achieving)the)mdgs.)lessons) learned) · level)of)care)) national regional district sub-district...

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)