Upper East, a relatively poor and rural region in Ghana’s north, has transformed its provision of maternal and child health care. In 2008, it had one of the lowest levels of basic maternal and child health service coverage in the country – yet by 2014, it had the best coverage of all regions in the country. The proportion of deliveries with a skilled birth attendant in the region was 70%, compared to the national average of 55%.
What happened? And what can be learnt from this example of rapid progress?
During this period, Dr Koku Awoonor-Williams was Regional Health Director for Upper East. He oversaw a range of initiatives to improve the use of disaggregated data in planning and service delivery; to recruit, train and retain significantly more health workers; and to mobilise additional funding from the government and donors. Dr Awoonor-Williams is now the Director of Policy, Planning, Monitoring and Evaluation (PPME) at the headquarters of the Ghana Health Service.
In March, I travelled to Accra, and met with Dr Awoonor-Williams. We discussed the lessons that can be learned from the case of ‘positive deviance’ in Upper East, as well as key challenges in making progress towards universal health coverage in Ghana.
‘Positive deviance’ involves exploring what works, and why. We used this approach as part of our five-year research project, Development Progress, that worked to measure, understand and communicate where and how progress happened.
The majority of problems in our health sector stem from challenges with the distribution of human resources. There is a disconnect in Ghana between policy and implementation. The rules are already in place, but they are not being applied. Staff are frustrated, but it is not that they want more money. They want resources to deliver services, to train and develop their careers, to be able to do their jobs well and be appreciated for that.
It starts with leadership: somebody who says, ‘the buck stops with me’; somebody who will take responsibility. When I started my reforms, I faced a backlash and was castigated. It got to the point where staff didn’t want to come to the Upper East. But I was firm, and the results showed.
How do you systematise good leadership? That is a difficult question. You need to develop and legitimise a common agenda across the sector, to create shared norms and embed them in the system, not only rely on an individual. For example, during my tenure in the Upper East, I tried to create leaders within the system across the districts. In my current role at central Ghana Health Service, I do peer mentoring with regional health directors.
The second thing is that you have to let people develop and own solutions themselves. When I started in Upper East, we mapped the distribution of nurses. Almost all of them were in the region’s two towns, Bolgatanga and Navrongo, and virtually none were in in the rural areas. We held a maternal health conference and called all the nurses to attend. When I showed them the results of the mapping, around 10% of the nurses themselves volunteered to move to rural posts. I allowed the remaining nurses to stay at their urban posts, but placed a ban on any new posting of nurses to those areas. I also required that 70% of admissions to the Upper East health training school were from the northern regions, because local people are more likely to want to stay in the area. This significantly reduced the pressure of nurses leaving their posts. Midwives were in particularly short supply. I asked every district to sponsor five nurses to be trained as midwives. Within three years, we had so many midwives that we were posting them to community health posts (CHPS compounds), and the rate of skilled deliveries in the region almost doubled.
The third factor was transparency and consultation. I made a point of visiting staff in remote communities and listening to their challenges. This helped them feel appreciated and that leaders were making efforts to address their problems. We instituted a clear career development plan for every single health worker, so that each nurse knew exactly when he or she would be authorised to go for further studies in the future, and would have something to work towards. Nothing was kept in secrecy. If you keep these things a secret, staff become demotivated – they think they are being kept back, while others are moving on.
Ghana’s middle-income status has brought many challenges. Many of the key bilateral partners have been withdrawing from the health sector, and Ghana is also transitioning from support from the Global Fund and Gavi, the Vaccine Alliance. The onus falls on us as a country. The Government of Ghana must holistically assess the health sector from top to bottom: what are the short-term needs and the long-term needs? How can these be financed?
We hear about ‘Ghana without aid’, but the Government is still borrowing because internal resources are not enough, and there are challenges and shocks. So what are the alternatives to mobilise resources for the health sector, and to use them judiciously and accountably? We need to look at what our development partners have been funding, and decide how to sustain this. The first shock we had was the introduction ofcounterpart funding for vaccines under Gavi. This hit us very hard. Over the years, Gavi has paid for the majority of our vaccines. It seems as though we have not adequately prepared for donor withdrawal. All of a sudden, the health sector is realising how important the Ministry of Finance is, but of course it was important all along.
Donors should take responsibility as well. They should stay engaged and support this strategic planning, including with technical assistance. Donors should not all pull out at the same time – but in reality, that is probably going to happen.
It is true that health coverage in Ghana has stagnated and even deteriorated recently. Much of this concerns the way the health system is financed. We need to refocus on the basics. In the beginning, we made a lot of progress. Ghana created a very strong primary health care system and mobilised communities with health promotion activities. But subsequently, we tried to do too many things. The National Health Insurance Scheme (NHIS) covers a very broad package of benefits, which its income stream [mostly from a VAT levy and public sector social security contributions] cannot sustain. Reimbursements to health facilities under the NHIS are made for clinical treatment, not public and preventive health care. This incentivises health workers to focus on clinical services, so that they can recoup resources to run the facilities. Patients now look down on Community-based Health and Planning Services (CHPS). If they have a health insurance card, they want to see a doctor at a hospital, not a community nurse.
We are currently planning a major reform, for which we have costed public and primary health services in each region, and will capitate funding for these, so they will be completely free for patients at the point of delivery. Half of this capitation funding will be paid by the National Health Insurance Authority and half will come from the World Bank-funded Maternal and Child Health and Nutrition Improvement Project. With a system that ensures geographical access to services and a national health insurance scheme that guarantees financial access, Ghana can no doubt quickly achieve universal health care at the primary care level – this is doable.
We need a national discussion about how we finance health care, which transcends party politics. As I earlier indicated, the fact that Ghana has the NHIS is very important – we should not try to create an additional architecture but use the NHIS as a mechanism to bring about reform of the public health system. I am determined that during my tenure at the Ghana Health Service at the policy level, we move towards universal primary health coverage.