Burden of disease

Ghana has a complex burden of disease, present across different age, gender, location, and socio-economic status groups in the country. The major health conditions affecting children are communicable diseases, with malaria prevailing. Moreover, maternal and neonatal health conditions remain challenging, especially in rural areas and amongst poor women. Non-communicable diseases (NCD) such as hypertension, strokes, diabetes, eye disorders, oral health conditions, cancers, genetic diseases; injuries, mental health disorders, and substance/medicine abuse are increasing in prevalence. This complex disease burden is influenced by risk factors such as the physical environment, education level, socio-economic situation, and demographic characteristics of the Ghanaian population.

Healthcare system

Health system organisation

Overview

Ghana has a pluralistic health sector in terms of ownership (public and private), and in terms of healthcare models (orthodox, traditional and alternative medicine).Ghana’s National Health

Policy and Universal Health Care (UHC) Roadmap  jointly set the policy direction for the health sector until at least 2030. The health sector sets out to provide an Essential Health Service Package (EHSP) that covers Family and Reproductive Health; communicable diseases; non-communicable diseases and their risk factors, as well as mental health; health

emergencies; and rehabilitative and palliative care service.

The institutional structure of the health sector is made up of the Ministry of Health (MOH) as policy maker and regulator. Healthcare services are provided by two public sector institutions, namely the Ghana Health Service (GHS) and the Teaching Hospitals (TH), as well as by private sector service providers made up of for-profit providers and non-profit faith-based health facilities.

The MOH delivers its mandate through 26 specialised agencies and affiliated organisations. These include regulatory bodies responsible for establishing and enforcing standards and guidelines for the training of health professionals, regulations on professional standards of conduct and practice, and standards for accreditation of health facilities in order to get qualified to provide health services.

Public sector

PHC services are delivered through interconnections between district hospitals, health centres, maternity homes, clinics and CHPS compounds. The CHPS compounds provide a minimum package of service for the universal coverage of Reproductive Health Services (maternal, neonatal and child health services), management of minor ailments, and provision of health education, sanitation and counselling on healthy lifestyles and good nutrition for community members. As of December 2020, there were 5 876 CHPS compounds, of which 80 % are functioning. This ensures service provision both at the compound and via household visits, that covers the most impoverished and vulnerable families.

Regional hospitals provide both public health and clinical services, and serve as referral points for facilities from the district level and below. Tertiary and specialized care is provided through five public teaching hospitals: one each in Accra (Greater Accra Region), Cape Coast (Central Region), Ho (Volta Region), Kumasi (Ashanti Region), and Tamale (Northern Region). Additionally, three psychiatric hospitals are located in the southern part of the country (two in Accra and one in Cape Coast). The major strength of the public sector service provider is the availability and accessibility to essential health services, at a cheaper cost, in both urban and rural areas across the country.

The Ministry of Health identifies challenges facing the public sector, for example:

• increasing population with varied disparities between urban and rural areas;
• inequitable distribution of human health resources;
• inadequate health infrastructure, logistics and equipment;
• suboptimal quality of care at all levels of the healthcare system;
• weak collaboration among government Ministries/Departments/Agencies (MDAs) whose functions impact on the health of the population;
• the lack of nationally representative data on mental health services and Non-Communicable Diseases (NCD);
• the lack of a national database for health data.

Private sector

The private sector complements government efforts in service delivery. The private sector is defined as any non-government health actor such as self-financing (also referred to as for-profit), mission faith-based facilities (referred to as not-for-profit) involved in the delivery of health services; input suppliers (medicines and medical equipment), health research and training institutions; traditional and informal providers of health services; health promotion and education; and health financing organizations. The private sector is also regulated by the MOH through licensing by the Health Facilities Regulatory Agency (HeFRA) and the legal compliance requirements to other regulatory bodies, national healthcare standards and policies.

The private sector provides a mix of types of healthcare models including orthodox, traditional, as well as alternative medicine practitioners. While government facilities and services are available and accessible in both urban and rural areas across the country, the private service providers are concentrated in urban and peri-urban areas, with the faith-based organisations providing primary and secondary care complementary to the government’s.

The quality-of-service provision in the private sector (both faith-based not-for-profit and the private self-financing institutions) is generally considered to be of better quality than the public sector healthcare. The cost of care is more expensive than that provided by the public sector. Significant areas of better service quality are acknowledged in the provision of patient-centred care, availability of medicines/medical supplies, and better access to modern technology. Increasingly more private-for-profit institutions are providing highly specialised care, comparable to or better than that provided in the public teaching hospitals.

More people (51.7 %) seek consultations at facilities in the private health sector as against 45.7 % in facilities in the public health sector and 2.6 % seek care in facilities providing alternative medical care (these are traditional and unorthodox medical practitioners). The challenges faced by the public sector, especially the inadequate health infrastructure, logistics and equipment and the suboptimal quality of care at all levels of the healthcare system, make utilisation of private healthcare services the preferred choice irrespective of the higher cost of care.

Human and technical resources

The World Health Organization (WHO) recommends that the ratio of doctors and nurses to the general population is 1:1,000. In 2021, the MOH stated that the national ratio of doctors and nurses to the general population stands at 1:5,705 and 1:530, respectively. There are variations across the regions, with better ratios in urban than in rural areas.

Ghana is a signatory to the International Health Regulations (IHR) and uses the third edition of the Integrated Disease Surveillance and Response (IDSR) strategy as a vehicle for its IHR implementation. This is done within the legal framework of the Ghana Public Health Act 2012 (Act 851). The country uses event-based surveillance, indicator-based, and all-hazard approaches to prevent, detect and respond to all potential public health threats of biological, chemical, and radio-nuclear origins, as well as natural and man-made disasters.

Pre-hospital emergency services are provided by the National Ambulance Service (NAS), which was first set up in 2004 as an agency of the Ministry of Health. In 2020, the National Ambulance Service Act established NAS and its mandate to provide effective and efficient administration and management of emergency care services. As of 2022, NAS has a national head office based in Accra, with regional dispatch centres in the respective regional capitals and 297 district stations covering all 216 districts in the country.

Finance resources

Ghana’s health sector is financed from four main sources: central funding by the Government of Ghana, internally generated funds (IGF) from health facilities, the National Health Insurance Fund (NHIF), and external financing from development partners. The Ministry of Health obtains its revenue from general government appropriation, IGF, technical assistance from bilateral and multilateral sources, and local authorities.

Per capita public spending on health increased on average by 8.7% over the 2000-2019 period. However, the health share of public expenditure decreased from 8% to 7% of the total government budget between 2000 and 2019, suggesting a de-prioritisation of health. In 2018, Ghana’s health expenditure was 4% of GDP or approximately USD 70 per capita. Government prioritisation on health fell from 12%, or USD 58.4 per capita in 2011 to 6% in 2018, or approximately USD 30 per capita. An important source of health financing is via the National Health Insurance Levy of 2.5% of VAT, 70% to 80% of which is allocated to the National Health Insurance Scheme (NHIS). Health sector budget support through Development Assistance for Health has decreased from 48% in 2004 to 9% in 2020.

The share of the national budget to the health sector saw a decline to 6.6% in 2021, a decrease of nearly 2.4 percentage points between 2020 and 2021.

Pharmaceutical sector

The Ghanaian pharmaceutical market consists of approximately 30% locally produced drugs and 70% imported products, mainly from India and China. Ghana is a net importer of medicines, with the private sector supplying about 70% of medicines. Ghana has had Essential Medicines Lists (EML) since 1988. The current 7th edition of the EML was issued in 2017. The list reflects medicines that are required to address the disease burden of the country and are safe, efficacious, and cost-effective.

Public sector procurement of medicines is guided by the EML, and the list is used by both public and private service providers. However, private sector providers are responsible for their own procurement of medicines and can purchase medicines outside of the EML. Generic medicines are promoted and readily available. NHIS subscribers are reimbursed only for generic medicines on the EML, although branded products are also available.

The supply chain for medicines involves both the public and private sectors. Public sector procurement is led by the Ministry of Health and the Ghana Health Service. Tertiary hospitals procure about half of their essential medicines through private wholesalers, and teaching hospitals occasionally import specialist drugs. Medicine availability in public health facilities is restricted by the level of care, with higher levels of care providing more varied and specialised medicines. In general, medicines are more available in urban areas and in private health facilities than in public ones.

Non-registered medicines cannot be imported into the country, but patients can bring unregistered medicines for personal use with a prescription.

Patient pathways

Information about where to access healthcare services and the quality of care is primarily available informally through friends, family, and facility social media posts. The Health Facilities Regulatory Agency has a register of accredited and licensed facilities that can be found in the Ghana Gazette HeFRA.

Ghana has three levels of care. Primary care consists of CHPS zones, health centres, and district hospitals. Secondary care includes regional hospitals providing specialised services, and tertiary care is delivered by teaching hospitals offering highly specialised healthcare. There are also quaternary care facilities like the National Cardiothoracic Centre.

Patients can access care by walking into primary or secondary facilities. If a facility cannot provide the necessary care, patients are referred to a higher-level facility. Access to tertiary and quaternary facilities requires a referral. Private health facilities also offer care at all levels, and public and private providers maintain referral relationships. The public sector regulates laboratory services, diagnostic imaging, and medicine availability by level of care.

The challenges facing the public sector, such as infrastructure and resource variability, mean there are differences in the services provided even at the same level of care. However, private sector facilities, while facing similar challenges, are generally more reliable in areas like laboratory, diagnostic imaging, and medicines support.

Economic factors

Risk-pooling mechanisms

Ghana has both public and private health insurance schemes. Approximately 70% of the population has health insurance coverage, with women having higher coverage than men (72.6% vs 64.5%). The public National Health Insurance Scheme (NHIS) is available to all Ghanaians and residents, covering 95% of diagnosed conditions. Members do not pay out-of-pocket for covered services from providers accepting the NHIS card. Some conditions like cancer (except breast and cervical) and organ transplants are excluded from the coverage.

NHIS funding comes from a 2.5% consumption tax and social security contributions. However, delays in payments and low NHIS tariffs have made accepting the NHIS card unattractive for many providers. As a result, both public and private providers may require patients to pay out-of-pocket.

Private health insurance schemes

Ghana also has licensed private health insurance schemes (PMHIS and PCHIS) regulated by the National Health Insurance Authority. These schemes offer broader coverage and higher service cost ceilings than the NHIS. Premiums range from GHS 1,200 to GHS 4,500 per individual and are primarily subscribed to by corporate bodies for employees.

Out-of-pocket health expenditure

People without insurance pay out-of-pocket for healthcare services, especially in urban forest areas where 70.6% of the population does so. Medical fees in the public sector are regulated, but private providers set their fees independently. Medicines prices, particularly in the private sector, are higher due to reliance on imports and are susceptible to foreign exchange rate fluctuations. Generic medicines in the private sector can cost up to 34 times the international reference price, while in the public sector, prices are regulated by the NHIS medicines list. Some medicines, such as for Tuberculosis and HIV, are provided free of charge but are only available in public facilities. When out of stock, patients may need to pay high prices in private pharmacies.