The state of health care provision in Ghana

The state of health care provision in Ghana

1. Introduction: The Ghana Health System

A health system, according to Roemer (1991) is the interplay of resources, organization, financing and management, all of which must come together to provide service to a giving population.  Health system in Ghana is managed by the Ministry of Health and the Ghana Health Services (GHS).  The Ministry is in charge of setting policy, norms and standards and the GHS, a semi-autonomous department under the Ministry is in charge of direct service provision. Health care is provided through three channels; the first is Government/Public facilities, the second private for-profit and the third, private non-profit, usually run by churches and NGOs.

2. Payment methods used in primary and inpatient care

After experimenting with various delivery methods, with mixed results, in 2003, Ghana introduced a National Health Insurance Scheme (NHIS) to offer the poor financial protection against shocks, and reduce the financial burden to health care through the removal of out of pocket payments (Kusi et al., 2015). The NHIS covers only 40% of the population, those outside the scheme pay out of pocket. The scheme uses a combination of provider payment methods to transfer funds from the purchaser to the service provider.

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According to the NHIS (2020), it uses the following payment methods.

• Itemized Fee for service (FFS) for non-insured clients for both services and medicines
• Diagnosis Related Groupings (DRG) for insured clients (Services only)
• Itemized Fee for service (FFS) to pay for medicines for insured clients

 

The FFS is based on the service provider listing the services provided to each “patient” and billing the NHIS. Although this system seems simple, it has an inbuilt moral hazard and potential for abuse. Given that most health seekers may not be aware of the services they need, the provider could abuse the system by billing more than what was provided. There is, therefore, a need to build in checks and balances to limit this occurrence (NHIS, 2020).

 

The DRG system groups related diagnosis and estimate an average cost. Service providers submit completed forms to the NHIS, which are then checked for accuracy and authenticity before payment is made; this is administratively more time for the scheme. Although there is a potential for cost inflation, this is less than in the FFS method (NHIS, 2020).

 

The third payment method, capitation follows a method where providers are paid in advanced on a pre-determined fix rate for a defined set of services. This payment is based on each individual enrolled for a specific period. Important to note that payments are made irrespective of use or non-use (NHIS, 2020).

3.0 Performance of healthcare services; accessibility, quality and efficiency of care

 

The NHIS has been recognised by the Global community as an exemplary, albeit ambitious plan to achieve universal health care (USAID, 2016). The health system in Ghana is therefore set up to buffer health shocks and reduce the financial burden caused by out of pocket payments, (Adua et al., 2017). Since the creation of the scheme in 2003 the performance has been impressive, the number of people enrolled in the scheme has increased, corresponding to an increase in health-seeking behaviour, reduction in some key indicators such as infant mortality.

3.1 Accessibility

Guildford et al. (2002) define access in health systems as the ability to command health care in order to preserve or improve one’s health, it must include physical availability of the service/product, the financial capability to obtain it, and the absence of any barriers to obtain the service.

 

In addition to the increase in Government health expenditure, the re-organised system has led to an increase in population access to health care. Kusi et al., (2015) assert that the insured are more likely to access health service and also pay less out of pocket; therefore, a critical barrier to access, which is cost has been lessened. The out of pocket expenditure was 54% before the NHIS became operational, reduced drastically after 2005 when the scheme became operational and now stands at around 36% in 2016 (WHO, World Bank, 2020). With regards to financial protection, Kusi et al., (2015) further establish that the likelihood of a household incurring a catastrophic health expenditure was 4.2 times less among insured households, and 2.9 times less likely for partially insured than uninsured households.

 

Adua et al. (2017), report that, although access has improved and out of pocket expenditures have reduced, it has not provided full relief to many, this is because the NHIS scheme currently covers only 40% of the population; therefore, it does not offer its benefits to a large section of the population. Additionally, due to inadequate funding to the government facilities, delays in paying private service provides, lack of adequate oversight on the private service providers, hospitals are compelled to generate resources and end up charging user fees to augment their resources.

 

According to Okorosoh et al., (2018), the out of pocket expenditure in Ghana constitutes 26% of health expenditure, exceeding the WHO recommended level of 15-20%. They report that 150 million people are affected by this challenge annually in Ghana. One can, therefore, conclude that although the NHIS has reduced the burden of out of pocket payments and improved access to health services, health care costs remain a burden to many, especially the poor.

 

3.2 Quality of care:

In defining quality of care, Blacks and Gruen, (2015), identify four critical attributes of interest, such as effectiveness, equity, humanity and efficiency, and state that a functional, high-quality health service must exhibit these attributes.  When one looks at effectiveness as the ability to optimally produce the desired outcome, then, although Government health expenditure in Ghana is low compared to other LICs, it has been able to effectively utilise its health finances for tangible results. Adua et al., (2017) report a definite link between the Government health care expenditure and the Country’s health outcomes in the last ten years. They posit that spending on health care has enhanced the efficiency of services and boosts health outcomes. Ghana had one of the highest maternal mortality figures, ranging from 540-650 per 100,000 births. However, the introduction of the NHIS in 2003, which came with the introduction of the delivery exemption policy, the country began to see improvements. The delivery exemption policy offers free maternal delivery, with trained and skilled health personnel, and helps to lower the financial burden and over-reliance unskilled birth attendants which increased maternal mortality (Adua et al., 2017).

3.3 Equity

If equity can be said to be the measure of the degree to which citizens have access to a service, regardless of income, gender, social standing and religion, then the NHIS has been a leveller when it comes to access to health. This is evident from the exemptions it provides to vulnerable groups, the poor, pregnant women and the aged. The scheme’s growing number of people who receive care covering 95% of health conditions in Ghana is testament to country’s efforts to ensure that the society as a whole has equal access to an “essential health package”. For example, mothers who were enrolled on the NHIS rose from 421, 234 in 2008 to 754, 648 in 2012. Skilled delivery rose from 47% in 2003 to 67% in 2015. These results put Ghana ahead of its West African neighbours (Adua et al., 2017).

 

This strive for equity has also resulted in some notable outcomes, such as a general increase in life expectancy from 60.7 years in 1995 to 64.8 in 2014. Although other factors such as improvement in vaccines and medicines, good governance and development may have contributed to this result, as illustrated in Fig 1 below, there is a marked increase from 2003 when the NHIS and the universal health care drive was introduced. This correlation has been identified by Adua et al., (2017) and others who see this as a positive outcome of the health insurance scheme.

 

FIG 1. Life expectancy by per capita total health expenditures from 1995 to 2014	Fig. 2: Infant and under-5mortality by per capita total health expenditures from 1995 to 2014.
Source: Adua, E., Frimpong, K., Li, X. et al., (2017)

 

Although it is difficult to measure humaneness, due to subjectivity, we can deduce that a humane system, will seek to support its most vulnerable. Using new-born babies as a proxy to analyse the humaneness of the Ghana Health care system, we see evidence of an initiative that cares for its polulation.  As shown by figure 2 above, as health care finance increases in Ghana, infant mortality and under-five mortality correspondingly also reduced.

 

3.4 Efficiency

Efficiency refers to “how well a health care system uses the resources at its disposal to improve population health and attain the related goals” (Yip and Hafez, 2015). The World health report of 2010 reports that 20-40% of resources spent on health is wasted through underuse of generics, oversubscription of costly medicines, an inadequate mix of health staff, poor and inadequate infrastructure.

 

Alhassan et al. (2012) conducted a study to explore the efficiency of both public and private health facilities affiliated to the Ghana NHIS and found widespread inefficiencies, more in urban areas. Of the 64 service providers, only 20 were accessed to meet the efficiency co-efficient.  Interestingly, the public sector facilities constituted 50% of the efficient ones, private for-profit was 40%, and the non-profit facilities 10%. The Ghana health system has also been found to exhibit corrupt practices, in addition to the over-invoicing, Agbenorku (2012) established that corruption in Ghana health system is widespread, and results in delays on treatment, sometimes leading to death.

 

 

 

 

4. Conclusions and Recommendations

 

In conclusion, one can assert that though the Ghana Health Systems fuelled by the NHIS has not entirely eliminated health expenditures, it has provided significant financial protection, increased access and offered much peace of mind, by reducing the burden of out of pocket payments. However, in order to maximise its potential, improve on access, equity, quality and efficiency, specific improvements need to make made to optimise the system. These can be addressed at different levels.

 

National Level: If Ghana is to achieve universal health care, then it must further increase the health finance, by enrolling more people into the insurance scheme and strengthen the regulatory oversight and the stewardship role of the MOH and GHS to ensure the country obtain more value for its health expenditures and investments.

 

Stringent regulation and enforcement methods must be enacted to reduce health provider fraud, overcharging, and corruption, this would help to buy more service with limited funds.

 

Sub National level: At the sub national level efforts must include investment in human resource and equipment to better equip health facilities, especially at the primary health care levels where health care is mostly first sought.

 

Other areas of focus to improve the health system, would include incentivising health workers to work in communities with low access to health care. This must be coupled with concrete activities to reduce the burden of disease, for both communicable and non-communicable diseases to lessen the burden on the NHIS.

 

Ghana has a promising health system, which if managed well has the potential to improve the health status and outcomes of its population. To ensure the system performs at its optimum, strategic decisions need to be taking and implemented to improve quality and access to health, reduce the cost of health, and extend health care to all the population.

 

References

1. Adams, I. Darko, D and Accorsi, S. (2014) The burden of diseases). Brief overview of disease profile, service utilisation patterns and health outcomes. Bulletin of health information 1 (1). Available at: https://www.Ghanahealthservice.Org/downloads/burden_of_diseases_bulletin-3-b.Pdf, Date accessed, 25^thJanuary 2020

2. Adua, E., Frimpong, K., Li, X. et al.(2017) Emerging issues in public health: A perspective on Ghana’s healthcare expenditure, policies and outcomes. EPMA Journal 8, 197–206. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607056/pdf/13167_2017_Article_109.pdf  https://doi.org/10.1007/. Date accessed. 24^th January 2020

 

3. Black, Nick, and Reinhold Gruen. Understanding Health Services, McGraw-Hill Education, 2005. ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/gmul-ebooks/detail.action?docID=287894.

 

4. Ghana National Health Insurance Scheme: PROVIDER PAYMENT MECHANISMS, 2020. Available at: http://nhis.gov.gh/capitation.aspx Date accessed. 1 January 2020.

 

5. Kusi, A., Hansen, K.S., Asante, F.A and and Enemark U. Does the National Health Insurance Scheme provide financial protection to households in Ghana?. BMC Health Serv Res 15, 331 (2015). https://doi.org/10.1186/s12913-015-0996-8

 

6. James Akazili, Bertha Garshong, Moses Aikins, John Gyapong, Di McIntyre, Progressivity of health care financing and incidence of service benefits in Ghana, Health Policy and Planning, Volume 27, Issue suppl_1, 1 March 2012, Pages i13–i22, https://doi.org/10.1093/heapol/czs004

 

7. Alhassan, R.K., Nketiah-Amponsah, E., Akazili, J. et al. Efficiency of private and public primary health facilities accredited by the National Health Insurance Authority in Ghana. Cost Eff Resour Alloc 13, 23 (2015). Available at: https://doi.org/10.1186/s12962-015-0050z

 

8. Pius Agbenorku, Corruption in Ghanaian healthcare system: the consequences (2012) Journal of Medicine and Medical Sciences Vol. 3(10) pp. 622-630. Available online http://www.interesjournals.org/JMMS Copyright © 2012 International Research Journals.

 

9. Okoroh, J. Essoun, S. Seddoh, A. et al (2018) Evaluating the impact of the national health insurance scheme of Ghana on out of pocket expenditures: a systematic review. BMC Health Serv Res. 2018; 18: 426.  available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5992790/ Date accessed, 12 January, 2020

 

10. Milton I. Roemer, National Health Systems of the World: The countries, 1991, Oxford University Press, 1991, 0195053206, 9780195053203, 688 pages

 

11. Gulliford M, Figueroa-Munoz J, Morgan M, Hughes D, Gibson B, Beech R, Hudson M.

‘What does “access to health care” mean?’ (2002) Journal of Health Services Research & Policy, 7(3), pp. 186–188. doi: 10.1258/135581902760082517.

 

 

12. USAID (2016) African Strategies for Health: Health Insurance Profile, Ghana. Available at http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/country_profile_-_ghana_-_us_letter.pdf, Date accessed 17^thJan, 2020.

 

13. Winnie Yip, Reem Hafez, (2015). Improving health systems efficiency: Reforms for improving the efficiency of health systems: lessons from 10 country cases, WHO, Geneva.

 

14. World Health Organization (2019) Health Expenditure Profile Ghana. Available at http://apps.who.int/nha/database/country_profile/Index/en. Accessed on 10^thJanuary 2020