Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized The Health Sector in Ghana The Health Sector in Ghana A Comprehensive Assessment Karima Saleh © 2013 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington, DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org Some rights reserved 1 2 3 4 15 14 13 12 This work is a product of the staff of The World Bank with external contributions. Note that The World Bank does not necessarily own each component of the content included in the work. The World Bank therefore does not warrant that the use of the content contained in the work will not infringe on the rights of third parties. The risk of claims resulting from such infringement rests solely with you. 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ISBN (paper): 978-0-8213-9599-8 ISBN (electronic): 978-0-8213-9600-1 DOI: 10.1596/978-0-8213-9599-8 Cover photo: Volunteer nurses and Motoko clinic staff working with children. Kudorkopey, Ghana. Photo by Randy Olson/National Geographic/Getty Images. Library of Congress Cataloging-in-Publication data has been requested. Contents Foreword xiii Acknowledgments xv About the Author xvii Abbreviations xix Overview 1 What Are Ghana’s Health, Nutrition, and Population Challenges as It Continues Its Transition to Universal Health Insurance Coverage? 1 What Are Some Health System Challenges? 3 How Is Ghana Faring in the Use of Public Resources for Health? 6 What Are the Population’s Health Outcomes and Access to and Use of Services? 9 Is the Population Financially Protected against Illness? 13 What Are the Next Steps for Ghana? 15 References 19 Chapter 1 Background and Objectives 21 Background 21 v vi Contents Population Dynamics and Demographic Changes 24 Epidemiological Changes 28 Labor Market Situation 29 Overview of Ghana’s Health System 31 Cross-Cutting Areas of Reform 33 The Book 37 Notes 38 References 39 Chapter 2 Health Delivery System 41 Key Messages 41 Health Infrastructure and Other Capital Investments 43 Human Resources for Health 53 Pharmaceuticals 69 Conclusion 78 Notes 80 References 81 Chapter 3 Health Financing System 85 Key Messages 85 Health Financing Functions 87 Trend Analysis on Health Budgets and Expenditures 94 Fiscal Space Analysis 103 Health Insurance Providers 105 Conclusion 131 Notes 132 References 134 Chapter 4 Assessment of Health Financing and Delivery Performance 137 Key Messages 137 Health Outcomes 139 Health Outputs 144 Efficiency 159 Financial Protection and Equity in Financing 163 Quality of Health Services 173 Conclusion 182 Notes 184 References 185 Contents vii Chapter 5 Key Reform Issues and Options 189 Reform Issues 189 Reform Options 195 Summary of Key Reform Options 209 Note 216 Reference 216 Boxes 2.1 Options Available to Address Shortage and Inequity in Distribution of Health Facilities 49 2.2 The Urban Bias in Human Resource Distribution 60 2.3 The Case of the Additional Duties Hours Allowance under the Ministry of Health, 1998–2005 68 3.1 The National Health Insurance Act 107 3.2 What Is the “One-Time Premium” Policy to Be Introduced by Ghana? 112 3.3 Ghana NHIS: Benefit Package Exclusion 114 3.4 Ghana NHIS: A Description of G-DRG Rates 116 3.5 Efficiency Measured for NHIS Claims Submission, Processing, and Reimbursements 119 4.1 Country’s Capacity to Address and Respond to Noncommunicable Diseases 157 4.2 Efficiency in Health Service Utilization 161 4.3 The Three Dimensions of Universal Coverage 166 4.4 Benefit Incidence of Public Health Facilities and Mission-Based Facilities 169 4.5 Satisfaction with Health Care Providers 183 Figures O.1 Ghana, Causes of Death, 2008 Estimates 3 O.2 Number of Health Workers in Ghana Compared with Other Countries with Similar Incomes and Health Spending Levels, 2009 4 O.3 Average Public Sector Procured Prices Compared with International Reference Pricing, 1993–2008 6 O.4 Per Capita Health Spending Compared with Countries with Similar Incomes, 2009 7 O.5 Total Health Spending Shares, 1995–2009 8 O.6 Global Comparisons of Mortality Rates Relative to Income and Spending, 2009 10 viii Contents O.7 Regional and Income Differentials in Institutional Deliveries, 2008 11 O.8 Income Differences in Households with Children under Age Five with a Fever and Seeking Care, 2008 12 O.9 NHIS Coverage by Gender and Income Quintile for Adults (Ages 15–49), 2008 14 O.10 Household Spending on Health by Consumption Quintile, 2005–06 15 1.1 Ghana: Real GDP Growth Rate, 1989–2015 23 1.2 Ghana: Demographic Trend and Future Projections, 1990–2050 27 1.3 Ghana: Changing Age Structure of the Population 28 1.4 Distribution of Years of Life Lost by Causes, 2008 29 1.5 Causes of Death, 2008 Estimates 30 2.1 Hospital-Beds-to-Population Ratios Relative to Total Health Spending and Income, 2009 47 2.2 Facilities with Access to Obstetric Care–Related Equipment, 2010 50 2.3 Facilities with Access to Filled Oxygen Cylinders, 2010 50 2.4 Limited Obstetric Services Offered in Health Facilities Due to Limited Access to Equipment, Drugs, or Supplies, 2010 51 2.5 Access to Transport at Health Facilities, 2010 52 2.6 Health-Workers-to-Population Ratios Relative to Total Health Spending and Incomes, 2009 54 2.7 Health Worker Profile, Selected Countries from Sub-Saharan Africa, 2009 54 2.8 Physician-to-Population Ratios, International Comparison 56 2.9 Selected Health Workers Distribution by Age, 2007 57 2.10 Regional Distribution of Health Workers (Doctors, Nurses, and Midwives) per 1,000 Population, 2009 58 2.11 Maldistribution of Staffing in Public Health Facilities, 2010 58 2.12 Ghana: Regional Variation in Health Worker Productivity, 2006 61 2.13 Annual Wages of Health Workers in Ghana and the Region, 2007 62 2.14 Average “Base” Salary across Different Public Sector Services and Institutions, 2008 63 Contents ix 2.15 Ghana: Health Worker Attrition Profile, 2004–08 63 2.16 Production of Doctors per Million People, International Comparison, 2007 64 2.17 Ghana: Enrollment into MOH-Run Paramedical Diploma Programs and Medical Schools, 2000–08 65 2.18 Availability of Essential Drugs in Health Facilities, 2008 70 2.19 Sources of Drug Procurement: Public and Private Sectors, 2002 71 2.20 Source of Procurement for Obstetric and Neonatal Care–Related Drugs, 2010 72 2.21 Average Public Sector Procured Prices Compared with International Reference Pricing, 1993–2008 73 2.22 Public and Private Sector Procured Prices versus Retail Prices of Generic Drugs Compared with International Reference Pricing, 2004 73 2.23 Cost Breakdown of Drugs Procured by the Public versus the Private Sector, 2004 74 3.1 Ghana: Sources of Financing for Health, 1995–2009 88 3.2 International Comparison: Total Per Capita Health Spending Compared with Countries with Similar Incomes, 2009 90 3.3 International Comparison: Health Spending as a Percentage of GDP, 1995–2009 91 3.4 International Comparison: Out-of-Pocket Spending for Health Relative to Other Countries with Similar Incomes, 2009 92 3.5 Ghana Ministry of Health: Sources of Financing for Health, 2005–09 93 3.6 Ghana Ministry of Health: Actual and Projected Donor Contributions, 2008–13 94 3.7 Ghana Ministry of Health: Internally Generated Fund Breakdown between National Health Insurance Authority and Out-of-Pocket Payments, 2005–09 95 3.8 International Comparison: Public Health Spending as a Percentage of Total Government Spending, 2009 96 3.9 Ghana Ministry of Health: Spending on Wages as Percentage of Recurrent and Total Spending, 2005–09 98 3.10 Ghana: Expenditure Allocation at Regional and District Levels, 2008 100 x Contents 3.11 Ghana: Variations in Subnational Health Expenditures Per Capita across Regions, 2008 101 3.12 Ghana: Total Health Expenditures Per Capita by District, 2008 102 3.13 Ghana: Financing