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Hospital Autonomy in Ghana: the Experience of Korle Bu and Komfo Anokye Teaching Hospitals

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Hospital Autonomy in Ghana: the Experience of Korle Bu and Komfo Anokye Teaching Hospitals Hospital Autonomy in Ghana: The Experience of Korle Bu and Komfo Anokye Teaching Hospitals Ramesh Govindaraj Harvard School of Public Health and A.A.D. Obuobi N.K.A. Enyimayew P. Antwi S. Ofosu-Amaah School of Public Health University of Ghana August 1996 Data for Decision Making Project i Table of Contents 1. Introduction ................................................................................................ 1 1.1 Project Goals and Objectives ........................................................................ 2 2. Framework and Methodology of Study ........................................................... 4 2.1 Hospital Autonomy: A Conceptual Framework ................................................. 4 2.2 Pros and Cons of Hospital Autonomy ............................................................ 9 2.3 Study Methodology ................................................................................... 11 3. Background: Ghana and itsTeaching Hospitals ........................................... 13 3.1 Ghana’s Health Sector ............................................................................... 13 3.2 Korle Bu Teaching Hospital ......................................................................... 15 3.3 Komfo Anokye Teaching Hospital ................................................................ 17 3.4 Informal Autonomy At Teaching Hospitals: A Historical Overview ...................... 18 4. The Formal Autonomy Process in Ghana ..................................................... 20 4.1 Motivations for Proposing Autonomy for Teaching Hospitals in Ghana ............... 20 4.2 Legal Provisions for Autonomy in Ghana: Law 209 ........................................ 21 4.3 Implementation of the Autonomy Law ......................................................... 22 5. Post-Autonomy Structure and Functioning of Teaching Hospitals: Description and Evaluation ............................................................................................... 24 5.1 Korle Bu Hospital ..................................................................................... 25 5.2 Komfo Anokye Hospital ............................................................................. 38 6. Interpretations of Hospital Autonomy in Ghana: One Vision or Many? .......... 49 6.1 Understanding of Key Players of Autonomy for Teaching Hospitals .................... 49 6.2 Implications of Multiple Visions of Autonomy ................................................ 59 7. Discussion ................................................................................................ 61 7.1 Legal Provisions for Autonomy in Ghana ...................................................... 61 7.2 Governance ............................................................................................. 62 7.3 General Management ................................................................................ 65 7.4 Financial Management .............................................................................. 68 7.5 Human Resource Management ................................................................... 72 8. Conclusion and Recommendations ............................................................. 74 ii R. Govindaraj, A.A.D. Obuobi, N.K.A. Enyimayew, P. Antwi and S. Ofosu-Amaah Bibliography ................................................................................................... 78 Appendix 1: Hospitals Administrative Law, 1988, Part 1 Pertaining to Teaching Hospitals .......................................................................................... 81 Appendix 2: Hospital Autonomy Study ............................................................ 86 Client Survey Instrument ................................................................................... 86 Appendix 3: Statistics From Korle BU Andkath ................................................ 90 Appendix 4: List of Persons Interviewed .......................................................... 91 Ministry of Health............................................................................................ 91 Korle Bu Teaching Hospital and University of Ghana Medical School, Accra ............... 91 Komfo Anokye Teaching Hospital and UST Medical School, Kumasi ......................... 92 Ministry of Finance & Economic Planning ............................................................ 92 Others ........................................................................................................... 92 Data for Decision Making Project iii Glossary CAG Controller and Accountant General DDM Data for Decision-Making EN Enrolled Nurse GMTHS Ghana Medium Term Health Strategy GOG Government of Ghana HHRAA Health and Human Resource Analysis for Africa KATH Komfo Anokye Teaching Hospital KBU Korle Bu Teaching Hospital MOE Ministry of Education MOF Ministry of Finance MOH Ministry of Health PNDC Provisional National Defense Council PPME Policy, Planning, Monitoring and Evaluation Unit, MOH. PWD Public Works Department SMS School of Medical Sciences SRN State Registered Nurse UGMS University of Ghana Medical School, Accra USAID United States Agency for International Development UST University of Science and Technology, Kumasi Exchange Rates (US$ 1 to Cedis) 1987 1988 1989 1990 1991 1992 1993 153.7 202.7 270.0 326.3 367.8 437.1 649.1 Source: International Financial Statistics, IMF. iv R. Govindaraj, A.A.D. Obuobi, N.K.A. Enyimayew, P. Antwi and S. Ofosu-Amaah Acknowledgements This study was supported by the United States Agency for International Develop- ment (USAID) Washington through the AFR/SD/Health and Human Resources for Africa (HHRAA) Project, under the Health Care Financing and Private Sector Devel- opment portfolio, whose senior technical advisor is Abraham Bekele. The authors gratefully acknowledge the contribution of officials at the Ministry of Health, Ghana; the Korle Bu and Komfo Anokye Teaching Hospitals; the medical schools at the University at Ghana and the University of Science and Technology, Kumasi; the Ghana Medical Association; and the Ghana Trade Union Congress, whose input and assistance made this study possible. The authors also wish to thank Hope Sukin and Abraham Bekele of the HHRAA project at the Africa Bureau, who reviewed and gave technical input to the report, and all colleagues at Harvard University and the University of Ghana School of Public Health, who provided useful comments and suggestions on earlier drafts of this report. The research and secretarial assistance of the staff at these institutions is also gratefully acknowledged. Data for Decision Making Project v Executive Summary Since the 1980s, public-sector teaching hospitals around the world have come under intense scrutiny in policy circles due to the complexity of these institutions, the heavy burden they impose on public funds, and the perceived difficulties in ensuring their efficient and effective functioning under centralized government con- trol. One policy alternative that has found favor with policy makers in many coun- tries is the grant of greater autonomy to these public-sector hospitals in running their operations. However, despite the implementation of “autonomy” in a number of public-sector hospitals around the world, very little research has been directed towards evaluating the experiences of these hospitals. Accordingly, as part of the overall strategy of the USAID to conduct policy relevant research into matters of importance to African policy makers and USAID missions in Africa, Harvard Univer- sity was commissioned to conduct five case-studies on hospital autonomy. Ghana was identified as one of the sites for this cross-national, comparative, study. Ghana, with an area of 238,537 square kilometers and a population of about 16.5 million (1994 estimate), lies along the west coast of Africa. For administrative purposes, the country is divided into ten regions, and one hundred and ten adminis- trative districts. There are “four main categories of health care delivery systems in Ghana - the public, private-for-profit, private-not-for-profit, and traditional systems. Ghana was one of the first African countries to attempt giving greater autonomy to public sector hospitals. Since the 1970s, the government has gradually moved towards greater decentralization of the health system, creating a new Ghana Health Service (GHS), and providing management teams in hospitals at various levels greater flexibility in allocating resources according to their own priorities, within the overall context of the national policy. As part of this general reform of its health sector, the two teaching hospitals in Ghana, namely, the Korle Bu Hospital (KBU), and the Komfo Anokye Teaching Hospital (KATH), have also been encouraged by the Government of Ghana to become “self-governing”. By far the most significant reasons underlying the grant of autonomy to teaching hospitals in Ghana are financial, the two teaching hospitals account for a dispropor- tionate share of the Ghanaion MOH expenditures. Other reasons also cited by stakeholders include: separating the policy formulation function of the MOH from health services delivery; freeing the hospitals from the constraints of civil service regulations; increasing management efficiency; improving the quality of care; and improving the overall public image of the teaching hospitals. vi R. Govindaraj, A.A.D. Obuobi, N.K.A. Enyimayew, P. Antwi and S. Ofosu-Amaah In 1988, a legal framework, the Provisional National Defence Council
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