CONTEXT FOR REFORM
Ghana’s health system is characterised by rising cost and lack of a sustainable financing model; limited availability of doctors (population growing faster than doctor levels). This has led to inefficient health care system that produces poor quality outcomes. There is an urgent need to improve accessibility, responsiveness, efficiency, coverage, quality, sustainability and value for money.
To achieve a health care system that is: universal, accessible, affordable, high quality, sustainable and good value for money
1. ACHIEVING UNIVERSALITY AND ACCESSIBILITY
i) Primary care: local health centres and mobile/ tele clinics manned by health care professionals – medical assistants, senior nurse practitioners. Ghana already operates the ‘close to patient’ system with community health centres manned by community nurses & auxiliary health professionals. Mobile & tele health centres should be use to complement these and achieve universal coverage and accessibility. Both the community health centres & mobile/tele clinics should be manned by medical assistants, senior nurse practitioners.
ii) Tele health services are expanding across South America – Mexico, Columbia & Peru. These services use special apps or software for patients to self report symptoms and receive rapid advice/referrals or for patients to self monitor and feedback to their health practitioners. Tele health services slash cost, unblock hospital beds and congestion, and reduce mortality. An ongoing study by the UK department of health shows that the use of tele health services to manage chronic diseases reduced cost and mortality by 20 and 45 percent respectively.
iii) Secondary care: hospitals will focus on secondary, specialist & emergency care. World class specialists facility in each regional capital and national centres of excellence like Korle Bu, Komfo Anokye, Tamale and Cape Coast teaching hospitals will established, encouraged and supported.
Non-profit local and international organisations will be fiercely attracted to establish hospitals and specialist centres to complement state ones. 50 and 90 percent of hospitals in Germany and Netherlands respectively are run by non-profits
Population growth and changing health needs of the population requires significant high numbers of doctors, which is impossible to provide both in the short and long terms if Ghana were to provide universal, affordable and quality health care. WHO recommends 1 doctor per 1000 people to achieve adequate health care package. Ghana has 0.15 per 1000 people (Sudan and Haiti have 0.22 and 0.25 per 1000 respectively).
i) New way of training doctors and new career path for doctors: doctors will be encouraged and incentivised to specialise (post graduate training) and left to do the complex procedures at secondary and tertiary health facilities. This is a win-win approach: boost career path and entitlements of doctors, and generate pool of expertise for efficient and quality heath care.
ii) Use auxiliary /alternative professionals to doctors: it takes less time and cost to train medical assistants and senior nurse practitioners. Studies in India, Britain, South Africa, Japan, Israel and Australia show that non-doctors (nurse practitioners, rural health care workers, physician assistants) are able to do basic diagnosis and treatment like doctors without compromising quality. Technology advancement makes this easier and helps non- doctor trained health professionals to examine, diagnose, prescribe and treat basic and common illnesses. India has proposed a 3 and half year degree programme to let graduates deliver health care in rural areas, to enhance its physician per population ratio. India is the pioneer of this system, although, other western countries including America and Britain are considering implementing some aspects. Narayana Hindayala (heart centre), Life Spring (maternity centre) and Aravind Eye Care Hospitals use doctors for complex surgeries/procedures and auxiliary health professionals for basic procedures without compromising quality – they are world renowned centres.
2. CREATING A SUSTAINABLE FINANCING MODEL
Ghana’s current per capita expenditure on health of $23 is far below the World Bank recommended $30 – 40 for the achievement minimum standard health package. A combination of public and private financing will be used to make accessibility, affordability and quality attainable.
i) Basic universal coverage (NHIS) through universal taxation (as in Canada, Sweden, Britain). Indirect tax system would be more effective given the large informal sector of Ghana’s economy. The National Health Levy will be enhanced and made more effective.
ii) Employee tax free contribution ( social insurance – as in Germany, France, Netherlands) for those in employment (formal and informal sectors) for ancillary health services e.g. dental and eye care
iii) Cost sharing of ancillary health services for the poor ( as in France): through general health budget or special fund
iv) Private health insurance for those who can afford. They can use this for top up ( private care provision) and luxury services e.g. cosmetic enhancement
3. MAKING THE SYSTEM RESPONSIVE TO CHANGING SOCIETAL NEEDS
Population growth and changing demographic make up has been accompanied by changing lifestyles and health issues including poor sanitation and eating habits – serious health implications.
i) Increase investment in prevention and a strong proactive public health service: good sanitation and environmental safety, smoking prevention & cessation, STI prevention and rapid treatment; lifestyle and healthy living education; obesity prevention. The three major causes of morbidity and mortality in Ghana now are malaria, acute respiratory tract infections and diarrhoea diseases, which are mainly caused by poor sanitation. Investing in prevention will save money and lives.
ii) Improving quality: put in place quality assurance systems – key performance indicators for practitioners, health centres, and hospitals; annual assessments of health centres and hospitals; evidence based universal practice & performance guidelines to standardise procedures across board, particularly for primary care practitioners who are not qualified doctors but medical assistants and senior nurse practitioners;
iii) Invest in and implement information technology systems to coordinate activities of health centres and hospitals – monitor demand for specialist services & outcomes; assess performance; coordinate treatment procedures between health centres and hospitals and among professionals.
iv) Reduce medical negligence and errors through use of evidence based universal practice & performance guidelines; better patient – professional relationship; enacting medical negligence laws, office of ombudsman and professional accountability standards; making available results of assessments of quality of health centres and hospitals to patients.
5. ACHIEVING VALUE FOR MONEY
America spends 18 percent of its GDP on health, Canada, France, Germany, Britain spends about half but have far better health outcomes. More (better outcomes and quality) can be achieved with less (cost).
i) Bulk purchase negotiations with pharmaceuticals, as done by Canada and most countries with public funded health systems. Most out of patent drugs are cheaper – even patented drugs cheaper when bulk purchased
ii) Establish a body similar to UK’s NICE (National Institute of Clinical Evidence) to provide independent and evidence based assessments and guidance on quality, cost effectiveness and value for money of medicines and interventions. 3 ways of doing this: a) Ghanaian version of NICE; b) broader regional version of NICE with others countries e.g. Nigeria, South Africa, Kenya – this version will increase the negotiation power of the body with pharmaceuticals re. bulk purchasing and pricing; c) Ghanaian version in partnership with UK NICE ( NICE UK provide advice and guidance to partner countries re. quality and cost effectiveness)
iii) Modify payments and incentive systems for practitioners to ensure incentives do not undermine provision and cost efficiency. Pay structures of practitioners will be modified. All levels of care practitioners (primary, secondary, tertiary) will be paid salaries. Alternatively, primary care practitioners may be paid with mix of capitation grant plus performance payments as in UK.
iv) Flexible working conditions for secondary and tertiary doctors will be encouraged and with an option to engage in private practice along side public practice as a long as they clock up their working hours with the public practice. This should minimise any opposition to the changes in personnel and payment structure by the powerful doctors unions.
v) Reallocate services/ resources to needed areas. Improved information systems will help monitor and coordinator activities of the sector, and help in predicting demand for services and resources.