Mr. Marty Makinen, Results for Development. Objectives and Approach of Assessment Supply Findings ...
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Transcript of Mr. Marty Makinen, Results for Development. Objectives and Approach of Assessment Supply Findings ...
GHANA PRIVATE SECTOR ASSESSMENT
Mr. Marty Makinen, Results for Development
ORGANIZATION OF PRESENTATION
Objectives and Approach of Assessment
Supply Findings
Demand Findings
Other Important Factors Affecting the Health
Market
Successes and Failures
ORGANIZATION OF PRESENTATION
Objectives and Approach of Assessment
Supply Findings
Demand Findings
Other Important Factors Affecting the Health
Market
Successes and Failures
ASSESSMENT’S OVERALL OBJECTIVES
Depict the role played by private actors in the health sector in Ghana and identify factors that created and sustain this role
Provide information to inform decision making concerning how to enhance the private role
Facilitate productive engagement between public and private sectors
ENGAGEMENT: HELD WORKSHOPS TO GUIDE RESEARCH AND FORMULATE RECOMMENDATIONS
Launch workshop (July 2009)
Validation and discussion workshop (Dec 2009)
Decision workshop (March 2010)
RESEARCH: CONDUCTED DATA COLLECTION AND ANALYSIS
Additional analysis of existing data: DHSs and GLSSs Mapping of 7 districts: 5 urban and 2 rural, 730
actors Patient exit interviews: >1,200 patients Community focus group discussions In-depth interviews of private actors Interviews of policy makers, regulators, private
association leaders Case studies
ORGANIZATION OF PRESENTATION
Objectives and Approach of Assessment
Supply Findings
Demand Findings
Other Important Factors Affecting the Health
Market
Successes and Failures
SIZE AND GEOGRAPHICAL DISTRIBUTION
Self-financing private (SFP) providers major suppliers of all forms of care, except hospital care• Even for hospital care, SFP providers represent 20% of
beds in the five urban districts studied SFP and government providers concentrated in
urban areas; CHAG and chemical sellers concentrated in rural areas
Chemical sellers represent the greatest and most accessible source of services in rural and urban-poor areas
SOURCES OF FUNDS FOR PRIVATE PROVIDERS
For capital expenditures:• Savings or profits are the key source for all private
providers• Bank loans only substantially used by private hospitals
For operations:• Patient payment and NHIS are major sources for
government and private hospitals and clinics• Government facilities are more likely to report that they
accept insurance reimbursement than private Biggest problem:
• Access to financing reported as the biggest obstacle to growth for private providers
ACCESS TO FINANCING AS MAJOR OBSTACLE TO PRIVATE GROWTH
Skills
and
edu
catio
n of
wor
kers
Lice
nsin
g an
d op
erat
ing
perm
its
Health
reg
ulat
ions
Acces
s to
fina
ncin
g0%
20%
40%
60%
80%
100%
Obstacles to growth among private providers
No or minor obstacle Moderate obstacleMajor or very severe obstacle
48% major/very
severe
ORGANIZATION OF PRESENTATION
Objectives and Approach of Assessment
Supply Findings
Demand Findings
Other Important Factors Affecting the Health
Market
Successes and Failures
MAJOR DEMAND FINDINGS
Access to services improved dramatically in past several years
Private sector important source of care NHIS seems to encourage consumers to choose
GHS providers (but unequal accreditation might be a factor)
NHIS coverage becoming more equal geographically
Nearness, customer service, medicine and lab availability, and NHIS acceptance factors attracting consumers to private providers
ACCESS TO CARE FROM ANY SOURCE WHEN ILL IS RISING
GLSS 4 (‘99)
GLSS 5 (‘05-’06)
Had a medical problem in survey recall
26% 20%
Had a medical problem and sought care
43% 60%
ACCESS TO CARE FROM ANY SOURCE WHEN ILL IS RISING
GLSS 4 (‘99)
GLSS 5 (‘05-’06)
Had a medical problem in survey recall
26% 20%
Had a medical problem and sought care
43% 60%
Perceived need for
care dropped
ACCESS TO CARE FROM ANY SOURCE WHEN ILL IS RISING
GLSS 4 (‘99)
GLSS 5 (‘05-’06)
Had a medical problem in survey recall
26% 20%
Had a medical problem and sought care
43% 60%Use of care
when needed way
up
ACCESS TO CARE FROM ANY SOURCE WHEN ILL IS RISING
GLSS 4 (‘99)
GLSS 5 (‘05-’06)
Had a medical problem in survey recall
26% 20%
Had a medical problem and sought care
43% 60%Annual contacts per
capita up from 3.19 to 3.33 – even with fewer
perceived medical problems
PRIVATE SECTOR IMPORTANT SOURCE OF CARE AND RISING SLIGHTLY
Sought care from
PublicPrivate for-
profitPrivate non-
profitGLSS 4 (1999) 48% 47% 5%
GLSS 5 (2005-06) 45% 49% 6%
PRIVATE SECTOR IMPORTANT SOURCE OF CARE AND RISING SLIGHTLY
Sought care from:
PublicPrivate for-
profitPrivate non-
profitGLSS 4 (1999) 48% 47% 5%
GLSS 5 (2005-06) 45% 49% 6%
Combined use of non- profit and self-financing private rose
from 52 to 55% of total use
NHIS COVERAGE LEADS CONSUMERS TO USE PUBLIC PROVIDERS A BIT MORE (GLSS 5)
51% 55%43% 45%
40% 40%51% 49%
9% 5% 6% 6%
0%
20%
40%
60%
80%
100%
Provider selection versus NHIS coverage status (%)
Private religious (CHAG)
Private non-religious
Public
NHIS COVERAGE LEADS CONSUMERS TO USE PUBLIC PROVIDERS A BIT MORE (GLSS 5)
51% 55%43% 45%
40% 40%51% 49%
9% 5% 6% 6%
0%
20%
40%
60%
80%
100%
Provider selection versus NHIS coverage status (%)
Private religious (CHAG)
Private non-religious
Public
Covered used
private 45% of the
time
Not covered
used private 57% of
the time
NHIS COVERAGE LEADS CONSUMERS TO USE PUBLIC PROVIDERS A BIT MORE (GLSS 5)
51% 55%43% 45%
40% 40%51% 49%
9% 5% 6% 6%
0%
20%
40%
60%
80%
100%
Provider selection versus NHIS coverage status (%)
Private religious (CHAG)
Private non-religious
Public
Covered used
private 45% of the
time
Not covered
used private 57% of
the time
Remember that accreditation
had not reached most self-financing
privates, however
BETWEEN 2006 AND 2008, NHIS COVERAGE INCREASED ACROSS ALL REGIONS
22,0
4%
34,7
5%
12,3
0% 18,8
8%
14,7
1%
7,81
%
9,05
%
5,29
%
6,30
%
16,1
9%
16,2
0%
35,0
%
52,1
%
23,6
%
43,3
%
23,3
%
35,0
% 42,4
%
45,1
%
27,3
%
36,4
%
34,6
%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
NHIS coverage, 2006 (GLSS) and 2008 (DHS)
GLSS (2006)
DHS (2008)
BETWEEN 2006 AND 2008, NHIS COVERAGE INCREASED ACROSS ALL REGIONS
22,0
4%
34,7
5%
12,3
0% 18,8
8%
14,7
1%
7,81
%
9,05
%
5,29
%
6,30
%
16,1
9%
16,2
0%
35,0
%
52,1
%
23,6
%
43,3
%
23,3
%
35,0
% 42,4
%
45,1
%
27,3
%
36,4
%
34,6
%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
NHIS coverage, 2006 (GLSS) and 2008 (DHS)
GLSS (2006)
DHS (2008)
For example, Upper West went from 5% to 45% of its population covered by NHIS
MEDICINES AND LAB TESTS DRAW CONSUMERS TO PRIVATE PROVIDERS (EXIT POLL)
36%
19%
39%28%
17%
4%
16%
11%
14%
5%
15%
10%
5%
17%
5%
18%
9%
48% 24%
25%
4%13% 13%
0%
20%
40%
60%
80%
100%
Public facilities
Private facilities
CHAG facilities Total
Perc
ent
Type of provider
Other
I came for medicines
I came for laboratory tests
I brought my son or daughter for a medical check upI came for a medical review (follow-up visit)I brought my son or daughter who has a medical problemI have a medical problem
MEDICINES AND LAB TESTS DRAW CONSUMERS TO PRIVATE PROVIDERS (EXIT POLL)
36%
19%
39%28%
17%
4%
16%
11%
14%
5%
15%
10%
5%
17%
5%
18%
9%
48% 24%
25%
4%13% 13%
0%
20%
40%
60%
80%
100%
Public facilities
Private facilities
CHAG facilities Total
Perc
ent
Type of provider
Other
I came for medicines
I came for laboratory tests
I brought my son or daughter for a medical check upI came for a medical review (follow-up visit)I brought my son or daughter who has a medical problemI have a medical problem
48% of users of SFP cited medicines as
reason for use
MEDICINES AND LAB TESTS DRAW CONSUMERS TO PRIVATE PROVIDERS (EXIT POLL)
36%
19%
39%28%
17%
4%
16%
11%
14%
5%
15%
10%
5%
17%
5%
18%
9%
48% 24%
25%
4%13% 13%
0%
20%
40%
60%
80%
100%
Public facilities
Private facilities
CHAG facilities Total
Perc
ent
Type of provider
Other
I came for medicines
I came for laboratory tests
I brought my son or daughter for a medical check upI came for a medical review (follow-up visit)I brought my son or daughter who has a medical problemI have a medical problem
17-18% of reasons for using
SFP and CHAG was lab tests
ACCEPTING INSURANCE AND NEARNESS MAJOR FACTORS IN CHOICE OF PROVIDER (EXIT POLL)
26% 22% 18% 21%
46%45%
41%47%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Public facilities
Private provider
CHAG provider
Total
Other
Short waiting time
Low price
Has agreement with my employerAccepts another health insurance cardAccepts my NHIS card
Good quality services
Only facility in my area
Nearest to my home
ACCEPTING INSURANCE AND NEARNESS MAJOR FACTORS IN CHOICE OF PROVIDER (EXIT POLL)
26% 22% 18% 21%
46%45%
41%47%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Public facilities
Private provider
CHAG provider
Total
Other
Short waiting time
Low price
Has agreement with my employerAccepts another health insurance cardAccepts my NHIS card
Good quality services
Only facility in my area
Nearest to my home
Accepts NHIS
Nearest to my home
FOCUS GROUP RESULTS
Women frequent users for themselves and others (use private more)Men less frequent users and wait until condition is serious (use GHS more)Self-treatment for minor ailments, herbalists used for specific conditions
NHIS improves accessCustomer service (advantage private) and comprehensiveness (advantage GHS) biggest factors in choicePrice not a major factorHigher income more likely to use private—but all groups make some use
ORGANIZATION OF PRESENTATION
Objectives and Approach of Assessment
Supply Findings
Demand Findings
Other Important Factors Affecting the
Health Market
Successes and Failures
OTHER IMPORTANT FACTORS AFFECTING THE HEALTH MARKET
Health Insurance• SFP providers complain of slow and low NHIS payments,
but see NHIS’s potential to be advantageous to them Pharmaceutical Supply Chain
• Private actors play a dynamic and important role in filling gaps and inefficiencies in public supply chain
• The pharmaceutical supply chain is highly fragmented and seems to be overly vertically integrated
Health Business Environment• SFP providers report greatest constraint is lack of
access to financing; small to medium sized SFP providers rarely use bank loans and even more rarely benefit from equity investments
OTHER IMPORTANT FACTORS AFFECTING THE HEALTH MARKET
Regulatory Environment• SFP providers report few constraints from regulation
and taxation, although some frustrations with under regulation are noted
Policy Environment• Ghana’s policy environment toward private sector
favorable but implementation of policies, along with a lack of resources, results in a disconnect between policy and practice
Quality• Structural quality overall is good across public and
private facilities; no clear advantage for government over private or vice versa
ORGANIZATION OF PRESENTATION
Objectives and Approach of Assessment
Supply Findings
Demand Findings
Other Important Factors Affecting the Health
Market
Successes and Failures
SUCCESSES
The public-private partnership with CHAG works well and makes CHAG an extension of the GHS in underserved rural areas
The overall policy environment in Ghana is business and private-sector friendly
There has been a specific Private Health Sector Policy since 2003 and many of the identified issues and proposed strategies are still relevant in 2010
Private providers respond to consumers with shorter waits, better drug availability, and courteous reception; but not with lower prices
FAILURES
Urban populations are much better served than rural populations by both SFP and government providers; the combination means that access is very unequal
Despite the identification of policy issues in 2003, the bulk of the agenda for action remains unimplemented
With the exception of the CHAG relationship, the private sector feels left out of the mainstream of MOH and GHS thinking and action
The regulatory councils and boards have insufficient resources to conduct on-going supervision and monitoring of private actors
FAILURES
The NHIA has uncovered important instances of fraud in claims for payment by both private and government providers
There is limited private pre-service training of health workers, and there are no private medical schools
Private sector health managers lack business and financial management skills that hinder success
Small to medium sized private health providers make little use of bank loans and almost no use of equity to finance investments
CONCLUSIONS
Use of privately provided services more than half of total
SFP much more important than non-profits Private role in provision likely to grow with
completion of accreditation and increased eligibility for NHIS
Public regulation hindered by lack of resources It has been a missed opportunity to shape the
private role by excluding and ignoring SFP from active interaction on national health policy
THANK YOU
EXTRA SLIDES
SERVICES AND HUMAN RESOURCES
Service offering in hospitals:• CHAG hospitals offer a broader range of services than
government hospitals in rural areas• Both public and SFP hospitals offer a broad range of
services in urban areas Human resources:
• CHAG hospitals have more HR per hospital bed and lower doctor to nurse ratio than government hospitals in rural areas
• Urban hospitals have more HR per bed than rural for all forms of ownership, but particularly for government hospitals
STAFFING OF RURAL HOSPITALS
GHS CHAG TOTAL
Doctors - FT 3 6 9
Doctors - PT 0 0 0
Nurses - FT 32 90 122
Nurses - PT 0 0 0
Midwives - FT 12 23 35
Midwives - PT 0 0 0
Laboratory staff - FT 3 5 8
Laboratory staff - PT 1 0 1
Pharmacists - FT 2 3 5
Pharmacists - PT 0 0 0
TOTAL 53 127 180
Staff to bed ratio 0.41 0.50 0.43
Nurses and midwives to doctors 15 19 17
STAFFING OF URBAN HOSPITALS
GHS CHAG PrivateQuasi-
Gov TOTALDoctors - FT 627 2 57 22 708Doctors - PT 13 0 99 6 118Nurses - FT 1,887 10 324 96 2,317Nurses - PT 32 14 59 5 110Midwives - FT 489 2 54 10 555Midwives - PT 0 1 29 0 30
Laboratory staff - FT 34 2 41 14 91Laboratory staff - PT 3 0 16 0 19Pharmacists - FT 33 0 27 4 64Pharmacists - PT 4 0 3 1 8TOTAL 3,122 31 709 158 4,020Total PT 52 15 206 12 285Adjusted total (PT=0.5*FT) 3,096 24 606 152 3,878
Staff to bed ratio 1.11 0.53 0.58 0.76 0.92Adjusted staff to bed 1.10 0.40 0.49 0.73 0.89Nurses and midwives to doctor 3.8 9.8 4.0 4.3 3.8
The staff to bed ratio is higher for urban (0.89) compared to rural (0.43) hospitals (brown arrow)
Ratio dramatically higher for GHS hospitals (1.10 urban, 0.41 rural) (blue arrow)
Better Health and Reduced Inequality
Strategic Objective 4 (5Yr
POW lll)Good Governance and Partnership
Objectives of Assessment
Depict current private sector role and
influencing factors
Engage stakeholders over (1) issues then (2)
evidence-based solutions
Information generated
Quality of service
Serving the disadvantaged
Human resource
availability (capacity)
Business environment
Public-Private Instruments of EngagementAssessment
Protocol
1. Mapping + interviews of private actors
X X X X X
2. Patient exit Interviews X X3a. CHAG X X X3b. Emergencies X 3c. Pharmaceutical supplies
X X X X
4. Population FDGs X X5. Secondary analysis of data X X6. Key informant interviews X X
Health Sector Goal
ASSESSMENT ANALYTICAL FRAMEWORK
Diagnose nature/effectiveness of private-public
interface
SCOPE OF RESEARCH ON THE PRIVATE HEALTH SECTOR
Not explored
Health NGOs (e.g., health
promotion organizations)
Limited review
Informal providers (e.g.
unlicensed practitioners,
traditional healers, TBAs)
Private health-training
institutions (e.g. medical
and nursing schools)
Focus of Assessment
Formal self-financed service providers (e.g. hospitals,
clinics, maternity homes, pharmacies,
labs)
Faith-based institutions
(e.g., CHAG, Amadea Muslim
mission)
Private input suppliers
(e.g., medical equipment suppliers,
pharmaceutical manufacturers)
CHEMICAL SHOPS APPEAR TO REPRESENT THE GREATEST AND MOST ACCESSIBLE SOURCE OF SERVICES IN RURAL AND URBAN-POOR AREAS
Facility Type
Urban Urban Poor Rural
Osu-Klottey
Bantama Tema
Tamale
Ashaiman Duayaw Nkwanta
Manya Krobo
Hospital 5 7 18 9 1 1 3 44
Clinic 25 4 45 12 8 1 13 108
Maternity home 2 2 3 6 4 0 4 21
Community-level Gov’t Centre
0 0 3 7 0 4 1 15
Laboratory 4 6 9 3 2 1 1 26
Pharmacy-wholesale
22 4 6 8 4 0 2 46
Pharmacy-retail 29 17 65 7 9 2 1 130
Chemical Seller 5 11 34 164 41 26 59 340
TOTAL 92 51 183 216 69 35 84 730
MARKET SUCCESSES AND FAILURES
Private supply of services offers many choices to urban populations
Chemical sellers give rural dwellers important access to drugs
Private providers respond to consumers with shorter waits, better drug availability, and courteous reception; but not with lower prices
Market Successes
Urban populations are much better served than rural populations by both SFP and GHS providers
Lack of business and financial skills and relatively high interest rates, short repayment periods, substantial collateral requirements restrict the use of bank loans for investment to expand all private providers
The pharmaceutical supply system is highly fragmented and seems to be overly vertically integrated
Market Failures