ghana private sector assessment

GHANA PRIVATE SECTOR ASSESSMENT

Mr. Marty Makinen, Results for Development

ORGANIZATION OF PRESENTATION

Objectives and Approach of Assessment Supply Findings Demand Findings Other Important Factors Affecting the Health

Market Successes and Failures

ASSESSMENT’S OVERALL OBJECTIVES Depict the role played by private actors in the

health sector in Ghana and identify factors that created and sustain this role

Provide information to inform decision making concerning how to enhance the private role

Facilitate productive engagement between public and private sectors

ENGAGEMENT: HELD WORKSHOPS TO GUIDE RESEARCH AND FORMULATE RECOMMENDATIONS

Launch workshop (July 2009)

Validation and discussion workshop (Dec 2009)

Decision workshop (March 2010)

RESEARCH: CONDUCTED DATA COLLECTION AND ANALYSIS

Additional analysis of existing data: DHSs and GLSSs Mapping of 7 districts: 5 urban and 2 rural, 730

actors Patient exit interviews: >1,200 patients Community focus group discussions In-depth interviews of private actors Interviews of policy makers, regulators, private

association leaders Case studies

SIZE AND GEOGRAPHICAL DISTRIBUTION

Self-financing private (SFP) providers major suppliers of all forms of care, except hospital care• Even for hospital care, SFP providers represent 20% of

beds in the five urban districts studied SFP and government providers concentrated in

urban areas; CHAG and chemical sellers concentrated in rural areas

Chemical sellers represent the greatest and most accessible source of services in rural and urban-poor areas

SOURCES OF FUNDS FOR PRIVATE PROVIDERS

For capital expenditures:• Savings or profits are the key source for all private

providers• Bank loans only substantially used by private hospitals

For operations:• Patient payment and NHIS are major sources for

government and private hospitals and clinics• Government facilities are more likely to report that they

accept insurance reimbursement than private Biggest problem:

• Access to financing reported as the biggest obstacle to growth for private providers

ACCESS TO FINANCING AS MAJOR OBSTACLE TO PRIVATE GROWTH

Skills

and e

duca

tion o

f wor

kers

Licen

sing a

nd op

erat

ing pe

rmits

Health

regu

lation

s

Access

to fi

nanc

ing0%

20%40%60%80%

100%

Obstacles to growth among private providers

No or minor obstacle Moderate obstacleMajor or very severe obstacle

48% major/very

severe

MAJOR DEMAND FINDINGS

Access to services improved dramatically in past several years

Private sector important source of care NHIS seems to encourage consumers to choose

GHS providers (but unequal accreditation might be a factor)

NHIS coverage becoming more equal geographically

Nearness, customer service, medicine and lab availability, and NHIS acceptance factors attracting consumers to private providers

ACCESS TO CARE FROM ANY SOURCE WHEN ILL IS RISING

GLSS 4 (‘99)

GLSS 5 (‘05-’06)

Had a medical problem in survey recall

26% 20%

Had a medical problem and sought care

43% 60%


GLSS 4 (‘99)

GLSS 5 (‘05-’06)


26% 20%


43% 60%

Perceived need for

care dropped


GLSS 4 (‘99)

GLSS 5 (‘05-’06)


26% 20%


43% 60%Use of care

when needed way

up


GLSS 4 (‘99)

GLSS 5 (‘05-’06)


26% 20%


43% 60%Annual contacts per

capita up from 3.19 to 3.33 – even with fewer

perceived medical problems

PRIVATE SECTOR IMPORTANT SOURCE OF CARE AND RISING SLIGHTLY

Sought care from

PublicPrivate for-

profitPrivate non-

profitGLSS 4 (1999) 48% 47% 5%

GLSS 5 (2005-06) 45% 49% 6%

PRIVATE SECTOR IMPORTANT SOURCE OF CARE AND RISING SLIGHTLY

Sought care from:

PublicPrivate for-

profitPrivate non-

profitGLSS 4 (1999) 48% 47% 5%

GLSS 5 (2005-06) 45% 49% 6%

Combined use of non- profit and self-financing private rose

from 52 to 55% of total use

NHIS COVERAGE LEADS CONSUMERS TO USE PUBLIC PROVIDERS A BIT MORE (GLSS 5)

51% 55%43% 45%

40% 40%51% 49%

9% 5% 6% 6%

0%

20%

40%

60%

80%

100%

Provider selection versus NHIS coverage status (%)

Private religious (CHAG)

Private non-religious

Public


51% 55%43% 45%

40% 40%51% 49%

9% 5% 6% 6%

0%

20%

40%

60%

80%

100%




Public

Covered used

private 45% of the

time

Not covered

used private 57% of

the time


51% 55%43% 45%

40% 40%51% 49%

9% 5% 6% 6%

0%

20%

40%

60%

80%

100%




Public

Covered used

private 45% of the

time

Not covered

used private 57% of

the time

Remember that accreditation

had not reached most self-financing

privates, however

BETWEEN 2006 AND 2008, NHIS COVERAGE INCREASED ACROSS ALL REGIONS

22,0

4%

34,7

5%

12,3

0% 18,8

8%

14,7

1%

7,81

%

9,05

%

5,29

%

6,30

%

16,1

9%

16,2

0%

35,0

%

52,1

%

23,6

%

43,3

%

23,3

%

35,0

% 42,4

%

45,1

%

27,3

%

36,4

%

34,6

%

0,00%

10,00%

20,00%

30,00%

40,00%

50,00%

60,00%

NHIS coverage, 2006 (GLSS) and 2008 (DHS)

GLSS (2006)DHS (2008)

BETWEEN 2006 AND 2008, NHIS COVERAGE INCREASED ACROSS ALL REGIONS

22,0

4%

34,7

5%

12,3

0% 18,8

8%

14,7

1%

7,81

%

9,05

%

5,29

%

6,30

%

16,1

9%

16,2

0%

35,0

%

52,1

%

23,6

%

43,3

%

23,3

%

35,0

% 42,4

%

45,1

%

27,3

%

36,4

%

34,6

%

0,00%

10,00%

20,00%

30,00%

40,00%

50,00%

60,00%

NHIS coverage, 2006 (GLSS) and 2008 (DHS)

GLSS (2006)DHS (2008)

For example, Upper West went from 5% to 45% of its population covered by NHIS

MEDICINES AND LAB TESTS DRAW CONSUMERS TO PRIVATE PROVIDERS (EXIT POLL)

36%

19%

39%28%

17%

4%

16%

11%

14%

5%

15%

10%

5%

17%

5%

18%

9%

48% 24%

25%

4%13% 13%

0%

20%

40%

60%

80%

100%

Public facilities

Private facilities

CHAG facilities Total

Perc

ent

Type of provider

Other

I came for medicines

I came for laboratory tests

I brought my son or daughter for a medical check upI came for a medical review (follow-up visit)I brought my son or daughter who has a medical problemI have a medical problem


36%

19%

39%28%

17%

4%

16%

11%

14%

5%

15%

10%

5%

17%

5%

18%

9%

48% 24%

25%

4%13% 13%

0%

20%

40%

60%

80%

100%

Public facilities

Private facilities


Perc

ent

Type of provider

Other




48% of users of SFP cited medicines as

reason for use


36%

19%

39%28%

17%

4%

16%

11%

14%

5%

15%

10%

5%

17%

5%

18%

9%

48% 24%

25%

4%13% 13%

0%

20%

40%

60%

80%

100%

Public facilities

Private facilities


Perc

ent

Type of provider

Other




17-18% of reasons for using

SFP and CHAG was lab tests

ACCEPTING INSURANCE AND NEARNESS MAJOR FACTORS IN CHOICE OF PROVIDER (EXIT POLL)

26% 22% 18% 21%

46%45%

41%47%

0%10%20%30%40%50%60%70%80%90%

100%

Public facilities

Private provider

CHAG provider

Total

Other

Short waiting time

Low price

Has agreement with my employerAccepts another health insurance cardAccepts my NHIS card

Good quality services

Only facility in my area

Nearest to my home

ACCEPTING INSURANCE AND NEARNESS MAJOR FACTORS IN CHOICE OF PROVIDER (EXIT POLL)

26% 22% 18% 21%

46%45%

41%47%

0%10%20%30%40%50%60%70%80%90%

100%

Public facilities

Private provider

CHAG provider

Total

Other

Short waiting time

Low price

Has agreement with my employerAccepts another health insurance cardAccepts my NHIS card

Good quality services

Only facility in my area

Nearest to my home

Accepts NHIS

Nearest to my home

FOCUS GROUP RESULTSWomen frequent users for themselves and others (use private more)Men less frequent users and wait until condition is serious (use GHS more)Self-treatment for minor ailments, herbalists used for specific conditions

NHIS improves accessCustomer service (advantage private) and comprehensiveness (advantage GHS) biggest factors in choicePrice not a major factorHigher income more likely to use private—but all groups make some use


Objectives and Approach of Assessment Supply Findings Demand Findings Other Important Factors Affecting the

Health Market Successes and Failures

OTHER IMPORTANT FACTORS AFFECTING THE HEALTH MARKET

Health Insurance• SFP providers complain of slow and low NHIS payments,

but see NHIS’s potential to be advantageous to them Pharmaceutical Supply Chain

• Private actors play a dynamic and important role in filling gaps and inefficiencies in public supply chain

• The pharmaceutical supply chain is highly fragmented and seems to be overly vertically integrated

Health Business Environment• SFP providers report greatest constraint is lack of

access to financing; small to medium sized SFP providers rarely use bank loans and even more rarely benefit from equity investments

OTHER IMPORTANT FACTORS AFFECTING THE HEALTH MARKET

Regulatory Environment• SFP providers report few constraints from regulation

and taxation, although some frustrations with under regulation are noted

Policy Environment• Ghana’s policy environment toward private sector

favorable but implementation of policies, along with a lack of resources, results in a disconnect between policy and practice

Quality• Structural quality overall is good across public and

private facilities; no clear advantage for government over private or vice versa

SUCCESSES

The public-private partnership with CHAG works well and makes CHAG an extension of the GHS in underserved rural areas

The overall policy environment in Ghana is business and private-sector friendly

There has been a specific Private Health Sector Policy since 2003 and many of the identified issues and proposed strategies are still relevant in 2010

Private providers respond to consumers with shorter waits, better drug availability, and courteous reception; but not with lower prices

FAILURES

Urban populations are much better served than rural populations by both SFP and government providers; the combination means that access is very unequal

Despite the identification of policy issues in 2003, the bulk of the agenda for action remains unimplemented

With the exception of the CHAG relationship, the private sector feels left out of the mainstream of MOH and GHS thinking and action

The regulatory councils and boards have insufficient resources to conduct on-going supervision and monitoring of private actors

FAILURES

The NHIA has uncovered important instances of fraud in claims for payment by both private and government providers

There is limited private pre-service training of health workers, and there are no private medical schools

Private sector health managers lack business and financial management skills that hinder success

Small to medium sized private health providers make little use of bank loans and almost no use of equity to finance investments

CONCLUSIONS

Use of privately provided services more than half of total

SFP much more important than non-profits Private role in provision likely to grow with

completion of accreditation and increased eligibility for NHIS

Public regulation hindered by lack of resources It has been a missed opportunity to shape the

private role by excluding and ignoring SFP from active interaction on national health policy

THANK YOU

EXTRA SLIDES

SERVICES AND HUMAN RESOURCES

Service offering in hospitals:• CHAG hospitals offer a broader range of services than

government hospitals in rural areas• Both public and SFP hospitals offer a broad range of

services in urban areas Human resources:

• CHAG hospitals have more HR per hospital bed and lower doctor to nurse ratio than government hospitals in rural areas

• Urban hospitals have more HR per bed than rural for all forms of ownership, but particularly for government hospitals

STAFFING OF RURAL HOSPITALS

GHS CHAG TOTAL

Doctors - FT 3 6 9

Doctors - PT 0 0 0

Nurses - FT 32 90 122

Nurses - PT 0 0 0

Midwives - FT 12 23 35

Midwives - PT 0 0 0

Laboratory staff - FT 3 5 8

Laboratory staff - PT 1 0 1

Pharmacists - FT 2 3 5

Pharmacists - PT 0 0 0

TOTAL 53 127 180

Staff to bed ratio 0.41 0.50 0.43

Nurses and midwives to doctors 15 19 17

STAFFING OF URBAN HOSPITALS

GHS CHAG PrivateQuasi-

Gov TOTALDoctors - FT 627 2 57 22 708Doctors - PT 13 0 99 6 118Nurses - FT 1,887 10 324 96 2,317Nurses - PT 32 14 59 5 110Midwives - FT 489 2 54 10 555Midwives - PT 0 1 29 0 30Laboratory staff - FT 34 2 41 14 91Laboratory staff - PT 3 0 16 0 19Pharmacists - FT 33 0 27 4 64Pharmacists - PT 4 0 3 1 8TOTAL 3,122 31 709 158 4,020Total PT 52 15 206 12 285Adjusted total (PT=0.5*FT) 3,096 24 606 152 3,878Staff to bed ratio 1.11 0.53 0.58 0.76 0.92Adjusted staff to bed 1.10 0.40 0.49 0.73 0.89Nurses and midwives to doctor 3.8 9.8 4.0 4.3 3.8

The staff to bed ratio is higher for urban (0.89) compared to rural (0.43) hospitals (brown arrow)

Ratio dramatically higher for GHS hospitals (1.10 urban, 0.41 rural) (blue arrow)

Better Health and Reduced Inequality

Strategic Objective 4 (5Yr

POW lll)Good Governance and Partnership

Objectives of Assessment

Depict current private sector role and

influencing factors

Engage stakeholders over (1) issues then (2)

evidence-based solutions

Information generated

Quality of service

Serving the disadvantaged

Human resource

availability (capacity)

Business environment

Public-Private Instruments of EngagementAssessment

Protocol

1. Mapping + interviews of private actors

X X X X X2. Patient exit Interviews X X3a. CHAG X X X3b. Emergencies X 3c. Pharmaceutical supplies

X X X X4. Population FDGs X X5. Secondary analysis of data X X6. Key informant interviews X X

Health Sector Goal

ASSESSMENT ANALYTICAL FRAMEWORK

Diagnose nature/effectiveness of private-public

interface

SCOPE OF RESEARCH ON THE PRIVATE HEALTH SECTOR

Not explored

Health NGOs (e.g., health

promotion organizations)

Limited review

Informal providers (e.g.

unlicensed practitioners,

traditional healers, TBAs)

Private health-training

institutions (e.g. medical

and nursing schools)

Focus of Assessmen

tFormal self-

financed service providers (e.g. hospitals,

clinics, maternity homes,

pharmacies, labs)

Faith-based institutions

(e.g., CHAG, Amadea Muslim

mission)

Private input suppliers

(e.g., medical equipment suppliers,

pharmaceutical manufacturers)

CHEMICAL SHOPS APPEAR TO REPRESENT THE GREATEST AND MOST ACCESSIBLE SOURCE OF SERVICES IN RURAL AND URBAN-POOR AREAS

Facility Type

Urban Urban Poor Rural

Osu-Klottey Bantama Tema

Tamale

Ashaiman Duayaw

Nkwanta Manya Krobo

Hospital 5 7 18 9 1 1 3 44

Clinic 25 4 45 12 8 1 13 108

Maternity home 2 2 3 6 4 0 4 21

Community-level Gov’t Centre 0 0 3 7 0 4 1 15

Laboratory 4 6 9 3 2 1 1 26

Pharmacy-wholesale 22 4 6 8 4 0 2 46

Pharmacy-retail 29 17 65 7 9 2 1 130

Chemical Seller 5 11 34 164 41 26 59 340

TOTAL 92 51 183 216 69 35 84 730

MARKET SUCCESSES AND FAILURES

Private supply of services offers many choices to urban populations

Chemical sellers give rural dwellers important access to drugs

Private providers respond to consumers with shorter waits, better drug availability, and courteous reception; but not with lower prices

Market Successes

Urban populations are much better served than rural populations by both SFP and GHS providers

Lack of business and financial skills and relatively high interest rates, short repayment periods, substantial collateral requirements restrict the use of bank loans for investment to expand all private providers

The pharmaceutical supply system is highly fragmented and seems to be overly vertically integrated

Market Failures

ghana private sector assessment

Documents

private sectorsengagement

private growth48

private sectorvalidation

private providers access

private providersbank

health marketsuccesses

discussion workshop

government providers