Moving toward UHC Ghana NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND THE ROLE OF COLLABORATIVE ACTIVITIES Moving toward UHC: Ghana Ghana’s snapshot 1 Ghana’s snapshot Existing national plans and policies to achieve UHC 2 44+56+C Key challenges on the way to UHC 4 UHC Service Coverage Results of Joint External Evaluation Collaborative efforts to accelerate progress toward UHC 6 Index (SDG 3.8.1, 2015) of core capacities for pandemic preparedness (JEE, 2017) 44% References and definitions 8 Score (for capacity) # of indicators (out of 48) 5 Sustainable 0 4 Demonstrated 2 Catastrophic OOP health expenditure incidence at the 10% threshold 3 Developed 14 (SDG 3.8.2, 2005) 2 Limited 25 3.1 % of households 1 No capacity 7 Health results Performance of service delivery – selected indicators LMIC Maternal Mortality Under-Five Mortality (PHCPI, 2014-2015) Ghana average Ratio (WHO) Rate (WHO) Per 100,000 Live Births Per 1,000 Live Births Care-seeking for symptoms of pneumonia 55.9% 61.5% 634 Dropout rate between 1st and 3rd DTP vaccination 9.3% 7.5% 319 Access barriers due to 127 treatment costs 41.7% 47.4% 62 Access barriers due to distance 25.4% 35.8% 1990 2015 1990 2015 70 (SDG target) 25 (SDG target) Treatment success rate for new TB cases 85% 80.1% Life Expectancy Wealth Differential at Birth (WHO) in Under-Five Mortality (PHCPI, 2014) Provider absence rate NO DATA 28.9% Caseload per provider NO DATA 9 26.9 per day 62 57 Diagnostic accuracy NO DATA 47.9% More deaths in lowest than highest wealth quintile Adherence to 2000 2015 per 1,000 live births clinical guidelines NO DATA 33.6% See page 8 for References and Definitions. 1 Moving toward UHC: Ghana Moving toward UHC: Ghana Existing national plans and policies to achieve universal health coverage (UHC) SERVICE DELIVERY REFORMS are exempted from paying premiums, further Community-based Health Planning and Services reducing their financial burden. In addition, (CHPS) is a national strategy that delivers access to care has become more equitable: community-based care by bringing health the ratio of NHIS coverage among women in services directly to communities. CHPS focuses the highest versus the lowest wealth quintile on improving health in minimally resourced decreased from 1.6 in 2008 to approximately sub-districts; empowering people; encouraging equal in 2014 (NHIS, 2017). community participation; and using task shifting to improve access to care. CHPS GOVERNANCE REFORMS also uses a systems approach to increase the Achieving UHC is a key objective of the coverage of primary health care interventions government; this agenda has been advanced critical to UHC. By 2016, CHPS services reached by the establishment of both the CHPS and all 10 administrative regions, and 4,400 CHPS NHIS, yet several challenges remain. The zones (67% of the total) were functional. government is also committed to implementing the International Health Regulations HEALTH FINANCING REFORMS (IHR 2005) Joint External Evaluation (JEE) The National Health Insurance Scheme (NHIS), recommendations and continuing quality established in 2003, has been instrumental improvement, which will help progress toward in increasing access to affordable health care. quality UHC and health security. Approximately two-thirds of NHIS members Ghana is the only country in the world to finance its national health insurance scheme with revenue from a value-added tax (VAT), which allows it to benefit from economic growth. 2 3 Moving toward UHC: Ghana Moving toward UHC: Ghana Key challenges on the way to UHC WEAKNESSES AND BOTTLENECKS of pandemic preparedness. Areas of readiness IN SERVICE DELIVERY where Ghana currently has inadequate capacity Coverage of essential health services. Ghana are: various aspects of antimicrobial resistance; has mixed results with respect to coverage of the capacity to activate emergency operations; essential health services. The proportion of and having systems in place for sending and births attended by a skilled health professional receiving medical countermeasures and has improved significantly, although there are receiving health personnel during a public large disparities across income groups. The health emergency. Ghana’s strongest aspects use of contraceptives remains very low, only of preparedness are a fairly well developed changing from 18.7% in 2003 to 22.2% in 2014 immunization program and the presence of a (World Bank, 2017). The proportion of fully field or applied epidemiology training program. immunized children increased in earlier years, In addition, almost all real-time surveillance but has recently plateaued. The proportion of capacities are developed, although more children under five with fever who are taking capacity needs to be built under the One Health anti-malarial drugs is lower now than in 2003. approach and in events-based surveillance. Access to mental health services is improving affecting the population and includes care reimbursements (estimated at US$181.8 million following the move toward community-based, THE STATE OF HEALTH FINANCING delivered in outpatient, inpatient, and in early 2017) (NHIS, 2017). The NHIS deficit as opposed to institutional, care, though more Overall funding for health. Ghana is the only emergency settings. For conditions covered by started in 2009 and has steadily increased since, capacity needs to be built among health workers. country in the world to finance its national the NHIS, beneficiaries do not have to pay out of necessitating urgent action to improve fiscal health insurance scheme with revenue from pocket for services or pharmaceutical products. responsibility and address inherent challenges Quality of care. The share of private health a value-added tax (VAT), which allows it to in the evolving health financing system. Rising facilities varies widely: ranging from 5.4% in benefit from economic growth. On average, Major financial protection schemes. The costs and deficits will affect the government’s the Northern region to 74.9% in the urban the National Health Fund has represented 3% two-pronged approach to achieve UHC includes ability to provide equitable, efficient, and Greater Accra region. The 10 administrative of total public spending. From 2010 to 2012, the NHIS, to eliminate financial barriers, and sustainable health care for all. regions of Ghana have a generally consistent public and external assistance declined, while CHPS, to make services accessible and equitable. distribution of public health workers; the the share of private expenditure (mostly out-of- By 2013, 38% of the population was enrolled Challenges with outbreak response. The Greater Accra, Upper East, and Upper West pocket payments) has almost tripled, indicating in NHIS. Utilization of health services (both country faced an unprecedented cholera regions have slightly higher numbers. There is increasing financial strain on people (World inpatient and outpatient) increased from 0.46 outbreak in 2014 with about 29,000 cases and sparse information on the distribution of private Bank, 2017). per capita in 2005 to 3.3 per capita in 2012 over 240 deaths reported. During the 2015–16 health workers, which could affect access to care. (World Bank, 2017). meningitis season, outbreaks of meningitis Despite improvements in utilization of antenatal Free and subsidized care. All residents of occurred in districts both in and out of the care and skilled birth attendance, maternal Ghana are eligible for NHIS coverage, and GOVERNANCE CHALLENGES traditional meningitis belt. Over 2,400 cases were mortality and neonatal mortality remain high, several people are exempted from paying Health financing. While working toward reported nationwide and the causative organisms raising concerns about quality of care. premiums, including those under the age UHC, the government of Ghana has faced included pathogens not typically responsible of 18, over the age of 70, indigent people, public liabilities in the health sector. These for outbreaks in the recent past. These incidents Pandemic preparedness. The 2017 JEE pregnant women, institutionalized persons, include financial commitments to international exposed the vulnerability of the health system assessment of core capacities identified limited and beneficiaries of social protection programs. organizations (e.g., co-financing for Gavi) and to major outbreaks, including weaknesses in key or developed capacity in Ghana in most aspects The NHIS covers 95% of common conditions NHIS commitments to providers for claims areas such as laboratory diagnostic capacity. 4 5 Moving toward UHC: Ghana Moving toward UHC: Ghana Collaborative efforts to accelerate progress toward UHC EXISTING INITIATIVES SUPPORTED PLANS FOR FUTURE BY EXTERNAL PARTNERS COLLABORATIVE WORK External partners are engaged in Ghana to build national capacity and strengthen the health Policy and Human Resources Development system, including by conducting a situation (PHRD)-funded advisory support analysis and updating and costing the National The work under the Tokyo Joint UHC Initiative Action Plan for Health Security. The Tokyo Joint falls within two major objectives: supporting UHC Initiative, supported by the government equitable, efficient, and sustainable health of Japan and led by the World Bank (WB), in financing for primary care/community-based collaboration with the Japan International health planning and services (CHPS) and Cooperation Agency (JICA), United Nations strengthening pandemic preparedness. Key Children’s Fund (UNICEF), and the World components of the first objective are technical Health Organization (WHO), is supporting the support for the NHIS reform strategy and government of Ghana and strives to accelerate policy development, and technical support for progress toward UHC. This support will enable refining mechanisms of paying for primary strengthening of nationally-led strategic health care. Activities in support of the second systems to achieve UHC, as well as pandemic objective entail: providing technical assistance preparedness. to strengthen capacity for preparedness and response to public health events and hazards Through budgetary support and technical including emergency operations; conducting a cooperation, the WB, U.K. Department for systems audit; mapping existing stakeholders International Development (DFID), and JICA and coordination mechanisms and developing have jointly supported and monitored CHPS an engagement protocol; and developing an implementation. UNICEF is also working with epidemiology information architecture, a government agencies (the Ghana Health Service technology gap analysis, and a business and the National Health Insurance Scheme) to and administration requirement document. demonstrate quality improvement models for Furthermore, the Tokyo Joint UHC Initiative maternal, newborn, and child health services. will closely cooperate with other investments in health, such as those by the Global Fund and Gavi, to contribute to health system strengthening. CConsidering that other sectors, such as nutrition and water and sanitation, 95% of common compose the foundations of heath for all, conditions challenges in these fields also will be considered are covered by under the joint work. Future efforts can further the NHIS. PHRD-funded pilot activities to generate evidence for mobilizing resources under IDA18 to better support the UHC agenda. 6 7 Moving toward UHC: Ghana References & Definitions (page 1 indicators) UHC Service Coverage Index (2015) – Life Expectancy at Birth (2000-2015), WHO/World Bank index that combines 16 Maternal Mortality Ratio (1990-2015), tracer indicators into a single, composite Under-five Mortality Rate (1990-2015) – metric of the coverage of essential health WHO Global Health Observatory: services. For more information: WHO/World http://apps.who.int/gho/data/node.home Bank (2017). Tracking UHC: Second Global Monitoring Report. Wealth Differential in Under-five Mortality (Single data point, year varies by country) Catastrophic out-of-pocket (OOP) health – Indicator used by the Primary Health Care expenditure incidence at the 10% threshold Performance Initiative (PHCPI) to reflect equity (Single data point, year varies by country) – in health outcomes. For more information: WHO/World Bank data from Tracking UHC: https://phcperformanceinitiative.org/indicator/ Second Global Monitoring Report (2017). equity-under-five-mortality-wealth-differential Catastrophic expenditure defined as annual household health expenditures greater than Performance of service delivery – selected 10% of annual household total expenditures. indicators (Single data points, years vary by country) – Indicators used by the Primary Health Results of the Joint External Evaluation of Care Performance Initiative (PHCPI) to capture core capacities for pandemic preparedness various aspects of service delivery performance. (2016/17, year varies by country) – A voluntary, PHCPI synthesizes new and existing data from collaborative assessment of capacities to validated and internationally comparable prevent, detect, and respond to public health sources. For definitions of individual indicators: threats under the International Health https://phcperformanceinitiative.org/about-us/ Regulations (2005) and the Global Health our-indicators#/ Security Agenda. 48 indicators of pandemic preparedness are scored using five levels (1 is no capacity, 5 is sustainable capacity). https://www.ghsagenda.org/assessments Photo credits: Page 3 & 7: Dominic Chavez / World Bank Page 5: Arne Hoel / World Bank Co-authored by: 8