Danida s involvement in the Ghanaian health sector

Danida s involvement in the Ghanaian health sector 1994-2015 DOCUMENTATION STUDY TECHNICAL REPORT Final report 20/01/2016 Andreas Bjerrum

TABLE OF CONTENTS LIST OF ABBREVIATIONS... 4 INTRODUCTION... 6 BACKGROUND... 7 GHANA AFTER 1957... 7 REDUCTION IN POVERTY... 8 ACCESS TO WATER & SANITATION... 8 NUTRITION... 8 EDUCATION... 8 THE HEALTH SECTOR... 9 DANIDA S SUPPORT TO GHANA S HEALTH SECTOR... 15 CHRISTIAN HEALTH ASSOCIATIONS OF GHANA (CHAG)... 18 BACKGROUND... 18 RECOGNITION OF CHAG BY MOH... 18 DANIDA SUPPORT TO CHAG... 18 EXEMPTIONS AND NATIONAL HEALTH INSURANCE... 20 BACKGROUND... 20 EXEMPTIONS FROM CASH & CARRY... 21 DANIDA SUPPORT TO EXEMPTIONS... 22 COMMUNITY BASED HEALTH INSURANCE... 22 MOVE TO NATIONAL HEALTH INSURANCE... 23 DANIDA SUPPORT TO THE NHIS... 24 SUPPORT TO INFRASTRUCTURE AND CAPITAL PROJECTS IN UPPER WEST REGION... 26 BACKGROUND... 26 DANIDA SUPPORT TO UWR... 26 SEXUAL AND REPRODUCTIVE HEALTH RIGHTS, HIV/AIDS AND THE MDG 5 ACCELERATION FRAMEWORK... 28 BACKGROUND... 28 ORGANISATION OF GHANA S RESPONSE TO HIV/AIDS... 28 DANIDA SUPPORT TO THE NATIONAL AIDS RESPONSE... 29 DANIDA SUPPORT TO SEXUAL AND REPRODUCTIVE HEALTH RIGHTS (SRHR)... 30 MDG 5 ACCELERATION FRAMEWORK (MAF)... 30 SECTOR WIDE APPROACH, DONOR COORDINATION AND DANIDA S FALL-BACK POSITION... 32 BACKGROUND... 32 DANIDA SUPPORT TO THE HEALTH SECTOR BUDGET... 32 DANIDA S FALLBACK POSITION... 33 MOVE TO SBS (2008-2014)... 33 MOVE AWAY FROM SBS TOWARDS EARMARKED SUPPORT (2015-2016)... 34 MASTER IN INTERNATIONAL HEALTH AT COPENHAGEN UNIVERSITY... 35 STATEMENTS FOR FORMER MIH STUDENTS... 35 2

TIMELINE... 38 ANNEX 1: METHODOLOGY... 39 THE TECHNICAL REPORT... 39 THE ELECTRONIC PAPER... 40 ACCOMPANYING VIDEO... 40 ANNEX 2: OVERVIEW OF DANIDA HEALTH SECTOR PROGRAMME SUPPORT PHASE I-V... 42 HEALTH SECTOR SUPPORT PROGRAMME (HSSP) I:... 42 HEALTH SECTOR PROGRAMME SUPPORT (HSPS) II:... 42 HEALTH SECTOR PROGRAMME SUPPORT (HSPS) III:... 43 HEALTH SECTOR PROGRAMME SUPPORT (HSPS) IV:... 43 HEALTH SECTOR PROGRAMME SUPPORT (HSPS) V:... 43 ANNEX 3: LIST OF ACCESSED DOCUMENTS AND LITTERATURE... 45 ANNEX 4: PERSONS INTERVIEWED (ALPHABETIC)... 50 ANNEX 5: TERMS OF REFERENCE... 51 3

LIST OF ABBREVIATIONS 5YPOW Five Year Programme of Work AIDS Acquired Immune Deficiency Syndrome ART Anti Retroviral Treatment CHAG Christian Health Associations of Ghana CHI Community Health Insurers CHPS Community Based Health Planning and Services CMA Common Management Arrangements CSW Commercial sex workers DFID UK Department for International Development DHS Demographic and Health Survey DMHIS District Mutual Health Insurance Scheme DP Development Partner EPI Expanded Programme of Immunisations GAC Ghana AIDS Commission GDP Gross Domestic Product GHC Ghana Cedi GHS Ghana Health Service GOG Government of Ghana GPRS Ghana Poverty Reduction Strategy GSGDA Ghana Shared Growth and Development Agenda HIV human immunodeficiency virus HSAO Danida Health Sector Advisory Office (after 2008) HSPS Health Sector Support Programme HSSO Health Sector Support Office (2008 and before) IGF Internally Generated Funds IMF International Monetary Fund LLIN Long lasting insecticide treated nets M&E Monitoring and Evaluation MAF MDG 5 Acceleration Framework MARP Most at Risk Populations MDG Millenium Development Goal MICS Multiple Indicator Cluster Survey MIH Mater of International Health MOF Ministry of Finance MOH Ministry of Health MSHAP Multi-Sectoral HIV/AIDS Project MSM Men having sex with men MTEF Medium-Term Expenditure Framework MTHS Medium Term Health Strategy NACP National AIDS Control Program NCD Non-communicable Disease NDC National Democratic Congress NGO Non-governmental Organisation 4

NHIF NHIL NHIS NHIS NPP NSF NSP OPD PLHIV POW RDE SBS SBS SPH SRHR SSNIT SWAp TB U5MR USAID UWR WHO National Health Insurance Fund National Health Insurance Levy National Health Insurance Authority National Health Insurance Scheme New Patriotic Party National HIV and AIDS Strategic Framework National Strategic Plan for HIV and AIDS Out-patient department People Living with HIV Programme of Work Royal Danish Embassy Sector Budget Support Sector Budget Support School of Public Health Sexual and reproductive health rights Social Security and National Investment Trust Sector Wide Approach Tuberculosis Under five-mortality rate United States Agency for International Development Upper West Region World Health Organisation 5

INTRODUCTION Denmark has supported the health sector in Ghana since 1994. Throughout the years, Danida has advocated for a strong pro-poor focus and advocated for primary health care interventions aimed at the poorest Ghanaians in the most remote areas and with the highest mortality rates. Since the first health sector support programme, the assistance has gradually moved from a project approach to sector wide approach and sector budget support (SBS). Danida has throughout valued a strong engagement in the policy dialogue on issues of key strategic importance to the sector development and to Danida. Despite being a relatively small player, Danida s support has been very well received amongst various government-, civil society- and fellow development partners. Danida s 22-year long commitment and both technical and financial support to the Ghanaian health sector has contributed to substantial improvements in the sector: The geographical- and financial access to health care has improved; the child mortality rates have gone down; the impact of communicable diseases, especially malaria, has been reduced, etc. Danida support to the health sector will end in 2016, and in October 2014, a consultant team came to Ghana to provide technical advice and recommendations to Danida for an exit strategy. One of the recommendations, the team made, was to document the experiences from Danida s long involvement in Ghana s health sector. This report is part of a larger attempt to follow up on this recommendation. The purpose of has not been to evaluate Danida s involvement but rather highlight and document aspects of a long partnership, which were found to be of particular interest. The selection of focus areas was based on an extensive and systematic review of available literature. Based on a desk-review of available literature, the report provides a thorough overview of the most significant results of the partnership in health between Denmark and Ghana. While the report discusses many of the major reforms in the sector, as well as their impacts on health, it is beyond the scope of the report to systematically document all sector reforms in the period under investigation. This report will provide the technical basis for and a more audience friendly communication for the Danish and Ghanaian public in form of an Electronic paper. The electronic paper contains a selection of casestudies that highlight Danida s influence on the health sector during the years and is accompanied by video material where the selected case-studies are displayed via film. 6

BACKGROUND GHANA AFTER 1957 Ghana is a medium sized country with a population of about 27 million people. The country is divided into 10 administrative regions, which his again sub-divided into 216 metropols, municipalities and districts. Approximately half of the population lives in rural areas with variable access to health care facilities. Ghana got independence in 1957 with Dr. Kwame Nkrumah as President. After 1966 the country went through a fairly unstable political period with a number of military coups. Multi-party democracy was reinstated by the military ruler Jerry John Rawlings in 1992, who with his party National Democratic Congress (NDC) won the elections in 1992 and 1996. This was followed by two victories for the New Patriotic Party (2000 and 2004). In 2008, NDC returned to power and maintained the presidential seat in the 2012 elections under the leadership of president John Dramani Mahama. These shifts in ruling party through relatively peaceful elections makes Ghana an example to follow in Africa. After relative prosperity in the 1960s, the economy experienced deterioration from the early 1970s, with falling GDP, soaring inflation (up to more than 100% per annum), increasing state control of the economy as well as increasing ineffective public sector management, decreasing exports and imports, and increasing poverty. On this background the Government adopted the Economic Recovery Programme in 1983 in agreement with the IMF, the World Bank and with support of bilateral donors. This resulted in several years of increasing economic stability, liberalisation, falling inflation (10% in 1992) and GDP growth rates of more than 5% a year, but also deteriorating conditions for the poorest population. Ghana s economy was rapidly growing, and in 2010, Ghana was classified as a Lower-Middle Income Country. Ghana s economic growth rate topped 9% in 2011, but three difficult years followed that were characterized by slowing activity, accelerating inflation, and rising debt levels and financial vulnerabilities 3. The country s economic prospects were put at risk by the emergence of large fiscal and external imbalances, as well as by electricity shortages. Growth decelerated markedly in 2014, to an estimated 4.2%, driven by a sharp contraction in the industrial and service sectors. This was due to the negative impact of the currency depreciation on input costs, declining domestic demand, and increasing power outages 3. Inflationary pressures rose on the back of a large depreciation of the cedi and the financing of the fiscal deficit by the Bank of Ghana. In 2015, the IMF approved a $918 million loan to Ghana to support a reform program aimed at faster growth and job creation while protecting social spending. The reform program seeks to boost growth and help cut poverty by restoring macroeconomic stability through tighter fiscal discipline, strengthened public finances, and slowing inflation 3. Today the health sector in Ghana still faces steep financial challenges. The sector requires more financial resources to consolidate the gains made and accelerate progress in several critical areas. The resources allocated to health sector programming in the 2016 Budget Statement is unlikely to make that possible to achieve. This has created concern that the progress made on several health indicators over the past decade will backslide and have a negative impact on the health status of the Ghanaian population 4. 7

REDUCTION IN POVERTY The population living in poverty decreased from 51.7% in 1991/92 to 24.2% in 2012/13 5. This indicates that about 6.4 million people in Ghana were poor in 2013. Extreme poverty is defined as those whose standard of living is insufficient to meet their basic nutritional requirements even if they devoted their entire consumption budget to food. Given the extreme poverty line, an estimated 8.4% of Ghanaians are considered to be extremely poor 5. The incidence of extreme poverty almost halved compared to the 2005/06 revised extreme poverty incidence of 16.5%. Still, more than 2 million cannot afford to feed themselves, even if they were to spend all their money on food. Although the absolute number living in extreme poverty has reduced significantly over time, it is still quite high given the fact that Ghana is considered to be a lower middle-income country. Extreme poverty is a rural phenomenon, with as many as over 1.8 million persons living in extreme poverty in rural areas. Urban localities contribute only about 10% to the national incidence of extreme poverty 5. ACCESS TO WATER & SANITATION In the latest Multiple Indicator Cluster Survey (MICS) survey from 2011, nearly 80% of household members in Ghana were using improved sources of drinking water, which means that Ghana had already achieved the MDG 7.C target of 78% of the population using improved drinking water 6. However, wide variations exist between areas of residence with 91% coverage in urban areas and only 69% in rural areas. In the 2011 MICS survey, only 15% of household members were using an improved and not shared sanitation facility 6. Nearly 1 out of 4 (23%) of households in Ghana practiced open defecation or had no toilet facility, and this was more pronounced in rural areas (35%) than urban areas (10%). FIGURE 1: PREVALENCE OF UNDERWEIGHT CHILDREN UNDER FIVE YEARS. SOURCE DHS AND MICS. 30 25 23% 25% 22% NUTRITION Ghana halved the prevalence of underweight among 15 children below the age of five years between 1990 11% and 2015 and met the target 1.C of the MDGs. Still 10 almost one in nine children (11%) under the age of five years is underweight (weight-for-age) and 2% can be classified as severely underweight 7. Moreover, 5 0 nearly 1 in every 5 children (19%) is moderately or severely stunted (height-for-age), and 5% are severely 1990 1995 2000 2005 2010 2015 stunted. Five percent of the children are moderately or severely wasted (weight-for-height), and 0.7% can be considered severely wasted. Children in the highest wealth quintile are less likely to be underweight (7%) and stunted (9%) compared to children from the lowest wealth quintile (16% and 25%, respectively) 7. 20 18% 14% 13% EDUCATION In 2011, 61% of young women (aged 15-24 years) and 71% of young men (aged 15-24 years) were literate 6. In the richest wealth quintile, 85% and 93% of young women and men respectively were literate while in the poorest wealth quintile only 31% and 41% of young women and men were literate. 8

THE HEALTH SECTOR There has been a remarkable progress in the health sector since 1990 compared to other countries in Sub- Saharan Africa. Life expectancy at birth increased from 57 years in 1990 to 61 years in 2012 8, child mortality declined by over 50% 7 and maternal health improved substantially 7,9. According to WHO, the leading causes of diseases are from the maternal, neonatal and nutritional cause group, the HIV, TB and malaria cause group, and the other infectious diseases cause group. The majority of health services are provided by the public sector and private-not-for-profit facilities 2. There are four teaching hospitals in Ghana, and regions without a teaching hospital have a regional referral hospital. Most of the 216 districts have a district hospital. Districts are further divided into sub-districts with health centres manned by midwives, nurses and/or physician assistants. At the lowest level of the health system, Ghana is expanding a community based health service (CHPS), which aims at placing a community health nurse in each of Ghana s electoral areas. HEALTH STATUS IMPROVEMENTS Since the period for Danida s support to Ghana s health sector is largely coinciding with the era of the Millennium Development Goals, health status improvement will be measured against progress towards achieving the health related MDGs. MDG 4 Child Health The under five-mortality rate (U5MR) is generally regarded as a good overall indicator of the health of a population. In 1990, U5MR was 128 deaths per 1000 live births. The target was reducing mortality by two thirds to 43. The latest survey from 2014, estimates U5MR at 60 deaths per 1,000 live births 7. While this mortality rate is substantially higher than the target of 43, it demonstrates that child mortality has fallen over 50% since 1990. Still one child dies for every 17 life births and it has been estimated that in average, a child dies every 15 minutes in Ghana. Reduction of infant mortality rates (death before age of 1 year) and neonatal mortality rates (death before age of 28 days) have seen similar trends but with less steep declines. FIGURE 2: UNDER FIVE MORTALITY RATE (PER 1000 LIVE BIRTHS). SOURCE MICS AND DHS. 140 120 119 120 100 80 60 40 20 108 111 80 82 0 1990 1995 2000 2005 2010 2015 60 MDG 5 Maternal Health Since 1990, there has been an impressive increase in the proportion of pregnant women who choose to deliver at health facilities, and the latest survey from 2014 showed that 74% of all deliveries were supervised by a skilled provider 7. Survey based figures for supervised delivery are normally higher than routine figures due to incomplete reporting, inadequate coverage of non-governmental providers and inaccurate population estimates in the routine reporting system. In 2014, the skilled delivery rate based on routine information was 57% 2. 9

The Maternal Mortality Ratio has dropped from an estimated 760 maternal deaths per 100,000 live births in 1990 to 380 in 2013 1. FIGURE 4: MATERNAL MORTALITY RATIO PER 100,000 LIVE BIRTHS 1. FIGURE 3:PROPORTION OF BIRTHS ATTENDED BY SKILLED HEALTH PERSONNEL (%) 800 700 600 500 400 760 650 570 470 380 80% 70% 60% 50% 40% 40% 44% 44% 47% 50% 59% 68% 74% 300 30% 200 20% 100 10% 0 1990 1995 2000 2005 2010 2015 0% 1990 1995 2000 2005 2010 2015 MDG 6 - HIV/AIDS, Tuberculosis and Malaria Tuberculosis A National TB prevalence survey was completed in 2013. Based on a sample of 64,000 individuals, the survey found an overall TB prevalence of among adults of 356/100,000 (National Tuberculosis Programme, Ghana, data unpublished); much higher that the current WHO estimated prevalence of 71/100,000. Low TB case detection remains one of the main challenges in Ghana. In 2009, WHO reported that only 26% of TB cases were detected. This was well below the African regional average of 47% and the WHO target of 70%. FIGURE 5: TB MORTALITY (DEATHS CAUSED BY TB PER 100,000 POPULATION) 35 32 30 25 20 15 10 5 27 23 0 1990 1995 2000 2005 2010 17 11 8 The estimated TB mortality has declined from 32 deaths per 100,000 per year in 1990 to 9 per 100,000 in 2013. These figures are however estimates that do not take the revised national TB prevalence into consideration. Once TB is diagnosed and the patient is started on TB treatment, the treatment success rate is high with treatment success figures above 85% since 2008. 10

HIV The HIV epidemic is moderate with a prevalence of 1.4% in the general population in 2012, but with a marked regional difference. Since Anti Retroviral Treatment (ART) was implemented in 2004, Ghana has rapidly scaled up provision of ART and by 2012, 58% of all individuals with advanced HIV were on ART. Deaths due to HIV decreased from 89.1 to 40.1 per 100,000 population between 1990 and 2013. FIGURE 6: HIV PREVALENCE AMONG WOMEN AGED 15-24 YEARS. 3.0% 2.5% 2.5% 2.0% 1.5% 1.9% 2.5% 2.6% 1.9% 2.1% 1.7% 1.7% 1.3% Malaria The number of children admitted with malaria has 0.5% continued to increase over the past years. This may indicate that efforts to prevent severe malaria are 0.0% not effective or that other infectious conditions are misclassified as malaria. It may be that health workers are not adhering to guidelines for diagnosing malaria particularly with the use of RDTs. In 2003, about 3.6% children admitted with malaria died from the infection 10. In 2014, this figure was reduced to 0.5% 2. This is a reduction of over 85%. The highest case fatality is observed in Central and Northern Regions with 1.38 and 1.06 deaths per 100 admissions, respectively. The use of long lasting insecticide treated nets (LLINs) is one of the most effective ways to prevent malaria infections and deaths. Since 2006, the proportion of children sleeping under LLINs has doubled and in 2014 almost half of all children slept under an LLIN the previous night. 1.0% 2004 2006 2008 2010 2012 UTILISATION OF HEALTH SERVICES The average number of outpatient visits increased from 0.38 in 1998 to 1.17 in 2012 2,10, but since 2012, the per capita attendance has been stable around 1.15 visits per person per year 2. The national average hides large regional variations in performance and trends. The region with highest uptake of OPD services is Upper East, while the lowest is Northern Region. Patients insured by NHIS make about three quarters of all new OPD visits. The largest providers of OPD services are government facilities with about 55%, private providers and Christian Health Association of Ghana (CHAG) with 23% and 19%, respectively 2. FIGURE 7: PROPORTION OF CHILDREN UNDER 5 SLEEPING UNDER INSECTICIDE-TREATED BEDNET 50% 47% 39% 40% 30% 28% 22% 20% 10% 4% 0% 2003 2005 2007 2009 2011 2013 11

HUMAN RESOURCES FOR HEALTH In 1999, Ghana had a total of 1,115 doctors 11. This number almost tripled to 3,016 doctors in 2014 2, and the doctor to population ratio improved from one doctor per 16,500 population in 1999 to one doctor per 9,043 persons in 2014. There are large interregional variations with one doctor per 2,700 population in Greater Accra compared to 1 doctor to 36,000 population in Upper West Region. But with an increase of 50% more doctors in Upper West, this inequity gap reduced in 2014. The large number of doctors in Accra, leading to marked inequity, can to some extend be explained by newly trained doctors who work as house officers and are attached to Medical and Dental Council in Accra 2. The number of nurses in Ghana was relatively stable between 1999 and 2011 with a nurse population of about 16,000 2,11. Since 2011 the number of nurses has seen tremendous increase to over 28,000 in 2014 2. In 2014, the nurse to population rate was about 1 nurse per 1,000 persons. About half of all nurses included in the computation are community health nurses. HEALTH SECTOR ORGANISATION Before passing of the Ghana Health Service and Teaching Hospitals Act, Act 525 in 1996 the Ministry of Health (MOH) was responsible for direct provision of health services in addition to stewardship functions, e.g. policy making, resource mobilization and monitoring. The Ministry found itself unable to perform all of these functions efficiently and effectively. There was a need to reassign them to different agencies with the MOH retaining overall responsibility for policy, resource mobilization and monitoring of outcome of healthcare interventions. What was envisaged ultimately was a purchaser-provider split with the MOH as the purchaser and regulator of service provision. Direct provision of health services was transferred to the Ghana Health Service (GHS) and the Teaching Hospitals, which became the key implementing agencies with responsibility for managing and delivering public sector health services. It was anticipated that the role of the MOH would increasingly focus on policy development, coordination, resource mobilisation, monitoring and evaluation. Statutory bodies were created to set out the rules of the game 11. As part of the health reforms, District Health Management Teams, responsible for overseeing health service delivery at district level, have since 1995 received, and directly managed, increasing non-wage resources. The private sector plays a large role in health care provision. 30-40% of health services are delivered by non-governmental providers with the Christian Health Association of Ghana as a central actor. Health Care Financing Health care financing in Ghana has gone from free health care with all costs borne by government, to the present era of a mixed government-funded and cost recovery system that includes a combination of health insurance and direct out-of-pocket payments. FIGURE 8: PROPORTION OF OPD SERVICES BY OWNERSHIP IN 2014 2 Quasi- Governmen t 3% Private 23% CHAG 19% Governmen t 55% 12

Immediately after independence in 1957, health care was financed entirely through tax revenue and provided to people free in public health facilities. There was no requirement for direct out-of-pocket payment at the point of consumption. Financial sustainability became challenging as the economy began to show signs of decline. The standard of health care provision fell considerably, and there were acute shortages of essential drugs and other commodities. The situation continued until 1985 when GOG introduced user fees for all medical conditions except certain specified communicable diseases. The feefor-service payment mechanism put in place was termed Cash and Carry. Patients that came to health facilities had to pay for services, but few could afford it. This led to a large decline in utilisation of health services and constituted a financial barrier to health care for the poor. Since the enactment of the National Health Insurance Act in 2003, the National Health Insurance Authority (NHIA) has, over time, become the main financing source of service delivery in Ghana 12. Some critical aspects of primary health care continue to be funded through MOH, i.e. health promotion, specific preventive campaigns and general system strengthening including quality assurance, supervision, and M&E 12. Despite a strong political commitment to prevention, the increasing significance of Internally Generated Funds (IGF), which basically can be seen as reimbursement for curative services, risks unintentionally to skew health expenditure towards curative care 12. The National Health Insurance Scheme has been increasingly financially challenged over the past years. This has led to delayed reimbursement of healthcare providers and introduction of informal user fees. The preventive health services are chronically underfinanced, which is becoming increasingly challenging as several international development partners are withdrawing their support. Cost of salaries is dominating the budget with over 98% of the Government of Ghana s allocations to the Ministry of Health spent on maintaining the work force in 2013 2. Total health expenditure, including private expenditure, for 2005 was US$680.55 million, rising to US$964.68 million by 2010 12. This represented a 42% increase in total health expenditure within the fiveyear period in terms of US dollars. In 2005, Ghana spent 6.4% of its GDP on health 12. However, total health expenditure as a percentage of GDP in 2010 fell considerably to 3.3%. This result is related to the rebasing of the GDP in 2006, which showed that the economy in US dollars grew by over 200% within the five year period 12. The increase in the size of the economy did not match the expansion in health expenditure, which increased by about 40%. Public funding for health increased sharply from US$201.4 million in 2005 to US$662.9 million in 2010 12. In 2005, Government of Ghana (GOG) general revenue amounted to US$180.7 million, constituting 89.7% of public funds 12. However, by 2010, GOG general revenue decreased to 58.1% due to a marked increase in National Health Insurance Fund (NHIF) levies in 2010. Public funds from the NHIF increased from US$20.8 million in 2005 to US$277.9 million in 2010 12. Private funds were relatively constant between 2005 and 2010, rising slightly from US$118.7 million in 2005 to US$122.8 million in 2010 12. Between 2005 and 2010, donor funds fell significantly from US$360.5 million to US$178.9 million 12. In summary, financing has seen increases in absolute terms in recent years although the health sector is losing ground as measured by percentage of GDP. The proportion of funding from public funds, private 13

funds and international funds has changed dramatically over the last five years and can generally be characterized as a shift from international funds to Ghana public funds. There are many new actors and changing financing structures with less donor financing of the health system and the NHIS becoming the main financing agent. Health Sector Programmes of Work In 1992, national conferences on 'decentralisation' and 'integration of vertical programmes' were held in Ghana. This was followed by a National Consultative Meeting on Health Development in late 1993, which set an agenda for reviewing overall policies and strategies. The MOH transformed the wide variety of inputs from the working groups into the Medium Term Health Strategy (MTHS) issued in late 1995. The MTHS was operationalised into the first Five Year Programme of Work (5YPOW), POW I, covering the period 1997-2001. The Programmes of Work serve as plans for the whole health sector and describe health activities funded through public resources, including Government, donor, and internally generated funds. The result of these processes was a more coherent and jointly supportive approach on policy and operational matters, including steps towards unified planning, implementation, and monitoring procedures. The Government reform initiative, as described in the MTHS, emphasised the development of systems through a sector-wide approach. Sector Wide Approach (SWAp) Prior to the first 5YPOW, the decline in the national economy meant that overall resources available to the health sector from government were shrinking in real terms. For 10 years (between 1985 and 1995), government allocation to the Ministry of Health was approximately $6 per capita per year compared to $10 per capita in 1978 11. Donor funding to the sector had increased substantially from 25% of the total public health budget prior to 1992 to 30% in 1994 11. However, donor funds were uncoordinated and tied to specific programmes and capital inputs. The channelling of the funds also created parallel management systems and disrupted overall systems development. In 1999, as a reaction to the poor donor coordination, the GOG stated that development aid to the health sector should be provided as part of the government budget and be managed through a strengthened government system rather than through parallel systems. This would allow the government budget to properly reflect overall health sector priorities 13. Danida participated actively and supported this direction with a view to changing its modality of support to health sector programme support 10. The health sector relationship with donors under SWAp underwent considerable change from project-type approaches (with donors in control) to a government-led-and controlled approach. The partnership gained considerable success in policy dialogue, joint performance assessment of the sector, co-ordination of activities to reduce duplication of effort, improved financial management and procurement and general planning for the health sector 10. Danida played a key role in furthering the SWAp approach internationally and co-hosted with the World Bank a conference on the issue in Copenhagen in 1997, and also co-sponsored with the European Commission, WHO and DFID the first guide on SWAp 10. Common Management Arrangements The Common Management Arrangements (CMA) represent one of the core components of the SWAp, and is a key accompanying document to the Programmes of Work. Whilst the POW documents set out the direction for the sector for the medium term in terms of policy and key implementation strategies, the 14

CMA focuses on the management systems, which need to be in place in the sector for the policies outlined in the POW to be successfully implemented. The CMA spells out the key functions and roles of the various sector agencies and partners in the various stages of management (planning and budgeting, financial management, performance monitoring etc.). Health sector reviews, health summit and business meetings Joint independent MOH/GHS/Health partner reviews with external assistance, assessing sector priorities and performance were carried out every year between 1998 and 2010. Since the review of 2011, annual sector reviews were conducted by MOH in the form of Holistic Assessments. The annual health sector review forms the basis for MOH/Health Summit meeting held in April, where findings and recommendations from the review are discussed, and conclusions on the sector performance for the previous year are made. Business meetings take place three times a year. The first is in conjunction with the April health summit and the two others are in August and November. Business meetings are attended by the key sector partners at senior management level, and are chaired by the Minister of Health. Business Meetings focus on: Stakeholder commitments to implementation of the sector program Current policy issues relevant to the sector Budget updates and disbursement schedules of Government and Development Partners The second business meeting in August reviews the sector s progress from the beginning of the year to date and provide an opportunity to agree on corrective measures to achieve planned outputs and table new issues. The business meeting in November is devoted to planning and budgeting and results in agreement on health sector plans and associated budget for the ensuing year 14. The Ministry of Health and representatives of Development Partners signs an Aide Memoire after each business meeting. The Aide Memoire records decisions taken during the business meeting and represents and agreement between MOH and its partners. Recommendations from the Aide Memoires are followed up on the monthly sector working group meetings. DANIDA S SUPPORT TO GHANA S HEALTH SECTOR Denmark has supported the health sector in Ghana since 1994. The main focus of Danida s health sector policy for the developing countries has been to improve the health status of the population, especially for the most vulnerable and poorest sections. Specific emphasis has been placed on women and children 10. The Danish support to the health sector in Ghana started with the Ghana-Denmark Health Sector Support Programme in 1994-1998. Danida reoriented its bilateral aid by advocating a move from project assistance towards a broader sectoral approach and adopted SWAp as its main modality in the Health Sector Support Programmes I-V (1999-2016). The objectives for Danida s Sector Programme Support to the health sector have been in line with the objectives for the Ministry of Health s Medium Term Health Strategy, the 5-Year 15

Programme of Work I-II and Health Sector Medium Term Development Plan I-II, the National Poverty Reduction Strategies 1, and the Common Management Arrangements I-IV. BUDGET SUPPORT Since HSPS II, Danida has provided budget support to Ghana s health sector. During HSPS II and III, the health sector budget support from Danida and other health partners was channelled through the Ministry of Health Health Account, an account operated by the Ministry of Health. Since HSPS IV budget support was transferred to Ghana s Ministry of Finance earmarked for the Health Sector. Annex 1 presents an overview of the Health Sector Support Programmes I-V. EARMARKED SUPPORT The rationale for the earmarked support in phases I-III was to secure funding for areas of crucial importance to the success of the programmes of work, but which were difficult to implement or at risk of being side-lined. Secondly, earmarked funds would enable the MOH and development partners to respond quickly and flexibly to arising needs and opportunities and particularly to support innovative activities. Once approved, the funds were disbursed through the Aid Pool Account, which was managed by MOH, to the implementing Budget and Management Centres. Financial reporting on earmarked funds was through the routine financial reporting system of the Ministry. Activity reports were submitted to the Danida Health Sector Support Office (HSSO) and the headquarters of the Ministry of Health. DANIDA HEALTH SECTOR SUPPORT OFFICE In 1994, a Steering Unit was set up to monitor, coordinate and supervise the Denmark-Ghana Health Sector Support Programme (HSSP phase I). For the Dania Health Sector Programme Support, phase II, which commenced in 1999, the office was transformed to The Danida Health Sector Support Office (HSSO). The Danida HSSO was continued until the end of phase IV of Danida s support to the Ghana Health Sector in December 2011. The purpose of the Danida HSSO was to function as a partner to the MOH/GHS during the implementation of the Programmes of Work and to facilitate Danida's support to Ghana's health sector including monitoring of areas of priority to Danida and enabling Danida to be a qualified policy dialogue partner for the MOH/GHS. It was the responsibility of HSSO to develop and maintain an in depth knowledge and understanding of Ghana's health sector to be familiar with government, private sector and development partners health policies and to report on key issues and developments. Moreover, HSSO should contribute to dialogue on health and health related issues, representing and promoting Danida views as required and agreed; to encourage collaboration between programmes and 1 Ghana Poverty Reduction Strategy (2003-2005), Growth and Poverty Reduction Strategy (2006-2009); Ghana Shared Growth and Development Agenda I (2010-2013) and Ghana Shared Growth and Development Agenda II (2014-2017) 16

activities of MOH, GHS, other related ministries, NGOs and other partners. The HSSO would assist the Danish Embassy on aid policy issues, liaise closely with the Embassy at all times and keep the Embassy informed in health programme issues. REFERENCES 1. World Health Organization. Trends in Maternal Mortality: 1990 to 2013, 2014. 2. Ministry of Health. Holistic Assessment of the Health Sector Programme of Work 2014, 2015. 3. International Monetary Fund. Ghana Gets $918 Million IMF Loan to Back Growth, Jobs Plan. http://www.imf.org/external/pubs/ft/survey/so/2015/car040315a.htm (accessed 23. November 2015. 4. Sector Lead USAID, Ghana Health Sector Working Group. Analysis of 2016 Health Budget, 2015. 5. Ghana Statistical Service. Ghana Living Standards Survey Round 6 - Poverty Profile in Ghana (2005-2013), 2014. 6. Ghana Statistical Service. Ghana Muliple Indicator Cluster Survey, 2011. 7. Ghana Statistical Service. Ghana Demographic and Health Survey 2014 2014. 8. World Bank. Life expectancy at birth, total (years). 2015. http://data.worldbank.org/indicator/sp.dyn.le00.in (accessed 29 Oct 2015). 9. Ghana Statistical Service. Ghana Maternal Health Survey 2007, 2007. 10. Particip. Joint Evaluation of the Ghana Denmark Development Co-operation from 1990 to 2006, 2008. 11. Ministry of Health. The Health of the Nation. Analysis of the Health Sector Programme of Work 1997 to 2001, 2001. 12. Ministry of Health. Ghana Health Financing Strategy. 2013. 13. Ministry of Health. Medium Term Health Strategy - Towards Vision 2020, 1999. 14. Minsitry of Health. Common Management Arrangements for Implementation of the Sector Medium-Term Develpoment Plan II (2014-2017), 2014. 17

CHRISTIAN HEALTH ASSOCIATIONS OF GHANA (CHAG) BACKGROUND Christian Health Associations of Ghana (CHAG) is a faith-based network organisation founded in 1967. CHAG has grown from 25 health institutions when established in 1967 to 183 owned by 21 different Christian Church Denominations in 2015. It serves about 35-40% of the population in mainly rural areas. It is the second largest provider of health care besides government 1. CHAG provides health care to the most vulnerable and underprivileged population groups particularly in the most remote areas of Ghana. CHAG is a recognised Agency of the Ministry of Health and works within the policies, guidelines and strategies of the Ministry of Health. Nonetheless, CHAG is autonomous and takes an independent position to advocate and promote improvements in the health sector and to promote the interest of its members and its target beneficiaries 2. Being an agency of the MOH, CHAG complies with the many sector policies, procedures, treatment guidelines, staffing norms and reporting requirements. CHAG is engaged with the Ministry of Health, the Ghana Health Service and many other stakeholders to strengthen the health sector through policy dialogue, technical input and sharing best practices. RECOGNITION OF CHAG BY MOH CHAG has since 1967 managed several Government of Ghana built hospitals referred to as Agency hospitals. Since 1975, the Government of Ghana is paying the salaries of CHAG health workers according to agreed staffing norms 3. CHAG has had access to the Central Medical Stores of MOH for the procurement of drugs and medical supplies at government approved rates as well as the granting of tax exemptions for medical supplies and equipment imported into the country by CHAG facilities. CHAG received allocations of the Health Fund from MOH to cover expenditure on service, administration and capital investment. The MOH/GHS gives full recognition to CHAG facilities as very important providers of health care in the country and as valued partners in the development of the health sector 3. CHAG is also included in each of the five-year programmes of work, the annual planning cycle of the Ministry as well as the monitoring and evaluations of the MOH. An external review of CHAG from 2007 showed that CHAG members got more support from government than is provided in any other country in Africa 4. In 2013, CHAG entered into a new Memorandum of Understanding with the GHS to improve collaboration at Regional and District levels 2. The existing partnership of between CHAG and MOH/GHS is considered to be for the mutual benefit of the respective parties. Whilst CHAG receives Government s support in cash and in kind, the government in turn sees the increase or improvement of its national health outputs by CHAG member institutions and services, especially in areas not covered by government health services 3. DANIDA SUPPORT TO CHAG During HSPS III, Danida provided financial and logistic support to CHAG for the development and implementation of a five-year strategic plan, the main purpose being to build the institutional capacity of

the CHAG Secretariat. The Danida support covered review and development of CHAG strategies, structures, and systems, particularly at the central level where the organisation was weak. Through that support, the advocacy skills of CHAG have been strengthened and thereby CHAG has been able to solicit funding from more donor partners. A review of CHAG from 2009 concluded that there was evidence that CHAG s role in this relationship with MOH was passive and CHAG did not participate or project itself as strongly as it could. The review further concluded that the relationship between CHAG and regional/district health authorities needed to be improved especially in some regions and districts 3. The support received through the HSPS IV has enabled CHAG to reorganise and to evolve into a strategically positioned, respected, and credible partner within the Ghanaian health sector 5,6. The CHAG Secretariat is evolving towards an effective lobbying, advocacy, coordination and membership support body. The main strategy of Danida s support in HSPS phase V was to support the implementation of the CHAG Strategic Plan and Programme of Work (2012-2015) by providing core funding to CHAG 6. The provision of core funding consists of two elements: a) the transfer of financial resources and b) a joint dialogue on crucial and strategic policy issues and planned achievements. The core funding is supplemented by funding for Technical Assistance to help build the capacity for implementation of the Health Systems Strengthening approach 6. REFERENCES 1. Danida Health Sector Support Office. 2003 Annual Report 2003. 2. Christian Health Associations of Ghana. CHAG Annual Report 2013, 2014. 3. Centre for Health and Social Services (CHeSS). Study on private health sectora assessment: Partnership between Ministry of Health and Christian Health Associations of Ghana, 2009. 4. Health Partners International. External Review of CHAG, 2007. 5. Danish Ministry of Foregin Affairs. Programme Completion Report - HSPS phase IV, 2012. 6. Danish Ministry of Foreign Affairs. Ghana Health Sector Programme Support Phase V, 2011. 19

EXEMPTIONS AND NATIONAL HEALTH INSURANCE BACKGROUND OVERVIEW OF NHIS TODAY The government s vision in instituting national health insurance in Ghana was to assure equitable access to health care for all residents, without requirement of out-of-pocket payment at the point of service 1. Under the National Health Insurance Law, Act 650 of 2003, each district established a District Mutual Health Insurance Scheme (DMHIS). The DMHIS were autonomous from each other but all operated under the National Health Insurance Authority (NHIA). The new NHI Act of 2012 (Act 852) merged all the DMHIS to form a nationwide National Health Insurance Scheme (NHIS) The National Health Insurance Authority (NHIA) was established as a regulatory body for health insurance operations including managing and overseeing the operations of the National Health Insurance Fund (NHIF) 2. The NHIF consists of a 2.5% Value Added Tax imposed on all goods and services (National Health Insurance Levy NHIL); 2.5% of the 17.5% workers contribution to Social Security and National Investment Trust (SSNIT); a graduated premium imposed on all residents except those who are legally exempted; Interest from investments; and grants. Membership in the NHIS is at the individual level and supposed to be mandatory by law for all residents of the country. According to Act 852, all employers are also obliged to ensure that all their employees are registered under the NHIS. Individual adults aged 18 69 years in the informal sector pay annual premiums. Premiums range between GHC 15 and GHC 48 and contribute relatively little to the NHIF compared to tax financing (NHIL & SSNIT), which in 2014 constituted 94% of the Fund s revenue 3. With the intention to promote equity in enrolment onto NHIS, the National Health Insurance regulations identifies seven population groups for premium subsidy, namely 4 ; Children under 18 years of age Persons in need of ante-natal, delivery and post-natal healthcare services Persons with acute mental disorder Persons classified by the Minister responsible for Social Welfare as an indigent Categories of differentially-abled persons determined by the Minister responsible for Social Welfare using a means test prescribed by the Minister in consultation with Minister responsible for Social Welfare and the Minister responsible for Local Government Pensioners of the Social Security and National Investment Trust Contributors to the Social Security and National Investment Trust From 2005, implementation of the NHIS gained considerable momentum and as at end of 2007, 145 district mutual health insurance schemes were operative, covering all districts in the country 5. From 2006 till 2014, the population coverage of NHIS increased from 18% to 38% 3. The most recent available breakdown of registrants per category revealed that 4% of NHIS members were formal sector workers (SSNIT contributors), 31% were adults of the informal sector and the remaining 66% belonged to one of subsidised population groups with the majority being children under 18 years of age 3.

Since 2012, the number of persons exempted from paying NHIS premium because of poverty increased from about 125,000 to almost 1,5 million 3 and in 2014, NHIS had registered about 4.1% of the total population as indigents. The ambition of NHIA is to cover a proportion equivalent to the proportion of the population who live under circumstances of extreme poverty, which the Ghana Living Standards Survey estimates at 8% 6. The primary method to enrol the poorest is by linking NHIS membership to the LEAP (Livelihood Empowerment Against Poverty) programme under the Department of Social Welfare, Ministry of Gender, Children and Social Protection. HISTORY OF CASH & CARRY, EXEMPTIONS AND NHIS Since independence, financing health care in Ghana has gone through a series of reforms. Immediately after independence in 1957, health care was financed entirely through tax revenue and provided to people free in public health facilities. There was no requirement for direct out-of-pocket payment at the point of consumption. Financial sustainability became challenging as the economy began to show sign of decline. The standard of health care provision fell considerably, and there were acute shortages of essential drugs and other commodities. The situation continued until 1985 when GOG introduced user fees for all medical conditions except certain specified communicable diseases. The fee-for-service payment mechanism put in place was termed Cash and Carry. EXEMPTIONS FROM CASH & CARRY Over the years, various services and categories of people have been deemed eligible for fee exemptions. The exemptions specified under these regulations focused on key diseases regarded as being of public health importance (e.g. leprosy, tuberculosis, cholera etc.), immunisations, antenatal and post-natal care and services targeted child welfare. Exemptions were later extended to victims of snake-bites and dog-bites and to broad demographic and socio-economic groups, namely children under five years, pregnant women, the elderly (defined as people above 70 years) and paupers or indigents. These changes were mainly introduced through a Presidential address to Parliament in January 1997. There was some flexibility to respond to local perceptions about what conditions were to be exempted, e.g. allowing Upper West Region to reduce the age limit on exemptions for the elderly to 60 years in recognition that there were few persons over 70 years (the national standard) and many persons in their 60s were overwhelmed by the costs of health care. From the onset, the exemption reform was challenged by long delays for service providers in obtaining reimbursement for exemptions. There were insufficient funds allocated to finance exemptions to allow for eligible children, women and the poor to take full advantage of available services. When funds were tight, providers had little incentive to provide free services to patients who would potentially further weaken their financial position. This policy, which would have increased access to poor people including children and pregnant women, had therefore only partial success in lifting financial barriers to health services utilisation. It was documented that budgets for exemptions amounted to far less than actual exemptions, to the extent that the Northern Region, which performed very well in making exemptions available to clients, received a 21

total of 1bn cedis (old denominations - about USD 150 thousand 2 ) to cover for exemptions in year 2000, whereas total claims for that year amounted to 2.2bn cedis (USD 326 thousand) 7. With the phasing in of the national health insurance to cover the whole population and the consequent phasing out of direct out-of-pocket payment, the exemptions system for user fees for the poorest was likewise was phased out. After the NHIS law was passed in 2003, less attention was given to the exemption scheme 8. DANIDA SUPPORT TO EXEMPTIONS Danida considered utilization of health services in Ghana to be low compared to other developing countries, due partly to financial barriers to care. Consequently, Danida included an earmarked component between 1997 and 2007 (HSPS II and III) Improving Access to Health Care, aimed are supporting government s efforts to improve financial access to care. Danida supported four regions (Northern, Upper East, Upper West and Central Regions) with support for exemptions and community health insurance schemes. The choice of the four regions was informed by GOG s Medium Term Health Strategy and was in line with the pro-poor policy of Danida since the three northern regions represented the poorest in the country. For several years, Danida financed the outstanding exemption bills for the supported regions. However, little success was attained in supporting the improvement in exemption policy due both to political and technical constraints 8. COMMUNITY BASED HEALTH INSURANCE Community Health Insurers (CHI) are non-governmental organisations that establish themselves in order to share the risks of the cost of health care for their members, and which can be distinguished from private insures by their not-for-profit basis. CHIs are often small in size and were springing up rapidly in Ghana in response to the lack of social security and the negative side effects of user fees introduced in 1985 and inefficient exemptions after introduction of cash-and-carry. One survey found 159 Ghanaian CHIs in existence in late 2002 9. Thus, communitybased health insurance schemes operated in Ghana for some time before the NHIS law was passed in 2003. Premiums required for membership and the benefits offered varied, although coverage tended to be focused on inpatient care. Providers were usually paid directly, although sometimes members were reimbursed after they themselves had paid (indemnity cover). External support was important to some CHIs, especially during the start-up period, in the form of funds, equipment or training. There was little official policy affecting CHIs either in a positive or a negative way. Most schemes were not registered with the Registrar General, for example, and were not subject to official inspections, financial reporting requirements or rules about premiums, benefits or provider payments 9. However, as part of the move towards NHIS, some 45 schemes were designated as pilots. Some of these were established by government, but most pilots were already in existence. 2 Historic exchange rate cedis 6,750 to USD 1, source https://en.wikipedia.org/wiki/ghanaian_cedi#exchange_rate_history 22