Pause…get it right…move on Review of Ghana Health Sector 2005 Programme of Work

1. Pause…get it right…move on Review of Ghana Health Sector 2005 Programme of Work

2. Overview Methodology Sector Performance Roles & responsibilities Financing & financial management Service delivery performance Human resource policies Health service management & information Common management arrangements

3. Methodology Review of documents Interviews with key informants Field trip to Eastern & Ashanti Regions In-depth study debriefings Exemptions CMAII Problems Full year expenditure not available Burden of disease study Capital investment programme Data preparation Regional reports

4. Sector performance

5. Roles & responsibilities GOG has constitutional responsibilities for the health of its citizens, particularly the poor These responsibilities are now enshrined in international agreements and conventions They imply getting the best value from limited resources (efficiency, equity & quality) in the performance of the sector The ways these responsibilities are exercised needs to be clarified & simplified In particular, Ghana’s `agency’ management model needs further development based on experience to date

6. Roles & responsibilities: issues to be resolved 1 MoH: strategic policy management budget management information management (observing the activities of its `agents’) management controls exercised through service level agreements with CEOs GHS: Responsible for delivering the right services at an appropriate volume & quality to the right people HR manager ?service purchaser ?service provider ? block funding ? fully decentralised budget management ?role of regional vs district health authorities

7. Roles & responsibilities: issues to be resolved 2 District Assemblies: ?service purchaser or priority setter ?functional roles in relation to district health authorities NIHF: service purchaser Facilities & individual clinicians: service providers

8. Roles & responsibilities: issues to be resolved: 3 Regulators (quality management): quality, price, volume a multiplicity of regulators is inefficient incentives are more powerful than sanctions professional organisations are necessary for effective regulation but insufficient a legal framework is necessary for effective regulation but insufficient health markets are prone to failures and require an independent regulator representing patients as well as providers

9. Roles & responsibilities: issues to be resolved: 4 Inter-sectoral collaboration : It’s difficult but necessary it works best when there is something to do guinea-worm nutrition & industry education & HIV-AIDS Social Welfare & beneficiary registration fix on a couple of priorities & make them work

10. Budget prospects The health budget has grown by nearly 400% in real terms since 2001 MoFEP foresees a decline in the health budget of 2% in nominal terms (more in real terms) Ghana has surprised us before but it is unlikely that the health budget share will rise much beyond 19% This means that any further real increases will depend on a further increase in the share of the economy being taxed economic growth

11. Overview of the recurrent budget There has been a substantial increase in the resources available to the sector ($6.3 pc in 2001 to $23.9 pc in 2005) Staff costs are now expected to account for 97% of the GoG recurrent health budget This implies substantial budget risks which may be difficult to manage Moreover, although it may be too early to expect them, as yet there is no evidence that the volume (? or the quality) of services has increased (this implies declining productivity) Recommended pay reforms offer important efficiency gains but are unlikely to reduce the government health wage bill

12. Overview of the capital budget The Capital Investment Programme Review was not available to the review team However, the evidence suggests that: The capital budget is still poorly planned and executed There has been disproportionate rise in capital expenditure cf PoW Existing infrastructure is not being used efficiently (61% BOR) There are unplanned debt repayments Capital expenditure is misclassified as maintenance The recurrent costs of capital expenditure must be estimated in advance of a capital budget plan being approved Debt servicing and repayment schedules must be built into recurrent budget plans as obligatory expenditure

13. Financing & budget management Funding gaps: multiple meanings: multiple causes Needs are always in excess of budget ceilings MoFEP does not allow PE costs to be estimated realistically Unplanned & unknown debt repayments and cashflow financing Many of the problems would be resolved by less formal & better discussions between MoH & MEFEP technical staff

14. Financing & budget management Needs based budgeting requires revision & simplification Multiple funding flows require a cost-revenue centre approach to budget management Resource flows remain unpredictable and will become more crucial as HPs move to budget support Predictable GoG flows of funds (as well as fiduciary effectiveness) are a prerequisite for budget support We recommend that the move to budget support be delayed until GoG funding flows are more predictable (PETS)

15. Efficiency & `pro-poor’ budget management? There has been an increase in the costs of the MoH and, more generally, of `non-clinical staff’ (48% of staff costs) There is little evidence that services are being better directed either to the greatest health needs or to the poorest Despite a large increase in the exemptions budget, exemptions remain under-funded Exemptions (or some substitute for them) will remain a central strategy until the NHIF is fully operational

16. `Pro-poor’ strategy supply side options IGF exemptions (provider incentive problems) Remote area allowances Blanket exemptions in Northern Regions Abolish fees nationally (IGFs) Weak incentives to increase provider activity Resource leakages from poor to rich

17. `Pro-poor’ strategy demand side options Expand NHIF premium exemptions from `destitute’ to `poor’ Replace exemptions with vouchers until NHIF is fully operational Stronger incentives to increase provider activity May be cost escalation problems Identification problems Needs to be funded from tax budget

18. The evolving role of National Health Insurance Good progress has been made with registration The financial viability of the NHIF needs to be assessed from a cashflow perspective The NHIF should not be used to subsidise the tax-funded health budget The NHIF exemptions criteria need to be clarified for services for poor people (expanded) The time it will take for NHIF `health cards’ to replace exemptions requires that exemptions need to be better funded in the meantime.

19. Service delivery performance Aggregate indices show some health gains (decline in malaria case fatality) but these gains were modest Although some service output indicators have improved (supervised deliveries) these gains were modest Aggregates hide inter-district differences There may be data problems Despite the sector’s large increase in resources, the average picture is one of stagnation in both health outcomes and the volume (and ?quality) of services being delivered

20. Sector level service delivery issues resource allocations (staff & finance) remain inefficient & inequitable shift more resources to priorities (particularly exemptions) (re) consider blanket exemptions for Northern Regions improve resources flows & HR management provider incentives remain distorted consider making exemptions & NHIF payments real `fees for service’ the poor are not being looked after broaden poverty exemption criteria & allocate appropriately for NHIF `health cards’ there are too many priorities to allow proper management focus revise & simplify the performance management system reflect district health priorities limit targets to 3

21. Local level service delivery issues

22. Local level service delivery issues The new attention being given to efficiency & productivity is to be applauded There appears to be great performance variability between hospitals and between districts This is probably attributable to differences in the quality of management make regional & district directors accountable for productivity improvements focus central GHS support on failing regions focus regional GHS support on failing districts replace directors who fail to respond

23. Human resource policies Ghana operates in an international health labour market There is a disequilibrium between demand & supply It has creative, experienced HR policy-makers It also has strong, well-connected labour unions Its HR problems are well analysed but difficult to solve

24. Human resource policies They will not be solved by administrative fiat They will not be solved by `ethical’ UK NHS recruitment They may be eased by the creative use of market forces Both demand-side and supply-side strategies should be considered

25. Demand side strategies The foundation stone of good HR policy is improving staff productivity Staff incentives are central to staff productivity (& not only financial ones) Ensure salaries arrive on time Ensure the payroll is updated on time Decentralise hiring and firing to regional (?district) level Consider a remote area postings `clearing house’ Consider mixed salary-fee-for-service payment regime Pay reforms…

26. Pay reforms Based on job evaluation study Proposals include Expanded pay range Appointments on merit Consolidated benefits (except for remote areas allowances) – no ADHAs Pay by post Promotion on performance (no automatic increments) Likely to reduce wage cost escalation Likely to improve incentives for remote area postings Likely to enhance productivity with good management Unlikely to generate savings or reduce budget distortions

27. Supply side policies Increase production of `non-tradable’ skills for domestic markets Consider aggressive international recruitment for domestic markets Consider expanding the production of tradable skills for international markets in private medical schools (Philippines, Pakistan, India, Bangladesh)

28. Improving HR equity Consider charging fees for `tradable’ skill training (it is wrong that the Ghanaian taxpayer subsidises the UK NHS) Consider student loans Provide scholarships for bright youngsters from poor families

29. Health service management PMS has been developed with the introduction of service level agreements there is evidence that performance varies widely `Lessons learned’ need to be incorporated fewer targets (3) local priorities managers held accountable for results

30. Health service management & information PMS relies heavily on credible information As a result HMI is receiving additional attention in Ghana The introduction of effective HMIS is a huge challenge everywhere The main lessons from international experience are Keep it simple at the expense of detail Link its design directly to the PMS Make sure that data providers get early results (database interrogation?) Watch out for `gaming’

31. Common management arrangements CMA I & II reflected a moment in the evolution of Ghana’s health services & government donor relations A `new deal’ is required because that moment has passed a shift to budget support requires new arrangements

32. Common management arrangements The `new deal’… should be more inclusive should restrict its scope to roles & responsibilities should recognise the importance of `earmarked’ funds after the shift to budget support should serve to strengthen the sector’s bids for government funds

33. Pausing… and getting it right… The budget The current budget structure is exposed to significant risks Until the NHIF is fully operational, and afterwards, `exemptions’ will need to be funded from GoG’s budget. Ghana will be ready for budget support when GoG resource flows are predictable and better directed to priorities Management 4. Managers need to be given strong incentives to improve performance in low-productivity facilities and districts. 5. They need only a few (3) strategic priorities reflecting local needs, including for non-communicable diseases, if key services are to improve. These can be changed as gains are won.

34. …moving on The sector needs a new long term vision that all stakeholders can support… With the further development of the NHIS, the new PoW might consider the following: Putting health promotion to the fore Attending to urban health policies Decentralising GHS to block funded Regional Health Authorities (RHAs) Moving clinical staff from government to RHA and large facility payrolls Decentralised staff & budget management Capitation-based payment regime with fees-for-priority-services (careful about cost inflation) Modernising primary care Increasing the diversity of providers & delivery models Ending the differences between government and non-government provider arrangements

35. …moving on .. and will need to come to terms with political decentralisation