achieving)the)mdgs.)lessons) learned) · level)of)care)) national regional district sub-district...
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ACHIEVING THE MDGs-‐ LESSONS LEARNED
Dr. Ebenezer Appiah-‐Denkyira DIRECTOR GENERAL
GHANA HEALTH SERVICE
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Contents -‐
• Short background • MDGs achievement – 1, 4, 5, 6 • Challenges • Lessons learnt • Way forward
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Map of Ghana
North: more deprived, with scaRered seRlement
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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).
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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
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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
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TRENDS MDG1, 4,5,6
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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
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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
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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
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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
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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
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Trend of supervised delivery by Regions 2006-‐2012
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Supervised (Skilled ARendant) Deliveries 2009 – 2013 half-‐years
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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
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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)
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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
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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
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• Mass exodus of ‘ brain drain’ was devastaSng.
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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
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…. there is a challenge of loosing the more experienced personnel as health workforce ages
22 Source: Antwi and Ekey, 2009;
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Ageing staff especially Midwives
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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
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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
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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
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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
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…..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
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DistribuSon had to be managed
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Trend in Doctor PopulaSon raSo -‐Ghana
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* 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.
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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)
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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
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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)
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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
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Infrastructure deficit
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General development required for universal access
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Nature of roads in district
Joseph Adomako; DDHS-‐Amansie West District
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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)
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• Thank you
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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
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• Partnership with InternaSonal Org. WHO – • Performance agreement with agencies • High ICT penetraSon – 23m • PPP
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Challenges cont. Poor Access to EmONC services
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Trend of Under five mortality rate by regions ( DHS and MICS Surveys 2003-‐2011)