Ministry of Health Ghana · equipment (of which 2 in 2010). The acceptance rate and use of FP remains also a challenge with a continuous drop in FP uptake from 33.8% in 2003 to a

MinistryofHealthGhana

IndependentReviewHealthSectorProgrammeofWork2010

Ghana(DraftReport)

April2011

GhanaIndependentHealthSectorReviewfor2010

Draft Report / April 2011 i

IndependentReviewHealthSectorProgrammeofWork2010

Ghana


Draft Final Report / April 2010 ii

TableofContents

Acknowledgement.................................................................................................................................iv

Listofabbreviationsandacronyms.......................................................................................................v

Executivesummary................................................................................................................................ix

1. Introduction...................................................................................................................................1

2. HolisticAssessmentofthehealthsectorperformancein2010....................................................2

2.1 Overallscore..........................................................................................................................2

2.2 Servicedelivery......................................................................................................................3

2.3 Regionsofexcellenceandregionsrequiringattention.........................................................5

3. Governanceandhealthsectororganisation..................................................................................7

3.1 Centrallevelgovernance.......................................................................................................7

3.2 Districtlevelgovernance......................................................................................................14

3.3 PublicFinanceManagement................................................................................................19

3.4 ImplementationoftheApril2010actions(2009Recommendations).................................23

3.5 Healthsector2010milestones............................................................................................24

4. Selectedmain2010POWpriorities............................................................................................25

4.1 Reducinginequityinhealthoutcomes................................................................................25

4.2 Maternalandreproductivehealth.......................................................................................28

4.3 NonCommunicablediseases...............................................................................................32

5. Mainconclusionsandrecommendations....................................................................................35

ANNEXES................................................................................................................................................1

Annex1.TermsofReference.................................................................................................................1

Annex2.HolisticAssessmentofperformanceintheHealthSector2010.............................................2

Annex3.HealthSector–PublicFinanceManagement2010..............................................................24

Annex4.Progressofactionsagreedinthe2010AprilSummit..........................................................40

Annex5.Noteonessentialnutritionactions.......................................................................................42

Annex6.Listofkeyinformants...........................................................................................................43

Annex7.Referencesanddocumentsconsulted..................................................................................45


Draft Final Report / April 2010 iii

Listoftables

Table1:Sectorscore..............................................................................................................................2Table2:SectorWideIndicators2006-2010,greyedoutindicatorsarenotmeasuredonannualbasis3Table3:Regionsofexcellence...............................................................................................................6Table4:Regionrequiringattention.......................................................................................................6Table6.ProportionofnewoutpatientdiseasesduetoNCDsinpublichealthfacilities(excludingteachinghospitals),2006-2010............................................................................................................32Table7.Summaryofmainrecommendations.....................................................................................39Table8:Penta3byregion2006-2010,sourceCHIM...........................................................................10Table9:TrendofEPI2009-2010,sourceCHIM...................................................................................10

Listoffigures

Figure1:OPDvisitspercapitabyregion,2006-2010,sourceCHIM......................................................5Figure2DraftorganogrammewithMoH,IALCandcentralagencies...................................................8Figure3:Superviseddeliveriesbyregion2006-2010,sourceCHIM....................................................26


Draft Final Report / April 2010 iv

Acknowledgement

Theindependentreviewofthehealthsector2010ProgrammeofWorkwasconductedonbehalfoftheMinistryofHealth (MoH)anddevelopmentpartnersbya teamof international andGhanaianexperts.ThecoremembersofthereviewteamwerePhilipB.Adongo,AndreasBjerrum,LeoDevillé(teamleader)andRuudvanderHelm.

Ghanaianmembersoftheteam,drawnfromtheMinistryofHealth,GhanaHealthServices,teachinghospitalsandacademia,were:IsaacAdams,KokuAwoonor-Williams,GeorgDakpallah,DanielDarko,McDamienDedzo,HenryDusu,KafuiKan-Senaya,SallyLake,FrankNyonatorandAfisahZakariah.

Theteamwouldliketothankthemanyindividualswhocontributedtothisreview.ParticularthanksareduetoAfisahZakariahwhohasfacilitatedthedifferentmeetings,fieldvisitsanddatacollection;toGeorgDakpallah andMcDamienDedzowho participated in several interviews and contributedkeyinformation.

The Review Teamwould like to express its gratitude to all officials and individualswho providedinformationandwhograciouslygavetheirtimeandsupporttothereviewprocess.

TheReviewTeam

Accra,April2011


Draft Final Report / April 2010 v

Listofabbreviationsandacronyms(tobeupdatedinfinaldraft)

ADHA AdditionalDutyHoursAllowance

ARI AcuteRespiratoryInfection

ART AntiretroviralTherapy

ATF AccountingTreasuryandFinancial

BCC BehaviourChangeCommunication

BMC BudgetManagementCentre

CHAG ChristianHealthAssociationofGhana

CHIM CentreforHealthInformationManagement

CHN CommunityHealthNurse

CHO CommunityHealthOfficer

CHPS CommunityHealthPlanningandService

CIP CapitalInvestmentPlan

CMA CommonManagementArrangement

CMR ChildMortalityRate

CMS CentralMedicalStores

CYP CoupleYearsProtection

DA DistrictAssembly

DANIDA DanishInternationalDevelopmentAssistance

DCE DistrictChiefExecutive

DFID UKDepartmentforInternationalDevelopment

DHA DistrictHealthAdministration

DHIMS DistrictHealthInformationManagementSystem

DHMT DistrictHealthManagementTeam

DMHIS DistrictMutualHealthInsuranceScheme

DP DevelopmentPartner

EC EuropeanCommission

EOC EmergencyObstetricCare

EPI ExpandedProgrammeonImmunisation


Draft Final Report / April 2010 vi

FC FinancialController

FP FamilyPlanning

GH¢ NewGhanacedis

GAS GhanaAmbulanceServices

GBS GeneralBudgetSupport

GDHS GhanaDemographicandHealthSurvey

GHS GhanaHealthServices

GOG GovernmentofGhana

GMA GhanaMedicalAssociation

GPRS GhanaPovertyReductionStrategy

GSS GhanaStatisticalServices

GWEP GuineaWormEradicationProgramme

HA HolisticAssessment

HF HealthFund

HIPC HighlyIndebtedPoorCountries

HIRD HighImpactRapidDelivery

HMIS HealthManagementInformationSystem

HR HumanResources

HRD HumanResourceDirectorate

IALC Inter-AgencyLeadershipCommittee

ICB InternationalCompetitiveBidding

ICT Information&ComputerTechnology

IEC Information,EducationandCommunication

IGF InternallyGeneratedFunds

ILO InternationalLabourOrganisation

IMR InfantMortalityRate

IRP InternationalReferencePrice

IRT IndependentReviewTeam

ITN InsecticideTreatedNet

JICA JapanInternationalCooperationAgency


Draft Final Report / April 2010 vii

KATH KomfoAnokyeTeachingHospital

KBTH Korle-BuTeachingHospital

MDG MillenniumDevelopmentGoal

M&E MonitoringandEvaluation

MA MedicalAssistant

MCH MaternalandChildHealth

MDBS MultiDonorBudgetSupport

MDG MillenniumDevelopmentGoal

MICS MultipleIndicatorClusterSurvey

MMR MaternalMortalityRatio

MoH MinistryofHealth

MOFED MinistryofFinanceandEconomicDevelopment

MOLGRD MinistryofLocalGovernmentandRuralDevelopment

MOU MemorandumofUnderstanding

MTEF MediumTermExpenditureFramework

NAS NationalAmbulanceServices

NBTS NationalBloodTransfusionServices

NCD Non-CommunicableDisease

NDPC NationalDevelopmentPlanningCommission

NHI NationalHealthInsurance

NHIA NationalHealthInsuranceAuthority

NHIF NationalHealthInsuranceFund

NHIS NationalHealthInsuranceSystem

OPD Out-PatientDepartment

PE PersonalEmoluments

PFM PublicFinancialManagement

PNC PostNatalCare

POW ProgrammeofWork

PPM PlannedPreventiveMaintenance

PPME Policy,Planning,MonitoringandEvaluation


Draft Final Report / April 2010 viii

PPP Public-PrivatePartnership

RCH ReproductiveandChildHealth

RDHS RegionalDirectorofHealthServices

RH ReproductiveHealth

RHA RegionalHealthAdministration

RHMT RegionalHealthManagementTeam

RHNP RegenerativeHealthandNutritionProgramme

RSIMD ResearchStatisticsandInformationManagementDirectorate

SBS SectorBudgetSupport

SD SupervisedDelivery

SWAp Sector-WideApproach

TA TechnicalAssistance

TBA TraditionalBirthAttendant

TH TeachingHospital

TTH TamaleTeachingHospital

TWG TechnicalWorkingGroup

U5MR Under-FiveMortalityRate

UNAIDS JointUnitedNationsProgrammeonHIV/AIDS

UNFPA UnitedNationsFundforPopulationActivities

UNICEF UnitedNationsChildren’sFund

USAID UnitedStatesAgencyforInternationalDevelopment

WHO WorldHealthOrganisation


Draft Final Report / April 2010 ix

Executivesummary

The independenthealthsector review2010wascarriedout fromMarch9th toMarch31st2011.Theoverallobjectiveofthe2010annualreviewistoassessthesectorperformanceanddeterminetheextenttowhichthe2010 Programme ofWork (POW) has been relevant in providing guidance to the sector. Original Terms ofReference(TOR)havebeenadjustedandthescopeofthereviewhasbeenreducedinlinewiththeavailableexpertise in the review team.Apart from theholistic assessmentof the sector the reviewwas supposed tofocuson4of5ofthepriorityareasofthePOW(reducinginequityinhealthoutcomes,reducematernalandchildmortality (focus limited tomaternal /reproductivehealth), improvehealthy lifestylebypreventionandcontrolofcommunicable(CD)andnon-communicablediseases(NCD),andstrengthengovernance)aswellasfinancialmanagement.AsagreedwiththeMoH,thereviewteamfocusedthisyearespeciallyondistricthealthmanagement.PreventionandcontrolfocusedonNCDsonly.

Holisticassessment,sectorperformanceandselectedPOWprioritiesTheholisticassessment2010scoresthesectorperformanceas‘highlyperforming’,withatotalscoreof3+.Itshouldbenotedthatnopopulationbasedsurveydatawereavailableforthe2010assessment,meaningthatall indicatorresultsareservicebased(whichmeansthat itreflectsthereportedactivityofthepublicsector,themissionsectorandonlypartoftheprivateforprofitsector)orreflectpublicsectormanagement.Ontheone hand this means that true coverage of some service indicators is likely to be underestimated (e.g.superviseddelivery)butalso thatdataareasgoodas thestandarddatacollection, reportingandvalidationsystemis.However,dataqualityalsoaffectedpreviousyearassessmentsandsomemajoreffortshavebeeninvested this year by GHS in validating data quality. It is however recognised that data quality andcompletenessisyettobeimproved.The ‘highlyperformingscore’maysomewhatoverestimate trueperformanceasappreciatedby the IRT,butoverall the IRT confirms that,with the exceptionof some important areas, the sector has beenperformingwell.However,thereisstillscopeforimprovementandsomekeyareasrequireurgentattention.

In2010severalservicedelivery indicatorscontinuedthepositivetrenddocumented in lastyear’sreview.Thecoverageofsuperviseddeliveriesincreased(nowat48%),institutionalmaternalmortalitydecreasedandtheaveragenumberofoutpatientvisitspercapitacontinuedpreviousyears’remarkableincrease(nowat0.89percapita). The cumulative number of patients initiated on antiretroviral treatment also continued to increase(plus41%comparedto2009).OntheotherhandcoverageofEPI,ANCandFPservicesexperiencedworryingnegativetrendsthatneedfurtheranalysisandaction.While3regionshavebeenidentifiedasregionsexcellingin selected key indicators in 2010 (UWR for supervised deliveries and institutional MM; ER for Penta 3coverageandFPacceptancerate;andWRforANCandOPDpercapita),Volta region isanoutlier regardingmanyindicatorsandrequiresattention.Althoughthecoverageofsuperviseddeliveriesimprovedin2010,theequityindicatorforsuperviseddeliveriesworsenedsignificantly,indicatingawideninggapbetweenthehighestandlowestperformingregion.Nursetopopulation and doctor to population ratio increased respectively by 1.8% and 1.5% compared to 2009. Thenumberof functionalCHPS zoneshas increasedby51% (!), a signofGOG’sdevotion to improvingequity ingeographicalaccess to services.ThenumberofOPDvisitsunderNHIS increased from2.4million in2007 to18.7 million in 2010. The IRT observed that a very large number of OPD visits were by insured patients(between85and95%of totalOPD).HoweverOPand IPdatadonotprovide informationaboutpeoplenotaccessingtheservices.Thefundamentalquestionwhetherpoorandmarginalizedpeopledonotaccesshealthservicesdueto financialorotherbarriersremains.The IRTrecommendsassessingaccessibilityviaanationalsurvey.

Maternal mortality remains high and with the present progress,MDG 5 will not be attained in 2015. It istherefore laudable thatmaternal health gets somuch attention at district level, but difficult to understandwhytheANCattendanceratedroppedsignificantlyoverthepasttwoyears.Superviseddeliveryremains lowandtimelyreferralremainsaprobleminmanydistricts,evenifcreativesolutionsareintroducedatoperationallevel;andcostsorreferralisoutsidetheNHISpackage.TheEmONCassessmenthasatlastbeencompletedbuttoolatetofactorfindingsintothe2011budgetandPOW;andonly4outof10regionshavereceivedEmONCequipment(ofwhich2in2010).TheacceptancerateanduseofFPremainsalsoachallengewithacontinuousdropinFPuptakefrom33.8%in2003toalow23.5%(!)in2010.TheIRTrecommendstoanalysethereasonsforthismajordrop;and,pendingtheresults,considercoveringFPundertheNHIS(whileaddingthenecessary


Draft Final Report / April 2010 x

resourcestoNHIA);andconsiderinitiatingdemandsidefinancingformaternalcareinordertoincreaseaccesstodeliveryservices.Noncommunicablediseases(NCD)didnotreceivemuchattentionattheregionalanddistrictlevelin2010butimportant activities have been carried out at central level, including developing the national policy forpreventionandcontrolofNCD.ThereexistsnofocalpersonforNCDatregionallevelandlimitedcompetenceforprevention,controlandmanagementofNCDatdistrict level.GuidelinesformanagingNCDareabsentatfacilitylevel.AlthoughprevalenceofsomeNCDisalarming,thelackoffocusonNCDreflectsacontinuousbiastowardscommunicableovernoncommunicablediseasesbybothpoliticalandprofessionalactorsinthehealthsector.Of the 4 milestones agreed for the 2010 POW, two were fully achieved: a) Essential Nutrition actionsimplemented in all regions with emphasis on complimentary feeding; and b) Roundtable dialogue with theUniversities(medicalschools)andotherkeystakeholdersoneffectivespecialistservicesindeprivedareas.Onemilestonewaspartlyachieved:Neworganizationalarchitectureforthesectoragreed;organizationalchangeroadmapagreed;organizationaldevelopmentplanscompleted.Thelastmilestonewasnotachieved,butworkwasinprogress:HealthIndustrystrategydevelopedwithintheframeworkofpublicprivatepartnership(PPP).

CentralGovernanceGovernanceofthesectorprovidesamixedpicturebutsomeimportantchangeshaveoccurredorbeeninitiatedin 2010. TheMoH has started a process of internal reorganisation with a view to strengtheningMoH keyfunctions and revitalising / reviewingperformance contractswithhealth agencies; aprocess thatneeds fullsupport (both from central agencies and DPs), also with a view to reduce the still perceived dichotomybetweenMoHandGHS,andavoidduplicationoffunctions.TheM&Efunctionisapointincasethatrequiresstrengthening under the MoH. The IALC met regularly and its functioning is appreciated by all agenciesinterviewedaskeytocounter fragmentationandsupportharmonisedapproachesbetweendifferentcentralagencies. Seven draft health bills are now with the PSC for finalisation. The IRT however noticed someinconsistencies that still need tobeaddressedand isof theopinion that someproposedbillsmayenhanceratherthancounterfragmentation.Other2010achievementsincludethefinalisationoftheCMAIII,theJANSreview,thepreparationoftheHSMTDP(pendingfinalisationoftheM&Eframework).Remarkably, the NHIA has become more transparent and more cooperative with MoH and other healthagencies,apositivechangeinleadershipstyle,whichwasappreciatedbyallcentralagenciesinterviewedandalsonotedbytheIRT.Coverageofregisteredmemberscontinuedtoincrease(nowat16.9millionmembers1),OP utilisation by insuredmembers has substantially increased and average lead time of reimbursement ofclaimshasbeensubstantiallyreduced.NHIAhasalsostrengthenedkeyfunctionsofthecentralorganisation.Understandably, NHIA faces still some legal, organisational and technical challenges: the draft Bill is stillpending;renewalofcardsbymembersisoftenuntimely;costcontainmentandfinancialsustainabilityrequirecontinuous attention. Testing capitation payment as planned in the pilot projectwill be crucial in order topotentiallyaddresssub-optimalproviderandclientbehaviour.

Nineoutof23actionsagreeduponintheAprilSummitAideMemoirebetweenDPsandGOGhavenotbeencompleted,includingmainactionsrelatedtoPFMandprivatesectorpolicyandinvolvement.Twomainareasof concern raised by the 2009 IRT still require further action: the high costs of drugs and the fragmentedfundingtodistricts. CoordinationamongstDPs isanareathatrequirescontinuedattentionandseveralDPshave expressed some concernswith the use / effectiveness of the existingmechanisms for sector dialogue(technicalandstrategic).Importantly,forthefirsttimeever,thehealthsectorbudgetpassedthe15%Abujatarget2andincreasedbothinabsoluteandrelativeterms(USD28.6percapitacomparedtoUSD25.6in2009).However,theproportionofnon-wageGOGrecurrentbudgetallocatedtodistrictlevelandbelowdecreasedby25%from62%in2009to46.8%in2010,areporteddropthatrequiresattention3.

DistrictGovernanceandManagementThe IRTassesseddistrict governanceandmanagement throughassessing thehealth systembuildingblocks.Main impressionondistrictandDHMTperformancewaspositiveanddynamic.MaternalhealthandCPSare

1 No2010datawereprovidedformemberswithavalidcard.Bytheendof2009coverageofvalidcardholderswasestimatedbyNHIAat48%. 2 TheremaystillbeanissueofdoublecountingofNHIF,butthiswasprobablyalsothecaseinpreviousyear’sbudget. 3 This indicatorwouldbemuchmoremeaningfulifreflectingactualexpenditures.


Draft Final Report / April 2010 xi

highonthedistrictagendaandaresupportedthroughcreative,innovative,locally-developedsolutions,someofwhichareexamplesofbestpracticethatcanserveotherdistricts.Non-communicablediseasesandaccesstoservicesbythepoorandvulnerableisnotonthemainagenda.

In the districts visited, most annual district plans are not ‘comprehensive’, a concept that may requireclarificationanda rationalapproach.Districthospitals tend tobe ‘virtually’ toomuchseparated fromDHMTmanagement and oversight, resulting in sub-optimal use of scarce resources and potentially in sub-optimalquality of care and referrals by peripheral facilities. Regions and districts request greater decentralisedauthorityonHRHmanagement.NobodyatdistrictlevelseemstobetrainedinHRmanagementandformalHRtrainingplansarenotavailableatdistrict level. Informationmanagement requirescontinuousattentionandregular updating of skills. The main problem observed is with data entry, validation and understanding atfacility level. Available transport is generally well managed, but ambulance services are absent in manydistricts,forcingDHMTstodeveloplocal,creativebutgenerallysub-optimalsolutionsforemergencyreferrals.DrugssuppliesatfacilitieshavegreatlyimprovedsincetheNHIAcameonstream.Somestockoutshappenedin 2010 (e.g. TB drugs, FP commodities, bed nets) which is unacceptable in the context of Ghana. SeveralDHMTs lacked sufficient skills in pharmaceuticals and laboratory.Main issues raised by DHMTs have notchangedoverthepastyearsandincludeinsufficient,irregularandinflexiblefunding;lackofguidelinesonhowto use funds, especially IGF; availability ofHR; strategies to improve staff retention andmotivation; lack ofambulanceservicesandessentialequipment(e.g.EmONC);anddatamanagement.

PublicfinancemanagementInthenarrowsenseofsystems,budgetplanningandpreparationarerelativelywellestablished,buttimelinesfor budget preparation remain very tight. The lack of timely budget information leads by default toincremental budgeting. Budgets are supposed to include all resources including IGF and earmarkedprogrammesbutthisisnotalwaysthecaseandoutstandingdebtswithsuppliersarekeptoffthebudget(butarerecorded).Allocationguidelineshavebeenestablishedbutarenotbasedonacomprehensiveassessmentoftotalflowsoffundtoeachregionanddistrict.Asaconsequence,redistributionoffundshappensonlyinanarrowsense,overlookingthebroaderpicture.Aggregatebudgetexecutionwasrelativelygoodin2010,butatoperationallevelitremainstheAchillesheelofthe PFM systems, mainly because of fragmented and partially earmarked flows of funds, with limiteddiscretionat the spendingunit. Comprehensive feedback from the top to the spending levelson theactualbudgetsandtimingofthereleasesislacking;andthereisnofunctioningtrackingsysteminplacethatprovidesinformation on the status of the releases throughout the system. Regarding IGF, the NHIS is becomingincreasinglydominant.The IRTnoticedthatseveralhealthproviderswerebuildingupcapital inthe IGFdrugaccountandwouldarguethatthereisscopeforacontrolledbroadeningofthediscretionofthedrugaccount,providedthatminimalthresholdsarerespected.Incontrasttothissurplus,allBMCsindicatetorelyextensivelyon supplier credits.Also,districtsare introducing innovativeways to share financial resourcesbetweensub-districtanddistrictlevel.Markedprogresswasmade in2010 in implementationand trainingof theATFmanual.Aggregatequarterlyfinancial reports are prepared on a regular basis but are not used by management to monitor policyimplementation. BothMoH and GHS have enrolled under the first phase of the introduction of the GhanaIntegrated Financial Management Information System (GIFMIS). Its roll-out will impact on all financialoperations within the health sector. The PFM Working group only met once in 2010. The 2009 IRTrecommendation to reprioritisewithin thePFMstrengtheningplanwasnotgiven followup (althoughsomeactionswerepursued)andtheIRTnoticedlittleeffortwithkeyGOGactorstoreinvigoratetheworkinggroup.

The InternalAudit,which iswellestablished in thehealth sector, ishamperedby insufficient staff levelsandoperationalresources.Intermsofexternalaudit,undertheauspicesoftheAuditor-General,aprivatefirmwashiredin2010toauditthe2009accountsoftheMoH.Furthermore,theGhanaAuditServiceperformedregularaudits of BMCs. Audit Report Implementation Committees (ARIC) were in place in most but not all BMCsvisited.ThepublicdiscussionoftheMoH2007,2008and2009auditreportstookplaceonMarch24th,2011.ThePublicAuditCommitteeinsistedontheneedtostrengtheninternalcontrolsandtoactmoreaggressivelyincasesoffraudandembezzlement.

RecommendationsTherecommendationsaresummarisedinthetableinsection5ofthereport.


Draft Final Report / April 2010 1

1. Introduction

Theindependenthealthsectorreview2010wascarriedoutfromMarch9thtoMarch31st2011.Itispart of a broader annual review including Budget Management Centre (BMC) reviews andperformance hearings (involving districts, regions and heath related agencies); the inter-agencyreview;thehealthpartner’sreview;andthein-depthreviewofsomeagreedkeyareas.TheMinistryofHealth(MoH)anditsagenciesbrieftheParliamentarySelectCommitteeonHealthonthesectorperformance,progressandchallenges.Finally, findingsandrecommendationsarediscussedat theHealthSummit,actionsagreedandthewayforwardmappedout.

The independent sector review has been carried out annually for many years by a mixedinternationalandnationalexpertteam.Thisyear’spreparationoftheindependentreviewwaslessadequate/timelythanbeforeandasaresultof latecontactingonlyfewinternationalexpertswereavailable. During the inception meeting MoH introduced a large team of local consultants andconfirmedthattheywouldbefull-timeparticipating.Aswasthecaseduringpreviousreviews,onlyfew local consultantsworked regularlywith the independent review teamandno local consultantwasavailablefull-time.Thelimitedteammayexplainsomeofthegapsorlessthandesiredin-depthanalysisofsomeaspectsoftheTOR.Thelessthansatisfactorypreparationfitswithinthelastyear’sobservationregardingsome‘fatigue’plaguingthisintensiveannualprocessofreviews.Ontheotherhandtheindependentreviewteam(IRT)confirmsthatcollaborationwithdifferentstakeholdersatdistrict,regionalandcentrallevelwasgood.However,someoftherequestedinformationhasbeenmadeavailablerather late in theprocessor isstillpending (e.g. financialperformancedata).Also,thequality of theholistic assessment inevitably reflects thequality and completenessof thedatareceivedandtosomeextentwassub-optimalatthetimeofwritingthedraftreport.Timingoftheindependentreviewisobviouslytooearlytogetafullyvalidated,completeandcomprehensivesetofpreviousyear’sservice,managementandfinancialdataintime.ItshouldbenotedhoweverthatfewcountriesindeedwouldbeabletodeliverthosedatabymidMarch.

Thisyear,next to theannualholisticassessment tobecompleted, theToRspecified the followingkey areas for review: a) reducing inequity in health outcomes, taking supervised deliveries as aproxy; b) maternal / reproductive health; c) prevention and control of communicable and non-communicablediseases;d)governanceandadministration;ande)financialmanagement.

At the first team meeting with the MoH it was agreed that this year a major focus would bespecifically on district level governance and management (complementary to the focus ongovernanceatthecentral level lastyear).Further,giventhe limitationsofthereviewteam, itwasdecidedbythe IRTtofocusonnoncommunicablediseases (whereaction ismostrequired)ratherthan on communicable diseases. Although not mentioned in the TOR the IRT added a progressreviewof theactionsagreed in theApril2009Summit,as this reflectspartof theperformance in2010.

Section 2 of the report summarises the findings of the holistic assessment 2010. The full holisticassessment ispresented inannex2.Governance isdiscussed insection3andcoverscentral level,districtlevel,financialmanagement,anupdateonprogressmadeontheactionsresultingfromthe2009reviewandanassessmentofthe2010milestones.Section4discussesprogressmadeinequity,maternal / reproductive health and non-communicable diseases. The main conclusions andrecommendationsaresummarisedinsection5.



2. HolisticAssessmentofthehealthsectorperformancein20104

2.1 Overallscore

The Holistic Assessment of the health sector was performed for the first time in 2008. Theassessment was done as part of the annual health sector review to provide a structured andtransparentmethodologytoassessprogressinachievingtheobjectivesoftheannualPOWsandthe5YPOW2007-2011.

The 2010 POWwas developed during the transition from the 5YPOW2007-2011 to the HSMTDP2010-2013.Mostoftheindicatorsfromthe5YPOWhavebeencontinuedinthe2010POW,buttheindicatorshavebeenclusteredundernewThematicAreas1 to7.TheMOH informedthe IRT thattheholisticassessmenttoolhasnotbeenredefined,andtheholisticassessmentofthe2010POWwas,therefore,basedontheoriginal5YPOWindicatorclusters.

Of the 4milestones specified in the 5YPOW for 2010, threemilestonesmadeway into the 2010POW. The 5YPOWmilestone for Thematic Area 1:Working group representing private and publicsectorsestablishedtoproposeprivateinvestmentstopromotewellnesswasnotincludedinthe2010POW. Instead, a new milestone was specified in the POW 2010: Roundtable dialogue with theUniversities(medicalschools)andotherkeystakeholdersoneffectivespecialistservices indeprivedareas.The IRTconsideredthismilestonetobepartofThematicArea3 (CapacityDevelopment) intheholisticassessment.

Theconclusionoftheholisticassessmentisthatthehealthsectorin2010washighlyperforming,withasectorscoreof+3.Goal3(reductionofinequalitiesinhealthservicesandhealthoutcomes),servicedeliveryindicators(ThematicArea2),capacityimprovementindicators(ThematicArea3)andgovernanceandfinancingindicators(ThematicArea4)weregenerallyimproving.ThescoreofGoal2(Reducetheexcessriskandburdenofmorbidity,disabilityandmortalityespeciallyinthepoorandmarginalizedgroups)wasneutral.

GOAL1 n/a GOAL2 0 GOAL3 +1 THEMATICAREA1 n/a THEMATICAREA2 +1 THEMATICAREA3 +1 THEMATICAREA4 +1Sectorscore +3

Table1:SectorscoreOfthe4milestonesagreedforthe2010POW,twowerefullyandonepartlyachieved:a)EssentialNutritionactionsimplementedinallregionswithemphasisoncomplimentaryfeeding;b)Roundtabledialoguewith the Universities (medical schools) and other key stakeholders on effective specialistservices indeprivedareas.Onemilestonewaspartlyachieved:Neworganizationalarchitectureforthe sector agreed; organizational change roadmap agreed; organizational development planscompleted. The draft Bill for the creation of the Health Coordination Council is submitted to the

4Thecompleteversionoftheholisticassessmentispresentedinannex2.



Parliamentary Select Committee. The lastmilestonewas not achieved, butworkwas in progress:HealthIndustrystrategydevelopedwithintheframeworkofpublicprivatepartnership(PPP). 2006 2007 2008 2009 POW2010Goal 2010

performanceSource

Goal1:Ensurethatchildrensurviveandgrowtobecomehealthyandreproductiveadultsthatreproducewithoutriskofinjuriesor

InfantMortalityRate(IMR)per1,000livebirths 71 - 50 - n/a -

Under5MortalityRate(U5MR)per1,000 111 - 80 - n/a

-

MaternalMortalityRatio(MMR)per100,000livebirths n/a - 451 - n/a -

Under5prevalenceoflowweightforage 18% - 13.9% - n/a

-

TotalFertilityRate 4.4 - 4 - n/a -

Goal2:Reducetheexcessriskandburdenofmorbidity.disabilityandmortalityespeciallyinthepoorandmarginalizedgroups

HIVprevalenceamongpregnantwomen15-24years 3.2 2.6 2.2 2.9 1.9 - IncidenceofGuineaWorm

4,136

3,358501 242 200 8 CHIM

Goal3:Reduceinequalitiesinhealthservicesandhealthoutcomes

Equity:Poverty(U5MR) 1.18 1.72 -

n/a - Equity:Geography,services(superviseddeliveries) 2.05 2.143

1.971.49 1.90 1.79 CHIM

Equity:Geography,resources(nurse:population) 4.14 2.257 2.03 1.87 2.00 1.83 HR-MOHEquity:NHIS,gender(Female/Maleactivememberratio) n/a n/a

1.22-

- Equity:NHIS,poverty(Lowestwealthquintile/wholepopulationactivemembers)

n/a - 1.3 -

n/a - ThematicArea1:Healthylifestyleandhealthyenvironment

%householdswithsanitaryfacilities 60.70% - - -

n/a - %householdswithaccesstoimprovessourceofdrinkingwater 78.10% - -

-n/a -

Obesityinadultpopulation(womenaged15-49years) 25.30% - 9.3% -

n/a - ThematicArea2:Health.ReproductionandNutritionServices

%children0-6monthsexclusivelybreastfed 54.0% - - - n/a - %deliveriesattendedbyatrainedhealthworker 44.5% 32.1% 42.2% 45.6% 50.3% 48.2% CHIMFamilyplanningacceptors 25.4% 23.2% 33.8% 31.1% n/a 23.5% CHIM%pregnantwomenattendingatleast1antenatalvisit 88.1% 91.1% 97.8% 92.1% 70% 90.6% CHIM%U5ssleepingunderITN 41.7% 55.3% 40.5% n/a 50% n/a %childrenfullyimmunized(proxyPenta3coverage) 84.2% 87.8% 86.6% 89.3% 87.9% 84.9% CHIMHIVclientsreceivingARVtherapy 7,338 13,429 23,614 33,745 51,814 47,559 CHIMOutpatientattendancepercapita(OPD) 0.55 0.69 0.77 0.81 0.82 0.89 CHIMInstitutionalMaternalMortalityRatio(IMMR)per100,000livebirths 187 230

200170 185 164 CHIM

TBtreatmentsuccessrate 73.0% 79.0% 84.0% 85.6% 86% 86.4% CHIMThematicArea3:CapacityDevelopment

%populationwithin8kmofhealthinfrastructure n/a - - - n/a - Doctor:populationratio 15,423 13,683 13,499

13,49911,981 11,500 11,479 HR-

MOHNurse:populationratio 2,1252,125

1,537 1,353 1,537 1,100 1,510 HR-MOHThematicArea4:GovernanceandFinancing

%totalMTEFallocationtohealth 16.2% 14.6% 14.9% 14.6% 11.5% 15.1% MOH%non-wageGOGrecurrentbudgetallocatedtodistrictlevelandbelow 40.0% 49.0% 49.0% 62.0% 50 46.8% MOHPercapitaexpenditureonhealth(USD/capita) 25.4 23.01 23.23

25.6026 28.64 MOH

Budgetexecutionrate(Item3asproxy) 89.0% 110.0% 115.0% 80.4% 95% 94.0% MOH%ofannualbudgetallocationstoitem2and3disbursedtoBMCbyendofJune n/a n/a 23.0% 39.0% 40% 31% MOH%populationwithvalidNHISmembershipcard(activemembers) 17.7% 36.2% 44.7% 50.0% 60,2% -

Proportionofclaimssettledwithin12weeks n/a n/a n/a n/a 40% -%IGFfromNHIS 45.0% n/a 66.5% 83.5% 70% 79.4% MOH

Table2:SectorWideIndicators2006-2010,greyedoutindicatorsarenotmeasuredonannualbasis

Table 2 summarizes the values of sector-wide indicators for the 5-Year Programme ofWork andannual targets specified in the 2010 Annual Programme ofWork. Please note that the indicatorshave been clustered according to the 5YPOW and not the 2010 POW to enable the holisticassessment.

2.2 Servicedelivery

Thethemeofthe2010ProgrammeofWorkwas“Goingbeyondstrategytoaction”toensurebetterresults and accelerate the attainment of targets, especially the MDGs. Indeed, in 2010 severalservice delivery indicators continued the positive trend documented in last year’s review. Thecoverage of supervised deliveries increased, institutional maternal mortality decreased and theaveragenumberofoutpatient visitsper capita continuedpreviousyears’ remarkable increase.OntheotherhandcoverageofEPI,ANCandFPservicesexperiencedworryingnegativetrends.Detailedanalysisrevealslargeinterregionalvariationsofbothperformanceandresources,whichisdiscussedbelow.



MDG4

In2010,thecoverageofPenta3immunizationdroppedby4.9%to84.9%.Nineregionsoutoftenexperienced a drop in coverage, only EasternRegion sustainedperformance. Themost significantdropwasrecordedinUpperEastRegionwith16%declinefrom106%to89%Penta3coverage.TheRegion, however, continued to perform above the national target and better than the nationalaverage.

Asobservedin2009,GreaterAccraRegionhadthelowestcoverageofPenta3at69.9%.In2009,anEPIsurveyinGreaterAccraRegionshowedsignificantlyhighercoverageofPenta3comparedtotheroutine reports,which indicates a possible underreportingwithin the routinehealthmanagementinformationsystem.

TheIRTrecommendsinvestigatingthecausesfortheobserveddropinPenta3coverage.

MDG5

Oneof thehealthsectorpriorities for2010was todecreasematernalandchildmortality throughimprovementinfamilyplanning,skilleddeliveries,accesstobloodservices,comprehensiveabortionandneonatalcareandmalnutritiontoachievetheMDGs.

In 2010, the coverage of pregnant women, who received one or more antenatal care visits,continuedtheprevioustwoyear’snegativetrendanddroppedby1.6%to90.6%.VoltaRegionhasthelowestcoverageat70.9%,whichisalmost20percentagepointsunderthenationalaverage.

Whiletheproportionofdeliveriesattendedbyatrainedhealthworkercontinuedthepositivetrendsince2007and increasedby5.6% to48.2%, the targetof50.3%wasnotmet.Please refer to theequitysection(section4.1)foramoredetaileddiscussionofthisindicator.

DespitethefocusonFPinthe2010POW,thenumberofFPacceptorsdecreasedbyalmost25%in2010comparedto2009,and isnowat23.5%.Surprisingly,FP indicatorshavebeenexcludedfromthedraftHSMTDP2010-2013providedto the IRT.FP isanessentialcomponentof thestrategy toreachtheMDGs,andtheIRTrecommendsreintroducingaFPindicatorintheHSMTDPmonitoringframework.

TheinstitutionalMMRdeclinedby3.5%to164,whichisbelowthetargetof185.Forthepurposeofyear-on-yearcomparison,thepreviousyears’estimationpracticehasbeencontinuedfortheholisticassessment. There are, however, challengeswith estimating this indicator due to pollution of theroutine health information data by TBA deliveries and exclusion of maternal deaths recorded atteachinghospitals.ProbablythispracticeofestimatingtheIMMRhasbeeninplaceformanyyears.ForadetaileddiscussionoftheIMMRindicator,pleaserefertoannex2.

PreviousreviewshavewarnedagainstthepracticeofusingIMMRasproxyfornationalMMR.Withincreasing use of facilities for deliveries, better transport, etc. IMMR may indeed take anever-growingshareoftotalMMR.

MDG6

Thecumulativenumberofpatients initiatedonantiretroviral treatmentcontinuedto increaseandwas 41% higher in 2010 compared to 2009. 85% of patientswho ever started ARV therapywerereceiving treatment in 2010. About 9% were lost to follow-up, 5.4% died and 0.5% stoppedtreatment.TheTBsuccessrateslightlyincreasedto86.4%in2010,whichisabovethetargetof80%.Comparedto2009,thenumberofGuineaWormcasesreducedby97%tojust8casesin2010,with



Ghana closing in on full eradication. All cases were from Northern Region and the last case wasreportedinMay2010.

OPD

Outpatientvisitspercapitacontinuedpreviousyears’increaseandreachedthe2010target.UpperEastRegioncontinuedtohavethehighestOPDutilisationwithalmost1½visitpercapita.Since2006Upper East Region has almost tripled the OPD per capita rate. On one hand, this is could be anindication of significant improvement in access to health services in the region, but on the otherhand the steep and rapid increase could result from a cross-border effect fromBurkina Faso andTogoor fromover-prescribingandoveruseof services.The increasedutilisationof servicesputsalarge pressure on both human and financial resources, which should be a subject for closerassessment.

GreaterAccraRegionhasthe lowestrateat0.52,butthismaypartlybeexplainedbyexclusionofKorlebuTeachingHospital’sOPDvisitsfromtheregionalfigureandbypresenceofastrongprivatesectorforwhichdataareonlyexceptionallycollected.NorthernRegionexperiencedstagnationfrom2009to2010andmaintainedperformanceatalow0.53visitspercapita.

Figure1:OPDvisitspercapitabyregion,2006-2010,sourceCHIM

2.3 Regionsofexcellenceandregionsrequiringattention

InthereviewofPOW2009,theIRTintroducedtheconceptof“RegionofExcellence”,whichhasbeencontinuedinthereviewofPOW2010.TheselectionofaregionisbasedonsubjectivejudgementbytheIRTbasedonselectedindicatortrends.

In2010,nosingleregionstoodoutasthemostexcellentperformer.Differentregionshadpresentedthemostpositivetrendsfordifferentindicators.Belowisatableofthethreebestperformingregionsin2010.

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

AR WR NR BAR CR VR UER ER UWR GAR Ghana

2006

2007

2008

2009

2010



Penta3 ANC Superviseddeliveries

FPacceptorrate

InstitutionalMMR

OPDpercapita

Mostpositivetrend 0.0% 4.2% 25.6% 1,8% -40.9% 45.7% Nationaltrend -5.0% -1.6% 5.6% -24.5% -3.5% 10.0% MDG5:UWR -8.8% -1.0% 25.6% -13.8% -40.9% 25.0% EPI:ER 0.0%(!) -3.4% -1.5% 1.8% 41.2% 16.0% OPD:WR -2.1% 4.2% -1.4% -39.0% -7.4% 45.7%

Table3:Regionsofexcellence

TheregionalanalysisindicatesthatanumberofVoltaRegion’sindicatorshadaworryingnegativetrendfrom2009to2010.Furthermore,VoltaRegiongenerallyhadlowperformancerankcomparedtotheother9regions.

Penta3 ANC Superviseddeliveries

FPacceptorrate

InstitutionalMMR

OPDpercapita

Mostnegativetrend -16.0% -20.2% -15.2% -39.0% 60.5% -0.1% Nationaltrend -5.0% -1.6% 5.6% -24.5% -3.5% 10.0% VoltaRegion -14.1% -20.2% -15.2% -19.0% 50.3% 0.2% Trendrank(1ishighest) 9/10 10/10 10/10 5/10 9/10 9/10 Performancerank 9/10 10/10 10/10 7/10 9/10 8/10

Table4:Regionrequiringattention

ThecoverageinVoltaRegionofPenta3,ANCandsuperviseddeliveries,institutionalMMRandOPDpercapitawereamongthelowestinGhana.

The analysis suggests that Volta Region may require special attention in 2011, and the IRTrecommends specific support to Volta Region in order to identify the causes of worseningperformance.

Keyrecommendations

• AnalysewhyANC,FPandEPIindicatorshavesubstantiallydecreasedandwhy,withafewexceptions,itappliestomostregions.Basedontheanalysis,developasector-wideactionplantoredressthesituationASAPin2011andimplement.

• PerformtogetherwiththeRMOofVoltaRegionacarefulanalysisoftheregion’sanddistrictspecificperformancevis-à-visallsector–wideindicators.Defineissuesbothwithdatacollection/validationandwithservice/managementperformance.Developaregionalanddistrictactionplantoredressthesituationandimplement.

• BuildcapacitywithintheMoHM&Edepartmenttocollateallhealth,serviceandmanagementrelateddataofGHS(includingCHAG),allcentralagencies(includingTeachingHospitals)andanalysesector-wideindicatorsforpolicyrelevance;andforimplementingtheannualsectorholisticassessmentbytheMoHM&Edepartment.



3. Governanceandhealthsectororganisation

3.1 Centrallevelgovernance

The2009IRTobserved,aftera15yearperiodofaimingatacomprehensive,sector-wide,integratedapproach regardinghealth serviceorganisationandhealth servicedelivery,a tendencyofevolvingagain to an increasingly fragmented approach in the health sector. As indicated in the 2009 IRTreport, this was reflected in several dynamics in the sector, butmainly through: a) an increasingnumber of health (related) agencies without effective communication between agencies andwithout performance based / results based financing; b) a greater complexity/variety in healthfinancing mechanisms; with an increasing tendency to earmarking financial and programmeresourcesfordistrict level;andmoreemphasisonclinical/curativecarethroughhealth insurancefinancing;andc)a lossoffocus intherespectivePOWs,movingfromathemebasedtoanagencybased focus. At the same time, the sector was observed to be constrained by some majorinefficiencieswhichincluded:a)thedelaysinfundingandinreimbursements;b)thehighpricesformedicines;andc)thelearningbydoingprocessofthenationalhealthinsurance.FragmentationwassaidtobeenhancedbyaweakMoHhavingsomecarrotstoimprovesectorandagencyperformancebutnosticks.

Althoughoneyear isshorttoexpect fundamentalchanges ingovernanceofthehealthsector, theIRThasobservedsomeimportanteffortstoaffectchange.Someofthoseareyetataninitialstage,butpromisingifimplementatedwell.

The MoH has started a process of internal reorganisation and strengthening of key functions.Reportedly,thiswouldincludethefollowing:a)StrengtheningthebudgetfunctionunderPPME,bybringingplanningandbudgetingtogether,separatefrompolicyanalysis;b)strengtheningtheM&EfunctionunderPPMEandreviewitsjobdescription;c)revitalisingtheexternalaidcoordinationunit;andd) strengthening theprocurementmonitoring function. In addition, theMoH is reviewing themechanism of performance based contracting with health agencies, with a view to strengthen aresultsbasedapproach.Theeffectsoftheaboveproposedchangesareyettobeseen5.

TheInter-AgencyLeadershipCommittee(IALC)metquarterlyin20106.Allkeyagencies(GHS,NHIA,CHAG) confirm that the IALC has been quite effective in its attempt to improve sharing ofinformation between agencies and reduce fragmentation. All interviewed agencies appreciate theIALC,whowouldbecomealegalbody,theHealthCoordinationCouncil,undertheMoH,aspicturedbelow(inlieuofthe‘NationalHealthService’).

5TheIRThasnotseenaneworganogrammeoftheMOHreflectingtheabovechanges.TheinformationhasbeenprovidedbytheChiefDirector.6TheIRTonlygottheminutesofthelastmeeting.



PROPOSEDHEALTHSTRUCTURE

MinistryofHealth

NationalHealthService(Inter-

AgencyLeadershipCommittee)

ServiceDelivery Research&Training Regulatory HealthInsurance

Figure2DraftorganogrammewithMoH,IALCandcentralagencies

All eight Regulatory Bodies would come under the Regulatory function. Service delivery wouldencompassGHS,TH,NBTS,NAS,CHAG,quasigovernmentfacilitiesandNGOs.Research&trainingwould cover the Centre for Research into Plants Medicine, the Ghana College of Physicians andSurgeonsandtheTrainingInstitutions.TheNHIAispartoftheaboveproposedstructureandMoHconfirmed thatNHIAnowconsiders itself andbehavesas ahealthagencyaccountable toMoH.AdraftHealth Coordination Council Bill has been submitted to the Parliamentary Select Committee(PSC).

Inadditiontotheabovementioneddraftbill,another6draftBillshavebeensubmittedbytheMoHtothePSC7,aswellastheNHISBillbytheNHIA8.

TheIRTNoteswithinteresttheproposedchangesbothwithinMoHandformalisingthestructureoftheHealthCoordinatingCouncil,picturedasanintermediarybetweenMoHandtheagencies.Giventhatthisisstillataproposalstage,theIRTwouldliketosharethefollowingobservations:

• TheDraftBillof theHealthCoordinationCouncil (HCC) specifies that itwill striveat jointdecision-making between agencies, ensuring alignment with sector priorities, fosterproblem-solving, create synergies between agencies and improve sector efficiency andeffectiveness.Itwillactasahealthsectoradviseror“cabinet”totheMinisterandprovideinputanddirection intotheMoHpolicies,amongstothers.WhiletheeffectivenessoftheIALChasbeenappreciatedin2010anditsformalisationinalegalstructureisunderstood,the HCC should not replace essential MoH functions. These include formal contractingbetweenMoHandagencies;accountabilityofagenciestoMoH;regulatoryfunctions;etc.TheIRTnotedthatthedraftBill listsaregulatoryfunction(regulatingtheactivitiesofthehealthsectorandagencies)undertheHCC,whichitconsidersinappropriate.

7Billssubmitted:mentalhealthbill;generalhealthservicebill;healthprofessionsregulatorybodiesbill;healthinstitutionsandfacilitiesbill;traditionalandalternativemedicinebill;medicaltrainingandresearchbill;andthehealthcoordinatingcouncilbill.8TheIRTdidnotreceiveacopyofthedraftNHISBill.



• TheDraftHCCBill lists themembersof theGoverningBodyof theCouncil. It includesallactorsoragenciesmentioned intheabovediagrambutomitsthefollowing:CHAG,AlliedHealthServicesBoard,PrivateHospitalandMaternityBoard,HealthTraining Institutions.Inordertobefullyrepresentativeandeffective, the IRTrecommendsconsideringaddingthe above agencies. In the future, when the Private Health Sector Alliance becomes arepresentativebodyfortheprivatesector,itwouldbelogictoalsoincludeitasamember.

• SomeoftheproposedBillsrisktofurtherincreasefragmentationofthesectorandtosomeextentwaste resourcesa) themental healthbill (why is a separate structureneeded formental health and not for child health?) foresees a parallel structure with regional anddistrictofficesratherthan integratingandresourcingmentalhealthservices inGHS(withtheappropriateprioritiesandresourcedosoeffectively);b)theRegulatoryBodieswouldhavedecentralisedofficesuptodistrict level (whydoesoneneedaregulatorybody–asopposedtofunction)atthedistrict level?;c) what istheneedforaseparateMortuariesandfuneralactivitiesAgencyoranAmbulanceCouncil?Interestingly,thereflectionofhowtostructurethehealthsectorseemstohavebeendoneinisolationofplannedreformsinLocalGovernmentat regional anddistrict level.At leastnoneof thedraftbillsmentionsthisfuturechange.

• TheIRT learnedfromdifferentagenciesthattheagency isaccountabletotheMinisterofHealthandnottheMinistryandthatthisshouldremainso.Whilefromalegalpoint(asperspecificagencystatutes)thismaybeso,agenciesshouldunderstandthattheMinister,forpracticalreasons,woulddelegatethistotheChiefDirector.

• Somekeyagenciesobserve that theMoHhasa tendency togobeyond its core function(policy development, health and health sector regulation, sector level planning &budgeting,sector-widemonitoringandevaluation,procurement)andgointo‘operations‘or ‘implementation’ (which is considered the core business of the respective agencies).Examplesgivenwerethetransferofitem3budgetsdirectlytotheregional/districtlevelin2010 bypassing the central GHS9; or the POW2010 for CHAG (as published in theMoH2010 POW)which does not adequately reflects the CHAG priorities but rather theMoHpriorities;ortheregenerativehealthunitwithMoHratherthanGHS,….CHAGexpressedsome frustrationwith how their ownprioritieswere notwell reflected in the documentandhowsomeMoHprioritiessuchastheimplementationofCHPSwereenforced10.Whileunderstanding the frustration of the agencies, the above examples are illustrative of acontinuous (healthy?) tension between policy and action, between respectiveresponsibilities, which one would find in any decentralised system. It is the role of theagenciestokeeptheMoHalertaboutitscorefunctionandoftheMoHtorequestagenciestodeliver/performandalignwithsectorpriorities.ItisalsotheroleoftheMoHtorequestCHAG to implement national priorities and provide additional resources to do so, ifneeded.ThisalsoreflectssomeofthestillexistingorperceiveddichotomybetweenMoHandGHS(anobservationalsomadebyseveralDPs,seefurther). Interestingly,bothMoHandGHSstatethattheirrolesarewelldefinedandthatthereisnodichotomy.Isitarealissueormerelyaperception?

• MoreimportantseemstheriskandinefficiencyofpotentialareasofduplicationbetweenMoH’scorefunctionsandagencyfunctions.Or lessthansatisfactoryfunctioningofsomeoftheMoHcorebusiness. Oneexampleofpossibleduplication,discussedfurther, istheM&E functionof theMoH (or responsibilities for regenerativehealth, health education).One example of less than satisfactory functioning is budgeting, resource allocation andpublicfinancemanagement(seesection3.3).

• TheM&E function of theMoH needs fundamental strengthening and developing. Sectorperformanceanalysisandassessingpolicyrelevanceissupposedtobethecorebusinessof

9TheIRTunderstoodthatthisonlyhappenedonceortwiceandwastheresultofadirectivebytheMinister.10CHAGwouldrathercontinuemobileoutreaches.



the M&E department of MoH, but this function is yet to be fully developed. The corecapacityofvalidatingandanalysingDHIMSdatalieswiththeGHS.Whilethisislogicinthesense that GHS should be able to assess its performance with a view to improve ormaintain it, it’s de facto scope of activity is wider: all CHAG facilities, some non-CHAGmissionfacilities,some(butveryvariablebydistrict)privateforprofitfacilitiesreportHIMSdata via the DHMT to GHS; Teaching Hospital data are partly covered (Tamale hospital)underGHSandother THdata are added to comeupwith sector-widedata;while someother agencies are not covered. Rather than using existing capacity of GHS, the M&Edepartment should have a well established capacity to do a full sector-wide analysis(mergingdatafromGHS,teachinghospitals,privatesector,allotheragencies).Whileitcandelegate some functions to the responsibleGHSdepartment, it shouldnotoverload thiswith functions it should develop itself (also to avoid the above stated dichotomy andoverlap). Also the holistic assessment and the analysis of its relevance should be a coreresponsibility of the M&E department and not a function outsourced to internationalconsultants.

• AccreditationofpublicandprivatefacilitiesisafunctionpresentlycarriedoutbyNHIA(seefurther).AccordingtoNHIAitremainsassuchinthedraftNHISBill;accordingtoMoHthisis still being debated. During the meeting with the IRT, the NHIA mentioned that thisfunctionrequiredconsiderableresourcesandtimefromNHIA.Alsothepost-accreditationmonitoringstillneedstobedeveloped.Inlinewiththe2009IRTrecommendations,theIRTwouldrecommendtodevelopaseparateagencyforaccreditationandpost-accreditationmonitoringoutsideoftheNHIA,inordertoavoidpotentialCOIandnottooverloadNHIAwithnon-corebusinessfunctions.

• Licensingofprovidersisundertheresponsibilityofrespectiveregulatorycouncils.Inordertopromotemaintainingqualityofservicesbothwithpublicandprivateproviders,theIRTrecommends to develop the concept of a renewable, time-limited provider licensingsystem;withtherenewaldependingonfulfillingsomespecificqualityrelatedcriteria(suchas following specific courses to update/maintain skills, participating in conferences andpeer reviews, etc.). This system exists inmany countries and is effective inmaintainingprofessionalquality.

Otherimportantelementsthathavebeenimplementedin2010includethefinalisationofCommonManagementArrangementsIII(CMAIII)andtheJANSReview(basedonwhichtheHSMTDPhasbeenre-assessed).TheHSMTDPisinapre-finalstage,awaitingfinalisationoftheM&Epart.

TheCommoditySecurityDraftActionPlanattemptstoaddressoneofthemajorsectorinefficiencies(asmentionedinthe2009IR),thehighcostsofdrugs.Itseemshoweverthattheactionplanlimitsitselftothepublicsector(CMS,RMS)anddoesnotlookatfactorsdeterminingpricesinthemissionandprivateforprofitsectors.Inaddition,solutionsarebasicallyaimedatimprovingefficiencyoftheexistingCMSandRMS,withoutanalysingcomplementaryoptions:e.g.howcompetitioncouldlowerdrugprices.

CollaborationbetweenNHIAandotheragenciesincludingMoH,GHS,CHAGaswellastransparencybyNHIAhasremarkably improvedover2010.Thishasbeenconfirmedbyallagencies interviewedandisperceivedasachangeofleadershipstyleatNHIA.TheIRThadaveryinformative,transparentandpositivemeetingwiththeNHIAtopmanagementandNHIApresenteditsperformancedataalsoattheDPperformancereviewmeeting.AccordingtoNHIAitscoverageofregisteredmembersattheendof2010isat16.9M(or69%bytheendof201011–provisionaldata;comparedto62%bytheend of 2009) an overall increase of 16% compared to 200912; the number of active members

11CalculationbyIRTbasedon2004populationfigures12TheindependentreviewhappenedtwoweeksafteranOxfampublicationclaimingthattheNHIScoverageinGhanawouldratherbeatabout18%ofthepopulation.Thispublicationraisedalotofheateddebate.While



(membershavingavalid / renewedmembershipcard stoodat48%,according toNHIA (figuresofend 2009, no update received). DHIMSdata confirm that theOP attendance by insured patientssignificantly increased in 2010 (74% of all OP, up from 67% in 2009), expectedly in line withincreasing membership coverage. Delayed reimbursement of claims, as was confirmed by allagenciesanddistrictsinterviewed,hassubstantiallybeenreducedandisnowclaimedbyNHIAtobeless than 3months13. The NHIA has now visited 2.915 health facilities out of an estimated 5000facilities in the country. Of those 2.647 have been accredited, of which 849 in 2010. It alsostrengthened its collaboration with LEAP, and (as observed during the field visits) citizens beingconfirmed as poor by LEAP, are registered as poor under the NHIS. The NHIA confirms that thedefinition of poverty aswell as the identifyingmechanisms still requires further attention by theMinistryofSocialWelfare14(seealsodistrictmanagement).

NHIAhasrestructuredandstrengtheneditscentralorganisationin2010amongstothersbysettingupofnewdivisions/cellsorstrengtheningexistingones,asfollows:theclinicalauditdivision,claimsprocessingcentre,internalaudit,strategicdivisionandprocurement.

Thepilotprojectwhichwasinitiallyforeseentostartin2010isstillinthepipeline.AmongstothersNHIA plans to test capitation payment for OP services up to district hospital level and with agatekeeper function. Depending on how the new financing mechanism is being implemented, itcould allow to fundamentally changing provider’s attitude and behaviour. In the present set-upincreasing OP attendance and prescribing more drugs allows generating more revenue for theprovider. This is reflected in the ever increasing OP attendance and the high number of drugsprescribed.Capitationpaymentallowsforcostcontainmentbyagreeingonanannualpaymentperregisteredpatient(includingservices,drugsandreferrals). Giventhedifficult financialsituationofNHIA today (a deficit of GHc 40 M at the end of 2010 - provisional), cost containment throughdifferentstrategieswillbecomeincreasinglyamajorchallengeforNHIA.

Now that average reimbursement lead time has become more acceptable, ongoing discussionsbetweenNHIAandserviceprovidersaremoreatthetechnicallevel(e.g.valuesofreimbursement;pricesofthenewdruglist;thepositiveandnegativeeffectsofclinicalaudits15;developingprovider

theIRThasnoevidenceoftruecoverage(whichwouldrequiresurvey-basedpopulationdata),basedonthesampleofhealthdistrictsandfacilitiesvisitedbytheIRT(seefurther)andthehighandeverincreasingcoverageofinsuredOPDattendanceacrossthecountry(seeDHIMSdata2010),itwouldexpectthatthetruthisclosertothecoveragedataclaimedbytheNHIAthanthoseclaimedbyOxfam.WhileOxfamraisesanumberofimportantandvalidpointsthatindeedaffectthesettingupofinsuranceschemesandthereforealsoapplytoNHIA(seeamongstotherstheabovechallengesstillfacedbytheNHIA),italsoputsintoquestiontheneedforasocialhealthinsuranceinGhanaandthealternativelesscostlyoptionofafreepublichealthsystem.WhilerecognisingtheextracostofsettinguptheneededadministrativestructurestomanagethehealthinsuranceandthelimitedcontributionoftheannualpremiumsinfinancingNHIS,theIRTconsidersittheresponsibilityoftheGoGandthecivilsocietyofGhanatomakefundamentaldecisionsaboutwhichfuturesystemstodevelop.13TheNHIAstatesthatallclaimsarenowbeingreimbursedinlessthan3months.GHSandCHAGconfirmedthisgeneraltrend.Fouroutoffivedistrictsvisited(March2010)hadallclaimsreimburseduptolateNovemberorDecember.OnedistrictstillawaitedreimbursementofNovemberclaims.AmoredetailedanalysisofAshantiregiondatasuggeststhatnotallclaimsareyetreimbursedwithin3months(seeannex3).TheIRThasnotbeenabletoascertainwhethertheperiodsofdelaysincludedlatesubmissionbyproviders.14TheIRTisoftheopinionthatidentifyingthepoorisnottheresponsibilityoftheNHIA/DHIS.TheMinistryofSocialWelfareshoulddevelopthemechanismsandprocedurestodosoandprovidetheinformationonpoorpeopletobecoveredbyNHIStotheDHIS/NHIA.ItisofconcernthattheLEAPprogrammedoesnotcoverthefullcountryandthatmostlikelystilllargenumbersofpoororvulnerablepeoplefallbetweenthecracks.15Someprovidersfindtheclinicalaudittooharshinpunishing:reportedly,a25%‘error’rateinasampleofclaimssubmittedbytheprovidercouldresultinadeductionof25%ofallclaimssubmitted.



profiles16).Alsothetimelyrenewalbyclientsofthemembershipremainsproblematic inthesensethatmanyclientswouldonlyrenewthecardwhentheyneedservices,whichisnotall in linewiththeinsuranceprincipleandmayfurtherundermineNHIA’srevenue.

Onemajor challenge faced by theNHIA is tomatch revenuewith expenditure. On the one handpressure on the NHIA to covermore for less will remain. However, when new drugs (e.g. FP) orservices (e.g. covering transport costs for emergencies) are being proposedunderNHIS coverage,sufficientadditionalresourcesneedtobeforeseen.Also,themarketcostsofdrugsinGhanaistoohigh,an issuewhichNHIA iswellawareoffandwould liketoaddress.Ontheotherhand,there isdefinitely scope for NHIA to better contain costs by providing the right incentives for clients torefrain from ‘shopping’ or ‘adverse selection’, and for providers tomisuse the system in order toincreaserevenue.

Finally,coordinationbetweenDevelopmentPartners(DPs)isanareathatstillcouldbeimproved(asis the case inmany countries). Positive points, amongst others, are the finalisation of the CMAIIIbetween the GoG and DPs; the participation of DPs in important undertakings such as the JANSreviewandthedevelopmentoftheHSMTDP.AlsotheactionpointsagreedfollowingtheIRT2009(aslaiddownintheAprilAideMemoire)arereportedlycloselymonitoredbytheDPs.Anoverviewof progress on actions is presented in section 3.4. The IRT however noticed some examples ofcontinuedweakalignment(e.g.parallelreportingrequirementsatdistrict levelbyspecificDPsand/or UN organisations) and less than satisfactory harmonisations (e.g. including the IRT itself, fourdifferentmissionshavebeenlookingintoaspectsofPFMissuesthepastmonth).

Although policy dialogue between MoH and DPs is generally considered good and regular; andmechanismsfordialogueexist,severalDPshaveexpressedconcernabout:a)discussionsbeingmoreof a technical than a strategic level; b)meetings often being attendedby toomanypeople to beefficient;c)seniorhealthstaffarenotalwaysbeingpresentwhichtendstomakethedialoguelessdecisionoriented;andd)thedichotomybetweenMoHandGHS(mentionedearlier)whichmakesitsometimesblurredwhotocontactwithaspecificrequest.ItisnotcleartotheIRTwhetherexistingmechanisms for regular dialogue (e.g. monthly meeting; quarterly meeting; bi-annual businessmeeting)specifywhichforumisfortechnicalorstrategicdialogueandwhethertherightpeoplearepresent for this type of dialogue. Also, channels of communication (e.g. should I contactMoH orGHS?) should be clear. Much effort has been invested in describing mechanisms for effectivedialogueintheCMAIII.Theseneedtobetestedand,ifnecessary,amended.

16DevelopingaprofileforeachproviderbytheNHIAisnotyetfeasibleatthisstage.Howeveritwillbecomepossibleonceclaimmanagementbecomesfullycomputerised,sayforallhospitals,todevelopaproviderprofileandtofollow-uponoutliers(thoseprovidersorfacilitieswhoseserviceanddrugprescribingfallsoutsidethe‘normal’or‘average’behaviour).



Keyrecommendations

Ø StrengthenMoHinstitutionalcapacity&authority

ü Continue supporting the ongoing re-organisation of MoH. This would requireconfirmationoftheroleoftheMoH(andthoseofdifferentagenciesvis-à-vistheroleoftheMoH),strengtheningitscorefunctions(skillsandcapacityespeciallyindomainsthatare considered weaker such as budgeting and M&E), avoiding duplication (with corefunctionsandcapacitiesofhealthagencies)andpossiblegaps.

ü PerformanorganisationalassessmentoftheMoHversusrolesandaskillsandcapacityassessmentversustasks(thisalsoinvolvesthoseagenciesthatcoversometasksthataresimilar to / potentially overlapping with MoH tasks); an example is monitoring &evaluation(seebelow)

ü Develop a roadmap & development plan for institutional / organisational change, ifconsideredrelevant

ü Provide technical support to carry out the above assessment and strengthen keyfunctionsasneeded

ü Aspartoftheaboverecommendation,developtheM&EfunctionoftheMoH,includingthe sector-wide performance analysis function and holistic assessment (seerecommendationsundertheholisticassessment)

Ø Furtherdeveloptheregulatoryframeworkforthesector

ü Harmonise and finalise the draft bills, avoiding fragmentation and setting upunnecessarybodies,withaview to,asmuchaspossible, integrate functions inexistingstructures

ü Considersettingupaspecificagencyforaccreditation

ü Consider developing renewable licensing of public / private providers with a view topromotequality

Ø Continuetoaddressexcessivecostsandfinancialsustainabilityofthesector

ü Ensurefuturefinancing&costcontainmentofNHIS

ü Assesswhether the Commodity Security Action Plan covers the right actions to reducedrugcosts.Considerwideningtheplantoincludeactionstoaddressmissionandprivateforprofitsectorsdrugprices;andpossiblyallowformore(selective)competition.



3.2 Districtlevelgovernance

TheIRTvisitedsixregions.InthreeofthosetheIRTfocusedspecificallyondistrictlevelgovernance,managementandorganisation(UWR,UER,WR). Intheotherthreeregions(ER,AR,BAR)themainfocuswasonpublicfinancemanagement(PFM,seesection3.3).Giventhemainfocusoflastyears’reviewoncentralgovernance, the IRT focusedsomeeffortsondistrict levelgovernance thisyear.Duringitsvisitsto5districtsitusedthemainhealthsystembuildingblocksasguidanceforitsreviewandassessedmanagementofmaternalhealthandnon-communicablediseasesas theentrypoint.Maternalhealthandnon-communicablediseasesaredealtwithmoreindetailinsection4.Asampleof 5 districts may not be representative of the situation in all districts. IRT observations havethereforetobetakenaspointersthatneedfurtheranalysis/follow-upanddiscussion.

Overallimpressions

Overallappraisalofthedynamicsobservedinthedistrictsvisitedispositive.Althoughdistricthealthmanagement teams (DHMT)donotalwayshave the full complementof skills required for the jobtheyareingeneraladynamic,motivatedteamofprofessionalsthataimatdoingagoodjobwiththemeanstheyhave.Theytrytosolveproblemsintroducingcreativesolutions,evenifthosesolutionsare not always ideal or per preferred standard (e.g. emergency referral ofwomen in labour on amotorbike) or according to the ‘book’ (e.g. sharing of revenue between sub-district and districtlevel).Creativitymayhowever lead to ‘bestpractices’ thatcouldbeanexample forotherdistricts(e.g. the network of means of transport for emergency referrals and the list of preferred phonenumbersprovidedtowomenattendingANC–seesection4).

AlthoughteambuildingskillsandteammanagementmaynotbepartofaformaltrainingofDHMT,they function very much as a team, share information regularly, plan and try to solve problemsjointly.InalldistrictsvisitedthelinkbetweentheDHMTandtheDistrictAssembly(DA)seemstoberathereffectivebothduringannualplanningexercisesand–tosomeextent-inimplementationandproblem-solving.Interestingly,muchtimeoftheDHMTisspentonmeetings(andminutes/records)but none of the DHMT members met by the IRT was ever trained in meeting / presentation /recording skills (an idea for the leadership training course?). Supervision of sub-district healthfacilities(publicandprivatenotforprofit)iscarriedoutregularly,tools/checklistexistandareused,findings are sharedwithin the team, feedback is provided to facilities. Supervision of clinical caremay be the weakest element (depending on the composition of the DHMT and the degree ofinvolvingthedistricthospitalstaff–DH-insupervision).

Remarkably,maternalhealthandCHPS(functioning,supervisionandextendingcoverage),areverymuch on the agenda of the DHMTs and indicators on supervised deliveries and functional CHPScoverageunderscorethepositiveeffectsofthisfocus.Onthecontrary,noncommunicablediseasesandpoverty (access tohealth services forpoororvulnerablepeople)aremuch lesson theagenda(seesections4.3and4.1).

ComprehensivePlanningandaction

Most annual district health plans are not comprehensive in the sense that: a) they most oftenexcludeprivateforprofitprovidersandlocallyactivehealthNGOs;b)thehospitalplanisnotalwaysintegrated in thedistricthealthplan;andc) it containsonly limited informationonother relevanthealth related sectors. Plans aremadewithout considerationof a realistic resource envelope andlimitedresourcesbecomingavailableduringtheyeararepartlyearmarked(e.g.diseaseprograms,GFATM)whichmeansthatsomedistrictprioritiesarenotmet.Positive is the linkwiththedistrictplanning exercise, the involvement of theDistrict PlanningOfficer in the health planning and theinvolvementoftheDistrictHealthCommittee/DAintheimplementation.Districthealthplansare



part of the overall district Plans. But basically the other sectors face the sameproblem as health(‘virtual planning’ without a realistic resource envelope), making part of the district planningexerciseobsolete.

Therearehowevergoodexamplesthatcanserveasbestpracticesorlearningexperiencesforotherdistricts.ThedistrictplanofEmbellelecoversall3privatehealthproviders inthedistrict;theyaresupervisedmonthly (as is the case for all public facilities) andprovideHMISdata regularly.WhileNGOsareoftennotincludedinthedistrictplan,collaborationduringimplementationhappens.

Thedefinitionofcomprehensivenessmayneedsomeclarification.IftheDHMT(orDD)isultimatelyresponsible for thehealthof thepeople livingwithin thedistrict, thiswouldrequire that theDD/DHMT not only dealswith health promotion, prevention, cure and care through all public healthfacilities/providers(includingthedistricthospitalandthecommunity level),privatenotforprofit(CHAG et al) and for profit providers, health NGOs, health insurance but also deals with healthrelated issues under the responsibility of other sectors (e.g. environment; water and sanitation;gender issues; food inspection; poverty & health such as access to health services and healthinsurance;education&health).While itmaynotberealistic fortheDHMTtofullycoveralloftheaboveaspectsinthedistricthealthplan,somedata/informationon,linkswith,qualityassuranceof,andprogressmadeshouldbedocumentedinthedistrictannualplanand/orannualreport.

TheIRTisoftheopinionthatcomprehensiveplanninginitselfisusefulbutshouldbedealtwithinarational / feasible way. The situation is quite different between for example an urban district inAccraandanisolateddistrictinUER.‘Comprehensiveness’shouldbetranslatedinthelocalcontextandDHMTsshoulddevelopa(multi-year,step-by-step)actionplanhowtoprogressivelymakethedistrict planning and action more comprehensive in terms of involving all actors and all healthrelatedsectors.

Districthealth&hospitalhealth:twoworldsapart?

The‘virtual’splitbetweenthedistricthospitalandtheDHMTisofsomeconcern17.Thesplitseemsto be evenmore obvious when the district hospital is a CHAG hospital or when the relationshipbetween the District Director (DD) and the Medical Superintendent (MS) is strained18. Whilerecognising that effective working relationships also depend on individuals (and therefore thesituationmayvarysubstantiallybetweendistricts),theIRTisoftheopinionthatclosercollaborationbetweenDHMTandDHwouldincreaseefficiency,servicequalityandsectorperformance,asfollows:a) joint planning brings actors closer, enhances mutual understanding and promotes potentialcollaboration in relevant areas; b) involving hospital staff in supervision of clinical care in healthfacilitieswouldenhancequalityofdecentralisedcareandpotentiallylowerunnecessaryworkloadatthe hospital19; c) using complementary resources increases efficiency (e.g. using the hospitalpharmacist, lab technician in supervising health facilities if theDHMT lacks those skills); d) jointlydeveloping referralmechanismsandguidanceon ‘how to refer’ could improve the timeliness andthephysical conditionofpatientsarrivingat thehospitalandenhance theirchances tosurvive;e)providingthepatientfeedbacksheetstotherespectivereferringfacility(whichnowarebeingkeptatthehospital–fornouse);f)analysinghospitalOPandIPdata(complementarytothedatafromtheotherdistrictfacilities)bythedistrictHISOfficerallowsformakingmoresenseofdistricthealthandmanagementdatafordecision-making.TheIRTisoftheopinionthatdistricthospitalsfunction

17InseveralofthedistrictsvisitedtheDHMThadnocopyofthehospitalplanandtheDHhadnocopyofthedistricthealthplan.18InmostdistrictstheDDisnotamedicaldoctor,makingthehierarchicalrelationshipwiththeMSofthehospitalnotalwayseasy.19Itshouldbenotedthatpresentfinancingmechanisminducesincentivesforproviderstoattractmoreoutpatientsattheirfacility;hospitalsmaythereforenotbeinfavourofsupervisingcareatdecentralisedfacilities,ifthiswouldlowerOPattendanceatthehospital.



toomuchinisolationoftherestofthedistrictasif‘intheirowncocoon’,de-linkedfromsomeofthepublichealthrealityoutside.ThisseemstobeevenmoresoforCHAGhospitals.Thissplit isalsoaconcern inmany industrialisedcountriesandpresent trendsare toopenup the inward lookingofhospitals, strengthening the links with referral facilities / providers and outside communities,comprehensively dealing with patients (taking charge of patients through a comprehensiveapproach:fromhome-localfacilityorprovider–specialistcare/hospital–follow-up/postcareatthelocalfacility–homebasedfollow-up).ThisrequiresafundamentalchangeinattitudeofhealthprovidersbutthisisnotimpossibleinGhana–evenmoresowiththegrowingcoverageofCHPSandclose-to-homeservicesprovidedbyCHOs.TheongoingleadershiptrainingcoursecouldstrengthencollaborationbetweenDHMTandDHstaff.

Humanresourcemanagement

Bothregionalanddistrictlevelstaffwouldliketohavemoreauthorityonstaffmanagement.Hiringand firing is not the authority of thedistrict level, except for casual staff.Disciplinary action is tosome extent decentralised (either district or region) but the local culture makes it difficult todisciplinestaff,referringdecisionsondisciplinaryactionupwardsinthesystem20.

Complaintsvoicedbyregionalanddistrict levelare:a)virtualappointmentsby thecentral levelofmedicaldoctors:appointedstaffneverarrivingattheplaceofappointment;b)casualstaff,trainedandinvestedinlocallyformanyyears,aptforthejobandwillingtoworkinisolated/lessattractiveplaces, cannot be appointed under the civil service; they are replaced by centrally or regionallyappointed staff (but how long will they be willing to stay?), de-motivating the casual worker; c)districtsarefullydependentonvacanciesbeingfilledbydecisionsatcentralorregionallevel,whichdonotalwaystakeintoaccountmainlocalpriorities;andd)therearelittleincentives21tomotivatestafftoworkinisolatedareas(ruralallowancesdonolongerexist22).

The districts visited have no HR training plan23 and are not fully aware of all existing or newlydevelopedtrainingopportunities24fordifferentcategoriesofstaff.

Interestingly, in the districts visited nobody of the DHMT staff is trained in human resourcemanagement.EvenwhenmainauthorityonHRHisstillcentralised,there isaneedtotrainDHMTstaffinHRmanagement:developingaHRtrainingplan;motivatingstaff;assessingskills&skillsgaps;disciplinary action; staff performance assessment (e.g. 360° peer performance assessment);contractingandmanagingcasualworkers;careerplanningandopportunitiesforcareerenhancing/additionaltraining;etc.

Informationmanagement

DistrictHISofficersmetbytheIRTareknowledgeableandmotivated.Theymakeeffortstovalidatethe data received from peripheral health facilities and analyse district data for some decision-making25 . These dynamic staff require continuous back-up and support in order to maintain /improvetheirskillsandfurtherthepositivedynamics.

20Reportedly,firingstaffisveryexceptionalintheGhanapublicsectorandistheauthorityofthecentrallevel.21TheIRTnoticedseveralpositiveinitiativessuchasthebuildingofpleasantdoctor’saccommodationinUERtoattractdoctorsatdistrictlevel;thepostbasicmidwiferytrainingofferedtoCHOsafter3yearspostqualificationexperienceindeprivedareas(ascomparedto5yearsforotherCHOs).22CHAGfacilitiesstillofferincentivessuchasfreeaccommodation,a7%toppingupofthebasicsalary,etc.23Thiswouldrequireinformationofallstaffonbasictrainingreceived,additionalpost-graduatetrainingdone,passedparticipationinad-hoccoursesandpresentskillsgapsrequiringfurthertraining.24ForexamplethedegreecourseforDHMTstaffatthePHschool.25PositiveexampleswereincreasedEPIeffortsafterHISdatashowedlowEPIperformanceinthefirstquarter;analysisofhospitalOPandIPdatainordertoperformaseparateanalysisofdistrictdatareflectingthedistrict



Mainproblemsfacedarethequalityofdataentry,validationandinterpretationatperipheralfacilitylevel.Thisisanareaofconcernthatneedstobeaddressed,alsowhenthenewDHIMS2willcomeon stream (computerisationmay help to identify some data errors but does not per se solve theproblem of garbage in, garbage out)26. Health facilities (and the DHMT office) have very fewperformance data visualised in graphs and diagrams on the wall, a custom that seems to havedisappearedwiththepresenceoflaptopsbutisveryusefulforengaginginperformancediscussionswithstaff,visitors(e.g.DPO)andclients.

MuchisexpectedfromtheDHIMS2tobelaunchedlaterthisyear.Itisstilltoseewhetherthenewtoolwillallowforgettingridof (orat leastgreatly reducing)parallel reporting (requestedbothbydifferentprograms,UNagenciesandsomeDPs)whichtoa largeextent isunnecessarilyburdeningtheworkloadofhealthandHISstaff.

Onlyonedistrictvisitedclaimstohaveaclientcomplaintsmanagementsysteminplaceatallhealthfacilities(customerofficerandmobilephonelinktotheDD).Complaintsmanagementseemstobemostlylimitedtosuggestionboxesatmainfacilitiessuchashospitals.

TransportManagement

Well trained transport managers (managing the vehicle fleet and drivers) and drivers (defensivedriving;preventivemaintenance)withrelevanttoolsinplaceandupdated(vehiclerecords)seemstobethestandardforGHS.

Main problems are the lack of ambulance services in several districts visited and the reportedfrequentbreakdownofrecentlyprovidedmotorbikes27.AndtheperceptionoftheDHMTthatfundsfor transport do not take into account district specific conditions (e.g. distances to be covered;difficulttoreachareas;unavailabilityofmaintenancefacilitiesinthedistrict;etc.).

Districtshavedevelopedcreative solutions for referrals in theabsenceofambulance services (e.g.usingtaxiservicesthatareplentyinonedistrictinWR;developinganetworkwithpublicandprivatemotorbikesinUER;providingANCattendantswithaprioritylistoftelephonenumbers–seesection4). There is obviously a need to improve on ambulance services being provided nation-wide.WhethertheNationalAgencyforambulanceserviceswillprovidepartofthatsolutionsoonisstilltobeseen.Asforotherdomains,theIRTisnotconvincedthatcentralisationthroughparallelagenciesisthemostefficientmanagementsolution.

Drugsandsuppliesmanagement

Generallyalldistricts report thatstocksofmedicinesandsupplieshavegreatly improvedsince theNHIScameonstream.Somereported(unacceptable)outofstockin2010weremedicinesforTB,SP,FPcommoditiesandbednets.

Several of the DHMTs visited lacked skills in pharmaceuticals (lack of pharmacist or pharmacytechnicianasaDHMTmember)andwerenotusingthedistricthospitalpharmacisttostrengthentheDHMTskills.

Itwasnoticedthatprescribinghighnumbersofdrugsandincreasingdrugturn-overseemstohavebecomeanincome-generatingactivityforhealthfacilities.Also,drugaccountsatsub-districtlevelsseemtohaveconsiderablebalance(seesection3.3).

populationaswellastotaldataincludingmanypatientsfromIvoryCoast(resultinginindicatorperformancehigherthan100%).26TransferringtheinformationfromtheGHSpatientfile/recordtothemonthlytallysheet(whichisthefirststepofdatacollection)isnotasimpleundertakingandmaybepronetocontentandquantitativeerrors.27ReportedlythiswouldbethecasewithsomemotorbikesmanufacturedinChina.



Financialmanagement

Financialmanagementatdistrictlevelisbeingdealtwithinsection3.3.

MainissuesraisedbyDHMTs

FromaDHMTperspectivethefollowingissueandgapsmakeithardforthemtoperformandliveuptotheexpectations:

ü Insufficient funding versus plans; irregular flow of funding resulting in irregular activities;some funding with strings attached (especially programme funds requiring fastdisbursement)interferingwithplannedactivities;resourceallocationnotneedsbased(e.g.fundsfortransport).

ü Lackofflexibilityinusingallocatedfundingandabsenceofclearguidelineshowsomefunds(e.g.IGFfordrugsremainingonbankaccount)canbeused.

ü AvailabilityofHRH(vacanciesformidwives;CHOs;pharmacytechnician;labtechnician)andtrainingopportunitiesforhealthstaff

ü Staff retention and motivation factors for attracting staff to deprived areas (e.g. staffhousing,ruralallowance,CHPScompound)

ü Lackofappropriateambulanceservicesü Lackofessentialequipment(e.g.EMONC)ü Dataunderstanding,validationanduseatfacilitylevel

PerformancecontractofDHMT

Does itmake sense to engage the DHMT via performance-based or results-based contracting? Inprinciplethiswouldbethepreferredmodalitybutthisshouldtakeintoconsiderationandpreferablyadapt some of the following realities: a) the gap between plans and available funds; b) thefragmented andpartly inflexible funds; c) resource allocation that does not consistently take intoaccount local needs; d) the limited authority of and action by the DHMT on staff issues; and e)limitedauthorityoftheDDontheDHresources.

This can be addressed by some or all of the following actions: a) study the total resource flowcoming into the district and streamline / simplify resource flows and use (e.g. consider singlepipelinefundingtoDHMTofmostoftheGOG,programme,SBSfunds;allowuseofIGFdrugfundsforpublichealth /preventiveactivities ifbalanceondrugaccountsexceeds futureneeds fordrugpurchaseandpaymentofdebts(seesection3.3formoredetailedanalysisandrecommendations);b) single pipeline funding to district level would allow using one consistent resource allocationformularatherthanmultipledifferentones(seesection3.3);c)trainDHMTstaffinHRmanagementand reinforce theauthorityofDHMTstaffon staffdiscipline; considerprogressivelydecentralisingHRHmanagement; d) reinstate or strengthen the authority of theDD on theDH; alternatively orcomplementary,seekwaystooptimisecollaborationbetweenDHMTandDHstaff.



3.3 PublicFinanceManagement

ThissectioncontainsthereviewofPublicFinanceManagement(PFM)intheHealthSectorin2010.It looksintothesystems,theperformanceofthesystemsin2010,andtheactivitiesundertakenin2010toimprovetheirfunctioning.AdetaileddiscussionandanalysiscanbefoundinAnnex3.

BudgetPlanningandPreparation

In the narrow sense of systems, budget planning and preparation are relatively well established.Sectorguidelineswereissued,basedontheguidelinesfromtheMinisterofFinance,andaseriesofpreparation workshops was organised in 2010 (in preparation of the 2011 budget). However,timelinesforbudgetpreparationwerestillverytight,measuredindaysratherthanweeks.Insomecases,districts reported thatdue to the short timelines, the regionwouldbudgeton theirbehalf.The lack of timely expenditure information in a format relevant for budget preparation leads bydefaulttoincrementalbudgetingagainstthebudgetoftheprecedingyear(s)andlessagainstactualexpenditurefigures.

Keyrecommendations

Ø Assess how comprehensive district health planning and implementation can bestrengthened in a rational, district-specificway and requestsDHMTs todevelopa localmulti-year action plan or specific roadmap for progressively increasingcomprehensivenessoftheplan;andasseshowbesttointegratethehospitalmoreinthedistrict-widemanagementwithaviewtooptimiseresourceuseandefficiencyofservicedelivery

Ø Assess resource flows in districts and how resources can be optimally used forsupporting priority public heath activities (e.g. IGF; disease programme funds; singlepipeline funding). Set up a dedicated TWG (including central, regional anddistrict staffbothfromGHSandCHAG)tostudytheaboveanddevelopguidelinesforresourceflowandresourceuseatdistrictlevel(seealsosection3.3)

Ø TrainDHMTinHRmanagement.ConsiderprogressivelydecentralisingelementsofHRM(alsoconsiderthecontextoftheupcomingLGreform).

Ø Continueworkstartedonadaptingworkingandretentionconditionsfordeprivedareas(conditionsofwork,housing,allowance,trainingopportunity,etc.)

Ø Assesswhether theongoingLeadershipTrainingCourse addresses the following issuesandifnot,howitcouldaddressallorsomeofthefollowing:tostrengthencollaborationbetweenDHMTandDHstaff; tobuildDHMTskills inmeetingandpresentation; instaffperformanceassessment(360degreepeerassessment)andpossiblydiscipliningstaff.

Ø



Budgetsaresupposedtoincludeallresources,includingIGFandearmarkedprogrammes.Inpractice,this is not always the case. To someextent budgets aredrawnup after the fact, basedon actualrevenuesandexpenditures(thisleadingtoasituationwhereexpenditureequalsbudgetstothedigitprecise,basicallyneutralising thepolicyandaccounting functionsof thebudget inthe firstplace).Furthermore, outstanding debts with suppliers are kept off the budget, even though they arerecordedseparatelyalongsidetheannualaccounts(fordistrictlevelBMCs).

There is still significant ‘below the line budgeting’, that is, the (re)allocation of resources to orbetweenpolicyobjectivesother thanapprovedby theappropriationact.Theofficialpolicy in thisregard has been strengthened: both the 2010 and 2011 budget guidelines stating firmly that “noformofoffbudgetexpenditureswillbe tolerated”,but it isunclearwhat instrumentsare inplacetodaythatwouldenforcethispolicy.

Allocation guidelines and criteria have been established in different ways. However, there are acoupleoflimitationstothecurrentapplicationofallocationcriteria:(i)theexistenceofmanyparallelflows of earmarked funds, over which spending units can exercise little influence; (ii) allocationguidelinesarenotbasedonacomprehensiveassessmentoftotalflowsoffundtoeachregionandeachdistrict, including Item1, Item4, donor funding andnet IGF; (iii) the budget guidelines onlycontainaggregateceilingsperitem(orpersourceoffunding)butnotperregionordistrict,allowingforlimitedex-antepolicysteering,and(iv)thereisnocomprehensivefeedbackthatwouldallowtoadjust allocation criteria against actual expenditure and against absorption capacity. As aconsequence,redistributionoffundshappensonlyinanarrowsense,andisoverlookingthebroadpicture,duetowhichpolicyrelevanceofcriteriacannotbeestablished.

Budgetexecution

Aggregatebudgetexecutionwas relativelygood in2010,with totalexpenditurea littleabove fivepercentoverbudget.However,attheoperational level,budgetexecutionremainstheAchillesheelofthePFMsystemsinthehealthsector.Aggregatesoverstepthecriticalfactthatthehealthsystemcontainsmanydifferentflowsoffunds,whicharetreatedinasegregatedway.Furthermore,quitesomeofthesefundsareearmarkedforparticularpurposesandallowforlittlediscretionatspendingunit level. As a consequence, the sector’s financial system is characterised bymany different butsmalltransactionstodistricts(mostnotexceeding5000Cedis),unreliabilityof inflows,and limiteddiscretionatthespendingunit.Nevertheless, fundsarebeingprovidedregularlytoallregionsanddistricts,eventhoughreleasepatternsarerelativelyunpredictable.

Besidesunpredictabilityofactualflows,thereisalsoalackofcomprehensivefeedbackfromthetoptothespendinglevelsontheactualbudgetsandtimingofreleases.Asaconsequence,mostBMCsdonotspendagainstapprovedbudgets,butagainstreleasesorcashflowwhichalsohindersproperannual planning of activities. Additionally, they cover part of the uncovered “expenditure” bysuppliercredit.

Keyrecommendations

Ø Use district level data (from quarterly and annual accounts 2010) for a study into theoverall financialenvelopeperdistrict (andregion),andtestpolicyrelevanceofcurrent(and potential) redistribution and allocation criteria. Consider merging some parallelresourceflowsintoasinglemorecomprehensive‘pipeline’fundingtodistricts,allowingfor more discretionary use at local level and more consistent use of agreed resourceallocationcriteria.



Despite the structural dependence on the reliability and timeliness of releases, there is nofunctioning tracking system inplace that canprovidequality informationon the statusof releasesthroughout the system.Asa consequence, the informationon (thequalityof)budgetexecution isratherpatchyandincomplete,anditisdifficulttoidentifyclearpatternsintimelinessandvolumesof releases, the underlying causes, and potential solutions to increase the quality of budgetexecution.

Regarding Internally Generated Funds (IGF), the NHIS is becoming increasingly dominant28; MoHresources havebecome increasingly less important for general operations, and virtually irrelevantfordistricthospitals.AlthoughIGFisprimarilytaggedforoperationalexpenses(Item3inparticular),a significant part of IGF is used for additional Item 1 spending (casual workers), and investmentactivities (30%of the health sector investment expenditure in 2010was covered by either IGF orNHIF).TheReviewTeamnotedthatseveralhealthproviderswerebuildingupcapitalintheIGFdrugaccount, in contrast with the services (or non-drug) account. The Review Teamwould argue thatthere is scope for a controlled broadening of the discretion of the drug account, provided thatminimal thresholds are respected. To establish these, a more comprehensive analysis would berequired,basedonthe2010financialstatementsofBMCs.

Incontrasttothissurplus,allBMCsindicatetorelyextensivelyonsuppliercredits.Thesecreditsareboth off-budget and off-accounts, but are monitored at BMC level. However, there is nocomprehensiveoverviewasofyet.

Districtsareintroducinginnovativewaystosharefinancialresourcesbetweensub-districtanddistrictlevel. For example some DHMTs levy an overhead on IGF income at sub-district level (varyingbetween5%and7%insomeofthedistrictsvisited).InonenewdistricttheDAFinanceCommitteewas levying contributions from sub-district health facilities ‘based on capacity’ to fund DHMTaccommodation,officeequipmentandoperationcosts.

Accountingandreporting

In 2010, marked progress was made in terms of implementation and training of the Accounting,Treasury and Financial Reporting Rules and Instructions (the “ATF-manual”). All BMCs visited hadreceivedthemanualandhadbeentrained.AccountingandreportingatBMClevelwasappropriate,and BMCs could produce proper monthly and quarterly financial reports upon request. RegionalHealth Administrations requested all district administrations, district and regional hospitals for aquarterly vetting of accounts before submission to the GHS HQ. Thus, the health sector has

28 Thishastwoconsequences.First,healthprovidersarelessreliantoncentralgovernmentforday-to-dayoperations,andcanactasmorefinanciallyautonomousbodieswithinthehealthsystem.Second,healthprovidersarefinanciallydependentonagoodfunctioninghealthinsurancesystem,duetowhichthesustainabilityoftheNHIShasbecomeasector-wideissue.

Keyrecommendations

Ø Strengthen release tracking information from source to expenditure, and producequarterlymanagementupdates(includinganalysisofthecausesofdelay).

Ø Conductacomprehensiveanalysisofaccumulationoffundsindrugaccount,andreviewguidelines to allow for increased flexibility of funds if appropriate. Also developguidelinesforsharingrevenuebetweensub-districtanddistrictlevel.



establishedarelativelysound(albeitmanual)methodforpreparingitsaccounts,providingareliablebasistoworkfrom.

Aggregatequarterlyfinancialreportshavebeenpreparedin2010onaregularbasis,butinallcaseswithmorethanthreemonthsdelay.Theiruseforfinancialmanagementpurposeswouldincreaseifthis delay could be brought down. Furthermore, these reports are not used by management tomonitor policy implementation, nor to engagewithdonorsondiscussionon aid effectiveness andincreaseduseofcountrysystems.

BothMoHandGHShaveenrolledunderthefirstphaseoftheintroductionoftheGhanaIntegratedFinancialManagement Information System (GIFMIS). Initial preparationswere done at both sites,includingtheestablishmentofanimplementationteamandthedraftingofanimplementationplan.AlthoughGIFMIS is inessenceanaccountingandreportingtool, itsroll-outwill impactall financialoperationswithin thehealth sector (inparticular commitment andexpenditure controls), andwillrequire strong coordination and involvement of senior management. Although roll-out has beenslightlydelayedattheControllerandAccountantGeneral’sDepartment,whoisleadingtheprocess,the introductionof theGeneral Ledger in2011willmarka first critical litmus test for theMoHtomoveontothesystem.

Externalscrutinyandaudit

TheInternalAudithasbeenwell-establishedinthehealthsector,butishamperedbyinsufficientstafflevelsandoperationalresourcestoexecuteis legalmandateproperly. Intermsofdeliverables,theInternal Audit provided regular reports. The MoH Internal Audit division provided four quarterlyreportsin2010.TheGHSInternalAuditDivisionprovidedtwohalf-yearlyreportsin2010.

In termsofexternal audit, under the auspices of theAuditor-General, a private firmwas hired in2010 to audit the2009accountsof theMinistryofHealth. Furthermore, theGhanaAudit Serviceperformed regular audits in the BMCs visited by the Review Team. This also included the privatefacility (benefiting from GoG resources for personnel emoluments) for which a payroll audit wasconducted.TheplannedProcurementAuditwastendered,butnocontractorwascommissionedforlackofqualityofthebids.

AuditReportImplementationCommittees(ARIC)wereinplaceinmostbutnotallBMCs.Inallcasesthe ARIC consists ofmembers ofmanagement,with the Financial Officer and/or Internal Auditorparticipating either as amember or as ex-officio. Responsiveness to audit recommendationswasconsideredassufficientbytheInternalAuditors.

In recent years, an important backlog of audit reports piled up at Parliament, but in particular in2010thePublicAccountsCommitteehasbeenforthcomingindiscussingthem.Thepublicdiscussion

Keyrecommendations

Ø EstablishgeneralpracticeofformallydiscussingtheQuarterlyFinancialStatementsandcollect and record feedback on the statements in view of improving quality ofinformationandpolicyrelevance.

Ø Increasesenior level involvement inGIFMIS implementation inviewofempowermentofimplementationteamswithinMoHandGHS,andestablishtightworkingrelationshipsbetweenMoHandGHSGIFMISImplementationteams.

Ø



of the MoH 2007, 2008 and 2009 audit reports took place on March 24th, 2011 (during thisIndependent Review) and was live broadcast on television. The PAC insisted on the need tostrengthen internalcontrolsandtoactmoreaggressively incasesoffraudandembezzlement.ThereportofthePACwasnotavailablebeforetheendofthereview,andcouldnotbeassessed.

PFMStrengtheningandCoordination

The Health Sector PFM working group convened only once in 2010 (on September 30th) forinformationsharingpurposes.ThePFMStrengtheningPlanwastabled,butnotdiscussed.Thelatestupdate on progress dates back to May 2010. The Recommendation to reprioritise within thestrengthening plan was not given follow up, although in practice some actions were pursuedwhereasotherswerenot.TheReviewTeamnotedlittletractionwiththekeyactorsinGovernmenttoreinvigoratetheworkinggroup.

3.4 ImplementationoftheApril2010actions(2009Recommendations)

Out of 23 actions specified in theApril 2010 SummitAideMemoire as a follow-upon the annualreview of 2009 performance, 8 actions have been fully completed and another 4 actions havestartedbuteitherhavenotbeencompletedorfurtheractionshavebeenplannedin2011(thelatterconcern mainly HRH actions and the draft Bills). Nine actions have not been completed. Theseinclude PFM actions, Private sector policy and involvement, funding / harmonisation of HMIS,finalisingtheSMTDP,factoringthefindingsoftheEmONCassessmentinthe2011budget/planandreviewingtheformatoftheregionalanddistrictperformancereviews.Twomoreactionswerenotassessedby the IRTbecauseof lackof information. Theactions and level of achievementof eachactionispresentedintableformatinannex4.

Keyrecommendations

Ø The lackofpro-active coordinationonPFM issues seemsunjustifiedby theneedsandactivitiesinthesector,andtheoverallrequestbytheGovernmentofGhanatoimprovetheusecountrysystems.Critical issuesthatneedtobetackledandwhichwouldbeontheagendaofthePFMworkinggroup,are:

ü periodicdiscussionoftheQuarterlyFinancialreports(outputofwhichisusedtoimprovethenextreport)

ü introduction of GIFMIS and the consequences for expenditure, accounting andreportingatalllevels,includingthecollaborationbetweenMoHandGHS(whichis supportedby three keyDPs in theHealth Sector, i.e.Denmark,UK-DFID andWorldBank);

ü improvementofreleasetrackingandpreparationofmanagementfeedbackü coordinatePFMassessmentsandmissionsbyDPsü identification of impediments for DPs in using country systems and set the

agendatoincreasetheiruseü identificationandcommissioningofanalyticalwork(asindicatedabove)ü PFMrelatedauditrecommendationsforfollowup.



3.5 Healthsector2010milestones

Essentialnutritionactions

ImplementationofEssentialNutritionActions(ENA)isongoinginalltenRegions29withemphasisontimelycomplementaryfeeding.Themainchallengereportedisthequalityof informationprovidedtowomenandlimitedfunding.InadditiontotheaboveENA,amalariaandnutritionprojectstartedin3outof5targetedregions(andcovered919communitiesattheendofSeptember2010),withamainfocusoncommunitymanagementofacutemalnutrition(CMAM).Seeannex5formoredetailsonnutritionactions.

Themilestonewasachievedin2010.

HealthIndustryStrategy

Milestone2010:HealthIndustryStrategydevelopedwithintheframeworkofpublicprivatepartnership

The Ghana Private Sector Analysis carried out in 2009 was completed early 2010 and presentedduring the Health Summit. In addition aMarket study30 on the private sector was carried out in2010.AsanoutcomeofthefirststudythePrivateHealthSectorAllianceofGhanawasestablishedinDecember 2009. This structure is still to be formally recognised by all sector partners and to belegalised(ongoingwithsupportfromtheRockefellerFoundation).

TheabovetwodocumentswillinformtheongoingdevelopmentofthePrivateSectorHealthPolicy.Theexpectationisforthepolicytobereadybytheendof2011.

Themilestonewasnotachievedin2010.

Neworganisationalarchitecture

Milestone2010:Neworganisationalarchitectureforthesectoragreedupon(organisationalchangeroadmapagreedupon&organisationaldevelopmentplanscompleted)

AccordingtotheMoHPPME,theneworganisationalstructureconcernstheinstalmentofaHealthCoordination Council, replacing the existing Inter-Agency Leadership Committee. According to theDraftBill31proposedtotheParliamentarySelectCommittee,thepurposeoftheCouncilistoensureeffective integrationof thehealth sector agencies in thepublic interest. Itwould strive to “fosterGhanaian health sector unity through collaboratively determining priorities, discussing issues,sharingstrategicideas,examiningresultstodate,shapingpolicyandstrengtheningoverallstrategic29ENAcomprisesofearlyinitiationofbreastfeedingwithin30minutesofbirthandexclusivebreastfeedingforthefirst6months;timelycomplementaryfeeding;feedingthesickchild;useofiodisedsalt;adequateintakeofvitaminAsupplementandiron;andmaternalnutrition.Mostrecentsurveydataindicatelimitedcoverageasfollows:iodizedsaltat32.4%(2007MICS),timelyinitiationofbreastfeedingat35.2%(2007MICS)andcomplementaryfeedingat63%(2008DHS).30FinalReportonHealthinAfrica2DeloitteandIFC,InitiativeMarketSurvey,SpanningtheRealmofPHIs,Ghana,August10,201031HealthCoordinatingCouncilBill,21stJuly2010.



direction”. The Council is an administrative and advisory body providing a platform for a holisticcoordinationof activities of all health delivery agencies, health regulatory bodies, health researchandhealthtraininginstitutions;andtoensurethecollaborationandgovernanceofthehealthsectoragencies.

The draft Bill is not yet final and still contains some omissions (CHAG and Private Sector are notmentioned in the list of members of the Governing body) and possible errors (one mentionedfunctionistoregulate,monitorandreviewtheactivitiesofthehealthsectoragencies;theIRTisoftheopinionthatregulation,isoutsideoftheauthorityofthePSC).

Themilestonewaspartlyachievedin2010.

Specialistservicesindeprivedareas

Milestone2010:Holdroundtabledialoguewithuniversities(medicalschools)andotherkeystakeholdersoneffectivespecialistservicesindeprivedareas

MoHHRHhasheldseveralmeetingswiththeuniversities(MoE).SpecialisttrainingbyGhanaCollegehas been re-organised in specialist sandwich courses for some specific disciplines (gynaecology,paediatrics, etc.; but not yet for ENT, ophthalmology, etc.), combining attachment at the TH andattachment at the district level under supervision by staff of the TH (regional specialist). Thisincreasesavailabilityofspecialistservicesatdistrictlevelinselecteddistricts,butappropriatetarifflevelsforspecialistservicesatdistrictlevelstillneedtobenegotiatedwithNHIA.

Themilestonewasachievedin2010.

4. Selectedmain2010POWpriorities

4.1 Reducinginequityinhealthoutcomes

Superviseddeliveries

In 2010, theprevious 4 years’ positive trendwas reversed and the equity indicator for superviseddeliveriesworsenedsignificantly,indicatingawidenedgapbetweentheregionswiththehighestandthelowestperformance.Despitetheworseningtrendoftheindicator,theindicatorratioachievedthetargetofbeingbelow1.9.

SixofGhana’stenregions improvedcoverageofsuperviseddelivery,butfourregionsexperiencednegative trends.WhileWestern Region, Eastern Region, and Greater Accra Region experienced aminordecrease,VoltaRegionreducedcoveragewithover15%.

Manyregionsexperiencedadramaticdropfrom2006to2007,butallregionsexceptVoltaRegionhaveimprovedperformancesignificantlysince2007.

UpperWest Region reversed the negative trend experienced in 2009 and improved coverage ofsuperviseddeliverieswithmorethan25%in2010.

TheIRTfindsthetrendinVoltaRegionworrying,whichisdiscussedinmoredetailbelow.



Figure3:Superviseddeliveriesbyregion2006-2010,sourceCHIM

Geographicalaccess

Thenursestopopulationratiocontinuedthepreviousyears’improvementwith1.8%morenursesin2010comparedto2009.In2010thenursetopopulationratewas1:1,510,andtheindicatordidnotreach the target of 1:1,100. The trend towards more equitable distribution of nurses improvedslightlyto1:1.83andattainedthetargetofaratiobelow1:2.0.

UpperEastRegioncontinuedtohavethehighestnursetoregionalpopulationratiowithonenurseper1,121inhabitants.Likein2009,AshantiRegionhadthelowestnumberofnursesperpopulation,but continued last year’s increase in total number of nurses with 6.2% to one nurse per 2,045inhabitants.

NorthernRegionexperiencedasignificantincreaseofmidwifesin2010,butstillhasGhana’ssecondlowestnumberofmidwifesperpopulation(afterWesternRegion).Thisisreflectedintheproportionofsuperviseddeliveries,whichisfarbelownationalaverageatonly37.5%.

In2010,bothVoltaRegionandUpperWestRegionexperiencedsignificantreductioninthenumberofmidwifes,buttheregionsarestillabovethenationalaverage.Midwifesaremuchneededinthesetwo regions since Volta Region had Ghana’s lowest coverage of supervised deliveries and UpperWestRegionhadGhana’shighestratesofneonatalandinfantmortality32.

Thedoctortopopulationratioincreasedfrom2009to2010by1.5%andachievedthetargetoflessthan11,500individualsperonedoctor(lowerisbetter).

NorthernRegionexperienced70%increaseofdoctorsfrom50to85,whichlikelycanbeattributedto the expansion of Tamale Teaching Hospital and a satellite training centre for foreign-traineddoctors,andtheregionisnomorehavingthepoorestdoctorstopopulationrate.Itwasnotpossiblefor the IRT to access whether district hospitals in Northern Region benefited from the increasednumberofposteddoctors.Thiscouldbeatopicfordeeperassessment.

ThelowestnumberofdoctorsintotalandalsoperpopulationwasregisteredinUpperWestRegion.17 doctors provide services to 682,451 inhabitants, and the doctor to population ratio was

32GhanaDemographicandHealthSurvey2008

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

AR WR NR BAR CR VR UER ER UWR GAR Ghana

2006

2007

2008

2009

2010



calculatedat1:40,144.Thisisalmost8timesworsethanGreaterAccraRegionwithonedoctorper5,073 inhabitants. With a total of 881 doctors, 41% of Ghana’s publicly employed doctors werepractisinginGreaterAccraRegion.

TheCommunity-basedHealthPlanningandServices(CHPS)initiativeisthestrategyadoptedbytheMOHfor improvingequity ingeographicalaccess tohealthcare.Among theessentialelementsofthe CHPS strategy is the creation of community health compounds. Community Health Officers(CHOs)carryoutclinicalandcommunityoutreachservicesincludinghouseholdvisits,antenatalandpostnatal care, provision of family planning services, health education, and child immunization.CHOs normally refer deliveries to the nearest clinic, but may perform emergency deliveries. TheCHPSfacilitiesserveasavitalreferrallinkbetweenthecommunityandhealthfacilities.ThenumberoffunctionalCHPSzoneshasgrownfrom345in2007to868in2009andhasfurtherincreasedwith51%to1,311in2010,whichisasignofgovernment’sdevotiontoimprovingequityingeographicalaccesstoservices.

Financialaccess

InGhana,theOPDpercapitafigureisgreatlyincreasing,andfinancialanalysisrevealsthatagrowingshareofIGFrevenueisgeneratedfromservicespaidbyNHIS.ThenumberofOPDvisitsunderNHISincreasedfrom2.4million in2006to18.7million in2010.Duringfieldvisits itwasconfirmedthatOPDcontactsathealthfacilitiestoaverylargeextentwereinsuredpatientcontacts(between85%and 95% of OPD contacts in the facilities visited). This indicates both that health utilisation hasincreasedduetoNHISandthatthemajorityofOPDcontactsarewithinsuredpatients,suggestingasubstantialcoverageoftheGhanaianpopulation33.Previousstudiesandreportshaveraisedconcernabout limited enrolment onto NHIS by the poorest and most marginalized. OPD and IGF figurescannottelluswhetherthe increasedhealthutilisationbenefitedthepopulationasawholeorwaslimited toapopulationwithunder-representationof thepoorandmarginalized.The fundamentalquestionofwhetherpoorandmarginalizedGhanaiansdonotaccesshealthserviceduetofinancialorotherbarriersremains.

A national survey is required to answer this question. The survey should not only estimate theproportionofNHIScardholderswithinthevariouswealthquintiles,butalsoseektodeterminetheirhealth seeking behaviours. This analysis could indicatewhether socio-economic status provides asignificantbarrier toobtaininghealth care; aswell asprovidebackground informationon reasonswhysomepeopledonotregisterwiththeNHIS.

IndividualswithoutanNHISmembershipcardareexpectedtopaythesamefeeforservices,asthefacility gets reimbursed from NHIS. The fees have seen steep increases over the past years, andwhile the increased out-of-pocket fee for non-insured personsmaywell increase the incentive toenrol,aconcernisthatthepoorest,whocannotaffordtheNHISpremium,nowfaceadoublebarrierto the formal health system; unaffordable premium and increasingly unaffordable out-of-pocketfees.

During the review of 2010 the IRT visited Upper West Region, which is one of Ghana’s poorestregions and historically had some of Ghana’s poorest performance indicators. Despite thesepredicaments,areport fromNHISshowsthatUpperWestRegionhasthecountry’shighesthealthinsurance coverage rate. Sissala East District Health Management Team and the district healthinsuranceofficeexplainedthatthehighcoverageresultsfromaconcertedeffortofIECactivitiesandsupport fromlocalgovernment, traditional leadersandNGO’s; localNGO’sactively identifiedpoor

33TheNHIA,bytheendof2010,claimstohave16.9Mpeopleor69%(IRTcalculation)ofthewholepopulationregisteredwithNHIS.Thetotalnumberofvalidmembers(withitsmembershipbeingregularlyrenewed)wasestimatedat48%late2009.ThehighfrequencyofinsuredOPDcontactscouldbeinlinewiththemembershipcoveragedatapresentedbyNHIA,butthiscanonlybeverifiedthroughapopulationbasedsurvey.



peopleinthedistrictandpaidfortheirNHISmembership;thedistrictsocialwelfareofficeidentifiedalistofpoorpersonstobenefitfromtheLEAPproject,andtheofficecollaboratedwiththedistricthealth insurance to automatically enrol these LEAP beneficiaries onto the health insurance; andGhana AIDS Commission registered HIV positives and paid for theirmembership. In 2010, SissalaEastDistrictHealthInsurancereportedcoverageof94%ofthedistrictpopulation,ofwhich81%wereactivemembers(i.e.activemembershipcoverageof77%ofthepopulation).InotherdistrictsvisitedbytheIRT,CHAGfacilitiespaidfortheNHISpremiumforpoorerpeople,whenattendingthefacility.InmostdistrictsvisitedbytheIRT,accesstoservicesbypoororvulnerablepeoplewasnotreallyontheagendaoftheDHMT.WhiletheIRTrecognisesthat identifyingthepooristheresponsibilityoftheMinistryofSocialWelfare,concertedactioncouldbemoreeffectiveiftheDHMTwouldprovideinformation on vulnerable people (e.g. through CHOs and through facility staff) to the localrepresentativeoftheMinistryofSocialWelfareandDHIS.

A new health insurance premium structure with a lifetime contribution of about GHc 100-200 isproposedaspartthecurrentrevisionofthehealthinsuranceact.Futurepremiumpayerswillbenefitfrom lifetime health insurance membership, but the steep increase from today’s premium ofapproximatelyGHc7-48willmostlikelypresentanexcessivebarrierformanyinformalworkers.Oneoptionpresentlybeingconsideredistosplitthepaymentofthelifetimepremiumoverseveralyearsinordertoreducethefinancialbarrier.Giventhatnofirmdecisionhasyetbeentakenonthefinalmodality of the life time premium, the IRT recommends careful consideration to mitigate thenegativeeffectsthelifetimepremiumcouldhaveonfinancialequityandaccesstohealthservicesforthepoorest.

4.2 Maternalandreproductivehealth

Maternalhealth

Maternalmortality remainshigh inGhana;with thecurrent slowprogress, theMGD5willnotbeattainedby2015.Therearesignificantdisparitiesininstitutionalmaternalmortalityratioacrossthe10regions inGhana,butthesearedifficultto interpret.AsperDHS2008,maternalmortalityratiodecreasedinallregionsexceptGreaterAccrawherematernalmortalityratiohasworsenedby87.6per 100,000. Given the less than satisfactory progress, the health sector is redoubling efforts toreversethetrend.

Thedistrict implements a comprehensiveANC (Antenatal Clinic) programme that is linked to CWC(ChildWelfare Clinic). Newborns and their mothers receive three monitoring visits to assess the

Keyrecommendations

Ø CarryoutanationalsurveytoestimatetheproportionofNHIScardholders(andvalidcardholders)withinthevariouswealthquintiles,butalsoseektodeterminetheirhealthseekingbehaviours.Thisanalysiscouldindicatewhethersocio-economicstatusprovidesasignificantbarriertoobtaininghealthcare;aswellasprovidebackgroundinformationonreasonswhysomepeopledonotregisterwiththeNHIS;andwhetherthe insurancepremiumhasbeencoveredbyathirdparty.

Ø PutpovertyandequitableaccesstohealthservicesontheagendaoftheDHMTandDA.



newborns’ health. Some districts have developed specific strategies that encourage collaborationbetweenmidwivesat the sub-district levelandTBAsat thecommunity.WomenattendingANCatthe hospital are screened and all those with previous history of caesarean, postpartumhaemorrhage, eclampsia, hypertension and the elderly identified as at risk clients. Specialcounsellingclinicsareorganisedforthesewomentogetherwiththeirspousesandtheyareadvisedto deliver in the hospital. Although the number ofwomen attending the ANC at least four timesduring pregnancy continues to raise, the coverage of pregnantwomenwho received at least oneantenatalcarevisitdroppedby7%since2008to90.6%.Nospecificreasonsareknownforthisdropinattendanceduringtwoconsecutiveyears.VoltaRegionhasthelowestcoverageat70.9%,whichisalmost20percentagepointsunderthenationalaverage(seeHolisticAssessment).ThecausesofthehighdropoutratesinANCattendanceneedtobecarefullyinvestigated.

In 2010, midwives received specific training on the use of partograph. Knowledge in the use ofpartograph promotes confidence, reduces prolonged labour, caesarean sections and intrapartumstillbirths(WHO,1994).Midwivesarehowevernotalwaysabletoputthisknowledgeintopracticein the sub-district facilitiesbecausemostwomenarrive lateat the facilities,usuallyat the secondstageoflabour.

EmONC is being implemented in all 10 regions, but not yet at with full complement of requiredresources(midwives,equipment).FourregionshavesofarreceivedEmONCequipment:EasternandBrongAhafoin2009,AshantiandNorthernregionsin2010.Inordertoacceleratetheachievementof MDG 5 by 2015, immediate steps should be taken to provide equipment to the remaining 6regions.

The 2009 independent review recommended that findings of 2010 EmONC assessment shouldfactored into the 2011 APOW and budget. Data was collected from 1271 facilities across the 10regionsfortheEmONCassessment.AnalysisofEmONCassessmentdatahasbeencompletedearly2011 and a fact sheet developed on key findings.With assistance from the DPs, several EmONCpolicies were reviewed including policy guidelines on PMTCT in line with the new WHOrecommendations,PMTCTtrainingmanualandtheMaternalDeathAuditguidelines.

In 2010, the following training were conducted to boost the skills of health: TOT on SafeMotherhood Clinical Skills training for Regional Resource Teams, comprehensive Abortion Caretraining for midwives and distribution of MVA kits, TOT on Lactation Management and Jadelleinsertionandremoval.

DistrictsvisitedbytheIRTbringcreativeandworkablesolutionstoenhancematernalhealth.Inonedistrict inUWRobstetric emergency protocols have been simplified into a poster format for easyreference by midwives in the labour ward. The protocols aid midwives and nurses to manageemergencieswhilewaitingthedoctoroncall.Thehospitaloffersultra-soundservicestoallpregnantwomen purposefully to detect any foetal distress. The district hospital with assistance from theNational Blood Bank established a functional blood bank. The blood banks aremainly to supportmaternalhealthservicesandparticularlydeliveries.Inordertoreducematernaldeaths,auditsareinprincipleconductedonallmaternaldeaths.Thisisgenerallyconfirmedbyobservationsinthefield.Maternalauditdevelopsthecultureofresponsibilityamonghealthstaffandthelocalcommunity.Insome other districts all mothers delivering at home are traced and followed-up by health stafftogetherwiththeTBAwhodidthedelivery.ItwasobservedinsomedistrictsthatsomeCHO’sdidnotfeelcomfortableconductingemergencydeliveries.SuchCHOsshouldbeidentifiedandprovidedadditionaltrainingtoenhancetheirskillsindelivery.Comprehensiveabortioncarehasbeenintroducedinallregions.Underthecurrentlaw,abortionisillegalbutpermissibleunderspecificcircumstancessuchasrapeorwhenthemother’shealthwillbecompromised.Theserviceisprovidedatthedistricthospital.Womenareultrasoundscannedbeforeabortionandmedicalabortionisuseduptill10gestationweeks.Vacuumextractionisusedafter10



gestationweeks. In Tumu district hospital, for example, about 122 cases received comprehensiveabortion care in 2010, of which about 56 camewith induced abortion and bleeding. Sub districthealthstaffcounselwomenabouttheserviceandrefertoDistrictHospitalforabortion.NHISpaysfortreatmentafterunsafeinducedabortions.Freshabortionsarepaidforbythepatientandrangefrom20-50GHC.ThelogicofnonpaymentforfreshabortionescapestheIRT.

SupervisedDelivery

Supervised delivery remains low in Ghana; the 2008 DHS reports the percentage of superviseddeliveries at 58.7% (including public and private facilities). Several long and short termmeasuresincluding the expansion of midwifery school intake, redistribution of midwives, life saving skillstraining,CHPSandfreedeliveryhavebeeninstitutedtoincreasesuperviseddeliveries(GhanaMAF,2010).The2010POW,aimedtoachieve50.3%coverageof superviseddelivery (this targetcoversmainlypublicandCHAGfacilitiesandisthereforebelowtheDHS2008figure).Althoughthistargetwas not met, there was a modest increase from 45.6% in 2009 to 48.2% in 2010 (see HolisticAssessment), continuing the progress since 2007. Poor staff attitude and unsatisfactory facilitieswereidentifiedaskeyfactorsaffectingdeliveryinfacilities,nexttoculturalandotherbarriers.TheIRT noticed that districts made efforts to improve on local conditions. In the UWR, TBAs areencouraged to accompany women in labour to the facilities to deliver. The TBA is provided theopportunity to observe the delivery and receives all benefits that she would have received ifconductingthedeliveryherself. In theUER,womenwhodeliver inpublic institutionsareprovidedfood(flourwater)andthisalsoencouragesdelivery inthehealthfacilities. IntheWesternRegion,thePROMISEprojectregistersallANCwomenandencouragesthemtodeliveryathealthfacilities.Theyalsofollowupathomeonallpregnantwomenafterdeliverytocheckuponthehealthofthemotherandnewborn.

Referrals still remain a problem in many districts. Three out the five districts visited had noambulance services. Although regional and district hospitals are well equipped to handlecomplicated labour cases, the main issue is how to timely transport women in labour to thesefacilities. The national ambulance service is said to be expensive (and probably not yet able toensuredistrictbasedservices).

Severaldistrictshaveadaptedinnovativewaystransportingwomentothehospital.Insomedistrictsof the Western Region, where private transport is easily available, the districts have identifieddedicated taxi drivers who provide ambulance services for women in labour. The drivers areexpectedtosendthewomentothefacilitiesandthenreceivepaymentfortheirservicelater.IntheUER,identifiedmotorbikesridersareusedambulanceduringlabour.IntheUWR,theGHShavesetupa telephonedirectoryofall seniorhealthpersonalandopinion leaders includingRDHS,DDHSs,DMOs,DPHNs, ambulance drivers, Chiefs, andAssemblymen,midwives, CHOs amongothers. Thistelephonedirectory isdistributedtoall facilities inthecommunitytoaidthereferralprocesses. Incaseofanemergency,allpersonalneededtoattendtothecaseareinformedinadvancebeforetheambulancearriveswiththepatient.Althoughtheuseoftheambulanceisfree,familymembersareexpected to replace the fuelused to convey the case from thecommunity to thehospital. Familymemberspayabout4gallonsofgasolinefortheuseoftheambulance.TheNHISdoesnotcoverthecostofconveyingwomeninlabourtothefacilities.Thefactthattheadditionalcostsoftransportingthewomen in labour togetherwith theresponsibleTBAto thenearbyhospitalorhealth facility isnotcoveredmaybeoneofthemajorfactorsexplainingthereluctanceofmotherstodeliveratthefacility(nexttotheotherfactorsmentionedabove).Oneofthemost importantreasonsexplainingthe recent major drop in maternal mortality in Bangladesh is thought to be the demand sidefinancingcoveringthiscostofboththemotherandtheTBA.TheNHISshouldconsidercoveringthiscost.



ProvisionofFamilyPlanningServices

FPpreventsunwantedpregnancyandreduces theriskofmaternaldeaths frompregnancy-relatedcomplicationsandunsafeabortion.FamilyPlanning(FP)activitieswereimplementedinalldistrictsvisitedbytheIRTandalldistrictshadcopiesoftheNationalFPprotocoltoguidethemincounsellingand preparing clients for services. However, the acceptance and use of FP remains a challenge.Although, according to the DHS (2008), the use of modern contraceptivesmethods has beenrelativelyconstantoverthelastfiveyears:from19%in2003to17%in2008,recentdatafromtheGHS showsacontinuousdecline inFPuptake from33.8% in2008 to31.1% in2010. From thedistrictsvisits, several factorswere identifiedwhichcouldaccount for thisnegative trendand lowuptake.These factors includea) lackofmale involvement in familyplanning;b) stock-outofdepoprovera;c)misconceptionaboutFP.Reportedly,maledominancestillweighsheavilyonwomen’sabilitytofreelyuseFPmethods.Mostwomen require expressedpermission from their husbands to use FP.Men tend to viewwomen’sability to control their fertility as a sign of autonomy and power. Apparently,manywomen feignillness inorder toget theopportunity togo to theclinic forFPservices.Rather thanan individualdecision,theuseofFPseemsamatterbutbetweenspousesandtosomeextenttheirfamilies.MoreeffortsshouldbemadetoinvolvemeninFPactivities.Some districts reported stock-out of depo provera in 2010. These reports were confirmed at thenationallevel.AlthoughGhanahasaNationalContraceptiveSecurity(CS)Strategicplan,supportedby a Financial Sustainability Plan (FSP), the issue of commodity stock-out keeps occurring. For acountry like Ghana, investing considerable resources in health, this is no longer acceptable. TheFamilyHealthDivisionoftheGHShastakennoteofthisastheyreviewedthe2004-2010CSstrategicplantotakecareofthefrequentcommoditystock-out.MostwomenholdseveralmisconceptionsabouttheuseofFP. Reportedly,youngwomenbelievethattheuseofFPbeforeyourfirstbirthaffectstheirabilitytohavechildren infuture.Alsouseofcontraception is associatedwithpromiscuity and is frownuponbywomen. Financial access to FPcommodities also remains a challengemostly in rural communities asmostwomenareunable toaffordthecostofcontraceptivesbecausetheycannotasktheirhusbandsformoneytotakeFP.Atdistrictandsub-districtlevelthereislimitedcapacitytoprovidesomeofthelonglastingmethodsparticularly implants (Jadelle and norplant) as few health staff have the skills to provide suchservices. More resources should be committed to training midwives and CHOs to provide theseservices.FromapublichealthpointofviewthereisastrongcaseforNHIStoaddFP(includinglong

Keyrecommendations

Ø ProvideASAPtheEmONCequipmenttotheremaining6regions.Continueresearchintothereasonsoflowinstitutionaldeliveriesandadoptbestlocalpracticestoencourageinstitutionaldeliveries.Specifically,considerinvestingonthedemandside(ratherthanonlyonthesupplyside)bycoveringthecostsoftransportforboththemotherandresponsibleTBAtothenearbyequippedfacility.

Ø Investinimprovingreferralandemergencyservices



lastingmethods34) to the services it insures.Asdiscussed, thenationalneeds shouldbeestimatedandtheresourcesaddedtotheannualbudgetofNHIS35.CurrentlytheNHIScoversclinicalservicessuchasvasectomy.TheNHIScouldalsoconsiderprovidingmoneyfortheprovisionof long lastingmethodstowomenatthecurrentsubsidisedcost.

4.3 NonCommunicablediseases

Non communicable diseases are grouped into four main categories: a) the traditionally calledchronicdiseasessuchasdiabetes,cardiovasculardiseases,chroniclungdiseasesanddifferentformsof cancer; b) genetic disorders such as sickle cell anaemia; c) injuries with chronic physicalimpairment;andd)specialdisorderscausingproblemssuchashearing impairment. Otherchronicdiseases such asmental health disorders,HIV andAIDS andoral diseases are addressed by otherspecificprogrammes.NCDsconstituteabout18.5%ofthetoptencasesofmortality(MOH,2007).

Table5.ProportionofnewoutpatientdiseasesduetoNCDsinpublichealthfacilities(excludingteachinghospitals),2006-2010

Disease 2006 2007 2008 2009 Jan-Oct2010

Hypertensionandotherheartdiseases 2.9 4.2 3.3 3.7 3.7

Hypertension 2.8 4.0 3.2 3.5 3.5

Diabetes 0.5 0.9 0.7 0.7 0.8

Injuriesandpoisoning 2.3 2.2 1.8 1.8 1.6

Asthma 0.2 0.3 0.3 0.4 0.4

Sicklecelldisease(SCD) 0.12 0.15 0.11 0.11 0.13

Source:CentreforHealthInformationManagement,GHS,2010.

34The2008DHSreportedthat41%ofwomenpreferreddepoproveratootherFPmethods.35Reportedly,theannualneedforFPcommoditiesisestimatedatUSD4million(orroughly1.5to2%ofthetotalannualbudgetofNHIA).

Keyrecommendations

Ø Ensuremen’sinvolvementinFPactivities.Strengthenbehaviorchangecommunicationthatwillfostersocialchangeandre-orientspousesandfamiliesinsteadofindividuals.

Ø In order to increase continuous access to FP, consider adding FP commodities and /orincludingfreeaccesstolonglastingFPmethodsunderNHI (thismayrequireadaptingthedraftNHIBill).Broadeningthe insuredpackagewouldrequireadequate increaseofannualresourcesforNHIA.



TheTableaboveshowsthattheproportionofOPDcasesduetohypertensionincreasedfrom2.8%in2006to3.5% in2010.Therewasacorresponding increase fordiabetes from0.5%to0.8%overthesameperiod.ThatofSCDhashoweverbeenmorestableataround0.13%onaverage,despitetherelativelysmallnumberofcases.

ThePOW2010mentionsfourmainbroadactivitiesonNCDswhichincludes:

• Promotinghealthylifestyles• Establishing screening and proper management programmes for diabetes, hypertension,

cancers,sicklecell,andasthma• ConductingresearchintoNCD• Establishingnationalcancerregistry

The Regenerative Health and Nutrition Programme (RHNP) emphasises healthy lifestyles throughhealthydiet, exercise, rest andenvironmental cleanliness.Healthpromotion is themajor strategyfor informing the community about regenerative health and nutrition programme. In 2010,television and radio programmes were organised at the national level. Also posters and bannerscontinued to be displayed at various vantage points. Stakeholders meetings were held with thePentecostalCouncilandtheMoslemPeaceCounciltointroducetheprogramme.

The MOH collaborates with key agencies such as GHS, Ghana Education Service, National SportCouncil,MinistryofEducation,MinistryofLocalGovernmentandRuralDevelopmentamongotherstopromoteregenerativehealth.AlthoughtheRHNPismanagedbytheMOH,itisexpectedthatitsactivitiesareimplementedbytheGHS,theGhanaEducationServiceandtheNationalSportsCouncilbut it isnot very clearwhether there is any formal agreement to this effect. Themain challengereportedishowtoscaleuptheprogrammethroughtheGHSasakeycollaborator.

Although thenational level confirms that guidelines for screeningandmanagementofNCDsexist(‘alsoontheworldwideweb’),noguidelineswereavailableorknowntheatdistrictandsub-districtlevel. However,somescreeningactivitiestakeplaceattheoperationallevel.Reportedly,alladultsabovetheageof18attendingahealthfacilityhavetheirBPtaken.AdhocscreeningforBP,BMIandbreastexaminationareorganisedbyNGOsandChurchesduringimportantfestivitiesornationalandinternational events. Also, occasional health education programmes about healthy lifestyles arebroadcastedvialocalradiostations.

ManagementofNCDswasgenerallyweakattheperipheralhealthfacilitiesvisitedbytheIRT.Inthedistricts, health education and promotion activities are often tied to other programmes such asmalaria, TB, HIV/AIDs and polio and do not systematically cover NCDs. Systematic screening forcancerhasnotbeenestablished.Cervical cancer screeningusingvisual inspectionwithaceticacid(VIA)isonlyavailableatRidgehospital inAccraandSouthHospital inKumasi.Someprivatehealthinstitutions provide cervical cancer screening services.However, these services are expensive andare accessed only by those who can afford. In 2010, Ridge Hospital provided cervical cancerscreeningservicestoabout1800womenusingVIAandabout2to3%wereVIApositive.

On the advice of the Sickle Cell Foundation of Ghana, a technical Advisory Committee (TAC) onNewbornscreeningforSCDwasinauguratedbytheMinisterofHealthinNovember2010.TheTACmet inDecembertodrawupplansontheroll-outofanationwidenewbornscreeningprogrammefor SCD. In 2010, both the public and private health facilities in Kumasi screened about 20,082newbornsforSCDandabout1.8%wereconsideredtohavepossiblySCD.

CancerregistrationisstilldoneinthetwoteachinghospitalsinKumasiandAccra.In2010,theKATHregistry in addition to collecting data from the Radiotherapy centre also collected data from thePathology Department. Current challenges include few data registration officers at NCDCP,unplanned trained staff transfers within and across hospitals, limited coordination between the



KATH and Accra Registries, incomplete data and software problems for national prevention datamanagement.In2010,theNCDCPcompletedthedraftNationalPolicyfortheControlandPreventionofNCDs.Themain objectives are to reduce the incidence of chronic NCDs; to reduce and prevent unhealthylifestylesthatcontributetoNCDs;toreducemorbidityassociatedwithNCDs;toimprovetheoverallqualityoflifeinpersonswithchronicdiseases.Also,thestrategicframeworkforNCDs,thenationalcancer care plan and the sickle cell anaemia strategic plan were developed. However, thesedocumentsareyettobedistributedtoimplementingagenciesintheregionsanddistricts.Althoughthereisnocoordinatedresearchplan,theNCDCPundertookasystematicreviewofstudiesonhypertensioninGhanapublishedbetween1975and2009.Thereviewfoundthattheprevalenceof hypertension amongst 18 years+ ranged between 19% and 48% (sic!) during this period. TheUniversity of GhanaMedical School completed aWHOmulti-country longitudinal Study on globalAGEingandadulthealth(SAGE) in2010.Thestudy inGhanawasnationwideand it involved5,573adultsandelderly(18years+).ThereisaperceivedneedatNCDCPforacoordinatedandsystematicresearchagendaonNCDs.OnefundamentalmanagementproblemisthattheNCDcontrolprogrammeshavenofocalpersonsat the regional levelandno staffdesignated forNCDsactivitiesat thedistrict level. Inaddition tothis,theNCDCPisfacedwithchronicunderfundingtocarryoutplannedactivities.Financialsupportis often provided by NGOs and pressure groups interested in NCDs. Such funds are usuallyearmarkedforspecificdiseaseconditionsparticularlysicklecell,diabetesorcancer.

Summarising, NCD did not receive much attention at the regional and district level in 2010 butimportantactivitieshavebeencarriedoutatcentral level, includingdevelopingthenationalpolicyfor prevention and control of NCDs. Although prevalence is alarming, the lack of focus on NCDsreflectsacontinuousbiastowardscommunicableovernoncommunicablediseasebybothpoliticalandprofessionalactorsinthehealthsector.ItisimportanttonotethattheeverincreasingeffectsofNCDsonthediseaseprofileofGhanaiansneedsattentionandthetimetoactisnow.

Keyrecommendations

Ø Speedupthedisseminationofthestrategicframeworkformanagement,preventionandcontrolofNCDsandimplementthescreeningguidelinesforNCDs

Ø PlanandbudgetforNCDprevention,controlandmanagementinthe2012nationalplanandbudget.IntroduceamajorfocusonNCDsin2012districthealthplans.

Ø AppointregionalNCDfocalpersonsasTOTtotraindistrictstaffandsupportDHMTsindevelopingaNCDfocusinthedistricthealthplan.UsetheCHOstotrace,follow-upandcounselchronicpatientsregardingregularclinicalfollow-upandtreatment.EnsuretheoperationallinkbetweentheresponsiblenurseatthehealthfacilitydealingwithchronicpatientsandtheCHOslivingintheareaofrespectivepatients.



5. MainconclusionsandrecommendationsHolisticassessment,sectorperformanceandselectedPOWprioritiesTheholisticassessment2010scoresthesectorperformanceas‘highlyperforming’,withatotalscoreof 3+. It should be noted that no population based survey data were available for the 2010assessment,meaning that all indicator results are service based (whichmeans that it reflects thereported activity of the public sector, the mission sector and only part of the private for profitsector) or reflect public sector management. On the one hand this means that true coverage ofsomeservice indicators is likely tobeunderestimated (e.g. superviseddelivery)butalso thatdataare as good as the standard data collection, reporting and validation system is. However, dataqualityalsoaffectedpreviousyearassessmentsandsomemajoreffortshavebeeninvestedthisyearbyGHSinvalidatingdataquality.Itishoweverrecognisedthatdataqualityandcompletenessisyettobeimproved.

The‘highlyperformingscore’maysomewhatoverestimatetrueperformanceasappreciatedbytheIRT,butoverall the IRTconfirms that,with theexceptionof some importantareas, thesectorhasbeenperformingwell. However, there is still scope for improvement and some key areas requireurgentattention.

In 2010 several service delivery indicators continued the positive trend documented in last year’sreview. The coverage of supervised deliveries increased (now at 48%), institutional maternalmortality decreased and the average number of outpatient visits per capita continued previousyears’remarkableincrease(nowat0.89percapita).Thecumulativenumberofpatientsinitiatedonantiretroviraltreatmentalsocontinuedtoincrease(plus41%comparedto2009).OntheotherhandcoverageofEPI,ANCandFPservicesexperiencedworryingnegativetrendsthatneedfurtheranalysisand action.While 3 regions havebeen identified as regions excelling in selected key indicators in2010 (UWR for supervised deliveries and institutional MM; ER for Penta 3 coverage and FPacceptance rate; andWR for ANC andOPDper capita), Volta region is an outlier regardingmanyindicatorsandrequiresattention.

Althoughthecoverageofsuperviseddeliveriesimprovedin2010,theequityindicatorforsuperviseddeliveries worsened significantly, indicating a widening gap between the highest and lowestperforming region.Nurse to population and doctor to population ratio increased respectively by1.8%and1.5%comparedto2009.ThenumberoffunctionalCHPSzoneshasincreasedby51%(!),asignofGOG’sdevotionto improvingequity ingeographicalaccesstoservices.ThenumberofOPDvisitsunderNHISincreasedfrom2.4millionin2007to18.7millionin2010.TheIRTobservedthatavery large number of OPD visits were by insured patients (between 85 and 95% of total OPD).HoweverOPand IPdatadonotprovide informationaboutpeoplenotaccessing theservices.Thefundamental questionwhetherpoorandmarginalizedpeopledonotaccesshealth servicesdue tofinancialorotherbarriersremains.TheIRTrecommendsassessingaccessibilityviaanationalsurvey.

Maternalmortalityremainshighandwiththepresentprogress,MDG5willnotbeattainedin2015.Itisthereforelaudablethatmaternalhealthgetssomuchattentionatdistrictlevel,butdifficulttounderstandwhytheANCattendanceratedroppedsignificantlyoverthepasttwoyears.Superviseddelivery remains low and timely referral remains a problem in many districts, even if creativesolutionsareintroducedatoperationallevel;andcostsorreferralisoutsidetheNHISpackage.TheEmONCassessmenthasatlastbeencompletedbuttoolatetofactorfindingsintothe2011budgetandPOW;andonly4outof10regionshavereceivedEmONCequipment(ofwhich2in2010).TheacceptancerateanduseofFPremainsalsoachallengewithacontinuousdrop inFPuptake from33.8%in2003toalow23.5%(!)in2010.TheIRTrecommendstoanalysethereasonsforthismajordrop; and, pending the results, consider covering FP under theNHIS (while adding the necessary



resources to NHIA); and consider initiating demand side financing for maternal care in order toincreaseaccesstodeliveryservices.

Noncommunicablediseases(NCD)didnotreceivemuchattentionattheregionalanddistrictlevelin2010butimportantactivitieshavebeencarriedoutatcentrallevel,includingdevelopingthenationalpolicyforpreventionandcontrolofNCD.ThereexistsnofocalpersonforNCDatregionallevelandlimitedcompetenceforprevention,controlandmanagementofNCDatdistrictlevel.GuidelinesformanagingNCDareabsentatfacilitylevel.AlthoughprevalenceofsomeNCDisalarming,thelackoffocusonNCDreflectsacontinuousbiastowardscommunicableovernoncommunicablediseasesbybothpoliticalandprofessionalactorsinthehealthsector.

Ofthe4milestonesagreedforthe2010POW,twowerefullyachieved:a)EssentialNutritionactionsimplemented in all regionswith emphasis on complimentary feeding; and b)Roundtable dialoguewiththeUniversities (medicalschools)andotherkeystakeholdersoneffectivespecialistservices indeprivedareas.Onemilestonewaspartlyachieved:Neworganizationalarchitecture for thesectoragreed;organizationalchange roadmapagreed;organizationaldevelopmentplanscompleted.Thelast milestone was not achieved, but work was in progress: Health Industry strategy developedwithintheframeworkofpublicprivatepartnership(PPP).

CentralGovernanceGovernanceofthesectorprovidesamixedpicturebutsomeimportantchangeshaveoccurredorbeeninitiatedin2010.TheMoHhasstartedaprocessofinternalreorganisationwithaviewtostrengtheningMoHkeyfunctionsandrevitalising/reviewingperformancecontractswithhealthagencies;aprocessthatneedsfullsupport(bothfromcentralagenciesandDPs),alsowithaviewtoreducethestillperceiveddichotomybetweenMoHandGHS,andavoidduplicationoffunctions.TheM&EfunctionisapointincasethatrequiresstrengtheningundertheMoH.TheIALCmetregularlyanditsfunctioningisappreciatedbyallagenciesinterviewedaskeytocounterfragmentationandsupportharmonisedapproachesbetweendifferentcentralagencies.SevendrafthealthbillsarenowwiththePSCforfinalisation.TheIRThowevernoticedsomeinconsistenciesthatstillneedtobeaddressedandisoftheopinionthatsomeproposedbillsmayenhanceratherthancounterfragmentation.Other2010achievementsincludethefinalisationoftheCMAIII,theJANSreview,thepreparationoftheHSMTDP(pendingfinalisationoftheM&Eframework).Remarkably, theNHIA has becomemore transparent andmore cooperative withMoH and otherhealthagencieswhichwasappreciatedbyallcentralagenciesinterviewedandalsonotedbytheIRT.Coverage of registered members continues to increase (now at 16.9 million members36), OPutilisationbyinsuredmembershassubstantiallyincreasedandaverageleadtimeofreimbursementof claimshasbeensubstantially reduced.NHIAhasalso strengthenedkey functionsof thecentralorganisation.Understandably,NHIA faces still some legal, organisational and technical challenges:thedraftBillisstillpending;renewalofcardsbymembersisoftenuntimely;costcontainmentandfinancial sustainability require continuous attention. Testing capitationpayment asplanned in thepilotprojectwillbecrucialinordertopotentiallyaddresssub-optimalproviderandclientbehaviour.

Nineoutof23actionsagreeduponintheAprilSummitAideMemoirebetweenDPsandGOGhavenot been completed, including main actions related to PFM and private sector policy andinvolvement.Twomainareasofconcernraisedbythe2009IRTstillrequirefurtheraction:thehighcostsofdrugsand the fragmented funding todistricts. CoordinationamongstDPs is anarea thatrequires continued attention and several DPs have expressed some concerns with the use /effectivenessoftheexistingmechanismsforsectordialogue(technicalandstrategic).

36 No2010datawereprovidedformemberswithavalidcard.Bytheendof2009coverageofvalidcardholderswasestimatedbyNHIAat48%.



Importantly, for the first time ever, the health sector budget passed the 15% Abuja target37 andincreasedbothinabsoluteandrelativeterms(USD28.6percapitacomparedtoUSD25.6in2009).However, theproportion of non-wageGOG recurrent budget allocated to district level and belowdecreasedby25%from62%in2009to46.8%in2010,areporteddropthatrequiresattention38.

DistrictGovernanceandManagementTheIRTassesseddistrictgovernanceandmanagementthroughassessingthehealthsystembuildingblocks. Main impression on district and DHMT performancewas positive and dynamic.Maternalhealth and CPS are high on the district agenda and are supported through creative, innovative,locally-developed solutions, some of which are examples of best practice that can serve otherdistricts.Non-communicablediseasesandaccesstoservicesbythepoorandvulnerableisnotonthemainagenda.

In the districts visited,most annual district plans are not ‘comprehensive’, a concept that mayrequire clarification and a rational approach. District hospitals tend to be ‘virtually’ too muchseparatedfromDHMTmanagementandoversight,resultinginsub-optimaluseofscarceresourcesand potentially in sub-optimal quality of care and referrals by peripheral facilities. Regions anddistrictsrequestgreaterdecentralisedauthorityonHRHmanagement.Nobodyatdistrictlevelseemsto be trained in HRmanagement and formal HR training plans are not available at district level.Information management requires continuous attention and regular updating of skills. The mainproblem observed is with data entry, validation and understanding at facility level. Availabletransport is generallywellmanaged, butambulance services are absent inmany districts, forcingDHMTstodeveloplocal,creativebutgenerallysub-optimalsolutionsforemergencyreferrals.Drugssupplies at facilities have greatly improved since the NHIA came on stream. Some stock outshappenedin2010(e.g.TBdrugs,FPcommodities,bednets)whichisunacceptableinthecontextofGhana.SeveralDHMTslackedsufficientskillsinpharmaceuticalsandlaboratory.Mainissuesraisedby DHMTs have not changed over the past years and include insufficient, irregular and inflexiblefunding; lack of guidelines on how to use funds, especially IGF; availability of HR; strategies toimprove staff retention andmotivation; lack of ambulance services and essential equipment (e.g.EmONC);anddatamanagement.

PublicfinancemanagementInthenarrowsenseofsystems,budgetplanningandpreparationarerelativelywellestablished,buttimelinesforbudgetpreparationremainverytight.The lackoftimelybudget information leadsbydefault to incrementalbudgeting.Budgetsaresupposed to includeall resources including IGFandearmarked programmes but this is not always the case and outstanding debtswith suppliers arekept off the budget (but are recorded). Allocation guidelines have been established but are notbased on a comprehensive assessment of total flows of fund to each region and district. As aconsequence, redistribution of funds happens only in a narrow sense, overlooking the broaderpicture.

Aggregate budget execution was relatively good in 2010, but at operational level it remains theAchilles heel of the PFM systems,mainly becauseof fragmented andpartially earmarked flowsoffunds,with limited discretion at the spending unit. Comprehensive feedback from the top to thespending levels on the actual budgets and timing of the releases is lacking; and there is nofunctioning tracking system in place that provides information on the status of the releasesthroughoutthesystem.RegardingIGF,theNHISisbecomingincreasinglydominant.TheIRTnoticedthatseveralhealthproviderswerebuildingupcapitalintheIGFdrugaccountandwouldarguethatthere is scope for a controlled broadening of the discretion of the drug account, provided that

37 TheremaystillbeanissueofdoublecountingofNHIF,butthiswasprobablyalsothecaseinpreviousyear’sbudget. 38 This indicatorwouldbemuchmoremeaningfulifreflectingactualexpenditures.



minimalthresholdsarerespected.Incontrasttothissurplus,allBMCsindicatetorelyextensivelyonsuppliercredits.Also,districtsareintroducinginnovativewaystosharefinancialresourcesbetweensub-districtanddistrictlevel.

Markedprogresswasmade in2010 in implementationand trainingof theATFmanual.Aggregatequarterly financial reports are prepared on a regular basis but are not used by management tomonitor policy implementation. Both MoH and GHS have enrolled under the first phase of theintroductionof theGhana IntegratedFinancialManagement InformationSystem (GIFMIS). Its roll-outwillimpactonallfinancialoperationswithinthehealthsector.ThePFMWorkinggrouponlymetoncein2010.The2009IRTrecommendationtoreprioritisewithinthePFMstrengtheningplanwasnotgivenfollowup(althoughsomeactionswerepursued)andtheIRTnoticedlittleeffortwithkeyGOGactorstoreinvigoratetheworkinggroup.

The Internal Audit,which iswell established in the health sector, is hampered by insufficient stafflevels and operational resources. In terms of external audit, under the auspices of the Auditor-General,aprivatefirmwashiredin2010toauditthe2009accountsoftheMoH.Furthermore,theGhanaAuditServiceperformed regularauditsofBMCs.AuditReport ImplementationCommittees(ARIC)wereinplaceinmostbutnotallBMCsvisited.ThepublicdiscussionoftheMoH2007,2008and2009auditreportstookplaceonMarch24th,2011.ThePublicAuditCommitteeinsistedontheneed to strengthen internal controls and to act more aggressively in cases of fraud andembezzlement.

RecommendationsThe recommendations summarised in the tablebelowaremeant tohelp theMoH, the respectiveagencies and civil society to address the above constraints for maintaining and continuouslyimprovinghighlevelsectorperformance.

Documents

Ministry of Health Ghana · equipment (of which 2 in 2010). The acceptance rate and use of FP remains also a challenge with a continuous drop in FP uptake from 33.8% in 2003 to a