Strong commitment to primary health care as a key strategy for improving health in Ghana
The health system in Ghana is organized as a five-tier system- Facility, Sub district, District, Regional and National. To improve access to health care, the sector has opened up to a wider range of providers, both public and private, at the national, regional and district levels; with the district having a sub-district level that incorporates a community health delivery system. Health interventions are packaged and delivered in communities, clinics, health centres, district, regional and tertiary hospitals. Each level of service delivery has its management functions and activities.
Districts are crucial for health systems as they provide a way of organising and managing health services at a local level. By dividing a country or region into smaller geographical areas, or districts, it is then possible to allocate resources and services in a more targeted and efficient way. This can include targeted interventions such as the number of medical staff, facilities, and equipment, as well as funding and other support in a specific area. To this end, the global health community has recognised that the primary healthcare approach is the most efficient way of achieving SDG 3 as this holistic and comprehensive approach to healthcare delivery emphasizes on accessibility, prevention, and community-based care. As such, the PHC approach addresses the health needs of the whole population, rather than just treating specific diseases or groups of people, and contributes to improving health outcomes, reducing healthcare costs and increasing equity in access to healthcare.
In Ghana, the country has made a commitment to primary health care as a key strategy for improving the health of its population. This commitment is reflected in the country's health policy and in the actions taken by the government and other stakeholders to implement primary health care. To this end, several primary healthcare initiatives have been implemented such as the Community-based Health Planning and Services (CHPS), which has been instrumental in expanding access to healthcare services in rural and remote areas of the country, as well as the National Health Insurance Scheme (NHIS) which aim to make healthcare more affordable and accessible to all citizens.
As of today, Ghana is divided into 16 regions and 261 Metropolitan, Municipal and District Authorities (MMDAs). The regions are administrative divisions that serve as the highest level of local government, while the districts are smaller subdivisions of the regions. To improve UHC and advance the achievement of SDG 3, Ghana plans to introduce a Network of Practice (NoP) at the sub-district level using a Hub and Spokes approach where the Hub is the Model Health Center and the surrounding health facilities are the spokes. This network of practice at the district level is intended to help improve the overall effectiveness and efficiency of healthcare delivery by facilitating collaboration, coordination, and knowledge-sharing among healthcare professionals and other stakeholders at the local level. However, the success of this NoP will depend on the functionality of the districts reason why the country decided to assess its district health functionality.
An assessment by the district – for the district
The need to have evidence on the functionality of the district health system in Ghana has been addressed in assessing the functionality of the districts. To do so, 5 districts of the 6 new regions of the country were identified as the assessment could not be done in all 261 MMDAs. These districts were selected based on their performance on a set of indicators that were predefined by the coordination and implementation team, led by the Ghana Health Service under the leadership of the Deputy Director General.
The evaluation was based on tools for assessing the functionality of district health systems developed by the WHO Regional Office for Africa (WHO/AFRO) and already being used in over 12 countries covering 454 districts as of December 2022. The tool consists of three sets of questionnaires structured into (1) those assessing the functioning of a sub-national unit, (2) determining level of outcomes the sub-national unit is attaining and (3) assessing the functionality of a specific health facility. These questionnaires were reviewed and adapted to fit the Ghanaian context. The adapted questionnaires were pretested in two districts before implementation in the six regions.
Leadership for the district assessment rested with the district health team, as the tools were designed as self-assessment tools. All questionnaires were supplemented by group interviews with relevant staff from the facility and the district health management team. In addition, staff from other decentralized agencies as well as community representatives collaborated with health staff to complete the questionnaires. Each district was advised to form a multidisciplinary team of at least six members to guide the assessment of district functionality. In each participating region, a centralised four-day orientation workshop was held at the regional headquarters for all district teams.
As part of the orientation, national facilitator explained the rationale and purpose of the District Functionality Assessment, as well as the process for conducting the assessment. Participants then went through the tools to be used for the assessment to ensure they fully understood the questions being asked. They also received guidance on how to access the online assessment tools, submit completed questionnaires, and access the results online.
Taking advantage of the presence of the district teams in one location, one day of the workshop was dedicated to the district team assessment of the district health system. Each district team worked as a team to complete the questionnaire and spent the day completing the questionnaires. To date, all the findings from the districts assessed in Ghana are available on the dashboard hosted on the integrated African Health Observatory (iAHO) website.
Moving forward
The country is currently using its results to provide precise and specific information for participating districts and regions on areas they need to focus on to improve their functionality. The feedback from the use of the tool and the dashboard analysis platform demonstrated that to tool could be used to support the annual health planning and budgting cycle for targeted programme and evidence based planning. The need to expand the evaluation to more districts has therefore arisen. In this sense, it is foreseen that the evaluation will also be carried out in the regions that were not selected in this first phase. Indeed, the country plans to use these results in the budget planning of the regions as well as set specific recommendation in order to improve the functionality of the participating districts. Additionally, good practices in the performing districts will be highlighted so that other districts can benefit from them.
Ghana, as well as other countries that have used this assessment, is also using this opportunity to consolidate at a country level the priorities that are most impeding the attainment of health results at the district level. Finally, these results will contribute to the definition at the regional level of priorities for investment in district health systems.
Acknowledgement: Antony Ofosu , Cornelius Depuur and Kidane Solyana Ngusbrhan