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

2. 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.

3. 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

4. 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)

5. Introduction 2 – GRADING Grade A+ 90-100% 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

6. SET 1

7. ACCREDITATION DATA ANALYSIS – 1 PERFORMANCE NATIONWIDE AND BY REGION

8. NATIONWIDE PERFORMANCE OF ALL FACILITIES BY GRADE GRADENUMBERPERCENTAGE GRADE A+70.2% GRADE A942.5% GRADE B73419.8% GRADE C156242.2% GRADE D114530.9% PROVISIONAL451.2% FAIL1143.1% TOTAL3701100.0%

9. NATIONWIDE PERFORMANCE OF ALL FACILITIES BY GRADE

10. 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

11. Performance nationwide – 2 835 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

12. PERFORMANCE BY REGION (NUMBER, %) REGION GRADE A+ (No., %) GRADE A (No., %) GRADE B (No., %) GRADE C (No., %) GRADE D (No., %) FAILED (No., %) NUMBER INSPECTED ASHANTI00.0101.68113.121234.428446.0304.9617 BR. AHAFO00.020.54712.714037.715341.2297.9371 CENTRAL00.0134.010732.613240.26118.6154.6328 EASTERN00.0112.48017.524553.711425.061.4456 GR. ACCRA10.2133.011827.017941.010323.6235.2437 NORTHERN10.3216.17421.515043.68725.3113.2344 UPPER EAST21.052.46430.69846.93416.362.8209 UPPER WEST10.684.54927.57642.74022.542.2178 VOLTA00.020.63511.411738.013543.8196.2308 WESTERN20.492.07917.421347.013429.6163.6453 TOTAL7 0.2942.5 734 19.81562 42.21145 30.9159 4.33701

13. PERFORMANCE BY REGION (%)

14. PERFORMANCE BY REGION (BASED ON QUALITY OF PASS) GRADES A+, A & B (70% AND ABOVE) GRADES C, D & FAIL (BELOW 70%) REGION NUMBERPERCENTAGENUMBERPERCENTAGENUMBER INSPECTED ASHANTI9114.752685.3617 BR. AHAFO4913.232286.8371 CENTRAL12036.620863.4328 EASTERN9120.036580.0456 GR. ACCRA13230.230569.8437 NORTHERN9627.924872.1344 UPPER EAST7134.013866.0209 UPPER WEST5832.612067.4178 VOLTA3712.027188.0308 WESTERN9019.936380.2453 TOTAL835 22.62866 77.43701

15. PERFORMANCE BY REGION (BASED ON QUALITY OF PASS)

16. 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%)

17. 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)

18. 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

19. GRADES BY REGION (PERCENTAGES) REGION GRADE A+ GRADE A GRADE B GRADE C GRADE D PASSED (ACCRED) FAILED ASHANTI0.01.613.134.446.095.14.9 BRONG AHAFO0.00.512.737.741.292.17.9 CENTRAL0.04.032.640.218.695.44.6 EASTERN0.02.417.553.725.098.61.4 GREATER ACCRA0.23.027.041.023.694.85.2 NORTHERN0.36.121.543.625.396.83.2 UPPER EAST1.02.430.646.916.397.22.8 UPPER WEST0.64.527.542.722.597.82.2 VOLTA0.00.611.438.043.893.86.2 WESTERN0.42.017.447.029.696.43.6 NATIONWIDE0.22.519.842.230.995.74.3

20. PERCENTAGE PASS (ACCREDITED) BY REGION

21. FAILED FACILITIES BY REGION

22. PASSED (ACCREDITED) AND FAILED BY REGION

23. GRADE A+ BY REGION

24. GRADE A BY REGION

25. GRADE B BY REGION

26. GRADE C BY REGION

27. GRADE D BY REGION

28. SET 2

29. ACCREDITATION DATA ANALYSIS – 2 PERFORMANCE BY FACILITY TYPE

30. SUMMARY PERFORMANCE BY FACILITY TYPE A+ABCDFAILINSP. No% % % % % % PRIM HOSP00.082.48625.714041.99227.582.4334 CLINIC10.320.65215.012235.212937.24111.8347 H. CENTRE20.2192.211913.539044.232136.4313.5882 MAT. HOME00.062.74017.77633.69642.583.5226 CHPS00.0343.228726.652248.522020.4141.31077 DIAG.31.4125.64420.78138.0639.6104.7213 PHARM10.382.46719.714241.810330.3196.6340 CHEM SELL.00.031.3259.87931.112047.22710.6254 TOTAL70.2942.573419.8156242.2114530.91594.33701

31. SUMMARY PERFORMANCE BY FACILITY TYPE

32. PERFORMANCE BY FACILITY TYPE (BASED ON QUALITY OF PASSES) FACILITY TYPEA+, A, B (NUMBER, %) C, D, FAIL (NUMBER, %) NO. INSPECTED PRIMARY HOSPITAL9428.124071.9334 CLINIC5515.929284.1347 HEALTH CENTRE14015.974284.1882 MATERNITY HOME4620.418079.6226 CHPS32129.875670.21077 DIAGNOSTIC5927.715472.3213 PHARMACY7622.426477.6340 CHEMICAL SELLER2811.022689.0254 TOTAL83522.6286677.43701

33. PERFORMANCE BY FACILITY TYPE (BASED ON QUALITY OF PASSES)

34. 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%)

35. 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

36. 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

37. GRADE A+ BY FACILITY TYPE

38. GRADE A BY FACILITY TYPE

39. GRADE B BY FACILITY TYPE

40. GRADE C BY FACILITY TYPE

41. GRADE D BY FACILITY TYPE

42. FAIL BY FACILITY TYPE

43. PRIMARY HOSPITALS GRADENUMBERPERCENTAGE GRADE A+00.0 GRADE A82.4 GRADE B8625.7 GRADE C14041.9 GRADE D9227.5 FAIL82.4 TOTAL334100.0

44. PRIMARY HOSPITALS

45. CLINICS GRADENUMBERPERCENTAGE GRADE A+10.3 GRADE A20.6 GRADE B5215.0 GRADE C12235.2 GRADE D12937.2 FAIL4111.8 TOTAL347100.0

46. CLINICS

47. HEALTH CENTRES GRADENUMBERPERCENTAGE GRADE A+20.2 GRADE A192.2 GRADE B11913.5 GRADE C39044.2 GRADE D32136.4 FAIL313.5 TOTAL882100.0

48. HEALTH CENTRES

49. CHPS COMPOUNDS GRADENUMBERPERCENTAGE GRADE A+00.0 GRADE A343.2 GRADE B28726.6 GRADE C52248.5 GRADE D22020.4 FAIL141.3 TOTAL1077100.0

50. CHPS COMPOUNDS

51. MATERNITY HOMES GRADENUMBERPERCENTAGE GRADE A+00.0 GRADE A62.7 GRADE B4017.7 GRADE C7633.6 GRADE D9642.5 FAIL83.5 TOTAL226100.0

52. MATERNITY HOMES

53. DIAGNOSTIC CENTRES GRADENUMBERPERCENTAGE GRADE A+31.4 GRADE A125.6 GRADE B4420.7 GRADE C8138.0 GRADE D6329.6 FAIL104.7 TOTAL213100.0

54. DIAGNOSTIC CENTRES

55. PHARMACIES GRADENUMBERPERCENTAGE GRADE A+10.3 GRADE A82.4 GRADE B6719.7 GRADE C14241.8 GRADE D10330.3 FAIL195.6 TOTAL340100.0

56. PHARMACIES

57. CHEMICAL SHOPS GRADESTOTALPERCENTAGE GRADE A+00.0 GRADE A31.2 GRADE B259.8 GRADE C7931.1 GRADE D12047.2 FAIL2710.6 TOTAL254100.0

58. CHEMICAL SHOPS

59. FAILURE RATE BY FACILITY TYPE FACILITY TYPETOTAL INSPECTEDFAILED PERCENTAGE FAILED PRIMARY HOSPITALS33482.4 HEALTH CENTRES882313.5 CLINICS3474111.8 MATERNITY HOMES22683.5 CHPS COMPOUNDS1077141.3 PHARMACIES340295.6 CHEMICAL SHOPS2542710.6 DIAGNOSTIC CENTRES213104.7

61. SET 3

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

63. 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 TOTAL108100.0%158100.0%57100.0%11100.0%

64. PRIMARY HOSPITALS

65. PERFORMANCE OF PRIM. HOSP. BY OWNERSHIP (BASED ON QUALITY OF PASSES) PUBLIC (NUMBER, %) PRIVATE (NUMBER, %) MISSION (NUMBER, %) QUASI-GOVT (NUMBER, %) A+, A, B3128.72817.72747.4872.7 C,D, FAIL7771.313082.33052.6327.3 TOTAL108100.0158100.057100.011100.0

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

67. 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

68. 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)

69. 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

70. 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 C33044.9%11734.9%5842.1%637.5% GRADE D27938.0%12637.6%4029.3%425.0% FAIL243.3%4112.2%64.3%16.3% TOTAL735100.0%336100.0%139100.0%16100.0%

71. CLINICS AND HEALTH CENTRES

72. PERFORMANCE OF HEALTH CENTRES AND CLINICS BY OWNERSHIP (BASED ON QUALITY OF PASSES) PUBLIC (NUMBER, %) PRIVATE (NUMBER, %) MISSION (NUMBER, %) QUASI-GOVT (NUMBER, %) A+, A, B10314.05215.53525.2531.2 C,D, FAIL63386.028484.510474.81168.8 TOTAL735100.0336100.0139100.016100.0

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

74. 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

75. 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

76. 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%220100.0%3

77. MATERNITY HOMES

78. PERFORMANCE OF MATERNITY HOMES (BASED ON QUALITY OF PASSES) PUBLIC (NUMBER, %) PRIVATE (NUMBER, %) MISSION (NUMBER, %) A+, A, B266.74319.5133.3 C,D, FAIL133.317780.5266.7 TOTAL3100.0220100.03

79. PERFORMANCE OF MATERNITY HOMES (BASED ON QUALITY OF PASSES)

80. 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

81. 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

82. Thank you for your kind attention