In his report entitled- Ghana: defining the African challenge published in the Lancet (2001; 358), Richard Horton observed that “if Ghana is to be a model for Africa, it is more a model of problems to be faced than solutions discovered”. I must confess I was a bit hurt by his assertion when I first read it. I thought Horton, like many western researchers, was being unduly critical of a struggling African nation that is doing its utmost best with resources available. However, the image of health system I saw during my six and half months of field study that took me to some of the remote districts in the Ashanti and Northern region is almost consistent with Horton's observation. In the field of health, Ghana as a model for Africa appears to be more a model of problems to be faced than solutions discovered. The issues are wide-ranging and complex. But there is one key question which underlies all - Are we doing enough as a nation to find lasting solutions to the problems or it is still business as usual? The impressions I got in the field suggest that we are doing less than enough to find long-term solutions to many of the problems that have bedevilled the health system. In this piece I will share some of my observations and findings during the fieldwork. I will focus mainly on funding and allocation of resources (funds) which I specifically investigated.
Let me begin with the all too familiar problem of inadequate funding. It is worthy to note that this problem is not unique to Ghana. Indeed, cash-strapped economies like ours invariably have difficulties maintaining adequate level of funding for health and other social services. However, inadequate funding of health systems has grave consequences for service delivery and needs to be seriously discussed. The former Director General of WHO observed that health systems which spend less than US$60 per capita are unable to even deliver a reasonable minimum of services, even through extensive internal reform (Brundtland 2000). Health expenditure per capital in Ghana in 2001 was US$60. This is not too bad comparing with countries like Sierra Leone which spent only $26 per capita in that year. However, compare to other African countries such as Cote´ d'Ivoire, our neighbour, which spent $127 per capita in 2001 or Kenya and Zimbabwe which spent $114 and $142 per capita respectively in the same year (Human Development Report 2004), Ghana is not doing that well. One thing we should understand as a country is that being the best among the worst does not augur well for a nation with the vision of achieving a middle-income status by the year 2020.
The Ghana Poverty Reduction Strategy (GPRS) commits government to increase allocation to the health sector. Admittedly, there has been some increase over the past few years. Percentage of government recurrent health spending for example increased from 10.2% in 2001 to 11% in 2002. A further increase to 12% was budgeted for 2003. While the increases are welcome, they are far less than enough to improve delivery of health services in the country considering the minuscule proportion that goes into non-salary recurrent expenditure (17.8% in 2001). Unarguably, the problem of inadequate funding will not go away until we manage to turn the economy around, but we can do more at current resource levels than presently doing if we improve allocation and management procedures.
Allocation of funds within the health system as I observed during the fieldwork has serious deficiencies, especially when one considers the issue of inter and intra regional equity. I am aware of the contentious nature of the word equity. Let us not engage in any conceptual dispute here. By equitable distribution I am simply referring to allocation on the basis of relative needs. Variations in health needs among the 10 regions in Ghana are irrefutable. We also know that conditions are more pressing in some regions than others. Globally, countries that are serious with bridging gaps of inequalities in health try to redistribute resources on the basis of relative needs. Thus, levels of relative needs are measured and use as basis for developing needs-based models for geographic resource allocation. Ghana's Ministry of Health (MOH) despite years of talking about needs-based allocation formula has still been unable to develop one. What I observed is that the inter-regional allocation procedure is ambiguous and appears to have no well-established basis. Health authorities at regional levels have no clear view of how resources are allocated to them from the centre. My inquiries at the national level only yielded patchy information about the allocation process.
Based on current resource allocation policy, 42% of the non-salary recurrent budget is expected to go to the district level (POW 2002-2006). Budgetary ceilings for districts are assigned in bulk to regional authorities who re-allocate to individual districts using independent regional criteria. It is unclear how these bulk ceilings are determined at the national level. Factors such as population size and number of districts were mentioned as key to the process. However, there is lack of transparency surrounding the entire inter-regional resource allocation process. This, coupled with lack of expenditure data makes it difficult for one to assess how well-developed and equitable the allocation mechanism is. There is the need for the MOH to take the necessary steps to develop a transparent needs-based formula for inter-regional resource allocation that is capable of bridging the existing inequities.
The current approach of 'top-slicing' the GHS budget for targeting the four regions considered deprived in the GPRS document (Northern, Upper East, Upper West and Central Region) is insufficient to promote equity. Top-slicing for targeting worst-off regions is more of a quick-fix approach that does not guarantee long-term equity. A well-developed needs-based allocation formula with inputs from relevant stakeholders is what will produce equity on a broader scale. We need to remember that equity is not simply about the worst-off, it is about each getting a just share.
Another disturbing observation made with regards to resource allocation is the chronic delays in disbursement of funds to district levels, particularly government funds for administrative expenditure otherwise known as GOG item 2. There was not a single district I visited where authorities never complained about this problem. It seems to be one of the main frustrations of health managers at district levels. Evidence gathered suggests that sometimes first quarter allocation which is supposed to be used between January and March is never disbursed until June. There is always a backlog of at least one quarter. I had the opportunity to witness this problem first-hand. District accountants were still chasing their 3rd quarter allocations when I was in the Northern region in December 2003.
What is even more disturbing is that in spite of the frequent late disbursements and the cumbersome nature of the procedure for accessing these funds, the government accounting system does not permit a roll-over to the following year of unutilised funds. Meaning all funds that are not accessed by December 31st are automatically forfeited and are paid back to government chest. This puts extra pressure on district accountants to access and spend the money before December ends. One can only imagine the implications for prudent financial management of this 'rush to spend' by district authorities.
At the national I probed into the causes of the persistent delays. The responses were inconsistent to give a good picture of what is actually going on. I am not too sure at this stage whether budgetary constraints are the cause of the delays or they are simply a product of administrative bureaucracy. Whatever the reasons, we need to understand that these problems are thwarting the efforts of managers at the district level and must be addressed with the urgency they deserve.
Funding and allocation of resources are crucial to the demise or survival of our health system. We cannot bridge the gap of inequities without establishing a proper and transparent mechanism for resource allocation. We are simply not doing enough at this stage.
Watch out for more on resource allocation in the health system and proposals for reform! The author is a researcher at the Uni. of New South Wales, Sydney- Australia. Comments should be directed to [email protected]