Progress has been made in expanding the coverage and treatment of infectious disease in Ghana. The rollout of public coverage has been central to these achievements, with the private sector also playing a pivotal role, both in terms of contracts with the government and through the operation of private facilities. A new generation of domestic start-ups has also begun to reshape the sector, utilising digital solutions to better address demand. Yet the sector still faces serious challenges, including shortages in medical professionals and the rise of non-communicable diseases (NCDs).
Oversight
The industry is overseen by the Ministry of Health (MoH), which is responsible for allocating government investment, as well as building hospitals and medical schools. The Ghana Health Service (GHS), founded in 1996, is an autonomous agency which directly administers the provision of health care services and implements national policies from the MoH. Meanwhile, the Private Hospitals and Maternity Homes Board, which also falls under the purview of the MoH, is responsible for registering, regulating and issuing licences to private institutions.
Universal Coverage
The administration of the National Health Insurance Scheme (NHIS), a programme introduced in 2003 with the aim of establishing universal coverage, is undertaken by the National Health Insurance Authority (NHIA). The NHIS is funded by the National Health Insurance Levy – a 2.5% duty on goods and services collected as part of value-added tax – social security contributions and premium payments made by uninsured patients of the NHIS, with additional funding provided from the government.
The NHIA’s role is to process and pay all claims for health services made under the scheme. It also serves as the national regulator and licensor of the country’s private health insurers. As of September 2019 there were 14 licensed health insurance providers in Ghana. To successfully register with the NHIA and operate legally, firms must hold a minimum of $1.5m in capital.
The public sector plays the largest role in health care provision. In 2017 some 56.9% of the country’s 23,829 hospital beds were managed by the government, 29.3% by the non-governmental Christian Health Association of Ghana, 13.4% by the private sector and 0.4% by quasi-governmental bodies, according to the latest figures from the GHS. The rollout of the NHIS has significantly increased health care coverage and played an important role in achieving improved health outcomes. According to the MoH, coverage under the NHIS grew from 1.3m people in 2005 to around 11m, or 38% of the population, in 2018.
However, this figure highlights that a large share of the public is not taking advantage of the scheme. Insights into the reasons for this can be found in a paper published in the scientific journal PLOS ONE in January 2018. Surveying 1903 households, it found that patients who were officially insured under the NHIS rated the care they received as lower than those who were not officially insured. The authors attribute these findings to differences in care between those insured under the scheme and those who pay directly for NHIS services. On the one hand, insured patients must often wait for claims to be processed before receiving treatment or obtain generic drugs, and are excluded from certain specialist treatments. On the other hand, uninsured patients who make out-of-pocket payments generally have shorter wait times, can receive branded pharmaceuticals and can opt for treatments that are unavailable to people insured through the NHIS.
The NHIS also faces other challenges. According to a January 2019 report published by the Cornell Institute for Public Affairs, funding for local health care facilities has not been delivered based on need, which has led to an uneven distribution of health infrastructure. The report also highlights a persistent shortage of health care professionals, particularly in rural areas. Furthermore, private companies contracted by the NHIS have highlighted delays of up to 12 months in the settlement of payments. While the MoH announced in August 2019 that it had paid four months of arrears to private firms and that a subsequent payment in September 2019 would avoid further delays, resolving the issue over the longer term will be imperative to its success.
Public Investment & Performance
The government allocated GHS6bn ($1.2bn) to the MoH in the 2019 budget, a 37% increase from 2018. This represented 8% of the total national budget in 2019, up from 7% the previous year. In addition, support for the sector from development partners was expected to increase by 92% to a projected GHS796m ($154.2m) in 2019. Priorities outlined in the budget include constructing one district hospital and five clinics in the Western Region, and 15 new community health services centres across an additional five regions. Upgrades are also planned for the Hohoe Municipal Hospital, east of Lake Volta.
The budget also prioritised the introduction of a verification system for online admission registration, the development of a strategy to classify different types of hospitals and the ongoing development of legislative instruments to better implement government health directives. The budget outlined 11 new district hospitals across the country and one regional hospital in Sewua that were scheduled for completion in 2019.
Workforce
Although improvements have been made, Ghana faces issues training and retaining adequate numbers of health care professionals. In 2017 there were 4016 registered doctors in the country, or one doctor per 7374 residents, according to the latest figures from GHS. This figure has increased by almost 50% since 2013, which saw 2730 doctors and a doctor-to-population ratio of 1:9749. Even considering the retirement and emigration of doctors and steady rise of population numbers, the ratio is continuing to improve, with 297 doctors and dentists graduating in December 2018 and 232 newly trained Ghanaian doctors arriving from Cuba in July 2019. Nevertheless, Ghana must continue to make a number of improvements in order to reach the World Health Organisation (WHO) recommended doctor-to-population ratio of 1:1000.
The country has made greater progress in boosting nursing figures. According to statistics from the GHS, the total number of nurses increased from 12,245 in 2013 to 58,608 in 2017. However, with Ghana’s population growing at a rate of around 2.2% per annum, the training of health professionals will need to grow quickly to keep pace with demand.
Disease Burden
Infectious diseases, particularly those arising from poor sanitation, continue placing a heavy burden on Ghana and contributing to the majority of premature deaths. According to the GHS, around 89,250 cases of infectious disease were reported in 2018. Acute diarrhoea in persons aged five years and over accounted for 58% of the total, while illnesses with influenza-like symptoms made up 33%. A total of 988 cases of meningitis were recorded over the year, representing 1% of the total. Meanwhile, all regions met government targets for the reduction of measles and fever, with the exception of the Central and Upper West Regions. However, all regions – with the exception of Ashanti – failed to meet the targeted polio reduction rate of two cases per 100,000 people. According to the government’s 2019 budget statement, fatality rates as a result of malaria fell from 0.22% in 2017 to 0.16% in 2018, while immunisation coverage rose from 45.8% in June 2017 to 46.9% in June 2018. Postnatal care coverage fell from 33.7% to 26.4% over the same period.
While some progress has been made in combatting infectious illnesses, the rise of NCDs presents a much larger challenge. According to a May 2019 study from non-profit organisation NCD Alliance, NCDs – including cancer, cardiovascular disease, chronic respiratory diseases and diabetes – account for 94,000 preventable deaths per year, or around 43% of the total number. While a number of factors contribute to NCDs, unhealthy diet and other lifestyle factors associated with increased disposable income are among the main causes, highlighting the fact that this issue is likely to deteriorate over the longer term.
“We are facing a looming catastrophe when it comes to NCDs,” George Kesse, global head of business development at the medical logistics firm mPharma, told OBG. “Current provisions are inadequate, as they only begin to address NCDs at the stage of treatment, when they should instead focus on prevention.”
Tentative steps have been made to address this issue. In 2012 the MoH launched a strategy, based on WHO recommendations, to reduce NCDs by increasing public awareness about the dangers of tobacco and alcohol use, and encouraging improved diet and physical activity. However, these policies appear to have fallen short, with NCDs continuing to rise and the NCD Alliance stating in 2019 that policies for preventive care have not been successfully implemented.
Another major challenge the country faces concerns adolescent reproductive health, with the rate of teenage pregnancy sitting at 14.2% in the Greater Accra Region and 20% in the rest of the regions. Godfred Bonnah-Nkansah, advocacy manager of the reproductive health charity Marie Stopes Ghana, told local media in May 2019 that a further GHS5bn ($968.5m) would be needed between 2019 and 2024 to address this issue.
Private Sector
Private facilities play an important role in health care provision in Ghana. Not only do they cater to the country’s growing middle class, who generally opt for private insurance or direct payment at private facilities, but they also support the government’s ongoing drive towards universal coverage, with the NHIA contracting private institutions to provide services for the NHIS. As such, in 2013 the MoH launched the Private Health Sector Development Policy, aiming to improve the investment climate and to create a stronger health care market.
According to a June 2019 report from the UK government, private health expenditure makes up around half of all spending, largely in the form of out-of-pocket payments, and private health insurance makes up 6%. Indeed, according to the most recent figures from the GHS, in 2017 approximately 3181 hospital beds, which account for 13.4% of the total, were managed by private companies. With demand for private treatment expected to rise, the sector shows considerable opportunity for international and domestic investors.
Health Tech
Both public bodies and private firms have increasingly turned to digital technologies to provide health care solutions. In line with a broader government drive towards the digitisation of public services, in December 2018 the NHIA rolled out an e-renewal system on a mobile phone platform, for NHIS insurance (see ICT chapter). The public sector is also collaborating with international tech companies to overcome bottlenecks in health care provision. In April 2019 the government announced a deal with the US-financed start-up Zipline to use drone technology to make on-demand deliveries of blood transfusions, vaccines and other medical supplies to remote areas. Once fully operational the project is expected to make 600 deliveries per day to a total of around 2000 health facilities.
Meanwhile, a new generation of innovative domestic tech start-ups are entering the market, seeking to address shortcomings in both traditional public and private care. In April 2019 two Accra-based start-ups, mPedigree and mPharma, were each awarded $1.5m in the Skoll Awards for Social Entrepreneurship. mPedigree provides a mobile phone platform that helps customers verify the authenticity of medicines to combat fraud, while mPharma uses logistics software to manage prescription drug inventories and streamline last-minute delivery of pharmaceuticals.
However, obstacles remain to the increased use of digital technologies in providing health solutions. “The biggest challenge by far is the lack of credible data. There needs to be further public-private collaboration in terms of data gathering,” Kesse told OBG.
Pharmaceuticals
Ghana is heavily reliant on the import of pharmaceuticals to meet demand, with imports accounting for 85% of medicines and equipment in 2018. However, while tax exemptions are in place for certain generics, import levies for branded and specialist medications weigh heavily on costs, with a net tax burden of between 20% and 25% on most pharmaceuticals. In an effort to boost affordability for consumers, in 2019 the MoH established a National Medicine Price Committee, whose role will be to increase affordability by setting maximum public and private sales prices for medicines and medical technologies. Though it also established a buffer against exchange rate fluctuations, some have raised concerns that these measures may disincentivise exports to Ghana.
However, according to Fitch Solutions, the move is set to benefit local manufacturers and international firms with production in Ghana. As of March 2019 there were 126 foreign pharmaceuticals companies with manufacturing facilities in the country, according to the Ghanaian Food and Drug Authority. While manufacturing by domestic firms remains small in comparison, it has strong potential for expansion in certain segments. “Domestic production is struggling to compete with cheap imports,” Kesse told OBG. “However, there are niche areas that domestic manufacturers could move into, notably injectables, basic generics, simple antibiotics and specialist vitamins.”
Outlook
While the NHIS has improved access to basic health care services, it still faces considerable issues in terms of its administration model and the distribution of health care infrastructure and personnel. Furthermore, the country’s economic development and increasingly affluent middle class is pushing demand for specialised health care services and contributing to the rise in NCDs. Overcoming these challenges will require greater coordination between the public and private sector, while further incorporation of digital technologies should help improve the provision of care.
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