UHC-Roadmap-2020-2030 Ee
UHC-Roadmap-2020-2030 Ee
UHC-Roadmap-2020-2030 Ee
MINISTRY OF HEALTH
ACCRA, GHANA
FOREWORD
This UHC roadmap is the commitment of the government and people of Ghana to shape the future
of health care in Ghana. We have reflected carefully on the Sustainable Development Goals, Global
Action Plan for Healthy Lives and Well Being, Declaration on Primary Health Care in Astana (2018),
UHC 2030 Compact, initiatives of UHC 2030 and the Political Declaration of UHC adopted at the
UN High Level Meeting in September 2019. These provide us with a clear framework for action.
Through broad based consultations and consensus building with various stakeholders, civil society,
private sector and development partners, a set of priority services and interventions have been
agreed to be made universally accessible to all persons living in Ghana. We believe that these
actions will serve as a catalyst to transforming our health systems, efficiently mobilize and apply
domestic resources to need; and strategically leverage partners resources for long term
sustainability.
The UHC roadmap takes inspiration from the National Health Policy and sets the strategic direction
for the heallth sector in the next 10 years. It also emphasizes health in all policies with the aim to
stir action in other sectors for health and Human Capital Development as articulated in the National
Health Policy. We are committed to achieving a critical set of goals, targets and milestones by 2030.
These are ambitious but hopeful and achievable targets. We urge all stakeholders and partners to
align their programs and harmonize their financing towards the implementation of this roadmap.
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CONTENTS
1. Policy direction 01
1.1 Context 01
i. Vision 01
ii. Goal 01
iii. Objectives 02
1.2. Guiding principle 02
2. Context of the PHC system 03
2.1 Strengths and opportunities 03
2.2 Challenges 04
3. Priority interventions 06
3.1 Essential services for the population 06
3.2 Management of clinical and public health emergencies 09
3.3 Improve quality of care and information management 10
3.4 Enhanced efficiency in HR performance 11
3.5 Institutional reforms for sector effectiveness 14
3.6 Health policy, financing and systems strengthening 16
4. Results framework 19
4.1 UHC core indicators 19
Annex 1: The political economy and health 21
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1. Policy direction
1.1 Context
The country over the years has undergone several health sector reforms aimed to improve
health outcomes. The current National Health Policy (2019) emphasizes systems
strengthening, improving service availability for the population through community health
services and expansion of public health interventions. A social health insurance scheme
was also introduced to ameliorate catastrophic expenditure particularly for the poor and
vulnerable. A detailed context is provided in annex 1. This roadmap further deepens the
reach and scope of previous interventions while improving access and quality of services
provided.
i. Vision
Ghana defines UHC as: “All people in Ghana have timely access to high
quality health services irrespective of ability to pay at the point of use.”
ii. Goal
Increased access to quality essential health care and population-based
services for all by 2030.
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iii. Objectives
a. Universal access to better and efficiently managed quality health care services
b. Reduce unnecessary maternal, adolescent and child deaths and disabilities
c. Increase access to responsive clinical and public health emergency services
The needs of the health sector are many and multi-faceted, but resources are limited. This
requires that choices are made to leverage investments into essential services, key
interventions and systems that target scalable high impact, high multiplier areas to deliver
value. The actions will catalyze change and scale up access to essential nutrition, health
promotion interventions, smart curative care, disease prevention, palliative, rehabilitative,
emergency care and mental health services.
Primary health care is the level of emphasis. Systems would be put in place to enhance
access to specialized care. The value proposition follows a five-point guiding principle:
• Target group: Focusing on the poor and vulnerable; particularly children and
adolescents, women, and the aged.
• Financial risk protection: Eliminating physical and financial barriers to accessing
PHC services; especially those most at risk of incurring adverse health expenditure
at the incidence of ill health.
• Strategic Partnerships: Build sustainable partnership and a harmonized agenda
between government, private sector, non-state actors and development partners to
upscale service delivery and secure predictable financing for long-term results.
• Effective Decentralized Management: Cement district level service governance with
the district assemblies and improve intersectoral collaboration to synergize
resource mobilization, efficient use and accountability particularly at the PHC levels
of service delivery.
• Domestic Financing Re-Prioritized: Rationalize allocation and expenditure of
domestic resources to focus on primary health care and manage existing and any
new co-financing requirements within a realistic budgetary framework.
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2. Context of the PHC system
2.1. Strengths and opportunities
The structure of the primary health care (PHC) system is as in figure 1. Maternal, child
health and nutrition services constitute the largest proportion of the PHC package. Non-
communicable diseases, mental health services, preparedness, response and
management of all types of emergencies including road traffic accidents, clinical and public
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health emergencies and issues related to natural disasters and floods are emphasized.
There is significant potential to increase the proportional contribution of PHC to service
delivery over the next ten years. In 2018, all immunization services, 52% of skilled
deliveries and 53% of 1st antenatal care visits are conducted at the primary level. Women
receiving postnatal care within 48 hours provided was 34%.
2.2 Challenges
Access to services by the population is uneven. Service availability and quality of care is
generally below expectation as shown in figure 2. Avoidable institutional maternal and
newborn deaths continue to be of concern. While DPT3 coverage is over 95%, other
vaccination coverages could be better. While prevalence is low, progress in pediatric HIV
and AIDs response is modest. Tuberculosis case detection is low. Micronutrient
deficiencies resulting in anemia and
obesity in children (stunting 8%) 06 01
Poor mix and mal-
and in pregnant women puts them distribution of critical
health personnel and
Low funding at 20%
of NHIS resources
spent on PHC
at risks of death. Under-nutrition health facilities
Basic infrastructure and equipment is not available in over 50% of primary level facilities.
The role of procuring commodities used in primary health facilities is splintered across
several entities affecting coordination of medicines supply. Framework contracting is being
piloted as one of the possible solutions to shortages in basic medicines.
Government non-wage budgetary allocation to health other than NHIS and total budget as
a percentage of GDP has reduced significantly. The national health insurance scheme
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currently covers only 36% of the population in 2018; a decline from 2016. This means over
64% of the population are exposed to out of pocket expenditure or are simply not
accessing normative care.
Direct service delivery expenditure mainly comes from the National Health Insurance
Scheme which constitute 80% of all payment of services. Seventy-nine (79) percent is
spent on secondary and tertiary care. Primary health care only constitutes 21% of the
insurance scheme’s expenditure. There are irregular payments of claims. Primary level
operating was capital of approximately *GHC 357 million in 2018 of which 48% were held
in NHIS debt. When open market creditors are accounted for, the primary level will record
a negative balance of *GHC 58 million. This is due to unpaid debt owed to suppliers.
Most public health interventions had significant financing input from development partners.
Financing was stable until recently when several development partners began
transitioning out with change in development status of the country as an LMIC. It is
estimated that Ghana will need an average of US$350 million annually to fund its vaccine
and other commodity commitments in co-payments and transition out of arrangements by
2027. Vitamin A and folic Iodates have occasionally run out since donor support seized.
Supply of family planning commodities have also reduced significantly. The country
introduced framework contracts for the supply of some essential medicines.
Implementation has had some difficulties.
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Maternal, child and adolescent health services will be made universally available at
all levels of service delivery. Malaria, Tuberculosis, HIV/AIDs, antenatal, postnatal,
skill birth attendance, immunization, neonatal care, diabetes, hypertension and
mental health services will be deepened. Dietary deficiency related conditions
including under-nutrition, anemia, obesity and micronutrient deficiencies will be
given adequate attention at the primary level. Efforts will be made to reduce gender
related socio-cultural barriers to access including stigma, abuse of patient
confidentiality and rights. In addition, sickle cell, cervical and breast cancers in
women and children, prostate cancer, congenital conditions in children, factors
contributing to deformities and disabilities in children including club foot, cleft lips
and pallets will be universally available at all levels. Palliative and rehabilitative
care has also been identified as important areas for further development.
Care of the aged will be integrated into home-based and primary health care. In
Ghana old age is itself a cause of vulnerability due to limited financial protection
and limited services. This roadmap recognizes the potential of cognitive and
physical decline at this stage of life. For example, impairment arising from
Alzheimer’s disease and other forms of dementia are more likely in later life, with
important implications for financial inclusion. There is also a unique problem of
gender or geographical location that impact older persons. Specific products,
services and financial incentives will be developed to promote elderly care.
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decreased health care costs. Every primary and junior secondary school within
one-kilometer radius will have an SBI located in a designated school to serve the
student population. Every senior high school and tertiary institution will be required
to establish an SBI located on their campuses. These SBI will be managed by
qualified professional registered nurses. An appropriate service package will be
defined. Every student on holiday will be given short medical record reports to take
with them during holidays to ensure continuum of care.
All SBI, WPI, WPHCs, CHPS, Health Centers and District Hospitals will be drawn together
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as networks of practice at the district level. The district hospital will be the Coordinating
Hub to which these are linked as satellite facilities. The network will enable adherence to
enforce quality standards; optimize use of resources, available staff and skills mix, support
professional development, strengthen primary level referral system for continuum of care. .
A performance-based financing mechanism will underpin the management incentive
system to reinforce efficiency in common and shared resource use, quality of care and
standards; data management for measurement, transparency and accountability.
Road traffic accidents, poisons and domestic accidents have been on the increase
recently. There is also the continuing need to transfer patients requiring critical care to
hospitals. The system of pre-hospital and hospital emergency care will be strengthened.
Hospital beds and mass casuality management system will be improved. All facilities from
health center level C and above will be supported to build capacity for handling
emergencies and equipped with a functional emergency reception and management
system appropriate to the level. District Emergency Command and Call Centers will be
established under a system of bundled development with the Fire Service, Ambulance,
National Disaster Management Organization (NADMO) and Police Service. These might
require some infrastructure upgrades. Additional ambulances will be deployed to improve
availability of services. Adequate staffing, capacity building and essential equipment will be
provided for paramedics. The private and non-state sector will be encouraged to
participate in the provision of pre-hospital and clinical emergency care service provision.
The Ebola crises in Africa demonstrated the urgent need to strengthen systems for health
security. Joint External Evaluation (2017) shows that there is no national policy and
strategy defining structures, roles and responsibilities. The National Action Plan for Health
Security has been drafted aimed to prevent avoidable epidemics; detect disease
outbreaks; establish a system for multisectoral responses; establish and sustain capacity
for effective public health response at the points of entry; and develop and maintain core
capacities for chemical and radio-nuclear emergencies and events. The animal and public
health disease surveillance, control, elimination and eradication will be strengthened
especially at the primary health care level. The Ghana Center for Disease Control will be
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established with a fully functional emergency operations system in place. The GCDC will
also have a training center made available for sub-regional training. A national infectious
diseases treatment center will also be completed. A strong information technology hub will
buttress a series of protocols to create a seamless network of facilities including
laboratories to form the ecosystem of the CDC. Community surveillance will be
strengthened and integrated into community health services and district public health
management systems. Three Field Coordinating Centers will also be completed during the
period. Ghana will aim to have all its emergency preparedness and response treatment,
laboratory and field coordinating centers accredited on international ISO standards and
become a regional hub.
Onchocerciasis, yaws, yellow fever, schistosomiasis and other soil transmitted helminths
will be targeted for elimination. Polio, Lymphatic Filariasis, Trachoma and Measles will be
put under high surveillance to ensure there is no recrudescence of disease. Outbreaks of
cholera and meningitis will also be controlled to levels where they will no longer be
diseases of public health concern.
To promote service quality, a focused approach as in Fig. 3 will guide implementation. The
government will develop an overarching national framework for continuing total quality of
care improvement that harmonizes the tools and process among various regulatory
bodies. A more systematic approach will be introduced for (i) facility-based assessment of
entry-level quality; (ii) the preparation of a facility-specific Quality Improvement Plan (QIP);
(iii) the implementation of the QIP through supervision/quality counseling; and (iv) the
development of harmonized monitoring tools. Emphasis will be placed on accurate
diagnosis and treatment protocols. Rational medicines prescription and use will be
strengthened. An active program to contain Anti-Microbial Resistance (AMR) will be
implemented to stem microbial resistance and anti-biotic abuse. Patient and client
satisfaction surveys will be undertaken to inform the development of people centered care
standards.
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Safety: Minimizes harm, including preventable injuries and
and medical errors, to the patient.
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Reform supply chain management:
The Logistics Management Information System (LMIS), which supports quantification and
planning, ordering and tracking medicines through the supply chain, will be strengthened
throughout the PHC system linked to the regional and central medical stores. The aim is
to improve the visibility of stocks and consumption at facility level. The Central Medical
Stores will be re-organized into an agency responsible for medicines and commodities
security, management and availability in both the public and private sector. All the regional
and district medical stores will be assigned to it for direct responsibility. The agency will
also manage the Last Mile Distribution System and its related LMIS. This will improve
strategic purchasing and management of the framework contracting system. It will ensure
end-to-end visibility of stocks and movement of goods through the supply chain from
suppliers to health facilities. This will also optimize quantification, ordering, buffer stocks
and availability of medicines and commodities at the point of dispensing to the patient.
Several bold reforms will be undertaken in human resource for health development. The
actual design and pace of reforms will be determined and implemented through extensive
consultation with all stakeholders, professional associations and regulatory bodies.
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Rational HRH production:
Human resource development will emphasize production for primary health care. The
MOH, professional regulatory bodies and Ministry of Education will work together to
implement a series of far reaching reforms. The teams will work together to enable the
regulators and universities introduce co-host standardized examinations to reduce the
burden on students and improve quality of products. Most professionals training will be
integrated into mainstream tertiary academic education to align certification and licensing.
This will allow health professional qualifications to be aligned with the upgrades taking
place in technical polytechnics while retaining professional integrity. All government
training institutions will rationalize and upgrade their professional certificates to 4-year
professional bachelor’s degrees. Production of some selected health personnel categories
will be systematically phased out. This however will not preclude the training of auxiliary
level staff at shorter duration for non-core but essential services in collaboration and
partnership with the private sector using memorandum of understandings.
Stewardship:
The Ministry of health stewardship functions particularly for policy development and
coordination of the health sector will be enhanced. A division for Intersectoral
Collaboration will be established to focus on social determinants of health and promote
health in all policies. A Health Financing and Economics Unit will also be established to
focus on external and domestic resource mobilization, coordination and expenditure
tracking. The technical coordinating functions of the MOH will be strengthened.
The Ghana Health Service and Teaching Hospitals Act 525, 1996 will be amended to
reflect changing trends. The GHS will be more agile under a decentralization framework in
line with the reforms envisaged for primary health organization of services to the district
assemblies. The Service focus on clinical standards, protocols and issuing of service
guidelines for all service providers in the public, private and non-state sector. It will have
an enforcing mandate under a new regulation for these standards. The governance,
management and operations systems and niche area of the specialist secondary, tertiary
and quart-level care hospitals will be redefined to meet the needs for highly specialized
care. The aim will be to increase their decentralization, authority and efficiency for
resource mobilization, use and decision-making.
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Regulation:
The functions of the Health Facilities Regulatory Agency, the National Health Insurance
Authority, the Pharmacy Council and the Health Professionals Regulatory Bodies with
respect to professionals and facilities licensing, accreditation and credentialing will be
harmonized under a common legislative, regulatory and institutional framework. Some
institutions such as the Food and Drugs Authority will be encouraged to become
autonomous. This will aim to improve efficiency in health sector regulation and reduce
transaction cost to clients. Regulation of the private health insurance industry will be
delinked from the NHIA to promote its growth and efficiency. A reorganized market
framework will be developed to enable the private health insurance market to provide
augmented and enhanced insurance for the better wealth quintiles; and essential back up
insurance for the population.
Purchasing:
After 15 years of operation the National Health Insurance Scheme is undergoing reforms
and achieved significant results. A business and sustainability plan will be developed and
implemented looking at the operations and governance efficiency and fiscal resource
management. The NHIA has already initiated reforms in the area of membership renewal,
benefit package, medicines rationalization and the review of payment mechanisms. This
will be further developed in the context of the broader reforms articulated in this roadmap.
The information management systems particularly for enrollment, claims and payments
under the NHIS will be reformed and integrated onto a single platform to ensure smooth
operations management linked with the wider national and service provider data systems.
The membership registration and management system will be made simpler and efficient
with a technology overhaul. The fund management framework will be independently
reviewed to address the issue of delayed releases of funds for payment of claims. The
health insurance market will be reassessed to enable the NHIA focus on securing
essential health care services for the poor and the vulnerable.
Non-State Actors:
A policy, regulatory framework and action plan for defining and promoting collaboration
and partnerships with non-state actors including civil society organizations and private
sector will be developed. This is aimed at easing the doing business environment and
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promote investments and growth in the non-state sector. To this end, a Chamber of Non-
State Health Actors will be established to legalize their coordination platform, strengthen
their capacity and promote self-regulation. This will make them attractive for funding by
government and donors and promote a systematic development of the non-state health
industry. A deliberate effort will be made to crowd in additional financial and management
resources through increased public-private partnerships and investments in this area.
Where feasible cooperation agreements will be signed with civil society organizations and
private hospitals to establish and manage public health, primary and specialist care on
behalf of the public sector. The traditional medicine sector will also be reformed to improve
its quality of products and services, marketability and integration into main health service.
The health in all policies approach will be adopted. This will require additional evidence,
policies and guidelines for effective implementation. Key areas will include evidence on
needs and costing of inputs to be provided. A primary health care policy and essential
package framework to include schools, workplaces and markets will be developed.
Specific documents on human resources decentralization policy, Health Technologies
Assessments, a policy on water, sanitation and hygiene including in health facilities and a
framework for private management of publicly funded facilities will also be produced. A
comprehensive ten-year sector investment case or UHC Prioritized Operational Plan and
Cost (UHC/POPC) will be developed. This will be complemented by a glossary of technical
assistants for the POPC implementation and essential evidence for policy. A national
health research agenda will also be developed and funded by various partners. Academia,
expert consultant and research institutions will play a key role in its implementation.
Financing is a major challenge. The strategy is to mobilize the equivalent of at least US$ 7
billion over 10 years in non-wage-resources including GDP allocation. The government will
work towards allocating at least an additional one (1) percent of GDP to primary health
care and seek additional sources of financing. Emphasis will be placed on optimizing fiscal
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allocation and use. The National Health Insurance Scheme financing framework and
management will undergo reforms to improve its efficiency. The NHIS will prioritize primary
health care and allocate at least 50% of its resources to fund PHC expenditure.
All primary healthcare facilities will have their operations debts paid off and recapitalized
using a fundholding approach. These funds will be considered operational credits based
on signed performance agreements and ensuring long term financial sustainability. The
Ministry of Finance has developed a plan to roll out the Ghana Integrated Financial
Information Management System (GIFMIS). The health sector will build on this to
introduce an effective Public Financial Management (PFM) system which will be rolled out
in all public institutions and facilities at all levels.
The health sector over the years had been co-funded by development partners. Donor
finances were stable until recently when several development partners began transitioning
out with change in development status of the country as an LMIC. Grants and credits will
be contracted more strategically based on the development of 5-year health sector
medium-term plans. Unsolicited technical assistance and assistance not directly linked to
advancing the roadmap agenda will be discouraged.
In aid and development partner management, the principles of the Paris Declaration and
the Global Action Plan for Healthy Lives and Wellbeing for All will be followed. All
development partners will sign up to a compact in which government and development
partners will agree a mutual framework for engagement, acceleration, alignment and
accountability. This will serve as a management arrangement and a commitment note to
reduce fragmentation, improve resource pooling, matching and predictability. Partners will
be required to align their resources with each other and with government through models
of co-financing or parallel co-financing arrangements. The aim is to improve synergies.
There will be de-emphasis of commercial loans. A commodities, medicines, supplements
and vaccine phase-in/phase-out and sustainability framework agreement will be
renegotiated with relevant partners and the private sector to improve long term
sustainability. A deliberate attempt will be made to crowd in private sector investments and
capital.
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4. Results framework
Measuring progress toward attaining UHC in Ghana is leveraged on the existing national
and global platforms for measurement, data collection and analysis. This includes the
UHC in Africa: A Framework for Action; the Astana Declaration framework and the health-
related Sustainable Development Goals targets and indicators.
The overall goal is to attain at least 80% coverage of Ghanaians having access to
essential health services. The broad targets are:
· Attain 100 percent health insurance coverage for primary level services
· Reduce maternal mortality ratio by two-thirds over 2017 figures
· Reduce by three-quarters neonatal, child and adolescent disabilities
· Reduce new born, infant and child mortality rates by half over 2017 figures
· Reduce by one-third pre-mature mortality from non-communicable diseases and
mental health
· Functional clinical emergency centers in all health facilities
· Reduce occurrence, morbidity and mortality associated with disease outbreaks by
half
These twenty-eight (28) indicators are not exhaustive but form the proxies for measuring
progress in implementation of the roadmap. All indicators will be disaggregated to account
for their equity efficiency ratios by geographical area, income group, educational level,
age, gender and vulnerability analysis. The baseline and targets will be defined in various
strategic and operational plans. A monitoring and evaluation framework will be developed
to include both quantitative and qualitative reviews of all indicators. It will acknowledge the
multi-dimensions of curative, preventive, palliative, rehabilitative and emergency care.
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Nutrition Status Health and related Services Health systems and
Health Status financing
• Maternal mortality rate • Prevalence of anemia · Ratio of children born · Ratio of facilities (care
• Under - 5 mortality rate among children of school free to HIV positive and diagnostic in public
• New born mortality rate going age mothers and non-state sectors)
• Teenage pregnancy rate • Prevalence of stunting · TB treatment success and with entry point licenses
• Total fertility rate among children under 5 cure rate · Ratio of NHIF spent on
• Ratio of premature • Prevalence of moderate PHC level and the UHC
· Total immunization
mortality from non- to severe wasting among essential package of
coverage ratio
communicable diseases children under 5 services
· Malaria prevalence as
including mental health • Obesity in adult · Health expenditure per
population- ages 24-60 ratio of total OPD cases capita financed from
• Prevalence of type 2 · Skilled attendance ratio domestic sources
diabetes in children and · Modern Contraceptive · Ratio of government
adolescents Use ratio health expenditure to
• Prevalence of · Ratio injuries and deaths total government
hypertension in persons from road traffic accident expenditure
less than 60 years · Ratio essential medicines · Percent of current health
• Prevalence of mental available expenditure devoted to
health among women · Prevalence of primary health care
and young adults onchocerciasis and soil · Incidence of financial
transmitted helminthiasis catastrophe due to out-
of-pocket payments
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Annex 1: The political economy and health
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Acknowledgement
We acknowledge the contributions of all technical staff of Ministry of Health and its agencies, other
government agencies and development partners who contributed significantly towards the
development of this roadmap. We specifically acknowledge the technical and financial support
provided by the Japanese Government through the Japan International Cooperation Agency and
the World Bank PHRD Advisory and Analytical Services.
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