Ghana - Population, health and nutrition sector review

Report No. 7S97-GH /< Ghana Population, Health and Nutrition Sector Review March 31, 1989 West African Department Population and Human Resources Division FOR OFFICIAL USE ONLY -. ~ , ;.J L~~~~~~~ -~~~~~~~~~~~~~~~~~~~~~~~~~~J ~..n) intepro-ac f hifiildte. Iscnert ma not otews D . o - . , t~ t' '~ o, 0 be disclosd ' W Bn . > < . a . 1, ' ' ^ C2:> > t~~~~~0-; .. . O <> " ' i > '''. 0o,| @ ~ ~ ~ ~ 0 Do0o ofteW dBn i , \ ..~~~~~~~~~~~~~~~ .. . . . .~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ o~~~~~~~~~~~~~~I a 4 X t; . ' \S , C~~~~~~~~ 07~~~~~~~~~~~~~~~~~~' _  CURRENCY AND EQUIVALENT UNITS Currency Unit = Cedi US$1 = Cedi 186 (Auction Rate on May 13, 1988) (This rate has been used throughout the report) WEIGHTS AND MEASURES Metric System LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care CCG Christian Council of Ghana CHAG Christian Health Association of Ghana CHN Community Health Nurse CHS Center for Health Statistics CHW Community Health Workers CMS Central Medical Store CRS Catholic Relief Services CWC Child Welfare Clinic DHMT District Health Management Team DPT Diphtheria Pertussis Tetanus (vaccine) EPI Expanded Program of Immunization FP Family Planning GIHOC Ghana Industrial Holding Corporation HIV Human Immune Deficiency Virus IEC Information - Education - Communication IUD Intra-Uterine Device XCH Maternal and Child Health MFEP Ministry of Finance and Economic Planning MOH Ministry of Health NDPS National Development Planning Secretariat NGO Non-Governmental Organization ORT Orsl Rehydration Therapy PHC Primary Health Care PHN Public Health Nurse PPAG Planned Parenthood Association of Ghana SOE State-owned Enterprises TBA Traditional Birth Attendant UCI 1990 Universal Child Immunization by 1990 UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Emergency Fund WHO World Health Organization FISCAL YEAR January 1 - December 31  FOR OMCIAL USE ONLY GHANA POPULATION. HEALTH AND NUTRITION SECTOR REVIEW TABLE OF CONTENTS Page SUMMARY AND CONCLUSIONS ........ ........................ i I. POPULATION .............................................. 1 A. Population Growth and its Consequences . ............... 1 B. Family Planning Program ............................... 3 1. Political Commitment and Leadership . ............. 3 2. Organizational Structure of the Program ..... ........ 4 3. Strategy aid Action Plans ............. * ............ 5 4. Targets ................................. ........... 6 5. Program Design and Content ......................... 8 6. Implementation Problems ................... ......... 14 7. Financial Requirements and External Assistance ..... 14 II. HEALTH ............................................ .. . 15 CURRENT SITUATION ................................................ 15 A. Health Problems .... ........... . ... ....... .... . 15 B. Overview of the Health Care System ............... ..... 17 1. Fixed Facilities ................................... 17 2. Manpower ........................................... 18 3. Utilization of Health Services ..................... 18 4. Nongovernmental Organizations ...................... 19 5. The Private Sector ................... . ... ....... ... 21 HAJOR ISSUES ..................... .............. 22 A. Organization and Management Issues ................... . 22 1. MOH Headquarters Level ...... ....................... 22 2. Regional Level ............................ ........... 27 This report is based on the findings of a Bank mission to Ghana in Harch 1988, comprising Messrs: D. Berk (economist, mission leader), N. Bennett (planner), R. Bulatao (population/family planning), and V. Kumar (pharmaceuticals); and S. Bradley (NGOs, consultant), J. Lecomte (public health, consultant) and J. Levinson (nutrition, consultant). CIDA (Canada) provided the services of Mr. F. Zufferey (IEC) and ODA (United Kingdom) those of Hr. H. Owen (private sector). Mr. R. Bankson (consultant) edited the report. is8. A. Joseph was responsible for its production. This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  TABLE OF CONTENTS (Cont-d) Pale B. Service Issues ....... ....... ................. . * ....... 29 1. Coverage and Access . .................... , , 29 2. Primary Health Care ........ ............. . 30 (a) Objectives and Strategy ...................... 30 (b) Organization and Management ... 30 (c) Programs and Services ........................ 32 (d) Information, Education, and Communication (IEC) ..... ............. . 33 3. Inputs .3 .. .... ... .. 35 (a) Manpower ......... .... . .. ......... .. 35 (b) Drugs...... 37 (c) Transport and Communications .. 41 C. Financial Issues ........................ .............. . 42 1. Health Expenditure .... . .......... 42 (a) MOH Recurr.ent Budget . .. 42 (b) Public Investment Program (PIP) .. 46 2. Health Financing ......... ... 51 (a) Cost Recovery S 1.. ....... . 51 (b) Health Insurance ............. ....... 52 TII. NUTRITION ....... ... .. . .. ......... . 53 A. Levels of Malnutrition .... ..... ...... . ..53 1. Protein-Energy Malnutriton........... 53 2. Preharvest Hunger.... ... . . ...... . ..... 54 B. Strategy . ........ .. ........ ... 54 C. Program Impact .............. ............. 54 D. Inputs ... .......*........... *......... ......... *-. 56 E. Recowmnedations ........................ ......... ........ 56 IV. REFORMS AND TARGETS ................. .......... ... 57 A. Preparation and Actions During 1988 .... ............... 57 B. Sector Reform Program, 1989-91 ............. * .......... 58 C. Medium-Term Reforms . ...................... ............ 60 D. Long-term Targets . .................... . . . . . .......... . 65 V. EXTERNAL ASSISTANCE .................... .......... ....... 67 TEXT TABLES Table 1s Implications of a Gradual Decline in Fertility 8........ Table 2: Regional Indicators .. ....................... #........ 31 Table 3: Expenditures .... ................... ................ .... 433 Table 4: Budgets, Fund Releases, and Actual Expenditures on Nonsalary Recurrent Items, 1987.... ..... 44 Table 5S Long-term Targets . ..... .... ... . ........ . ... 66  TABLE OF CONTENTS (Cont'd) ANNEX TABLES Table l Population, Health and Nutrition Indicators Table 2: Alternative Population Projections and Their Implications Table 3: Leading Causes of Outpatient Morbidity, 1987 Table 4: Outpatient Attendances, 1976-1987 Table 5: MOH Staffing, 1987 Table 6: MOH Recurrent Budgets by Type of Expenditure, 1987-1989 Table 7: Public Investment Program in Health, 1988-1991 Table 8s New Primary Health Care Facilities Required for 802 Rural Population Coverage by the Year 2000 Table 9: Malnutrition Among Children: National Nutrition Survey, 1986 Table 10: External Assistance Table 11: Priorities, 1989-91 MUP Ghana (18112R1, March 1987)  GHANA POPULATION, HEALTH AND NUTRITION SECTOR REVIEW SUMMARY AND CONCLUSIONS Introduction 1. This summary and conclusions first sets out background informa- tion and current issues in Ghana's population, health and nutrition sectors. It then deals with recommended reforms and targetss first, the Government's preparations and actions during 1988; second, a recommended sector reform program for the period 1989-91; third, recom.tended medium- term reforms; and finally, long-term targets. It concludes with background and recommendations on external assistance to these sectors. I. BACKGROUND AND ISSUES POPULATION A. The Population Situation and Population Projections 2. Ghana's population was 12.2 million at the 1984 census, yielding a density of 51 persons per square kilometer -- the second highest in West Africa. In the 1980s, the population growth rate is estimated to have reached a rapid 3.22 per annum, and the total fertility rate remains 6.4. At this rate, the population will double every 22 years, and triple by 2020, i.e. within one generation. 3. Future population growth is likely to be substantial. Annually between 1988 and 2000, about 700,000 babies will be added to the popula- tion. Alternative paths for fertility could mean greatly different popula- tion sizes early in the next century. A rapid decline in fertility, for example, will yield a papulation of 25 million by 2020, whereas constant fertility will cause the population to swell to 45 million. Gradual fertility decline, the most likely path if a serious family planning effort is mounted, will result in a population of 32 million. 4. Current population growth is already eating up a major portion of the gains from economic recovery and structural adjustment. lJnless it is slowed, the projected population growth will put great pressure on food supplies, energy resources, the environment, the education system, the labor market and the health services. It will make it difficult or impos- sible for the Government to afford its goals for the improvement and universalization of health, education and food security/adequate nutrition. And it will preatly slow the rise in per capita income, which could reach a level in 202 up to nearly 40Z higher under gradual fertility decline than with today's fertility. 5. There is a high return to the relatively modest cost of family planning programs, in terms of savings on future education and health budgets and probably on future food imports. Furthermore, many of the benefits accrue immediately: o maternal and child health, and conse- quently reduced loads on the health services, and to per capita income  - ii - growth; while the reduced load on the education system and budget is felt within about six years. 6. Contraceptive prevalence in Ghana is estimated at only 11-132 in 1987, and current estimates of the proportion using efficient methods differ considerably (from 52 to about 102). The Ministry of Health (MOH) accounts for 402 of the 300,000-odd clients through family planning offered at about SOZ of its 400-plus maternal and child health (MCH) clinics. The Planned Parenthood Association of Ghana accounts for 32Z of clients through 46 clinics (half urban, half rural) and 125 community-based programs, and another nongovernmental organization (NGO) for 62. Pharmacies account for 19X, including contraceptives sold through a social marketing program. USAID and UNYPA are the chief donors in the area of population. B. Family Planning ProRrsm 7. Ghana was a pioneer in adopting a broad population policy in 1969 with explicit demographic targets, in establishing a family planning program, and in carrying out the Danfa project to test alternative program designs5 but implementation has been erratic, so that after almost twenty years, desired and actual fertility remain high, and contraceptive preva- lence is only in the range of 11-13Z. This is despite the opportunity provided by an apparently large unmet need among both women and men for both child spacing and limitation of births. 8. The major family planning program issues ares (a) a lack of explicit commitment and leadership by high-leve,& Government officials, including public statements of support, broad target-setting and active monitoring of progress; (b) a lack of a felt objective of increasing the nuLber of family planning acceptors as fast as possible, and of specific targets for the program; (c) a lack of a program str2tegy and of action plans for the various institutions and components involved, including the need to define priorities for design of an accelerated program; (d) implementation problems, especially contraceptive supplies; and (e) future financing: need to coordinate the next round of donor assistance to support the Government's strategy and action plans. HEALTH CURRENT SITUATION A. Health Problems 9. Ghana has made considerable progress in increasing life expect- ancy at birth (to 54 years in 1985) and in reducivg mortality. Neverthe- lese, the available indicators point to two major issuess (a) the health status of the population remains poor, as evidenced Ly infant mortality of 90 per 1000 and maternal mortality of 5-10  - iii - per 1,000 births; high prevalence of preventable infectious and parasitic diseases (malaria accounts for 43Z of outpatient morbidity, followed by upper respiratory infections and diarrheal dieeases); and poor nutritional status; and (b) there is considerable inequality of health status between urban and rural areas and among regions, as well as different disease patterns. B. Overview of the Health Carc System 10. Fixed Facilities. In the mid-1980s Ghana's health system counted some 1,220 service facilities. The public sector included 46 MOH general hospitals at teaching (2), regional (8) and district (36) levels, and about 250 rural health centers and posts: missions, 35 hospitals and a similar number of clinics; and the private sector, 400 clinics and nearly 300 maternity homes. Total bed capacity was about 18,600 (one for 684 people in 1985), with 14,0CO in the public sector and 4,600 in missions. There were also some 3,500 drug outlets. MOH facilities at all levels require extensive rehabilitation, including basic systems and medical equipments mission facilities may be in better condition. Very little expansion is taking place by either MOH or the missions. 11. Manpower. Ghana has trained fairly impressive numbers of medical personnel. Unfortunately, however, the years of economic decline have led to a mass exodus of qualified people both from the public sector and from Ghana. About 965 doctors currently work in Ghana (one for 20,450 people), of which 611 in the public sector, 55 (plus 25 expatriates) in missions, and 300 in the private sector. MOH employs 10,000 nurses, 80Z of them clinical. Primary health care (PHC personnel) number about 4,000 at the health centeripost level (level B) and another 4,000 (only 102 of original plans) at the village level (level A). 12. Utilization of Health Services. The major issue is under- utilization of services. Outpatient attendances have fallen from 10-11 million by 1973 to nearly 5 million in 1987 (perhaps 6 million after correcting for under-reporting), mainly as a result of declining standards including shortages of drugs. 13. NonRovernmental Organizations (NGOs). Around 300 NGOs operate in Ghana, providing health, population, and nutrition services to a large portion of the Ghanaian people. In 1987 the service was valued at more than 02.6 billion. Of this,