PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Case study from Ghana
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Editing and design by Inís Communication – www.iniscommunication.com Primary Health Care Systems (PRIMASYS) Case study from Ghana
Overview
Ghana is a lower middle-income country with a population of delays in reimbursement of service providers due to a number 28 million, an area of 238 537 square kilometres, and a per capita of factors,7 including inadequate funding, moral hazards, gross domestic product (GDP) of US$ 1387.9 per year.1 Life corrupt practices and inefficiencies. The Presidential Committee expectancy at birth was 63 years in 2015, and the total fertility set up in 2016 recommended that the scheme give priority to rate was 4.2. Under‑5 child mortality has steadily reduced from primary health care. 155 to 60 per 1000 live births and the maternal mortality ratio Health service delivery is broadly organized by level as primary, has also reduced, from 634 to 319 deaths per 100 000 live births secondary and tertiary, and has pluralistic service providers in 1990 and 2015 respectively. Neonatal deaths account for consisting of public, private, traditional and alternative service almost half of the under-5 mortality rate. The country is going providers. The primary level is based on PHC principles and through a triple transition: epidemiological,2 demographic3 and a three-tier district health system model comprising the economic,4,5 with a continuing high burden of communicable community level, sub-district level (health centre with sub- diseases; a rising burden of noncommunicable diseases district health management team), and district hospital and and road traffic accidents; rural-urban migration and rapid district health management team at the apex. The community urbanization associated with the breakdown of traditional social level – Community-based Health Planning and Services support systems; poor housing and sanitation, and seasonal (CHPS)8 – is the base of health service organization and delivery cholera outbreaks; and health problems of adolescents and and involves demarcation of sub-districts into CHPS zones, older people. mobilization of communities and deployment of trained health In 2014, government health expenditure as a percentage of workers for integrated basic primary care, including health total expenditure was 10.6% (short of the Abuja Declaration promotion and disease prevention. target of 15%), total health expenditure as a percentage of GDP There is a referral system to link the various levels of care but it was 3.6%, and out-of-pocket expenditure as a percentage of is currently not working well, resulting in secondary and tertiary health expenditure was 36.2%. The National Health Insurance hospitals also using significant proportions of their resources Scheme (NHIS), established by law in 2003 and revised in 2012, for primary care services. is a social insurance scheme that seeks to provide access to quality health services, financial protection against catastrophic Table 1 summarizes key demographic and health indicators for illness and universal health coverage. The active membership Ghana. is 40% coverage of the population.6 However, there are long
1 World statistics pocketbook, 2016 edition. United Nations Statistics Division; 2016. 2 Global burden of diseases, injuries, and risk factors study 2010: Ghana. Institute for Health Metrics and Evaluation; 2010. 3 2010 Population and Housing Census. Ghana Statistical Service; 2010. 4 National Health Accounts, Ghana. Ministry of Health; 2012. 5 Ghana statistics. World Health Organization; 2017 (http://www.who.int/countries/gha/en/). 6 Health sector holistic assessment report, 2015. Ministry of Health; 2015. 7 Proposed redesign and restructuring of the National Health Insurance Scheme: final draft of main report. Presidential NHIS Committee; 2016. 8 National Community-based Health Planning and Services (CHPS) Policy. Ministry of Health; 2016. Ghana Case Study
Table 1. Key demographic and health indicators, Ghana
Indicator Results Source Remarks Total population of country, 2016 28 308 301 Ghana Statistical Service 2010 census population: 24 658 823 (growth projection (male/female ratio) (50.9/49.1%) (GSS): Population and rate 2.5%) a Housing Census Rural/urban: 49.1/50.9% 1960 census population: 6 726 815 Life expectancy at birth (2010–2015) 61 (62/60) United Nationsb African Region lower middle-income countries: (male/female) in years 58 years World lower middle-income countries: 66 years Infant mortality rate per 1000 live 41 Ghana Demographic and Neonatal deaths not changed much from 1990 births (2014) Health Survey (GDHS)c to date Under-5 mortality rate per 1000 live 60 GDHSc Declined from 155 in 1988 but could not births (2014) achieve Millennium Development Goal (MDG) 3 target of 41 Maternal mortality ratio per 100 000 319 United Nations estimated 2007 Ghana Maternal Health Survey reported live births (2015) 350; MDG 5 target was 185 % coverage of fully immunized under 77% GDHSc Increased from 50.5% in 1998 to 69% in 2003 1 year (including pneumococcal & and 79% in 2008 rotavirus) (2014) Income or wealth inequality (Gini 0.409 GSS: Ghana Living Improved from 0.373 in 1992 to 0.388 (1998), coefficient) (2013) Standards Surveye 0.406 (2006) Total health expenditure as % of GDP 3.6 United Nationsb Shows an increasing trend though fluctuating (2014) General government expenditure on 60.6 African Health Peaked at 74.4 in 2011 and started declining health as % of total expenditure on Observatoryf health (2013) General government expenditure 10.6 African Health Met the Abuja Declaration target of 15% in on health as % of total government Observatoryf 2005, 2007 and 2009 expenditure (2013) % of total public sector expenditure 60% World Health This is an estimate from the National Health on PHC Organization (WHO)g Accounts Per capita total expenditure on 58 WHOg Compared to US$ 97 average for African Region health (2014 in US$) lower middle-income countries Out-of-pocket payments as % of total 26.8% WHOg Fluctuating but likely to increase as unofficial expenditure on health (2014) co-payment is common due to long delays in NHIS reimbursements to providers
a. 2010 Population and Housing Census. Ghana Statistical Service; 2010. b. World statistics pocketbook, 2016 edition. United Nations Statistics Division; 2016. c. 2014 Ghana Demographic and Health Survey. Ghana Statistical Service; 2014. d. United Nations Maternal Mortality Estimation Inter-agency Group; 2015. e. Ghana Living Standards Survey Round 6: poverty profile in Ghana (2005–2013). Ghana Statistical Service. f. African Health Observatory/WHO; 2016. g. Public financing for health in Africa: from Abuja to the SDGs. WHO/HIS/HGF/Tech.Report/16.2. Geneva: World Health Organization; 2016.
4 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)
Timeline: key milestones in the development of primary health care in Ghana
National independence in 1957 was followed by a decade of practitioners to provide needed leadership for the district rapid expansion of health facilities across the country, resulting health system and PHC. In response to the government’s Vision in a rapid increase in access to basic medical services. 2020 strategy for economic and social transformation launched in 1995, the Ministry of Health developed the Medium Term A military coup d’état in 1966, followed by five more over Health Strategy and embarked on health sector reforms, the next three decades, coincided with a period of economic including the establishment of the Ghana Health Service and decline and slowdown in the development of basic health adoption of the health sector-wide approach. This in turn led services. That notwithstanding, several key events continued to collaboration with health development partners in the to shape the course of PHC development. development of a series of medium-term health plans and Government, in partnerships with religious mission hospitals Common Management Arrangements that improved funding in the 1970s, provided services in rural and underserved areas for district health services. through mobile clinics and training and use of village health A Human Resources for Health Policy and Strategy was workers for community-based primary care. The findings of developed in 1997 and revised twice, in 2002 and 2007. three projects – Brong Ahafo Basic Health Services Project Implementation of the strategy increased the production of (1967), Danfa Comprehensive Rural Health and Family Planning health professionals, especially middle-level personnel, and the Project9 and Brong Ahafo Rural Integrated Development Project retention of skilled health professionals in the country. – informed the design of Ghana’s PHC strategy (district health system model) adopted in 1979.10 The research findings of the Navrongo Community Health and Family Planning h Project11,12 informed the development of the In the 1980s, user fees for health services were introduced to national CHPS strategy in 2000.13,14,15 Though it was embraced raise revenue for medical services, which had a negative impact by communities and politicians, and demonstrated some on access to services. A search ensued for appropriate financing success, implementation of the CHPS strategy faced a number mechanisms, such as community health insurance schemes, of challenges,16 including poor community mobilization in most culminating in the introduction of the NHIS. areas; weak capacity of the subdistricts to supervise and provide The adoption of a devolved local government system in 1988 technical support; lack of alignment of vertical programmes; and the return to democratic civilian rule in 1993, with three inadequate investment in CHPS infrastructure and equipment; peaceful changes of government from one political party and absence of dedicated funding for operations at this level. to another, provided a conducive environment for effective The revised policy seeks to address some of these challenges. stakeholder engagement and popular participation in Figure 1 provides a timeline of key developments relevant to governance, discourses on public issues, and service delivery. the Ghana PHC system. In the 1990s the Ministry of Health instituted the training of district health management teams and public health
9 The Danfa Comprehensive Rural Health and Family Planning Project, Ghana: final report. UGMS/UCLA; 1979. 10 Ghana Medium Term Health Strategy. Ministry of Health; 1996. 11 The Navrongo Community Health and Family Planning Project: lessons learned, 1994–1998. NHRC; 1999. 12 Phillips JF et al., Accelerating reproductive and child health program development: the Navrongo initiative in Ghana. 2005. 13 Community-based Health Planning and Services handbook. Ministry of Health; 1999. 14 CHPS: the strategy for bridging the equity gaps in access to quality health services. Ministry of Health; 2002. 15 Community-based Health Planning and Services (CHPS): the operational policy. Ghana Health Service; 2005. 16 In-depth review of the Community-based Health Planning Services (CHPS) programme. Ministry of Health; 2009.
5 Ghana Case Study
Figure 1. Timeline of key developments relevant to the Ghana PHC system
1957 Gained independence, followed by 1966 rapid expansion of medical services and Government overthrown by military coup d’état followed by four more training of mid-level health workers successful coups over the next 15 years (1972, 1978, 1979 and 1981) Late 1960s to 1970s Local initiatives include mobile clinics and training of village health workers; PHC precursor projects; Basic Health Services Project (1967–1971); Danfa Comprehensive Rural Health 1978 and Family Planning Project (1970–1979); Brong-Ahafo Rural Ghana PHC paper finalized; Integrated Development Project (1975–1979) Expanded Programme on 1979 Immunization (EPI) established PHC strategy adopted and implementation started in one district 1980s in each of the then Several PHC initiatives and structural adjustments; nine regions staff redeployment; Bamako Initiative; essential 1983 drugs list; eight elements of PHC; National Traditional User fees introduced and substantially Birth Attendants Programme; Strengthening District increased in 1985, resulting in decreased 1988 Health Systems; introduction of Ghana Demographic service utilization District Assembly and Health Surveys (GDHS) Decree on 1992 decentralization of Fourth Republican Constitution governance to district promulgated and multiparty elections 1993 level under military rule Return to constitutional rule (fourth return to civilian rule); and Local 1994 Government Law passed Community-based Health Planning 1995 and Services (CHPS) precursor Ghana Vision 2020 (national medium- studies started in Navongo 1996 term development agenda) document Medium Term Health Strategy developed, and with PHC focus launched Ghana Health Services and Teaching Hospitals Act No. 525 passed 1997 First Five Year Programme of Work (POW I), 1997–2001; 2000 first Sector-wide Approach (SWAp I) introduced; first CHPS policy adopted, reviewed Common Management Arrangements (CMA I) 2001 in 2009 and 2014; Ghana Health Change of government; Ghana declared a highly Service established with the indebted poor country and priority given to social Ministry of Health delegating policy programmes including primary health care the service delivery function and retaining the policy and other functions of the sector 2002 2003 SWAp II; POW II, 2002–2006; CMA II NHIS Act No. 650 passed; first Ghana Poverty Reduction Strategy (GPRS I), 2003–2005; policy on new community 2007 health nurse training schools and increased intake GPRS II, 2007–2009; POW III; CMA III 2008 Introduction of free maternal services 2010 First Ghana Shared Growth and Development Agenda (GSGDA I), 2010–2013; economy 2012 rebased as lower middle-income country; first Ghana Millennium Accelerated Framework Health Sector Medium Term Development Plan developed with focus on addressing MDG 5 2014 GSGDA II, 2014–2017; Health Sector Medium Term Development Plan, 2014–2017; CMA IV 2016 CHPS revised policy launched; and review of NHIS by Presidential Committee 2017 A different political party took over government after 2016 parliamentary and presidential elections
6 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)
Governance
Ghana has a unitary democratic government system17,18 the country, and therefore works with all service providers at all comprising the executive, legislature and judiciary with levels to ensure access to quality primary care services, including separation of powers, and a decentralized local government tertiary, faith-based, private, traditional and alternative service system consisting of 216 district assemblies, with 10 regional providers. PHC governance at the national level is through coordinating councils performing a coordinatingrole. Common Management Arrangements agreed among the The Ministry of Health is the sector ministry providing sector stakeholders through various meetings, such as sector overall policy direction to all players in the health working groups, interagency technical group meetings, sector: public and private entities, health development business meetings and health sector reviews and summits.20,21 partners, nongovernmental organizations (NGOs) and The PHC-level various technical management teams and health-related agencies. The Ghana Health Service19 corresponding committees, with representation from key is the agency responsible for providing direction and stakeholders, are the governance structures for PHC, as implementation of primary and secondary health services in illustrated in Figure 2.
Figure 2. Ghana PHC governance and health service delivery structure
Health training Ministry of Health institutions Other ministries, Regulatory bodies • Meeting: interagency leadership, department & agencies sector working group, technical in-agency committee, business • Annual holistic assessment and health National Health Insurance summit Health partners Authority Bilateral & multilaterals, faith-based, NGOs & private organizations 3rd hospitals Ghana Health Service headquarters • Governed by a council, Director- General, deputy & 10 directors Regional coordinating • Plan & oversee primary and secondary council health services in the country
Regional / 2nd hospitals Regional health committee Regional health directorates (10) Regional health management teams oversee and support DHMTs & health facilities and provide public health services
PHC SYSTEM District level District/primary hospitals District health directorates (216) MMDAs District health management teams Social services committee (DHMTs) oversee health facilities and provide public health services District health committee Subdistrict level Health centres/clinics Subdistrict health management committees (SDHMCs) Oversee health services in the zonal/urban/town area subdistricts councils CHPS compounds, Representation in SDHMCs Community level maternity homes, chemical sellers, traditional providers, etc. Community health committees Mobilize communities and provide feedback & support to health service providers Unit committees Health service providers: Representation in community public, faith-based, private, health committee traditional & alternative Health sector governance medicine practitioners structures Local government governance structures
Referral & Deconcentrated Delegated Devolution Adminstrative/ Collaborative counter-referral decentralization decentralization management relationship relationship
17 Ghana 1992 Constitution. 18 Local Government Act (1993), Act 462. 19 Ghana Health Service and Teaching Hospitals, Act 525. 20 Ministry of Health 1996, 2002, 2014: Common Management Arrangements I, II and III. 21 Ghana health sector Common Management Arrangements for Implementation of the Health Sector Medium Term Development Plan, 2014–2017. Ministry of Health; 2014. 7 Ghana Case Study
The regional and district health management teams, The public contributions are increasing as the international representing the Ghana Health Service at regional and district funds are diminishing. With further analysis of the National levels, provide leadership for, coordinate and provide technical Health Accounts. WHO23 reported that public and private support to the lower levels, and report administratively to expenditure accounted for 60% and 40% of Ghana’s total the appropriate local government bodies. Regional and PHC expenditure respectively, The results of the 2013 to 2015 district health committees, with representation from the National Health Accounts are not yet available, but the audited corresponding local government, religious and traditional accounts of the Ministry of Health for the period showed a authorities, have advisory status, and represent the voice of decreasing trend in the proportion of the public expenditure communities and other stakeholders in health. The governance on PHC (district health services), with most of it going to pay system at subdistrict level is weak, especially the linkages with salaries and counterpart payments, with little remaining for the local government system. In CHPS zones (community level), logistics and operations. community health teams, comprising health workers and community volunteers, deliver integrated primary care services Figure 3. Sources and amounts of health sector funding, with community health committees playing an oversight Ghana, 2005, 2010 and 2012 (US$ millions) and supportive role. This is also weak in some areas. These structures will need strengthening to support PHC, irrespective 2005 of how the government’s ongoing decentralization policy is Donor 360 / 53% implemented in the health sector. The Coalition of NGOs in Private 119 / 17.4% Health, an umbrella organization of NGOs with advocacy and Public watchdog roles and direct service delivery in the health sector, 201 / 29.6% has a national secretariat and regional branches and is a key Total 681 / 100% partner, as are associations of private midwives and medical practitioners. These are, however, not organized at the district 2010 level, where their integration into the district health system is Donor 179 / 18.5% vital for effective PHC. Private 123 / 12.7% Health financing Public 663 / 68.7% Total 965 / 100% The main funding sources for PHC are the same as for the rest of the health system, and are broadly classified 2012 in the National Health Accounts22 as public, private and Donor 175 / 9.1% international funds (Figure 3). The public funds consist of Private 660 / 43.2% those from the consolidated fund, financial credits and the Public 1097 / 56.8% NHIS funds, excluding the premiums and donor support. The Total international funds consist of donor funds routed through the 1933 / 100% Ministry of Finance as multidonor budget support and sector 0 500 1000 1500 2000 2500 budget support or earmarked funds provided to the Ministry Source: Ministry of Health (2014), National Health Accounts for 2012. of Health or its agencies for programmes. The private funds are the out-of-pocket payments by households for service delivery, the health insurance premiums and other private resources spent on health. These funds are channelled through multiple routes (Figure 4).
22 Ministry of Health (2014), National Health Accounts for 2012. 23 Public financing for health in Africa: from Abuja to the SDGs. Geneva: World Health Organization; 2016.
8 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)
Figure 4. Flow of PHC funds in Ghana health system Figure 5. Sources of PHC expenditure, 2013–2015
PHC expend. Ministry of Finance as % of Health 45% sector expend. 35% Development partners/ donors 28% National Health Insurance Authority Ministry of Health Public 64% District assemblies 62% Private Ghana health service 63%
Donor/ 13% Programmes Households Regional health 12% directorates 12%
Internally District health generated 22% *IGF directorates revenue 25% 24% Health service providers 0% 10% 20% 30% 40% 50% 60% 70%
2013 2014 2015 Private Public International *IGF = Internally Generated Funds Source: Ministry of Health 2013, 2014 and 2015 audited accounts statements.
The government is resorting to credit financing of capital Figure 6. Public versus private expenditure on PHC (%) projects. The NHIS has become the main source for financing Public goods and services for clinical care, and any delays in reimbursement of providers has serious consequences for the quality of care; some providers are resorting to unofficial co-payment. Most of the international funds are also 60% Private earmarked, and releases are often tied to conditionalities. Public health services, supervision, information gathering and 40% community-based activities are thus left unfunded. Meanwhile, as Ghana is a lower middle-income country, international funds will continue to diminish as most development partners have Source: Public financing for health in Africa: from Abuja to the SDGs. Geneva: World started implementing graduation schemes to eventually end Health Organization; 2016. their support between 2020 and 2022. As the government is undergoing fiscal consolidation under the guidance of the Figure 7. PHC versus non-PHC expenditure (%) International Monetary Fund, the fiscal space is tight for any PHC prospects of a significant increase in government funding. The best option will be to reform the NHIS and give greater focus to PHC. 60% Non-PHC Figures 5, 6 and 7 present data on various aspects of PHC expenditure. 40%
Source: Public financing for health in Africa: from Abuja to the SDGs. Geneva: World Health Organization; 2016.
9 Ghana Case Study
Human resources Figure 8. Population per doctor by region, Ghana, 2015 The availability of trained workers at PHC level has improved Ashanti 7,196 significantly in the past decade due to increased production from both public and private sectors. The increased intake into Brong-Ahafo 15,956 training schools has not been matched by a commensurate Central 19,439 increase in teaching and learning materials, clinical training sites and tutors, leading to lower first-time pass rates in the Eastern 15,975 professional examinations, compromising the quality of graduates. In 2015, 5347 medical doctors and 69 121 nurses Greater Accra 3,186 and midwives were registered, with an estimated 30% of Northern doctors and 21% of nurses working in the private sector, 18,412 though not fully employed.24 The human resources for health Upper East 24,253 in the public sector have been increasing in the past decade, with doctor and nurse to population ratios of 1:8934 and 1:739 Upper West 30,601 respectively in 2015, but the distribution is skewed in favour Volta of teaching hospitals and urban areas, with rural and deprived 18,578 areas poorly staffed, especially in the northern part of the Western 28,861 country (Figure 8). The high standards set by the new staffing norms25 may worsen the inequities unless a quota system is Ghana 8,934 set and enforced, and supported with a rural incentive system. Both public and private sectors have limited fiscal capacity Population/Doctor to absorb the large numbers of health professionals turned Source: 2015 Health sector holistic assessment. out annually. This has become a political issue, with the frequent picketing of unemployed graduates at the Ministry of Health agitating for employment. Essential health worker to planning, some financiers of technical programmes and population density was reported to double from 1.07 in 2005 to projects hold additional and separate planning sessions with 2.14 per 1000 population in 2015, but could be higher if there districts based on their interest areas. Hence, districts have were full employment of the available workforce. multiple plans, and implement activities for which funds are made available.
Planning and implementation Multiple plans26 and poor coordination during implementation At the beginning of each planning year, the Ministry of Health result in inefficiencies and suboptimal performance. For issues guidelines with budget ceilings, and districts develop instance, the increase in staff availability has not translated and submit their plans for review and collation through the into increased service coverage because of lack of logistics and regions, the Ghana Health Service, the Ministry of Health funds for operations. The referral system is also compromised and the Ministry of Finance for parliamentary approval. Once because providers compete for NHIS clients to generate approved, the human resources and investment budgets are more revenue. Thus antenatal care coverage (at least four centralized, and the goods and services budget is released visits)27 declined from 72% in 2012 to 63% in 2015, and skilled quarterly by the Ministry of Finance through the Ministry attendance at delivery and penta-5 vaccine coverage have of Health for implementation. Apart from this mainstream stagnated at around 55% and 85–88% respectively.
24 Acquah S. Human resources for health projections for the Ghana health sector. 2016. 25 Staffing norms for the health sector: Volume I. Ministry of Health; 2015. 26 Global Fund to Fight AIDS, Tuberculosis and Malaria, and bilateral programmes and projects. 27 Health sector holistic assessment report, 2015. Ministry of Health; 2015.
10 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)
Health information, monitoring and evaluation
Monitoring and evaluation frameworks28 of plans and As part of the Common Management Arrangements with programmes, Medical Records Policy and guidelines,29 health partners, annual reviews by key stakeholders start at the and the Common Management Arrangements guide facility level, through district, regional, and agency entities, to monitoring and evaluation of institutional and overall health the health summit at the national level. A holistic assessment sector performance. report of the sector is presented at the annual health summit, where consensus is built on key issues of the sector, followed The Ghana Health Service has replaced the paper-based routine by the signing of an aide-memoire. health information management with an integrated Internet- based electronic District Health Information Management In the regions and districts in particular, the health sector System (DHIMS2). Summary data, once entered into the is acknowledged to have the most robust monitoring and database at the facility level, are accessible to policy-makers and evaluation system, with broad participation from local implementers at all levels by authorization, and standard and government, traditional authorities, NGOs and the private customized summary reports can be generated. Completeness, sector. However, its current inefficiencies will improve and timeliness and data quality are improving but data analysis synergy will be achieved if there is timely release of funding and use for decision-making are major challenges. The Ghana and if management at all levels ensures integration of the Health Service is currently piloting etracker, transactional data multiplicity of vertical programme monitoring visits and software for capturing service delivery data at peripheral health reviews. The routine information systems are complemented facilities that is integrated with DHMIS2 database for easy by information from periodic population-based surveys such data transfer. Discussions are also ongoing for all hospitals to as demographic and house surveys, multiple cluster surveys deploy integrated electronic medical and management records and special studies. The Research Division of the Ghana Health systems that are compliant with DHIMS2. These efforts aim to Service and the three research centres, together with the minimize errors, reduce workload in data entry and facilitate universities and other research institutions, have the capacity immediate use of data for decision-making at all levels. to conduct quality research to inform policy and programme implementation; however, government funding for research is The health sector uses a broad range of sectorwide indicators almost non-existent. to monitor sector plans and programmes, and specific ones for assessing regional, district, and institutional performance. These indicators are reported through the DHIMS2 database, management reports, monitoring visits, review meetings, and peer reviews at all levels.
28 Ghana Health Sector Monitoring and Evaluation Framework. Ministry of Health; 2014. 29 Medical Records Policy. Ministry of Health; 2008.
11 Ghana Case Study
Regulatory processes
Regulatory systems in health have been developing and training and practice of all health professions, establishing expanding over the years through the enactment of laws separate regulatory bodies for medical and dental practitioners, and establishment of statutory bodies to ensure equipment nurses and midwives, pharmacists, pharmacy technicians and standardization, safe food and health products, and chemical sellers, and a varied group classified as allied health certification of health facilities and health professionals. The professionals. Medical and Dental, Nurses and Midwives, and Ghana Standards Authority ensures that all products and Pharmacy Councils have developed strong regulatory systems equipment meet national or International Organization for for training, registration and renewal. Standardization (ISO) standards. The Food and Drugs Authority Challenges, however, still remain in post-registration monitoring provided for in the Public Health Act No. 85130 regulates and and enforcement, especially regarding the operations of ensures the safety of food and health products. Act No. 851 chemical sellers and traditional and alternative medicine also has provisions for disease and tobacco control, vaccination practice. There is also a lack of coordination of agencies for and environmental sanitation. The Health Facilities Regulatory effective and efficient regulation. The consequences are seen Agency31 is the regulator of both public and private orthodox in occurrences of substandard foods, medicines and diagnostic health service delivery facilities, whereas the Traditional and equipment on the market, and unsubstantiated claims and Allied Medicine Council is responsible for traditional and allied advertisements by some traditional and alternative medicine medicine products and practice. The Health Professionals practitioners in the media. Act No. 85732 of 2013 consolidates all the laws governing the
30 Public Health Act No. 851. Ministry of Health; 2012. 31 Health Institutions and Facilities Act No. 829. Ministry of Health; 2011. 32 Health Professionals Act No. 857. Ministry of Health; 2013.
12 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)
In response to the government’s Vision 2020 strategy for economic and social transformation launched in 1995, the Ministry of Health developed the Medium Term Health Strategy and embarked on health sector reforms.
UN Multimedia Photo/Kay Muldoon
Quality and safety
Quality and safety in PHC is ensured through effective regulation Quality assurance is led and coordinated by the Quality and quality assurance mechanisms in service delivery. The Assurance Department under the Institutional Care Division Food and Drugs Authority and the Pharmacy Council also of the Ghana Health Service. The sector has developed a implement programmes in pharmacovigilance to ensure the catalogue33 of quality assurance policies, standards, guidelines safety of drugs and medicines, including monitoring adverse and protocols, the latest being the National Healthcare Quality drug reactions and adverse effects following immunization. Strategy launched in 2016, but dissemination and use of the The regulatory bodies are intensifying their efforts to seize and knowledge products remains a challenge. Other challenges destroy substandard, fake and expired products, and there have that need to be addressed include negative staff attitudes, been occasional cases of sanctions imposed on health facilities poorly functioning emergency systems, and inefficient and professionals, and in some instances the law courts have institutional and management systems. applied fines and compensations. The increase in cases may not necessarily result from increased incidence of infringement of regulations, but may be consequent on increased vigilance by the regulatory bodies.
33 Directory of MOH/GHS policies, standards, guidelines and protocols. Ministry of Health and Ghana Health Service; 2006.
13 Ghana Case Study
Way forward and policy considerations
The way forward to universal health coverage in Ghana is to A sustainable leadership and management development reform the NHIS to prioritize the delivery of integrated PHC programme at all levels, especially in the districts and regions, services, and to strengthen the district health services to is essential to ensure effective implementation of policies. provide integrated quality and affordable health services. A The PHC governance system should also be strengthened revised CHPS policy should be implemented with the active to promote more participation by communities and other engagement of communities and other stakeholders to stakeholders and to enhance accountability. Any further ensure closer-to-client basic PHC services in all communities. decentralization of the health sector should ensure that it is Subdistrict and district hospitals should be strengthened with supported by a human resources budget and quota system the necessary skilled staff, logistics and infrastructure to provide with realistic incentives that will promote equitable human backup to the CHPS level. Investment in construction of new resources distribution. The current numerous and siloed hospitals should be limited to underserved areas. national agencies will also need to be realigned to provide coherent policy direction.
Authors
Faculty of Public Health, Ghana College of Physicians and Surgeons:
Erasmus E.A. Agongo Patrick Agana-Nsiire Nana K.A. Enyimayew Moses Komla Adibo Emmanuel Nonaka Mensah
14
This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system, tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems in selected low- and middle-income countries.
World Health Organization Avenue Appia 20 CH-1211 Genève 27 Switzerland [email protected] http://www.who.int/alliance-hpsr