PERFORMANCE OF HEALTH FACILITIES IN NHIS ACCREDITATION: AN ANALYSIS OF NHIS ACCREDITATION DATA JULY 2009-DECEMBER 2012 Preliminary Findings

PREAMBLE Presentation is part of a study into the performance of health facilities in the NHIS accreditation aimed at supporting weaker facilities and accreditation in Ghana Commissioned by IFC and supported by IFC, NHIA, GHS and SPMDP Key investigator Dr Nicholas A. Tweneboa supported by: o GHS: Mrs Susana Larbi Wumbee and Mrs Christiana Akufo o SPMDP: Dr Kwasi Odoi-Agyarko o NHIA: Mrs Vivian Addo-Cobbiah and Mrs Constance Addo Quaye Analysis of NHIS accreditation data and field work Data analysis by consultant and Mrs Addo-Cobbiah still in progress. Following are preliminary findings.

PRESENTATION OUTLINE INTRODUCTION ANALYSIS 1 Nationwide performance of all facilities Performance by region ANALYSIS 2 Performance by facility type ANALYSIS 3 Performance by ownership (1° hospitals, clinics /health centres, maternity homes) Note: Further analysis in progress

INTRODUCTION – ACCREDITATION PROCESS Facility applies Application vetted Facility inspected by trained accreditation surveyors Data analysed Accreditation decision made Communication of inspection result and accreditation decision Accreditation certificates issued (not done in most cases) Post accreditation monitoring (not systematic)

Introduction 2 – GRADING Grade A % overall score and pass in critical areas Grade A: 80-89% Grade B: 70-79% Grade C: 60-69% Grade D: 50-59% Grade E (Fail): Less than 50% Provisional: fail but provisional to create access

SET 1

ACCREDITATION DATA ANALYSIS – 1 PERFORMANCE NATIONWIDE AND BY REGION

NATIONWIDE PERFORMANCE OF ALL FACILITIES BY GRADE GRADENUMBERPERCENTAGE GRADE A+70.2% GRADE A942.5% GRADE B % GRADE C % GRADE D % PROVISIONAL451.2% FAIL1143.1% TOTAL %

NATIONWIDE PERFORMANCE OF ALL FACILITIES BY GRADE

PERFORMANCE NATIONWIDE 3,701 facilities were inspected between July 2009 and December 2012 The 3,701 includes 11 secondary hospitals of which 2 had A, 8 had B and 1 had C. Most of the facilities inspected (over 95%) passed and were accredited; 4.3% failed Majority of the facilities (73%) obtained Grade C or D 101 facilities (2.7%) obtained A+ or A

Performance nationwide – facilities (22.5%) obtained top three grades (A+, A, B) and 2,866 (77.4%) obtained lowest three grades (C, D, E or fail) Conclusion o The nationwide pass rate of facilities in the NHIS accreditation was high but the quality of the passes was not impressive

PERFORMANCE BY REGION (NUMBER, %) REGION GRADE A+ (No., %) GRADE A (No., %) GRADE B (No., %) GRADE C (No., %) GRADE D (No., %) FAILED (No., %) NUMBER INSPECTED ASHANTI BR. AHAFO CENTRAL EASTERN GR. ACCRA NORTHERN UPPER EAST UPPER WEST VOLTA WESTERN TOTAL

PERFORMANCE BY REGION (%)

PERFORMANCE BY REGION (BASED ON QUALITY OF PASS) GRADES A+, A & B (70% AND ABOVE) GRADES C, D & FAIL (BELOW 70%) REGION NUMBERPERCENTAGENUMBERPERCENTAGENUMBER INSPECTED ASHANTI BR. AHAFO CENTRAL EASTERN GR. ACCRA NORTHERN UPPER EAST UPPER WEST VOLTA WESTERN TOTAL

PERFORMANCE BY REGION (BASED ON QUALITY OF PASS)

PERFORMANCE BY REGION The region with the largest number of inspected facilities is Ashanti (617 or 16.7% of facilities inspected nationwide), followed by Eastern Region (456 or 12.3%) and Western Region (453 or 12.2%) By pass rate or failure rate alone, the best performing regions are Eastern (failure rate of 1.4%), Upper West (2.2%) and Upper East (2.8%) By pass rate or failure rate alone, the least performing regions are Brong Ahafo (7.9% failure rate) followed by Volta (6.2%) and Greater Accra (5.2%)

Performance by region – 2 Based on the quality of the passes, best performing regions are Central (36.6% of inspected facilities obtained A+, A or B), Upper East (34%) and Upper West (32.6%). Hence Upper East and Upper West performed well on both pass rate and quality of passes However, on quality of passes, Eastern dropped from 1 st to a distant 5 th (20.0%, falling below the national average of 22.6% inspected facilities obtaining A+, A or B)

Performance by region – 3 The three least performing regions were Volta (12% inspected facilities fell in the A+, A, B bracket), Brong Ahafo (13.2%) and Ashanti (14.7%) Conclusion: o The best performing regions were not ‘better endowed’ ones but ‘less endowed’ regions

GRADES BY REGION (PERCENTAGES) REGION GRADE A+ GRADE A GRADE B GRADE C GRADE D PASSED (ACCRED) FAILED ASHANTI BRONG AHAFO CENTRAL EASTERN GREATER ACCRA NORTHERN UPPER EAST UPPER WEST VOLTA WESTERN NATIONWIDE

PERCENTAGE PASS (ACCREDITED) BY REGION

FAILED FACILITIES BY REGION

PASSED (ACCREDITED) AND FAILED BY REGION

GRADE A+ BY REGION

GRADE A BY REGION

GRADE B BY REGION

GRADE C BY REGION

GRADE D BY REGION

SET 2

ACCREDITATION DATA ANALYSIS – 2 PERFORMANCE BY FACILITY TYPE

SUMMARY PERFORMANCE BY FACILITY TYPE A+ABCDFAILINSP. No% % % % % % PRIM HOSP CLINIC H. CENTRE MAT. HOME CHPS DIAG PHARM CHEM SELL TOTAL

SUMMARY PERFORMANCE BY FACILITY TYPE

PERFORMANCE BY FACILITY TYPE (BASED ON QUALITY OF PASSES) FACILITY TYPEA+, A, B (NUMBER, %) C, D, FAIL (NUMBER, %) NO. INSPECTED PRIMARY HOSPITAL CLINIC HEALTH CENTRE MATERNITY HOME CHPS DIAGNOSTIC PHARMACY CHEMICAL SELLER TOTAL

PERFORMANCE BY FACILITY TYPE (BASED ON QUALITY OF PASSES)

PERFORMANCE BY FACILITY TYPE Largest number inspected was CHPS (1,077 of 3,701 or 29.1% inspected); least number was diagnostic (213 or 5.8% of inspected facilities) By pass rate alone, the best performing facility type was CHPS (with pass rate of 98.7%), followed by primary hospitals (pass rate of 97.6%), health centres and maternity homes a joint third (96.5%) By pass rate alone, the least performing facility types were clinics (with failure rate of 11.8%, chemical sellers (10.6%) and pharmacy (6.6%)

Performance by facility type - 2 Adjusted for quality of passes, CHPS and primary hospital still lead (29.8% and 28.1% respectively inspected had Grade A+, A or B) However, diagnostic moves up from 5 th place to 3 rd (27.7%) and pharmacy (22.4%) moves up from 6 th to 4 th Maternity home (20.4%) and health centre (15.9%) move down from joint 3 rd to 5 th and 6 th respectively Clinic (15.9% obtaining A+, A or B) and chemical seller (11.0%) remain poorly performing

Performance by facility type – 3 Conclusions o Primary hospitals and CHPS performed well in accreditation o Clinics and health centres which are midway between CHPS and primary hospitals in the referral chain performed poorly o Chemical sellers as a group was the least performing facility type

GRADE A+ BY FACILITY TYPE

GRADE A BY FACILITY TYPE

GRADE B BY FACILITY TYPE

GRADE C BY FACILITY TYPE

GRADE D BY FACILITY TYPE

FAIL BY FACILITY TYPE

PRIMARY HOSPITALS GRADENUMBERPERCENTAGE GRADE A+00.0 GRADE A82.4 GRADE B GRADE C GRADE D FAIL82.4 TOTAL

PRIMARY HOSPITALS

CLINICS GRADENUMBERPERCENTAGE GRADE A+10.3 GRADE A20.6 GRADE B GRADE C GRADE D FAIL TOTAL

CLINICS

HEALTH CENTRES GRADENUMBERPERCENTAGE GRADE A+20.2 GRADE A192.2 GRADE B GRADE C GRADE D FAIL313.5 TOTAL

HEALTH CENTRES

CHPS COMPOUNDS GRADENUMBERPERCENTAGE GRADE A+00.0 GRADE A343.2 GRADE B GRADE C GRADE D FAIL141.3 TOTAL

CHPS COMPOUNDS

MATERNITY HOMES GRADENUMBERPERCENTAGE GRADE A+00.0 GRADE A62.7 GRADE B GRADE C GRADE D FAIL83.5 TOTAL

MATERNITY HOMES

DIAGNOSTIC CENTRES GRADENUMBERPERCENTAGE GRADE A+31.4 GRADE A125.6 GRADE B GRADE C GRADE D FAIL104.7 TOTAL

DIAGNOSTIC CENTRES

PHARMACIES GRADENUMBERPERCENTAGE GRADE A+10.3 GRADE A82.4 GRADE B GRADE C GRADE D FAIL195.6 TOTAL

PHARMACIES

CHEMICAL SHOPS GRADESTOTALPERCENTAGE GRADE A+00.0 GRADE A31.2 GRADE B259.8 GRADE C GRADE D FAIL TOTAL

CHEMICAL SHOPS

FAILURE RATE BY FACILITY TYPE FACILITY TYPETOTAL INSPECTEDFAILED PERCENTAGE FAILED PRIMARY HOSPITALS HEALTH CENTRES CLINICS MATERNITY HOMES CHPS COMPOUNDS PHARMACIES CHEMICAL SHOPS DIAGNOSTIC CENTRES

SET 3

ACCREDITATION DATA ANALYSIS – 3 COMPARATIVE ANALYSIS OF PERFORMANCE BY OWNERSHIP (primary hospitals, clinics/health centres, maternity homes)

PERFORMANCE OF PRIMARY HOSPITALS BY OWNERSHIP PUBLIC (NUMBER, %) PRIVATE (NUMBER, %) MISSION (NUMBER, %) QUASI-GOVT (NUMBER, %) GRADE A+00.0%0 0 0 GRADE A00.0%21.3%35.3%327.3% GRADE B3128.7%2616.5%2442.1%545.5% GRADE C5248.1%6440.5%2136.8%327.3% GRADE D2523.1%5836.7%915.8%00.0% FAIL00.0%85.1%00.0%0 TOTAL % % % %

PRIMARY HOSPITALS

PERFORMANCE OF PRIM. HOSP. BY OWNERSHIP (BASED ON QUALITY OF PASSES) PUBLIC (NUMBER, %) PRIVATE (NUMBER, %) MISSION (NUMBER, %) QUASI-GOVT (NUMBER, %) A+, A, B C,D, FAIL TOTAL

PERFORMANCE OF PRIM. HOSP. BY OWNERSHIP (BASED ON QUALITY OF PASSES)

PERFORMANCE OF PRIMARY HOSPITALS Largest number of primary hospitals inspected were privately owned (158 or 47.3% of all primary hospitals inspected) Other primary hospitals inspected: o Public (108 or 32.3%); o Mission (57 or 17.1%); o Quasi-government (11 or 3.3%) All primary hospitals inspected passed and were accredited except for private primary hospitals of which 8 (5.1%) failed

Performance of primary hospitals by ownership - 2 By either pass rate or quality of the passes, private primary hospitals performed least among the primary hospitals inspected, with pass rate of 94.9% compared to 100% for other ownerships By quality of passes private primary hospitals still performed least as 17.7% inspected obtained Grade A+, A or B as compared to mission (47.4%), public (28.7%) and quasi-govt. (72.7%, n=11)

Performance of primary hospitals by ownership - 3 Conclusion o Private primary hospitals performed least among the primary hospitals inspected, based on either pass or failure rate or the quality of the passes

PERFORMANCE OF CLINICS AND HEALTH CENTRES BY OWNERSHIP PUBLIC (NUMBER, %) PRIVATE (NUMBER, %) MISSION (NUMBER, %) QUASI (NUMBER, %) GRADE A+10.1%10.3%10.7%00.0% GRADE A141.9%20.6%53.6%00.0% GRADE B8812.0%4914.6%2920.7%531.3% GRADE C % %5842.1%637.5% GRADE D % %4029.3%425.0% FAIL243.3%4112.2%64.3%16.3% TOTAL % % % %

CLINICS AND HEALTH CENTRES

PERFORMANCE OF HEALTH CENTRES AND CLINICS BY OWNERSHIP (BASED ON QUALITY OF PASSES) PUBLIC (NUMBER, %) PRIVATE (NUMBER, %) MISSION (NUMBER, %) QUASI-GOVT (NUMBER, %) A+, A, B C,D, FAIL TOTAL

PERFORMANCE OF HEALTH CENTRES AND CLINICS BY OWNERSHIP (BASED ON QUALITY OF PASSES)

PERFORMANCE OF CLINICS AND HEALTH CENTRES BY OWNERSHIP Private clinics had the highest failure rate of 12.2% (41 out of 336 clinics failed) 6 of 139 (4.3%) of mission health centres failed compared to 24 of 735 public health centres (3.3%) Only 16 quasi-government health centres and clinics were inspected and 1 failed

Performance of health centres and clinics by ownership In respect of quality of the passes, CHAG health centres performed best, with 25.2% of inspected obtaining A+, A or B Public health centres and private clinics had similar quality of passes (14.0% and 15.5% respectively had Grade A+, A or B) Conclusion o Mission health centres performed better than private clinics and public health centres

PERFORMANCE OF MATERNITY HOMES BY OWNERSHIP PUBLIC (NUMBER, %) PRIVATE (NUMBER, %) MISSION (NUMBER, %) GRADE A+00.0%0 0 GRADE A00.0%62.7%00.0% GRADE B266.7%3716.8%133.3% GRADE C133.3%7433.6%133.3% GRADE D00.0%9543.2%133.3% FAIL00.0%83.6%00.0% TOTAL3100.0% %3

MATERNITY HOMES

PERFORMANCE OF MATERNITY HOMES (BASED ON QUALITY OF PASSES) PUBLIC (NUMBER, %) PRIVATE (NUMBER, %) MISSION (NUMBER, %) A+, A, B C,D, FAIL TOTAL

PERFORMANCE OF MATERNITY HOMES (BASED ON QUALITY OF PASSES)

PERFORMANCE OF MATERNITY HOMES BY OWNERSHIP 8 of 220 private maternity homes (equivalent to 3.6%) failed the accreditation ; 96.4% passed Just about one-fifth of private maternity homes had A+, A or B The number of public and mission maternity homes (3 each) is too small to make comparisons with private maternity homes Conclusion o Private maternity homes had a good pass rate but the quality of the passes was weak

OVERALL CONCLUSIONS Nationwide, the pass rate of inspected facilities was high but the quality of the passes was generally not impressive Facilities in relatively less endowed regions rather than relatively well endowed regions performed best in the accreditation Clinics and health centres which constitute the link between CHPS (community) and primary hospitals performed poorly. Chemical sellers also did poorly. Private facilities generally performed poorly

Thank you for your kind attention