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Assessing Facility Capacity and Costs of Care

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Assessing Facility Capacity and Costs of Care HEALTH SERVICE PROVISION IN GHANA A CCESS, Assessing Facility Capacity B OTTLENECKS, C OSTS, AND and Costs of Care E QUITY This report was prepared by the Institute for Health Metrics and Evaluation (IHME) in collab- oration with Ghana’s Ministry of Health, the Ghana Health Service (GHS), the Ghana UNICEF office, and UNICEF. This work is intended to help policymakers understand the costs of health service delivery and health facility performance in Ghana. The numbers may change following peer review. The contents of this publication may not be reproduced in whole or in part with- out permission from IHME. Citation: Institute for Health Metrics and Evaluation (IHME). Health Service Provision in Ghana: Assessing Facility Capacity and Costs of Care. Seattle, WA: IHME, 2015. Institute for Health Metrics and Evaluation 2301 Fifth Ave., Suite 600 Seattle, WA 98121 USA Telephone: +1-206-897-2800 Fax: +1-206-897-2899 Email: [email protected] www.healthdata.org ©2015 Institute for Health Metrics and Evaluation Photo credit: C.C. Chapman flickr photostream, Koforidua, Ghana, April 2012 HEALTH SERVICE PROVISION IN GHANA A CCESS, Assessing Facility Capacity B OTTLENECKS, C OSTS, AND and Costs of Care E QUITY Contents 4 Acronyms 6 Terms and definitions 8 Executive summary 12 Introduction 16 ABCE study design 21 Main findings Health facility profiles Personnel and outputs Service provision and pharmaceuticals Trends in facility expenditures and revenues Efficiency and costs of care 45 Conclusions and policy implications 48 References About IHME The Institute for Health Metrics and Evaluation (IHME) is an To express interest in collaborating or request further in- independent global health research center at the Univer- formation on the Access, Bottlenecks, Costs, and Equity sity of Washington that provides rigorous and comparable (ABCE) project in Ghana, please contact IHME: measurement of the world’s most important health prob- Institute for Health Metrics and Evaluation lems and evaluates the strategies used to address them. 2301 Fifth Ave., Suite 600 IHME makes this information freely available so that poli- Seattle, WA 98121 cymakers have the evidence they need to make informed USA decisions about how to allocate resources to best improve population health. Telephone: +1-206-897-2800 Fax: +1-206-897-2899 Email: [email protected] www.healthdata.org About this report Health Service Provision in Ghana: Assessing Facility Ca- Melinda Gates Foundation to comprehensively estimate pacity and Costs of Care provides a comprehensive yet the costs and cost-effectiveness of a range of health inter- detailed assessment of health facility performance in ventions and delivery platforms. Data collection in Ghana Ghana, including facility capacity for service delivery and also was supported by UNICEF. costs of care. This report provides expanded results from The ABCE project is a collaborative study with IHME, Gha- the preliminary findings presented at the Ghana Health na’s Ministry of Health (MOH), the Ghana Health Service Summit in April 2013. A preliminary policy report was dis- (GHS), Ghana UNICEF office, and UNICEF. At IHME, Christo- seminated at that time, titled Access, Bottlenecks, Costs, pher Murray, Emmanuela Gakidou, Michael Hanlon, Santosh and Equity: Assessing Health System Performance and Bar- Kumar, Kelsey Moore, and Annie Haakenstad had key roles riers to Care in Ghana. Results from 2013 have not changed; in the project. At the MOH, the project was led by Kwakye rather, researchers have now completed analyses on fa- Kontor. Evelyn Ansah, Ivy Osei, and Bertha Garshong served cility levels of efficiency and costs of care, which were not as the ABCE project leads for GHS. At the Ghana UNICEF of- available at the time of the 2013 Ghana Health Summit. This fice, the project was led by Anirban Chatterjee, who was the report includes the results from the 2013 publication, as in-country principal investigator (PI), and Jane Mwangi. Data well as the additional analyses mentioned above. collection was conducted by a team of research associates Findings presented in this report were produced from GHS. Analyses were jointly conducted by several re- through the ABCE project in Ghana, which aims to collate searchers at GHS and IHME, including Roy Burstein, Brendan and generate the evidence base for improving the cost- DeCenso (now of RTI International), Kristen Delwiche, Laura effectiveness and equity of health systems. The ABCE Di Giorgio, Samuel Masters (now of UNC-Chapel Hill), Allen project is funded through the Disease Control Priorities Roberts, and Alexandra Wollum. This report was written by Network (DCPN), which is a multiyear grant from the Bill & Nancy Fullman of IHME. 2 Acknowledgments The ABCE project in Ghana is a collaboration between the traveling from facility to facility and interviewing staff and pa- Ghana MOH, GHS, the Ghana UNICEF office, UNICEF, and tients, that we are able to present these findings today. We IHME at the University of Washington in the United States. are immensely grateful to the ABCE Ghana field team. We are most grateful to these organizations, especially for A number of IHME research fellows contributed to data their willingness to facilitate data access and provide crucial collection and verification in Ghana. We appreciate the content knowledge. Additional survey input and cooper- work of Miriam Alvarado (now of Chronic Disease Research ation were provided by the Clinton Health Access Initiative Centre of Barbados), David Chou (now of Columbia Uni- (CHAI) and Instituto Nacional de Salud Pública. versity), Michael Freeman, and Thomas Roberts (now of We especially thank all of the health facilities and their Stanford University). staff, who generously gave of their time and facilitated the At IHME, we wish to thank Kelsey Moore, Annie Haaken- sharing of the facility data that made this study possible. stad, and Aubrey Levine for managing the project; Ellen We are also most appreciative of the patients who partic- Squires for data support; Patricia Kiyono for managing the ipated in this work, as they, too, were giving of their time production of this report; Adrienne Chew and Kate Muller and kindly willing to share their experiences with the field for editorial support; and Dawn Shepard for graphic design. research team. Funding for this research came from the Bill & Melinda The quantity and quality of the data collected for the Gates Foundation. UNICEF provided financial support for ABCE project in Ghana are a direct reflection of the dedi- facility data collection in Ghana. cated field team. It is because of their months of hard work, 3 Acronyms 3TC Lamivudine ABCE Access, Bottlenecks, Costs, and Equity ACT Artemisinin-based combination therapy AIDS Acquired immunodeficiency syndrome AL Artemether-lumefantrine ARV Antiretroviral (drug) AS+AQ Artesunate-amodiaquine AZT/ZDV Zidovudine CHAI Clinton Health Access Initiative CHPS Community-based health planning and services CMS Central Medical Stores C&C Cash and carry DAH Development assistance for health DEA Data Envelopment Analysis DCPN Disease Control Priorities Network DHMT District Health Management Team DHS Demographic and Health Survey EFV Efavirenz ELISA Enzyme-linked immunosorbent assay GDP Gross Domestic Product GHS Ghana Health Service GOG Government of Ghana HIV Human immunodeficiency virus 4 IGF Internally generated funds IHME Institute for Health Metrics and Evaluation IPTp Intermittent preventive therapy during pregnancy LMIC Lower-middle-income country MICS Multiple Indicator Cluster Survey MOH Ministry of Health MMR Maternal mortality ratio NCD Non-communicable disease NHIA National Health Insurance Authority NHIS National Health Insurance Scheme NVP Nevirapine RDT Rapid diagnostic test RMS Regional Medical Stores TDF Tenofovir UNICEF The United Nations Children’s Fund VAT Value-added tax 5 Terms and definitions Constraint: a factor that facilitates or hinders the provision of or access to health services. Constraints exist as both “supply-side,” or the capacity of a health facility to provide services, and “demand-side,” or patient-based factors that affect health-seeking behaviors (e.g., distance to the nearest health facility, perceived quality of care given by providers). Data Envelopment Analysis (DEA): an econometric analytic approach used to estimate the efficiency levels of health facilities. District sampling frame: the list of districts from which the ABCE district sample was drawn. Efficiency: a measure that reflects the degree to which health facilities are maximizing the use of available resources in pro- ducing services. Facility sampling frame: the list of health facilities from which the ABCE sample was drawn. This list was based on a 2011 Ministry of Health (MOH) Needs Assessment. Inpatient bed-days: the total number of days spent in a facility by an admitted patient. This statistic reflects the duration of an inpatient visit rather than simply its occurrence. Inpatient visit: a visit in which a patient has been admitted to a facility. An inpatient visit generally involves at least one night spent at the facility, but the metric of a visit does not reflect the duration of stay. Inputs: tangible items that are needed to provide health services, including facility infrastructure and utilities, medical sup- plies and equipment, and personnel. Outpatient equivalent visits: different measures of patient visits, such as inpatient bed-days and births, scaled to equal a comparable number of outpatient visits. This approach
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