Report Leaving no one behind in the health and education sectors An SDG stocktake in Ghana Catherine Blampied, Soumya Chattopadhyay, Romilly Greenhill, Imran Aziz, Christine Ellison, Rachel Thompson, Abdul-Gafaru Abdulai and Adam Salifu April 2018 Overseas Development Institute 203 Blackfriars Road London SE1 8NJ Tel: +44 (0) 20 7922 0300 Fax: +44 (0) 20 7922 0399 Email: [email protected] www.odi.org www.odi.org/facebook www.odi.org/twitter Readers are encouraged to reproduce material from ODI publications for their own outputs, as long as they are not being sold commercially. As copyright holder, ODI requests due acknowledgement and a copy of the publication. For online use, we ask readers to link to the original resource on the ODI website. The views presented in this paper are those of the author(s) and do not necessarily represent the views of ODI. © Overseas Development Institute 2018. This work is licensed under a Creative Commons Attribution-NonCommercial Licence (CC BY-NC 4.0). Cover photo: A student writes in an exercise book at the Finger of God Preparatory School in Madina, a suburb of Ghana’s capital, Accra. Credit: Nyani Quarmyne/Panos. Acknowledgements This report has been written by an international and multidisciplinary team of researchers comprising Catherine Blampied, Soumya Chattopadhyay and Romilly Greenhill (ODI), Imran Aziz (independent researcher), Christine Ellison (independent researcher), Rachel Thompson (Chatham House), Abdul-Gafaru Abdulai (University of Ghana Business School) and Adam Salifu (University of Professional Studies). Naila Malik and Luca Marchina (ODI) supported the research process. We would like to thank the following individuals and organisations, who facilitated and advised our fieldwork in Ghana: Christopher Dapaah and Amos Baffour Mensah (Resource Link Foundation) and George Osei-Bimpeh, Richard Bekyieriya, Jonathan Dery and Mohammed Mumuni (SEND Ghana). We are most grateful to all the interview and focus group participants from whom we learnt during the course of the work. The following individuals at ODI made up the advisory group: Edward Hedger, Tim Kelsall, Andrew Rogerson, Andrew Shepherd and Elizabeth Stuart. Peer review was provided by Patrick Asuming (University of Ghana Business School), Ama Fenny (ISSER at the University of Ghana, and Chatham House), Tom Hart (ODI), Caine Rolleston (Institute of Education, University College London), Emma Samman (ODI), Olivia Tulloch (Options), Martin Williams (Blavatnik School of Government, University of Oxford) and Sophie Witter (Queen Margaret University). The authors are grateful for their carefully considered comments. Any mistakes, however, remain the authors’ own. This study was funded by the Bill and Melinda Gates Foundation. The views expressed are those of the authors and do not necessarily reflect those of the Foundation. The research was conducted between June and September 2017, and the report does not necessarily reflect subsequent developments. 3 Contents Acknowledgements 3 List of boxes, figures and tables 6 Executive summary 11 1. Introduction 13 1.1. Rationale for the study 13 1.2. What is the leave no one behind agenda? 13 1.3. Health and education in the SDGs 14 1.4. Definitions and terminology 15 1.5. The centrality of politics 16 1.6. Conceptual framework 17 1.7. Research methods 19 1.8. Case selection 19 2. The political, social and economic context 23 2.1. Political context 23 2.2. Constitutional provisions on marginalisation and inequality 23 2.3. Trends in poverty and inequality 24 2.4. Ghana’s national development strategy 24 2.5. Macroeconomic and fiscal context 25 2.6. Decentralisation 27 2.7. The health sector in Ghana 29 2.8. The education sector in Ghana 30 3. Who is left behind in access to health and education in Ghana? 32 3.1. The data ecosystem 32 3.2. Who is using health services and who is left behind? 34 3.3. Who is using education services and who is left behind? 43 4. How fit for purpose are Ghana’s health and education policies to leave no one behind? 54 4.1. The policy framework in health 54 4.2. The policy framework in education 60 4 5. How well is public financing allocated and delivered in line with the commitment to leave no one behind? 67 5.1. Financing of health 67 5.2. Financing of education 79 6. How are policy and financing translating into service delivery for left-behind groups? 92 6.1. Service delivery in the health sector 92 6.2. Service delivery in the education sector 97 7. Conclusions and recommendations 101 7.1. Data to leave no one behind 102 7.2. Policies to leave no one behind 103 7.3. Financing to leave no one behind 105 7.4. Service delivery to leave no one behind 107 References 109 Annex 1: Methodological appendix 117 Annex 2: Sustainable Development Goals and targets for health and education 120 5 List of boxes, figures and tables Boxes Box 1: Historical origins of inequality in Ghana 25 Box 2: Reaching the poor 57 Box 3: Successful innovations in health resourcing in the Upper East region 59 Box 4: Ghana and the vertical health funds 73 Box 5: Financing human resources in the health sector 77 Box 6: The Global Partnership for Education in Ghana 84 Figures Figure 1: Conceptual framework 18 Figure 2: Trends in GoG revenues and expenditures 26 Figure 3: Actual revenue collected and expenditures (as share of planned) 26 Figure 4: Map of Ghana 28 Figure 5: Ghana’s sub-national governance structure 29 Figure 6: Parallell lines of governance in Ghana’s health and education systems 29 Figure 7: Structure of the health sector in Ghana 31 Figure 8: Public health facilities across Ghana by type, 2016 35 Figure 9: Number of public health facilities per 100,000 population by region, 2016 35 Figure 10: Number of public health facilities per 1,000 km2 area by region, 2016 36 Figure 11: Outpatient service utilisation rates among men and women by region, 2016 37 Figure 12: NHIS coverage of outpatients by region, 2016 37 Figure 13: NHIS coverage in outpatient service use for men and women by region, 2016, as proportion of population 38 Figure 14: Spread of CCI across best and worst regions, selected countries 38 6 Figure 15: CCI by region, 2014 39 Figure 16: CCI by marginalised versus non-marginalised groups, 2014 39 Figure 17: CCI by household wealth in each region, 2014 40 Figure 18: CCI by urban versus rural location in each region, 2014 40 Figure 19: CCI by highest level of education attended in the household in each region, 2014 40 Figure 20: Average CCI in 2008 and 2014 by region 41 Figure 21: Percentage of respondents ‘satisfied’ with the quality of health care 41 Figure 22: CCI by wealth quintile in each region, 2008 and 2014 42 Figure 23: CCI by ethnic minorities versus non-minorities in each region, 2008 and 2014 42 Figure 24: Percentage of respondents ‘satisfied’ with the quality of health care, rural and urban 43 Figure 25: Gross enrolment rate by region, 2016 44 Figure 26: Student age profile of kindergarten enrollees, 2014 and 2008 44 Figure 27: Proportion of school attendees by time taken to reach school in minutes, 2014 45 Figure 28: Proportion of school attendees by time taken to reach school in minutes – bottom income quintile versus the rest, 2014 46 Figure 29: Proportion of school attendees by time taken to reach school in minutes – rural versus urban households, 2014 47 Figure 30: Gross enrolment rates by gender in each region, 2015-16 48 Figure 31: Share of total school enrolment in public vs private sectors, 2010-11 and 2015-16 49 Figure 32: Junior high school-age children with no formal education by region, by percentage of age group population 49 Figure 33: Average number of years of education for primary school-age children, by region 50 Figure 34: Average number of years of education for junior high school-age children, by region 50 Figure 35: Average number of years of education, national average, bottom wealth quintile and the top four quintiles, 2014 51 Figure 37: Pass rates for key subjects at primary school level, 2014-15 51 Figure 36: Average number of years of education, national average, rural and urban, 2014 51 Figure 38: Pass rates for key subjects at primary school level – national, Northern (NR) and Brong Ahafo (BA), 2014-15 52 7 Figure 39: Pass rates for key subjects at secondary school level – national, Northern (NR) and Brong Ahafo (BA), 2014-15 52 Figure 40: Percentage of respondents satisfied with the quality of education, urban, rural and national 53 Figure 41: Percentage of respondents satisfied with the quality of education, poorest income quintile versus the rest 53 Figure 42: Percentage of NHIS enrolment by population group, 2014 56 Figure 43: School attendance history by age, 2014 61 Figure 44: The public–private crossroads in Ghana’s education system 63 Figure 45: Percentage of trained teachers in the public and private education sectors, 2015-16 63 Figure 46: Pupil-to-trained teacher ratios by region, 2015-16 65 Figure 47: The flow of funds in Ghana’s health sector 68 Figure 48: Government health expenditure 68 Figure 49: Out-of-pocket payments as a share of total health expenditure 69 Figure 50: Share of government health spending by level 70 Figure 51: Share of funding for district health services by source 71 Figure 52: ODA to basic health in Ghana 72 Figure 53: Health budget per capita by region, 2015 73 Figure 54: Health budget per capita vs poverty rate by region, 2015 74 Figure 56: Health budget per capita vs poverty by district, Brong Ahafo region, 2015 74 Figure 55: Health budget per capita vs CCI by region, 2015 74 Figure