Health Sector Has Seen Many Reforms (Page 43)

Compiled by Lucy Adoma Yeboah and Rebecca Quaicoe Duho.

THE health sector, which is one of the critical sectors of the Ghanaian economy, has over the past 50 years played its role through the introduction of many policies and reforms to provide health care to Ghanaians.
These policies and reforms have been assigned to a governmental institution, the Ministry of Health (MoH), with the responsibility to see to their implementation so as to improve the health status of all people living in Ghana to enable them to contribute to the country’s development.
Although the MoH has seen changes in its policies over the years, its main focus of improving the health status of the Ghanaian population through the development and promotion of proactive policies for good health and longevity, the provision of universal access to basic health service, and provision of quality health services which are affordable and accessible, have remained the same.
The MoH has over the years been directly responsible for the provision of public health services delivery in the country until the creation of the Ghana Health Service (GHS) in the late 1990s.
Since Ghana’s independence 51 years ago, various governments have been challenged with the task of improving the country’s health care system. 
As part of the country’s Golden Jubilee Celebration last year, Professor Agyeman Badu Akosa, the former Director-General of Ghana’s health services, admitted that the country had achieved “mixed success” in its bid to ensure health for all Ghanaians.  
In a report carried by the Voice of America (VOA), Professor Akosa stated that the colonial legacy in the health sector was pretty bad; hospitals had been built for the Europeans, and Ghanaians had virtually nothing to contend with — few medical units to deal with some public health problems, but that was about all.
After independence in 1957, the situation improved, Akosa said. “The first government set out to develop health infrastructure; the government made a bold initiative of starting a medical school in Ghana and starting with employing Ghanaians.”
Prof Akosa added that Ghana’s first medical school became “one of the best” of such schools in the world. “Graduates from the medical school were everywhere,” he said. But, he explained, Ghana receded into terms of quality health care when subsequent governments failed to invest in the system.
“We have a policy that every district should have a hospital … but this is difficult to accomplish because building a hospital is a lot of money. And, therefore, we are heavily reliant on support from donors … So what I will say is that the amount of investment in health certainly has not been the best. And I think this would be applicable to all regimes. Some people have invested more in health; others have not,” he revealed.
As a policy, Ghana operated a cost-recovery health delivery system known infamously as the ‘cash-and-carry’ system since 1985, whereby patients were required to pay up-front for health services at government clinics and hospitals. That, however, pushed health care far beyond the reach of the ordinary Ghanaian until the introduction of the National Health Insurance Scheme (NHIS) in 2003.
Health Sector Reforms
Ghana’s health sector has had many reforms. The most recent reform that has been in process since the early 1990s has been finally documented in what is popularly known as “Medium Term Health Strategy, 1996-2000”. It aims at improving access to health services, quality of care and efficiency, strengthening links with other sectors such as the Ministries of Agriculture and Education which also have health components in their activities or impact on the health of people (Ministry of Health, 1996). Its main achievement or focus has been the introduction of user fees.
The introduction of user fees in Ghana has also been a component of a range of strategies that are part of an international health reform agenda. They are linked to a broad set of public sector reform ideas and initiatives collectively known as the ‘new public management’ (NPM).
The NPM in the health sector has other policies apart from the user fees — decentralisation of the health sector with changes in organisational management and culture, and autonomous hospital boards and deregulation, and regulation of the private sector.
The main objectives of these policies are achievement of sustainable financing of health services, quality improvement, and equity with respect to access.
Institution of User Fees and Exemption of the Poor
Fees for health services in public facilities, first introduced in 1971, were very low and aimed at reducing unnecessary use of services rather than to generate revenue.
The fees were raised slightly in July 1983 and increased substantially in July 1985 when a new hospital act was passed under the military regime of the Provisional National Defence Council (PNDC), aimed at recovering at least 15 per cent of operational costs.
Initially, the Act allowed health centres and clinics to retain only 25 per cent of the revenue from fees collected while hospitals were allowed to retain 50 per cent. In 1990, this provision was amended and some public health institutions were selected for a pilot programme and allowed to keep all revenue generated from user fees.
In 1992, the new fees were implemented nation-wide as the government, influenced by multilateral donors, abandoned a phased implementation procedure started in 1990. Since then, a decentralised system of charging fees has been operating in the public health facilities and all revenue has been retained for operational or non-salary budget. Budget surpluses that are not invested in improving the quality of care are sent to the Ministry of Health (MoH).
A revolving fund for drugs was initiated in 1992 by which all health institutions were to recover the full cost of drugs and keep this revenue to purchase drugs only. An overhead cost of 10-15 per cent is added and the full cost was revised in line with inflation.
The public health facilities also charged other fees for the following: Out Patient Department (OPD) cards and initial registration, consultation, admissions, gloves gauze, needles and syringes. Informal fees with various shades of legality and unauthorised fees were also collected from users.
Implementation of Ghana’s Health User Fee Policy and the Exemption of the Poor.
The 1992 law, however, has a clause providing for exemption for the poor and treatment of emergencies whether patients are in a position to pay immediately or not. It does not indicate the criteria by which the poor can be identified though — whether by income, geographical area, occupation, etc.
Health workers were just instructed to use their discretion to grant exemption to anyone who said he/she could not afford fees. They later applied for refund from government, the exemptions that they granted.
The implementation of the new user fee was described by some as successful with respect to revenue generation despite some registered abuses. Revenue raising dominated other concerns and was at the expense of health care needs, to the extent that the exemption clause had been either ignored or just labelled as difficult to implement, even in clear-cut cases where exemption could be granted.
The National Health Insurance Scheme (NHIS)
In March 2004, President John Agyekum Kufuor launched a National Insurance Health Scheme designed to offer affordable medical care, especially to the poor and vulnerable among Ghana’s 19 million people.
Under the scheme, adult Ghanaians are paying a yearly minimum subscription of GH¢7.20. In addition to free services to contributors to the Social Security and National Insurance Trust (SSNIT) and SSNIT pensioners, the government is catering for health treatment of the aged, the poor as well as children of parents who both subscribe to the scheme.
Currently, about 50 per cent of Ghanaians have registered under the scheme, which covers all districts in the country under District Mutual Health Insurance Schemes (DMHISs).
New Health Policy.
Currently, the health sector has initiated a new health policy that emphasises health promotion and prevention of ill-health in the promotion of healthy lifestyles, behavioural changes and healthy environment.
Dubbed, “Regenerative Health and Nutrition Programme”, the health sector is educating Ghanaians on the need to reduce their salt, sugar, fat and alcohol intake and rather drink enough water, consume vegetables and fruits, have physical exercises and enough rest to live healthily. The programme has the theme — “Renew Your Strength-Prevent Diseases”.
With this and other policies previously introduced, the health sector believes the country would be relieved of most of its health problems such as malaria, HIV/AIDS, cholera, measles, typhoid, tuberculosis, chicken pox, yellow fever, trachoma, and river blindness.
Others are guinea worm, various kinds of dysentery, river blindness or onchocerciasis, pneumonia, dehydration, venereal diseases, poliomyelitis and malnutrition, among others.