WHO HIS HSR 17.41 Eng
WHO HIS HSR 17.41 Eng
(PRIMASYS)
Comprehensive case study from Ghana
PRIMARY HEALTH CARE SYSTEMS
(PRIMASYS)
Comprehensive case study from Ghana
Tables
Table 1. Key demographic, macroeconomic and health indicators, Ghana . . . . . . . . . . . . . . . . 10
Table 2. Trends in main sources of health sector funding, Ghana, 2005–2015 (%) . . . . . . . . . . . . 28
Table 3. Basic information on Ghana’s human resources for health . . . . . . . . . . . . . . . . . . . . . 31
Table A4.1 Demographic profile: total fertility rate by region . . . . . . . . . . . . . . . . . . . . . . . . 58
Table A4.2 Trends in selected health expenditure indicators, Ghana, 1995–2015 . . . . . . . . . . . . 59
Table A4.3 Trends in Ghana burden of disease: top five causes of death, 1990–2015 . . . . . . . . . . 59
Table A5.1 Timeline of key developments relevant to the Ghana PHC system . . . . . . . . . . . . . . 60
Table A5.2 Ghana PHC reforms and programmes: relative success and factors . . . . . . . . . . . . . 63
Table A6.1 Community health nurses’ perspectives on stakeholder collaboration at the
community level by region, Ghana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Table A6.2 Summary information on organizations providing PHC services in Ghana . . . . . . . . . 70
Table A8.1 Density of key health workforce in Ghana, 2015 . . . . . . . . . . . . . . . . . . . . . . . . . 74
Table A8.2 Nurse–population ratio by region, Ghana, 2009–2015 . . . . . . . . . . . . . . . . . . . . . 74
Box 1. List of issues by thematic area explored during the second phase of the study
3.1 Demographic profile The total fertility rate (6) declined from 6.4 births
per woman in 1988 to 5.2 in 1993 and 4.4 in 1998
Ghana is located north of the Guinea coast of West and 2003, dropping to 4.0 in 2008 and rising again
Africa, with Burkina Faso, Togo and Côte D’Ivoire to 4.2 in 2014. The fertility rate has thus apparently
bordering it on the north, east and west respectively. stabilized in the last three decades. There is marked
It has an area of 238 537 square kilometres. A map of variation in fertility by region, urban–rural location,
Ghana is presented in Annex 4. and educational and socioeconomic status. The
Ghana was the former British colony called the Gold three northern regions (Northern, Upper East and
Coast. It attained independence on 6 March 1957, Upper West) have the highest total fertility rates
and became a republic on 1 July 1960. After nearly a of 6.6, 4.9 and 5.2 births per woman respectively,
decade of relative stability and prosperity following compared to 2.8 in Greater Accra region, with the
independence, a military takeover of government rest of the regions ranging between 3.6 and 4.8. The
on 24 February 1966 ushered the country into a urban total fertility rate is 3.4, compared to 5.1 in rural
turbulent period of political history, with a series of areas. Those without education have a total fertility
military coups and governments interspersed with rate of 6.2, compared to 2.6 for those with secondary
constitutional civilian governments for more than education and above. By wealth quintile, the total
three decades. A new Constitution in 1992 laid the fertility rate is 6.3 and 2.8 for the lowest and highest
foundation for the Fourth Republic, characterized quintiles respectively. Annex 4 provides further data
by a multiparty democratic political system with a on the total fertility rate by region.
four-year cycle of government commencing in 1993. The male–female ratio has shifted from a male-
Ghana has since seen six peaceful elections and to-female majority to the reverse – from 102.2:100
three changes of government from different political in 1960 to 95.2:100 in 2010. The life expectancy at
parties over a 24-year period. birth has progressively increased from 38 years to 61
The country has 10 administrative regions and a local years in 2015, with a transition towards an ageing
government system comprising 216 administrative population (9, 10). The total dependency ratio of 73 is
and political districts categorized into metropolitan, therefore a huge burden for the working population,
municipal and district assemblies (MMDAs) with and there is a large population of unskilled and
limited legislative functions. Ecologically the country unemployed youths (11).
may be divided into three ecological zones: northern The population density increased from 29 persons
savannah, middle forest and coastal savannah belts per square kilometre in 1960 to 103 in 2010, with
with marked differences in climatic, demographic very wide regional variations, ranging from 35 and
and socioeconomic features. The 2016 projected
Population growth rate (2010–2015) 2.4% 2010 census growth rate was 2.5%
Distribution of population (rural/ 46%/54% United Nations (8) Ghana Statistical Service Population and
urban) Housing Census reported 49.1%/50.9% (6)
Total fertility rate 4.2 Ghana Demographic Declined from 6.4 in 1988 to 4.2 in 2014 with
and Health Survey (7) marked regional and rural–urban variations
Life expectancy at birth (2010–2015) 61 (62/60) United Nations (8) African Region lower middle-income countries:
(male/female) in years 58 years
World lower middle-income countries: 66 years
Top five main causes of death (ICD- Lower respiratory infections Ghana health data
10 classification) Cerebrovascular diseases (19)
Ischaemic heart disease
Malaria
HIV/AIDS
Infant mortality rate per 1000 live 41 Ghana Demographic Constitutes 68% of all under-5 deaths
births (2014) and Health Survey (7)
Under-5 mortality rate per 1000 live 60 Ghana Demographic Declined from 155 in 1988 but could not
births (2014) and Health Survey (7) achieve MDG 3 target of 41
Maternal mortality ratio per 100 000 319 Maternal Mortality 2007 Ghana Maternal Health Survey reported
live births (2015) Estimation Inter- 350
agency Group (26) MDG 5 target was 185
% coverage of fully immunized 77% Ghana Demographic Increased from 50.5% in 1998 to 69% in 2003
under 1 year (including and Health Survey (7) and 79% in 2008
pneumococcal and rotavirus) (2014)
Income or wealth inequality (Gini 0.409 Ghana Living Worsened from 0.373 in 1992 to 0.388 (1998),
coefficient) (2013) Standards Survey (17) 0.406 (2006)
Total health expenditure as 3.6% United Nations (8) The recently completed but unpublished 2015
proportion of GDP (2014) National Health Accounts reported 5.96
Total public expenditure on health as 2% WHO (28) The recently completed but unpublished 2015
% of GDP (2014) National Health Accounts reported 0.9
General government expenditure 10.6% African Health Met the Abuja Declaration target of 15% in
on health as % of total government Observatory (29) 2005, 2007 and 2009: highly indebted poor
expenditure (2013) country (HIPC) funds were available to health
sector
General government expenditure on 60.6% African Health Peaked at 74.4 in 2011 and started declining
health as % of total expenditure on Observatory (29)
health (2013)
% total public sector expenditure 47% Primary Health Range 2–56% for some 28 low- and middle-
on PHC Care Performance income countries
Initiative (30)
Per capita total expenditure on 58 WHO (28) National Health Accounts figures are 88.4, 80
health (2014 in US$) and 81 for 2013, 2014 and 2015 respectively,
but still below US$ 97 average for low- and
middle-income countries in African Region
Out-of-pocket payments as % of 26.8% WHO (28) Fluctuating but likely to increase as unofficial
total expenditure on health (2014) co-payments are common due to long delays
in NHIS reimbursements to providers
Proportion of households 1.5% WHO and World Bank % of households spending 25% of total
experiencing catastrophic health (31) household expenditure on health
expenditure
PHC SYSTEM
District level District/primary hospitals District health directorates (216) MMDAs
District health management teams Social services committee
(DHMTs) oversee health facilities and
provide public health services
District health committee
Subdistrict level Health centres/clinics
Subdistrict health management
committees (SDHMCs)
Oversee health services in the zonal/urban/town area
subdistricts councils
CHPS compounds, Representation in SDHMCs
Community level maternity homes, chemical
sellers, traditional providers,
etc. Community health committees
Mobilize communities and provide
feedback & support to health service
providers Unit committees
Health service providers: Representation in community
public, faith-based, private, health committee
traditional & alternative Health sector governance
medicine practitioners structures Local government governance
structures
generation and pooling strategies, as well as effective Private Ghana health service
purchasing and provider payment mechanisms that
promote access to and cost containment for quality
Regional health
care (77).The PHC expenditure classification has three Households
directorates
main categories: compensation (salaries and wages),
goods and services, and investment. The financing District health
*IGF directorates
system mirrors the national financing architecture,
which comprises a myriad of multiple financing
Health service
sources and routes, as illustrated in Figure 2. providers
The NHIS is a pro-poor scheme financed from Apart from the reimbursement delays, service
the National Health Insurance levy of 2.5% value providers also complained of low tariffs, as they
added tax, 2.5% deduction from the social security were not reviewed to take account of the high
contributions of workers registered with the country’s inflation rate in the economy. Consequently, service
social security body, premiums, allocations from providers have not been able to stock adequate
consolidated funds, and interest from investment supplies because of their own indebtedness to their
(80–82). About two thirds of the population are in suppliers, and have therefore adopted various coping
the exemption categories, with the following annual mechanisms, including unofficial co-payments,
ranges: pregnant women (5.5–8.5%), children clients given prescriptions to buy from external
aged under 18 years (40–46%), and those aged 70 sources, and opting out of the NHIS altogether.
years and above (3.8–5.5%). The benefit package is From the scheme’s inception, it had been projected
generous and covers about 95% of health conditions that it could not be sustainable after 2009 unless
in the country. Of the health facilities credentialed additional funding sources were identified. In
by the scheme to provide services to clients in addition, various reviews and monitoring systems
2013, 54% were governmental, 40% were private have revealed many problems with the scheme
for profit, 5% were faith-based and 1% were quasi- management, including high administrative costs,
governmental. A combination of fee-for-service and moral hazards, management inefficiencies and
Ghana diagnosis-related group fee schedules are the corrupt practices by both providers and scheme
main payment mechanisms. personnel. A presidential committee set up to review
The introduction of biometric registration and the scheme in 2016 recommended a number of
electronic claims systems improved the operation of reforms, including prioritization of PHC services in the
schemes, though there are concerns about difficulties benefits package (83). A capitation payment method
in the registration and renewal processes, especially piloted in one region from 2012 to contribute to
for rural residents, because of the small number of cost containment was programmed for scale-
centres located in the urban areas. The smaller PHC up nationally, but was slow in taking of before the
facilities cannot afford the electronic claims systems 2016 general elections brought a different political
and still use manual submission schemes that are party into government. Subsequently, the decision
laborious and more expensive, as they have to travel was made to suspend the capitation and review the
every month to ensure that their claims are properly whole scheme. It is hoped the review by the new
registered at the four zonal centres established across government will take place soon to avoid a decline in
the country. confidence in the scheme, which would be difficult
to re-establish.
The scheme started facing fiscal challenges in 2012,
when service providers’ claims for services rendered 6.3 PHC expenditure
exceeded the annual income, resulting in increasing
Data on the main sources of health funding, as
delays in the imbursement of providers, averaging
contained in the National Health Accounts reports
more than nine months instead of the agreed three
(Table 2), show an increasing trend in public
months. These delays have a greater effect on the
and private spending and a decreasing trend
rural PHC providers, as 90–95% of their outpatient
in international funds. It is also significant that
attendants are NHIS card bearers, and they are not
the public and private expenditure categories
in a position to adopt the coping measures used in
fluctuate inversely, implying that when government
urban areas. Hence they tend to pass clients to the
Number of nurses per 1000 population (plus midwives/minus midwives) 1.83/1.57 Significant proportion are unemployed
Number of community health workers per 1000 population (community 0.64 Volunteer community health workers and
health nurses only) temporary youth employment workers not included
8.1 Primary health care policies The tendency has also been observed for initiatives to
be instigated but then abandoned, even when they
Planning and implementation of PHC services in
have proven to be successful. Example cited included
Ghana are guided by general health sector and PHC-
the Strengthening of District Health Systems initiative,
specific policies that reflect the health problems and
the District Health System Operations Programme,
disease burden of the country. The PHC strategy
the Leadership Development Programme, and the
adopted in 1978 is still the thrust of national health
high-impact, rapid delivery approach.
policy. As stated in the Medium-Term Health Strategy
towards Vision 2020 policy document: “The health 8.2 PHC planning and budgeting
service in Ghana will be reorganized in such a way that
services provided at the community, subdistrict and
processes
district levels adequately meet the basic needs of the There is a strong planning and budgeting culture
majority of Ghanaians.” Services at these levels would in the public sector that has evolved over the years
constitute the primary health services delivered in commencing with the introduction of the Medium-
the context of a District Health System. The objective Term Expenditure Framework in 1998, and continuing
of this reorganization was to ensure universal access with the adoption of a programme-based budgeting
to primary health services. The successor to the approach in 2014. There are, however, concerns
Medium-Term Health Strategy – National Health about the short interval between the issuance of
Policy: Creating Wealth through Health (96) – was guidelines and the deadline for submission of plans,
adopted in 2006. It retained the focus on PHC but which makes it difficult for the planning process
placed more emphasis on the broader determinants to be sufficiently vigorous and analytical. The
of health, such as lifestyle, nutrition and environment. uncoordinated and parallel planning of the vertical
The CHPS policy and strategy (97, 98) specifically programmes, including donor-supported projects,
provide for comprehensive operationalization can increase the workload of those engaged in the
of PHC at the community level. Several specific health system and interfere with implementation at
policies under the various health system building PHC level.
blocks provide the standards, packages of services,
medium-term strategic plans and guidelines for 8.3 Service delivery and performance
implementation (see Annex 9). The PHC service providers may be classified as public,
Most stakeholders expressed the view that there private non-profit, and private self-financing, with
are too many policy documents that have been the public sector providing the bulk of the services
inadequately implemented, due to the following (24, 25). At each level of the District Health System
factors: inadequate dissemination (99), non- the public sector has multidisciplinary teams of
inclusive policy development processes for the professional, auxiliary and support workers who
buy-in of implementers, conflicting policies, and provide comprehensive and integrated promotive,
inadequate resources for implementation (97, 100). preventive, curative and rehabilitative services, with
PHC providers have difficulties in referring to several appropriate task shifting as required. These teams
documents during planning and implementation, also coordinate the activities of the various providers,
and call for a more user-friendly consolidation and with varying levels of success.
simplification of information. At the community level one or more trained health
workers with a team of volunteers provide integrated
2. Dr Emmanuel Nonaka Mensah Health system development in the One of Ghana’s representatives at Alma-Ata PHC
Director-General of GHS, 2000–2003 country Conference, 1978
(retired) Traditional and alternative medicine Served in a number of managerial positions in
the Ministry of Health
First Director-General of GHS
3. Dr Kofi Ahmed Health programme development and Epidemiologist; was key player in the health
Lecturer, Mount Crest University College implementation sector reforms in the late 1980s and 1990s
Health service organization
Epidemiology and disease control
Human resources development
Health regulations
4. George Amofah Health service organization Served as medical officer at various levels, and
Consultant to local and international Health programme development and as Deputy Director-General of GHS
organizations implementation
Epidemiology and disease control
5. Dr Samuel Akortey Akor Health human resource sand systems Former Executive Secretary of NHIS
Lecturer, Mount Crest University College development Former Director in Ministry of Health
NHIS Lecturer and administrator in health training
Private health training institutions institutions, including Kwame Nkrumah
University of Science and Technology Medical
School
6. Dr Alex Koshie Nazzer Health developments in Ghana Was principal investigator of the Navrongo
World Bank Development projects Community Health/Family Planning Project
7. Dr Chris Atim Health financing in Ghana and elsewhere Was leader of the presidential committee to
Executive Director of Africa Health in Africa review NHIS
Economists and Policy Association Community-based health financing Technical team leader piloting public-private
International consultant, providing Health economics partnership network
technical assistance for NHIS in Ghana
and Nigeria
9. Robert Kurugu Ajene School health Former Regional Health Committee chair, Upper
Educationist and administrator (retired) Governance and leadership East region
Local government
12. Dr Yaw Adusei-Poku Human resource for health Former President of Ghana Medical Association
Director, Tema General Hospital, Greater Service organization
Accra region Planning and implementation
Health professionals associations
16. Dr Koku Awoonor Health governance and leadership Former District Director and Regional Director
Director, Policy, Planning, Monitoring Policies, planning, and implementation Has done extensive work on CHPS
and Evaluation Division, GHS
19. Mr Dan Osei Planning and budgeting Health financing, budget responsibilities in GHS
Deputy Director, Budget, Ministry of National Health Accounts
Health
20. Dr Sagoe Human resources and health system Former Chief Executive, Tamale Teaching
Consultant, Ministry of Health development Hospital, and Human Resources Director in GHS
Quality assurance
21. Mr Seth D. Acquah Human resource for health Former Deputy Director, GHS
Human resources consultant Health sector reforms
22. Mr Alhaji Saed S. Al-Hussein Human resources development in Ghana Former Deputy Director for training, GHS
Private consultant
24. Dr Margaret Chibere Human resource operational policies Nurse by professional training
Director, Human Resources (training and management)
Development Division, GHS
28. Epsona Ayamga Health sector and local government and Former Physician Assistant, Ministry of Health
Private service provider, Asankunde private sectors Former Municipal Chief Executive, Bolgatanga
Clinic, Bolgatanga, Upper East region Health regulation Municipal Assembly
Municipal Health Committee Chair NHIS
30. Dr Kofi Issah Policies, planning and implementation Regional Directors Group
Regional Director of Health Services, Health programmes
Upper East region Health service organization
31. Dr John Eleeza Public health administration Has worked in Volta and Central regions
Deputy Director, Public Health, Greater
Accra region
15. Ministry of Health and agencies annual reports and audited accounts
Northern zone
2. Ahaji Abu Yahaya Community and religious sectors Community and regional
Contractor, Regional Health Committee Chair
3. Mr George Yaw Segnitome Trainers of professional and auxiliary Public health training
Principal, Nursing Training College, Wa, Upper West region nurses
4. Naa Bob Loggah Education, health, nutrition and the Traditional leadership
Traditional leader, retired educationist, environmental environment sectors
advocate, Upper West region, Health Training School Board
Chair
5. Madam Faith Loggah Nursing training and administration Nurse trainers and administrators
Retired nurse, clinical trainer, examiner, and administrator,
Wa, Upper West region
7. Stakeholder meeting with Upper West RHMT: attendants, Upper West region RHMT Regional
focus group discussion
9. Sissala East district stakeholder consultation: DHMT, District DHMT, district hospitals, NHIS District
NHIS Manager, hospital management, etc.
10. Banu CHPS, Sissala East district, Upper West region: focus Community health officers, CHPS level
group discussions with two community health officers, community health committees,
Community Health Committee Chair and assembly member community health volunteers
11. Focus group discussions: community health nurses and Community health nurses in CHPS level
community health officers in Northern region Northern region
12. Focus group discussions: community health nurses and Community health nurses in Upper CHPS level
community health officers in Upper East region East region
13. Focus group discussions: community health nurses and Community Health nurses in Upper CHPS level
community health officers in Upper West region West region
14. Evergreen Maternity Home, Sawla, Sawla-Tuna-Kalba Private maternity homes Community
district, Northern region
Focus groups discussion with owners (Mr and Mrs Tambro)
and staff
Middle zone
19. Ashanti cross-section of stakeholders (RHMT, environmental RHMT and other stakeholders Regional
health, Pharmacy Council, etc.): 65 attendants
21. Focus group discussions: community health nurses and Community health nurses in CHPS level
community health officers in Ashanti region Ashanti region
22. Focus group discussions: community health nurses and Community health nurses in Brong- CHPS level
community health officers in Brong-Ahafo region Ahafo region
24. Faculty of Public Health Membership Cohort, 11 residents Public health professionals District/institutional
Southern zone
27. Greater Accra regional stakeholder meeting: RHMT, DHMTs, Greater Accra region stakeholders Regional and district
private providers: 106 attendants
28. Stakeholder meeting with residents of Faculty of Public A cross-section of stakeholders from District and institutional levels
Health of Ghana College of Physicians and Surgeons: Nine governmental, quasi-governmental
attendants and private sectors
29. Suhum community health officers and subdistrict health Community health officers and Subdistrict /CHPS
teams: 30 attendants subdistrict health teams
30. Focus group discussions: community health nurses and Community health nurses in CHPS level
community health officers in Eastern region Eastern region
31. Nsawam-Adoagyri Municipal Assembly stakeholder Key PHC stakeholders in districts District to CHPS level
meeting, Eastern region: DHMT, subdistrict health teams,
hospital management team, Municipal Chief Executive
and other assembly officers, Health Committee Chair, etc.:
74 attendants
32. Focus group discussions: community health nurses and Community health nurses in Central CHPS level
community health officers in Central region region
33. Focus group discussions: community health nurses and Community health nurses in CHPS level
community health officers in Greater Accra region Greater Accra region
35. Focus group discussions: community health nurses and Community health nurses in CHPS level
community health officers in Western region Western region
National level
39. GHS senior managers from national and regional levels GHS senior staff across country National
40. GHS Director-General and Deputy, national directors GHS headquarters senior staff National
43. Director of Local Government Service, Policy, Planning, Local government services National
Monitoring and Evaluation Division
44. Health Sector Working Group: Minister of Health and Senior management and technical National
Ministry of Health senior staff, development partners, experts of the health sector across
teaching hospitals, private sector, Christian Health all stakeholders
Association of Ghana, NHIS, training institutions, etc.
Source: Demographic and Health Surveys 1988, 1993, 1998, 2003, 2008, 2014.
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Total health 3.1 3.4 3.0 3.2 3.1 3.0 3.6 3.0 3.1 4.0 4.5 4.6 5.3 4.9 5.2 5.3 4.8 4.9 5.4 3.6 6.0
expenditure as
% of GDP
Public health 1.6 2.0 1.4 1.8 1.6 1.5 2.0 1.5 1.6 2.4 2.9 3.0 3.7 3.2 3.7 3.8 3.6 2.8 3.3 2.0
expenditure as
% of GDP
Out-of-pocket 30.5 26.5 33.7 28.6 30.5 31.8 27.2 32.3 31.9 25.6 22.8 22.5 19.5 22.2 18.9 18.4 16.1 32.2 30.4 26.8 36.0
expenditure
as % of
total health
expenditure
Table A4.3 Trends in Ghana burden of disease: top five causes of death, 1990–2015
3 Diarrhoeal diseases Lower respiratory infections Lower respiratory infections Ischaemic heart diseases
Table A5.1 Timeline of key developments relevant to the Ghana PHC system
Date Events
1471 • Europeans arrive on Guinea Coast of West Africa
1918–1951 • Moderate increase in health facilities and health workers mainly through Governor Guggisberg’s Development Plan
1918–1930
1951–1957 • Local political party rule under the granting of limited self-government, 1951–1957
• Rapid expansion of health services
24 February • Government overthrown by first police-cum-military coup d’état and ruled by decrees under the National Liberation
1966 Council, followed by four other coups in 1972 (SMC I), 1978 (SMC II), 1979 (AFRC), and 1981 (PNDC)
1967 • First reforms of the colonial Health Department replaced Chief Medical Officer with Director of Medical Services as technical
head of Ministry of Health, and created new divisions for health education and nutrition
• Ministry of Health divisions decentralized with regional offices; the centralized Medical Field Unit was regionalized, all with
separate budget lines under the supervision of regional medical officers
1967 • Basic Health Services Project with support from WHO, 1967–1971
1969 • October 1969: second Republican Constitution: return to democratic civilian rule under Busia lasted two years
• Establishment of Kintampo Health Training School for training middle-level health workers for health centres and health
posts
• Development of first National Population Policy
1970 • Danfa Comprehensive Rural Health and Family Planning Project, 1970–1979
• National Family Planning Programme established under Ministry of Finance
1972 • Military coup d’état: Supreme Military Council topples civilian government, 13 January 1972
1978 • Internal coup within the SMC resulting in change of leadership and rule by Supreme Military Council II (SMC II)
• Ghana PHC paper finalized; Ghana participated in the Alma-Ata PHC Conference in September 1978, adopted as the
country’s PHC strategy
• National Expanded Programme for Immunization (EPI) established with six antigens for childhood immunization
1979 • 4 June 1979: AFRC military coup overthrows SMC II: ruled for only three months, prepared the third Republican Constitution
and held general elections
• September 1979: return to third constitutional civilian rule under Dr Liman
• PHC strategy implementation started in one district in each of the nine regions
31 December • Military overthrow of the third republican government and the launch of a revolutionary government that embarked on
1981 grass-roots mobilization, probity and accountability for national renewal and development
1983–1989 • Economic Recovery Programmes (ERPs) and structural adjustments: ERP I (1983–1986) and ERP II (1987–1989), which
included staff redeployment
• User fees introduced and substantially increased in 1985 as structural adjustment programmes, resulting in decreased
service utilization
1980s • Selective PHC-dominated implementation of Bamako Initiative: essential drugs list, GOBI-FFF, Safe Motherhood Initiative,
National Traditional Birth Attendants Programme
1987–1992 • Strengthening of District Health System initiative for building management capacity of DHMTs
• Conduct of the first Ghana Demographic and Health Survey, subsequently repeated every five years (1987/1988, 1993,
1998, 2003, 2008 and 2014)
1988 • District Assembly Decree on Decentralization of Governance to Districts (PNDC Law No. 207), establishing 110 MMDAs
• Hospitals Administration Law (PNDC Law No. 209 of 1988) providing for the establishment of teaching hospital boards and
management committees for other public hospitals
1992 • Fourth Republican Constitution promulgated after a national referendum and multiparty elections conducted
1993 • 7 January 1993: return to constitutional rule under the Fourth Republic
• Local Government Act No. 462 passed, legitimizing PNDC Law No. 207 under the constitutional rule
1994 • Navrongo Community Health and Family Planning Project, 1994–1998, the findings of which led to adoption of CHPS policy
• Establishment of School of Public Health in University of Ghana with collaboration of health sector to train leaders for
DHMTs
1995 • First economic and social development programme: Ghana Vision 2020, with aspiration for Ghana to attain middle-income
status within 25 years, 1997–2020
• First national medium-term development document with strong focus on PHC and Ghana Vision 2020
1996 • Medium-Term Health Strategy developed with focus on PHC, based on the District Health System
• Ghana Health Services and Teaching Hospitals Act No. 525 passed to separate service delivery function from the Ministry of
Health; a long-term effort by the medical fraternity to move health service delivery out of the civil service bureaucratic system
• Management and budgeting decentralized to health facility and district levels, creating them as budget and management
centres with limited autonomy in the management of their resources
• The Government of Ghana introduced the Public Financial Management Reform Programme to improve public sector
financial management
1997–1998 • Medium-Term Expenditure Framework, a subcomponent of the Public Financial Management Reform Programme, was
launched by the Ministry of Finance
• First Health Sector Five-Year Programme of Work, 1997–2001, developed with the adoption of a sectorwide approach
(SWAp I), and Common Management Arrangements (CMA I) instituted
Continues…
Date Events
1999 • CHPS strategy dissemination conference held for consensus building on its adoption
• WHO/UNICEF IMCI strategy adopted and implemented as a pilot in some districts
2000 • CHPS policy adopted and implementation started, reviewed in 2009 and 2014
• Ghana Health Service established
• General elections conducted and the major opposition party elected to govern
2002–2006 • Implementation of second Programme of Work 2002–2006 under SWAp II and CMA II, and the health sector response to
GPRS I
• Policy on new community health nurse training schools and increased intake implemented
2002–2005 • UNICEF-supported Accelerated Child Survival Development (ACSD) project implemented in Upper East and Northern
regions 2002–2004, which informed the adoption of the expanded strategy, including the maternal health high-impact,
rapid delivery strategy
2003 • NHIS Act No. 650 passed, and establishment of the NHIS
2007–2011 • Government Growth and Poverty Reduction Strategy (GPRS II), 2006–2009
• Third Health Sector Five-Year Programme of Work, SWAp III and CMA III, and the health response to GPRS II 2007–2011
2008 • Introduction of free maternal services implemented through registration with the NHIS for pregnant women to cover health
care during pregnancy and delivery
• General elections, with the major opposition party victorious
2010 • Ghana Shared Growth and Development Agenda (GSGDA I), 2010–2013
• Economy rebased and country attained lower middle-income status, 2010
• Health sector truncated the Five-Year Programme of Work III and developed Health Sector Medium-Term Development Plan
(HSMTDP) 2010–2013 to conform to National Development Planning Commission requirements
2011 • Health Institutions and Facilities Act No. 829, replacing the Private Hospitals and Private Maternity Homes Board Act, and
expanded to cover both public and private institutions and health facilities
• Specialist Health Training and Plant Medicine Research Act No. 833
2012 • Ghana MDG Accelerated Framework developed with focus on addressing MDG 5
• Several health bills passed: Public Health Act No. 851, Mental Health Act of 2012 (replacing Mental Health Decree of 1972),
and National Health Insurance Act No. 852 (replacing Act No. 650), consolidating the autonomous district schemes with a
centralized system with regional and district offices
• President’s Committee on Decentralization working to speed up implementation
2013 • Health Professions Regulatory Bodies Act No. 857 of 2013 passed
2016 • CHPS revised policy launched and CHPS made a presidential special initiative
• President’s NHIS Review Committee submitted report, though no decision was taken on it before the general election
• Presidential and parliamentary elections conducted: major opposition political party wins
Successful or
Reforms/programmes Barriers Enablers Source of information
unsuccessful
1920–1930. Governor Successful • Drop in the international • Governor’s vision and • Ghana Seven-Year
Gordon Guggisberg’s plan for price of cocoa commitment to the plan Development Plan
socioeconomic transformation of • Reassignment of the • Reserves from good 1964–1970
Gold Coast colony (1920–1930), Governor to British international cocoa prices
with expansion of health facilities Guiana
and medical staff in hospitals,
dispensaries, child health services,
mobile clinics
1967–1981. First major reform of Successful • International economic • Core medical officers • Key informant
the colonial Health Department: crisis of the late 1970s trained in public health interviews
Ministry of Health divisions with and national economic • Support from international
regional offices, health workforce crises community and local
training, regulation and expansion • Political instability Christian missions’ health
of rural health services services
• Mass exodus of health
professionals abroad
in search of greener
pastures
1985–2000. Restructuring of Successful • Vertical programmes • Visionary political and • Key informant
regions and districts into RHMTs with vertical planning technical leadership interviews
and DHMTs and creation of BMCs and generic activities • Technical and
increased decision space and budgets without financial support from
flexibility development partners
• Fragmentation of the • Capacity-building of BMCs
sector into agencies
1997–2001. Donor mobilization Partially • Frequent changes of • Transparent systems for • Addai E, Gaere L.
and Ministry of Health-led health successful ministers for health partnership engagement Capacity-building and
sector programmes of work and • Government not • Top-level commitment systems development
SWAp, CMAs, and creation of donor satisfying its side of the for sector-wide
pool account • Development partners’ approaches (2001)
bargain commitment
• Development of sector
strategic plans
• Capacity developed at all
levels
Successful or
Reforms/programmes Barriers Enablers Source of information
unsuccessful
1996–2000. Creation of Ghana Successful • Earmarking of funds • Top-level commitment
Health Service by some development • Lobby of health
partners professionals, especially
• Vertical programmes Ghana Medical Association
with vertical planning • International trend at the
and generic activities time towards separation of
and budgets without policy and service delivery
flexibility functions
• Fragmentation of
the central level into
agencies that tend to
work in silos
National traditional birth Unsuccessful • Poor supervision and • Regular supervision and • Interviews
attendants and village health regular support retraining
workers programmes • Was too top down • Regular replenishment
without room for local of kits
initiative • Health programmes with
• Health professionals’ community component
negative attitude
towards community
health workers
Human resources for health Successful • Low standard of tutors • Large pool of qualified • Ministry of Health,
production strategies • Inadequate candidates seeking 2011
infrastructure and admission • Acquah S. Human
teaching and learning • Liberalizing training to the resources for health
equipment and private sector projections for the
materials • Policy-makers interest in Ghana health sector
• Inadequate funding creating employment (2016)
Strengthening of District Health Successful • Reliance on only donor • Strong regional and
Systems initiative earmarked funds district leadership
• Centralized training, • District Health System
requiring a whole team Operations programme
to be away for a long institutionalized at
time regional level with regional
resource teams
• Available national
in-service training policy
District Health System Operations Unsuccessful • High cost • Donor financial support
Programme developed; • DHMT and some • Modules were developed
Strengthening of District Health facilitators had to leave for the course
Systems workshops at the research their workplaces for long
centres at Navrongo and Kintampo, periods
coordinated by GHS Human
Resources Development Division • Too much reliance on
donors
• Inadequate funding
Leadership Development Unsuccessful • Poor record keeping • Involvement of policy level • Leadership
Programme training Development
Programme
Human resource distribution Unsuccessful • Lack of political will and • Appropriate incentives • Stakeholder
strategies deployed over the past sometimes political attached to posting to discussions
two decades have not succeeded interference rural and deprived areas
in adequately addressing the • Lack of commitment to • Decentralized human
inequitable distribution of health implement the policies resources budget
personnel
• Centralized human • Policies for staff
resources budget distribution exist
• Insufficient incentives to
attract and retain staff in
rural and deprived areas
Task shifting strategies to auxiliaries Successful • Professional • Community acceptance of • In-depth interviews
and middle-level professionals protectionism by some substituted health workers and stakeholder
in clinical, nursing, paramedical professionals • Adequate skills transfer consultations
services and public health services • Inadequate training and and supervision • Review reports
supervision
Free health services at point of use Unsuccessful • Inadequate funding • Adequate funding and its
• Weak monitoring and management
accountability systems • Strong monitoring and
under free services accountability system
regime
• Abuse of the system
Introduction of user fees for health Mixed: was able • Decreased financial • Effective monitoring
service delivery to recover 15% of to generate access to services, system
recurrent cost and full recovery internal funds to especially for the poor
for drugs achieved objective but sustain services • Catastrophic illness
negative effect on financial access but the poor pushing some people
had no access into poverty
Bamako Initiative Unsuccessful • Was in conflict with the • Unifying the management
government policy of of the different sources of
exemptions for some financing service
categories from paying
fees
2008. Free maternal services Partially • Poor distribution of • Easily identifiable target • Evaluation of the free
implemented through NHIS successful health facilities group maternal health care
• Attitudes and perceived • Integration into the NHIS initiative in Ghana
hostility of staff • High awareness
• Delays in National Health
Insurance Authority
reimbursement of
service providers
Continues…
Successful or
Reforms/programmes Barriers Enablers Source of information
unsuccessful
Establishment of NHIS by Act No. Successful, • Lack of consensus • Political commitment
650 in 2003 (replaced by Act No. though among political parties • Lessons from the
852 in 2012) facing some on structure and implementation of
challenges payment mechanisms of experience from home-
currently the scheme grown actors
• Low tariffs, delayed claim • Donor technical assistance
payments, unexplained and financial support
cancellations of claims
and an unmanageable • High acceptability by
increase in workload service providers and the
were cited people
Extension of medical services to Failure but • Poor roads with • Leadership commitment
the northern territories through revealed the high running and of the colonial governor
travelling clinic services from 1927 magnitude of maintenance costs • Increased resources from
but stopped in 1933 the disease • Inadequate resources exports
burden and the
high need for • Low educational level of
medical services the population
1967–1971. Basic Health Services Successful • Military coup of January • Effective technical team
Project with support from WHO 1972 leadership
• WHO support
1978. EPI started in 1978 with six Successful • Limited electricity and • Government commitment • In-depth interviews
antigens; now 12 antigens cold chain facilities • Effective technical and stakeholder
Contributed to the elimination of • Hard-to-reach leadership at all levels consultations
maternal and neonatal tetanus, and populations due to • Integration into PHC • Programme reports
last polio case reported in 2010 geographical and and reviews
cultural barriers • Effective cold chain and
EPI logistics management
• Inadequacy of resources
• Strong monitoring and
• Misinformation and fear evaluation system
of side-effects
Ghana PHC implementation started Successful but • Recall of the district • Visionary national
in 1978 in nine districts of the nine was stalled medical officers for technical leadership and
regions Master of Public Health commitment
programme, leaving the • Effective district and
DHMT without leaders regional leadership
• Inadequate resources
• Comprehensive versus
selective PHC debate
CHPS adoption as policy, and Successful • Lack of key stakeholders’ • Effective regional and • CHPS review report
implementation understanding of the district leadership • Ministry of Health
strategy • Political commitment and 2009 sector review
• Poor community action
mobilization
• Inadequate investment
2002–2005. UNICEF-supported Successful • Conflicting national • Effective district leadership • Ghana ACSD report
Accelerated Child Survival and policies and regional support (2008)
Development project in Upper East • Duplication and • Community mobilization
region and part of Northern region parallel activities of and engagement of other
some vertical health stakeholders
programmes
Continues…
Successful or
Reforms/programmes Barriers Enablers Source of information
unsuccessful
High-impact, rapid delivery • Implemented as a • Additional earmarked • Ministry of Health/
strategy evolved from the ACSD project with vertical resources from GHS and development
approach, and adopted in 2005 planning, and without development partners partners, November
to accelerate the achievement of lower-level ownership • Promoted rigorous analysis 2005
MDGs 4 and 5 • Engagement of other and evidenced-based
stakeholders (e.g. planning
MMDAs, NGOs) was not
sustained
Adoption of IMCI strategy Partially • Funding challenge • District ownership is key • Review of IMCI, 2005
successful • Lack of regional or • Development of regional
district capacity resource teams
• Implementing IMCI as a • Sustained involvement of
vertical programme key stakeholders
• Prescribing under IMCI
was in conflict with NHIS
payment mechanisms
Regenerative Health and Nutrition Unsuccessful • Implemented at Ministry • Top leadership • Ministry of Health
Programme started in 2006 of Health as vertical commitment (2009) sector review
programme outside • Effective engagement of • Ministry of Health
existing system implementing agencies, (2011) sector review
communities and the
public
GHS-JICA Upper West region Successful • High patronage of the • Effective regional and • Participatory planning
Maternal and Child Health Projects: foreign implementing district leadership • Regular follow-up of
Phase I (2006–2009), Phase II NGO • Timely resources flow resources
(2010–2015)
Kwahu East district: GHS, Japanese Successful • District assembly • Effective partnership
Organization for International could not provide dialogue and
Cooperation in Family Planning, the necessary staff co‑management of the
Planned Parenthood Association accommodation due to project
of Ghana, and District Assembly financial constraints
Joint Maternal Health and Family • GHS could not provide
Planning Project, involving some of the essential
increased access to services in a health staff for service
rural deprived community through delivery when the
partnership in the construction project was completed
of a health centre at Kotoso and
network of four CHPS compounds
and transport system, 2011–2014
Total 33 29 32 24 60 45 29 45 34 33 36.4
Average 4.1 3.6 4.0 3.0 7.5 5.6 3.6 5.6 4.3 4.1 4.6
Source: Focus group discussions with community health nurses, 23 May 2017.
Figure A6.1 Community health nurses’ perspectives on key stakeholder collaboration at the
community level
Community health
committees
10
6.9
Subdistrict 8 Community
health teams 8.2 health volunteers
6
6
4
Private providers 2 Assembly
(orthodox) 4.9 0 3.9 members
2.1 2 2.4
Chemical sellers/
pharmacies
Source: Focus group discussions with community health nurses, 23 May 2017.
3.6
Upper East 5.6 Upper West
7.5
5.6
Ashanti
Greater Accra
Mode of
Type of Nature of Source of
employment of Range of PHC services provided Remarks
sector facility information
providers
Public Functional CHPS Ministry of Health Integrated basic PHC covering: • Highest and lowest • 2016 health sector
zones (4400/6000 and permanent • Health, nutrition education and regional coverage: holistic assessment
demarcated 2016) promotion Ashanti region 91%, report
Greater Accra region • DHIMS2 database
• Treatment of minor ailments and 30.7%
injuries
• Basic reproductive, maternal,
newborn, child and adolescent
health
• Disease surveillance and control
Public Ambulance Ministry of Health • Prehospital care • About 60% (130) of • 2015 health sector
stations, and permanent • Transport of referred patients or the 216 districts have holistic assessment
emergency emergencies to health facilities stations report
medical
technicians
Private Chemical shops Self-employed and • Sell over-the-counter medicines • Wide distribution • Stakeholder
for profit assisted by family • Sell short-term family planning including rural areas discussions
members commodities • Some sell drugs
beyond their limit
Private Maternity homes Self-employed • Antenatal care, supervised delivery, • Mostly located in • 2015 health sector
(325) and temporary postnatal care urban areas facts and figures
assistants • Family planning services • DHIMS2 database
• Treatment of minor ailments
Private Pharmacy stores Temporary or part- • Dispensing of prescribed and • Crowded in the big • Stakeholder
time staff over-the-counter medicines cities and large urban discussions
and short-term family planning areas
commodities
Private Private medical Self-employed • Provide basic outpatient care • Few and mainly
herbal clinics using Ghana traditional medicine located in two cities
pharmacopeia (Accra and Kumasi)
Faith Clinic Ministry of Health • Similar to public clinics but more • DHIMS2 database
based and permanent limited public health services
and most do not provide modern
family planning for religious
reasons
Private Clinic • Mainly outpatient clinical services • Located mainly in • DHIMS2 database
urban areas
Public Health centre Ministry of Health • Integrated general clinical services • All 1145 subdistricts • DHIMS2 database
and permanent with basic laboratory services should have a health • Health sector 2015
• Emergencies, including basic centre but those facts and figures
emergency obstetric and newborn with hospitals and
care some deprived ones
have a clinic or CHPS
• Disease surveillance and control compound
• Outreach and technical support for
CHPS zones
Faith Health centres Ministry of Health • Similar to public health centres but • Located mostly in • DHIMS2 database
based and permanent more curative service focus rural areas
Public Polyclinics Ministry of Health Expanded health centres plus the • Located in districts • DHIMS2 Database
and permanent following: without hospitals or • Ministry of Health
• Eye, dental and mental health large urban centres annual reports
outpatient care (30), excluding the
two in some teaching
• Comprehensive emergency hospitals
obstetric and newborn care
• Basic radio-imaging services
• Short stay inpatient care
Public Government Ministry of Health Expanded polyclinic services plus the • A few hospitals are • Holistic assessment
general hospitals and permanent following: piloting integrating reports
• General inpatient care herbal medical clinics • GHS annual reports
run by four-year
• Surgeries university-trained
• Nutrition and dietetics medical herbal
• Mental health services graduates
• Rehabilitative services
Quasi- Ministry of Health • Similar to public hospitals but focus • Provide services for • DHIMS2 database
governmental and permanent is on clinical services the staff and their
hospitals (military, families but open to
police, universities, the general public
mines, etc.) • Some provide
specialist services
Public Teaching hospitals Ministry of Health • Range of services similar to the • No linkages with the
(4) and permanent other polyclinics except that they other PHC service
have no geographical coverage providers apart from
area receiving referrals
Mode of
Type of Nature of Source of
employment of Range of PHC services provided Remarks
sector facility information
providers
Public District health Ministry of Health • Disease surveillance and control • RHMTs provide • GHS reports
directorate and permanent • Health promotion and mass public support
health campaigns
Public Centre for Plant Ministry of Health • Similar to public hospitals but • Hospital section and • Ministry of Health
Medicine Research and permanent using both orthodox and herbal herbal production reports
products and limited public health research departments
services
Private NGOs in health Temporary • Mobilize and educate communities • Each NGO limits its • Ghana Coalition
non- (service delivery, employees and on the control of specific operations to some of NGOs in Health
profit nongovernmental, volunteers, diseases (malaria, TB, HIV/AIDS, services for certain reports
community- including public noncommunicable diseases, etc.), communities
based, civil society officers mental health, immunization, • Most operate from
organizations) nutrition, water and sanitation the large urban
• Treatment of minor ailments centres
• Family planning services
• Advocate and mobilize resources
for PHC, and monitor for
accountability
Private Traditional Sole self-employed, • Treat wide range of physical and • A mixture of • Key informant
for profit medical family members or mental conditions, including bone static and mobile interviews
practitioners assistants fractures and sprains, etc. practitioners • Stakeholder
discussions
Private Alternative Self-employed and • Provide diagnostic, preventive and • Located mainly in • Key informant
for profit medical few temporary curative services using traditional large urban areas interviews
practitioners assistants medicine from the East, including • Stakeholder
clinics acupuncture, etc. discussions
Source: Ministry of Health National Health Accounts: 2005, 2010, 2012, 2013-2015
Figure A7.2 Trends in Ghana total health expenditure per capita and total health expenditure as
% of GDP
100 83.85 15
75.55 80.58
80
80.37 10
60 63.15
% GDP
5.96
HE
40 6.41
4.78 5
3.28 4.86 5.13 5.51
20 13.6 20.05
0 0
2002' 2003' 2004' 2005' 2006' 2007' 2008' 2009' 2010' 2011' 2012' 2013' 2014' 2015'
HE as % of GDP Health Expenditure/capita
Source: Ministry of Health 2013, 2014 and 2015 audited accounts statements.
Public Private
Health workers per
Occupations 2015 1000 population
Number % Number %
Source: Acquah S. Human resources for health projections for the Ghana health sector. Accra: Government of Ghana, Ministry of Health; 2016.
Brong- Greater
Year Ashanti Central Eastern Northern Upper East Upper West Volta Western Ghana
Ahafo Accra
2009 1:2100 1:1868 1:1400 1:1197 1:1158 1:1960 1:1138 1:1145 1:1264 1:1797 1:1494
2010 1:1994 1:1915 1:1607 1:1376 1:1043 1:2077 1:1158 1:1204 1:1434 1:1727 1:1516
2011 1:2023 1:1850 1:1700 1:1565 1:1192 1:1942 1:1161 1:1160 1:1570 1:1777 1:1599
2012 1:1699 1:1671 1:1412 1:1303 1:960 1:1791 1:1045 1:1036 1:1470 1:1448 1:1362
2013 1:1296 1:1245 1:1185 1:1041 1:826 1:1423 1:715 1:855 1:1135 1:1142 1:1084
2014 1:1088 1:1132 1:996 1:900 1:764 1:1255 1:669 1:813 1:925 1:1077 1:959
2015 1:798 1:827 1:778 1:712 1:642 1:946 1:449 1:536 1:706 1:892 1:739
A. Broad policies
A.1 Medium-Term Health Strategy towards Vision 2020, 1999 revised edition
1. First Five-Year Programme of Work, 1997–2001
2. Second Five-Year Programme of Work, 2002–2006
A.3 National Community-Based Health Planning and Services Policy, 2016 revised edition
1. Community-Based Health Planning and Services: implementation guidelines, 2016, revised edition
DHIMS2 e‑tracker Electronic, transactional, case-based, Data can be used Requires computing Work continuing towards
system data-related records system piloted to improve case equipment and good expanding scope of
in 86 health facilities in four districts management and Internet connectivity services and geographical
for maternal and child health and TB also uploaded into the at all service delivery coverage
control services DHIMS2 database in points
summary form
Eliminated the tallying
and data re‑entry
errors, with time
savings
Human resource Integrated Personnel Payroll Database Integrated Personnel Issue is mainly lack of
information iHRIS piloted in one region but Payroll Database limited direction on the issue
systems could not scale up due to financial to public sector only
constraints; even the pilot region is not
using it
Population-based Ghana has conducted six Demographic Validate the routine Results give
surveys and Health Surveys and six Ghana data performance in the
Living Standards Surveys since 1988, Provide information past 3–5 years and not
as well as Multiple Indicator Cluster that is not generated the time of the survey
Surveys routinely
Important sources of information for
planning and monitoring progress
3. Government to adhere to mutually agreed health sector programme of work Development partners
Government to commit more resources to health sector, especially at the PHC level and NGOs
Ministry of Health and its implementing agencies should be efficient and should meet
agreed reporting deadlines and performance targets National
5. The public sector to engage the private sector more and support them with resources to Private sector service
contribute to the sector objectives delivery agencies
6. Health service delivery should be decentralized from the central level Health and PHC experts
There is a need for leadership and management development and strengthening of the
governance systems at all levels
8. Health service providers should submit their progress reports in a timely manner to the Regional coordinating Regional
regional coordinating councils councils and other
regional ministries,
departments and
agencies
9. Public sector should engage the private sector more to contribute to policy dialogue Private sector providers
10. NHIS to settle outstanding arrears and reimburse service providers promptly Public health service
District health managers to be involved in the siting of health facilities providers
The national level should ensure adequate and equitable resources for service delivery
Should be equity in resource allocation, including human resources
11. GHS should realign subdistricts with electoral areas MMDAs and
DHMTs should provide timely reports of health sector performance to MMDAs decentralized ministries,
departments and
DHMTs should disclose the resources they use before requesting support from MMDAs agencies District
Health should second nurses to schools for primary care and school health
12. Health sector should assist providers with resources to contribute to improved health Local NGOs and
community-based and
civil society organizations
13. NHIS to pay arrears and reimburse submitted claims promptly Private health providers
Regulatory agencies should simplify their processes, decentralize their operations and
reduce the cost of registration and renewal
15. Regulatory agencies should simplify their processes, decentralize their operations and Private service providers
reduce the cost of registration and renewal
16. Provide suitable furnished accommodation, security, transport, equipment, logistics and Public sector service
funds for operations providers (community
DHMTs and subdistrict health teams should provide facilitative supervision and regular health officers)
technical support
Provide opportunities for in-service training and career progression
There is a need for community meetings to encourage community participation in health
17. Scale up functional CHPS and improve back-up support and referral system by Public health service
strengthening health centres and hospitals providers
18. NHIS to pay arrears and reimburse submitted claims promptly Private health service
Regulatory agencies should simplify their processes, decentralize their operations and providers Community
reduce the cost of registration and renewal
19. Government to improve health infrastructure, such as hospitals, clinics, and CHPS Community leaders and
compounds members, civil society
Service providers should ensure the availability of health logistics and community-based
organizations
Government should improve the NHIS performance
Health workers should attend to patients promptly and be courteous
The NHIS to improve its performance by making the registration and renewal processes
accessible and easy
NHIS should reimburse providers regularly