Policy Brief 2, David Dingus

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Policy Brief 2: The Burden of Disease in Ghana A look at the growing number of NCDs in an underfunded health system still battling Malaria. !

Abstract

Ghana is a low-income country facing a disease burden of both communicable and non-communicable diseases. After instituting a National Health Insurance system in 2003, the system has remained largely underfunded and understaffed, unable to meet the needs of Ghanaians and forcing many people to seek the services of traditional medicine. The system fails everyone, but above all those in the informal sector and in rural areas. To solve these

problems, the costs for the informal sector must be eliminated, and be better funded through increased taxes and payroll deductions in the formal sector. Furthermore, many communicable diseases could be prevented through improved sanitation standards.

Ghana has a dual burden of disease that is increasingly affected by non-communicable diseases while still facing communicable diseases. In total, 39% of mortality in Ghana is attributed to NCDs. (WHO, 2014) Today the top ten causes of death include hypertension, stroke, diabetes, and cancer. (Abiiro & McIntyre, 2012)

In the next 20 years Ghana’s burden of disease will continue to shift to more chronic non-communicable disease due to a population that is living longer and in more urban environments, with poor diets and decreasing physical activity, especially around the major city of Accra and the Ashanti region. (Addo, Aikins, Bosu, & Ofei, 2012) Almost 29% of the adult population is considered overweight and that is increasing at a rate of 1% per year, while 33.7% of the population is between the ages of 25 and 54. This means that we can expect to see an increasing burden of NCDs in the forceable future as a large portion of the adult population begins to enter old age, when they are at a greater risk for NCDs. (World Bank, 2014)

Meanwhile, Ghana continues to face communicable diseases such as Malaria, and Diarrhoea a common symptom and the ultimate killer of many communicable diseases. Many of these

Essentials of Global HealthJuly 4, 2014David Dingus: 11403109

(WHO, 2014)

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diseases and symptoms result from poor water sanitation, which provides breeding grounds for vectors and other pa thogens . Whi le da ta surveys from the WHO (2014) show that improved water standards have increased, only 18% of the population has access to improved sanitation standards. There is continued growth in access to improved water and sanitation, but the rate at which improved sanitation is growing is much slower. More striking is the difference in these standards between urban and rural areas. In general, urban areas have higher improved water and sanitation standards, whereas open defection has increased in rural Ghanaian. (WHO, 2014)

In 2003 Ghana passed the The National Health Insurance Scheme Act. While this system is a contributory National Health Insurance system, it functions as a hybrid of a National Health Insurance system and a Pluralist system. This is largely because the informal sector is expected to make out-of-pocket contributions and also because the public sector is unable to meet the needs of the people, and so the private sector has begun to fill the gap for those who can afford it. As such, medical facilities are owned by the public and private sectors. There is both public and private insurance and the system is financed through a VAT, employers and employees payroll deductions, and income generated by out-of-pocket expenses. In 2005 the NHIS had about 7% of the population enrolled and that had increased to 66.4% in 2010. Even though enrolment is increasing, this does not mean that the medical needs of the population are being met. (Abiiro & McIntyre, 2012)

Approximately 70% to 75% of the the system is tax funded, but only 1/3 of members actually contribute to the system. There are exemptions for children, core poor, and the elderly. Those in the informal sector are supposed to pay annual premiums indexed to their incomes, but it can be difficult to obtain true earnings, so usually a flat rate is asked for. As a result, many in the informal sector choose not to contribute to the system and there are inadequate funds to pay for both resources and medical staff, which explains the shortage and understaffed facilities throughout the country. This is especially true in rural areas and at the tertiary level of care. (O’Connor, 2010) There are approximately .15 medial personnel per 1000 Ghanaians, which is far too few to meet even the most basic needs of the people. Nearly 75% of Ghanaians seek traditional care initially, while those who can afford to, go to private hospitals or self medicate. (Baidoo, 2009)

The Ghanian healthcare system is not properly staffed to handle the burden of disease for today or in the future, as it does not have the necessary funds to pay for trained medical staff, drugs, and other resources. In the future, as the burden of disease shifts increasingly to NCDs, more resources and funds will be needed as these diseases are more complex and require more


Urban sanitation

trends

Cov

erag

e (%

)

0

20

40

60

80

100

1990 2012

10 7

31 1

46

72

1320

Improved facilitiesShared facilitiesOther unimproved facilitiesOpen defecation

Rural sanitation

trends

Cov

erag

e (%

)

0

20

40

60

80

100

1990 2012

29 33

4715

20

44

48

Improved facilitiesShared facilitiesOther unimproved facilitiesOpen defecation

(WHO, 2014)

(WHO, 2014)

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expensive drugs. Every year newly qualified graduates who would normally choose to enter the medical field, choose instead to go abroad. Resulting in a brain drain and robbing the country of its ability to provide for its own medical needs. (Addo, Aikins, Bosu, & Ofei, 2012)

While all Ghanaians regardless of gender or socio-economic status are being increasingly affected by NCDs, the wealthy groups generally have better access to care through private insurance and hospitals. On the other hand, the poorest Ghanaians who usually work in the informal sector with no insurance or funds, rely on alternative methods to meet their basic medical care needs. Because of the structure of the healthcare system, those working in the informal sector are the most underserved and make up 80% of the population. They are unable to pay for the premiums that would grant them access to the NHIS and thus do not receive the care they need. Those in middle and middle-low income groups, who work work in the formal sector, are served by the NHIS, but because of improper funding there is a deficit of hospital staff, accessibility, and overall healthcare can be slow and ineffective. In sum, the wealthy quartile is

the most targeted and biggest benefactor of the healthcare system in Ghana, the same group which contributes most of the taxes that fund this healthcare system. Nonetheless, all income quintiles and the entire population is being underserved. (O’Connor, 2010) However, Ghana has seen positive results from previous policies that have granted free health care to pregnant mothers and children. Today most Ghanaian women visit the doctor at least once during their pregnancy across all income quintiles. On the other hand, as income decreases, the rate of care by trained medical staff decreases, yet immunisation remains high and relatively uniform across all income quantiles. (WHO, 2014) (Baidoo, 2009)

Policy changes must address the challenges Ghana faces in communicable and NCDs. First, a focus on improved sanitation standards across the country and especially in rural areas would greatly help reduce the risk for communicable diseases such as Malaria and deadly symptoms such as Diarrhoea, which impact the poor the most, and at the same time this would free up resources for the growing number of NCDs.

Furthermore, current public campaigns and additional ones should be implemented to educate the public on the importance of healthy food and an active lifestyle. Overtime, these campaigns positively influence preferences and would reduce the number of people requiring medical care for the growing number of chronic NCDs.

Finally, structural reform should first and foremost focus on the funding and accessibility shortage, and the cost barrier for the informal sector. In order to be effective in the prevention and treatment of communicable and non-communicable diseases, health insurance and care must be universal. Essentially, the NHIS should move away from being contributory and Pluralistic. It is


(WHO, 2014)

(WHO, 2014)

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especially important that there be no out-of-pocket or premium costs for the informal sector, and that all funding come from employer, employee, and tax based payments. However, it is not feasible to switch the country entirely to a National Health Insurance system, because the costs would be too great and would require much higher taxes. (Abiiro & McIntyre, 2012)

While many opponents argue that any increase in taxes is not possible, the current funding system simply does not provide enough money. Furthermore, Ghana continues to be dependent on foreign aid and this is not sustainable in the long-run. Instead, the current system can be adjusted incrementally to include free access for the poor and correct the funding deficit through a combination of increased payments from the formal sector and taxes, especially the VAT. By focusing on the VAT, the NHIS would be funded through consumption, which would be higher for wealthier individuals and have a a negligible effect on the poor given how little they consume in the market. Furthermore, funding for NHIS will grow as the country continues to develop and incomes increase, because people will consume more, which will increase revenues from the VAT. (Abiiro & McIntyre, 2012)

Private hospitals and insurance companies should remain, because they will ensure continued access to healthcare for some individuals, and closing these facilities would only place further burden on already strained public facilities. Private hospitals would also help attract more medical personnel in staying in Ghana and eventually lead to spill over effects into the public sector.

Concluding, improved sanitation standards in combination with public awareness campaigns and an adjustment in the funding structure of the current NHIS, will help the health system of Ghana better meet a growing number of health challenges. Above all, these policies will help better serve the poor who work in the informal sector, the most underserved group, by reducing the risk for the most common communicable diseases, and removing the prohibitive costs of medical care. This will become increasingly important as the country’s disease burden continues to shift towards NCDs. Only a well funded system will be able to provide greater access to care and drugs that are essential in combating the growing rate of NCDs.

!!!


!“Health care is an essential safeguard of human life and dignity and there is an obligation for society to ensure that every person be able to realise this right.”

-Joseph Bernadin

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References

Abiiro, G. A., & McIntyre, D. (2012). Achieving universal health care coverage: Current debates in Ghana on covering those outside the formal sector, BMC International Health and Human Rights. Retrieved from http://www.biomedcentral.com/1472-698X/12/25 !Addo, J., Agyemang, C., Aikins, D., Bosu, W. K., Ofei, F. (2012). GHANA’S BURDEN OF CHRONIC NON- COMMUNICABLE DISEASES: FUTURE DIRECTIONS IN RESEARCH, PRACTICE AND POLICY. GHANA MEDICAL JOURNAL, 46 (2). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3645141/ !Baidoo, R. (2009). Toward a Comprehensive Healthcare System in Ghana. Retrieved from https://etd.ohiolink.edu/!etd.send_file?accession=ohiou1237304137&disposition=inline !O’Connor, F. D. (2010). An Evaluation of the National Health Insurance Scheme in Ghana. Retrieved from: https://www.academia.edu/1873350/An_Evaluation_of_the_National_Health_Insurance_Scheme_in_Ghana !WHO. (2014). Proportional Mortality [Chart]. Retrieved from http://www.who.int/nmh/countries/gha_en.pdf?ua=1 !WHO. (2014). Improved water and sanitation [Chart]. Retrieved from http://www.who.int/gho/countries/gha.pdf?ua=1 !WHO. (2014). Health services equity [Charts]. Retrieved from http://who.int/gho/health_equity/countries/gha.pdf?ua=1 !WHO. (2014). Sanitation trends [Charts]. Retrieved from http://www.wssinfo.org/fileadmin/user_upload/resources/Ghana.xls !World Bank. (2014). Ghana: Prevalence of Overweight. Retrieved from http://api.worldbank.org/countries/GHA/indicators/SH.STA.OW15.MA.ZS?per_page=1000


Policy Brief 2, David Dingus

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