Election 2024: Advancing primary health care: A path to strengthening Ghana’s health system

Healthcare has been a consistent subject in Ghana’s electoral politics since 1992 when the first election in the Fourth Republic was held. A conversation with either of the two political parties that have been given a mandate at different times to govern will indicate that they both feel they have done better. Sadly, a look at Ghana’s health outcomes compared with countries that had similar GDP per capita would indicate that our health system has underperformed over the last three decades.

Based on 2023 data from Knoema, Ghana’s life expectancy is 63.8 years and has a population structure where 5.9% of the population is over 60 years and 3.6% are above 65 years. This means that 39% of all Ghanaians who retire at the mandatory age pass away before their 65^th birthday.

As Ghana approaches the 2024 election year, there is a pressing need to reevaluate and revamp the nation’s health system as a means of addressing our poor health outcomes. To achieve this there will be a need to reorient the health-seeking behaviours of citizens, identify the bottlenecks that drive poor health-seeking behaviour and realign health delivery to be more proactive and less reactionary.

Central to this effort must be an emphasis on primary healthcare and true decentralization of healthcare delivery. This article explores the significance of prioritizing primary care, improving health-seeking behaviours, and decentralizing care to achieve the goal of significantly increasing Ghana’s outpatient per capita from the current 1.2 to about 4 within the next 5-7 years.

The Importance of Primary Health Care and Decentralization:

Primary health care serves as the foundation of a well-functioning health system, providing essential services such as preventive care, health promotion, and early detection of diseases. A functioning primary healthcare system would keep citizens healthier for longer and decrease the pressure of secondary and tertiary care, thereby driving down the overall healthcare cost.

Decentralization of healthcare delivery is equally crucial in ensuring equitable access to healthcare services across urban and rural areas. Health outcomes are heavily dependent on sociocultural settings, meaning the closer to home a patient is kept, the better their prognosis following an initial diagnosis. A decentralized health system could thus benefit from the creation of community health groups that could help improve local health by enhancing patient understanding of their disease states.

A look at the Ghana Harmonized Health Facilities Assessment published in 2023, points to huge disparities in the availability of basic equipment at the primary care level. A quote from the document reads, “Overall, only 5% of facilities had the full complement of basic consulting room examination set and physiological measurement and anthropometric equipment.” A further read points to the fact that CHIPS compounds and other rural health facilities were the least endowed when it came to resources.

This suggests that by empowering local communities and strengthening primary care facilities, Ghana can address the disparities in healthcare access and better serve the needs of its diverse population. The advantage of such an approach will mean that many midlevel health workers could be upskilled to provide vital care locally.

Improving Health-Seeking Behaviours:

Improving health-seeking behaviours is integral to achieving the desired increase in outpatient per capita. Education and awareness campaigns can play a significant role in promoting preventive healthcare practices, encouraging regular health check-ups, and fostering a culture of proactive health management among citizens. It would be helpful if healthcare could be taken to the doorstep of citizens in marketplaces and other areas of mass gatherings so that routine screening for chronic diseases could be undertaken.

It is not enough for such outreaches to be done at cultural festivals or by religious institutions on an ad-hoc basis. There is a need for a structured approach that allows for patient follow-ups to ensure those identified as having an undiagnosed chronic disease can be followed up and monitored.  By empowering individuals to take charge of their health and seek care proactively, Ghana can reduce the burden of preventable diseases and improve overall health outcomes.

Examples of Successful Health System Reforms:

Several countries have successfully reformed their health systems by prioritizing preventative healthcare and primary care. For example, Finland implemented comprehensive primary healthcare reforms in the 1970s, leading to improved health outcomes and reduced healthcare costs. According to data from the World Health Organization (WHO), Finland’s life expectancy increased from 68.9 years in 1970 to 81.7 years in 2020, while healthcare expenditures as a percentage of GDP remained stable at around 9% during the same period.

Similarly, Thailand’s universal health coverage scheme, which emphasizes primary care and preventive services, has resulted in significant improvements in life expectancy and overall population health. According to the WHO, Thailand’s life expectancy increased from 61.4 years in 1970 to 77.3 years in 2020, while healthcare expenditures as a percentage of GDP remained below 5% during the same period.

In 1965 Ghana had a life expectancy at birth of 47.8 years whilst Indonesia had 42.6 years. Currently, Indonesia has a life expectancy of 67.8 years having surpassed Ghana in 1967. This was achieved by undertaking health reforms that prioritised primary health although health expenditure as a percentage of GDP has been between 1.85% and 3.41%. With a health expenditure as a share of GDP of 4% and little fiscal space, Ghana could with proper planning and avoidance of waste improve its health outcomes without having to significantly increase its health spend.

The Impact on Healthcare Costs and Life Expectancy:

Prioritizing preventative healthcare and primary care can have a profound impact on healthcare costs and life expectancy. By investing in early intervention and disease prevention, countries can reduce the burden of chronic diseases and costly hospitalizations. According to a study published in The Lancet in June 2023, every dollar invested in primary healthcare can yield a return of up to $10 in economic productivity and reduced healthcare costs over time.

Furthermore, countries with strong primary healthcare systems tend to have higher life expectancies and better health outcomes. According to data from the WHO, countries with higher levels of primary healthcare coverage have lower mortality rates from preventable causes and higher life expectancies compared to those with weaker primary healthcare systems.

The Correlation between a Healthy Population and Development Outcomes:

A healthy population is a cornerstone of sustainable development, contributing to economic growth, social stability, and human capital development. The World Bank indicates that investing in healthcare and improving population health can lead to higher productivity, reduced poverty, and improved overall development outcomes.

For instance, another study published in The Lancet in December 2021 found that improvements in health outcomes, such as reduced child mortality and increased life expectancy, are associated with higher levels of economic growth and development. By prioritizing primary healthcare and preventive measures, Ghana can lay the foundation for achieving its development goals and improving the well-being of its citizens.

Expectations for the Health Conversation in Election 2024:

We are aware that political parties are working on their manifestos for the upcoming elections. We expect that these views will find their way into their approach to tackling Ghana’s health system challenges. We expect that they show an understanding of the problems in the sector and demonstrate how their policy choices will help address them.

As voters, we must have clear expectations for the future of the health system. These expectations must align with a proper diagnosis of the problems in the space. Some major expectations that must be highlighted include:

1. Improved Access: We expect those seeking executive public office to demonstrate their approach to increasing accessibility to primary health care services, particularly in underserved rural areas and urban slums.
2. Quality Care: Voters must demand a commitment to higher standards of care, including proper regulation of health facilities, adherence to the patient charter, the availability of essential medicines and retention of trained healthcare professionals.
3. Preventative Measures: Voters expect the government to prioritize preventative healthcare initiatives, including immunizations, health education, and screenings for early detection of diseases. Manifestos must not just mention this but indicate how this can be achieved.
4. Decentralized Care: There is a need for a commitment to providing the enablers for decentralized care based on the gaps identified in the Ghana Harmonized Health Facilities Assessment that brings health services closer to communities whilst empowering individuals to take charge of their health.
5. Accountability and Transparency: Lastly, there must be a commitment to transparency in the management of healthcare resources and accountability for the delivery of quality care. Candidates must show commitment to the appointment of healthcare leaders based on competency and merit. The era where party loyalty is the driving criterion must not be countenanced.
6. Health Financing: The viability of the National Health Insurance Scheme (NHIS) is critical to the achievement of a viable and functional proactive health system. Without adequate fund flow health providers would be unable to function optimally. Political parties must commit to complying with the National Health Insurance Act. There must be an undertaken that funds collected in the name of the scheme would be ringfenced and paid directly into the National Health Insurance Fund and not the consolidated fund. Also, all parties must commit to removing the cap imposed on the NHIS funds by the current government. Politicians must understand that a major contributor to Ghana’s poor health-seeking behaviour is the absence of funds among citizens.

Citizens must expect that those seeking public office demonstrate a commitment to finding sustainable funding streams for patients on high-cost chronic care such as dialysis and chemotherapy as is unrealistic for the state to expect patients to fund these out of pocket. The era where these are seen as sources of  Internal Generated Funds is cruel and must be done away with.

Conclusion:

Building the health system that Ghana wants requires a holistic approach that prioritizes primary health care, improves health-seeking behaviours, and decentralizes care to reach all segments of the population. It will also require a multisectoral approach where public and mental health becomes a priority in all organisations.  A careful look at the Ghana Harmonized Health Facilities Assessment will reveal that any politician who comes promising major health infrastructural projects would at best be selling snake oil or at worst misdiagnosing the problems in our health sector. To start with there is no fiscal space in the health budget to accommodate any new projects. Listening to the President in his State of the Nation Address (SONA), the real GDP growth rate for the first three quarters of 2023 was 2.8%. With a population growth rate of 2.1%, it is unlikely that our economy is going to expand significantly in the next four years for health expenditure as a percentage of GDP to increase leading to a fiscal space improvement.

Also, there are too many projects started by governments that must be completed with the resources available. A better approach would be for any incoming government to undertake an inventory of all incompleted health projects detailing their stage of completion based on this have a road map to finish them off. Finally, even if the current stock of health infrastructural projects were to be completed, the country would lack adequate health human resources to make them all functional.

We must also be mindful that Ghana has undertaken to achieve Universal Health Coverage (UHC) by 2030 in line with Sustainable Development Goal 3 (Good Health and Wellbeing). This means Ghana undertakes that by 2030, all citizens will have access to the full range of quality health services they need, when and where they need them, without financial hardship. Whichever government we put in place at the next election will be largely responsible for ensuring that this happens rather than become another missed opportunity.

As citizens, we must be prepared to exercise our voting franchise in a manner that guarantees us access to good affordable healthcare. Politicians must also know that should they renege on their commitment, we would be prepared to punish them at the next election. We hold the view that by learning from the experiences of other countries and emphasizing preventative measures, Ghana can significantly improve its outpatient per capita, healthcare outcomes, and overall population health within the next 5-7 years. This is the advocacy we must drive to ensure we have a health system that meets the voter’s expectations and contributes to the nation’s development goals.