficient interventions especially in the rural Recipient and Community Level communities of the country. Cuba and some other nations do provide volunteers to offer The attitudes, beliefs and practices make some individuals, groups or communities resist medical services in Ghana. every attempt towards effective interventions. Due to religious practices, some com- Other constraints at this level may be seen in terms of weak technical guidance for the munities do not accept orthodox medical treatment. They see such treatments as taboos professional staff; poor programme management by responsible officers, either due to and not only frown upon them, but also do everything in their powers to resist medical incompetence emanating from appropriate project management skills, or simply due to acroeconomic and paramedical officials, who dare impose these on them. A classical example is where greed and inadvertence; ineffective supervision due to logistical problems; and inade­ M most Christian churches frown upon the message of encouraging the use of condoms, quate supplies of drugs, medical equipment and medical supplies. as a means to reduce the alarming rate of the spread of HIV/AIDS in the country. It is also on record that, a particular religious group does not accept blood transfusion to their anaemic patients. The attitude of these groups of people can be attributed to high Policy Makers Level illiteracy rate in the country. About 20% of male population and 37 % of female popula- The constraints at this level may be discussed in terms of government policies and spe­ hana tion25 in Ghana are illiterates. The concentration of the illiteracy rate is higher among cific health sector policies both of which impact health care delivery is the country. G rural folks in the country. Most illiterates attribute certain kinds of diseases to spiritual The government or public policies affect most if not all sectors in an economy. As a attacks from people they claim to be their enemies or witches. Such people would simply result the health sector may be adversely affected by certain policies, which the sector not co-operate with medical officers want to provide interventions. The combined effect may not easily have control over. In Ghana, each government has its own policy focus. of all these attitude, beliefs and practices is that the nation’s drive to attain specific This will reflect what goes into the health sector and at what rate. For instance, whilst levels of coverage may be a mirage. This is because the problem in the above-discussed one government identified itself with the cash-and-carry system of health care delivery, scenario is not financial. If it were, donors could help. However, because it concerns another sings the tune of health insurance for all. The health sector may make input into beliefs and practices, it is very dicey and will probably take a match longer time to be these policies yet, the overall policy directions depend on the political aspirations of the for better health, economic growth and accelerated poverty reduction s resoled effectively and completely. ruling government.

Furthermore, at the community level, it is observed that many rural communities are Similarly, the government holds the key as far as the provision and development of infra- eport of the R deprived. They lack the basic infrastructure needed to support effective interventions. structure are concerned. The development of infrastructure in the rural communities Access roads are impassable during the rainy season. In the dry season, these same com- is essential for the delivery of health care in these communities. It does not only open s tment munities do not have access to portable water. Consequently, medical officers who have up such communities for development, but also it helps to improve the lives of the rural been trained in the cities and are glued to relatively cosy city lives, may not easily survive folks. The governments, efforts towards the provision of infrastructure have both direct in these communities. The rural folks are therefore denied access to proper interventions and indirect effects on the level of health care delivery in the country. all year round due to no faults of theirs. Another crucial factor identified by Hanson et al (2001) is government bureaucracy. This has the tendency of affecting all the sectors of an economy. It may delay unduly the development and the implementation of policies, which concern the health sector.

25 Adult illiteracy rate, 2000(% of population 15 years and over). Source: World Development Indicators 2002 .

74 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 75 Scaling-up health inve The health sector policy and strategy management has it own peculiar problems. Weak Recommendations for Minimizing the Major Risks and data capturing and management of health related data, has adversely affected the avai­ Addressing the Major Constraints lability of timely and relevant information needed for planning and management of the health sector. Though plans are underway to improve upon this, one would expect that The major risk categories discussed in the chapter are the controllable and uncontrollable nitiative it should be at a faster pace. risks. It came out in the discussions that most of the controllable risks are human centred. I This means they are due to human errors, attitudes, standards, etc. It is recommended Again, there is ineffective enforcement of regulations of pharmaceutical and private that training and re-training, education, monitoring and motivation be used as the tools sector participation in health care delivery in the country . The governments system of to address this class of risks. Where the risk comes form managerial lapses, the “carrot monitoring and enforcement of are not full proof.

and stick principle” could be used. By this, there should be reward for excellence, and ealth

“Ghana’s pharmaceutical market is small, but promising. There are tremendous punishment from negligence and non-performance. H opportunities for the pharmaceutical industry in Ghana. Approximately 70 per- For the uncontrollable risk, we can only design means to cope with them, since the cent of pharmaceutical products are imported and about 30 percent produced parameters for eliminating them are mostly out our reach. Our programme budgets should locally… All foreign companies can export their pharmaceutical products into be prepared based on the principle of flexible budgeting. Those who prepare these budgets Ghana provided they meet the requirements of Ghana’s Food and Drugs Board and should critically think through all the stages and make budgets for different level of pos- s 26 (FDB).” sible funds receipts, base on sensitivity analysis. The GPRS mentions some innovations The above statement suggests that many foreign drugs flood the Ghanaian market. The in the funding of the budgets including the involvement of the private sector. This is a FDB has an enormous responsibility to ensure the efficacy of all these drugs that enter laudable idea. The issue of Non-resident Ghanaians Fund, which the GPRS addresses, has into the country. They might have been doing their best, but then, is their best enough? to be critically considered further and specific sub-sectors, within the health sector, be Are they properly resourced to live up to expectation? There were occasions that the FDB identified as vital focal points to be tackled in the fund raising endeavours. Whilst doing issued statements demanding the withdrawal of some drugs from the market. How timely all these, we need the realization that good health is inextricably linked to the economic are such notice to forestall and serious repercussions on the consuming public? The performance of the nation. Also, when the economy performs well, many more people enforcement of regulation constraint would probably continue to be a major constraint are able to spend more of health. Our strategy must therefore be an integrated health for some time, as long as the support systems for the enforcement remain ineffective. care delivery package. This should not address health in terms of diseases alone, but must acroeconomic include water and sanitation, malnutrition, education and environmental degradation.

Again, the over reliance of donors funding and for the supply of pharmaceuticals reduces M the flexibility and ownership of programmes and projects initiated by Ghanaians, since The major constraints that concern attitudes, beliefs, practices and illiteracy could be the success of these are in firm grips of sympathetic foreigners. effectively addressed through education. Formal education could help resolve most of the issues addressed. It can be argued that most of the constraints addressed in this context An important constraint that the health sector has been battling with over the year is the

are symptoms of one basic problem: i.e. illiteracy. Education will therefore be a long-term hana inability to design a package that would attract and retain competent and skilled medical

solution to the problem. As a short-term solution, however, informal education using G professionals trained in Ghana. The brain drain suffered by Ghana due to the exodus of audio-visual aids such as clips and film shows to expose the perils of ignorance may be the medical professionals is a national problem, which needs to be addressed not only an effective tool. by the health sector, but also by the whole nation. To address the issue of shortage of personnel, we believe training of more professionals Natural and Environmental Characteristics is not the issue. The bone of contention is how do we retain the trained staff. Legislation is necessary to effectively address this. The Government should not prevent professional Geographically, Ghana is located within the tropics, which is a conducive domicile for the from leaving the country. Rather, there should be an enactment which will require all mosquitoes, the vector for malaria. Malaria happens to be one of the most prevalent dis- the medical professionals, who would like to leave the country to freely register. The law

for better health, economic growth and accelerated poverty reduction 27 s eases, which accounts for about 44% of all outpatient attendance in Ghana in 2002 . should make it mandatory that wherever their go, a portion of their income be withheld

By the very nature of the country’s location, we are prone to situations that we can only and paid to the government of Ghana. The sum so received could be used to train more eport of the learn to cope with, but not to eradicate completely. An example is the excessive heat that professionals and also to provide incentive packages for those professionals at home. R many of our peasant farmers have to bath daily on their farms. This could have some This policy would be helpful to the Government of Ghana, who would recoup some of s tment adverse effect on their lives. the cost of training these professionals. The professionals who travel would also be satis- fied that they have the opportunity to do what the wanted. Lastly, it would benefit the international community, which has developed such as imaginable taste for the service of our medical professionals.

It is necessary for the government to step up its mechanisms for the enforcement of the laws that guide the operations of the pharmaceutical industry. This should be made more 26 http://www.osec.doc.gov/africatrademission/Pharmaceuticals.htm transparent and rigorous to make it unattractive to unscrupulous persons and institutions 27 Source: MOH, Centre for Health Information Management that would like to exploit existing loopholes to their advantage.

76 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 77 Scaling-up health inve Analysis of costs nitiative and investment I

plan ealth H and

3 s

Introduction This section of the GMHI document analyses the costs and investment plan for scaling-up priority interventions in health, water and sanitation. It analyses costs of health inter- ventions and provides broad cost estimates for scaling up priority health interventions of the health sector. It also provides an update of investment plans in terms of health

interventions and budget levels. The purpose of this analysis is to provide information acroeconomic and guidelines for health policy planning. An important input to determining the volume M of investment in health is the determination of costs of health interventions, which are intended to be scaled-up. However, the magnitude of the costs would involve the estimation of the frequency of utilization, the size of the population in need of such an

intervention and the unit value of inputs needed for the various activities which make hana

up the health intervention. These estimations can be done against the backdrop of cer- G tain assumptions and analytical techniques. Moreover, just as with all investments it is important for policy makers to know the costs and outcomes of health investments so as to be able to relate them to country’s long-goal of welfare maximization. For health policy implementers such information affords them the basis and tools for monitoring and evaluating the impact of such long term investment decisions. Thus such an exercise of analysing costs of health interventions would not only afford policy makers information for designing financing strategies but also on how, and how much resources to mobilise

for better health, economic growth and accelerated poverty reduction for such investments. The cost analysis of scaling-up investment in the health sector s reflects the incremental cost analysis of additional resources that would be required for eport of the a large-scale expansion of activities from existing levels of selected basic priority health R services at the close to client (CTC) level. s tment The section spells out the assumptions, methodology, and the process used in estimat- ing the costs of scaling-up a close-to-client set of priority interventions in Ghana. The analysis identifies a set of health priority areas of intervention and achievable target levels of interventions, which the health sector authorities of Ghana have designated as key health priorities because of their potential or actual impact on health MDGs, economic growth and poverty reduction. The analysis uses the MTEF format to investigate the costs of the interventions in the priority areas. Using the above costing information it develops an investment plan for scaling up investments for two scenarios: 2007 and

SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 79 Scaling-up health inve 2015, along the lines of the recommended per capita health expenditure targets of the or on the overall health of the Ghanaians and poverty reduction. The list of selected CMH, MDGs, and the Abuja declaration. It further identifies the total mix of resources, priority intervention areas, whilst not covering all the major diseases that can be found including the resource gap yet to be additionally mobilised, to deliver the set levels of in Ghana, contains the known leading causes of mortality and the burden of diseases in close-to-client services in the field of health care and water and sanitation to a defined Ghana and conforms to the top ten diseases ranked in terms of mortality rates (see table nitiative target population. 3.1). In order to meet the MDGs the GMHI reviewed the target coverage levels or health I outcomes under the GPRS upward to reflect the expectations of the scaled-up situation The health status of a nation reflects the comparative levels of many health indicators (see table AI in the appendix). We must, however, point out that the selection of a few including child, infant and maternal mortality, life expectancy at birth, and other health but salient interventions was done with due regard to resource and absorptive capacity outcomes. Apart from medical treatment of diseases there are certain health related inter- constraints of the country and also reflects what is really achievable in the country within ealth ventions, which are critical to reducing or improving the levels of these health outcomes. the stipulated MDG period under review. It is believed that the identified interventions H As we learnt from the previous section one such important input is access to potable are key in addressing the major health conditions among the poor and cover diseases water and proper sanitation. This is more so particularly in a country in which infectious whose substantial reduction or eradication will help to improve substantially health and parasitic diseases are predominant proximate causes of ill-health. In such situations, conditions and consequently poverty levels in Ghana or help the country to achieve the it is argued that attention to the environment is the effective preventive measure, rather and

MDGs fairly. This short list is also in line with the recommendation of the Commission s than mere curative specific drug intervention. on Macroeconomics and Health (2001), which emphasised the identification of a small For this reason we would include in this costing exercise estimates of scaling-up invest- number of priorities. Thus together with the target outcomes of these interventions, as ment in the water and sanitation sector to cater for a health related or environmental illustrated in table AI, the country may be able to achieve not only the health MDGs but strategy for health development. Our cost estimation for achieving water and sanitation also reduce poverty. We would like to point out that underlying the analysis is, however, MDG targets uses a base and ideal scenario, by which the government is expected to the attempt to estimate the cost of bridging access gaps to health services of the poor and raise coverage from the present low level of 41.28% (water) and 28% (sanitation) of the rural dwellers and of delivery of close-to-client intervenetions . The analysis therefore population to about 71% (base scenario) and 85% (Ideal scenario) in 2015 respectively. assesses the costs of the Ghanaian strategy, dubbed CHPS, for empowering communities We make use of a statistical estimation model for the forecasting of the costs. to improve health status and access to quality basic health care to overcome the access constraints of distance in the health services, and provide health services that are close- Health Priorities and Health Target Outcomes In Ghana to-client, and also linked to district hospitals and sub-district health centres. acroeconomic M The epidemiological profile of Ghana reveals a high preponderance of communicable Table 3.1 Leading causes of mortality and burden of disease: preventable diseases, under-nutrition, and poor reproductive health. As pointed out in prior estimates for Ghana, 2000 section two the most prevalent diseases killing Ghanaians include malaria, upper respi- Mortality (deaths) Burden (DALYs)

ratory tract infection, diarrhoea, tuberculosis and pregnancy related complications, in hana %

addition to other epidemics such as cerebrospinal meningitis (CSM), guinea worm, buruli % total total G ulcer, yellow fever and cholera. These cases seem also to be compounded by the ‘new’ Rank Disease or injury deaths Rank Disease or injury DALYs threat to life expectancy from HIV and AIDS which, as highlighted by the CMH, has 1 HIV/AIDS 13.7 1 HIV/AIDS 12.5 significant and direct implications on poverty. 2 Perinatal conditions 8.3 2 Perinatal conditions 9.5 There are various health interventions for almost all these diseases ran either by the 3 Malaria 6.9 3 Malaria 7.7 Ministry of Health in collaboration with or by other non-governmental agencies. Some of these interventions were discussed in section two of this document. The numerous 4 Measles 6.2 4 Measles 6.8 nature of the interventions have stretched the available health resources so thinly that Lower respiratory

for better health, economic growth and accelerated poverty reduction 5 5.7 5 Lower respiratory infections 4.5 s the interventions are able to cater for only a small target population-in-need and conse- infections

quently are able to achieve only low levels of health outcomes. It was in the wake of this 6 Ischaemic heart disease 5.6 6 Tuberculosis 4.0 eport of the

situation that the GPRS (2002-2005) sought to increase resources for the health sector so R 7 Tuberculosis 5.1 7 Diarrhoeal diseases 3.1 as to improve overall health outcomes and consequently poverty reduction. The increase s tment in resource flow to the health sector under the GPRS, however, fall woefully short of not 8 Cerebrovascular disease 4.7 8 Unipolar depressive disorders 2.0 only the recommendations of CMH in terms of per capita health expenditure but also 9 Diarrhoeal diseases 3.6 9 Road traffic accidents 1.9 short of the level that would allow the country to achieve the health MDGs, which Ghana 10 Road traffic accidents 1.9 10 Violence 1.8 has adopted, and hence poverty reduction. In the light of this the GMHI in conjunction with Ministry of Health has designated a limited number of diseases or leading causes of mortality as key health priorities (see table 3.1), whose interventions are to be scaled- up against the backdrop of the CMH recommendations. The diseases on the list were selected on account of their potential or actual impact on mortality and disease burden,

80 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 81 Scaling-up health inve Health Priority Areas in Ghana and MDGs Table 3.2. Association Between Selected Diseases for Eradication and the MDGs Even though the essence of the analysis is to provide the evidence for scaling-up invest- percent Association with Base disease list total deaths MDG association Poverty Reduction ment to achieve the tripartite goals of improved health, economic growth and poverty

Measles 6.2 Reduce Poverty nitiative reduction, it seeks to provide the best possible route of achieving the health MDGs, which I by half of 1990 the country has adopted. This raises the questions about the relationship between the Lower respiratory MDG 4: A two-third reduction in 5.7 levels. selected lists of key diseases, their interventions and outcomes, and the MDGs. How far infections child mortality do these interventions and their possible outcomes allow the country to achieve, at least, Diarrhoeal disease 3.6 the health MDGs? MDG 5: Reducing maternal ealth Perinatal conditions 8.3 The MDGs are a set of numerical and time-bound goals with defined targets that express mortality by three-quarters H key elements of human development. The goals include eradicating extreme poverty and HIV and AIDS 13.7 hunger; achieving universal primary education, promoting gender equality; reducing MDG 6: Halting and reversing Malaria 6.9 child and maternal mortality; reversing the spread of HIV/AIDS; and ensuring environ- HIV and AIDS, TB and malaria and

mental sustainability, whose target sets to halve, among others, the proportion of people TB 5.1 s without access to safe water. These targets are to be achieved by 2015, from their level Ischaemic heart disease 5.6 in 1990 [United Nations, 2000]. Ghana has adopted the MDGs and has consequently Cerebrovascular disease 4.7 realigned its poverty reduction strategy framework to the MDGs. Hence this document is to provide background information for mainstreaming health issues into government’s Road traffic accidents 1.9 strategic policy framework and budgets. In reviewing the links between the set health out- Widening Access and MDG 8: Increase access to comes and MDGs we compare in table 3.2 what disease or key intervention would allow Health Insurance essential and affordable drugs which particular MDG to be achieved if that particular disease were to be eradicated or MDG 7: Halving the proportion substantially controlled through the scaling-up of investment or that intervention. of people without access to safe Water and Sanitation water and Ensure environmental The picture that emerges from a close look at table 3.2 shows that controlling or eradicat- sustainability acroeconomic ing the top ten list of diseases by scaling-up investments or their respective interventions M would go a long way in achieving the health MDGs and its overarching goal of halving Total and Incremental Costs Analysis poverty by 2015. For instance, scaling-up investment in some of the identified diseases for eradication or control and water and sanitation can help the nation to achieve at least As mentioned earlier this costing exercise analyses the total and incremental cost of 5 (MDG 4, 5, 6, 7 and 8) key health related MDGs. resources that would be required for a large-scale expansion of activities from existing hana

levels of selected basic priority health services that would facilitate the achievement of G Indeed we acknowledge the deficiency associated with such a tabular direct assigning of the health MDGs. The total costs of the selected health interventions reflect the total list of diseases or interventions and MDGs, which is subject to serious conceptual and estimated value of all resources needed to implement the selected health interventions. measurement constraints. This is just to simplify and clarify the assumed connections It is equivalent to the full economic price (Drummond and McGuire 2001; Drummond et between a possible health outcome and a specific MDG. It does not suggest any direct al 1997) of providing the selected set of key interventions with the potential of impacting causal relationship, since we lack the evidence to substantiate the existence of such a on the health and welfare of the poor, which positions the country adequately to achieve direct causality between a particular disease control and an MDG achievement. the health MDGs, economic growth and poverty reduction. An important part of this exercise concerns the incremental costs, which reflect the additional resources that would

for better health, economic growth and accelerated poverty reduction be needed to expand the activities or services of the selected health interventions from s existing low levels to higher health outcomes. The costs of expanding the additional services are the additional expenditure, which is required over and above the current pat- eport of the R tern of expenditure. For this analysis the incremental costs reflect the difference between the total estimated costs of the selected health intervention for achieving the MDGs and s tment the projected resource envelope available to the Ministry of Health annually from the government’s budgetary allocations. The costs components include the capital and other related requirements for implementation cost as well as complementary management and institutional support and also additional investments in training new personnel and expanding facilities in order to deliver services at these higher levels of coverage. The incremental costs involved include the following costs dimensions:

82 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 83 Scaling-up health inve 1. Investment in Health Systems and Infrastructure in capacity and infrastructure, and feasible levels of target coverage required to achieve health benefits. The 2007 scenario determines a medium term scaling-up (2002-2007) in 2. Implementation costs the context of large-scale investment at both the peripheral and local-health care units 3. Management and Administration Costs as well as referral treatment centres, but is restricted by resource and absorptive capacity nitiative constraints. The 2015 scenario assumes scaling-up on the basis of large-scale investments I The costing methodology over a longer period, which can permit high levels of coverage for a number of interven- tions, because it is less restricted by resource and absorptive capacity constraints. Health services are complex and costing them appropriately is challenging because of the extraordinary diversity in services offered. For this reason various approaches (Mitchell There are several factors, which influence the quantum of resources needed for the scal­ ealth et al 1999) have been widely used to determine the costs of providing health services. ing-up of services in the health sector. Salient among them may include the following: H These include the absorption costing method, the opportunity costing method, the mar- » Population in need (PIN): The PIN refers to the relevant target groups that the preven­ ginal costing method, and the activity based costing method. Each of these methods tion and care interventions are designed to reach. Any cost estimate requires first the has strengths and weaknesses and an application of a particular one may depend upon estimation of the PIN, since it determines the size of the costs or the quantum of the the specific circumstance. The Ministry of Health, for instance, in a recent unit costing needed resources for the scaling-up. However, it must be pointed out that the estimation and s study, used the absorption approach, which links actual expenditure to service utilisa- of the PIN for a particular service depends on two principal parameters concerning the tion levels. Here all costs were directed towards their final destination or department. population size and the incidence of a condition or risk. Due to lack of current data on The remaining indirect costs including administrative costs were apportioned to direct morbidity and risks, we follow the advice of CMH, by assuming that the incidence and hospital outputs being costed. The opportunity cost is also the one, which relies on price prevalence of certain diseases or risks, particularly, for HIV/AIDS and tuberculosis, data available in either the private or the public sector, or both for alternative uses of remain constant over time and ignore any potential changes in disease prevalence inputs for the output being costed. or incidence and any effect of the increased service coverage on patterns of disease. Our attempt to estimate costs of scaling-up investment in the health sector uses the Under this assumption we use available information on demographic, behavioural and activity-based approach. Activity-Based-Costing (ABC) is an accounting technique epidemiological data to estimate the PIN for our costing analysis. for allocating overhead costs to services (or goods), which differs from the traditional » Coverage: The estimate of the PIN allows us to determine the baseline and target acroeconomic approach, because of its fundamental concentration on activities (Baker 1998). The coverage levels for the various priority interventions. Information on projected high M ABC methodology measures overhead costs and their consumption by activities used target coverage levels of selected priority interventions, which also represents a review to perform services – recognizing the causal relationship: overhead costs to activities of the target outcomes as reflected in existing strategic documents as the GPRS and to services – so that overhead costs can be allocated to services. Thus a typical ABC POW II can be taken from table AI in the appendix. Actual coverage data vary widely approach utilizes a series of cost pools and a proportionately greater number of activities depending on the location or region, with some regions in Ghana, for instance, register- hana than do most traditional costing approaches to overhead costing. The ABC approach ing high coverage levels whilst others achieve low levels of coverage. For example, the G also differs from the traditional approach to assignment of overhead costs because of its spectrum of supervised deliveries achieved in 2002 ranges from 43.7% in the Central fundamental concentration on the inputs to services. After activities are identified and Region to 110% in the Upper West Region (GHS 2003). Since these variations do not defined, ABC is done in two steps: 1. overhead costs per unit activity are estimated for allow for homogenous process of scaling-up, it is proper to base our cost analysis model one or more activities used in producing services and 2. the allocation of overhead costs partly on achieving minimum coverage levels for the whole country. to each service is then calculated, first by multiplying the unit costs from step 1 by the It is also pertinent to note that the differences in the coverage or target levels of health respective quantities of activities used to produce each service (e.g. for physician office outcomes as illustrated in table AI may differ from target levels using a list different from visits take X minutes of physician time, Y units of staff time, etc.), and then summing the the list that underlies our analysis. Owing to the fact that our list is limited to a few but results (Peden and Baker 2002). Indeed the ABC forms the basis of the Medium Term for better health, economic growth and accelerated poverty reduction key health interventions that do not cover all the diseases found in Ghana, the target s Expenditure Framework (MTEF) methodology from which the costs of programmes and 28 levels may represent outcomes that only allow the country to achieve the MDG. projects are derived for Ghana government’s budgeting . eport of the

» Costs: The total expenditure requirements over the projected period are based on R costing of prioritised activities, which then form the total costs of achieving the set

s tment Assumptions objectives. The costing is done using the Medium Term Expenditure Framework, under The total costs of scaling-up investment in the health sector consist of costs for on-going which costs of programmes are computed by determining the unit costs of the inputs selected programmes and projects necessary for meeting the set health targets. Following required to perform activities within programmes and projects. The unit costs of the the recommendation of CMH (2001), the cost of expanding services were analysed for two inputs are then multiplied by the number of inputs needed to produce specific amounts timeframes or time scenarios (2007 and 2015) based on the level of investment and ability of the outputs required to achieve the targets of the programmes and projects. The to expand services. These reflect different assumptions about the timeframe, investments estimated costs of scaling-up a specific health intervention is therefore the unit cost of the health intervention multiplied by the population in need of that health interven- 28 MTEF involves the preparation of Strategic Plans in which MDAs define their Mission, Objectives, Outputs and Activities. On the basis of the Strategic Plans, MDAs produce an integrated budget that reflects the cost of programmes.

84 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 85 Scaling-up health inve tion. These estimates give an idea of the magnitude of resources, which are required Total Costs and Incremental Cost of Scaling-up Health Spending on an annual basis to achieve the annual target coverage levels. This section estimates the total and incremental cost of scaling-up health expenditure to achieve the set target levels of health outcomes. On the basis of the estimated PIN and

Cost components nitiative

coverage for the various key interventions we present a summary of cost estimates in table I » Investment in Health Systems and Infrastructure: Expanding coverage of health 3.3. The cost estimates are arrived at by multiplying the unit cost of an identified priority delivery services to higher levels requires new investments in staff training and logis- health intervention by the population-in-need of that intervention. In calculating the cost tics/facilities. We estimate these costs on the basis of the size of the PIN for each health estimates, it is important to note that the selected population-in-need and the unit costs scenarios allow for the achievement of target levels that ensure the parallel achievement

condition and scenario. We also use various factors including contact time with health ealth of the health MDGs, rapid economic growth and poverty reduction. personnel, use of inpatient or ambulatory facilities, etc., to calculate the required H investments in health systems and infrastructure or training and facilities. The estimated total costs or resource requirements for scaling-up the identified health » Implementation costs: Implementing the scaled-up interventions involves carrying interventions range from US$237.5 million in 2002 to US$444.6 million in 2007 (see table out significant number of proposed programmes and activities. Our costing model AVII). These costs rise further from US$470.19 in 2008 to US$1.02 billion in 2015. In and

estimates the implementation costs of the proposed programmes and activities mak- terms of the two timeframe scenarios the total estimated cost for the 2007 medium term s ing objective assumptions about demographic, behavioural and epidemiological and scenario is about US$2.06 billion, whilst the selected health interventions were estimated facility or project-level cost data. to cost about US$5.6 billion for the 2015 long-term scenario. For the whole planning period of 2002-2015 under review our cost estimates suggest that about US$7.66 billion » Management and Administration Costs: This cost component includes costs of man- shall be needed to enable the country to achieve the health MDGs. It is believed that the agement and institutional, administrative and support functions, monitoring, super- expenditures underlying these cost estimates would allow the country to achieve a per vision, and institutional strengthening within the CHPS level. It must, however, be capita public health spending of about US$12.62 in 2002 and raise it to US$21.08 and pointed out that all these costs are strongly influenced by the size of PIN. US$40.45 in 2007 and 2015 respectively (see also table 3.3).

Resource Envelope Table 3.3 Summary of Incremental Cost of Scaling-up Health Spending, 2002-2015 Incremental acroeconomic We refer to the resource envelope as the entire resources or inputs available or poten- Total Costs Costs M tially available to the health sector from the government, donor agencies and internally 2 060.08 generated funds. The estimation of the present or potentially available or earmarked 2002-2007 (US$ million) 1 144.39 resources allows us to undertake an analysis of the resource gap, i.e., what is addition- ally necessary to scale-up investment in order to achieve the set higher health outcomes. 5 602.00 2008-2015 (US$ million) 3 836.86 hana The analysis of the resource envelope is presented on the basis of the financing plans of G the annual budgetary allocations of the government. The estimated resource envelope 7 662.08 2002-2015 (US$ million) 4 981.24 is then compared with the estimated costs of scaling-up investment to ascertain the resource gap, i.e., the resource yet to be additionally mobilised, to deliver the set levels Per capita Health Expenditure (in US$) of close-to-client services. After converting these estimates into per capita indicators, 2007 Scenario 12 21 the results would then be compared with other resource envelope scenarios such the low case projections of the programme of work (POW II) of the Ministry of Health and 2015 Scenario 31 40 simulations using the minimum required commitment under the Abuja Declaration in Average Annual Costs

for better health, economic growth and accelerated poverty reduction 2001, to which the government of Ghana is a signatory29, and has thus pledged to devote 2002 – 2007 (US$ million) 190.73 343.35 s about 15 percent of its annual budget to improve the health sector. These comparisons

2008 – 2015 (US$ million) 479.61 700.25 eport of the are to enable us win a better picture about the appropriateness and size of the alternative R options or financing projections for determining the resource gap for scaling-up invest- 2002 – 2015 (US$ million) 355.80 547.29 ments in health interventions. s tment The incremental costs as presented in the table 3.3 above reflects the difference between the total estimated costs of the selected health intervention for achieving the MDGs and the projected resource envelope available to the Ministry of Health annually from the government’s budgetary allocations. Underlying the estimates of the incremental 29 On April 27, 2001 African leaders meeting in Abuja, Nigeria, declared the battle against HIV/AIDS, tuberculosis costs is the assumption that the government budgetary allocations were used to finance and other infectious diseases as their top priority for the first quarter of the 21st century. As they adopted the Abuja only the selected set of health interventions, which the government wants to scale up Declaration, the signatory countries pledged take all necessary measures to ensure that the needed resources are made available from all sources and that they are efficiently and effectively utilized. The governments further to achieve the health MDGs. The estimates of the incremental costs for scaling-up indi- pledged to devote 15 percent of their budgets to improving the health sectors (http://www.uneca.org/adf2000/ Abuja%20Declaration.htm (10.10.2004)).

86 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 87 Scaling-up health inve vidual priority health interventions including costs of widening access to health services expected to raise its health care spending to about ¢2,021.2 billion in 2007 and further to are presented in table AII. ¢3,775 in 2015. In real prices the increase is expected to rise from US$114.27 million in 2002 to about US$369.61 million in 2015. It must be pointed out that these cost estimates As table 3.3 illustrates, we estimate an incremental cost of US$1,144.39 million for the for the period 2002 and 2015 include the costs of the implementation for higher coverage 2007 scenario and about US$ 3,836.86 million for the 2015 scenario. The total incremen­ nitiative levels and the required investment in infrastructure and systems as well as management I tal costs of scaling-up investments or health interventions to achieve the set target lev- and administration costs. Even though the expected increase in government expenditure els during the whole period (2002 – 2015) amount to about US$4,981.24. These total in these prioritised areas seems substantial, equivalent to an annual average growth rate incremental costs can be decomposed into annual expenditures for the two simulated of about 12.07% in real dollars terms, the increase apparently can only raise the per space scenarios. For the 2007 and 2015 space scenarios the annual average expendi- capita public health expenditure minimally from $6.07 in 2002 to about $9.57 in 2007 ealth tures run at US$190.73 and US$479.61 million respectively. For the years running the and to only US$11.76 by 2015. These estimates do not only fall short of the CMH recom- H additional annual expenditures are expected to increase from about US$123.19 million mendations but fall far below that, which, in the view of the technical committee of the in 2002 to about US$257.75 million by 2007 or to US$787.17 million by 2015. These addi- GMHI, could achieve the tripartite goal of improving health care, economic growth and tional expenditures are expected to allow Ghana to increase its per capita public health poverty reduction. This situation underscores the urgent need to scale-up investment in expenditures additionally by approximately US$12 in 2007 and by about US$31 in 2015. and

health care in Ghana to facilitate the country to achieve the set higher health outcomes s These additional per capita health expenditures are likely to raise the total public health and poverty reduction. expenditure per capita to about US$21 and US$40 by 2007 and 2015 respectively. These expenditure levels are not only comparable to international standards but are also likely Let us now compare per capita indicators of this health financing plan with other alterna- to allow Ghana to achieve the per capita health expenditure levels seen by the CMH and tive options that possibly can be resorted to by the government to finance improved health WHO as minimum levels for developing countries for achieving the MDGs. We reiterate care in Ghana. These alternative health financing options include the financing plans at this juncture that the incremental health expenditure estimates give an idea of the under the Programme of Work of the Ministry of Health30. The POW covers the whole magnitude of resources, which need to be spent on annual basis in addition to the already budget of the Ministry of Health. It includes resources such as Government of Ghana planned government health expenditures, in order to reach the target coverage levels. funds, internally generated funds, and donor funds which are consistent with the “Sector Wide Approach” (SWAp)31. The financing plan of the POW II operates with a low case 32 Cost in relation to GNP scenario and a high case scenario . Applying the accounting principle of prudence our acroeconomic analysis uses the low case scenario of the financing plan of the POW II. Under the low M The additional preliminary resource costs with respect to predicted GDP for the period case scenario of the POW II the per capita health expenditure is expected to rise from 2002 and 2015 are presented in table AIII in the appendix. It was assumed that the GNP US$8.36 in 2002 to about US$12.34 in 2007 and US$16.45 in 2015 (table AV). This per would grow by an average of 5% annually. According to the results of our analysis, the capita expenditure, however, does not come anywhere near the GMHI recommended incremental resources claim on the GDP by the health sector is estimated to range bet­

minimum health expenditure target of $21 per person per year by 2007 or US$40 by 2015, hana ween 2% and 5% of GDP during 2002-2015. The average health expenditure-to-GDP

which can allow Ghana to catch up in its drive to meeting the Millennium Development G ratio for the period under review is equivalent to 2.9% (see table AIII). Goals of improved health outcomes for the poor and hence reduce poverty.

Even though a great deal of effort has gone into the attempts to analyse costs of scal- Another alternative resource envelope is a financing strategy with which the MoH envis- ing-up investment or health interventions to higher levels, the costing for programmes ages to fulfil the Abuja declaration33. The Abuja Declaration requires that the contribution and projects cannot be definitive. For this reason the precise estimation of the cost of of the Government of Ghana in terms of budgetary allocations to the health sector be activities will be one of a continuous exercise, which would give room for consideration increased from the present low level of about 8% to 15% by 2007. We present in table of specific activities which could not presently be predetermined. AVI the projected graduated resource shifts envisaged by the Ministry of Health. The for better health, economic growth and accelerated poverty reduction s Potential Available Resource Envelope 30 The POW is a 5-year rolling plan of action which spells out in more detail the key priorities and activities to be As has already been pointed out the estimation of the present or potentially available or implemented in any particular year and the resources to finance these activities. Its root goes back to 1997 when the eport of the

Ministry of Health, against the background of growing financial distress of the health sector, the government initiated R earmarked resources allows us to undertake an analysis of the resource gap, i.e., what is a 5-year programme of work for the Ministry of Health, which spanned the period between 1997-2001, with the main additionally necessary to scale-up investment in order to achieve the set higher health objective “to increase overall resources in the health sector.” The current running 5-Year Programme of Work II (2002- s tment 2006) clearly presents Government’s agenda for improving the health status of all Ghanaians and reducing inequalities outcomes. The potential resource envelopes show the alternative financing plans available in access to services. It spells out the key objectives and targets and sets out the priorities, strategies and resources to the government of Ghana in executing its functions with respect to health care. This required to achieve them. The financing plan of the POW II operates with a low case scenario and a high case scenario. The low case, which we use for our analysis is presented in table AV in the appendix. cost analysis exercise uses the rolling health financing plan of the projected government 31 SWAp is an approach that emphasises one single sector programme that is owned by the government, accepted and budgetary allocations to the health sector overtime, which have been developed on the supported by development partners/donors and all stakeholders. 32 The low and high case scenarios reflect two different views about the financing plans of the Ministry of Health with basis of set health objectives. These estimates are presented in table AIV. As can be seen respect to its programme of work. In the low case the Ministry of Health takes a less optimistic view of the resource in the table AIV, from an estimated annual health care costs of about ¢899.1 billion for flows from potential donors, whereas in the case of the high case scenarios the ministry maintains a more optimistic expectation of the inward flows from outside. 2002 the government, if we extrapolate its 3-year rolling budget into the future, can be 33 Ghana Health Service (2002) Financial Sustainability Plan Of The Expanded Programme on Immunisation, Submitted on 20 November 2002 to the Global Alliance for Vaccines and Immunization (GAVI) and the Vaccine Fund.

88 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 89 Scaling-up health inve basis of the financing strategy is the assumption that the Government of Ghana will ary expenditure of the previous past five years. Underlying this is the assumption that work towards meeting the Abuja commitment to the health sector. It thus begins with the actual expenditure trends in the past would continue in the future. We present the a graduation from an 8% in 2002 to 15% of total government budget in 2007. For the preliminary total resource requirements and resource gap for scaling-up investment in period following 2007 we assume in the face of lack of data that it would plateau at that the health sector necessary to meet the set health targets in table AVII. The resource gap nitiative level. Coupled with this assumed gradual increase in government budgetary allocations arises where the total resource requirement for achieving the set health targets to achieve I to the health sector, as we can observe in table AVI, is an apparent gradual increase in the health MDGs exceeds the available financing resource envelope. per capita public health expenditure from US$6.56 in 2002 to US$13.52 in 2015. But this We present the estimated resource requirements, the resource envelopes and resource increase is also woefully inadequate to bring about any appreciable increase in health gaps of the various health financing options according to the various time scenarios in outcomes towards the achievement of the health MDGs. ealth table 3.4. Detailed results are presented in tables AV, AVI and AVII. H We represent in figure 3.1 the per capita health public expenditure indicators of the vari- ous alternative resource envelopes available for health care financing. From the figure we observe that per capita health expenditures of the alternative financing options are likely to

increase over time. In spite of that all the various financing plans, which rely on government and budget allocations, POW II of the Ministry of Health and the resource shifts under the s Abuja Declaration, fall substantially short of fulfilling the recommendations of the CMH to shift resources towards health care to the level of about US$40 per person by 2015 so as to achieve substantial improvement in health care and poverty reduction. The financing option from POW II provides the first best alternative, with the Abuja option attaining the second best position in terms of per capita expenditure, whilst the option which relies on government budget allocations can be seen as the least best financing option in fulfilling the recommended per capita requirement necessary for achieving the MDGs.

Figure 3.1 Per capita Public Health Expenditure according to possible acroeconomic

alternative Financing Options M

18 POW II 16 Abuja 14 Declaration hana G $

US 12 Budgetary 10 Allocations

8

6 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

for better health, economic growth and accelerated poverty reduction Resource Gap Analysis s

A gap is sometimes spoken of as “the space between where we are and where we want to eport of the

be.” Hence a gap analysis is undertaken as a means of bridging that space. It is therefore R the study of the differences between two different systems, often for the purpose of deter­ s tment mining how to get from old state to a new desired state. In our case the gap analysis is supposed to determine the difference between the present low levels of health investment and a scaled-up investment level that allows the achievement of higher health outcomes. As mentioned earlier the resource gap analysis was conducted using the resource enve­ lope from the projected annual government budgetary expenditure of the health sec- tor to achieve the set high coverage levels or the MDGs. The projected annual actual government budgetary expenditures of the health sector were extrapolated into the period 2002-2015 with the help of a trend regression of the annual actual government budget-

90 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 91 Scaling-up health inve Table 3.4 Estimates of Resource Requirements, Envelopes and Gaps by Health identified donors who have already committed themselves. Since the existing pledges are Financing Options voluntary ones, it should be difficult on the part of the government to approach them with Financing Options additional requests for assistance to fulfil its intent to scale up investment in the health sector to achieve the MDGs and poverty reduction. nitiative

Govt Budgetary Abuja I POW II Allocations Declaration Total Resource Requirements Proposed Capital Investment Plan 2002-2007 2 060.08 2 060.08 2 060.08 The capital investment plan is designed to address the overall priority areas of the sector,

covering infrastructure development of health systems, new and replacement of equipment ealth 2008-2015 5601.99 5601.99 5601.99

and transport in stated intervention strategies, geographical equity concerning access, H 2002-2015 7 662.07 7 662.07 7 662.07 service packages, rehabilitation and expansion of training institutions and improved staff Total Resource Envelope accommodation. The plan is built upon a policy objective of equitable scaling up of a new close-to-client bottom-up service delivery structure. This new bottom-up structure,

2002-2007 915.70 1 069.89 1273.21 and which is anchored at community level, is illustrated in section 2.5. s 2008-2015 1765.15 2398.74 2789.75 Already the Ministry of Health has developed a five-year capital investment plan for the 2002-2015 2 680.85 3 468.63 4 062.96 health sector, which covers the period 2002-2006 within the framework of the POW II. Total Resource Gap Our simulated new investment plan, summarised in table AVIII, should therefore be 2002-2007 1 144.38 990.19 786.87 seen as just a revision of that under POW II to reflect the scaled-up new health system to deliver a certain level of close-to-client services in the field of health care and water 2008-2015 3 836.84 3 203.25 2 812.24 and sanitation to a defined target population. The investment plan also puts emphasis on 2002-2015 4 981.22 4 193.44 3 599.11 systemic approaches to address absorptive capacity constraints. Using the WHO human As table 3.4 illustrates the resource gap for the period 2002 -2015 ranges from a low level resource scenario model, the report estimates staff requirements and incremental costs of the human resource gap to include in the total resource costs of scaling-up health

of US$3,519,11 using the POW II financing option to a high level of US$4,981.22 using the acroeconomic annual government budgetary allocations as the alternative health financing option. The interventions to achieve the MDGs. M largest resource gap as reflected in the difference between the total resource requirement The plan proposes to allocate almost 70% of the capital investment resources to the dis- of the various financing plans and potential available resource envelope is represented trict and sub-district level institutions to implement the proposed close-to- client strategy by the financing plans with regard to annual budgetary allocations. This resource gap to address the epidemiological and systems evidence, particularly for the poor. It estimates

presents the best possible alternative financing plan, from the government’s point of view, additional costs for human resource to facilitate the scaling-up exercise to be equivalent hana

because it is that which ensures that the government will be able to offer the contribution to 69% of total resources for management and administration or about 26% of total incre- G or resources required of it. Even though this gap may require the government to make mental costs of scaling-up health interventions during the period 2002-2015. The total least contribution itself toward improving health care, it is, however, that which may incremental cost of catering for the additional human resource need for the scaling-up is necessitate the mobilisation of huge external resources. However, given the difficulty on estimated at US$1,302.25 million for the whole period 2002-2015 (see also table 3.15). the part of the government in mobilising even donor pledged resources at the right time The basis of this new plan is, however, the level of adequate infrastructure (health facili- in the past, it may be very difficult to implement this scenario. ties) required to deliver an optimum close-to-client health (CHPS) system. The plan The second largest resource gap is the one built on the resource envelope from commit- builds on the premise of addressing the gap between the present status of health facilities ments under Abuja declaration, which stipulates a health-expenditure target of 15% rela- and systems, and the ideal situation of health infrastructure that facilitate the achieve- for better health, economic growth and accelerated poverty reduction s tive to government expenditure annually by 2006. It is also the scenario, which obliges the ment of the recommended health targets.

government to contribute increasing resources to the health sector on its own. However, eport of the given the competing demands on available government resources, it is unlikely that it can Resources Allocation by Line Item R allocate such high increasing resources to the health sector in so short a time. s tment The policy guidelines for resource allocation of the Ministry of Health can be listed as The smallest resource gap results from the financing scenario involving financial flows follows: i) make resources available for the attainment of universal access to primary secured by the POW II and represents, probably, the best alternative scenario, because the health services, ii) achieve a better balance between development and recurrent budgets, available resource envelope comprises only finances which have already been pledged or and iii) realign existing inequalities in regional allocations (World Bank 2003). With committed by specific or identified donors and the government for the health sector in the regard to resource allocation the scaling up does not plan any major shift from the near future. Moreover, it is that which represents the smallest resource gap, as illustrated targets of the POW II, especially during the period of the 2007 scenario, but adopts a in table 3.4. The resource gap therefore represents the additional resources that must be top-up approach. However, it is important to note that there may be slight changes in the mobilised from external sources such as GAVI, GFATM, etc., possibly, other than the

92 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 93 Scaling-up health inve percentage allocation of the total budget of a programme depending on the size of the The recommendation for the sharp increase in investment expenditure is against the respective resource envelope available. background of the less than expected progress made towards the strategic objectives of the 5-year programme of work. This is also in response to the observed decline in In the past the Ministry of Health has classified its expenditure into two main components, allocations to the districts, where the poor mostly reside and which are in dire need of viz: recurrent and capital or investment expenditure. Available records of the Ministry, nitiative investments in infrastructures. Hence the present scaling-up of investment exercise puts I however, show sharp increases in recurrent expenditure since the mid nineties, leading the focus on poverty reduction by targeting the poor through allocation of a large propor- to a downward trend in investment expenditure. As can be seen in Table 3.4, investment tion of the resource envelope for scaling-up to the districts and sub-district health systems expenditure, for instance, has declined from a high level of 44% of total health expen- whose services benefit the poor. Such a focus of the scaling-up dovetails into the broad diture in 1997 to about 9% in 2001 (Table 3.5). However, to be able to provide effective policy objectives of the GPRS of providing basic services to the poor at the community ealth health care and thus achieve the MDGs, it is necessary to direct expenditures towards the level by redirecting resources to enhancing health access and reducing geographical H provision of drugs, materials, buildings, transportation, health systems, equipment and inequities of deprived regions. maintenance of existing facilities. In order to achieve an appropriate balance between the input mix of recurrent and other non-recurrent items as well as achieve the set targets, it » Capital Investment: On the whole an average of about 50% of the total incremental

is important under the scaling-up effort to shift resources towards investment, so as to resource envelope available for investment for the 2007 scenario would be earmarked and at least achieve the investment levels of the mid-nineties. for civil development (See Table 3.7). This is expected to increase to 54% during the s Table 3.5 Percentage Distribution of Health sector Expenditure by Line Item, implementation of the 2015 scenario. The capital investment shall cover civil works, 1997-2002 equipment, transport and facilities maintenance. For the whole of 2002-2015 the resource allocation within the proposed Capital Investment Plan (2002-2015) shall be Actual Plan shared with an average of about 53.08% going to civil works and 39.54% to equipment, Line item 1997 1998 1999 2000 Est. 2001 2002 whilst about 6.29% and 1.11% go to transport and facilities maintenance respectively 1: Personnel (see Table 3.7). 23 25 35 34 42 32 emoluments Table 3.7 Planned Distribution of Investment Resource Envelope by Activity 2-3: Administration – (US$ million and %) 33 44 49 49 49 63

and Services acroeconomic Type of Capital 2002-

4: Investments 44 31 16 17 9 5 Investment Activity 2007 % 2008-2015 % 2002-2015 % M Total in % 100 100 100 100 100 100 Civil Works 337.60 50.00 1 222.43 54.00 1 560.02 53.08 Total (in bn. Cedis) 325 360 398 644 874 987 Equipment 256.57 38.00 905.50 40.00 1 162.07 39.54

% Wages/Total Transport 70.89 10.50 113.19 5.00 184.08 6.26 hana 41 37 41 41 47 34

recurrent G Facilities Maintenance 10.13 1.50 22.64 1.00 32.77 1.11 Note: Subventions mainly consists of subsidies to the mission sector for wages. Total 675.19 100.00 2 263.75 100.00 2 938.94 100.00 Source: Mick Foster et al., MOH Financial statement 2000, MOH Financial report 30/9 2001, Consolidating Statement of Revenue and Expenditures by BMC group, for the year ending 31/12/2001; Exhibit G. (MOH August 2002) About 10-18% of resources earmarked for investment, would be designated for tertiary and central administrative units. It is planned to allocate almost 70% of the capital The recommendation therefore is to allocate about 59% of the total incremental resource investment resource to the district and sub-district level institutions to give the policy envelope available for scaling-up to capital investment in health systems and infrastructure. linkage of the scaling-up exercise to the broad policy objectives of the Ghana Poverty Projections for implementation costs can be approximated at 3-5% of the total cost of scal- Reduction Strategy.

for better health, economic growth and accelerated poverty reduction ing-up health interventions to achieve the MDGs. The rest of the projections which come s to about 38% is estimated to cover management and administrative costs (Table 3.6). » Personnel remunerations: Owing to the dire consequences of the drain of qualified

staff from the health sector, it is proposed to increase the share of the total resource eport of the

Table 3.6 Distribution of Major Cost Components of Scaling-up (US$ million) R envelope for personal emoluments from initial 22% of total resource envelope available % for scale-up successively to 35% in 2007 and stabilise it around 30% during the 2015 s tment Major Cost Component Share Amount scenario. It is expected that incentive payments or staff remuneration additional to Investment in Health Systems and what the government already pays would account for about 69% of the total resources 1 59 2 938.93 Infrastructure (Capital Investment) available to management and administration. This increase is intended to facilitate 2 Implementation Costs 3 149.44 recruitment of new and qualified as well as to maintain old essential staff. 3 Management and Administration Costs 38 1 892.87 » Non-wage costs: Since wages and non-wage recurrent costs take a heavy chunk of the resources available to the health service, efforts would be made under the programme Total 100 4 981.24 to realign these costs toward capital investment. For this reason, it is envisaged to

94 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 95 Scaling-up health inve reduce the total resource envelope for administration and services successively from each region will need a referral hospital. The current situation will therefore require the its present level of 49% to about 42% by 2007 and then stabilise it at about 38% during refurbishment of all the existing regional hospitals and the construction of an additional the 2015 scenario. ‘regional hospital’ for the Ashanti Region. About 20 health centres shall also be upgraded to district hospitals to meet increasing demand. A major civil work at the national level nitiative Resource allocation by level of service will also be the construction of an office block complex to house the newly created Ghana I Health Services. As part of this plan the epidemiology block shall be rehabilitated. Owing Considering the resource allocation under the POW II it is recommended under the to the enormous demand for medical doctors there shall be the need to raise the status Macroeconomics and Health Strategy to shift more resources between the institutional of some two additional regional hospitals to teaching hospitals. This could imply the

levels in favour of non-wage recurrent expenditure. This is necessary in view of the upgrading of the Tamale regional to teaching hospital to cater for the needs of students ealth

change to close-to-client (CHPS) strategy for delivering services, which puts emphasis on in the University of Development Studies in the Northern Region. H engaging communities, districts and users in the planning and delivery of health services. Table 3.9 Number of Facilities available and Number Needed The relative share of non-wage recurrent resources meant for the districts would increase successively from about 43% in 2002 to about 52.7% in 2007 (Table 3.8). The sources of Number of Additional these shifts include cuts in non-wage recurrent expenses at headquarters (MOH-GHS and Facilities Structures and Level needed Current Situation Needed s statutory bodies). Both the tertiary institutions and regional health services may have to give up a small amount of money to the districts to enable them carry out their intended 6 CHC’s X 6 Community level Subdistricts X close-to-client (CHPS) health services. – Community 139 Districts = Table 3.8 Health Sector Non-Wage Recurrent Budget Allocations compounds 4896 47 + (374 Clinics) 4475 (budget line items 2-3), Percentage Distribution 6 Health 2002 2003 2004 2005 2006 2007 Sub-district Level Centres X 139 – Health Centres Districts = 834 488 346 Headquarters (MOH-GHS 16.8 16.0 15.8 15 14.0 13.5 + statutory bodies) 139 District District Hospitals Hospitals 62 + 10 67

Tertiary Institutions 18.6 18.0 17.5 17 16.2 15.5 acroeconomic Regional Hospitals 10 9 1 Regional Health Services 19.8 19.5 18.5 18.0 17.0 16.0 M Teaching Hospitals 2 2 District Health Services 42.6 44.3 45.9 47.7 50.5 52.74 There shall be a general rehabilitation of all health facilities at all levels when and where CHAG/Mission sector 2.2 2.2 2.3 2.3 2.3 2.26 needed. Along the lines of the POW II the focus of the plan shall be on the major reha- Total 100 100 100 100 100 100 bilitation of all existing regional hospitals to the required technical level. In recognition hana of the fact that human resource is a major constraint to the scaling-up of health inter- G Civil Works ventions in Ghana it is proposed to rehabilitate and expand all training institutions for medical personnel as well as construct new ones, especially, for highly qualified special- In the view of the technical committee of the GMHI, any “ideal” scaled-up health system ists training, like a College Surgeons. This is to meet the need to provide the support for should be capable of addressing the gap between the present status of health facilities increased students intake and also address the perennial problem shortage of staff as well and systems, and the ideal situation of health infrastructure that would facilitate the as meet the national international requirements. In order to fulfil the main goal of the achievement of the MDG health targets for Ghana. In Ghana the system with such scaling-up exercise, i.e., to improve health and reduce poverty, the capital investment plan capabilities is the CHPS, which comprises a set of CHPS zones within a sub-district, sub- envisages to allocate about 70% of all civil works and medical equipment expenditures for better health, economic growth and accelerated poverty reduction district health facilities (health centres) providing technical backstopping for these zones s to the district and sub-district levels. and at least a district hospital providing referral services for the Sub-district structures It must, however, be pointed out that, it may not be possible to build the whole “ideal” health eport of the

as depicted in figure 2.9. In line with the expected roll out of CHPS strategy, such an R ideal health system for Ghana would require about 4,475 additional Community Health system as described above, during the period under review (2002-2015), due to absorptive s tment Compounds to be constructed at the community level (see table 3.9). In addition to that, capacity constraints. It is proposed to ensure the completion of about 80% of it during the about three hundred and forty-six – 346 – new health centres will have to be constructed period under review, so as to support the achievement of the MDGs. From the new invest- at the sub-district level to enhance access to health care and also ensure equity in the ment plan it is envisaged to cull out annual capital investment plans, to be developed using distribution of health facilities. These numbers are derived from the assumption that the integrated capital investment model, which would focus on a theme. For instance, the each of the 139 districts in Ghana will have an average of six sub-districts, with each focus for 2004 capital programme is expected to be “improving equity in access to services sub-district being allocated with at least a health centre, against the background of the and efficient implementation of the planned preventive maintenance programme”. fact that a properly located district hospital will provide adequate referral support for the sub-district constructed at the district level. With this kind of health system as outlined,

96 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 97 Scaling-up health inve Medical Equipment and appropriate transfer of patients and timely delivery of vital medical supplies. For this reason the capital investment plan projects to allocate about 6.26% of the total projected In this ‘high-tech’ era medical equipment do not only directly affects the quality of treat- plan expenditure to transport, and equivalent to about US$184.08 million. The gross ment patients receive, but can lessen considerably the absorptive capacity constraints list of transport schemes under the capital investment plan includes saloon vehicles to nitiative

faced by a health system. It is therefore important to include the acquisition of efficient I be allocated to health personnel as part of the enticement package for working in the new and rehabilitation of existing medical equipment in the capital investment plan at country and is presented in table AX. all service levels, with the view to expanding service delivery or at least maintaining the status quo. Absorptive Capacity Constraints

Using the format of the Ministry of Health the medical equipment to be procured shall ealth

be categorised as follows: Considering the low level of health status of Ghanaians and the resource constraints H facing the sector, scaling-up health investment can be considered critical to the success 1. Health facilities Systems Development: This may include the procurement of new of achieving improvements in health outcomes, economic growth and poverty reduction. equipment, intra and internal level upgrading to meet standard requirements or to new However, it must be pointed out that the presence per se of resources does not in any way

higher levels and major rehabilitation of existing facilities. and guarantee the translation of such into effective programmes that may lead to the achieve- s 2. Replacement to maintain status quo of existing facilities: The main goal shall be to ment of the expected outcomes, for there may yet be other factors that act as constraints to introduction of better technology to improve upon service quality and efficiency of the efficient utilization of resources34. For this reason it is important, for any wide-ranging service delivery. Under this category it is important to scale-up the installation of X-ray effort to scale up health-related priority interventions, to identify the factors which will equipment under the Country-Wide Diagnostic Imaging Project and the replacement hamper the widespread implementation of these interventions, particularly amongst the of laundry Equipment. poor, and the options that are available to deal with these. These factors that restrict or limit the pursuit of desired outcomes or goals can be broader than inputs per se, and can 3. Upgrading of Technology: In order to improve efficiency, safety and quality of health also include processes or functions. Hanson and others (2001) have, in their attempts to services, it is proposed to upgrade existing facilities with new technology. measure the constraints, categorized these constraints according to the different levels 4. Introduction of new Services: Such services may be centrally driven equipment input- of operation of the constraints as shown in table AXI. This categorisation highlights the

outside to cater for crisis containment, which may also bring about expansion of health level of control held by Government in relation to necessary changes. acroeconomic

services or improved delivery. M Given these constraints it is important that as Ghana begins to scale up health intervention Table AIX presents a gross list of detailed proposed medical equipment to be procured programmes, emphasis is put on systemic approaches which address absorptive capacity. by destination. Where possible, projections have been undertaken for various categories One of such critical absorptive capacity, that is key to success, is labour, since any effort on of medical equipment narrated above on the basis of unit costs. About 40% of the total the part of the government to achieve a better coverage of people with priority health ser- hana incremental resource envelope meant for capital investment activities or an equivalent of vices requires human resources to implement them (Wyss et al 2003, Hanson et al 2003). about US$1,162.07 million, have been earmarked for the procurement of medical equip- G ment during the period under consideration. It is projected to spend about US$256.57 Human Resource Constraint million or 38% of the projected sum for medical equipment procurement during the period between 2002 and 2007, whilst the rest of US$905.50 is spent during 2008 – 2015. The provision of human resources in adequate quantity and with appropriate competence As can be read from table AIX, expenditures at the district and sub-district levels account to provide health care services is critical to scaling-up health interventions in any country. for about 70% of the projected total bill for medical equipment. Given the fact that most Ghana is presently severely short of qualified human resources for health. This can be of the poor in Ghana live in these areas, we believe a commensurate high proportion to attributed partly to the low production levels of medical personnel by the available train- these areas will give the policy linkage of the scaling-up exercise to the broad policy of ing institutions, which always fall short of annual requirements. In 2002, for instance, for better health, economic growth and accelerated poverty reduction s the GPRS. For this reason the investment plan similarly recommends the allocation of the medical training schools in Ghana produced only 159 physicians as against a higher

about 70% of the civil works and other expenditure to the district and sub-district level potential demand of over a thousand. This situation is also exacerbated by the high rates eport of the

to target the provision of basic services to the poor. The total number of the respective of emigration of trained professionals, inequitable distribution of staff and great disparities R equipment includes replacements of equipment which may come out of use due to usage between the urban southern regions and the more rural northern ones. This has resulted in s tment during the period under consideration. a far cry of medical personnel-to-population ratios in Ghana that can hardly support the optimal running of the present health system, let alone any scaled-up health system. For Transport instance, the Ghana Service Provision Assessment (SPA 2002) estimated for the year 2002 a doctor-population ratio of about 8,554 as compared to the internationally recommended Transport is of obvious importance in health service delivery by providing spatial mobility levels of 1:5,000 and 1:1,320 by the Commonwealth and WHO respectively, or to 1:300 by of health personnel, by facilitating outreach services to the isolated and rural population in need of health services, which make up over 65% of the total population of Ghana. It 34 In addition to absolute lack of resources, access to health interventions is hindered by problems of demand, weak is also a more important factor in the providing quality health service by ensuring safe service delivery systems, policies at the health and cross-sectoral levels, and constraints related to governance, corruption and geography (Hanson et al 2003).

98 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 99 Scaling-up health inve European standards. As can be seen in table 3.10 these personnel-population ratios mark Not only is Ghana losing medical doctors but also nurses. The attrition of nurses has, not only wide geographical disparity, but also by type of practitioner. however, reached alarming proportions during the past 5 years. It is estimated that Table 3.10 Selected Health Staff Population Ratio (both public and private) Ghana has lost about 50% of its professional nurses to United Kingdom, United States of America and Canada in the last 10 years. The available records show that about 1,209 nitiative

Doctor- Nurse- I Nurses left Ghana in 2002 compared to 387 in 1999. Even the Enrolled Nurses categories Nr. of Nr. of Population Population Regions Pop 2000 Doctors Nurses Ratio Ratio (non professional grade) have found a niche in Canada and are also leaving. Up to 3000 nurses have left the Public health services in the past six years (see table 3.11). Western 1 924 577 122 1 361 15 775 1 414 Table 3.11 Migration and Destination of Ghanaian Nurses

Central 1 593 823 104 1 427 15 325 1 117 ealth

1998 1999 2000 2001 2002 2003 total H Greater Accra 2 905 726 1 016 5 694 2 860 510 USA 50 42 44 129 81 80 426 Volta 1 635 421 103 1 895 15 878 863 UK 97 265 646 738 405 317 2468 Eastern 2 106 696 132 2 429 15 960 867

Canada 12 13 26 46 33 10 140 and

Ashanti 3 612 950 509 2 250 7 098 1 606 s South 9 4 3 2 6 24 Brong Ahafo 1 815 408 113 1 493 16 066 1 216 Africa Northern 1 820 806 42 1 104 43 353 1 649 Others 4 4 8 8 5 29 Upper East 920 089 43 874 21 397 1 053 Total 172 328 727 923 530 407 3087 Upper West 576 583 27 524 21 355 1 100 Source: Ghana Nurses Seeking Verification: Country & Year (Ghana Nurses and Midwives Council) National 18 912 079 2 211 19 051 8 554 993 The increasing outflow of medical personnel has worsened the already precarious human Source: Ghana SPA 2002 resource situation and created a human resource gap in the health sector, which as an important “bottleneck” seems not only to limit the return on investment in the health

Whilst, for example, the ratio for private sector practitioners was estimated to be about acroeconomic 1:20,357, the ratio for the public sector was about 1:14,752. The nurse-population ratio sector but also poses a serious threat to any scaling-up effort; and possibly to economic M followed a similar trend. The private sector showed a ratio of about 1: 3,675 whereas growth and poverty reduction in Ghana. that for the public sector was about 1:1,295. On the other hand the large shortage of medical personnel is also worsened by an inequitable distribution of health personnel, Bridging the Human Resource Gap

with over 80% of various categories of health personnel, with the exception of medical hana The prevailing human resource gap in the country raises the issue of the absolute norm

assistants, community health officers and field technicians, being concentrated in certain G regarding the “right” ratio of medical personnel to population. The consensus is that regional centres. For instance, the doctor-to-population ratio ranges from 1:2,137 in the there exists no such right norm and that this may depend upon a number of factors36. In Upper East to 1:43,352 in the Northern Region as opposed to 1:300 and 1:287 in UK and the following we attempt to simulate or project workforce requirements for the health Germany respectively. The nurse population ratio ranges from 1:1,380, Eastern Region sector which can ensure the achievement of the set targets for the MDGs. The literature to 1:4,198 in Brong . discusses various projection methods including health worker-to-population ratio37, Of late the human resource problems seem to be compounded by a high rate of internal and externals attrition. The public sector is losing large numbers of its health workers primarily to the private for profit sector but equally and to mission health institutions. for better health, economic growth and accelerated poverty reduction

s The more serious threat seems to emanate from external attrition. The situation is no

different with other health workers such as nurses, pharmacists and laboratory techni- eport of the

cians. The State of the Ghanaian Economy Report for 2002 (ISSER 2003) notes that 68.2 R per cent of medical officers, trained between 1993 and 2000, have left the country. The s tment major beneficiaries of Ghana’s loss of medical personnel include the US, UK, Germany and Canada. The United States of America, for instance, is estimated to be employing 1,200 physicians of Ghanaian origin; whilst United Kingdom and Germany35 have about 36 These factors may include 1) demand factors, e.g. demographic and epidemiological trends, service use patterns, and macroeconomic conditions; 2) supply factors, such as labour market trends, funds to pay salaries, health professions 300 Doctors respectively, South Africa 150 and Canada 50. On the whole there seem to education capacity, licensing and other entry barriers; 3) factors affecting productivity, e.g. technology, financial be more Ghanaian doctors working outside the country than inside Ghana. incentives, staff mix, and management flexibility in resource deployment, and 4) priority allocated to prevention, treatment, and rehabilitation in national health policies. Generally, shortages or oversupply are assessed based on comparisons with countries in the same region or at the same level of development. 37 The, health worker-to-population ratio, as the most common method, specifies the desired worker-to-population 35 Most of the Ghanaian doctors in Germany comprise largely those trained in Germany and have decided to stay and ratio(s), using often current best region ratio or a reference country with a similar but presumably more developed health work there. sector or an internationally recognised norm.

100 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 101 Scaling-up health inve needs-based38, demands-based39, target-setting40 or the managed care methods41, which a reduction of the doctor-to-population ratio from its high level 1:8,554 to 1:5,000. It is may convert population into health personnel, either directly or indirectly. We shall, also assumed that that local production of medical doctors would increase in the course however, adapt the WHO scenario model, which develops alternative scenarios of a future of scaling-up investment in the health sector to reduce the external recruitment to about health care system and projections for its human resource requirements, because of easy 32 in 2015. Assuming a monthly salary of about US$1,000 for a doctor, we simulate for the nitiative availability of most core data from existing sources. period 2002-2015, an annual average cost of about US$16.07 million. This gap and cost I represent the incremental resources that must be mobilised to enable the achievement For our projections we shall assume all active health workers to be in one of following of the MDGs or the set targets. locations: Table 3.12 Simulation of Potential Medical Doctor Demand Gap, 2002-2015

1. Public sector hospitals (including clinics); ealth

2. Public sector ambulatory facilities without beds; H

3. Academic settings (eg, medical schools);

4. Non-clinical public health settings (eg, MoH, provincial public health departments); and etirement R 5. Private sector. s raining, Death urrent Status osts xpected New Year Population C Doctor needed Loss to Attrition, T and Graduates Adjusted Ghanaian Workforce Disparity C E Under these assumptions we shall determine the health care staff needs by 1 2 3 4 5 6 7 8 » Projecting numbers of hospitals and ambulatory facilities, by type (acute care, chronic, 5000 3+6-5 4-7 preventive, large, small); 2002 18.91 2211 3 782 221 168 2 158 1 625 19.49 » Determining the satisfactory level of base year population per facility and distribution of hospital beds; 2003 19.42 2158 3 885 216 176 2 119 1 766 21.19

» Dividing the projected population by assumed facility-to-population ratio to determine 2004 19.95 2 119 3 989 212 185 2 092 1 898 22.77 number of facilities required; 2005 20.49 2 092 4 097 209 194 2 077 2 020 24.24 acroeconomic » Assuming staffing norms for each type of facility; 2006 21.04 2 077 4 208 208 428 2 297 1 910 22.93 M

» Multiplying target year facilities of each type by staffing norm to determine clinical 2007 21.61 2 297 4 321 230 449 2 517 1 805 21.65 staff requirement; and 2008 22.19 2 517 4 438 252 494 2 759 1 679 20.14 » Adjusting the ratio to achieve a desired balance between facilities and population. 2009 22.79 2 759 4 558 276 544 3 027 1 531 18.37 hana

On the basis of this methodology we present in table 3.12 estimates of staff require­ 2010 23.40 3 027 4 681 303 598 3 322 1 359 16.30 G ments and incremental costs of the human resource gap to include in the total resource 2011 24.04 3 322 4 807 332 658 3 648 1 160 13.91 costs of scaling-up health interventions to achieve the MDGs. According to the Service 2012 24.69 3 648 4 937 365 724 4 007 931 11.17 Assessment Report 2002 the health service employed about 2,211 doctors, comprising all categories of doctors, in 2002. Our analysis, however, estimates about an annual aver- 2013 25.35 4 007 5 070 401 796 4 402 669 8.02 age doctor-staff requirement of about 2,962 during the period 2002-2015. Considering 2014 26.04 4 402 5 207 440 875 4 837 370 4.44 external and internal staff attrition due to emigration, training and retirement as well as 2015 26.74 4 837 5 348 484 963 5 316 32 0.38 expected new graduates entering the service, our simulation calculates an annual average

for better health, economic growth and accelerated poverty reduction doctor resource gap equivalent to about 55% of requirement for the period. The results Total 2 962.36 4 523.43 296.36 518.00 3 184.14 1 339.64 16.07 s of our simulation of staff requirement for the health service is based on an assumption of

Assumptions: eport of the » Assumed annual population growth rate is 2.7%. R » Assumed annual attrition rate of working staff is 10%. 38 The needs-based method on the other hand, which is logical, and consistent with professional ethics, projects age- and » Expected rate of increment of new Graduates between 2002-2005 is 5%. Rate in 2006, when construction of new training s tment gender-specific “service needs” on the basis of service norms and morbidity trends. It estimates the projected service institutions and expansion of existing ones might have been completed, is 220%. Rate after 2006 is 10%. needs by multiplying each projected population segment by projected service needs for that segment, before combining » Desired doctor-to-population ratio 1:5000. segment-specific needs to calculate national needs. » Assumed monthly salary of doctors during the period US$1000. 39 The demand-based method also measure health service utilization rates according to age, gender, income, education, insurance, etc. After projecting population for each “utilization category” and multiplying it by observed base year utilization rates, the projected service demands is then converted to personnel requirements using productivity norms. Similarly given that the service employed 19,051 nurses, comprising general and degree 40 Under specific assumptions about population size, characteristics, and priority service needs and demands, this method then sets targets for either numbers of services to produce, or numbers and types of health facilities and services to nurses, midwifes, as well as technical and other laboratory and medical assistants in calculate workforce required to satisfy target year assumptions. 2002 (see Table 3.13), we estimate an average annual nursing staff requirement of about 41 The managed care method identifies an existing health care provider or system that provides acceptable care at affordable cost as the “reference system” either in the country or another country. The norms observed in the reference 34,796 as against potential supply of only 24,407, leaving a potential gap of 8,813 nurses health system are then used as a basis for future planning.

102 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 103 Scaling-up health inve at a cost of about US$52.87 million. It is estimated that filling this gap would help reduce Our estimation of staff requirement for pharmacist for the health service in Ghana is the nurse-to-population ratio in Ghana from its present high level of about 1:993 to 1:650, about 1:4500 and ranges between 3.375 and 133 during 2002-2015 period (see Table comparable to international standards. Underlying the cost estimates is the assumption 3.14). Even though this benchmark it far higher than the recommended WHO standard that a nurse shall be paid an average monthly salary of US$500. of 1:2000 for a developed country, this, that notwithstanding, represents an improvement nitiative I Table 3.13 Simulation of Potential Nurses Demand Gap, 2002-2015 from the present pharmacist-to-population ratio of 1:7100. Out of the estimated average annual staff requirement of 5,026 against a potential supply of 2,162 our simulation calculates average annual pharmacist gap equivalent to about 57% at an average annual cost of US$24.07 million. This nurse resource gap is also confirmed by the vacancy

levels of about 57% estimated by the Ministry of Health in 2002 (Nyonator et al 2003). ealth force k The assumption for the cost estimation of the gap is that each pharmacist would earn a H monthly salary of US$800. Table 3.14 Simulation of Pharmacists Demand Gap, 2004-2015 and etirement raining, Death urrent Status osts of Gap (US$ xpected New Graduates Year Population C Nurse needed Loss to Attrition, T R E Adjusted Wor GAP C million) s

1 2 3 4 5 6 7 8 9 cists cists

1:650 3+6-5 4-7 a etirement lation R 2002 18.91 19 051 29 096 1 905 1 462 18 608 10 488 62.93 u raining, Death Death raining, urrent Status urrent osts of Gap (US$ Gap of osts xpected New New xpected Year Pop C Pharm needed Attrition, to Loss T and Graduates Adjusted Ghanaian Workforce GAP C million) E 2003 19.42 18608 29 881 1 861 1 608 18 355 11 526 69.15 1 2 3 4 5 6 7 8 2004 19.95 18 355 30 688 1 836 1 769 18 289 12 399 74.39 1 / 4500 3+6-5 4-7 2005 20.49 18 289 31 516 1 829 1 946 18 406 13 111 78.66 2002 18.91 810 4 203 81 99 828 3 375 32.40 2006 21.04 18 406 32 367 1 841 2 141 18 706 13 662 81.97

2003 19.42 828 4 316 83 119 864 3 452 33.14 acroeconomic 2007 21.61 18 706 33 241 1 871 2 355 19 190 14 052 84.31 2004 19.95 864 4 433 86 143 920 3 513 33.72 M 2008 22.19 19 190 34 139 1 919 4 709 21 980 12 159 72.95 2005 20.49 920 4 552 92 171 999 3 553 34.11 2009 22.79 21 980 35 061 2 198 4 945 24 727 10 334 62.00 2006 21.04 999 4 675 100 205 1 105 3 571 34.28

2010 23.40 24 727 36 007 2 473 5 192 27 446 8 562 51.37 2007 21.61 1 105 4 802 110 246 1 240 3 561 34.19 hana G 2011 24.04 27 446 36 979 2 745 5 451 30 153 6 827 40.96 2008 22.19 1 240 4 931 124 616 1 732 3 199 30.71 2012 24.69 30 153 37 978 3 015 5 724 32 861 5 117 30.70 2009 22.79 1 732 5 064 173 677 2 236 2 828 27.15 2013 25.35 32 861 39 003 3 286 6 010 35 585 3 418 20.51 2010 23.40 2 236 5 201 224 745 2 758 2 443 23.45 2014 26.04 35 585 40 056 3 559 6 311 38 337 1 719 10.31 2011 24.04 2 758 5 341 276 820 3 302 2 040 19.58 2015 26.74 38 337 41 138 3 834 6 626 41 130 8 0.05 2012 24.69 3 302 5 486 330 902 3 873 1 612 15.48 Total/ 24 406.71 34 796.43 2 440.86 4 017.79 25 983.79 8 813.00 52.88 2013 25.35 3 873 5 634 387 992 4 478 1 156 11.10

for better health, economic growth and accelerated poverty reduction Average Cost s 2014 26.04 4 478 5 786 448 1 091 5 121 665 6.38 Assumptions: eport of the » Assumed annual population growth rate is 2.7%. 2015 26.74 5 121 5 942 512 1 200 5 809 133 1.28 » Assumed annual attrition rate of working staff is 10%. R Total/ » Expected rate of increment of new Graduates between 2002-2007 is 10%. Rate in 2007, when construction of new training 2 161.86 5 026.14 216.14 573.29 2 518.93 2 507.21 24.07

s tment institutions and expansion of existing ones might have been completed, is 200%. Rate after 2007 is 5%. Average Cost » Desired Nurse-to-population ratio 1:650. Assumptions: » Assumed annual population growth rate is 2.7%. » Assumed annual attrition rate of working staff is 10%. » Expected rate of increment of new Graduates between 2002-2007 is 20%. Rate in 2008, when construction of new training institutions and expansion of existing ones might have been completed, is 250%. Rate after 2007 is 10%. » Desired Nurse-to-population ratio 1:4500.

104 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 105 Scaling-up health inve On the whole it is estimated that additional costs for human resource to facilitate the scal- 1. Determine the facility coverage for water and sanitation in the rural communities of ing-up exercise would be equivalent to about 69% of total resources for management and Ghana administration or about 26% of total incremental costs of scaling-up health interventions 2. Establish the anticipated demand for the various technologies based on a criterion of during the period 2002-2015. The estimates hover around US$1,302.25 million for the population sizes for each of the scenarios nitiative whole period 2002-2015. Table 3.15 presents a summary of these cost estimates together I with other information on human resources. 3. Project population information over the entire SIP period, and Table 3.15 Selected indicators of Human Resources, 2002-2015* 4. Determine specific resources and cost estimates to provide the facilities. 2002-2007 2008-2015 2002-2015 Model Assumptions ealth H ­ ­ The model has been designed with the community as its base. This means that all calcula- tions in the model are done at the community level and the results that come from the mental

e model at the district, regional and national levels are only the aggregation of community and cy Rate values. The following assumptions were made in order to put the model into operation: s n » The population growth rate is constant over the programme period and is based on the Type of Human Resource Gap AnnualAve. Staff Requirement AnnualAve. Incre mental Costs Vaca Gap AnnualAve. Staff Requirement AnnualAve. Incremental Costs Vacancy Rate (%) Gap AnnualAve. Staff Requirement AnnualAve. Incre mental Costs Total Incr Costs Vacancy Rate relevant rate presented for each region by the 2000 Population Census Doctors 1 837 4 047 22.05 45.39 966 4 881 11.59 20 1 340 4 523 16.07 225.025 30 » Prices and organizational costs are calculated in constant 2003 US dollars and remain Nurses 12 540 31 132 75.24 40.28 6 018 37 545 36.11 16 8 813 34 796 52.88 740.27 25 unchanged during the period, and Pharmacists 3 504 4 497 33.64 77.92 1 760 3 093 16.89 57 2 507 5 026 24.07 336.95 49.88 » Number of latrine artisans required is calculated on a regional basis. Total 130.93 64.59 93.02 1302.25

* = The cost estimates are in US$ million Coverage acroeconomic Analysis of the Costs of Scaling-up Investment in Water and Available records as at 2002 estimate that only about 41.28% of the population of Ghana M Sanitation in Ghana have access to potable water, leaving a projected population of about 58.72% without potable water. As can be seen in Table AXII in the appendix the target population, living As has been pointed out already, the provision of water lies largely in the hands of in 22,978 rural communities and small towns, was estimated to be 15.05 million in 2002 two institutions: the Water Company and the Community Water and Sanitation Agency and projected to grow to 20.8 million in 2015. With this rapid growth of the population it (CWSA). While the CWSA takes care of the provision of community water supply and is feared that the above-mentioned access ratio will decline to about 35.4% by 2015 if the hana sanitation (human excreta disposal) in rural areas and small towns, the provision of current low trend of investment continues. On the other hand if the MDG for water is to G potable water in the urban and metropolitan centres has been placed exclusively under be achieved the country should be expected to additionally cover at least half of the pro- Ghana Water Company Limited. This section attempts to estimate costs of scaling-up jected population without access by 2015, which implies the achievement of a projected coverage levels of water and sanitation in the rural and small towns in Ghana. The aim is target coverage level of 71% by 2015. This shall be referred to as the base scenario. to achieve the MDGs as well as determine the mix of investments to be applied to ensure In the view of the CWSA, it should be possible for the country to achieve higher cover- the achievement of the set targets. age levels with a little more effort. In this light we undertake calculations for a higher The section also relies on data gathered from a series of strategic investment plans (SIP) target of 85% (that is, increase the target of the base scenario by 20%). The 85% shall that have been developed since 1993 by the CWSA. The latest of the SIPs cover the

for better health, economic growth and accelerated poverty reduction be referred to as the ideal scenario in this analysis. This scenario allows an additional 3 s period between 2003 and 2015 while determining the facility coverage at the national, million people to benefit from the provision of safe water. Consequently the number of regional, district and community levels. The estimation of coverage and costing levels people served will increase from 14.8 million to 17.7 million people, leaving only about 3 eport of the R uses a dynamic model, developed by the CWSA, that determines the mix of financial million rural inhabitants without access to potable water. Tables AXIII and AXIV provide and other resources to be applied to deliver safe water along with sustainable sanitation the details of facility projections for the period between 2002 and 2015 for the base as s tment services to a defined rural target population. well as ideal scenarios. For the base scenario the target population deficit to be covered is about 6.3 million (see Table AXII). This would require 12,873 boreholes, 6,225 hand- Design of the Cost Estimation Model dug-wells (HDW) and 1,926 piped systems to be provided (Table AXIII). This demands the construction of about 990 boreholes, 479 hand-dug-wells and 148 piped systems on The model is designed to deliver reliable data that results from a number of separate tasks the average on an annual basis during the period between 2003 and 2015. including the following: In the ideal scenario, as represented in Table AXIV, the water deficit or the population without access is about 9.2 million people (see Table XII). It is estimated that about 16,431

106 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 107 Scaling-up health inve boreholes, 7,221 HDW and 2,005 piped systems would be provided to serve this popula- In the ideal case, the population deficit to be covered for water is 9.2 million. Fulfilling tion (see Table AXIV). On an annual basis it is estimated to construct an average of 1,264 the unmet need for water of this population would require the provision of about 16,400 boreholes, 560 hand-dug-wells and 154 piped systems during the planned period. boreholes, 7,200 HDW and 2,000 piped systems. The respective costs, as shown in Table 3.16, are US$100.2 million for boreholes, US$21.8 million for HDW, and US$410.6 million In the case of sanitation, available data shows that only 28% of Ghanaians have access to nitiative for piped systems. The total costs for water provision alone are estimated to be about I proper sanitary conditions or toilet facilities, with the urban centres having higher access US$532.6 million. Additionally about US$248.5 million would be needed for sanitation, ratios than the rural areas. Because of the low level of access to sanitation in Ghana, it is US$22.7 million for software and US$46.6 million for project management (see also Table envisaged to raise access ratios from its current to a minimum average of 71% or to the 3.17 for details of annual cost estimates). same level of water provision, so as to achieve a greater impact of improvement on health ealth and economic growth. Similar to the water provision we present in Table AXV estimated H coverage levels for sanitation for the base and ideal scenarios. Implementation Scenario The investment programme underlying this investment plan can be implemented along Estimating Costs of Coverage for Water and Sanitation various growth paths, namely the rapid approach and gradual approach. Any of these approaches can be influenced by predictable and unanticipated constraints as well and In estimating how much it would cost to achieve the earmarked coverage levels for water s as by the exploitation of existing conditions. These two competing scenarios must be and sanitation the following cost components were considered: assessed and the option selected that best reflects national capacities. Regarding the rapid 1. Investment in water and sanitation systems and infrastructure (including hardware, approach, the implementation is assumed to start aggressively but taper off in the later and construction costs) years. This approach, however, presupposes the availability of financial resources and 2. Software community commitments. The gradual approach allows the implementation to be evenly spread over the period under the assumption that the supply of facilities starts slowly to 3. Implementation costs, and allow for the mobilisation of resources and the acquisition of the relevant experience. 4. Programme management (including CWSA expenditures and capacity building). We depict both approaches in Figure 3.2 to illustrate the importance of the targeted Table 3.16 presents a summary of the total costs of the two scenarios: growth path, with each diagram showing the behaviour of : acroeconomic

Table 3.16 Summary of Total Cost of Water and Sanitation, 2003-2015 (US$ 1. Facility coverage over the plan period, assuming no additional facilities are provided M million) during the period

Base Ideal 2. Existing level of financial commitment to the NCWSP, and Activity Scenario Scenario 3. Level of projected coverage and commitment. Borehole 78.5 100.2 hana G Hand-Dug Well 18.3 21.8 Figure 3.2 Projected Coverage and Expected Levels, 2002-2015 Piped System 399.8 410.6 80.0 Sub-Total Water 496.6 532.6 70.0 66.1 71.0 62.5 64.7 Sanitation 188.5 248.5 59.8

60.0 59.7 57.7 56.2 55.7 Software 21.1 22.7 49.4 53.9 54.6 55.0 53.0 52.4 46.1 51.5 50.0 49.9 47.8 41.3 43.1 46.1 Project Management 25.9 46.6 41.9 44.8 44.2 44.4

for better health, economic growth and accelerated poverty reduction 40.0 40.4 39.9 39.5 40.8 39.0 38.6 38.1 ercent 37.7 s 37.2 36.7 Total 732.1 850.4 P 36.3 35.8 35.4 30.0 eport of the Source: SIP 2003 20.0 R U$496.7 million would be needed for water facilities. This amount is made up of US$78.5 10.0 s tment 2.8 million for boreholes, US$18.3 million for hand-dug wells and US$399.8 million for piped 1.8 5.9 6.3 6.2 6.0 5.9 5.7 5.6 5.4 0.0 4.3 4.9 5.4 systems for the base scenario. The total cost of providing sanitation facilities for the 71% 0.0 coverage was estimated to be US$188.5 million. The total cost of software is assumed 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

to be about US$21.1 million and about US$25.9 million would be needed to provide for Expected Coverage (Gradual) Current Facility Coverage Commitments Expected Coverage (Rapid) project management. The total cost for providing water and sanitation facilities to cover about 71% of the population is about US$732.1 million. Details of the annual costs for the base scenario are presented in Table AXIII.

108 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 109 Scaling-up health inve In the case of the rapid implementation structure the coverage level rises from 41.3% in the base year (2002) to 46.1% in 2003 to 49.4% in 2004. This approach shows the extent of front loading and the massive extent of resources required in the early period of the APPENDICES plan. In the case of the gradual approach the coverage level rises gradually from 41.3 in nitiative 2002 to 41.9% in 2003, and attaining the 46% level first in 2008, which is achieved in I 2003 in the case of the rapid approach. Appendix A Table AI Baseline and Projected Target Coverage Levels (Outcomes) of Table 3.17 Estimated Cost of Sanitation Facilities in US Dollars Key Interventions by type of Disease, 2002 – 2015* Total

Indicator 2002 2003 2004 2005 2006 2007 2010 2015 ealth Facilities Cost for Cost for

Reducing Maternal Mortality H to be Household Cost for Shared Institutional Maternal Mortality Rate 214 214 214 210 200 185 160 120 Year provided Facilities – VIPs Facilities – KVIPs Facilities Total Cost ANC Coverage 95 99 95 95 95 96 96 99 2004 34 878 5 129 138.64 1 994 664.03 911 846.87 8 035 649.54 Supervised Delivery 55 58 58 59 60 62 65 70 Maternal Mortality (Instnl) 2.6 2.4 2.4 2.3 2.2 2.1 1.8 1.5 2005 84 520 12 429 461.76 4 833 679.57 2 209 682.09 19 472 823.42 and

TT2+Immunisation 80 90 90 91 92 93 95 96 s 2006 134 431 20 063 468.40 7 802 459.93 3 566 838.83 31 432 767.16 IPT coverage in pregnant women <1 >1 20 25 30 33 40 55 TFR 5.5 4.4 4.4 4.4 4.4 4.3 4.3 4.2 2007 218 483 32 129 879.04 12 494 952.96 5 711 978.50 50 336 810.50 CPR for modern methods 0.25 0.26 0.26 0.27 0.28 0.3 0.35 2008 347 103 51 044 585.76 19 850 672.24 9 074 593.02 79 969 851.02 Child Morbidity and mortality IMR 57 64 66 66 64 62 59 53 2009 511 096 75 161 298.96 29 229 394.04 13 362 008.70 117 752 701.70 CMR 108 111 111 110 105 103 100 90

2010 653 044 96 035 879.28 37 347 286.39 17 073 045.21 150 456 210.88 Districts implementing IMCI NA 0.35 0.37 0.4 0.43 0.45 0.55 0.65

2011 770 982 113 379 623.28 44 092 075.72 20 156 377.47 177 628 076.47 Penta 3 coverage 0.85 0.9 0.91 0.91 0.92 0.92 0.94 0.94 2012 862 859 126 890 927.28 49 346 471.72 22 558 387.07 198 795 786.07 Districts with ≥80% EPI coverage NA NA 0.6 0.65 0.66 0.7 0.75 Underweight in chn ≤5 yrs 25 22.1 22.1 20 19 18 16 14 acroeconomic 2013 958 784 140 997 749.76 54 832 458.24 25 066 266.62 220 896 474.62 Reducing Old Communicable Disease Burden M 2014 1 025 777 150 849 664.56 58 663 758.44 26 817 718.14 236 331 141.14 Malaria Control 2015 1 078 462 158 597 440.56 61 676 782.44 28 195 100.54 248 469 323.54 At risk group sleeping under ITN NA 0.035 0.04 0.07 0.09 0.15 0.25 0.35 Correct management of malaria cases in NA NA 0.35 0.37 0.39 0.41 0.5 0.6 health institutions hana Guinea Worm cases 4733 5545 5900 4000 3500 3000 2000 1500 G Threats to Life Expectancy

HIVAIDS HIV Sero-prevalence 3.4 3.4 3.6 3.6 3.5 3.5 3 2 HIV awareness 0.9 0.92 0.95 0.99 0.99 0.99 0.99 0.99 Condom use 0.06 0.18 0.18 0.2 0.22 0.23 0.26 0.3 PLWHA on ART >1% >1% >1% 0.02 0.04 0.08 0.15 0.25 Tuberculosis Treatment success 0.49 50% 0.5 0.52 0.53 0.54 0.6 0.7 Case detection rate 0.31 36% 0.37 0.4 0.45 0.47 0.55 0.6 for better health, economic growth and accelerated poverty reduction

s Neglected Diseases

eport of the CDTI coverage for lymphatic Filariasis 0.74 75% 0.75 0.75 0.75 0.75 0.75 0.75 R Coverage of Schisto treatment 0 0% 0.05 0.08 0.1 0.12 0.15 0.25

s tment TT prevalence in women NA NA NA <3% <3% <3% <3% <3% Buruli prevalence in endemic districts/100 150.8 147 147 146 146 144 140 130 000 Buruli cases on treatment 853 739 720 720 705 730 750 800 Widening Access and Bridging Inequality CHPS 110 320 320 320 320 320 320 320 Widening Access Health Insurance 2 2 30 40 50 55 65 80

* The targets reflect an upward review of the GPRS targets by the GMHI

SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 111 Scaling-up health inve Table AII Estimated Incremental Costs of Expanding Coverage of Key Interventions – 2002-2015 (US$ million)) 2002 2003 2004 2005 2006 2007 2002-2004 2008 2009 2010 2011 2012 2013 2014 2015 2008-2015 HIV/AIDS 25.54 27.62 38.02 43.49 48.21 54.35 237.23 49.66 56.06 63.20 79.90 93.97 108.50 125.68 152.90 729.88 nitiative Tuberculosis 5.44 6.17 8.29 9.04 10.22 12.25 51.41 13.53 15.77 18.27 24.12 29.04 34.13 40.14 49.66 224.66 I Malaria Prevention 13.21 14.98 24.47 29.62 33.83 39.09 155.19 43.86 49.30 55.37 69.57 81.53 93.88 108.48 131.61 633.60 and Control Lower Respiratory 5.44 6.17 8.29 9.04 10.22 12.25 51.41 13.53 15.77 18.27 24.12 29.04 34.13 40.14 49.66 224.66 Infections ealth Measles 7.77 8.81 11.84 12.91 14.61 17.51 73.45 20.33 23.53 27.10 35.45 42.49 49.75 57.34 70.95 326.94 Ischaemic Heart H 6.22 7.05 9.48 10.33 11.69 14.01 58.76 15.46 18.03 20.88 27.56 33.19 39.00 45.87 56.76 256.75 Diseases Peri-natal 17.43 19.09 28.28 33.33 37.37 42.34 177.85 46.93 52.05 57.76 71.12 82.38 94.00 107.75 129.52 641.50 Conditions Cerebrovascular and 5.44 6.17 8.29 9.04 10.22 12.25 51.41 13.53 15.77 18.27 24.12 29.04 34.13 40.14 49.66 224.66 s Diseases Diarrhoeal 3.88 4.40 5.92 6.46 7.30 8.75 36.72 9.66 11.27 13.05 17.23 20.74 24.38 28.67 35.47 160.47 Diseases Road Traffic 7.33 7.64 8.55 8.87 9.38 10.25 52.03 10.80 11.76 12.83 15.34 17.45 19.63 22.20 26.28 136.28 Accidents Widening Access: 25.49 34.68 34.68 34.68 34.68 34.68 198.91 34.68 34.68 34.68 34.68 34.68 34.68 34.68 34.68 277.47 CHPS Total Incremental 123.19 142.77 186.12 206.81 227.75 257.75 1,144.39 271.98 304.00 339.68 423.19 493.55 566.19 651.10 787.17 3,836.86 Costs Total Per capita Incremental Health Expenditure 6.54 7.41 9.45 10.26 11.05 12.22 12.61 13.77 15.04 18.32 20.89 23.42 26.33 31.12 acroeconomic Total Per capita Health 12.62 14.15 16.96 18.28 19.55 21.08 21.79 23.13 24.52 27.87 30.45 32.95 35.77 40.45 M Expenditure

Table AIII Estimated Incremental Costs in Relation to GDP – 2002 – 2015 (Percent)

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 hana

HIV/AIDS 0.42 0.35 0.42 0.45 0.47 0.50 0.44 0.47 0.51 0.61 0.69 0.76 0.84 0.97 G Tuberculosis 0.09 0.08 0.09 0.09 0.10 0.11 0.12 0.13 0.15 0.19 0.21 0.24 0.27 0.32 Malaria Prevention and Control 0.22 0.19 0.27 0.30 0.33 0.36 0.39 0.42 0.44 0.53 0.60 0.66 0.72 0.84 Lower Respiratory Infections 0.09 0.08 0.09 0.09 0.10 0.11 0.12 0.13 0.15 0.19 0.21 0.24 0.27 0.32 Measles 0.13 0.11 0.13 0.13 0.14 0.16 0.18 0.20 0.22 0.27 0.31 0.35 0.38 0.45 Ischaemic Heart Diseases 0.10 0.09 0.10 0.11 0.11 0.13 0.14 0.15 0.17 0.21 0.24 0.27 0.31 0.36 Peri-natal Conditions 0.29 0.24 0.31 0.34 0.36 0.39 0.41 0.44 0.46 0.55 0.60 0.66 0.72 0.82 Cerebrovascular Diseases 0.09 0.08 0.09 0.09 0.10 0.11 0.12 0.13 0.15 0.19 0.21 0.24 0.27 0.32

for better health, economic growth and accelerated poverty reduction Diarrhoeal Diseases 0.06 0.06 0.07 0.07 0.07 0.08 0.09 0.09 0.10 0.13 0.15 0.17 0.19 0.23 s Road Traffic Accidents 0.12 0.10 0.09 0.09 0.09 0.09 0.10 0.10 0.10 0.12 0.13 0.14 0.15 0.17

Widening Access: CHPS 0.42 0.43 0.38 0.36 0.34 0.32 0.31 0.29 0.28 0.27 0.25 0.24 0.23 0.22 eport of the Total Incremental Costs 2.02 1.78 2.05 2.13 2.20 2.38 2.40 2.56 2.73 3.25 3.61 3.96 4.34 5.01 R s tment

112 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 113 Scaling-up health inve Table AIV Government budgetary allocations to the health sector (in ¢ million) Objectives and Item of Expenditure 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 nitiative

Overheads 672 947.06 864 365.60 1 037 359.50 1 187 138.40 1 352 394.00 1 513 780.40 1 686 467.24 1 844 086.84 2 006 172.03 2 172 633.17 2 336 187.98 2 499 816.69 2 661 845.17 2 826 785.03 I To increase geographical and financial access to 87 273.75 112 098.60 132 458.60 155 186.00 176 335.10 197 878.70 220 384.62 241 607.56 263 596.85 285 202.56 307 105.70 328 887.15 350 525.35 372 390.49 all basic services for all people ealth living in Ghana H To provide better quality of care in all health facilities 40 254.56 51 704.90 61 730.90 70 227.70 79 743.90 89 005.30 99 081.29 108 071.14 117 395.71 127 010.61 136 434.12 145 858.69 155 167.68 164 685.84 and outreach

centres and To improve s Efficiency at 54 854.30 70 457.50 84 010.00 97 269.90 110 724.90 124 131.10 138 285.89 151 442.58 165 005.77 178 642.07 192 242.04 205 810.22 219 270.39 232 917.42 all levels of the health sector To foster closer collaboration and partnership between the health sector on 2 091.79 2 686.80 3 065.50 3 493.60 3 888.80 4 292.20 4 756.73 5 139.77 5 562.51 5 978.47 6 400.64 6 818.07 7 226.56 7 649.95 one hand and communities other sectors and the acroeconomic private sector To increase M overall resources 214.72 275.8 227.1 224.1 190.6 164.8 165.37 130.70 115.38 92.89 76.14 56.61 33.18 16.08 in the health sector yearly Reducing equity gaps in access hana

36 179.90 46 471.20 55 522.90 63 275.80 71 894.50 80 296.80 89 400.91 97 569.25 106 027.63 114 732.90 123 275.62 131 818.69 140 262.16 148 885.76 G to quality health services Ensuring sustainable financing 5 268.88 6 767.60 8 085.80 9 214.90 10 470.00 11 693.70 13 019.52 14 209.09 15 440.90 16 708.67 17 952.77 19 196.90 20 426.54 21 682.41 arrangements that protect the poor Total Annual 899 084.96 1 154 828.00 1 382 460.20 1 586 030.20 1 805 641.70 2 021 242.80 2 251 561.34 2 462 256.64 2 679 316.49 2 901 001.01 3 119 674.62 3 338 262.61 3 554 756.60 3 775 012.50 Expenditure Projected for better health, economic growth and accelerated poverty reduction s Budgetary 114.27 129.76 150.27 163.51 191.07 210.55 227.76 248.66 269.06 290.21 308.76 329.04 349.70 369.61 Expenditure eport of the (MTEF) (million $) R Per Capita Annual 6.07 6.74 7.66 8.34 9.01 9.57 10.12 10.50 10.84 11.14 11.37 11.55 11.67 11.76 Expenditure ($) s tment

114 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 115 Scaling-up health inve Table AV Projected Expenditure Envelope for the Health Sector 5-Year Programme of Work (POW 2002-2006) (in $ million) Source/Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 nitiative

GOG 82.35 111.39 127.49 146.77 169.86 183.85 205.04 223.58 241.16 261.03 279.09 297.81 316.78 335.17 I GOG regular 67.95 81.39 97.49 116.77 139.86 153.85 175.04 193.58 211.16 231.03 249.09 267.81 286.78 305.17 GOG HIPC 14.40 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 IGF 15.00 15.00 15.00 15.00 15.00 16.50 16.50 17.25 18.00 18.38 19.13 19.69 20.25 20.91 ealth

External Aid 60.00 60.00 60.00 60.00 60.00 60.00 60.00 60.00 60.00 60.00 60.00 60.00 60.00 60.00 H Grand Total of POW II 157.35 186.39 202.49 221.77 244.86 260.35 281.54 300.83 319.16 339.40 358.21 377.50 397.03 416.08 Projected Per capita (US$) 8.36 9.68 10.28 11.00 11.88 12.34 13.05 13.63 14.14 14.69 15.16 15.62 16.06 16.45 and

Source: Health Sector 5 Year Programme of Work II -2002-2006, revised August 2002 s acroeconomic M hana G for better health, economic growth and accelerated poverty reduction s eport of the R s tment

116 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 117 Scaling-up health inve Table AVI Projected Gradual Resource Shift to Meet the Health Abuja Objective 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Projected Total Government 114.27 129.76 150.81 167.98 185.67 201.79 218.23 231.70 244.79 257.32 268.66 279.11 288.55 297.51 nitiative Expenditure (US$ million) I

% Health share (Graduated) 8% 11% 12% 13% 14% 15% 15% 15% 15% 15% 15% 15% 15% 15%

Total Expected Health 123 144 169 190 212 232 251 266 282 296 309 321 332 342

Expenditure (US$ million) ealth

Projected Per capita H 6.56 7.48 8.57 9.42 10.27 11.00 11.63 12.07 12.47 12.81 13.08 13.28 13.42 13.52 Expenditure (US$)

Table AVII Resource Requirements and Resource Gap and

According to Alternative Financing Options s 2002-

2002 2003 2004 2005 2006 2007 2007 2008 2009 2010 2011 2012 2013 2014 2015 Total Resource Requirements 237.46 272.53 334.06 368.45 403.00 444.59 2 060.08 470.19 510.44 553.63 643.80 719.50 796.46 884.62 1 023.35 (US$ million) Per Capita Expenditure 12.62 14.15 16.96 18.28 19.55 21.08 102.64 21.79 23.13 24.52 27.87 30.45 32.95 35.77 40.45 Total Projected Financing Plan-Projected Expenditure 114.27 129.76 147.94 161.64 175.26 186.84 915.70 198.22 206.44 213.95 220.62 225.95 230.27 233.52 236.18 from Budget Allocations (US$ million) acroeconomic

Resource Gap (US$ million) 123.19 142.77 186.12 206.81 227.75 257.75 1 144.39 271.98 304.00 339.68 423.19 493.55 566.19 651.10 787.17 M Per Capita Resource Gap 6.54 7.41 9.45 10.26 11.05 12.22 9.57 12.61 13.77 15.04 18.32 20.89 23.42 26.33 31.12 Total Projected Financing Plan Projected Expenditure

157.35 186.39 202.49 221.77 244.86 260.35 1273.21 281.54 300.83 319.16 339.40 358.21 377.50 397.03 416.08 hana from MOH POW II (US$

million) G Resource Gap (US$ million) 80.11 86.14 131.57 146.68 158.14 184.24 786.87 188.66 209.62 234.46 304.40 361.28 418.96 487.59 607.28 Per Capita Resource Gap 4.26 4.47 6.68 7.28 7.67 8.74 6.58 8.74 9.50 10.38 13.18 15.29 17.33 19.72 24.01 Total Projected Financing Plan –Expenditure 123.41 144.03 168.91 189.82 211.66 232.06 1 069.89 250.97 266.46 281.50 295.92 308.96 320.97 331.83 342.13 Commitments under Abuja Declaration (US$ mil.) Resource Gap (US$ million) 114.05 128.50 165.15 178.63 191.34 212.53 990.19 219.23 243.99 272.12 347.89 410.54 475.49 552.79 681.22 for better health, economic growth and accelerated poverty reduction s Per Capita Resource Gap 6.06 6.67 8.38 8.86 9.28 10.08 8.28 10.16 11.05 12.05 15.06 17.37 19.67 22.35 26.93 eport of the R s tment

118 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 119 Scaling-up health inve Table AVIII Summary of a Scaled-up Capital Investment Plan – (in US$ million) Table AIX Medical Equipment Investment Plan – Base Case –, 2002-2015 (US$ million) 2002-2007 2008-2015 2002-2015

GHS HEAD QUARTERS - PROJECTS 35.11 55.57 90.68 nitiative I Ministry of Health - HQ AND - 27.01 532.11 559.12 Level of MATCHING FUNDS PROJECTS ategory Service Project Detail C 2002-2007 2008-2015 2002-2015 REPLACEMENT OF EQUIPM,ENT AND Sub-District 23.63 345.93 369.56 TRANSPORT 200 New Health Centres 1 1.94 7.67 9.61 ealth ACCRA MENTAL HOSPITAL 40.51 8.92 49.43 160 Rehabilitated Health Centres 1 1.75 5.99 7.73 H 1000 CHPS Projects Equipped 4 1.51 6.34 7.85 PATANG PSYCHIATRIC HOSPITAL 29.71 36.84 66.55 12 Polyclinics Upgraded 1 2.00 6.84 8.84 ANKAFUL 28.36 48.24 76.60 233 Health Centres Equipped 1 3.26 11.19 14.45

9 Health Centres Upgraded 1 2.51 10.89 13.40 and

GREATER ACCRA REGION 37.81 22.77 60.58 s District CENTRAL REGION 33.76 25.20 58.96 10 New Hospitals 1 38.29 101.61 139.90 WESTERN REGION 30.38 99.92 130.30 14 Polyclinics Upgraded 1 6.02 20.37 26.39 14 Rehabilitated Hospitals 1 17.96 61.61 79.57 ASHANTI REGION 29.71 61.78 91.49 30 Hospitals, Automated Lab 3 8.24 28.28 36.52 VOLTA REGION 25.66 35.33 60.99 44 Hospitals, Medical Gas 3 63.17 240.75 303.92 EASTERN REGION 39.84 21.09 60.93 44 Hospitals, Anaesthesia 4 1.92 12.59 14.52 65 Hospitals, Ultrasound 4 3.78 15.97 19.76 BRONG-AHAFO REGION 27.68 19.08 46.76 65 Hospitals, Multipurpose X-ray 4 11.27 43.65 54.92 NORTHERN REGION 32.41 38.75 71.16

49 Hospitals, Theatre Suit 4 15.67 56.77 72.44 acroeconomic UPPER WEST REGION 37.14 58.42 95.56

Region M UPPER EAST REGION 37.81 29.28 67.09 9 Rehabilitated Hospitals 1 31.21 143.14 174.35 3 Hospital, Intensive Care Unit 2 1.08 2.47 3.55 TRAINING SCHOOLS 30.38 152.52 182.90 3 Hospital, Renal Dialysis Unit 2 0.91 2.13 3.04 KORLE-BU TEACHING HOSPITAL 24.98 94.98 119.96

Hospitals, Intensive Care hana 9 4 4.81 10.50 15.31 Units KOMFO ANOKYE 33.08 147.08 180.16 G 3 Pharmacy Production Unit 4 1.83 6.29 8.12 TAMALE 33.76 250.88 284.64 15 Physiotherapy Services 4 0.52 1.71 2.23 STATUTORY BODIES/ SUBVENTED 9 Blood Transfusion Services 4 0.09 0.31 0.40 36.46 179.05 215.51 ORG. Tertiary (KBTH) OVERALL TOTAL 675.19 2 263.74 2 938.93 14 Major Projects 1 6.82 20.40 27.22 5 Intensive Care Unit 4 1.03 3.54 4.57 Tertiary

for better health, economic growth and accelerated poverty reduction (KATH) s 4 Major Projects 1 2.40 8.25 10.66 eport of the

3 Children’s Block Equipped 1 4.58 15.71 20.29 R Radiology (MRI) 4 4.12 14.14 18.26

s tment Tertiary 3 Specialised Facilities 1 1.15 3.92 5.07 National Equipment WKS 3 18.67 50.13 68.79 Total 256.57 905.5 1162.07

120 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 121 Scaling-up health inve Table AX Transportation Investment Plan, Base Case, 2002-2015 US$) Table AXI Categorisation of Constraints Total Costs (US$ Levels Constraints Item Quantity Unit Costs mil) Levels Community - Lack of demand for effective interventions; Double Cabin Pick 2000 18 750.00 37.50 nitiative I and household - Barriers to use of effective interventions: physical, financial, gender, I Single Cabin Pick up 150 16 250.00 2.44 level cultural, social. Saloon Car 3400 15 500.00 52.70 - Shortage and poor distribution of appropriately qualified staff; Motorcycle 5350 1 625.00 8.69 - Weak technical guidance, programme management and supervision; Health services ealth II Bicycle 5211 62.50 0.33 delivery level - Inadequate supplies of drugs and medical supplies; H Ambulance FWD 620 43 750.00 27.13 - Lack of equipment and infrastructure (including labs and communications) and poor accessibility of health services. Station Wagon 400 31 250.00 12.50 - Weak systems for planning and management; Blood Collection 240 25 000.00 6.00 and

Health sector s - Weak drug policies and drug supply systems; Van 30 50 000.00 1.50 policy and III strategic - Inadequate regulation of pharmaceutical and private sectors; Medium-size Bus 180 37 500.00 6.75 management level - Lack of intersectoral action and partnership for health between Mini Bus 100 22 500.00 2.25 government and civil society. Stores Truck 140 43 750.00 6.13 Public policies - Government administration (civil service rules and remuneration; Water Tanker 60 50 000.00 3.00 IV cutting across centralised management system; civil service reform measures); sectors Audio Video Van 60 31 250.00 1.88 - poor availability of communication and transport infrastructure. Cold Van 24 37 500.00 0.90 A. Governance and overall policy framework

Motor Boat 50 31 250.00 1.56 - Corruption, Weak Government effectiveness, Weak rule of law acroeconomic

and enforceability of contracts; M Fork Lift 4 25 000.00 0.10 - Political instability and insecurity; Spares 12.24 - Low priority attached to social sectors and to meeting the needs of Registration/Insurance/ the poor for basic services; Assembling/Training/ 0.50 Environmental hana

V - Weak structures for public accountability and opportunities for G Local Cost characteristics public opinions to be voiced; Total 184.08 - Lack of free press; B. Physical environment - Climatic and geographic predisposition to predominance of tropi cal disease in disease burden; - physical environment unfavourable to service delivery.

for better health, economic growth and accelerated poverty reduction Source: Hanson et al 2001. s eport of the R s tment

122 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 123 Scaling-up health inve Table AXII Projected Population and Coverage Levels for Water (Base and Ideal Scenarios), 2002-2015 Expected

Coverage Expected Deficit yet to Expected Deficit yet to be nitiative (Percent) be served served (Percent) I Projected Financial Projected Projected Projected No No Access Base Ideal Base Ideal Base Ideal Financial Commitments Year Pop. Pop. Served Coverage Access Percent Scenario Scenario Scenario Scenario Scenario Scenario Commitments Percent 2002 15 052 813 6 214 168 41.28 8 838 645 58.72 41.28 41.28 0 0 0.00 0.00 0 0.00 ealth 2003 15 426 138 6 298 631 40.83 9 127 507 59.17 46.14 47.91 651781 924866 4.23 6.00 167 087 1.83 H 2004 15 809 704 6 383 841 40.38 9 425 863 59.62 49.38 52.33 987612 1454071 6.25 9.20 434 915 2.75 2005 16 204 025 6 469 750 39.93 9 734 275 60.07 51.54 55.27 1186754 1792339 7.32 11.06 694 343 4.29

2006 16 609 556 6 556 378 39.47 10 053 178 60.53 52.97 57.24 1422460 2130322 8.56 12.83 820 021 4.94 and s 2007 17 026 357 6 643 384 39.02 10 382 973 60.98 53.93 58.55 1618856 2404020 9.51 14.12 920 762 5.41 2008 17 454 591 6 730 828 38.56 10 723 763 61.44 54.57 59.42 1773271 2618873 10.16 15.00 1 021 503 5.85 2009 17 895 036 6 819 099 38.11 11 075 937 61.89 55.00 60.00 1900927 2795679 10.62 15.62 1 122 244 6.27 2010 18 347 897 6 908 078 37.65 11 439 819 62.35 56.15 61.80 2261010 3297582 12.32 17.97 1 134 125 6.18 2011 18 813 354 6 998 012 37.20 11 815 342 62.80 57.69 64.21 2722112 3947914 14.47 20.98 1 134 125 6.03 2012 19 292 082 7 088 751 36.74 12 203 331 63.26 59.75 67.42 3303613 4786379 17.12 24.79 1 134 125 5.88 2013 19 784 625 7 180 613 36.29 12 604 012 63.71 62.48 71.69 4047568 5869728 20.46 29.67 1 134 125 5.73

2014 20 290 935 7 273 806 35.85 13 017 129 64.15 66.13 77.40 5011265 7296602 24.70 35.96 1 134 125 5.59 acroeconomic M 2015 20 811 804 7 368 132 35.40 13 443 672 64.60 71.00 85.00 6274124 9187776 30.15 44.15 1 134 125 5.45

Source: CWSA, SIP 2003-2015 hana G for better health, economic growth and accelerated poverty reduction s eport of the R s tment

124 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 125 Scaling-up health inve Table AXIII National Facilities Coverage for Water (Cumulative and Annual), Base scenario

Facility Description 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Water Borehole 4 071 4 346 5 042 5 293 6 064 6 155 6 177 7 131 7 727 8 781 9 995 11 350 12 873

Water Hand-Dug Well 3 682 3 801 4 237 4 284 4 433 4 530 4 397 4 867 5 033 5 302 5 644 5 976 6 225 nitiative I Water Piped System 697 762 822 877 1 102 1 170 1 220 1 322 1 431 1 571 1 766 1 852 1 926 Sub-Total Software WATSAN 7 276 7 625 8 596 8 836 9 869 10 111 10 101 11 114 11 619 12 565 13 624 14 354 14 836 Software DWST 55 58 64 65 74 76 75 82 85 92 100 104 105

Software Partner Organisation 7 276 7 625 8 596 8 836 9 869 10 111 10 101 11 114 11 619 12 565 13 624 14 354 14 836 ealth

Software HDW Contractors 7 276 7 625 8 596 8 836 9 869 10 111 10 101 11 114 11 619 12 565 13 624 14 354 14 836 H Sub-Total Annual National Facilities Facility Description 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Water Borehole 4 071 275 696 251 771 91 22 954 596 1 054 1 214 1 355 1 523 and Water Hand-Dug Well 3 682 119 436 47 149 97 337 166 269 342 332 249 s Water Piped System 697 65 60 55 225 68 50 102 109 140 195 86 74 Sub-Total 8 450 459 1 192 353 1 145 256 72 1 393 871 1 463 1 751 1 773 1 846 Software WATSAN 7 276 349 971 240 1 033 242 1 003 505 946 1 059 730 482 Software DWST 55 3 6 1 9 2 6 3 7 8 4 1 Software Partner Organisation 7 276 349 971 240 1 033 242 1 003 505 946 1 059 730 482 Software HDW Contractors 7 276 349 971 240 1 033 242 1 003 505 946 1 059 730 482 Sub-Total 21 883 1 050 2 919 721 3 108 728 3 015 1 518 2 845 3 185 2 194 1 447 National Costing (Cumulative and Annual), base scenario Cumulative National Costing Facility Description 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 acroeconomic 30 894

Water Borehole 24 956 000 26 647 000 32 452 000 37 114 000 37 678 000 37 827 000 43 596 000 47 214 000 53 608 000 61 028 000 69 267 000 78 552 000 M 000 Water Hand-Dug Well 11 046 000 11 403 000 12 711 000 12 852 000 13 299 000 13 590 000 13 590 000 14 601 000 15 099 000 15 906 000 16 932 000 17 928 000 18 675 000 Water Piped System 136 922 865 151 834 140 164 127 590 174 272 955 223 751 130 239 099 870 250 262 130 272 657 850 296 803 230 324 923 195 359 578 180 380 932 105 399 848 340 Sub-Total 172 924 865 189 884 140 207 732 590 219 576 955 274 164 130 290 367 870 301 679 130 330 854 850 359 116 230 394 437 195 437 538 180 468 127 105 497 075 340

Software WATSAN 4 365 600 4 575 000 5 157 600 5 301 600 5 921 400 6 066 600 6 066 600 6 668 400 6 971 400 7 539 000 8 174 400 8 612 400 8 901 600 hana

Software DWST 27 500 29 000 32 000 32 500 41 500 43 000 43 000 47 000 49 000 53 500 58 500 60 500 61 000 G Software Partner Organisation 5 093 200 5 337 500 6 017 200 6 185 200 6 908 300 7 077 700 7 077 700 7 779 800 8 133 300 8 795 500 9 536 800 10 047 800 10 385 200 Software HDW Contractors 873 120 915 000 1 031 520 1 060 320 1 184 280 1 213 320 1 213 320 1 333 680 1 394 280 1 507 800 1 634 880 1 722 480 1 780 320 Sub-Total 10 359 420 10 856 500 12 238 320 12 579 620 14 055 480 14 400 620 14 400 620 15 828 880 16 547 980 17 895 800 19 404 580 20 443 180 21 128 120 Annual National Costing Facility Description 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Water Borehole 24 956 000 1 691 000 4 247 000 1 558 000 4 662 000 564 000 149 000 5 769 000 3 618 000 6 394 000 7 420 000 8 239 000 9 285 000 Water Hand-Dug Well 11 046 000 357 000 1 308 000 141 000 447 000 291 000 1 011 000 498 000 807 000 1 026 000 996 000 747 000 Water Piped System 136 922 865 14 911 275 12 293 450 10 145 365 49 478 175 15 348 740 11 162 260 22 395 720 24 145 380 28 119 965 34 654 985 21 353 925 18 916 235

for better health, economic growth and accelerated poverty reduction Sub-Total 172 924 865 16 959 275 17 848 450 11 844 365 54 587 175 16 203 740 11 311 260 29 175 720 28 261 380 35 320 965 43 100 985 30 588 925 28 948 235 s Software WATSAN 4 365 600 209 400 582 600 144 000 619 800 145 200 601 800 303 000 567 600 635 400 438 000 289 200 Software DWST 27 500 1 500 3 000 500 9 000 1 500 4 000 2 000 4 500 5 000 2 000 500 eport of the R Software Partner Organisation 5 093 200 244 300 679 700 168 000 723 100 169 400 702 100 353 500 662 200 741 300 511 000 337 400 Software HDW Contractors 873 120 41 880 116 520 28 800 123 960 29 040 120 360 60 600 113 520 127 080 87 600 57 840 s tment Sub-Total 10 359 420 497 080 1 381 820 341 300 1 475 860 345 140 1 428 260 719 100 1 347 820 1 508 780 1 038 600 684 940 Source: CWSA, SIP 2003-2015

126 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 127 Scaling-up health inve Table AXIV National Facilities Coverage for Water (Cumulative and Annual, Ideal scenario)

Cumulative National Facilities Facility Description 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 nitiative

Water Borehole 4 731 5 771 6 058 6 808 7 105 7 634 7 927 9 013 9 999 11 107 12 167 14 078 16 431 I Water Hand-Dug Well 3 986 4 455 4 578 5 010 5 010 5 124 5 124 5 470 5 722 6 127 6 491 6 836 7 271 Water Piped System 854 951 1 015 1 099 1 184 1 299 1 394 1 518 1 637 1 720 1 833 1 945 2 005 Sub-Total 9 571 11 177 11 651 12 917 13 299 14 057 14 445 16 001 17 358 18 954 20 491 22 859 25 707 Software WATSAN 8 182 9 389 9 694 10 660 10 957 11 500 11 765 12 777 13 565 14 175 14 607 15 308 15 905

Software DWST 65 73 74 80 82 85 87 94 100 103 104 108 108 ealth

Software Partner Organisation 8 182 9 389 9 694 10 660 10 957 11 500 11 765 12 777 13 565 14 175 14 607 15 308 15 905 H Software HDW Contractors 8 182 9 389 9 694 10 660 10 957 11 500 11 765 12 777 13 565 14 175 14 607 15 308 15 905 Sub-Total 24 611 28 240 29 156 32 060 32 953 34 585 35 382 38 425 40 795 42 628 43 925 46 032 47 823 Annual National Facilities

Facility Description 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 and s Water Borehole 4 731 1 040 287 750 297 529 293 1 086 986 1 108 1 060 1 911 2 353 Water Hand-Dug Well 3 986 469 123 432 114 346 252 405 364 345 435 Water Piped System 854 97 64 84 85 115 95 124 119 83 113 112 60 Sub-Total 9 571 1 606 474 1 266 382 758 388 1 556 1 357 1 596 1 537 2 368 2 848 Software WATSAN 8 182 1 207 305 966 297 543 265 1 012 788 610 432 701 597 Software DWST 65 8 1 6 2 3 2 7 6 3 1 4 Software Partner Organisation 8 182 1 207 305 966 297 543 265 1 012 788 610 432 701 597 Software HDW Contractors 8 182 1 207 305 966 297 543 265 1 012 788 610 432 701 597 Sub-Total 24 611 3 629 916 2 904 893 1 632 797 3 043 2 370 1 833 1 297 2 107 1 791 Cumulative National Costing

Facility Description 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 acroeconomic Water Borehole 28 931 000 35 269 000 37 055 000 41 599 000 43 416 000 46 645 000 48 409 000 54 988 000 61 026 000 67 784 000 74 253 000 85 857 000 100 214 000 M Water Hand-Dug Well 11 958 000 13 365 000 13 734 000 15 030 000 15 030 000 15 372 000 15 372 000 16 410 000 17 166 000 18 381 000 19 473 000 20 508 000 21 813 000 Water Piped System 171 313 035 190 909 605 203 835 885 220 672 005 238 674 370 260 242 680 279 071 525 304 571 330 328 918 150 348 405 030 370 158 050 393 538 725 410 570 795 Sub-Total 212 202 035 239 543 605 254 624 885 277 301 005 297 120 370 322 259 680 342 852 525 375 969 330 407 110 150 434 570 030 463 884 050 499 903 725 532 597 795 Software WATSAN 4 909 200 5 633 400 5 816 400 6 396 000 6 574 200 6 900 000 7 059 000 7 666 200 8 139 000 8 507 000 8 766 200 9 186 800 9 545 000 Software DWST 36 500 40 500 41 000 45 000 46 500 48 500 50 000 95 000 99 000 100 500 101 000 103 000 103 000 hana Software Partner Organisation 5 727 400 6 572 300 6 785 800 7 462 000 7 669 900 8 050 000 8 235 500 8 943 900 9 495 500 9 922 500 10 224 900 10 715 600 11 133 500 G Software HDW Contractors 981 840 1 126 680 1 165 280 1 281 200 1 316 840 1 382 000 1 413 800 1 535 240 1 629 800 1 703 000 1 754 840 1 838 960 1 910 600 Sub-Total 11 654 940 13 372 880 13 808 480 15 184 200 15 607 440 16 380 500 16 758 300 18 240 340 19 363 300 20 233 000 20 846 940 21 844 360 22 692 100 Annual National Costing Facility Description 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Water Borehole 28 931 000 6 338 000 1 786 000 4 544 000 1 817 000 3 229 000 1 764 000 6 579 000 6 038 000 6 758 000 6 469 000 11 604 000 14 357 000 Water Hand-Dug Well 11 958 000 1 407 000 369 000 1 296 000 342 000 1 038 000 756 000 1 215 000 1 092 000 1 035 000 1 305 000 Water Piped System 171 313 035 19 596 570 12 926 280 16 836 120 18 002 365 21 568 310 18 828 845 25 499 805 24 346 820 19 486 880 21 753 020 23 380 675 17 032 070 Sub-Total 212 202 035 27 341 570 15 081 280 22 676 120 19 819 365 25 139 310 20 592 845 33 116 805 31 140 820 27 459 880 29 314 020 36 019 675 32 694 070 for better health, economic growth and accelerated poverty reduction s Software WATSAN 4 909 200 724 200 183 000 579 600 178 200 325 800 159 000 607 200 472 800 368 000 259 200 420 600 358 200

Software DWST 36 500 4 000 500 4 000 1 500 2 000 1 500 45 000 4 000 1 500 500 2 000 eport of the

Software Partner Organisation 5 727 400 844 900 213 500 676 200 207 900 380 100 185 500 708 400 551 600 427 000 302 400 490 700 417 900 R Software HDW Contractors 981 840 144 840 38 600 115 920 35 640 65 160 31 800 121 440 94 560 73 200 51 840 84 120 71 640

s tment Sub-Total 11 654 940 1 717 940 435 600 1 375 720 423 240 773 060 377 800 1 482 040 1 122 960 869 700 613 940 997 420 847 740

Source: CWSA, SIP 2003-2015

128 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 129 Scaling-up health inve Table AXV Projected Coverage for Sanitation and Number of Facilities, (Ideal Case)

Sanitation Gap Projection Number of Facilities APPENDIX B Expected

Coverage Household Shared Institu- Total nitiative I (ideal Projected Facilities- Facilities tional Facilities to Year Scenario) Population Target Population Population Gap KVIPs – KVIPs Facilities be provided Description of the Coverage and 2002 28% 15 052 813.00 4 214 787.64 - - - - - Costing Estimation Model for Water and 2003 23% 15 426 138.00 3 548 011.74 - - - - -

2004 31% 15 809 704.00 4 901 008.24 427 428.22 34 194 570 114 34 878 Sanitation ealth H 2005 34% 16 204 025.00 5 509 368.50 1 035 788.48 82 863 1 381 276 84 520 The model underlying the coverage and costing of scaling-up water and sanitation is 2006 37% 16 609 556.00 6 145 535.72 1 671 955.70 133 756 229 446 134 431 a dynamic tool developed by the CWSA to estimate coverage and cost levels as well as

2007 42% 17 026 357.00 7 151 069.94 2 677 489.92 214 199 3 570 714 218 483 monitor actual performance of its strategic investment plan at the national, regional,

district and community level. and

2008 50% 17 454 591.00 8 727 295.50 4 253 715.48 340 297 5 672 1 134 347 103 s

2009 60% 17 895 036.00 10 737 021.60 6 263 441.58 501 075 8 351 1 670 511 096

2010 68% 18 347 897.00 12 476 569.96 8 002 989.94 640 239 10 671 2 134 653 044 Main Assumptions Main Assumptions of the model include the following: 2011 74% 18 813 354.00 13 921 881.96 9 448 301.94 755 864 12 598 2 520 770 982

2012 78% 19 292 082.00 15 047 823.96 10 574 243.94 845 940 14 099 2 820 862 859 » The population growth rate is constant over the programmed period and is based on the rate given by the Ghana Statistical Service in the 2000 Population Census 2013 82% 19 784 625.00 16 223 392.50 11 749 812.48 939 985 15 666 3 133 958 784 Report 2014 84% 20 290 935.00 17 044 385.40 12 570 805.38 1 005 664 16 761 3 352 1 025 777 Prices and organisational structures remain unchanged over the planned period 2015 85% 20 811 804.00 17 690 033.40 13 216 453.38 1 057 316 17 622 3 524 1 078 462 »

» The technology prescribed would have corresponding water sources for the provision acroeconomic

of that facility. In real situations if the source of water does not meet requirements for M the provision of the facility, it may not be possible to put up the facility

» The communities and districts would be ready and prepared to demand the facility

» External Support Agencies (ESA) and GoG funding would be available at the various hana times when the physical facilities are to be provided G » Private sector capacity would be available to deliver the facilities. Scenario Building in the Model Various scenarios of the model can be built on the following parameters:

» The population is the basis for the coverage and the target of any investment plan.

» The sub-parameters (issues) that bear on the population are: for better health, economic growth and accelerated poverty reduction s » The definition of population is what the community refers to as those who can eport of the access the facilities provided and is not identical to that defined by the population R census s tment » The population of the communities form the basis for any population projection

» The year in which the population census was taken, forms the basis for population growth projection

» The population growth rates have been prioritised in the following order, com- munity, district, region and national. In the case of the absence of the growth rate for a particular level, the next higher priority available is chosen

130 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 131 Scaling-up health inve » Within the current parameters only national and regional population growth rates Table B1 Growth Rates (Obtained from 2000 Population Census) are available. Since the regional growth rate is of higher priority between the two, Abbreviation Growth Rate it is that which has been used for the current calculations. National 2.70% Ashanti Region ASH 3.40% » The following considerations determine the facilities to be provided: nitiative Brong Ahafo Region BAR 2.50% I » The size of population the facility can cover Central Region CR 2.10% Eastern Region ER 1.40% » The recommended facility or technology for the community based on the projected Greater Accra Region GAR 4.40% population size. Northern Region NR 2.80% ealth » The unit cost of providing the facility. Upper East Region UER 1.10% Upper West Region UWR 1.70% H » The readiness factor takes care of other issues which may be of qualitative nature and Volta Region VR 1.90% that may not readily respond to a strict mathematical evolution. Issues that come into Western Region WR 3.20% play here include: and

» The readiness of the communities to demand facilities. The provision of facilities Facility Parameters s are demand driven and thus unless the community demands the facility, the facility The facility factor and their respective capacities are defined in the Tables A2 – A5 below: would not be imposed on them. Their readiness also depends on their ability to pay Table B2 Facility their statutory contributions Facility Recommended » The readiness of the private sector to deliver the facilities. This includes the capacity Facility Description abbreviation Population of the drillers and the availability of the rigs and other equipment. Borehole BH 300 Hand-Hand Well HDW 1050 » The availability of the sources of water for the delivery of the facility that can support Design Capacity the community for the planned period Piped System PS (i.e. Total coverage)

» The disbursement procedure that will deliver the facilities as planned. Coverage is Table B3 Population Range with Corresponding Recommended Facility acroeconomic

not determined by the quantum of money spent but on the provision of the physical M facilities Population Range Facility 75 – 300 Borehole » Other factors that may not have been considered e.g. political direction, management 301 – 2000 Hand-Dug Well policy change, etc.

2001 – 5000 Pipe System hana

The population factor and facility factor all respond to perfect mathematical models. Over 5000 Pipe System G Table B4 National Unit Cost of Facility (US$) Population parameters Facility Costing Base Unit Cost of Facility Borehole Facility 6000 The definition of the population related parameters are as follows: Hand-Hand Well Facility 3000 PP = Projected population Piped System Per Capita 45 Water and Sanitation Committee Community 600 GR = Growth Rate District Water and Sanitation Teams District 500

for better health, economic growth and accelerated poverty reduction TY = Target Year (The year in which the population is to be evaluated) Partner Organisation Community 700 s BPY = Base population year (The initial population that was considered) Hand-Dug Contractors Community 120 eport of the

Table B5 Regional Unit Cost (US$) R BP = Base population (The year of the base population) Unit s tment The projected population (PP) for any target year (TY) within the planned period (PPTY) Region Facility Costing Base Cost is determined by the formula in Equation 1: Brong Ahafo Borehole Facility 7000 Brong Ahafo Hand-Hand Well Facility 3000 PP = [(1 + GR) ^ (TY – BPY)] * BP [1] TY Brong Ahafo Piped System Per Capita 50 The population growth rates for the various regions as given by the 2002 Population Ashanti Water and Sanitation Committee Community 600 Census are presented in Table B1. Ashanti District Water and Sanitation Teams District 1000 Brong Ahafo District Water and Sanitation Teams District 500 Ashanti Partner Organisation Community 700

132 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 133 Scaling-up health inve Since all the parameters would either be provided or derived except PC1 we can then Readiness Factor derive PC1 to complete the model as in the planned horizon sample table below: The Deficit Gap (DG) may be defined as the difference between the Expected Coverage Table B6 Milestone and Set Target

(EC) to a Milestone Year (MsY) and the Total Current Coverage (TCC). The Deficit Gap Expected Interval Differential nitiative Year I may be viewed more in percentage terms rather than population value terms. This is Coverage Factor (λ) because the population figure will change with changing years while percentage cover- 2007 60.00% 0.8 ages are retained. 2015 85.00% 1.2 The Deficit Gap can be estimated with the formula as represented in equation 2: From equation 10 it can be understood that the behaviour of the investment programme ealth

DG = EC – TCC [2] H MsY MsY is determine by the choice of λ. The behaviour of the model curve depends on the setting A Milestone Year (MsY) is basically a year for which a specific attainment target has λ. been set. Example, to obtain 85% coverage of the population in 2015, a milestone could If λ = 1 then we would obtain a straight-line slope. This assumes that all things would be

be set to attain 60% coverage by 2009. This gives us two milestones for 2009 and 2015. available over the fully planned period and provision of facilities would evenly spread and s Assuming the intermediate milestone of 2009 is not provided then the terminal year of over the period. 2015 becomes the single milestone. If 0 < λ < 1 then the provision of physical facilities starts slowly and rises sharply towards Facilities provided in a particular year (e.g. the jth year) would produce a coverage (per- the end of the milestone. This allows a slow start and room for any initial preparations,

centage terms) (PC) achieved in that year, which is defined as PCi. then hasten the pace towards the end of the milestone.

The cumulative coverage progression can be represented in a series as If λ > 1 the provision of the physical facilities starts very intensely and flattens out towards the end of the milestone. This assumes that preparations have already been made for the SPC = PC1 + PC2 + ···· + PCn [3] presentation of the physical facility, and communities are ready waiting for the facilities. Where n is the number of years to a milestone year. It presumes that all the readiness factors have been over come. To compensate for the readiness to deliver facilities a dummy parameter has been intro-

λ acroeconomic A combination of different milestone and different natures of λ can deliver more realistic duced into the model. This factor is called Interval Differential Factor (λ). The Interval investment programmes. M Differential Factor can be any positive value

0 < λ [4]

Mathematically put, hana G 1 PCi = PCi+1 ( ) 1 [5] PCi = ( )PCi+1 Substituting equation 5 into equationi - 1 3 we obtain then - 1 following result: SPC = PC1 + ( 1 ) PC1 + ···· + (1 ) PC + ( 1 ) PC1 i - 1 n - 1 [6] SPC = PC1 + ( 1 ) PC1 + ···· + (1 ) PC + ( 1 ) PC1

PCi can be factored out to produce 2 3 i 1 n 1 1+ 1 + 1 + 1 +...+ 1 + ...+ 1 [7] SPC = PC1 ( ) ( ) ( ) ( ) ( ) for better health, economic growth and accelerated poverty reduction s

To be able to achieve the set target within the planned period then the sum of the coverage eport of the R of the planned period should be equal to the total deficit gap to be covered. Thus s tment S = DG [8] PC MsY2 3 i 1 n 1 1+ 1 + 1 + 1 + ... + 1 + ... + 1 PC1 ( ) ( ) ( ) ( ) ( ) = DGMsY 2 3 i 1 n 1 1+ 1 + 1 + 1 + ... + 1 + ... + 1 PC1 ( ) ( ) ( ) ( ) ( ) = DGMsY [9]

And eventually 2 3 i 1 n 1 1 1 1 1 1 [10] PC1 1+ ( )+ ( ) + ( ) + ... + ( ) + ... + ( ) = [ECMsY TCC] 2 3 i 1 n 1 1 1 1 1 1 PC1 1+ ( )+ ( ) + ( ) + ... + ( ) + ... + ( ) = [ECMsY TCC]

134 • SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION SCALING–UP HEALTH INVESTMENTS FOR BETTER HEALTH, ECONOMIC GROWTH AND ACCELERATED POVERTY REDUCTION • 135 Scaling-up health inve Canagarajah, S. and X. Ye (2002) “Public Health and Education Spending in Ghana in 1992–98: Issues of Equity and Efficiency.” The World Bank, Washington, D.C. (http://rru. REFERENCES worldbank.org/Documents/PapersLinks/1156.pdf

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Scaling-up health investments for better health, economic growth and accelerated poverty reduction