OVERVIEW OF HEALTHCARE SYSTEM IN GHANA

2.1 Chapter Introduction

2.2 History of Health Care System
2.3 Organizational Structure and Management of Health Care System
2.4 Health Care Financing and Resource Utilization
2.5 Targeted Health Care Programs
2.6 Health Infrastructure
2.7 Indigenous Health Care System
2.8 Health Sector Reform/Health Care Policy
2.9 Health Information Technology
2.10 Chapter Summary
 OVERVIEW OF HEALTH CARE SYSTEM IN GHANA1

Chapter Introduction

Improving the health status of the population of any nation has been identified as an important
ingredient in influencing its socio-economic development. Policies directed at health care
provision seek among other things to offer access to sustainable quality health and in developing
countries, improving the delivery of health services is critical to the achievement of the
Millennium Development Goals (MDGs). In Ghana, the mission of the Ministry of Health
(MoH) as captured in its policy document is to contribute to socio-economic development and
wealth creation by promoting health and vitality, ensuring access to quality health, population
and nutrition services for all people living in Ghana and promoting the development of a local
health industry. This mission puts the concept of health beyond the confines of curative care to
other socio-economic determinants of health. The ultimate goal of the health sector is to ensure a
healthy and productive population that reproduces itself safely. Three key objectives have been
set out to achieve this goal of the health sector and these are: to ensure that people live long,
healthy and productive lives and reproduce without an increased risk of injury or death; to reduce
the excessive risk and burden of morbidity, mortality and disability, especially in the poor and
marginalized groups; to reduce inequalities in access to health, populations and nutrition services
and health outcomes (MoH, 2007). The attainment of these policy objectives are very critical to
the efficient functioning of the health care system in Ghana.

The structure of a country’s health care system is critical in ensuring efficient health care
delivery. Understanding the health care system is also important in explaining the hospital
governance structures. This chapter provides an overview of the health care system in Ghana. It
provides a review of the history of the health care system, the structure and governance of the
health care system, and health care financing and resource utilization. It then discusses targeted
health programs, health infrastructure, and health sector reforms. It then discusses targeted health
programs, health infrastructure, indigenous health care system, health sector reforms, and health
information technology.

History of Health Care System

The history of Ghana’s health system can be looked at under three eras: the pre-colonial era
(1844), the colonial era (1844-1957), and the post-colonial era (1957-1980). In the pre-colonial
era, the country had no organized health system and modern medical care was not available at

1
Part of this chapter has been published as a book chapter “Abor, P. A. (2011), Healthcare System in Ghana” in
Rout, H. S. (Ed.), Healthcare Systems: A Global Survey, New Century Publications, New Delhi, pp. 553 – 575.
the time. The key providers of healthcare were the traditional health practitioners, including
herbalists, bonesetters, priest healers and traditional birth attendants (Yeboah, 2003).

The colonial era witnessed the establishment of modern health care on a limited scale, however
this was not organized as a national system to benefit all people. The few who were privileged to
benefit from this health system were mostly Europeans and their Ghanaian house helps (Kunfaa,
1996). Other Ghanaian indigenes who also utilized orthodox medical care included labourers
from the mines, forestry/timber industry and construction workers so as to prevent the Europeans
from getting infected by these workers. Health care during this period was centralized and
basically curative which forms the root for the current urban and curative bias health care system
(Yeboah, 2003). Clearly, Ghana’s health care system has been modeled along the lines of its
colonial masters, Britain. The first government health services in Ghana can be traced back to
1880 when the Gold Coast Medical Department was established and concentrated on providing
health care for the European population and government officials in particular. The health care
system was focused on curative rather than preventive health services (Akortsu and Abor, 2011).
Most of the health care facilities were therefore located in the core administrative districts with a
centralized form of administration. The centralized health care system existed even after Ghana’s
independence in 1957.

The post-colonial period commenced from 1957-1980s during which various governments
(military and democratic) put in place strategies and policies to bring up the existing health
system to modern standards. These expectations were however not met. It started with the
Kwame Nkrumah government which ambitiously took steps to expand health services to every
part of the country since economic conditions at the time were good. A number of commissions
were set up and charged with the responsibility of restructuring the health system inherited from
the colonial masters. Recommendations made by these commissions differed from the colonial
health system mainly in the scope of health facilities the nation should have. This led to the
formulation and implementation of a national plan referred to as the 7-year National
Development Plan (1963-70) with the following objectives;
 To extend and modernize existing hospitals (30 out 37 Government Hospitals were
targeted).
 To construct additional health posts.

The 7-year plan was abandoned when the first military intervention took over government in
1966 and put in place a 2-year Development Plan (1968-70) which aimed at reversing the urban
biased health system, with equity being the key driving force. This was to be achieved by;
 Allocating resources to enhance rural health throughout the country.
 Emphasising on preventive and promotive health, including maternal and childcare,
health education, water and sanitation and school health.
 Training of more community and public health nurses.
 Constructing more health posts in deprived regions and districts.
 Strengthening inter-sectoral collaboration especially with the Ministry of Education in
order to develop the school health programme.

There was a similar military intervention by Busia whose government continued with various
health reforms till the final coup in the 1980s by Ft. Lt. Jerry John Rawlings during which the
concept of Primary Health Care was emphasized and Decentralization of health service
administration Policy was strongly advocated and backed with the Local Government Law
PNDC Law 207 of 1988. This policy sought to strengthen District Health Systems for effective
management (Yeboah, 2003).

It was not until 1972 that the government at the time attempted to decentralize health care
services to the districts with policy formulation still being done at the central level. Several
reforms that took place in 1977, 1997 and 2002 and these have brought about a completely
decentralized health care delivery system in the country, right from the national level to the sub-
district levels. Subsequent to these reforms, two main functions had been identified for the health
sector in Ghana. The first is policy formulation, regulation and coordination of the actions of
actors in the health sector and the second had to do with the implementation of policy via health
service delivery. The MoH has the responsibility of carrying the function of formulation,
regulation and coordination of the actions of actors in the health sector. The public and private
health service providers are responsible for the implementation of policy via health service
delivery. In the public sector, the main health service provider is the Ghana Health Service with a
national secretariat and service provision points (facilities) at the regions, districts, sub-district
and community levels. In the private service, providers are the mission providers who operate
mainly in rural areas as private not-for-profit organizations and the private for-profit
organizations (Abekah-Nkrumah, 2005; Abekah-Nkrumah et al, 2009).

Structure and Governance of the Health Care System

The health care system revolves around the MoH. Administratively, it has a hierarchical
organizational structure from the central headquarters in Accra (the capital city) to the regions,
districts, and sub-districts. Health services are delivered in primary, secondary, and tertiary
health institutions. The primary health care system incorporates all institutions (clinics, health
centres, and hospitals) and individuals whether private, public or traditional. All districts have
also been subdivided into four to six sub-districts, and each sub-district covers a defined
geographic area containing 20,000-30,000 people. The health centres are responsible for
providing clinical, public health, and maternity services to the catchment population using a
combination of clinic-based, regular outreach, and mass campaigns in close collaboration with
communities, community institutions and leaders, and village-based health workers and health
institutions (MoH, 2009).

The district hospitals serve as the first referral point in the primary health care system. They
provide clinical (outpatient and inpatient) and maternity services and serve as backup for health
centres in the district. The regional hospitals are the second referral level. They act as the
technical focal point for specialized clinical and diagnostic care in broad specialized areas like
medicine, general surgery, paediatrics, and obstetrics and gynaecology. The teaching hospitals
form the apex of specialized care in the country. They are the leading training and research
institutions, and offer undergraduate and postgraduate training for doctors and other health
professionals (MoH, 2009).
Health services in Ghana are provided by four main categories of health care delivery systems.
These are the public, private-for-profit, private-not-for-profit, and traditional systems. The public
sector, which is supported by the government, accounts for over 70 percent of the institutions.

The MoH is charged with the responsibility of regulating the entire health sector and its main
function is policy formulation, coordination and regulation of the stakeholders in the health
sector. In formulating such policies or guidelines for regulation, it collaborates with various
ministries, departments and agencies (MDAs) as well as development partners and stakeholders
in the health sector (Ackon, 2003; Abekah-Nkrumah, 2005). Policy implementation is carried out
through the public, private and traditional sectors. At the public sector end, the Ghana Health
Service, Teaching Hospitals Board and the quasi-government institution hospitals are the
implementing agencies of the MoH.

The Ghana Health Service is responsible for the implementation of government’s health policy
and regulation of state-run health institutions (i.e. government hospitals, Polyclinics, and health
centres). For the purpose of carrying out its functions, the Ghana Health Service has a secretariat
that has been decentralized from the national level to the regions and the districts. At each level
there is a team of management that administers the affairs of the service. The districts report to
the regions and the regions report to the national level as stipulated in the Ghana Health Service
and Teaching Hospitals Act (1996), Act 525. The Teaching Hospital Board (THB) is the
institution responsible for the implementation of government’s health policy and regulation at the
teaching hospital level. The Teaching Hospital Boards established under the Hospital
Administration Law, 1988 (P.N.D.C.L. 209) are, subject to Act 525, continued in existence. This
means, teaching hospitals are still required even under Act 525 to have a hospital board. The last
of the public sector agencies is the quasi-government institution hospitals. This is currently an
association and not a statutory body backed by relevant legislation. It is responsible for the
implementation and regulation of hospitals owned by quasi-government institutions (Ackon,
2003; Abekah-Nkrumah, 2005). With the exception of teaching hospitals, the other public
hospitals are not required under Act 525 to have a board. Public hospitals with a board might be
following an existing practice prior to the passing of Act 525 or might be responding to
administrative directive from their regional health directorate to have a board in place.

The private sector also plays a significant role in Ghana’s health sector, representing about 40
percent of total health care delivery in the country. The Private Hospitals and Maternity Homes
Board, established by Act 1958 (No. 9) as amended, is the regulatory body responsible for the
private health sector. The main providers in the private sector are the mission-based providers;
consisting of Christian and Moslem hospitals and the private medical and dental practitioners.
Finally, activities of the traditional sector are regulated by a directorate in the MoH. However,
the institutional and legal framework necessary to carry out such work is currently not in place.
The main traditional health care providers in this sector are the traditional medical providers,
alternative medicine and faith-based healers (Ackon, 2003; Abekah-Nkrumah, 2005). The
private hospitals are also not required by any Act to have a board. The formation of hospitals
boards is at the discretion of the hospitals. In the case of the mission-based hospitals, most of the
churches for instance have a dedicated board overseeing a group of their hospitals in a particular
district.
Health management in Ghana can be said to be fairly decentralized. Within the Ghana Health
Service, a nested approach involving District Health Management Teams, Regional Health
Management Teams, and headquarters have been put in place. Complementing these
arrangements are institutional/health facility management teams. Each of these management
levels is a budget management centre with the responsibility for a defined programme of work
supported by a defined operational budget. Presently, a sector-wide approach to health service
delivery exists in Ghana. The principles underlying implementation of the sector-wide approach
include an agreement between the Government of Ghana and health partners on a coordinated
programme of work, an integrated approach to funding, and common implementation and
evaluation arrangements. Under this arrangement, the MoH prepares an annual programme of
work, which is funded from Government of Ghana funds, internally generated funds, and pooled
donor funds. The MoH and partners meet twice a year to review and agree on the sector-wide
performance targets (MoH, 2009). The structure of the health sector is illustrated in Figure 2.1.

Figure .1: Structure of Ghana’s Health Sector

Ministry of Health

Partners
MDA’S

Public Sector Private Sector Traditional

PHMHB
DTAM

GHS T HOSP QGIH

TMP

MBP PMDP
G HSP PC HC AM
 Key:
 MDA’s – Ministries Departments and Agencies
 GHS – Ghana Health Service
 THOSP – Teaching Hospitals
 QGIH – Quasi Government Institution Hospitals
 PHMHB – Private Hospitals and Maternity Homes Board
 DTAM – Department of Traditional and Alternate Medicine
 GHSP – Government Hospitals
 PC – Poly Clinics
 HC – Health Centres
 MBP – Mission Based Providers
 PMDP – Private Medical and Dental Practitioners
 TMP – Traditional Medical Providers
 AM – Alternative Medicine
 FH – Faith Healers
Source: Five Year Program of Work (2002-2006, p. 48)

Health Care Financing and Resource Utilization

Prior to independence, the financing of healthcare was the sole prerogative of the colonial
government at the time (Dummett, 1993). After independence in 1957, Ghana provided free
healthcare services to its population through public health facilities. There were no out-of-pocket
payments in these facilities and care was financed solely from tax revenues. However, this was
not sustainable in the light of the needs of other sectors of the economy, and the government had
to find alternatives to this financing mechanism (Twumasi, 1975).

In the 1970s, nominal fees were introduced through legislations, but these proved insufficient to
meet the needs of the health sector. The user fees were as a result of economic difficulties during
the period (Twumasi, 1975). Between the 1970s and early 1980s, the global oil crisis from the
sudden hike in oil prices on the international market severely affected the country. This
immediately resulted in balance of payment difficulties, heavy debt burden and general
economic disequilibrium. As a result, the World Bank and the International Monetary Fund
(IMF) proposed structural changes to improving the economy, which suggested withdrawal of
state subsidies. This led to declines in the health budget, putting the health sector under severe
economic pressure (World Bank, 1993). Government budget fell from 18.3 percent to 10.1
percent of Gross National Product (GNP) between 1972 and 1982, resulting in a fall in real
expenditure in the education and health sectors of the economy. Equipment in health institutions
fell into disrepair due to lack of spare parts and basic drugs were desperately in short supply and
were often unavailable in rural clinics (Bawumia, 1998).

In 1985, the government at the time introduced a cost recovery programme known as the “user-
fees system”. Laws enabling the charging of fees dates back to 1969 with the introduction of the
Hospital Fees Decree, 1969 National Liberation Council Decree (NLCD) 360; Hospital Fee
Decree, 1969 (Amendment) Act, then, the 1970 (Act 325); then again the Hospital Fees Act,
1971 (Act 387). These charges were however token fees charged compared to the 1985
legislation which raised the fees above token levels (Smithson et al, 1997). There were however,
exemptions for antenatal and family planning and communicable diseases (Nanda, 2002). The
introduction of user fees greatly reduced the utilization of health services because most people
could not afford the user fees and the fees were also not matched with improvement in quality of
services provided. In spite of the introduction of the user fees, government still bore a
considerable proportion of the expenditure in healthcare (Arhin-Tenkorang, 2000).

In 1992, the government, in conformity with the Bamako Initiative of 1988 introduced the
Revolving Drug Fund, which officially introduced the Full Cost Recovery Policy for drugs as a
way of generating revenue to address the shortage of drugs. It was envisaged that, the cost
recovery process would contribute about 15 percent of the health sector resources. A review of
the process in the First Five Year Programme of Work (1997-2001) of the MoH revealed that the
contribution of the cost recovery process to the country’s health sector financing was below 10
percent. The application of the revolving drug fund policy was popularly termed “cash and carry
system”. The cash and carry system caused a decline in the utilization of healthcare services,
especially for the very poor, who needed the services most, since this represented a financial
barrier to access healthcare (Arhin-Tenkorang, 2000).

In order to improve access to healthcare services, a law (Act 650, 2003) establishing a national
health insurance scheme was enacted in October 2003 known as the National Health Insurance
Scheme. This was with the ultimate vision of assuring equitable and universal access to
healthcare for all residents of Ghana (MoH, 2004). The health insurance scheme is expected to
provide funds to healthcare providers in bulk to aid in planning and to reduce the incidence of
bad debt or charitable services which tend to increase the expenditure pattern of healthcare
facilities. This is ultimately expected to ensure efficient and effective delivery of healthcare
service. The funding mechanism includes premiums paid by members to the insurance scheme
they are registered for. Currently, 2.5 percent of all commercial invoices and pension
contributions are paid into the health insurance fund. In year 2006, the health insurance fund
represented about 31.6 percent of the total resource envelope of the health sector and in 2008,
this accounted for 32.6 percent of total health sector financing (MoH, 2006, 2008). According to
the Medium Term Expenditure Framework for 2009, the NHIS was estimated to contribute 41
percent of overall revenue for 2009. In relation to its financing sources, the NHIS is heavily
reliant on tax funding for 70–75 percent of its revenue. The National Health Insurance Scheme
has been decentralized into District Mutual Health Insurance Schemes and every Ghanaian is
supposed to be a member of a district scheme in his or her area. The district schemes are the ones
that contract the services of healthcare providers. The major problem confronting the Scheme is
financial sustainability; considering that with a growing utilization of members, only a third is
contributing to the scheme. There is also the problem of delays in reimbursing the facilities for
services rendered to subscribers (Witter and Garshong, 2009).

The various sources of financing public healthcare institutions in Ghana include government
subvention, donor pooled funds and internally generated funds. The Government of Ghana funds
is from budgetary allocations of the consolidated vote. This comes from budgetary allocation for
healthcare institutions approved by the Ministry of Finance and Economic Planning. This
funding could be viewed as government’s contribution to the financing of public hospitals and
the source of this funding for healthcare delivery is usually from taxes. It has been the
predominant source of funds for the health sector and constitutes about 60 percent of total
transfer to the MoH. The subvention from government is used for paying salaries for healthcare
staff on government payroll. The government subvention also covers administrative cost and
services, including stationery and other items for the smooth running of hospitals. General
investments and Highly Indebted Poor Counties [1] (HIPC) funds considered as investment also
form part of subvention to the healthcare facility. The contribution of government to investments
in general, such as the rehabilitation of old buildings and the purchase of equipment is generally
minimal.

Donor pooled and earmarked funds are external aid funding for the health sector. The pooled
funds are from various countries and organizations that are pooled into an account for use by the
health sector. The earmarked funds are also contributions by donors that are given for specific
projects in the health sector. Sometimes the donations come in the form of vaccines for
immunizations. Total inflows from donors into the health sector constitute about 25 percent of
the sectors budget (Drechsler, 2006). Donor pooled funds usually cover investment items and
service delivery of the hospitals are generally the least reliable of all the other sources of funds
(Akortsu and Abor, 2011).

The internally generated funds come in the form of user charges. The Hospital Fees Regulation
L.I. 1313 of 1985 introduced this system into public hospitals and the hospitals keep internally
generated funds to supplement the annual budgetary allocation from the MoH (Ackon, 2003).
These are revenues generated from drug fees and other patient fees raised by the hospitals. These
funds could be from the payment of services by health insurance organizations that contracted
hospitals and individuals who use the facility. Other activities that generate such funds are fees
for the use of cafeteria services provided by health facilities, the use of parking space and other
such activities. The internally generated funds are generally a very reliable source of funding the
public hospitals. The internally generated funds are used on personal emoluments of contract
workers, administrative expenses, services and investments. The use of internally generated
funds for administrative expenses, investments and personal emoluments confirm the fact that
government subvention, although may appear to be the highest financing source is actually
inadequate in running the health facility (Akortsu and Abor, 2011). Internally generated funds
represent about 24.85 percent of the total approved health budget (MoH, 2006).Targeted Health
Care Programs

One key targeted health care program in Ghana is in respect of the safe motherhood program of
the MoH and the Ghana Health Service. The basis for this program lies in the fact that, many
women in the country die as a result of complications related to pregnancy and child birth (NPC,
2006). Maternal health has not received the attention it deserves and therefore maternal mortality
rate is still high, ranging from between 214 to 700 maternal deaths per 100,000 live births with
some rural communities showing even higher rates (Ghana Health Service, 2005). The access to
and use of quality maternal health care services are thus crucial for improved maternal-child
survival. The effectiveness of a maternal health care program also depends on how women at
risk are willing to comply with necessary health care. It is argued that the use of maternal health
services is a function of demographic, cultural, and socio-economic factors, such as age of
women, birth order, size of household, education, ethnicity, place of residence, religious
background, marital status, employment, income level and accessibility (Addai, 2000; Abor,
2008). Therefore, the goal of the safe motherhood program is to improve women’s health in
general and especially, to reduce maternal morbidity and mortality, thereby contribute to
reducing infant morbidity and mortality (Ghana Health Service, 2005). To achieve the above
goal the program seeks to among other things:

1. Make child bearing safe for all women

2. Contribute to improvement in infant health
3. Promote and maintain the physical, mental and social health of mother and baby by
providing education on nutrition, family planning, STI prevention including HIV/AIDS, the
danger signs of pregnancy, rest/sleep and personal hygiene.
4. Help clients develop birth preparedness and complication readiness plans.
5. To detect and treat all complications arising in pregnancy, whether surgical, medical or
obstetric.
6. Ensure the delivery of full term healthy baby with minimal stress or injury to mother and
baby
7. Help prepare mothers to breastfeed successfully, experience normal puerperium and take
good care of child physically, psychologically and socially and finally to
8. Prevent mother-to-child transmission of HIV/AIDS.
To ensure appropriate and expected return on interventions, the safe motherhood program targets
married couples and individuals, adolescents, pregnant women including adolescents, women
and adolescents in their puerperium and their babies, men as well as families and communities.
To manage the program effectively and ensure effective monitoring, it has been sub-divided into
six major areas; Antenatal care, Labour and delivery care, Postnatal care, Family planning,
Prevention and management of unsafe abortion and finally health education (Ghana Health
Service, 2005).

The main aim of the antenatal care program is to establish contact with women in order to
identify and manage current and potential risk and challenges. The providers are public and
private healthcare facilities as well as Traditional Birth Attendants (TBAs). The main tool used is
the supervision of labour and deliveries to ensure proper management of the four stages of
labour, as well as early identification, proper management and or referral of complications by
using personnel such as such midwives, general medical practitioners, obstetricians and TBAs.
The mix of postnatal services include; comprehensive screening for detection and treatment or
referral of complications in both mother and child, health education and counseling and finally
family planning and motivation. Postnatal care is seen as one of the most important in the
spectrum of maternal services since most maternal deaths occur during this period. The family
planning programme is based on methods and practices to space births, limit family size and
prevent unwanted pregnancies in addition to the prevention and management of reproductive
tract infections (RTIs) such as STI/HIV/AIDS. The emphasis of the program is on adolescents
and couples (Ghana Health Service, 2005).

Some progress appears to have been made in the area of reproductive and child health, especially
maternal health services. The current rate of progress is expected to continue to improve, looking
at programs put in place by the health authorities, such as increasing levels of acceptance by men
to become part of family planning programs amongst others (Ghana Health Service, 2005; NPC,
2006). However, there are still challenges to deal with. These include high maternal mortality
and abortion rates, poor access (financial and geographical) to safe motherhood services in the
remote parts of the country, the high levels of poverty and low levels of education amongst
women. These are likely to adversely affect efforts at reducing maternal mortality and morbidity
(Abor, 2008).

Health Infrastructure

Health infrastructure is important in improving the health status of people in the country. In
Ghana, there is wide disparity in terms of the availability of health infrastructure in the country
in terms of human resources, hospitals, primary health care, community health care, and blood
banks. We now discuss the individual health infrastructure in the country.

Human Resources: Human resources for health is now widely recognized as the key element
for achieving the MDGs and scaling up health interventions. The health workforce accounts for 9
percent of the total labor force and more than 65 percent of national health care budgets in
Ghana. Experiences in Ghana reveal that shortage of human resource for health as well as
misdistribution of the limited numbers pose great challenge not only to the health sector, but also
to economic prosperity generally (Ghana Health Force Observatory, 2007). Health workforce is
mostly concentrated in the Greater Accra and Ashanti regions. For instance, these two regions
account for about 49.6 percent of doctors on government payroll. It has being reported that
Korle-bu Teaching Hospital (located in Greater Accra) alone has more doctors than the three
northern regions. There are over 5,000 professional nurses in the country and many other
community health nurses and health assistants. Also, there are over 350 pharmacists, and over
2500 midwives all over the country.

Health Facilities: There is uneven distribution of health facilities across the various regions of
the country. Though there is at least one regional hospital in every region in addition to other
hospitals, not all the districts have a hospital. This is particularly true in the case of the new
districts. The country currently has 1,887 health facilities, including 3 teaching hospitals and 3
psychiatric hospitals. Nine regional hospitals, 86 district hospitals, 11 polyclinics, and 927 health
centres under the Ghana Health Service represent about 55 percent of the total health facilities
(MoH, 2009).

Community Health Care and Primary Health Care: Community-based Health Planning and
Services (CHPS) has been adopted by the Ghana Health Service as a national strategy for
promoting accessible, quality and equitable services to all Ghanaians--particularly those in rural
areas. The CHPS model is based on the results of four years of field experimentation and
demonstration by the MoH and the Navrongo Health Research Center’s Community Health and
Family Planning project, with technical assistance from the Population Council and USAID.
Less than 40 percent of rural population has access to primary health care.

Blood Banks: In every region of the country, there is at least one regional blood bank. There is
also a national blood bank in the country that supplies the other blood banks in event of shortage.
However, blood given out to any blood bank is expected to be replaced later. The Korle-bu and
Okomfo Anokye teaching hospitals have their blood bank. There are other mission/private/quasi-
government hospitals that run their own blood banks in the country.

Indigenous Health Care System

Indigenous or traditional medicine refers to health practices, approaches, knowledge and beliefs
incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques
and exercise applied singularly or in combination to treat, diagnose and prevent illness or
maintain well-being (World Health Organization, 2008). In most developing countries like
Ghana, both the modern/orthodox and traditional forms of medicine are critical to the health care
system. With an estimated population of over 22 million, the number of health professionals
responsible for delivering orthodox healthcare in Ghana is woefully inadequate. Over 70 percent
of the population lives in the rural areas. Yet, over 75 percent of Ghanaian orthodox medical and
paramedical personnel are concentrated in urban areas that have the large majority of modern
health facilities to the detriment of the teeming rural dwellers. Many rural Ghanaians, therefore,
have not been exposed to the benefits of modern changes in orthodox healthcare system.
Consequently, most of these rural communities have to resort to the traditional health care
system.
The traditional health system can be described using four broad aspects. First of all, it is a
holistic approach that focuses on the whole person’s health rather than particular organs or
disorders. Secondly, the body, spirit and environment (mainly spiritual and social) are all
considered important to one’s health. Thirdly, the traditional healers use rituals, divination
(getting information through supernatural ways), faith healing, offerings, herbs and other
naturally derived medicines. Fourthly, there are different types of traditional healers –odinsinin
who are skilled in natural medicines, okomfo who heal through communication with ancestral
spirits (spiritualists), traditional birth attendants and traditional surgeons. Traditional health care
delivery provides a client-centred, personalized approach that is culturally appropriate and
tailored to meet the specific needs of the patient. It embraces a wide range of practices including
herbalism and spiritualism, and practitioners such as diviners, priests and faith healers.

Since the late 1970s, a number of international resolutions have been passed to promote
regulation of traditional medicines and implementation of specific measures to govern
Traditional Health Practitioners (THPs). A typical example is the primary health care concept
which advocates the use of appropriate technologies and methods in each country. From the
early 1990s, the World Health Organization (WHO) has advocated for the inclusion of THPs in
the national AIDS programmes. In 2003, the 56th World Health Assembly of the WHO resolved,
under its global strategy on alternative medicine, that its member states must ensure that their
health care systems promote and support provision of training and, if necessary, retraining of
THPs, and a system for the qualification and/or accreditation or licensing of the practitioners .

A few years later, the Ghana government enacted an Act to integrate THPs into the mainstream
of primary health care. This Act affirms the dignity and respect of traditional medicine and offers
a framework to ensure the efficacy, safety and quality of traditional health care services from
registered and trained traditional practitioners. It also provides management and control over
regulations, training and conduct of practitioners. A traditional health council has also been
instituted to develop interest in traditional health practices by encouraging research, education
and training. The Council must promote, regulate, and liaise between traditional health
practitioners and other health sectors.

The traditional health system is running parallel with the Ghana health service playing
complementary roles to each other. The MoH is charged with the responsibility of identifying,
training, regulating, standardizing and monitoring their activities. In recent times, traditional
health system has been put on limelight projecting its implementation to the health care system
in Ghana. In view of this a scale up training programme was necessary. THPs received training
and mentoring in divers areas such as: HIV/AIDS, Home-based care, tuberculoses and directly
observed treatment short-course, prevention and transmission of certain diseases. It was assumed
that capacity building of THPs in identified areas of training and mentoring, and linking them to
the health care system would result in increased acceptability and awareness of their role in
health delivery, improved capacity to support the management of certain diseases and improved
quality of traditional healing and access to voluntary counseling testing (VCT) services.

The main challenges confronting the practice of indigenous medicine include, inadequate
resources, inadequate staff capacity, low level of literacy among majority of practitioners, and
slow compliance of THPs to regulatory mechanisms
Health Sector Reform/Health Care Policy

Health sector reform is the sustained, purposeful change to improve the efficiency, equity and
effectiveness of the health sector (Berman, 1995). Ghana’s health system has since independence
undergone three major reforms in 1957, 1977 and 1997. The first of these reforms which
occurred at independence saw a massive development in infrastructure and human resources with
the aim of addressing major health challenges, confronting the nation at the time. Significant
among these problems were environmental sanitation, malnutrition and high infant mortality
rate, variety of diseases and shortage of medical personnel.

The second attempt at reforming the health sector took place in 1977, as a result of the perceived
inadequacies of the 1957 reform to effectively address the existing increasing and complex
health challenges. It was significantly modeled on the Primary Healthcare system, which
emphasized community healthcare and community involvement in promoting health and
healthcare. The health system witnessed another attempt at reform in 1997, the main
components of which were stipulated in the medium term strategy that spanned from 1997 to
2001. This reform aimed at achieving the ff:
 Significant reduction in the infant, child and maternal mortality rates.
 Effective control of risk factors that expose individuals to the major communicable
disease.
 Increased access to health services especially in the rural areas.
 Establishment of health systems effectively reoriented towards the delivery of public
health services.
 Strengthening and effective management of health systems.

The second five year programme of work which began in 2002 and was expected to end in 2006
detailed the current health sector strategy. The overall goal was to help address the health
inequalities in the country. Evidence abound that this particular strategy was tailored in harmony
with the immediate past one (strategy) to:
 Improve the quality of health delivery
 Increase access to health services
 Improve the efficiency of health service delivery
 Fostering partnerships to improve health
 Improving financing to the health sector

Then came the third five year programme of work (5YPOW) which gives consideration to
lessons learnt from the 5YPOW I and II. This particular programme of work was strategically
developed to respond effectively to the challenges met during the implementation of the previous
ones. It contains the goals, mission and strategic objectives of the health sector, as has been
stipulated in the first and second ones. This document provides the basis for the drawing of the
annual work plan to ensure adequate response to priority interventions for human resource
development and the ultimate reduction of poverty and the creation of wealth. Over the five year
period, the document is expected to offer the basis for guiding and coordinating the activities of
players in the country’s health sector (MoH, 2008a).
In an attempt to ensure clarity and less difficulty in the achievement of its set objective, the third
5YPOW is grounded on the following principles:
 Creation of wealth through health- this is in acknowledgment of the fact that poor health
is expensive to individuals, societies and nations, and thus any attempt to fight poverty,
as well as create wealth should incorporate health issues.
 Making sure that the National Health Insurance works well- Admittedly, one of the
significant innovations in Ghana’s health system has been the introduction of the
National Health Insurance Scheme. In spite of the enormous positive impacts of this
scheme, however, there are still challenges confronting its implementation. For this
reason, the 5YPOW has been developed in a way as to help overcome these challenges,
significant among which is poor access, including both geographical and financial access.
The document aims to facilitate the provision of incentive to healthcare providers,
organizational arrangements and quality service management.
 Limiting inequalities – This basically aims at bridging the gap between the rich and the
poor in accessing healthcare delivery.
 Giving maximum attention to priorities- Although there are a lot of challenges
confronting the health system, in an attempt to address these problems, there is the need
to prioritize, i.e. identifying which of the problems to address first before the other.

The 5YPOW is fashioned as a departure from the past by setting out priorities that will
emphasize concentration on each year’s annual programme of work. Below are the four strategic
objectives of the third 5YPOW:
 Promoting an individual lifestyle and behavioral model for improving health and vitality,
by addressing risk factors and by strengthening multi-sectoral advocacy and actions.
 Rapid scaling up within the existing capacity, high impact interaction and services
targeting the poor, disadvantaged and vulnerable groups.
 Investing in strengthening health system capacity to sustain high coverage.
 Promoting governance, partnership and sustainable financing.

Health Information Technology

Health information technology is necessary for improving information management needed for
achieving the health system’s goals and objectives. Advancements in technology and the
increasing value of integrated health data, as well as the management of that data also represent a
vital thrust underpinning information management in the health sector. An efficient health
system requires accurate and instantly accessible information and this is vital for improving care
for patients, improving the performance of the health care system and the health status of
Ghanaians. It is also about providing decision-makers with accurate information so that they can
make informed decisions (MoH, 2006; MoH, 2008b). Health information is particularly
important for resource allocation and public health action in countries such as Ghana, where
resources are limited (MoH, 2007). The health sector information system in Ghana is confronted
with a number of challenges, including:

 Multiple and uncoordinated information systems. These systems do not communicate

with each other resulting in data redundancy, duplications and inconsistencies amongst
the various information sources.
  No formal links to sources of information outside the health sector and overall
performance of health information system is dependent on abilities of individual
managers rather than corporate needs.
 Weak policy and legal framework for the health information system and lack of national
plan for health information.
 Low level of human resources and capacity. Inadequate personnel with advanced skills in
health information and Districts do not have formally designated health information
officers.
 Limited capacity for effective health information system planning, implementation,
monitoring and evaluation.
 Absence of an updated strategic plan to guide the overall development and
implementation of a sector-wide health information leading to the slow progress in
developing systems for managing health information in the sector.
 Lack of systematic investment in the development of data management capabilities
within the health sector. Most investments continue to be programme focused and centred
around the development of reporting systems based on specific indicators.

Some attempts have however, been made to improve information management in the health
sector. The first is improving the human resource available for data collection and analysis at the
district and regional levels. Steps have been taken in this regard to set up and support the training
of health information officers at the Kintampo Rural Health Training School. The second major
strategy is improving central level capacity for collation and analysis to support decision-
making. The focus has been on building the capacity at the Centre for Health Information
Management to be able to produce the kind of analysed data required by the sector. The third is
strengthening of data collection and analysis at the district level. Steps were therefore taken to
study and understand the health information needs and demands at the district level and to design
systems that will improve data collection and reporting, enhance the use of data and to facilitate
self-assessment at the district level. A “platform” for the collation of reports at the district level
was introduced through the District Health Management Information System. It was also to
enhance the management of data generated and the reports required to be produced by the
districts. It also looks at improving the scope of use of the information generated as a result for
decision-making. Two key tools have been developed for the purpose: a “Decision Support
Manual” to guide the interpretation and presentation of the routinely collected data at the district
level and, a “District-Wide Computer Assisted Information Management System” to facilitate
the management of reports at the districts (MoH, 2008b).

r Summary

This chapter examined the health care system in Ghana. It provided a review of the history of the
health care system, the structure and governance of the health care system and health care
financing and resource utilization. The paper then discussed targeted health programs, health
infrastructure, indigenous health care system, occupational health care system, health sector
reforms, health information technology, demand for health care, and health output. It also
discussed the strength and weaknesses in the Ghanaian health care system. The major strengths
of the health system in Ghana include, inter-sectoral collaboration, services provided by
traditional health providers, and support from development partners. The health sector is also
confronted with a number of challenges, including high prevalence of communicable and
preventable diseases, under-nutrition, and poor levels of reproductive health. Also, health
threatening non-communicable diseases such as obesity, diabetes, cancers, hypertensions and
cardiovascular diseases are increasingly becoming major public health challenges. Other
problems include, inadequate funding, weak human resource capacity, lack of adequate
infrastructure and equipment, and poor health information system, and inequitable distribution of
human resource and health infrastructure across the country.

The structure of the health care system in Ghana and for that matter in any country would have
implications for the type of governance structures adopted by health care institutions. In Ghana,
teaching hospitals are required under the Ghana Health Service and Teaching Hospitals Act 1996
(Act 525) to continue having a board. However, in the case of the other public hospitals, they are
not required under Act 525 to have a board. Therefore, public hospitals with a board might be
following an existing practice prior to the passing of Act 525 or might be responding to
administrative directives from their regional health directorate to have a board in place. The
private hospitals are also not required by any Act to have a board. The formation of a hospital
boards is thus at the discretion of the respective private hospitals. In the case of the mission-
based hospitals, some of the churches for instance have a dedicated board overseeing a group of
their hospitals in a particular district. The next chapter discusses the extant literature on health
care governance.

References
Abekah-Nkrumah, G. (2005): Organizational Learning and Organizational Performance: A
Study of Selected Healthcare Institutions in Ghana, Unpublished M.Phil Thesis, University
of Ghana Business School, Legon.
Abekah-Nkrumah, G., Dinklo, T. and Abor, J. (2009): Financing the Health Sector in Ghana: A
Review of the Budgetary Process, European Journal of Economics, Finance and
Administrative Sciences, 17(2009): 45-59.
Abor, P. A. (2008): The Socio-economic Determinants of Maternal Health Care Utilization in
Ghana, Unpublished M. Phil Thesis, University of Ghana Business School, Legon.
Ackon, E. K. (2003): Management of Health Care Organizations in Developing Countries, Bel-
Team Publications, Accra.
Addai, I. (2000): Determinants of Use of Maternal-child Health Services in Rural Ghana,
Journal of Biosocial Science, 32(1):1-15.
Akortsu, M. and Abor, P. A. (2011): Financing Public Healthcare Institutions in Ghana, Journal
of Health Organization and Management (forthcoming).
Arhin-Tenkorang, D. C. (2000): Mobilising Resources for Health: The Case for User Fees Re-
visited, Report submitted to Work Group Three of the Commission of Microeconomics and
Health, World Health Organization, Geneva.
Bawumia, M. (1998): Understanding the Rural-Urban Voting Patterns in the 1992 Ghanaian
Presidential Election: A Closer Look at the Distributional Impact of Ghana’s Structural
Adjustment Programme, Journal of Modern African Studies, 36(1): 47-70.
Berman, P. (1995): Health Sector Reform: Making Health Development Sustainable, Health
Policy, 35(): 13-28.
Buor, D. (2004): Determinants of utilization of health services by women in rural and urban
areas in Ghana, GeoJournal, 61(): 89–102.
Clarke, E. (2006): Do occupational health services really exist in Ghana? A special focus on the
agricultural and informal sectors, In Lehtinen S. (ed.) Challenges to occupational health
services in the regions: the national and international responses, Proceedings of a
WHO/ICOH/ILO Workshop, Finnish Institute of Occupational Health, Helsinki 2005.
Drechsler, D. (2006): Financing Development: Findings from Ghana Field Study, A Paper
Prepared for the expert Workshop on Development Finance Architecture – What Flows,
Channels, and Pools, 3-4 July 2006, Paris.
Dummett, R. (1993): Disease and Mortality amongst Gold Miners of Ghana: Colonial
Government and Mining Company Attitudes and Policies, 1900-1938, Social Science and
Medicine, 37(2): 213-32.
Ghana Demographic and Health Survey (GDHS), 2000-2009.
Ghana Health Force Observatory (2007), http://www.ghanahrhobservatory.org/
Ghana Health Service (2005): Reproductive and Child Health Unit, Annual Report, Public
Health Unit.
Ghana Health Service and Teaching Hospitals Act 1999 (Act 525)
Ghana Statistical Service (2007), Maternal Health Survey, 2007
Hospital Administration Law, 1988 (P.N.D.C.L. 209)
ILO/WHO (1950) Joint Committee on Occupational Health, Geneva.
Kunfaa E. Y. (1996): Sustainable Rural Health Services through Community-based
Organizations: Women’s Groups in Ghana, Spring Research Series No. 16, University of
Dortmund.
Ministry of Health (2004): National Health Insurance Policy Framework for Ghana, Accra.
Ministry of Health (2006): Health Information Management Strategic Plan, 2007-2011, Draft
Report, www.moh-ghana.org/moh/policybrief.asp, accessed 5th December, 2009.
Ministry of Health (2007): National Health Policy, Creating Wealth through Health, September,
www.moh-ghana.org/moh/policybrief.asp, accessed 5th December, 2009.
Ministry of Health (2008a): Ghana Health Sector Five Year Programme of Work
(5YPOW):2007 – 2011, February.
Ministry of Health (2008b): Legal and Policy Framework for Health Information and Health
Data Reporting, Draft Report, March, www.moh-ghana.org/moh/policybrief.asp, accessed
5th December, 2009.
Ministry of Health (2009): Assessment of Medicines Procurement and Supply Management
Systems in the Public Health Sector, A Country Report 2009.
Nanda, P. (2002): Gender Dimensions of User Fees: Implications for Women’s Utilisation of
Health Care, Reproductive Health Matters, 10(20): 127-134.
NPC (2006): ICPD + 10 Ghana Country Report (1994 – 2004), Okonofua FE Integrating TBAs
into reproductive health care in Nigeria: a conceptual model, In Defining the future role of
traditional birth attendants in reproductive health care in Nigeria, Report of a seminar
organized by WHARC, Nigeria, in collaboration with UNFPA.
Smithson, P., Asamoa-Baah, A., and Mills, A. (1997): The Role of Government in Adjusting
Economies: The Case of the Health Sector in Ghana, Paper 26, Development Administration
Group, University of Birmingham.
Twumasi, P. K. (1975): Medical Systems in Ghana: A Study in Medical Sociology, Ghana
Publishing Corporation.
WHO (2008): Traditional medicine, Fact sheet No. 134, Revised December 2008,
http://www.who.int/mediacentre/factsheets/fs134/en/.
Witter, S. and Garshong, B. (2009): Something Old or Something New? Social Health Insurance
in Ghana, BMC International Health and Human Right, 28(): 9-20.
World Bank (1993), World Development Report 1993: Investing in Health.
Washington DC.
Yeboah, Y. (2003): Partnerships in Health Service Planning and Provision: Prospects and
Challenges in Ghana, Spring Research Series No. 43, Dortmund

Note
1. HIPC is a debt forgiveness initiative where interests to be paid on debt from the World Bank
and IMF are used for developmental projects in the owing country