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Has Resource Allocation Policy Change Improved Equity? Lessons from Ghana

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Has Resource Allocation Policy Change Improved Equity? Lessons from Ghana HAS RESOURCE ALLOCATION POLICY CHANGE IMPROVED EQUITY? LESSONS FROM GHANA AUGUSTINE DANSO ASANTE A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy School of Public Health and Community Medicine Faculty of Medicine The University of New South Wales March 2006 CERTIFICATE OF ORIGINALITY I hereby declare that this submission is my own work and to the best of my knowledge and belief, it contains no material previously published or written by another person, nor material which to a substantial extent has been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project’s design and conception or in style, presentation and linguistic expression is acknowledged. ………………………… Augustine Danso Asante ii ACKNOWLEDGEMENTS This project would not have been possible without the overwhelming support of my supervisors Professor Anthony Zwi and Dr. Maria Theresa Ho. Their guidance and encouragement coupled with critical but constructive feedbacks steered the project to its completion. Anthony and Tessa went beyond the call of supervisory duty over the course of this project. I am particularly grateful for the key role they played in ensuring that fieldwork in Ghana could be undertaken. I also thank my previous co-supervisor Dr. Anna Whelan for her support in the early stages of my candidature. I am indebted to The University of New South Wales for the financial support it provided towards this study. Without the University International Postgraduate Award (UIPA), which I was priviledged to enjoy for two and half years, it would have been very difficult to complete this project. I am also pleased to acknowledge the financial and logistic support provided by the School of Public Health and Community Medicine to this project. During my fieldwork in Ghana, I enjoyed the help and support of so many people. I am pleased to acknowledge the support of Dr. Elias Sory (Regional Director of Health Services – Northern Region), Dr. Kofi Asare (Regional Director of Health Services – Ashanti Region) Mr. Yakubu Zakaria (Ministry of Finance and Economic Planning), and many others who in diverse ways facilitated the data collection. My friends in Sydney have also been very supportive. I specially thank Dr. Alfred Yawson and wife, Mr. George Asabre and family and Mrs. Yolanda Fenandez and family for their support. Dr. Yawson was particularly instrumental in helping me think through the statistical analysis in this study. I also acknowledge the support of my colleagues and fellow PhD students at the SPHCM, particularly the ‘night team’. Finally, I owe a special debt of gratitude to my family, most especially to my wife and children who have equally paid a hefty price for my long absence from home. I hope one day the kids will grow to appreciate this sacrifice and pardon me for being an “absentee” father. This work is dedicated to the memory of my parents, particularly my father, whose advice and words of encouragement continue to guide and inspire me in this difficult pursuit of knowledge. I will forever be grateful to him for setting me on this path despite the challenges. iii CONTENT Page Declaration ii Acknowledgements iii List of Tables ix List of Figures xi List of Boxes xii Acronyms xiii Abstract xv Chapter 1: Decentralisation, Resource Allocation and Equity: An Introduction to the Study Overview........................................................................................................................................1 1.1 Background..............................................................................................................................1 1.2 Factors Driving Reform in the Health Sector ..........................................................................3 1.3 Health Sector Decentralisation.................................................................................................6 1.4 Equity and Resource Allocation ..............................................................................................8 1.4.1 Interpretation of Equity ..................................................................................................9 1.5 Equity in Resource Allocation under Decentralisation in Ghana ..........................................11 1.5.1 Purpose and Main Research Questions ........................................................................11 1.5.2 Scope and Outline of Study..........................................................................................12 Chapter 2: Ghana and Its Health Care System Overview......................................................................................................................................15 2.1 Geography, Population and Administrative Divisions...........................................................15 2.2 Political Context.....................................................................................................................17 2.3 Economic Context..................................................................................................................19 2.4 Structure of the Health Care System......................................................................................21 2.5 Health Status ..........................................................................................................................24 2.6 Inequalities in Health .............................................................................................................25 2.6.1 Inequalities in Access to Facilities ...............................................................................26 2.6.2 Inequalities in Child Mortality .....................................................................................27 2.7 Health Policy Objectives........................................................................................................28 2.8 Health Sector Reforms...........................................................................................................30 2.8.1 Decentralisation and Re-organisation of the Health System ........................................30 2.8.2 Decentralisation of Resource Allocation Decision-Making.........................................32 2.8.3 Implementation of Budget Management Centre (BMC) Concept................................33 iv Chapter 3: Health and Social Justice: A Search for a Theoretical Framework Overview......................................................................................................................................37 3.1 Introduction............................................................................................................................37 3.2 Utilitarian Theory...................................................................................................................41 3.2.1 Critique of Utilitarian Theory.......................................................................................41 3.3 Entitlement Theory ................................................................................................................43 3.3.1 Critique of Entitlement Theory ....................................................................................45 3.4 Rawls’ Theory of Justice: The Framework for Current Study...............................................46 3.4.1 The Rawlsian Theory and Health .................................................................................48 3.4.2 Equality of Opportunity and Health .............................................................................50 3.5 Theories of Social Justice and this Study...............................................................................52 Chapter 4: Equity and Equitable Distribution of Health Care Resources Overview......................................................................................................................................59 SECTION 1 - EQUITY: CONCEPT, INTERPRETATION AND MEASUREMENT ..............59 4.1 Equity and Equality: A Conceptual Clarification ..................................................................59 4.2 Defining Equity......................................................................................................................61 4.2.1 Horizontal and Vertical Equity.....................................................................................61 4.2.2 Equal Treatment for Equal Need..................................................................................63 4.2.3 Equality of Access (Equal Access for Equal Need) .....................................................63 4.2.4 Equality of Health ........................................................................................................65 4.3 Measuring Equity...................................................................................................................66 4.4 Defining Health Need ............................................................................................................68 4.4.1 Measurement of Need...................................................................................................69 4.4.2 Deprivation as a Proxy of Need....................................................................................71
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