Access, Bottlenecks, Costs, and Equity (ABCE) Understanding the costs of and constraints to health service delivery in Ghana On behalf of the ABCE research team Institute for Health Metrics and Evaluation | Ghana Health Service | UNICEF January 2015

Overview Overview of the ABCE project in Ghana Key findings o Facility capacity and service provision o Efficiency and costs of care Using ABCE work and findings for policymaking Conclusions

Overview of the ABCE project in Ghana

Overview of the ABCE project in Ghana ABCE study design and implementation Collaboration between Ghana Health Service (GHS), UNICEF, and IHME Primary data collection took place June-October The ABCE Facility Survey was used to collect primary data from health facilities.

Overview of the ABCE project in Ghana ABCE Facility Survey Primary data collection from a nationally representative sample of 240 facilities Collected data on a broad range of indicators o Inputs, finances, outputs, supply- side constraints, and bottlenecks Randomly sampled a full range of facility types o Referral hospitals, district hospitals, maternity clinics, health centers, CHPS, drug stores or pharmacies, and DHMTs

Key findings from the ABCE project in Ghana Facility capacity and service provision

Facility capacity and service provision Human resources for health: overall trends The average number of facility personnel grew 69% across facilities in Ghana, from 49 in 2007 to 82 in The most dramatic growth was observed among public hospitals, followed by private clinics and maternity clinics. The average number of internally funded personnel at publicly owned facilities substantially increased between 2009 and 2011.

Facility capacity and service provision Average number of facility personnel, 2007–2011

Facility capacity and service provision Average number of internally funded personnel, 2007–2011

Facility capacity and service provision Human resources for health: facility composition Types of personnel working at facilities substantially varied by facility type, but non-medical staff generally accounted for the largest proportion of facility personnel. Growth in personnel types varied by platform from 2007 to 2011: o Regional referral hospitals: the number of nurses or midwives rose 24% o Public hospitals: non-medical personnel nearly doubled o Health centers: the average number of nurses or midwives increased 65%. o CHPS: on average, an additional nurse or midwife was added to each facility.

Facility capacity and service provision Average percent of personnel type, by platform, 2011

Facility capacity and service provision Average number and types of personnel, 2007–2011

Facility capacity and service provision Outputs, 2007–2011 Most facility types saw gradual growth in both outpatient and inpatient volumes between 2007 and o Private clinics were the exception, recording rapid growth in both outpatient and inpatient visits. These results somewhat contrast with previous reports of quickly escalating patient volumes across facility types o Past reports attribute such rapid rises to heightened affiliation with Ghana’s National Health Insurance Scheme (NHIS).

Facility capacity and service provision Outputs: average outpatient visits, by platform, 2007–2011

Facility capacity and service provision Outputs: average inpatient visits, by platform, 2007–2011

Facility capacity and service provision Drug procurement sources Facilities generally obtained pharmaceuticals from a mixture of private and public sources. o E.g., over 70% of hospitals used both public and private suppliers to procure pharmaceuticals. The majority of surveyed private clinics, maternity clinics, and pharmacies reported obtaining all drugs from only private sources. Health centers were the only facility type where at least 50% of facilities reported using only public sources for pharmaceutical procurement.

Facility capacity and service provision Average drug procurement source, 2011

Facility capacity and service provision Availability and stock-outs of antimalarials Most facilities stocked some kind of artemisinin-based combination therapy (ACT) and did not experience stock-outs during the previous quarter. o Some facilities still stocked chloroquine, despite policies calling for its discontinuation. Fansidar, the main drug for intermittent preventive therapy during pregnancy (IPTp), was also widely available for most facilities. o Compared to other facility types, CHPS and pharmacies generally had slightly lower availability of ACTs and Fansidar. Of the two types of ACTs stocked in Ghana, artemether- lumefantrine (AL, or Coartem) was generally more available than artesunate-amodiaquine (AS+AQ).

Facility capacity and service provision Availability of antimalarials for the previous quarter, 2012

Facility capacity and service provision Availability of ACTs for the previous quarter, 2012

Facility capacity and service provision Availability of ACTs and ACT stock-outs for the previous quarter, 2012

Facility capacity and service provision Capacity to test for and treat malaria Facility capacity varied for being able to both diagnose and treat malaria (i.e., have lab testing or rapid-diagnostic tests [RDTs] and stock ACTs). o 100% hospitals, 77% of private clinics, 53% of health centers, 23% of CHPS Availability of malaria testing was the primary constraint for most facility types, with 47% of health centers and 68% of CHPS lacking malaria diagnostic capacity. CHPS and pharmacies experienced a similar proportion of facilities that lacked both malaria diagnostic capacity and treatment (just under 10% of facilities).

Facility capacity for service provision Capacity to test for and treat malaria, 2012

Facility capacity and service provision Availability and stock-outs of antiretroviral drugs (ARVs) Of surveyed facilities, only regional referral hospitals and public hospitals carried ARVs. On average, regional referral hospitals had a higher availability of ARVs than public hospitals and experienced slightly lower levels of stock-outs. Tenofovir (TDF), nevirapine (NVP), and lamivudine (3TC) were generally more available at all hospitals, and experienced lower levels of stock-outs, than efavirenz (EFV) and zidovudine (AZT/ZDV). In terms of stocking all first-line ARVs, 60% of regional referral hospitals and 33% of public hospitals had all five.

Facility capacity and service provision Availability of ARVs for the previous quarter, 2012

Facility capacity and service provision ARV stock-outs for the previous quarter, 2012

Facility capacity and service provision Diagnostic capacity for a subset of infectious diseases Facility capacity to diagnose two infectious diseases that affect Ghana – malaria and HIV/AIDS – varied by facility type. 100% of hospitals had malaria testing capacity, and about 90% of hospitals had HIV/AIDS testing. Facilities generally had a higher availability of malaria testing than HIV tests; CHPS and maternity clinics were the exceptions. o 23% of CHPS had malaria tests; 29% had HIV testing o 50% of maternity clinics had malaria tests; 69% had HIV testing

Facility capacity and service provision Diagnostic capacity for a subset of infectious diseases

Facility capacity and service provision Laboratory testing capacity Laboratory-based diagnostic capacity varied across facility types but largely diverged by level of care (hospitals vs. primary care). All hospitals had lab capacity for malaria testing and urinalysis, and over 90% of hospitals had blood draw capacity. Primary care facilities had much lower levels of laboratory capacity, which generally reflects their infrastructure and organization. o Privately owned or specialized facilities had much higher availability of lab testing. Among maternity clinics, for example, 63% of facilities provided urinalysis, an important component of antenatal care.

Facility capacity and service provision Laboratory equipment availability for the previous quarter, 2012

Facility capacity and service provision Vaccine storage capacity and monitoring efficacy Of the facilities that routinely stored vaccines, only 64% of facilities had temperature-monitoring systems in place. Among facilities reporting routine vaccine storage, 25% stored vaccines out of the recommended temperature range (colder than 2° C or warmer than 8° C). The majority of facilities with a temperature-monitoring chart stored vaccines within the recommended range. o 90% of hospitals o 80% of CHPS o 25% of private clinics The majority of facilities that stored vaccines outside of the recommended temperature range did not have a monitoring chart.

Facility capacity for service provision Vaccine storage capacity and monitoring efficacy, 2012

Key findings from the ABCE project in Ghana Efficiency and costs of care

Efficiency and costs of care Estimating efficiency: Data Envelopment Analysis (DEA) DEA: quantifies the relationship between a facility’s resources (medical staff, beds) and its production of services (outpatient visits, inpatient bed-days, and births) relative to comparably sized facilities in the ABCE sample. Efficiency score: a value between 0% and 100%, reflecting the alignment of facility resources to service production. o 100% = maximum use of facility resources for output production Outpatient equivalent visits (OEV): weighting different outputs in a standardized way to allow for direct comparisons across facilities. o Average across facilities:  Inpatient bed-day = 3.8 outpatient visits  Birth = 10.9 outpatient visits

Efficiency and costs of care Average production of outputs across facilities Across platforms, facilities averaged a total of four outpatient equivalent visits per medical staff per day, ranging from 2.2 visits at CHPS to 6.8 visits at maternity clinics. Outpatient visits accounted for the largest proportion of patient visits experienced per medical staff per day at primary care facilities. Inpatient bed-days accounted for the largest proportion of patient visits produced per medical staff per day at regional referral hospitals and public hospitals.

Efficiency and costs of care Average production of outputs across facilities, 2011 Note: All visits are in outpatient equivalent visits, with an average of one inpatient bed-day equaling 3.8 outpatient visits; and one birth equaling 10.8 outpatient visits.

Efficiency and costs of care Efficiency scores varied across and within platforms Across all facilities, the average efficiency score was 27%. More than 80% of facilities had an efficiency score at or less than 50%. Average efficiency scores declined in parallel with decreasing levels of care. Private facilities averaged higher efficiency scores than public facilities at similar levels of care. Tremendous range in efficiency scores within platforms: o At least one facility had an efficiency score of 100% for nearly all platforms. o Multiple facilities had efficiency scores close to 0% for most facility types. Urban facilities generally had higher levels of efficiency than rural facilities, but this relationship was not as clear-cut at lower levels of care.

Efficiency and costs of care Efficiency scores across platforms, 2007–2011

Efficiency and costs of care Estimated potential for expanded service production We estimated that facilities had substantial potential for increasing output production, especially among lower levels of care. An average of 13 additional visits, measured in OEV, could be added across facilities, based on observed resources. This potential for expanded service production does not reflect the quality of services delivered; it shows the alignment of facility resources and output production.

Efficiency and costs of care Estimated potential for expanded service production, 2011

Efficiency and costs of care Cross-country comparison of efficiency Ghana showed more potential for expanded service provision, given observed resources, than other sub-Saharan African countries involved in the ABCE project.

Efficiency and costs of care Facility expenditures: overall trends Average facility expenditures grew 38%, largely driven by increases in service and personnel expenditures. Hospitals spent the most among facility types, and private clinics documented the strongest growth between 2007 and 2011.

Efficiency and costs of care Average annual facility expenditures, 2007–2011

Efficiency and costs of care Average annual expenditures, 2007–2011

Efficiency and costs of care Facility expenditures: spending composition Spending patterns by facility type were largely similar, with personnel expenses generally accounting for the bulk of spending at the facility level. Expenditure growth varied by platform from 2007 to 2011: o Regional referral hospitals: moderate increases, largely driven by service increases (a 41% rise) o Public hospitals: overall average expenditures increased 62% o Health centers: spending on services more than doubled o CHPS: average spending on personnel increased by 35%, but percent of total spending on personnel decreased over time

Efficiency and costs of care Average percent of expenditure type, 2011

Efficiency and costs of care Average levels and types of expenditures, 2007–2011

Efficiency and costs of care Facility revenues: overall trends Average facility expenditures grew 30% between 2007 and 2011, largely driven by expanded NHIS reimbursements and continued growth in government spending. Facility revenue growth generally kept pace with spending. Private clinics recorded the largest and most consistent increases in revenues from 2007 to 2011.

Efficiency and costs of care Average annual facility revenues, 2007–2011

Efficiency and costs of care Average annual revenues, 2007–2011

Efficiency and costs of care Facility revenues: funding composition Funding patterns by facility type widely varied, largely diverging along facility ownership (public vs. private). Most hospital revenues were composed of government funds and NHIS reimbursements, whereas publicly owned primary care facilities were largely funded by the government. Revenues at private clinics and maternity clinics were largely drawn from NHIS or cash and carry. Funding trends and composition varied by facility type, but across a subset of platforms, the overall revenue composition generally shifted with the expansion of NHIS funds and small declines in cash and carry.

Efficiency and costs of care Average percent of revenue source, 2011

Efficiency and costs of care Average levels and types of revenue sources, 2007–2011

Efficiency and costs of care Estimating costs of care Using information produced through DEA, output-specific spending by facilities was divided by outputs produced by each facility. All cost data were adjusted for inflation and reported in 2011 Ghanaian cedi. o All US dollar estimates were based on the 2011 exchange rate of 1.60 cedi per $1.

Efficiency and costs of care Average facility cost per visit, across outputs and by platform Facility costs per patient visit varied across platforms and by output type. Based on average facility costs, outpatient visits were generally the least expensive to produce, and births were the most expensive. Regional referral hospitals generally spent the most per patient visit produced, whereas maternity clinics generally produced patient visits at the lowest facility cost per output.

Efficiency and costs of care Average facility cost per visit, across outputs and by platform

Efficiency and costs of care Cross-country comparison of output costs Ghanaian facilities generally averaged higher production costs per visit than the other sub-Saharan African countries involved in the ABCE project.

Using ABCE work and findings for policymaking

Using ABCE for policymaking Identifying health system progress and challenges Provides policymakers with the evidence to pinpoint areas of success and for improvement as linked to national goals and priorities Enables direct comparisons across facility types and ownership, allowing policymakers to contrast facility capacity in the public sector with that of the private sector Supports the timely use of data to inform policy dialogue

Using ABCE for policymaking ABCE Ghana policy report

Conclusions

Conclusions Facility capacity for service provision Ghana recorded substantial growth in facility personnel, but composition of staff varied widely by facility type. Facilities generally had a high availability of ACTs for treating malaria, but the concurrent availability of malaria diagnostics was much lower, particularly among primary care facilities. Hospitals appeared to be the only type of facility that stocked ARVs for HIV treatment, but HIV testing was generally available across levels of care. The majority of facilities in Ghana procured pharmaceuticals from both public and private sources, which has implications for the country’s regulatory capacity. While 25% of facilities that routinely stored vaccines had storage temperatures outside of the recommended range, the presence of a monitoring chart was related to better storage practices. o 90% of facilities with monitoring charts had proper thermal conditions for vaccine storage.

Conclusions Facility production of health services Average patient volumes gradually increased across platforms, except for private clinics, which recorded rapid growth. Shortages in human resources and facility overcrowding have been viewed as problems in areas in Ghana; in the ABCE sample, most facilities averaged fewer than four visits per medical staff per day. Given observed facility resources, facility service production could potentially be increased by an additional 13 outpatient equivalent visits per day, on average, per medical staff.

Conclusions Facility costs of care Average facility spending increased over time, often driven by heightened spending on personnel. Growth in facility revenue generally kept pace with spending, with increased spending by the government and NHIS largely accounting for growth. o For a number of facility types, the percentage of facility revenues coming from cash and carry – or out-of-pocket expenditures – has declined. Average facility cost per patient visit differed substantially across platforms and types of visits. In comparison with a subset of other countries in the ABCE sample, average facility costs in Ghana were generally higher.

Conclusions Priority considerations for future work Updated analyses across indicators to assess progress and to identify areas that may require more investment Targeting a broader set of facilities to capture a clearer picture of levels and trends in facility performance Linking estimates of efficiency to quality of the services produced at facilities, as well as other factors. o e.g., expediency with which patients receive care, demand for increased services Generating estimates of cost-effectiveness based on facility delivery of services and costs of production, and linking to ongoing work on estimating trends in health outcomes and disease burden

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