Ministry of Health Ghana

Ministry of Health Ghana Holistic Assessment of the Health Sector Programme of Work 2012 Ghana Version 11 th June 2013 1

Table of Contents List of abbreviations and acronyms... 3 Acknowledgements... 4 Executive summary... 5 Introduction... 13 1.0 Assessment of the Health Sector Performance in 2012 using the Holistic Assessment Tool... 13 2.0 Assessment of indicator trends... 16 3.0 Regions of excellence and regions requiring attention... 33 4.0 Implementation status of the POW 2012... 34 5.0 Agencies assessments and performance contracts... 39 6.0 Follow-up on Aide Memoire recommendations... 57 7.0 Conclusion... 58 Annex 1: Sector Wide Indicators and Targets POW 2012... 61 Annex 2: Sector wide indicator trends based on 3% proportion... 63 Annex 3: Holistic Assessment Tool and Analysis... 64 Annex 4: Indicator definitions and calculations... 91 Annex 5: Analysis framework for POW 2012 implementation... 94 Annex 6: Capital Investment Update POW 2012... 107 Annex 7: Procurement plan... 115 2

List of abbreviations and acronyms ART Antiretroviral Therapy CHAG Christian Health Association of Ghana CHPS Community Health Planning and Service CIP Capital Investment Plan DFID UK Department for International Development DHIMS District Health Information Management System DMHIS District Mutual Health Insurance Scheme EmOC Emergency Obstetric Care EmONC Emergency Obstetric and Neonatal Care EPI Expanded Programme on Immunisation FP Family Planning GHS Ghana Health Services GOG Government of Ghana HIRD High Impact Rapid Delivery HMIS Health Management Information System HR Human Resources HRD Human Resource Directorate IGF Internally Generated Funds IMR Infant Mortality Rate ITN Insecticide Treated Net KATH Komfo Anokye Teaching Hospital KBTH Korle-Bu Teaching Hospital MDG Millennium Development Goal M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Survey MMR Maternal Mortality Ratio MoH Ministry of Health MTEF Medium Term Expenditure Framework NCD Non-Communicable Disease NDPC National Development Planning Commission NHIA National Health Insurance Authority NHIF National Health Insurance Fund NHIS National Health Insurance Scheme OPD Out-Patient Department POW Programme of Work PPME Policy, Planning, Monitoring and Evaluation SBS Sector Budget Support TBA Traditional Birth Attendant TH Teaching Hospital U5MR Under-Five Mortality Rate WHO World Health Organisation 3

Acknowledgements The holistic assessment of the health sector 2012 Programme of Work was done internally by the Ministry of Health. A team of five people from Ministry of Health and Ghana Health Service undertook the review and holistic assessment. The members of the team were Dr. Afisah Zakariah, Daniel Degbotse, Dan Osei, Dr. Anthony Ofosu and Dr. Andreas Bjerrum. The team would like to thank all individuals who contributed to this review and who kindly gave their time and support to the review process. 4

Executive summary The year 2012 represented the third year of the implementation of the current Health Sector Medium Term Development Plan (2010-2013). The review has placed emphasis on the performance of the sector according to identified health objectives as outlined in the Four-Year Sector Medium Term Development Plan and the derived Annual Programme of Work for 2012. The review assessed the overall sector performance for the year 2012 using the agreed Holistic Assessment tool. The Holistic Assessment tool was adopted in 2008 and has been used to assess the sector performance since its inception. The report is organized into six chapters and a conclusion. 1. Assessment of the Health Sector using the Holistic Assessment Tool The purpose of the holistic assessment is to form a basis for a balanced discussion between the Ministry of Health, its agencies and development partners to reach a common conclusion of the sector s performance. The outcome of the assessment is that the health sector in 2012 was a positive sector score of +3, which is interpreted as a highly performing sector. 2. Assessment of indicator Trends Health Objective 1: Bridge equity gaps in health care and ensure sustainable financing arrangements that protect the poor The equity index for supervised deliveries by region improved and reached the target of 1.7 comparing the best to the worst performing region with regards to coverage. Performance improved among both the best and worst off regions. Almost all regions performance were above 50% except Volta Region at 46.5% and Northern Region at 49.9%. Coverage increased in all regions except for Ashanti Region, which experienced a drop of 2.1%. The poorest staffed region with regards to nurses is the Northern Region Volta and Upper West Regions stand out with critical reductions in midwife populations. The Doctor to population ratio did not change much and with 11 times less doctors per population in Upper West Region compared to Greater Accra Region equitable distribution of doctors remains a major challenge to the health sector with one nurse to 1,601 population compared to the national average of one nurse to 1,251 population. The National Health Insurance since its introduction has led to increase in utilization of OPD services across all the regions. Ashanti region like all the regions showed an increase in OPD attendance till 2012 when it experienced a drop in OPD per capita Health Objective 2: Strengthen governance and improve efficiency and effectiveness of the health system In 2012, the ministry introduced performance contracts with four agencies: the three Teaching hospitals and Ghana Health Service. Government of Ghana contribution increased by 126.9% from GH 771 million in 2011 to GH 1,750 million in 2012. Internally Generated Fund (IGF) increased by 8.9% from GH 392 million in 2011 to GH 427 million in 2012. Contribution from donors in 2012 was GH 290.8 million whilst there was GH 259.2 million contribution in the same period of the previous year, an increase of 12.2% over the same period of 2011.Total Gross Revenue, recorded by the Ministry was GH 2,489.8 million. The Ministry recorded a total expenditure of GH 2,613.4 million for the period under review Debtors have decreased from GH 137.7 in December 2011 to GH 115.9m in December 2012, a decrease of 15.8%. 5

Health Objective 3: Improve access to quality maternal, neonatal, child and adolescent health and nutrition services The total fertility rate increased from 4.0 to 4.3. Meanwhile the contraceptive prevalence rate for the same period has improved significantly, increasing to 23.4% from 16.6% in 2008. The proportion of pregnant women attending four or more antenatal care visits increased slightly to 72.3%. For the 2011 MICS report, the corresponding figure was 86.6%. Over the past 3 years, supervised delivery coverage has increased by 28.2%, and over the past 5 years by 66.5%. Coverage of supervised deliveries in 2012 was 58.5%, based on the estimated expected delivery of 4% of the population and 77.9% based on 3% estimate The MICS gave the country a skilled attendant at delivery coverage of 68.4%. The proportion of children below the age of six months that are exclusively breastfed has significantly dropped since 2008, and the current performance at 45.7% is below 2003 levels and far below the target of 70%The national Infant Mortality Rate (IMR) increased by 6% over the DHS 2008 figure from 50 to 53. IMR is highest in Volta, Upper West, Northern and Brong-Ahafo Regions. Northern Region and Upper West Region have since 2003 had relatively high U5MR. Upper West Region has been able to bring down under-five mortality rate by 50%. Health Objective 4: Intensify prevention and control of communicable and non-communicable diseases and promote a healthy lifestyle According to the MICS 2011, use of ITNs has improved by almost 50% since 2008 and the proportion of children under five sleeping under ITN the previous night has also increased. The national prevalence of malaria parasitaemia in children aged 6-59 months based on microscopy was 27.5% with the highest prevalence in Upper West Region (51.2%) and Northern Region (48.3%). Lowest prevalence was recorded in Greater Accra Region (4.1%). While the national number of expected malaria cases among children has not dropped significantly, case-fatality of malaria for children under five years has improved, dropping from 1.2 in 2011 to 0.6 in 2012 deaths per 100 confirmed malaria cases. In 2012 coverage of Penta 3 was 87.8%. The MICS gave the corresponding survey based coverage of 92.1%.. The country continues to maintain surveillance for guinea worm. While the proportion of the population with access to improved sanitary facilities that are not shared increased, the access to all improved sanitary facilities, shared and not shared, reduced. TB treatment success went up to 86.2% but the target of 89% was not achieved. The adverse outcomes reduced from 16.7% to 13.8%. Health Objective 5: Strengthen institutional care including mental health service delivery The total number of mental health nurses in the three psychiatric institutions was 1,068. This comprises both community psychiatric nurses and registered mental nurses. Total number of patients seen during the year was 67,732. No formal training exists for training community psychiatric nurses. The current crop of community psychiatric nurses amount to 400 who are registered nurses converted to practice as community psychiatric nurses. Institutional infant and under five mortality rates improved significantly in 2012 with more than 50% reduction in both. Institutional Maternal Mortality (immr) dropped significantly from 211 maternal deaths per 100,000 live births in 2011 to 193 in 2012. While immr at Komfo-Anokye Teaching Hospital continued to be high with 1,252 deaths per 100,000 deliveries, Korle-Bu Teaching hospital reduced institutional maternal mortality ratio significantly from 1,133 in 2011 to 841 in 2012. The continuous high maternal mortality ratio at the teaching hospitals calls for stronger and more structured collaboration between the teaching hospitals and the referring hospitals and clinics at all levels. 6

3. Regions of excellence and regions requiring attention In the review of POW 2011, the review team introduced a simplified holistic assessment based on regional performance of selected indicators to identify the region of excellence and the region requiring attention. The scoring of each indicator follows the rules of the holistic assessment adapted to regional analysis. It is important to note that the regional performance assessment is only indicative since it is based on a limited number of service delivery indicators In the regional analysis of POW 2011, three regions came out with a score of zero or below. In the current review all regions have a positive score, which indicates a relative improvement over 2011 for these selected service delivery indicators. The two regions doing very well are Central and Upper East Region, those not doing so well are the three Regions Volta, Ashanti and Brong-Ahafo. 4. Implementation status of the POW 2012 In the Programme Work for the year 2012, some activities were planned to be implemented under the five strategic objectives. The extent to which these activities are carried out determines the performance of the health sector. Reasons for non-performance in some instances range from non-availability of funds to lack of a clear framework for implementing such planned activities. The objective of the Ministry of Health is to improve coverage of PHC services at sub-district level through strengthening community health systems. The Ministry planned to do this by expanding CHPS coverage to achieve 500 new functional zones during the year. Although the target was exceeded some challenges remain. The development of the health care financing strategy could not be carried out. The capitation pilot was undertaken in Ashanti Region. Though the leadership development programme training is progressing as planned, an assessment of the relevance of the programme in enhancing performance of district and subdistrict teams is necessary. Although a performance contract was signed with the Ghana Health Service and the three teaching hospitals, contract management in terms of supervision, reporting and evaluation was not adequate. A lot of health bills have been passed into law, efforts aimed at operationalising the law through legal instruments however needs to be facilitated. The Ministry of Health developed a private sector policy, however it was not printed or disseminated. This policy will provide for cross-sectoral activities in the mobilsation of resources for health and health care. The implementation of the MAF action plan has delayed. Indeed part of the MAF plan is being implemented at all levels. Although the community case management of malaria, diarrhoea and acute respiratory disease is being implemented in some districts as planned it is facing challenges. Community health workers face difficulties in recouping funds for the drugs they dispensed at the community level. I The adolescent health strategic plan and policy was disseminated to all stakeholders during the year. The emergency obstetric care equipment meant for the three remaining regions (Upper West, Greater Accra and Volta Regions) has not been delivered according information provided during the review. 7

The pneumococcal, meningococcal and rotavirus vaccines including second dose of measles vaccines were successfully introduced. It was planned to disseminate and implement the National Nutrition Policy. The draft of the policy has been developed and is being prepared for submission to cabinet. Nutrition, Malaria and Child Survival Program was implemented to improve the nutritional status of children using community based approaches in districts in Upper West, Upper East, Volta and Central Region. To reduce malaria case fatality for the vulnerable groups, ACTs for treatment were procured and distributed through the AMFm programme. LLINs Hang Up campaign was organized in all the regions. The plan for the year was to maintain the polio free status of the country and validate eradication of guinea worm and polio. To achieve this, surveillance activities including case searches were intensified. The plan for the year was to increased case detection for NTDs. To achieve this, the Ministry finalized the NTD Master Plan for Ghana for the period 2011 to 2015 in collaboration with WHO. The plan was shared with the relevant stakeholders. Mass drug administration was conducted for Onchocerciasis, schistosomiasis and Lymphatic Filariasis in communities and schools The scaling up of the detection and management of non-communicable diseases through the implementation of the national strategy for cancer control and expansion of screening program for hypertension, diabetes and sickle cell were also not done. Though the guidelines for the cancer programme have been developed they are yet to be printed. 5. Agency assessments Centre for scientific research into plant medicine The Centre for Scientific Research into plant medicine was set up to conduct and promote scientific research relating to the improvement of plant medicine. Total staff at post at the centre is 192. The centre screened and selected 4plants each for diabetes, hypertension and malaria respectively and 2 plants for prostate cancer. Preliminary analysis on 4 anti hypertensive plant extracts showed promise in decreasing blood pressure over a four week period in laboratory rats. Safety and efficacy evaluations of three out of four herbal products which not dose dependent showed considerable reduction in parasitemia. With regards to Dissemination of research findings (4 research papers and 6 technical reports) on quality, efficacy and safety of herbal medicines; Two (2) papers were published Allied health profession It also works with other relevant organizations to provide accreditation to qualified training institutions providing allied health programmes. It regulates practice standards of professionals. Planned activities include among others the development of guidelines for accrediting training institutions and programs in collaboration with the National Accreditation Board. A total of 34 applications were received from training institutions for accreditation. A workshop on curricula for allied health programs in the West African sub-region was held. The allied health professions Bill was passed by parliament and is awaiting presidential accent. 8

Food and Drugs Authority From the number of activities planned to be implemented for 2012, Food and Drugs Authority was belt to ; Train One hundred and ten (110) food manufacturing industries in Food Safety Management Systems. Train Street Food Vendors in 30 Food Service Establishments in Basic Food Safety and Hygiene practices. Three Hundred and Seventy samples of antimalarial preparations on the market were sampled and screened with Minilabs. The first round of Quality Surveillance of Uterotonic preparations namely Oxytocin Injections and Ergometrine Maleate Preparations (Injections and Tablets) was carried out 279 samples were analysed of which 178 (63.7%) failed. The Public Health Bill, 2012, (Act 851) (which includes the Tobacco Bill, FDA Bill and Clinical Trials) was passed into law. The challenges of the authority are Inadequate operational vehicles. Limited border post-activities. For the coming year post-market surveillance functions will be enhanced to rid the market of fake, substandard and unwholesome regulated products. Ghana College Of Physicians And Surgeons The Ghana College was established to promote specialist education in medicine, surgery and related disciplines. It also promotes continuous professional development in medicine, surgery and related disciplines including research. The college in 2012 planned to publish a journal and a newsletter and install ICT infrastructure to aid in the colleges training programme. The college has 24 faculties. Other key activities planned for the year include accreditation of training sites and medical knowledge fiesta. The college published one journal and 2 newsletters and organized 20 CPDs out of the expected 24. A knowledge fiesta was also organized for English speaking West Africa to exchange knowledge on current happenings in the medical field. An ICT infrastructure sponsored by MTN was installed and commissioned during the year. Some of the challenges of the college include Developing alternate funding arrangements for post graduate medical education, maintenance of College building and accreditation for training for decentralized sites. The College will continue with its core functions of producing specialists in medicine, surgery and related disciplines and develop options for funding post graduate specialist training The college will also support implementation of WAHO initiative towards harmonization of curricula and accreditation criteria with subregional Colleges. Ghana Health Service The Ghana Health Service identified 8 main priority areas for improvement in 2012 under the five strategic objectives The major priority activity under this objective one was the scaling up of the Community-based Health Planning and Services (CHPS) as a close-to client policy to increase access to basic health services. This achievement was made possible by simplifying the community health community training manual and trainer of training programmes for the regional teams. One of the major challenges of the Ghana Health Service is the availability, distribution and appropriate mix of relevant health staff at the health facilities. 9

The GHS introduced the leadership and management capacity development as a capacity building effort in the Central region in 2010. Since then 161 health personnel have been trained. The processes were started for the Implement the MAF country Action plan for improved maternal and neonatal care. Activities were initiated to develop and implement the National Nutrition Policy and strategy. All Districts (170) were also trained In Community Management Of Malaria (CMM) and and some districts commenced implementation of CMM. As part of effort to improve prevention and control of communicable diseases, the GHS planned to procure and distribute ICT equipment to support district level surveillance activities, which was done in three regions. The following guidelines, policies and strategies were developed or reviewed Laboratory accreditation guidelines for clinical labs in hospitals Laboratory Quality Control of Taylor & Taylor Analysers in selected Laboratories in Greater-Accra Region Antimicrobial policy for Ghana Community Mental Health Strategy The Ghana Health Service plans to re-prioritize the numerous activities in 2013, to ensure that the key ones are implemented. Komfo Anokye Teaching Hospital A patient satisfaction survey conducted during the year indicated that 62% of hospital clients were satisfied with the hospital s services. Customer Care Service Training was organised for staff during the period under review to improve services provided to clients. A Magnetic resonance Imaging (MRI) Centre was completed during the year and handed over to the hospital Services at the center commenced. Work on the uncompleted Maternity & Children s Block was reactivated whilst construction of Eye Centre is 95% complete OPD attendance and services provided at the hospital either declined or remained stagnant over the period. Sustain activities aimed at reducing mortality, (especially maternal mortality), and improving general care outcomes were undertaken. The maternal mortality however did not reduce. Daily clinical meetings and monthly maternal mortality meetings were held to audit all Maternal Deaths. Continue to support Doctors & Nurses to pursue training programme in Emergency Medicine 5 Doctors and 20 nurses qualified as Emergency Physician and emergency nurses respectively. The Hospital embarked on several outreach programmes in eye screening and surgeries, ENT, Cleft, Child Health and Infectious Diseases during the period under review. The Hospital visited One Teaching Hospital and Eight Districts. Twenty-five (25) research activities initiated by directorates during the period are on-going. Two (2) research reports were completed and disseminated:some of the challenges of the Hospital were,congestion, especially at maternal & children s wards, Delays in the payment of health insurance claims and unrealistic tariff,old & Non-functional Oxygen Plant and Rent Expenditure for House Officers & Residents 10

Korle-Bu Teaching Hospital The hospital has a total staff strength of 4419 with clinical staff constituting 72% (3,184) and Non clinical staff 28% (1,235). To improve maternal health outcomes and general clinical outcomes, a number of projects and programmes were initiated. A Blood bank established at the Maternity Block Laboratory and the renovation of the Maternity OPD, 4 th and 6 th Floors which was started at the beginning of the year are 80 to 90% complete. The hospital saw a reduction in maternal deaths. The emergency department is being refurbished to improve emergency medicine services. Capacity building in Client/Patient care aimed at addressing Staff attitudes was initiated. About 50% of staff have undergone the training. The challenges of facing the hospital are High cost of incentives to attract and retain critical staff. Tamale Teaching Hospital The objectives for the hospital in 2012 were among others to strengthen and improve governance and efficiency of the TTH s management systems, provide excellent quality Maternal and Child Health Service and attract and retain health staff. In an effort to improve general hospital management through informed decision-making, an ICT Firm was commissioned to develop a Health Management Information System. The hospital introduced measures aimed at improving maternal and neonatal outcomes. Radiology/Endoscopy/Urology services including new and improved imaging services have been introduced. National Ambulance Service The Service opened 97 new ambulance stations during the year bringing the total number of ambulance stations in the country to 121. Thirty-five emergency medical technician basic (EMTB) were upgraded to emergency medical technician advance (EMTA) during the year. Inadequate Budgetary Allocation and late release of funds hampered the programme and activities of the service. Lack of dedicated training facility leading to delays in training schedules National Health Insurance Scheme Some of the objectives of the scheme at the beginning of the year was to ; To increase efficiency in the financial operations of the scheme, to increase active membership to 45% of population by December 2012 and to provide support to increase access to quality basic health care services in all districts To strengthen premium collection scheme level, a consolidated premium account was established. The World Bank is supporting the Health Insurance Project (HIP) whiles DANIDA is supporting the authority with an M&E advisor. Until recently, returns from investment formed a substantial part of the total funds of the scheme. However due to recent financial difficulties, the authority had not been able to invest and have had to plough back its savings to keep the scheme afloat. To reverse this trend, the authority developed an investment policy and guidelines to provide guidance to the authority. The authority realised 6.5% real rate of returns on investment exceeding its target of 4%. The NHIA intensified clinical audit of the district schemes and providers. The authority also hoped to improve efficiency by diversifying provider payment mechanism. 11

Some of the challenges facing the scheme are Financial sustainability of the concerns,ict Challenges Claims Management, Renewal of membership by clients and Irrational Prescription of medicines by providers. 12

Introduction The year 2012 represented the third year of the implementation of the current Health Sector Medium Term Development Plan (2010-2013). The review has placed emphasis on the performance of the sector according to identified health objectives as outlined in the Four-Year Sector Medium Term Development Plan and the derived Annual Programme of Work for 2012. The review assessed the overall sector performance for the year 2012 using the agreed Holistic Assessment tool. The Holistic Assessment tool was adopted in 2008 and has been used to assess the sector performance since its inception. For the second year running, the review was performed by an internal team drawn from the Ministry of Health and its agencies. For this year s review, a section on agencies performance was added. The new census data from 2010 was available for the year s review. From the census report, the proportion of children under one year as well as expected pregnancies was estimated to be 3% of the total population. When this proportion is applied to the data several indicators exceeds 100% coverage. Since most of the analysis in this report is based on trends over time, and the targets of the HSMTDP was based on 4% the review team finds it technically sound to continue basing the analysis on the 4% as in the previous reviews. However data based on the 3% is made available for comparison and official purposes. The report is organized into six chapters. The first chapter deals with the health sector performance using the holistic assessment tool. The second chapter discusses the trends of sector wide indicators. The third chapter provides an assessment of regions of excellence and regions requiring attention. The fourth chapter looks at the implementation status of the programme of work 2012. The fifth chapter is a brief report of the agencies performance. The sixth chapter follows up on the recommendation of previous Aidememoire. Annexes are provided with further details of the basis of the analysis. 1.0 Assessment of the Health Sector Performance in 2012 using the Holistic Assessment Tool 1.1 Sector score The purpose of the holistic assessment is to form a basis for a balanced discussion between the Ministry of Health, its agencies and development partners to reach a common conclusion of the sector s performance. The outcome of the initial assessment is that the health sector in 2012 was a positive sector score of +3, which is interpreted as a highly performing sector (For the detailed analysis of the indicators and the holistic assessment calculations, please refer to Annex 3: Holistic Assessment Tool and Analysis). Health Objective 1 0 Health Objective 2 0 Health Objective 3 +1 Health Objective 4 +1 Health Objective 5 +1 Sector score +3 13

Table 1: Sector Score 2012 Table 1 shows the overall scores for the five Health Objectives in the HSMTDP 2010-2013. Table 2 provides a detailed overview of the indicators and trends from 2007 to 2012. Annex 2: Sector wide indicator trends based on 3% proportion provides a presentation of trends of sector wide indicators over time based on the latest projections from Ghana Statistical Services. 14

2012 POW 2007 2008 2009 2010 2011 Target Performance (4%) Performance (3%) Source Health Objective 1: Bridge equity gaps in health care and nutrition services and ensure sustainable financing arrangements that protect the poor 1 % children 0-6 months exclusive breastfed - 62.8% - - - 70% 45.7% 45.7% MICS 2 Equity: Poverty (U5MR) - 1.72 - - - 1:1.5 2.04 2.04 MICS 3 Equity: Geography - Services (supervised deliveries) 2.47 2.17 1.49 1.89* 1.66* 1:1.70 1.48 1.48 GHS 4 Equity: Geography - Resources (nurse: population) 2.26 2.03 1.81 1.99* 1.73* 1:1.95 1.75 1.75 MOH 5 Equity: NHIS Gender - 1.22 - - 1.38-1.23 1.23 MICS 6 Equity: NHIS Poverty - 0.82 (F) - - - - 0.69 (F) 0.69 (F) MICS 7 Outpatients attendance per capita (OPD) 0.69 0.77 0.81 0.91* 1.04* 0.88 1.17 1.17 GHS /TH 8 % population living within 8 km of health infrastructure - - - - - N/A - 9 Doctor: population ratio 1:13,683 1:13,499 1:11,698 1:11,833* 1:10,217* 1:9,700 1:10,452 1:10,452 MOH 10 Nurse: population ratio 1:1,537 1:1,353 1:1,494* 1:1,516* 1:1,262* 1:900 1:1,251 1:1,251 MOH Health Objective 2: Strengthen governance and improve efficiency and effectiveness in the health system 1 % total MTEF allocation on health 14.6% 14.9% 14.6% 15.1% 15.8% 15.0% 15.4% 15.4% MOH 2 % non-wage GOG recurrent budget to district level and below 49.0% 49.0% 62.0% 46.8% 55.3% 50.0% 38.5% 38.5% MOH 3 Per capita expenditure on health 23.0 23.2 25.6 28.6 35.0 30.0 50.7 50.7 MOH 4 Budget execution rate (Item 3 as proxy) 110.0% 115.0% 80.4% 94.0% 82.1% 95.0% 86.8% 86.8% MOH 5 % of annual budget allocations disbursed to BMC by end of year - 23.0% 39.0% 31.0% 89.8% 50.0% - - - 6 % of population with valid NHIS membership card - - - 33.7% 33.4% 70.3.0% 34.0% 34.0% NHIA 7 Proportion of claims settled within 12 weeks - - - - - 70.0% - - - 8 % IGF from NHIS N/A 66.5% 83.5% 79.4% 85.0% 75.0% - - - Health Objective 3: Improve access to quality maternal, neonatal, child and adolescent health services 1 Maternal Mortality Ratio (MMR) per 100,000 live births - 451 - - - - - 2 Total Fertility Rate - 4.0 - - - 3.8 4.3 4.3 MICS 3 Contraceptive Prevalence Rate 16.6% - 23.4% 23.4% MICS 4 % of pregnant women attending at least 4 antenatal visits 62.8% 63.8% 81.6% 71.1% 71.3% 80.1% 72.3% 96.4% GHS 5 Infant Mortality Rate (IMR) per 1,000 live births - 50 - - - <30 53 53 MICS 6 Under 5 Mortality Rate (U5MR) per 1,000 live births - 80 - - - <50 82 82 MICS 7 % deliveries attended by a trained health worker 35.1% 42.2% 45.6% 48.2% 55.8% 60.0% 58.5% 77.9% GHS/TH 8 Under 5 prevalence of low weight for age - 13.9% - - - 8.0% 13.4% 13.4% MICS Health Objective 4: Intensify and control of communicable and non-communicable diseases and promote a healthy lifestyle 1 HIV prevalence among pregnant women 15-24 years 2.6 1.9 2.1 1.5 1.7 <1.7% - - GHS 2 % of U5s sleeping under ITN 55.3% 40.5% - - - 70.0% 41.5% 41.5% MICS 3 % of children fully immunized by age one - Penta 3 87.8% 86.6% 89.3% 87.4% 88.1% 91.4% 87.8% 117.1% GHS 4 HIV+ clients ARV treatment 13,429 23,614 33,745 40,575 59,007 80,014 73.339 73.339 NACP 5 Incidence of Guinea Worm 3,358 501 242 8 0 <50 0 0 GHS 6 % households with improved sanitary facilities - 12.4% - - - 21.3% 15.0% 15.0% MICS 7 % households with access to improved source of drinking water - 83.8% - - - 80% 79.3% 79.3% MICS 8 Obesity in population (women aged 15-49 years) - 9.3% - - - - - - - 9 TB treatment success rate 74.5% 84.6% 85.4% 87.0% 85.3% 89.0% 86.2% 86.2% NTP Health Objective 5: Strengthen institutional care, including health service delivery 1 Psychiatric patient treatment and rehabilitation rate - - - - - 25% >bl. 84.8% 84.8% Chief Psy. 2 Equity index: Ratio of mental health nurses to patient population - - - - - 25% >bl. 1:63 1:63 Chief Psy. 3 Number of community psychiatric nurses trained and deployed - - - - - 25% >bl. 400 400 Chief Psy. 4 % tracer psychotropic drug availability in hospitals - - - - - 75.0% 85.0% 85.0% Chief Ph. 5 Institutional infant mortality rate - 7.0 7.4 6.8 6.4-2.2 2.2 GHS 6 Basket equipment functioning in hospitals - - - - - 80.0% - - - 7 % tracer drugs availability in hospitals - - - - 94.1% 90.0% 85.7% 85.7% Chief Ph. 8 % of hospitals assessed for quality assurance and control - - - - - 90.0% - - - 9 Institutional under-five mortality rate - 9.0 10.2 9.7 9.7-4.0 4.0 GHS 10 Institutional MMR - - - 190 211-193 193 GHS /TH Table 2: Sector wide indicators 2007-2012, both 3% and 4% proportion of children under 1-year/expected pregnancies, greyed out indicators are not measured on annual basis. 15

2.0 Assessment of indicator trends 2.1 Health Objective 1: Bridge equity gaps in health care and ensure sustainable financing arrangements that protect the poor 2.1.1 Equity: Under-five mortality With twice as many under-fives dying per 1,000 live births in the poorest wealth quintile compared to the richest, the under-five mortality inequality gap between richest and poorest children is widening. While children of the richest quintile seem to be on track to meet the MDG target, children from other quintiles and especially the poorest children are faring much worse. The same widening of inequity is observed for infant and neonatal mortality rates. Since 2003, according to the DHS and MICS there have been no observed reduction of infant mortality and only 5% reduction in neonatal mortality among the poorest children. There have been 35% and 43% reduction of infant and neonatal mortality among the richest quintile during the same period. Further analysis of these trends to isolate the determinants of high mortality among children, e.g. urban/rural dwelling, socio-economic status, education status of parents, child gender etc. is needed, in order to device strategies to ensure more equitable health development for children in Ghana. Wealth Quintile DHS 2003 MICS 2006 DHS 2008 MICS 2012 Poorest 128 118 103 106 Second 105 126 79 85 Middle 111 100 102 83 Fourth 108 101 68 86 Richest 88 100 60 52 Equity Ratio 1.45 1.18 1.72 2.04 Table 3: Under-five mortality rate 2003-2012, source DHS and MICS 2.1.2 Equity supervised deliveries The equity index for supervised deliveries by region improved and reached the target of 1.7 comparing the best to the worst performing region with regards to coverage. Performance improved among both the best and worst off regions. Almost all regions performance was above 50% except Volta Region at 46.5% and Northern Region at 49.9%. Coverage increased in all regions except for Ashanti Region, which experienced a drop of 2.1%. Volta, Northern and Western Regions have worse midwife to WIFA (women in fertility age) ratio compared to the other regions. This could be the reason for the lower performance in these three regions. Upper East Region continues to improve its supervised delivery coverage over the years. It will be of beneficial to look to Upper East Region for best practices in supervised delivery coverage. Although Volta region is showing an improvement in supervised delivery, it has consistently been the lowest performer with regards to supervised delivery for the past three years. There may be various reasons for this performance which came up in the joint monitoring visit report to the Region in 2011, among the issues may be inadequate infrastructure, ageing and inadequate numbers of midwives and the fact that Volta Region is one of the regions with very few maternal and child health interventions outside the regular budget provided by the Ministry of Health. The region should over the coming years receive special attention and support to catch up with the other regions. 16

Figure 1: Supervised deliveries by region 2007-2012, source GHS 2.1.3 Equity HRH distribution The indicator of nurse distribution did not improve over 2011 performance, but reached its target of being below 1:1.95. The poorest staffed region is Northern Region with one nurse to 1,601 population compared to the national average of one nurse to 1,251 population. Equity with regards to nurses has however improved significantly overall since 2007. The improvement over the years has been due to the establishment of new nursing training schools in all the regions. The recent stagnation is possibly due to the high failure rate among the nursing students over the past two years that has reduced the number of nurses who are passing out of the schools. The decision of Upper East Region to strictly implement the policy of retaining nurses that train in their region appears to be yielding good results. Other regions, especially Northern Region, should also adopt this approach. From 2011 to 2012, the numbers of midwives are reducing across all the regions with the exception of Ashanti Region, which showed a marginal increase. There appear to be a lag time between the increase in the intake of trainees to the midwifery training schools and the rate of retirement of midwives. There is the still the need to get more nurses into training; this can be accelerated if the community health nurses are given diplomas instead of certificates when they undertake the post-basic midwifery course. Most of them are reluctant to enrol in the post-basic midwifery course because they are awarded certificates. Figure 2 shows the percentage change in midwife population by region since 2009. Volta and Upper West Regions stand out with critical reductions in midwife populations. Despite these reductions, both regions have more 17

favourable midwife to WIFA ratios than the national average, and both managed to increase the number of women delivering in facilities by 18.1% and 53.7% respectively in the same period. Figure 2: Percentage change in midwife population by region 2009-2012, source Free Maternal Health Care Policy Review 2013 The doctor to population ratio did not change much and with 11 times less doctors per population in Upper West Region compared to Greater Accra Region equitable distribution of doctors remains a major challenge to the health sector. Greater Accra Region continues to be the region with the highest number of doctors per capita with one doctor per 3,540 inhabitants. Fifty percent of all Ghana s doctors are in Greater Accra Region and another twenty percent are in Ashanti Region. The number of doctors in training in Greater Accra and Ashanti Region might be accounting for these high numbers. The proportion of female doctors in Greater Accra is higher than for the other Regions, indicating that some of these doctors are in Greater Accra Region because of domestic reasons. Northern Region has consistently improved its doctor population ratio over the past three years, however this increase has only benefitted the Teaching Hospital. Twenty five government Hospitals in Ghana are without doctors. Eight of them are found in the Northern Region. There is the need for establishment of clear staffing norms for facilities and the Ministry of Health will need to address the inequitable distribution of doctors. 18

Figure 3: Doctor: population ratios (lower is better), 2009-2012, Source MOH 2.1.4 Equity NHIS The gender ratio of NHIS cardholders remains stable with 23% (MICS 2011) more female cardholders (15-49 years) than male cardholders (15-49 years) compared with 27%(DHS 2008). Women aged 15-49 years have higher need for health care services (including maternal care) than men of the same age group, and until NHIS reaches universal coverage the ministry both expects and desires relatively higher female enrolment. Inequity in terms of socioeconomic status of NHIS active members by DHS and MICS surveys has significantly worsened since 2008. The indicator is calculated as the ratio of valid cardholders among women 15-49 years from the poorest quintile compared to women 15-49 years in the general population. The MICS survey demonstrates a modest increase in cardholders among the poorest women, but this increase is largely overtaken by a relatively higher national increase in cardholders. Curiously, equity among men of the same age group is significantly improving over the same period. The observed trend indicates that there is a financial access barrier for women from the lowest wealth quintile to enrol onto NHIS and/or renew their membership card. Reports from the district hospitals suggest that the poorest citizens choose to register with NHIS only when they anticipate a need for health services and subsequently discontinue their membership. This can lead to adverse selection that potentially creates challenges for the financial sustainability of NHIS. The recent evaluation of the Free Maternal Health Care Policy concludes that NHIS membership provided to pregnant women under the policy favours the poor. The evaluation also reports an increase in equity in the utilisation of health facilities for delivery. Analysis of survey-based coverage of supervised delivery 19

confirms this finding. Between 2008 and 2011 the surveys demonstrate a relative increase of 60% supervised delivery coverage among women from the poorest quintile. Figure 4: Supervised deliveries by wealth quintile, 2003-2011, Source DHS and MICS 2.1.5 Access to health services The National Health Insurance since its introduction has led to increase in utilization of OPD services across all the regions. The number of outpatients per capita continued previous years increase, and in 2012, the relative increase was 11%. OPD per capita reached 1.17, more than doubling 2006 figure. In regions like Upper East and Brong-Ahafo, which share borders with neighbouring countries, the high figure may be partly explained by patients coming from the neighbouring countries. Over 60% of those attending outpatient were females and overall women between the ages of 20-34 years were seen more often at the OPD than any other age group for males or females (Figure 5). With the backdrop of doubling OPD per capita rate, 80% of total outpatients insured and 34% of the population being active NHIS members, important questions can be raised: 1. Could the high proportion of OPD services be a reflection of frivolous use of services by NHIS members (moral hazard)? 2. Could it be a reflection of high NHIS membership among those in need of services, i.e. persons only register when they fall sick and refrain from renewing membership the following year (adverse selection)? 3. Has the NHIS led to increased equity in utilization of health services, i.e. equal access for equal need? 4. Could it be due to data capture problems? While the third question is a goal of establishing NHIS, a positive answer to question 1 and 2 provide a financial risk to NHIS, and these issues should be further analysed and addressed. 20

Figure 5: OPD visits by gender and age-group 2012, source GHS Ashanti region like all the regions showed an increase in OPD attendance till 2012 when it experienced a drop in OPD per capita (Figure 6). It was the year that the capitation was piloted in the region. It is not clear whether this reduction in OPD was due to reduction in inappropriate utilization by insured clients or reduction in access on account of the capitation. Ashanti Region was also the only region where the proportion of OPD clients with insurance fell (from 82.6% to 76.9%). Figure 6: NHIS membership and OPD visits per capita in Ashanti Region, 2012, source GHS and NHIA 21

Northern Region s low OPD per capita rate might be a reflection of poor geographical access in the Region. Although financial access has been facilitated with the health insurance, their overall OPD per capita remained low compared to the other regions. With the increase in OPD visits across the regions, there has not been equally significant improvement in infrastructure of most of the facilities to accommodate these increases. It is now more important than ever to ensure good service and clinical quality. Strategies for quality assurance for clinical care services should be developed for inclusion in new HSMTDP. Figure 7: OPD per capita by region, 2006-2012, Source GHS The National Ambulance Service expanded significantly opening 97 new stations in 2012. Total number of stations is 121 covering 70% of the 172 districts that existed when the HSMTDP was developed and targets were set. 2.2 Health Objective 2: Strengthen governance and improve efficiency and effectiveness of the health system 2.2.1 Improving efficiency and accountability In 2012, the ministry introduced performance contracts with four agencies; the three Teaching hospitals and Ghana Health Service. The ministry will sign performance contracts for 2013 with all its agencies. 2.2.2 Financing (based on MOH financial report 2012) In 2012, Government of Ghana contribution increased by 126.9% from GH 771 million in 2011 to GH 1,750 million in 2012. Internally Generated Fund (IGF) increased by 8.9% from GH 392 million in 2011 to GH 427 million in 2012. Contribution from donors in 2012 was GH 290.8 million whilst there was GH 259.2 million contribution in the same period of the previous year, an increase of 12.2% over the same period of 2011. In terms of percentage contributions by the various sources to the sector, GOG and IGF contributed 87.5% as compared with 78.6% in the same period of 2011. Donor contribution was 11.7% of Gross Revenue as against 17.5% of the previous year. 22

Total Gross Revenue, recorded by the Ministry was GH 2,489.8 million, the sources of which have been broken down in Table 4 and Figure 8. Source of Funds 2012 (as at December 2012) 2011 (December) Amount (GHC Mn) US Dollar (Mn) Percent Amount (GHC Mn) Percent GOG 1,750.2 921.1 70.3% 771.3 52.1% IGF 427.4 224.9 17.2% 392.4 26.5% Program - Donor 181.6 95.6 7.3% 154.5 10.4% Budget Support 109.2 57.5 4.4% 104.7 7.1% NHIA 15.1 7.9 0.6% 23.2 1.6% F/Credits 6.4 3.3 0.3% 35.5 2.4% TOTAL 2,489.8 1,310.4 100.0% 1,481.66 100.0% Table 4: Gross revenue distribution by source, source MOH Financial Report 2012 Figure 8: Percent gross revenue distribution by source, source MOH Financial Report 2012 The Ministry recorded a total expenditure of GH 2,613.4 million for the period under review (Table 5). Out of this amount, 63.4% was for Employee Compensation as against 53.9% for the same period of 2011. 23

Expenditure incurred on Goods and Services was 34.5% as compared to 38.0% in 2011 whilst that incurred on Assets was 2.2% compared to 8.1% in 2011 for the same period. For the Year Ended 31st December, 2012 (GH 'million) GOG IGF B/SPT MOH PROG NHIA F/CRED TOTAL Percent Employee Compensations 1,613.4 42.2 0.0 0.0 0.0 1,655.7 63.4% Goods and Services 104.7 407.0 156.6 220.1 12.1 0.0 900.5 34.5% Assets 30.5 6.7 12.0 0.0 1.7 6.4 57.2 2.2% TOTAL 1,748.6 455.88 168.55 220.1 13.9 6.4 2,613.4 100.0% Table 5: Expenditure distribution by item, source MOH Financial Report 2012 Figure 9 below shows comparative pattern of expenditure between 2011 and 2012 in absolute terms. Employee Compensation increased significantly from GH 754.7million in 2011 to GH 1,655.7millon as a result of the movement from the Health Sector Salary Scale (HSS) to the Single Spine Salary Pay Policy (SSSPP). Figure 9: Comparative Expenditure Distribution 2011 and 2012, source MOH Financial Report 2012 At the end of 31st December 2012, total cash balances were GH 173.5 million as against GH 215.1 at the end of 31st December 2011. These amounts represent balances standing in the books of the various health facilities nationwide and MOH/GHS Headquarters. Debtors have decreased from GH 137.7 in December 2011 to GH 115.9m in December 2012, a decrease of 15.8%. A large proportion of the debts are IGF related, emanating from non-payment of service bills by the NHIA. Most of the debts are owed to the District Hospitals; institutions which are no more benefiting from GOG and Sector Budget Support/Health Fund but are now depending solely on IGF for the operation of the Goods and Services budgets. 24

2.2.3 National Health Insurance Active membership of the scheme stood at 34% short of the target of 45% (Figure 10). The indigent definition was revised and the common targeting developed. With these revisions, some categories of persons with disability and mental health patients were covered under the exemption policy. The Common targeting mechanism is being piloted in 90 districts. Fifty three thousand two hundred and seventeen out of 200,000 LEAP beneficiaries were covered. The National Health insurance authority accessed only 48% of all receivable funds during 2012 and this had implication for timely reimbursement to providers. An analysis by the NHIA showed that the scheme cannot be sustained at the current level of operation. A policy paper including sustainability analysis was submitted to the government for consideration. To strengthen premium collection scheme level, a consolidated premium account was established. About 46% of earmark funds for the ministry of health was released whiles 94% of expected funds was released to members of parliament. Until recently, returns from investment formed a substantial part of the total funds of the scheme. However due to recent financial difficulties, the authority had not been able to invest and have had to plough back its savings to keep the scheme afloat. To reverse this trend, the authority developed an investment policy and guidelines to provide guidance to the authority. The authority realised 6.5% real rate of returns on investment exceeding its target of 4%. Its investment income for the year was GHc27.67m as against a target of GHc18m. The NHIA intensified clinical audit of the district schemes and providers. During the year, 157 providers were audited and 128 schemes visited. An amount of GHc20.1 was recommended for recovery for the 2010-2012 period with GHc7.5m recovered in 2012. A uniform prescription form was piloted in the Greater Accra Region and systems for linking treatment to diagnosis were developed. These were meant to increase technical efficiency. The authority also hoped to improve efficiency by diversifying provider payment mechanism. As a result Capitation was piloted in the Ashanti region for which a mid-term evaluation was conducted. 25