Ghana’s health care delivery system: Some improvements required

This article is not intended to be academic in nature. If it ends up sounding so, I apologise. My intent is to draw enough attention to the health care system which, in my view requires a shakeup, in structure, processes, and outcomes.

Ghana’s health care system, since independence has witnessed changes in an effort to guarantee the health and well-being of the populace. From the early periods of statehood when the government, through the Ministry of Health, and with the collaboration of religious missions and para-statal agencies such as the military, police and mines, assumed sole responsibility for health care delivery, today the private sector is being embraced in the health care delivery system, and many policy and regulatory institutions established as part of the reforms to the sector.

The private sector’s role in health care, however, continues to be minimal, due to the preponderance of the Ghana Health Service, teaching hospitals and statutory institutions in health care delivery. This is seen in the allocations in the national budget. While the 2018 financial budgetary estimates shows that the health budget is 6.57% of GDP, and therefore less than the 15% anticipated by the Abuja Declaration, the health sector, together with education, continue to be the two largest sectors of public expenditure.

With over GHS 19 billion to be spent this year on human assets in the health sector, 3.5 billion on consumables and other services and a gross expenditure in excess of GHS 67 billion, there is need to relook at expenditure within the sector, with a view to focusing attention on the quality of expenditure and its allocation.

As the French philosopher and academic Michel Foucault suggests, the structuring of information is key to the success of many things; not least the health sector in Ghana. This is because, within the medium to long-term horizon for economic growth, there is unlikely to be a substantial increase in the budgetary allocation to the sector within sustainable limits. It is therefore time to critically look at the sector and adopt some innovative approaches to health care delivery. In our view, there are some suggestions that can be considered.

First, even though there are many people on public payroll in the health sector, the balance needs to be struck between those in administrative roles and those in health service delivery functions. This is where Foucault comes in. The information on the payroll needs to be restructured to show those actually working in hospitals and other facilities and by population.

Thereafter, a conscious effort needs to be made to deploy health professionals into health delivery functions without loss of rank or prestige. This may require the Ghana Health Service to devolve almost all managerial functions and authority to district hospitals and above, with only the health centres and CHIPS under the district management. Recruitment should be done at facility level and the assets so managed, on the basis of nationally approved frameworks.

A robust information management system for both internal staff management and patient care should be able to free staff resources at some levels and act as quality control safeguards. For instance, post-diagnosis, and based on a patient’s values, prescriptions that are not right should not be possible in an automated framework, unless the medical practitioner overrides and writes in his justifications for a proposed prescription override.

Secondly, the private sector needs to be invited to participate in specialised health care delivery as a business model. Private medical practice of earlier periods while useful is inadequate for current needs. Super specialty hospitals with critical equipment and several hundreds of in-patient beds will be required for the era. The limited resources of the State necessitate that public spending should be focused on areas where only the government can act. Regulation, accreditation, training, primary health care, health care in rural areas and in district capitals are a necessity under public spending. However, for tertiary and specialised care there is a lot of scope for private actors to enter and make reasonable returns on investments.

Thirdly, the National Health Insurance Scheme (NHIS) will need some retooling to make it responsive to the needs of Ghanaians. While the NHIS has a universal focus and has indeed improved access and coverage of health care, the abuses it has been subjected to in the past and the funding challenges it continues to have gives encouragement to suggest improvements. Many contributors of the national insurance scheme do not use the national medical insurance, but private insurance.

There are also many who enjoy access to the national medical insurance without any significant contribution. It is perhaps time for the NHIS to create personal accounts of the insured and also to have graduated premiums for those who may seek to use the NHIS for more than basic approved care. As will be well known many people in Ghana have more than one medical insurer and the NHIS, for those who can afford is not the preferred.

Fourthly, the establishment of a National Ambulance Service under the Ghana Health Service was a good initiative but has fallen on difficult times. It is time for the State to invite private individuals and local communities to be partners of the national ambulance system. Currently, it is reported that for a population of over 28.1 million people Ghana has only 54 functional public ambulances and there have been too many reported incidents of emergency failure that we will not wish to recount.

It is recommended that the Ministry of Health should establish criteria for participation by non-governmental actors, within a centralised management system run by the National Ambulance Service. In this regard, the certification of EMTs, accreditation of ambulances and drivers, the designation of emergency hospitals, schedule of fees for reimbursement (presumably from NHIS), etc, will be centralised, while private players, and pubic ones such as the Ghana National Fire Service also , act within the space. This should remove the constraint of availability greatly, and aid in emergency care.

Lastly, ambulatory care needs to be strengthened across the country to reduce in-patient medical care. As may be known, ambulatory care is outpatient and includes diagnosis, observation, consultation, treatment, intervention and rehabilitation services. In the United States for instance, most major medical facilities are increasing their focus on ambulatory care and applying innovative methods in this area. Ghana has a lot to learn from such experiences on account of the shortage of beds in many tertiary level hospitals.

In conclusion, it is important to emphasise that health is a multi-dimensional matter and requires cross-sectoral collaboration. For instance, preventing an outbreak of Cholera in the rainy season or malaria requires that the district assemblies and other local authorities deal with sanitation matters when needed. Having a healthy population is not only about curative health, the availability of sport centres through proper spatial planning and the deliberate encouragement to do sport impacts the nation’s health wage bill.

We need all of Ghana for our forward march to create a prosperous nation beyond aid. Health is important and deserves our attention, not only or necessarily in additional funding but by the quality of expenditure we incur in the sector.

Let us be healthy!!

Harold Agyeman, Antoa, A/R