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HEALTH INSTITUTE OF GHANA (HIG)

Introduction

Health is increasingly included as an important goal of national development. Health sector reform is seen as an important contributor to sustainable national development.
In response to worsening economic conditions in the 1980 and 1990s and reduced public finance for health services, most developing countries including Ghana, undertook reforms of various aspects of their health services. The Health Sector Reform (HSR) was part of the IMF’s Structural Adjustment Programme and was to lead to greater efficiency, equity and effectiveness in health service delivery.

Ghana started her Health Sector Reforms in the early 1990s. It initially led to major changes in institutional and managerial roles. Decentralization was introduced to enhance efficiency and responsiveness to local health needs. District health managers were empowered to make decisions on many issues within the framework of national policies. What is obvious today is that what was required was a policy package rather than implementation of isolated reform strategies.

A reform is not supposed to be a one-time effort but needs to be sustained and must make a real difference in the way things work over time. It, therefore, implies not only action but also information to assess and modify the actions; as well as the means to use the information. What is not obvious in the country today are clearly defined objectives, strategies for achieving the reform objectives and efforts to monitor the changes and modify the strategies as and when needed.

Challenges of the Ghanaian Health Sector

The health sector refers to the totality of policies, programmes, institutions and actors that provide health services. The Health Sector in Ghana is one of the sectors in the country’s general structural and management arrangement for its development. The sector is on the threshold of making significant contribution to the nation’s socio-economic development when performance is effectively managed and improved. Globally and locally, there is increasing awareness of the pivotal role of the health sector in development.

However, there are several challenges faced by the sector that need to be carefully identified and addressed, to make it efficient and equitable in its operations.

The key challenges of the health sector in Ghana include the following:

Weak environmental scanning, institutional arrangement and management: this has existed since the promulgation of Act 525 and operationalising of the Ghana Health Service (GHS). The existing institutional arrangements do not promote efficiency. This is further exacerbated by overlapping functions between MOH and its implementing agencies (namely GHS, Teaching Hospitals and CHAG). The direction for integration of the traditional sector continues to be a mystery, with expectation that it will be integrated into GHS. The absence of a legislative instrument (LI) to guide the implementation of Act 525 after over a decade of its promulgation also is negatively affecting operations in the health sector.
Weak leadership, management and monitoring and evaluation: Weak leadership, management and monitoring and evaluation (M&E) and weak administrative systems have undermined performance in the health sector. The development and transition of clear management and leadership development strategies into overall sector performance has not been realized.
Weak governance system: there is general failure on the part of the MOH to lead and provide direction in the health sector. This hampers the setting of agenda and providing direction by senior managers to lead, mentor and guide staff in the sector. Weak governance is the result of ineffective communication with poor feedback, poor interpersonal relationships leading to poor information flow on policy and strategic issues to lower levels. In addition, inadequate delegation of responsibilities with micro-management leads to poor work climate, low morale and poor performance in the sector. Problems of weak planning processes leading to non-realization of goals and objectives continue to exist in the sector.
Poor service delivery performance: though health sector has shown positive trend in some indicators including EPI, TB control, malaria, nutrition and HIV/AIDS, coverage in priority health interventions has remain inadequate. This results in slow improvements in health outcomes. Weaknesses of the health systems including human resources and capacity building have further impeded the scaling up of cost effective interventions. Most health facilities at the periphery notably the health centres do not provide full range of services. The rollout of Community-Based Health Planning and Services (CHPS), a proven effective strategy to increase access to health care is extremely slow. Additionally, not enough attention has been given to reducing risk factors in the clinical areas.
Weak financing and financial management, and ineffective resource allocation: the health sector continues to experience inadequate budgetary provision and irregular inflow of funds. This hampers planning and implementation of programmes. Decentralization of financial and personnel responsibilities have lagged far behind managerial responsibility. Systems of financial management and audit systems are weak and Accounting Treasury and Finance Rules and other government regulations are often not complied with. The inability of districts to capture all available resources during their annual planning process, mainly attributed to continued existence of vertical funding of programmes and initiatives is leading to duplications and inefficiencies. Persistent inequities in resource allocation, lack of rational criteria for allocating budget and inefficiencies in resource management continue to remain within the sector. There is no consensus on resource allocation criteria at all levels leading to lack of transparency in disbursement of funds. There is tremendous pressure to spend on specialized services/programmes as opposed to primary health care. Furthermore, the continued vertical funding of programmes at the district level imposes undue administrative burden which further stretches the limited managerial capacities.
Weak monitoring, support and supervision: There is inefficient monitoring and supervision across all levels of the health sector. This contributes to a general lack of commitment and little accountability for performance. Inadequate support and oversight from the national level to the regional and district levels through supervisory visits and performance appraisal also lead to reduced morale and sometimes indiscipline in lower level managers. Self assessment or routine assessment of individual performance within the sector is lacking due to non-functional appraisal systems with no uniform tools for assessment and if available not well disseminated and shared with all managers.
Weak health information management: there is a huge challenge with reporting systems within the sector hence often data is not used in defining district priorities, planning and allocation. This creates a gap between data collection and the decision making process. Inadequate information also hinders effective planning, monitoring and evaluation of health services, and poor data quality often lead to inadequate utilization of information for policy decision making. In spite of numerous efforts to improve communication and coordination within the sector, Information Communication and Technology (ICT) has been slow to develop, especially at the regional and district levels. Existing technology for communication are underutilized by sector managers and new initiatives to expand ICT throughout the sector are uncoordinated. In addition, the introduction of new software for data collection by some programmes is creating parallel system of data collection within the health sector and over burdening staff at the district level.
Weak Human Resources for Health (HRH) management system: production of the human resource has not been matched with need. The HR planning process does not take into account the standard institutional requirements. This is compounded by the sectors inability to define and attract resources to meet the standards and norms for each level of care/operations. Chronic staffing imbalance due to attrition and inequitable distribution continue to plague the sector despite various efforts and initiatives to retain and deploy staff to the rural areas. The situation is further compounded by an aging workforce negatively affecting the uptake of services. The introduction of National Health Insurance (NHI) has brought with it challenges leading to increased workload and over reliance on casual staff. There also appear to be lack of coordination between needed HR and the management of the available HR. Despite increasing HR investment, poor staff attitudes and low productivity continue to persist with intermittent strike actions resulting in decline in utilization of service in health facilities.

What is Needed Now

A thorough analysis of the current state of the Ghanaian Health Sector will reveal that we have not managed the transition of the Health Sector Reforms well. A critical look at the chapters under the management of the reforms will reveal their porosity. For example the roles of the actors have not been well defined and structured leading to duplication of functions even at the national level. Though the confusion is palpable even from afar, there has not been a concerted effort to call the actors to order. This sorrowful state emanates from the fact that there is no committed body/organization that can look over the shoulders of the actors and identify issues for redress before degenerating into uncontrolled levels.
But for how long can we continue groping in this menace. We have come far from the days when only few could dictate the direction in health. We need bodies/organization to play the role of watchdog and raise flags when things take wrong turns. The referee/player approach we have over the years adopted does not auger well for the health of the nation.
What the nation needs in our present circumstance is a vibrant, independent, non-governmental organization or institution committed to facilitating improvement in the Ghana Health Sector. Such an organization must have the clout, ability and capacity to respond promptly, favourably and adequately to challenges and issues emanating from strategies and operations. The institute/organization must be made up of people with high integrity, adequate knowledge and rich experience that can match up to the task at all times. Such an institute will play a lead role in transforming the health sector from its current abyss by assisting in marshalling the potentials within the country, providing strong advocacy, assisting in analysis and formulating far reaching national health policies and vigorously pursuing fund raising strategies for funding key activities such as capacity building, research, knowledge management and dissemination of technical information. The institute, above all, will mediate over controversies and resolve health matters to the satisfaction of all actors in the health sector. The Health Institute of Ghana is to provide this.

Imperative for the Institute

The world is at the threshold of the deadline for achieving the Millennium Development Goals (MDGs). Ghana has made some modest gains to the achievement of the MDGs, in the health sector; the last lap to the deadline requires an acceleration of efforts. This requires the facilitation of the processes for stepping up:

development of individual leadership capacity in the health sector
ultimate accountability for both clients and practitioners
accelerating change from the top line towards the bottom
facilitating the acceleration process by focusing on the following:
continuously reviewing of performances of the health sector and priority interventions on the basis of their key results areas
shedding light on issues that require immediate action
strengthening the team spirit among various actors including civil society organizations on health issues, as against unnecessary hierarchies
clients/patients, stakeholders and health workforce acknowledge the critical role of the leadership of the health sector movement
an organization that must speak unequivocally about the interests of the health sector and for that matter the health needs of the citizenry
a watchdog or umpire role by:
Putting health and wellbeing on the front line
Helping the health sector to remain a priority in resource allocation
Facilitating the development of improved models of services in the sector
Supporting others to access more opportunities
Enhancing the value of critical thinking within the health sector
Facilitating professional accountability in the health sector