PERFORMANCE OF HEALTH FACILITIES IN NHIS ACCREDITATION:

AN ANALYSIS OF NHIS ACCREDITATION DATA

JULY 2009-DECEMBER 2012

Preliminary Findings

PREAMBLE• Presentation is part of a study into the performance of

health facilities in the NHIS accreditation aimed at supporting weaker facilities and accreditation in Ghana

• Commissioned by IFC and supported by IFC, NHIA, GHS and SPMDP

• Key investigator Dr Nicholas A. Tweneboa supported by:o GHS: Mrs Susana Larbi Wumbee and Mrs Christiana Akufoo SPMDP: Dr Kwasi Odoi-Agyarkoo NHIA: Mrs Vivian Addo-Cobbiah and Mrs Constance Addo

Quaye• Analysis of NHIS accreditation data and field work• Data analysis by consultant and Mrs Addo-Cobbiah still in

progress. Following are preliminary findings.

PRESENTATION OUTLINEINTRODUCTION

ANALYSIS 1

• Nationwide performance of all facilities• Performance by region

ANALYSIS 2

• Performance by facility type

ANALYSIS 3

• Performance by ownership (1° hospitals, clinics /health centres, maternity homes)

Note: Further analysis in progress

INTRODUCTION – ACCREDITATION PROCESS• Facility applies• Application vetted• Facility inspected by trained accreditation

surveyors• Data analysed• Accreditation decision made• Communication of inspection result and

accreditation decision• Accreditation certificates issued (not done in

most cases)• Post accreditation monitoring (not systematic)

Introduction 2 – GRADING

• Grade A+ 90-100% overall score and pass in critical areas

• Grade A: 80-89%• Grade B: 70-79%• Grade C: 60-69%• Grade D: 50-59%• Grade E (Fail): Less than 50%• Provisional: fail but provisional to create access

SET 1

ACCREDITATION DATA ANALYSIS – 1PERFORMANCE NATIONWIDE

AND BY REGION

NATIONWIDE PERFORMANCE OF ALL FACILITIES BY GRADE

GRADE NUMBER PERCENTAGE

GRADE A+ 7 0.2%

GRADE A 94 2.5%

GRADE B 734 19.8%

GRADE C 1562 42.2%

GRADE D 1145 30.9%

PROVISIONAL 45 1.2%

FAIL 114 3.1%

TOTAL 3701 100.0%

NATIONWIDE PERFORMANCE OF ALL FACILITIES BY GRADE

PERFORMANCE NATIONWIDE

• 3,701 facilities were inspected between July 2009 and December 2012

• The 3,701 includes 11 secondary hospitals of which 2 had A, 8 had B and 1 had C.

• Most of the facilities inspected (over 95%) passed and were accredited; 4.3% failed

• Majority of the facilities (73%) obtained Grade C or D

• 101 facilities (2.7%) obtained A+ or A

Performance nationwide – 2

• 835 facilities (22.5%) obtained top three grades (A+, A, B) and 2,866 (77.4%) obtained lowest three grades (C, D, E or fail)

• Conclusiono The nationwide pass rate of facilities in the NHIS

accreditation was high but the quality of the passes was not impressive

PERFORMANCE BY REGION (NUMBER, %)

REGIONGRADE A+

(No., %)

GRADE A

(No., %)

GRADE B

(No., %)

GRADE C

(No., %)

GRADE D

(No., %)

FAILED

(No., %)

NUMBER

INSPECTED

ASHANTI 0 0.0 10 1.6 81 13.1 212 34.4 284 46.0 30 4.9 617

BR. AHAFO 0 0.0 2 0.5 47 12.7 140 37.7 153 41.2 29 7.9 371

CENTRAL 0 0.0 13 4.0 107 32.6 132 40.2 61 18.6 15 4.6 328

EASTERN 0 0.0 11 2.4 80 17.5 245 53.7 114 25.0 6 1.4 456

GR. ACCRA 1 0.2 13 3.0 118 27.0 179 41.0 103 23.6 23 5.2 437

NORTHERN 1 0.3 21 6.1 74 21.5 150 43.6 87 25.3 11 3.2 344

UPPER EAST 2 1.0 5 2.4 64 30.6 98 46.9 34 16.3 6 2.8 209

UPPER WEST 1 0.6 8 4.5 49 27.5 76 42.7 40 22.5 4 2.2 178

VOLTA 0 0.0 2 0.6 35 11.4 117 38.0 135 43.8 19 6.2 308

WESTERN 2 0.4 9 2.0 79 17.4 213 47.0 134 29.6 16 3.6 453

TOTAL 7 0.2 94 2.5 734 19.8 1562 42.2 1145 30.9 159 4.3 3701

PERFORMANCE BY REGION (%)

PERFORMANCE BY REGION (BASED ON QUALITY OF PASS)

GRADES A+, A & B (70% AND ABOVE)

GRADES C, D & FAIL (BELOW 70%)

REGION NUMBER PERCENTAGE NUMBER PERCENTAGE NUMBER INSPECTED

ASHANTI 91 14.7 526 85.3 617

BR. AHAFO 49 13.2 322 86.8 371CENTRAL 120 36.6 208 63.4 328EASTERN 91 20.0 365 80.0 456GR. ACCRA 132 30.2 305 69.8 437NORTHERN 96 27.9 248 72.1 344UPPER EAST 71 34.0 138 66.0 209UPPER WEST 58 32.6 120 67.4 178VOLTA 37 12.0 271 88.0 308WESTERN 90 19.9 363 80.2 453TOTAL 835 22.6 2866 77.4 3701

PERFORMANCE BY REGION(BASED ON QUALITY OF PASS)

PERFORMANCE BY REGION

• The region with the largest number of inspected facilities is Ashanti (617 or 16.7% of facilities inspected nationwide), followed by Eastern Region (456 or 12.3%) and Western Region (453 or 12.2%)

• By pass rate or failure rate alone, the best performing regions are Eastern (failure rate of 1.4%), Upper West (2.2%) and Upper East (2.8%)

• By pass rate or failure rate alone, the least performing regions are Brong Ahafo (7.9% failure rate) followed by Volta (6.2%) and Greater Accra (5.2%)

Performance by region – 2

• Based on the quality of the passes, best performing regions are Central (36.6% of inspected facilities obtained A+, A or B), Upper East (34%) and Upper West (32.6%).

• Hence Upper East and Upper West performed well on both pass rate and quality of passes

• However, on quality of passes, Eastern dropped from 1st to a distant 5th (20.0%, falling below the national average of 22.6% inspected facilities obtaining A+, A or B)

Performance by region – 3

• The three least performing regions were Volta (12% inspected facilities fell in the A+, A, B bracket), Brong Ahafo (13.2%) and Ashanti (14.7%)

• Conclusion: o The best performing regions were not ‘better

endowed’ ones but ‘less endowed’ regions

GRADES BY REGION (PERCENTAGES)

REGIONGRADE

A+GRADE

AGRADE

BGRADE

CGRADE

DPASSED

(ACCRED)FAILED

ASHANTI 0.0 1.6 13.1 34.4 46.0 95.1 4.9BRONG AHAFO 0.0 0.5 12.7 37.7 41.2 92.1 7.9CENTRAL 0.0 4.0 32.6 40.2 18.6 95.4 4.6EASTERN 0.0 2.4 17.5 53.7 25.0 98.6 1.4GREATER ACCRA 0.2 3.0 27.0 41.0 23.6 94.8 5.2NORTHERN 0.3 6.1 21.5 43.6 25.3 96.8 3.2UPPER EAST 1.0 2.4 30.6 46.9 16.3 97.2 2.8UPPER WEST 0.6 4.5 27.5 42.7 22.5 97.8 2.2VOLTA 0.0 0.6 11.4 38.0 43.8 93.8 6.2WESTERN 0.4 2.0 17.4 47.0 29.6 96.4 3.6NATIONWIDE 0.2 2.5 19.8 42.2 30.9 95.7 4.3

PERCENTAGE PASS (ACCREDITED) BY REGION

FAILED FACILITIES BY REGION

PASSED (ACCREDITED) AND FAILED BY REGION

GRADE A+ BY REGION

GRADE A BY REGION

GRADE B BY REGION

GRADE C BY REGION

GRADE D BY REGION

SET 2

ACCREDITATION DATA ANALYSIS – 2PERFORMANCE BY FACILITY TYPE

SUMMARY PERFORMANCE BY FACILITY TYPE

A+ A B C D FAIL INSP.No % No % No % No % No % No % No

PRIM HOSP 0 0.0 8 2.4 86 25.7 140 41.9 92 27.5 8 2.4 334

CLINIC 1 0.3 2 0.6 52 15.0 122 35.2 129 37.2 41 11.8 347

H. CENTRE 2 0.2 19 2.2 119 13.5 390 44.2 321 36.4 31 3.5 882

MAT. HOME

0 0.0 6 2.7 40 17.7 76 33.6 96 42.5 8 3.5 226

CHPS 0 0.0 34 3.2 287 26.6 522 48.5 220 20.4 14 1.3 1077

DIAG. 3 1.4 12 5.6 44 20.7 81 38.0 63 9.6 10 4.7 213

PHARM 1 0.3 8 2.4 67 19.7 142 41.8 103 30.3 19 6.6 340

CHEM SELL. 0 0.0 3 1.3 25 9.8 79 31.1 120 47.2 27 10.6 254

TOTAL 7 0.2 94 2.5 734 19.8 1562 42.2 1145 30.9 159 4.3 3701

SUMMARY PERFORMANCE BY FACILITY TYPE

PERFORMANCE BY FACILITY TYPE (BASED ON QUALITY OF PASSES)

FACILITY TYPE A+, A, B (NUMBER, %)

C, D, FAIL (NUMBER, %)

NO. INSPECTED

PRIMARY HOSPITAL 94 28.1 240 71.9 334

CLINIC 55 15.9 292 84.1 347

HEALTH CENTRE 140 15.9 742 84.1 882

MATERNITY HOME 46 20.4 180 79.6 226

CHPS 321 29.8 756 70.2 1077

DIAGNOSTIC 59 27.7 154 72.3 213

PHARMACY 76 22.4 264 77.6 340

CHEMICAL SELLER 28 11.0 226 89.0 254

TOTAL 835 22.6 2866 77.4 3701

PERFORMANCE BY FACILITY TYPE(BASED ON QUALITY OF PASSES)

PERFORMANCE BY FACILITY TYPE

• Largest number inspected was CHPS (1,077 of 3,701 or 29.1% inspected); least number was diagnostic (213 or 5.8% of inspected facilities)

• By pass rate alone, the best performing facility type was CHPS (with pass rate of 98.7%), followed by primary hospitals (pass rate of 97.6%), health centres and maternity homes a joint third (96.5%)

• By pass rate alone, the least performing facility types were clinics (with failure rate of 11.8%, chemical sellers (10.6%) and pharmacy (6.6%)

Performance by facility type - 2

• Adjusted for quality of passes, CHPS and primary hospital still lead (29.8% and 28.1% respectively inspected had Grade A+, A or B)

• However, diagnostic moves up from 5th place to 3rd (27.7%) and pharmacy (22.4%) moves up from 6th to 4th

• Maternity home (20.4%) and health centre (15.9%) move down from joint 3rd to 5th and 6th respectively

• Clinic (15.9% obtaining A+, A or B) and chemical seller (11.0%) remain poorly performing

Performance by facility type – 3

• Conclusionso Primary hospitals and CHPS performed well in

accreditation

o Clinics and health centres which are midway between CHPS and primary hospitals in the referral chain performed poorly

o Chemical sellers as a group was the least performing facility type

GRADE A+ BY FACILITY TYPE

GRADE A BY FACILITY TYPE

GRADE B BY FACILITY TYPE

GRADE C BY FACILITY TYPE

GRADE D BY FACILITY TYPE

FAIL BY FACILITY TYPE

PRIMARY HOSPITALSGRADE NUMBER PERCENTAGE

GRADE A+ 0 0.0

GRADE A 8 2.4

GRADE B 86 25.7

GRADE C 140 41.9

GRADE D 92 27.5

FAIL 8 2.4

TOTAL 334 100.0

PRIMARY HOSPITALS

CLINICS

GRADE NUMBER PERCENTAGE

GRADE A+ 1 0.3

GRADE A 2 0.6

GRADE B 52 15.0

GRADE C 122 35.2

GRADE D 129 37.2

FAIL 41 11.8

TOTAL 347 100.0

CLINICS

HEALTH CENTRES

GRADE NUMBER PERCENTAGE

GRADE A+ 2 0.2

GRADE A 19 2.2

GRADE B 119 13.5

GRADE C 390 44.2

GRADE D 321 36.4

FAIL 31 3.5

TOTAL 882 100.0

HEALTH CENTRES

CHPS COMPOUNDS

GRADE NUMBER PERCENTAGE

GRADE A+ 0 0.0

GRADE A 34 3.2

GRADE B 287 26.6

GRADE C 522 48.5

GRADE D 220 20.4

FAIL 14 1.3

TOTAL 1077 100.0

CHPS COMPOUNDS

MATERNITY HOMES

GRADE NUMBER PERCENTAGE

GRADE A+ 0 0.0

GRADE A 6 2.7GRADE B 40 17.7

GRADE C 76 33.6

GRADE D 96 42.5

FAIL 8 3.5

TOTAL 226 100.0

MATERNITY HOMES

DIAGNOSTIC CENTRESGRADE NUMBER PERCENTAGE

GRADE A+ 3 1.4

GRADE A 12 5.6

GRADE B 44 20.7

GRADE C 81 38.0

GRADE D 63 29.6

FAIL 10 4.7

TOTAL 213 100.0

DIAGNOSTIC CENTRES

PHARMACIESGRADE NUMBER PERCENTAGE

GRADE A+ 1 0.3

GRADE A 8 2.4

GRADE B 67 19.7

GRADE C 142 41.8

GRADE D 103 30.3

FAIL 19 5.6

TOTAL 340 100.0

PHARMACIES

CHEMICAL SHOPS

GRADES TOTAL PERCENTAGE

GRADE A+ 0 0.0

GRADE A 3 1.2

GRADE B 25 9.8

GRADE C 79 31.1

GRADE D 120 47.2

FAIL 27 10.6

TOTAL 254 100.0

CHEMICAL SHOPS

FAILURE RATE BY FACILITY TYPE

FACILITY TYPE TOTAL INSPECTED FAILEDPERCENTAGE

FAILED

PRIMARY HOSPITALS 334 8 2.4

HEALTH CENTRES 882 31 3.5

CLINICS 347 41 11.8

MATERNITY HOMES 226 8 3.5

CHPS COMPOUNDS 1077 14 1.3

PHARMACIES 340 29 5.6

CHEMICAL SHOPS 254 27 10.6

DIAGNOSTIC CENTRES 213 10 4.7

SET 3

ACCREDITATION DATA ANALYSIS – 3 COMPARATIVE ANALYSIS OF

PERFORMANCE BY OWNERSHIP(primary hospitals, clinics/health

centres, maternity homes)

PERFORMANCE OF PRIMARY HOSPITALS BY OWNERSHIP

PUBLIC(NUMBER, %)

PRIVATE(NUMBER, %)

MISSION(NUMBER, %)

QUASI-GOVT(NUMBER, %)

GRADE A+ 0 0.0% 0 0.0% 0 0.0% 0 0.0%

GRADE A 0 0.0% 2 1.3% 3 5.3% 3 27.3%

GRADE B 31 28.7% 26 16.5% 24 42.1% 5 45.5%

GRADE C 52 48.1% 64 40.5% 21 36.8% 3 27.3%

GRADE D 25 23.1% 58 36.7% 9 15.8% 0 0.0%

FAIL 0 0.0% 8 5.1% 0 0.0% 0 0.0%

TOTAL 108 100.0% 158 100.0% 57 100.0% 11 100.0%

PRIMARY HOSPITALS

PERFORMANCE OF PRIM. HOSP. BY OWNERSHIP(BASED ON QUALITY OF PASSES)

PUBLIC(NUMBER, %)

PRIVATE (NUMBER, %)

MISSION(NUMBER, %)

QUASI-GOVT(NUMBER, %)

A+, A, B 31 28.7 28 17.7 27 47.4 8 72.7

C,D, FAIL 77 71.3 130 82.3 30 52.6 3 27.3

TOTAL 108 100.0 158 100.0 57 100.0 11 100.0

PERFORMANCE OF PRIM. HOSP. BY OWNERSHIP(BASED ON QUALITY OF PASSES)

PERFORMANCE OF PRIMARY HOSPITALS

• Largest number of primary hospitals inspected were privately owned (158 or 47.3% of all primary hospitals inspected)

• Other primary hospitals inspected:o Public (108 or 32.3%); oMission (57 or 17.1%); o Quasi-government (11 or 3.3%)

• All primary hospitals inspected passed and were accredited except for private primary hospitals of which 8 (5.1%) failed

Performance of primary hospitals by ownership - 2• By either pass rate or quality of the passes, private

primary hospitals performed least among the primary hospitals inspected, with pass rate of 94.9% compared to 100% for other ownerships

• By quality of passes private primary hospitals still performed least as 17.7% inspected obtained Grade A+, A or B as compared to mission (47.4%), public (28.7%) and quasi-govt. (72.7%, n=11)

Performance of primary hospitals by ownership - 3

• Conclusiono Private primary hospitals performed least among

the primary hospitals inspected, based on either pass or failure rate or the quality of the passes

PERFORMANCE OF CLINICS AND HEALTH CENTRES BY OWNERSHIP

PUBLIC(NUMBER, %)

PRIVATE(NUMBER, %)

MISSION(NUMBER, %)

QUASI(NUMBER, %)

GRADE A+ 1 0.1% 1 0.3% 1 0.7% 0 0.0%

GRADE A 14 1.9% 2 0.6% 5 3.6% 0 0.0%

GRADE B 88 12.0% 49 14.6% 29 20.7% 5 31.3%

GRADE C 330 44.9% 117 34.9% 58 42.1% 6 37.5%

GRADE D 279 38.0% 126 37.6% 40 29.3% 4 25.0%

FAIL 24 3.3% 41 12.2% 6 4.3% 1 6.3%

TOTAL 735 100.0% 336100.0% 139 100.0% 16 100.0%

CLINICS AND HEALTH CENTRES

PERFORMANCE OF HEALTH CENTRES AND CLINICS BY OWNERSHIP

(BASED ON QUALITY OF PASSES)

PUBLIC(NUMBER, %)

PRIVATE (NUMBER, %)

MISSION(NUMBER, %)

QUASI-GOVT(NUMBER, %)

A+, A, B 103 14.0 52 15.5 35 25.2 5 31.2

C,D, FAIL 633 86.0 284 84.5 104 74.8 11 68.8

TOTAL 735 100.0 336 100.0 139 100.0 16 100.0

PERFORMANCE OF HEALTH CENTRES AND CLINICS BY OWNERSHIP

(BASED ON QUALITY OF PASSES)

PERFORMANCE OF CLINICS AND HEALTH CENTRES BY OWNERSHIP

• Private clinics had the highest failure rate of 12.2% (41 out of 336 clinics failed)

• 6 of 139 (4.3%) of mission health centres failed compared to 24 of 735 public health centres (3.3%)

• Only 16 quasi-government health centres and clinics were inspected and 1 failed

Performance of health centres and clinics by ownership

• In respect of quality of the passes, CHAG health centres performed best, with 25.2% of inspected obtaining A+, A or B

• Public health centres and private clinics had similar quality of passes (14.0% and 15.5% respectively had Grade A+, A or B)

• ConclusionoMission health centres performed better than

private clinics and public health centres

PERFORMANCE OF MATERNITY HOMES BY OWNERSHIP

PUBLIC

(NUMBER, %)PRIVATE

(NUMBER, %)MISSION

(NUMBER, %)

GRADE A+ 0 0.0% 0 0.0% 0 0.0%

GRADE A 0 0.0% 6 2.7% 0 0.0%

GRADE B 2 66.7% 37 16.8% 1 33.3%

GRADE C 1 33.3% 74 33.6% 1 33.3%

GRADE D 0 0.0% 95 43.2% 1 33.3%

FAIL 0 0.0% 8 3.6% 0 0.0%

TOTAL 3 100.0% 220 100.0% 3 100.0%

MATERNITY HOMES

PERFORMANCE OF MATERNITY HOMES(BASED ON QUALITY OF PASSES)

PUBLIC(NUMBER, %)

PRIVATE (NUMBER, %)

MISSION(NUMBER, %)

A+, A, B 2 66.7 43 19.5 1 33.3

C,D, FAIL 1 33.3 177 80.5 2 66.7

TOTAL 3 100.0 220 100.0 3 100.0

PERFORMANCE OF MATERNITY HOMES (BASED ON QUALITY OF PASSES)

PERFORMANCE OF MATERNITY HOMES BY OWNERSHIP

• 8 of 220 private maternity homes (equivalent to 3.6%) failed the accreditation ; 96.4% passed

• Just about one-fifth of private maternity homes had A+, A or B

• The number of public and mission maternity homes (3 each) is too small to make comparisons with private maternity homes

• Conclusiono Private maternity homes had a good pass rate but

the quality of the passes was weak

OVERALL CONCLUSIONS• Nationwide, the pass rate of inspected facilities was

high but the quality of the passes was generally not impressive

• Facilities in relatively less endowed regions rather than relatively well endowed regions performed best in the accreditation

• Clinics and health centres which constitute the link between CHPS (community) and primary hospitals performed poorly. Chemical sellers also did poorly.

• Private facilities generally performed poorly

Thank you for your kind attention