achieving)the)mdgs.)lessons) learned) · level)of)care)) national regional district sub-district...
TRANSCRIPT
ACHIEVING THE MDGs-‐ LESSONS LEARNED
Dr. Ebenezer Appiah-‐Denkyira DIRECTOR GENERAL
GHANA HEALTH SERVICE
Contents -‐
• Short background • MDGs achievement – 1, 4, 5, 6 • Challenges • Lessons learnt • Way forward
Map of Ghana
North: more deprived, with scaRered seRlement
Vision – creaSng wealth through health …
4
…in ensuring « access to a mo0vated, skilled, and supported health worker by every person in every village everywhere » (WHO).
Sector ObjecSves • Bridge equity gaps in access to health care and nutriSon
services • Health systems strengthening and support infrastructure • Ensure improved maternal and child health care • Ensure the reducSon of HIV/AIDS/STIs/TB transmission,
malaria and promote healthy lifestyle • Ensure sustainable financing arrangement that protects the
poor • Strengthen insStuSonal care including mental health
Services
Level of Care
National
Regional
District
Sub-district
Community level
National : Advanced
care, training, research
Regional: secondary,
Tertiary care, Training,
Research,
District : comprehensive Emergency
Obstetric care, surgery In-patient Care
Sub-district: Basic Emergency Obstetric care,
IMCI, admissions overnight
Community level: health promotion, ANC, PNC, emergency delivery, home
visits, counseling, treatment of minor ailments
TRENDS MDG1, 4,5,6
MDG 1 StunSng, WasSng and Underweight in Ghana
34
9
23
31
10
20
35
8
18
28
9
14
22.8
6.2
13.4
0
10
20
30
40
50
60
StunSng WasSng Underweight
Per C
ent
Nutri+onal Status of Children under-‐5 yrs
1988 1993 1998 2003 2008 2011
Target for Underweight is 8% for 2013
Key Above 30%
20-‐30%
Below20%
Trend of stunSng by Regions 2008 DHS and 2011 MICS
Northern 32%
Volta 27%
AshanS 27%
Brong Ahafo 25%
Western 27%
Eastern 38%
Upper West 25%
Central 34%
Upper East 36%
Greater Accra 14%
Northern 37%
Volta 22%
AshanS 22%
Brong Ahafo 19%
Western 23%
Eastern 21%
Upper West 23%
Central 23%
Upper East 32%
Greater Accra 14%
2008 2011
11/7/2013 9
NR is worsening GAR has stagnated
11/7/2013 10
Trends in childhood Mortality, 1988-‐2011
77 66
57 64
50 53
22
155
119 108 111
80 82
40 52
41 30
43 30 32
14
0
20
40
60
80
100
120
140
160
180
GDHS 1988 GDHS 1993 GDHS 1998 GDHS 2003 GDHS 2008 MICS 2011 MDG Target 2015
Dea
ths
per 1
,000
live
birt
hs
Infant Mortality Under 5 Mortality Neonatal Mortality
Percentage of infant deaths that is due to neonatal mortality by regions (2011 MICS)
53
65
53
69 65 63
68
59 59 61
0
10
20
30
40
50
60
70
80
90
100
Western Central Greater Accra
Volta Eastern AshanS Brong Ahafo
Northern Upper East
Upper West
Percen
t
11/7/2013 11
740
590 540
451
350
185
1990 1996 2000 2007 2008 2015
Trends in Maternal Mortality Ra+o in Ghana and MDG Target
Maternal Mortality
In the current WHO/UNFPA/WORLD BANK TRENDS IN MMR REPORT 2008 GHANA‘S MMR IS 350/100,000 LB AND CLASSIFIED AS MAKING PROGRESS AND MMR REDUCED 42% FROM THE 1990’S -‐ Represents 2,600 maternal Deaths a year
Trend of supervised delivery by Regions 2006-‐2012
Supervised (Skilled ARendant) Deliveries 2009 – 2013 half-‐years
MDG 6
• Measles – no deaths since • Guinea worm – no cases since ? 2008 • Neonatal tetanus – no cases since • PoliomyeliSs – no cases -‐ • Malaria – case fatality reduced • Tuberculosis – cure rate 75% • Penta – 85% ( Rota/ flu, HPV, Rubella , measles
• HIV – prevalence <2.0 reducing over Sme
Annual Incidence Guinea Worm Cases, 2000-‐2008
7395
47395611
8290
7275
3981 41293358
5010
100020003000400050006000700080009000
2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Cases
479 (95.6% of cases were reported in the NR)
LESSONS LEARNT
• PoliScal commitment / courage • Flexible HR policy • Planning with deprived areas in mind • Aggressive NaSonal Health Insurance • Private sector engagement • DecentralizaSon of health system CARMA • Focused Funding that allows health system strengthening – GAVI, PEPFAR, HIRD, MAF etc
Tackling the Challenges
• Human Resource – – effect of brain drain, – not enough producSon, – skewed distribuSon all being addressed
• Health Financing – – reaching the poor with NaSonal Health Insurance – Sustainable Financing health care (low government and donor funding)
• Improving Access – – Community based planning & services (CHPS), – SSll more hospitals required
• Infrastructure – – Equipment Retooling not yet complete – fake medicines now a growing menace – Community based Planning and services
• Mass exodus of ‘ brain drain’ was devastaSng.
DevastaSng effect of health worker migraSon…
• OutmigraSon rates have decreased
• And aRriSon trends have generally reduced
020406080
100120140160180
2002 2003 2004 2005 2006
Time (years)
No.
doctorspharmacistsnursesmidwivesLab TechsX-Ray Techs
21
Source: WB
Source: CAGD Payroll Database , 2009
Figure 7
0
0.05
0.1
0.15
0.2
2004 2005 2006 2007 2008 Year
Attrition Rate
All Healthworkers High-Skilled workers
F
…. there is a challenge of loosing the more experienced personnel as health workforce ages
22 Source: Antwi and Ekey, 2009;
Ageing staff especially Midwives
Recovery: ACTIONS TAKEN
• Train 1000 Health care Assistants in 6 months • Expand and increase number of schools Schools (public and Private)
• Introduce direct midwifery and cerSficate programmes
• Introduced sandwished teaching programme at university too produce tutors
scaling up ProducSon of professionals-‐-‐-‐ • Medical – increase intake, increase Cuban
medical brigade, diasporan recruit • Physician Assistants – introduce P/Assistant Psychiatry,
• Private sector – producSon recruited by public sector
• specialist training in KBTH (South), KATH (Middle), TTH (Northern) Health workers Hired Purchase vehicles revolving funds established -‐1000 cars annually
20701
29763
5271
15462
700
12771 13390
2810
9530
420 1638
2330
872
2397
200 0
5000
10000
15000
20000
25000
30000
35000
CHN HAC MID RGN RHTS
NUMBE
R
PROGRAMME
ADMISSION INTO HEALTH TRAINING INSTITUTIONS 2010
No Appl No Qual No Enroll
Human Resource ProducSon Staff At post 2010 2013 Target
(prodn/yr Target HR ra+o/pop 2016
RGN+ EN/HAC)
1:2125 (11,000)
1:1,200 (23000)
4000/yr
1: 1000)
Midwife* 1:7759 (3500)
1:5,000 (5000)
1200/yr 1: 3000
CHN 1:5747 (5000)
1:2,300 (11,000)
2000/yr 1: 2000
Doctor** 1:11,000 2300 -
1:8,700 3000
500/yr 1: 6000*
Physician Assitants
1:34,610 (650)
1: 24,000 (1100)
200/yr 1: 15000
…..but sSll remains below internaSonal benchmarks
For physicians: For nurses:
0
0.1
0.2
0.3
0.4
0.5
0.6
JLI-‐WHO benchmark WHO benchmark Existing density
Physicians
00.20.40.60.81
1.21.41.61.82
JLI-‐WHO benchmark WHO benchmark Existing density
Nurses and midwives
HRH benckmarks: HIGH end: JLI-‐WHO benchmark: -‐ At least 0.55 doctor for 1,000 people; -‐ At least 1.88 nurse/midwife for 1,000 people. LOW end: WHO benchmark: -‐ At least 0.1 doctor for 1,000 people; -‐ At least 0.3 nurse/midwife for 1,000 people. 28
DistribuSon had to be managed
Trend in Doctor PopulaSon raSo -‐Ghana
* Addressing equity in staff distribuSon demand mulS-‐sectoral support.
• Site Nurse and Midwifery Training Schools deprived Regions (‘recruit, train and retain’)
• OrientaSon centre for ‘Ghanaian medical returnees’ in the Northern Region before professional exams are taken.
• Rural incenSves, promoSon out of turn, shorter Sme for further studies etc
• Cuban Medical brigade posted to areas of need • Shorter years for first PromoSon and years served arer engagement before further studies are granted for staff in deprived areas.
Health Financing -‐Historical
• Free health care arer Independence-‐ unsustainable -‐1960s
• Cost recovery (“cash and carry with exemp0ons) plummeted health seeking behaviour-‐ 1980s
• Community based insurance scheme-‐ 1990s • NaSon-‐wide social health insurance scheme – 2000s (PresidenSal Campaign promise)
NaSonal Health Insurance
• LAW – social, mutual, private-‐ compulsory • formal and informal sector, cross subsidizaSon • 95% of all diseases, both in-‐paSent & OPD • financed from VAT (85%), Social Security deducSons (2.5%), premium (exclusion – 60%)
• Private and public faciliSes accredited • Move to biometric registraSon, e-‐claims, capitaSon
Results • 35% NHIS coverage • Increased OPD aRendance from 0.44/capita to 1.07 (598,000 in 2005 to 23.0m in 2012-‐ 40x – Admissions increased from 29,000 to 4m same period
• 80% -‐90% of clinic aRendants have NHIS cards (more patronized in the rural areas)
Trend of OPD Visits Per Capita, 2000-‐2008
0.00.10.20.30.40.50.60.70.8
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
OPD
vis
its/c
apita
Infrastructure deficit
General development required for universal access
Nature of roads in district
Joseph Adomako; DDHS-‐Amansie West District
Way forward -‐ • Improved use of ICT – mhealth, e-‐learning etc • Improve access through Community based services and demand side strengthening
• Public Private Partnership in health care • Sustainable Health Financing strategies to enroll all the poor
• ConSnual PoliScal Commitment to infrastructure development and funds allocaSon
• Strengthen decentralizaSon to Local Government(devoluSon)
• Thank you
23223 20848
26107
22276 23832 24949
16051
20873
25330
30385
42568
37412
42144 39939 39493
33816
22922
45184 43747
55371
45066 43035
44591
41033
50790
35820
23329
45497
53354
67619
0
10000
20000
30000
40000
50000
60000
70000
80000
AshanS Brong Ahafo Central Eastern Greater Accra Northern Upper East Upper West Volta Western
Ra+o
Region
Med/Phys Asst to Pop Ra+o 2009-‐2011 Compared
2011
2010
2009
• Partnership with InternaSonal Org. WHO – • Performance agreement with agencies • High ICT penetraSon – 23m • PPP
Challenges cont. Poor Access to EmONC services
Trend of Under five mortality rate by regions ( DHS and MICS Surveys 2003-‐2011)