Ghana Private sector assessment

1. Mr. Marty Makinen, Results for Development Ghana Private sector assessment

2. Organization of presentation • Objectives and Approach of Assessment • Supply Findings • Demand Findings • Other Important Factors Affecting the Health Market • Successes and Failures

3. Organization of presentation • Objectives and Approach of Assessment • Supply Findings • Demand Findings • Other Important Factors Affecting the Health Market • Successes and Failures

4. Assessment’s overall objectives • Depict the role played by private actors in the health sector in Ghana and identify factors that created and sustain this role • Provide information to inform decision making concerning how to enhance the private role • Facilitate productive engagement between public and private sectors

5. Engagement: Held workshops to guide research and formulate recommendations • Launch workshop (July 2009) • Validation and discussion workshop (Dec 2009) • Decision workshop (March 2010)

6. Research: Conducted data collection and analysis • Additional analysis of existing data: DHSs and GLSSs • Mapping of 7 districts: 5 urban and 2 rural, 730 actors • Patient exit interviews: >1,200 patients • Community focus group discussions • In-depth interviews of private actors • Interviews of policy makers, regulators, private association leaders • Case studies

7. Organization of presentation • Objectives and Approach of Assessment • Supply Findings • Demand Findings • Other Important Factors Affecting the Health Market • Successes and Failures

8. Size and geographical distribution • Self-financing private (SFP) providers major suppliers of all forms of care, except hospital care • Even for hospital care, SFP providers represent 20% of beds in the five urban districts studied • SFP and government providers concentrated in urban areas; CHAG and chemical sellers concentrated in rural areas • Chemical sellers represent the greatest and most accessible source of services in rural and urban-poor areas

9. Sources of funds for private providers • For capital expenditures: • Savings or profits are the key source for all private providers • Bank loans only substantially used by private hospitals • For operations: • Patient payment and NHIS are major sources for government and private hospitals and clinics • Government facilities are more likely to report that they accept insurance reimbursement than private • Biggest problem: • Access to financing reported as the biggest obstacle to growth for private providers

10. 48% major/very severe Access to financing as major obstacle to private growth

11. Organization of presentation • Objectives and Approach of Assessment • Supply Findings • Demand Findings • Other Important Factors Affecting the Health Market • Successes and Failures

12. Major demand findings • Access to services improved dramatically in past several years • Private sector important source of care • NHIS seems to encourage consumers to choose GHS providers (but unequal accreditation might be a factor) • NHIS coverage becoming more equal geographically • Nearness, customer service, medicine and lab availability, and NHIS acceptance factors attracting consumers to private providers

13. Access to care from any source when ill is rising

14. Access to care from any source when ill is rising Perceived need for care dropped

15. Access to care from any source when ill is rising Use of care when needed way up

16. Access to care from any source when ill is rising Annual contacts per capita up from 3.19 to 3.33 – even with fewer perceived medical problems

17. Private sector important source of care and rising slightly

18. Private sector important source of care and rising slightly Combined use of non- profit and self-financing private rose from 52 to 55% of total use

19. NHIS coverage leads consumers to use public providers a bit more (GLSS 5)

20. NHIS coverage leads consumers to use public providers a bit more (GLSS 5) Not covered used private 57% of the time Covered used private 45% of the time

21. NHIS coverage leads consumers to use public providers a bit more (GLSS 5) Not covered used private 57% of the time Covered used private 45% of the time Remember that accreditation had not reached most self-financing privates, however

22. Between 2006 and 2008, NHIS coverage increased across all regions

23. Between 2006 and 2008, NHIS coverage increased across all regions For example, Upper West went from 5% to 45% of its population covered by NHIS

24. Medicines and lab tests draw consumers to private providers (exit poll)

25. Medicines and lab tests draw consumers to private providers (exit poll) 48% of users of SFP cited medicines as reason for use

26. Medicines and lab tests draw consumers to private providers (exit poll) 17-18% of reasons for using SFP and CHAG was lab tests

27. Accepting insurance and nearness major factors in choice of provider (exit poll)

28. Accepting insurance and nearness major factors in choice of provider (exit poll) Accepts NHIS Nearest to my home

29. Focus group results • Women frequent users for themselves and others (use private more) • Men less frequent users and wait until condition is serious (use GHS more) • Self-treatment for minor ailments, herbalists used for specific conditions • NHIS improves access • Customer service (advantage private) and comprehensiveness (advantage GHS) biggest factors in choice • Price not a major factor • Higher income more likely to use private—but all groups make some use

30. Organization of presentation • Objectives and Approach of Assessment • Supply Findings • Demand Findings • Other Important Factors Affecting the Health Market • Successes and Failures

31. Other important factors affecting the health market • Health Insurance • SFP providers complain of slow and low NHIS payments, but see NHIS’s potential to be advantageous to them • Pharmaceutical Supply Chain • Private actors play a dynamic and important role in filling gaps and inefficiencies in public supply chain • The pharmaceutical supply chain is highly fragmented and seems to be overly vertically integrated • Health Business Environment • SFP providers report greatest constraint is lack of access to financing; small to medium sized SFP providers rarely use bank loans and even more rarely benefit from equity investments

32. Other important factors affecting the health market • Regulatory Environment • SFP providers report few constraints from regulation and taxation, although some frustrations with under regulation are noted • Policy Environment • Ghana’s policy environment toward private sector favorable but implementation of policies, along with a lack of resources, results in a disconnect between policy and practice • Quality • Structural quality overall is good across public and private facilities; no clear advantage for government over private or vice versa

33. Organization of presentation • Objectives and Approach of Assessment • Supply Findings • Demand Findings • Other Important Factors Affecting the Health Market • Successes and Failures

34. Successes • The public-private partnership with CHAG works well and makes CHAG an extension of the GHS in underserved rural areas • The overall policy environment in Ghana is business and private-sector friendly • There has been a specific Private Health Sector Policy since 2003 and many of the identified issues and proposed strategies are still relevant in 2010 • Private providers respond to consumers with shorter waits, better drug availability, and courteous reception; but not with lower prices

35. Failures • Urban populations are much better served than rural populations by both SFP and government providers; the combination means that access is very unequal • Despite the identification of policy issues in 2003, the bulk of the agenda for action remains unimplemented • With the exception of the CHAG relationship, the private sector feels left out of the mainstream of MOH and GHS thinking and action • The regulatory councils and boards have insufficient resources to conduct on-going supervision and monitoring of private actors

36. Failures • The NHIA has uncovered important instances of fraud in claims for payment by both private and government providers • There is limited private pre-service training of health workers, and there are no private medical schools • Private sector health managers lack business and financial management skills that hinder success • Small to medium sized private health providers make little use of bank loans and almost no use of equity to finance investments

37. Conclusions • Use of privately provided services more than half of total • SFP much more important than non-profits • Private role in provision likely to grow with completion of accreditation and increased eligibility for NHIS • Public regulation hindered by lack of resources • It has been a missed opportunity to shape the private role by excluding and ignoring SFP from active interaction on national health policy

38. Thank you

39. Extra Slides

40. Services and human resources • Service offering in hospitals: • CHAG hospitals offer a broader range of services than government hospitals in rural areas • Both public and SFP hospitals offer a broad range of services in urban areas • Human resources: • CHAG hospitals have more HR per hospital bed and lower doctor to nurse ratio than government hospitals in rural areas • Urban hospitals have more HR per bed than rural for all forms of ownership, but particularly for government hospitals

41. Staffing of rural hospitals

42. The staff to bed ratio is higher for urban (0.89) compared to rural (0.43) hospitals (brown arrow) • Ratio dramatically higher for GHS hospitals (1.10 urban, 0.41 rural) (blue arrow) Staffing of urban hospitals

43. ASSESSMENT ANALYTICAL FRAMEWORK Health Sector Goal Better Health and Reduced Inequality Strategic Objective 4 (5Yr POW lll) Good Governance and Partnership Objectives of Assessment Depict current private sector role and influencing factors Diagnose nature/effectiveness of private-public interface Engage stakeholders over (1) issues then (2) evidence-based solutions

44. Scope of research on the private health sector

45. Chemical shops appear to represent the greatest and most accessible source of services in rural and urban-poor areas

46. Market Successes and Failures Market Successes • Private supply of services offers many choices to urban populations • Chemical sellers give rural dwellers important access to drugs • Private providers respond to consumers with shorter waits, better drug availability, and courteous reception; but not with lower prices Market Failures • Urban populations are much better served than rural populations by both SFP and GHS providers • Lack of business and financial skills and relatively high interest rates, short repayment periods, substantial collateral requirements restrict the use of bank loans for investment to expand all private providers • The pharmaceutical supply system is highly fragmented and seems to be overly vertically integrated