By Makafui Aikins
Time is running out. We have made and keep making many time-bound health-related promises onto ourselves. Yet, consistently, we have failed to meet these targets. Whether they are global undertakings like the UN’s Sustainable Development Goals (SDGs), AU’s Agenda 2063, the UN’s Astana Declaration on Primary Health Care, the Abuja Declaration, Ecowas Vision 2020 (now Vision 2050), etc., or national commitments such as the National Health Policy, the Roadmap for Attaining Universal Health Coverage (UHC), 2020–2030, or the Health Sector Medium-Term Development Plan (2022-2025)—all of which you will find discussed in this Health Report—one cannot help but see this recurrent theme playing out:
- Promises are made;
- The populace knows little to nothing about these promises;
- Timelines are missed.
International Commitments
Take the Abuja Declaration, for instance. In April 2001, African Union (AU) member states met in Abuja with a mission: “We, the Heads of State and Government of the Organisation of African Unity [now AU] met in Abuja, Nigeria from 26-27 April 2001, at a Special Summit devoted specifically to address the exceptional challenges of HIV/AIDS, Tuberculosis and Other Related Infectious Diseases…” The preamble to the Declaration reads. It went on to set certain crucial targets: “We pledge to set a target of allocating at least 15% of our annual [national] budgets to the improvement of the health sector.”
15% of national annual budgets to healthcare?
That is very interesting, especially looking at the fact that Ghana’s national budgetary allocation for the sector has remained below this target, and in fact, has been dwindling even further over the years. For instance, in 2022, the country’s health sector budgetary allocation stood at 7.6%—half of the Abuja target. In 2023, this was to reduce to 6.7%. Even worse, this downward trajectory has been projected to continue in the coming years—due to the harsh economic conditions prevalent across the continent.
In fact, for Ghana, the private sector has historically and presently remained the larger contributor to the health sector. In the year 2021, for instance, when total national health expenditure stood at $2.4billion, the private sector’s share was an impressive 58%. While the public sector—being a much more institutionally prolific segment—raked in a 42% contribution.
Take also, the UN Universal Health Coverage (UHC) declaration which sets a target that by the year 2030, every human being on this earth should have unimpeded ‘access to the healthcare they need, when and where they need it, without experiencing financial hardship.’
The world is 5 years shy of this timeline, and needless to say, things are not looking good—we won’t make the deadline. In fact, the UN has reported that global progress towards attainment of universal health coverage has stagnated since 2015, even coming to a halt in 2019.
National Promises
We come back home and we have a similar slew of promises awaiting us—from the National Health Policy, to a personal favourite of mine, the Roadmap Towards The Attainment of Universal Health Coverage policy (which was set to run from the year 2020-2030). By 2030, all people in Ghana are to have access to timely, high-quality healthcare services, irrespective of their ability to pay. The UHC Roadmap promises.
The UHC Roadmap (2020-2030)
The Roadmap states its objectives as:
- Providing universal access to efficient healthcare services.
- Reducing preventable maternal, adolescent, and child deaths.
- Improving access to responsive clinical and public health emergency services.
And it sets out to achieve these objectives by focusing on these key priority areas:
- Prioritising the vulnerable groups (children, adolescents, women, the aged).
- Minimising the Ghanaian’s out-of-pocket payments for healthcare.
- Forging strategic partnerships for enhanced healthcare delivery. Public/private partnerships (PPPs) are to feature prominently.
- Decentralising management of health systems for effective service delivery.
- Re-prioritising domestic financing for the health sector. (In essence, the loss of USAID shouldn’t be mourned).
Emphasis on Primary Health Care (PHC)
In this Roadmap, primary health care (PHC) is given much-needed emphasis. It is the ultimate aim to strengthen maternal, child, and nutrition services, effectively treat and manage non-communicable diseases, mental health issues, boost emergency preparedness, etc. This is in line with the Astana Declaration of 2018, for PHC has, worldwide, shown itself to be an effective way of attaining UHC.
This is a step in the right direction, for primary health care needs all the help it can get. The Roadmap, itself, notes the many challenges the sector is plagued with—from uneven access, to poor healthcare delivery, lack of essential infrastructure, high rates of avoidable maternal and newborn deaths, low vaccination coverage for some diseases, increased non-communicable diseases (NCDs) like hypertension and diabetes, decreased government spending, decreased development partner support, limited coverage of the NHIS (covering only 36% of the population), etc.
I am not the one alleging these; as noted, the Roadmap itself makes important note of these shortfalls. And in fact, you will see these same issues highlighted in the interviews and opinion articles of the various experts, policymakers, industry players, etc., who partook in this Health Report.
Hon. Dr. Nyakotey, MP of Yilo Krobo, for instance, makes note of the endemic infrastructural and funding shortages his constituency faces. Dr. Thomas Baah, CEO of Save the Nations Sight Clinic bemoans the challenges faced by practitioners like himself, with the limited and insufficient coverage of the NHIS. Experts like Dr. Akua Ampadu and Samuel Agyekum allude to the prevalence of NCDs like hypertension and diabetes, and the inadequacy of the nation’s health systems to adequately tackle these issues. Others like Michael Osei Dickson, an insurance expert, touch on the need to strengthen primary health care, so as to advance the attainment of universal health coverage.
The Interventions
Realising these challenges, the government, under this UHC Roadmap, avowed to undertake certain crucial interventions. It categorised these interventions into 6 groups:
Intervention 1:Optimise the Delivery of Certain Essential Services for the Population
Under this plan, the government sets out to optimise access to basic essential health services—primary services like outpatient care, birth and newborn care, treatment of common diseases like hypertension and sickle cell, etc. It also undertakes to promote access to preventive care, such as immunisations, screenings for cancers, HIV, malaria prevention, family planning, and maternal care. The plan is to also promote access to specialised and emergency care, promotive, palliative, and rehabilitative health care.
My personal favourites under this Intervention are the plans by the government to establish, firstly, School-Based Infirmaries (SBIs) in all primary and secondary schools—to provide healthcare access to children and adolescents. And then there is also the Workplace Infirmaries (WPIs), where workplaces within every one-kilometre radius will be provided a healthcare facility—to cater for their workforce. And for the informal sector, Marketplace Health Centres (MPHCs) are to be established, specifically in urban and peri-urban marketplaces, to provide healthcare under similar conditions as the WBIs.
And even better, these SBIs, WPIs, and MPHCs are to be set up, operationalised, and managed through public/private partnerships (PPPs). This presents a great opportunity for the private sector to further impact the health sector—all the while making good returns on their investments. However, it is yet to be seen, the implementation of this brilliant initiative.
There are more promises under this intervention—more than we have room for in this publication. So, let’s move on to Intervention 2…
Intervention 2: Improve the Management of Clinical and Public Health Emergencies
The Roadmap, under this intervention, sets out to, among others, strengthen clinical emergency management, including improving pre-hospital care, hospital emergency systems, and mass casualty management systems. This is critical because, as the WHO observed following the Covid-19 pandemic, many countries worldwide—developed countries inclusive—are ill-prepared to handle mass casualties.
This Roadmap promises the establishment of certain indicated institutions and the enhancement of health systems to see to the elimination of diseases such as onchocerciasis, yaws, yellow fever, and polio, while controlling cholera and meningitis outbreaks. It is to do this by improving infrastructure systems, improving the availability of ambulances, improving community surveillance systems, etc.
Intervention 3: Improve Quality of Care and Information Management
The Roadmap pledges to improve healthcare quality by ensuring people-centeredness, safety, effectiveness, and equity in healthcare delivery. It seeks to do so by, among others, creating national quality assurance frameworks, implementing Quality Improvement Plans (QIPs), enhancing diagnosis protocols, etc. Under this Intervention, health infrastructure and systems in the country are to be upgraded, equipped with standard service delivery kits and essential medicines.
Supply chain management in the sector is to be reformed to optimise distribution. Data systems and digital health are to be strengthened through improved digital records, the integration of private sector data, etc. In fact, under this Roadmap, digital innovation—as advocated for by contributing writers of this Report, like Dr. Gladstone Elikem Doh and Dufie Boakye—is to define the Ghanaian health sector.
Intervention 4: Enhance efficiency in HR performance
Under this Intervention, the human resource capital of the health sector is to face a facelift—right from the education and training stages to the employment stages. Notably, management of health personnel are to be decentralised, with incentives given to practitioners serving in deprived areas. Such an intervention would undoubtedly solve the challenges faced by these remote areas—challenges of which are raised by sector players and policymakers alike; for instance, Hon. Nyakotey, in this very Health Report.
Intervention 5: Institutional reforms for sector effectiveness
The Ministry of Health, under this Intervention, seeks to enhance stewardship—focusing on intersectoral collaboration, health financing, and technical coordination. The public sector’s healthcare delivery systems are to be decentralised, with the Ghana Health Service made to focus on standardisation and ensuring operational efficiency. Regulatory bodies within the health sector are to be harmonised, and private health insurance, enhanced.
Notably, it promises reforms and improvement on the NHIS—on its governance, efficiency, and sustainability. Public/private partnerships, collaborations with non-state actors (both health and non-health actors) are to be strengthened. Traditional medicine—as highlighted by contributing writers of this Health Report, like Yaw Owusu-Ababio and Jonathan Bossaer—is also to receive much-needed reform under this Roadmap.
Intervention 6: Health Policy, Financing, and Systems Strengthening
It has been the plan of the government to adopt a ‘Health in All Policies (HiAP)’ approach towards ensuring the nation’s attainment of UHC. This is where health issues are integrated into all aspects of national policy-making, not just health-related policies. Under this plan, the government also promised to mobilise $7 billion over the period of 10 years, for health funding, while allocating an additional 1% of GDP to primary health care (PHC). The government also avowed to ensure all agreements signed with development partners are in alignment with national health goals.
The Dynamic Between the Promisor and Promisee
Reading through such national policies, one cannot help but, first and foremost, get prematurely excited. But sadly, after this excitement often comes disappointment—especially when one realises that, firstly, the average Ghanaian is often kept out of the loop. The average Ghanaian barely knows what these commitments and promises are.
Not knowing the full extent of what has been promised them, it is ever-so easy for leaders to escape accountability. Because who cares? What at all is the value of a promise if the promisee is unaware of it in the first place? Cherished reader, I tell you what, almost every concern raised by all the brilliant contributors of this Health Report, I see solutions proffered for—in one national health policy or the other.
The situation we find ourselves in is tragic because this reality often manifests itself as a vicious cycle—it never ends. Even before these promises can see the light of day, there is a change in government—and a consequent change in policy direction. New government, of course, must naturally beget new policies/promises. And we discuss this unfortunate dynamic with Hon. Nyakotey in this Report. And these new policies/promises, they get this same ‘benefit’ of obscurity—the average Ghanaian unaware of the full extent of the health-related commitments made to them.
And sadly, not only do these obscurities result in the short-changing of the populace, it also freezes out potential private sector investments.
So then, we must endeavour to, very consistently and efficiently, shed a light on the nation’s health sector—on all its nooks and crannies. For that is the only true way of ensuring accountability, inspiring action, and effecting sustainable change. And that is precisely what this year’s Health Report—and all future editions—sets out to accomplish.
BYLINE
Makafui Aikins
Co-founder/CEO, Nvame
+233 534 130 362
