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When Inputs do not match Outcomes: Healthcare Efficiency in Ghana

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Over the years we have been made to believe that the reasons for poor healthcare delivery in Ghana are a result of inadequate health professional numbers, lack of infrastructure and the availability of money. In this piece, ...

Philip José Farmer in The Dark Design argues “You had to make your choice between survival and efficiency, though in the long run survival was optimum efficiency, no matter how much time and effort it took.”

Throughout history, the biggest driver of development has been ignorance. The statements “I don’t know” and “I want to find out” have driven the agricultural revolution, the creation of money, the development of the steam engine, the industrial revolution and capitalism. Societies that have failed to evolve and undergo substantial transformational development and social mobility are those that have dwelled in the illusion that they have all the answers, question more and answer less.

Over the years we have been made to believe that the reasons for poor healthcare delivery in Ghana are a result of inadequate health professional numbers, lack of infrastructure and the availability of money. In this piece, we at Thinknovate have tried to test this hypothesis by comparing health and health-related economic data from six African Countries; Ghana, Kenya, Nigeria, Rwanda, Uganda and Zambia. We selected these countries based on the fact that their respective average life expectancy was approximately 42 years (± 5 years) in 1960. We tracked the following parameters; Strategic Development Goal (SDG) Index, Total Health Workers per 10,000 citizens, Health Efficiency Score (%), GDP per capita ($), Health spend as a proportion of GDP (%) and Life Expectancy.

The table provides a summary of our results:

When Inputs do not match Outcomes: Healthcare Efficiency in Ghana

To the average Ghanaian, the most important object of a health system are the outcomes which manifest in two major parameters; the efficiency of the service and improved life expectancy. Though none of the countries meets the requirement in the Abuja Declaration for African countries to spend 15% on the GDP on health, it is clear from the table that Ghana is not faring badly with respect to health spending as a proportion of GDP at 6.9% and places third behind Rwanda (8.9%) and Uganda (8.3%). Ghana also has been outperforming all these countries in the achievement of its SDG with an index of 39. Likewise, it has much higher health workers as a proportion of the population (30 per 10,000) second only to Kenya (32 per 10,000).

The real question is, do these inputs transfer to outcomes? To answer this we tracked the life expectancies of each country from 1960 to 2016. The data is as represented in the diagram below.

 When Inputs do not match Outcomes: Healthcare Efficiency in Ghana

Rwanda, with the second-lowest life expectancy (42.4 years) in 1960, had a steady increase until 1980. It then suffered a serious drop in its life expectancy between 1980 and 1990, achieving a low of 31.8 years that year (the lowest of all six countries). It reversed the trend rising steadily to become the nation with the highest life expectancy (68 years) among the group by 2016. Even more intriguing is the fact this was achieved with the lowest number of health workers per 10,000 citizens (18). The argument can be made that as a percentage of GDP, Rwanda spends more on health (8.9%) than any of the other countries. But with the lowest GDP per capita amongst the lot, that in itself does not explain how life expectancy has appreciated so rapidly.

Perhaps, the answer lies in the efficiency with which healthcare is delivered. Below is a diagram showing the relative comparison of all tracked parameters.

 When Inputs do not match Outcomes: Healthcare Efficiency in Ghana

A look at the health efficiency scores for all countries indicates that though Rwanda had the lowest number of health workers per 10,000 citizens, its efficiency score was the highest (49%), a difference of 7% better than the next country Zambia (42%). Ghana with over 1.5 times more health professionals per 10,000 (30) has the lowest efficiency score (27%). Further, though Rwanda spends more on health as a percentage of GDP, in real currency terms the unit spend on health is higher for Ghana; with Ghana spending $317 (6.9% of $4,600) compared with $186.90 (8.9% of $2,100).

In real terms, Ghana outspends all the other countries on health (Kenya $217, Nigeria $271.4, Uganda $199.20 and $216). Yet, according to reports on Assessing Facility Capacity and Costs of Care for all these countries, Ghana has the poorest efficiency score.

A careful study of the health systems of all these countries provides a number of reasons why Rwanda, Uganda and Zambia, with lower GDP per capita compared to Ghana, invest less per capita in real terms on health, have comparatively lower SDG Indices and a lower number of health workers per citizen but have ended up with more efficient health delivery systems. The first amongst these is an acceptance that strategic leapfrogging based on entrepreneurship in health using startup incubators is the fastest option for encouraging foreign direct investment and social enterprises in especially primary health delivery that ultimately benefit the society and decrease the financial cost of health provision for governments. The second is the democratisation of ignorance by those in leadership and their willingness to learn rather than profer solutions where intellectually they are out of their depth. Finally the willingness of technocrats to concede that their approaches to ensuring quality healthcare commensurate with the affordability of the respective countries have failed.

Like it is always said, man can argue in solitude but with real evidence, let the data speak. In an era where health delivery has moved from an emphasis on finding cures for diseases that affect the masses to a system that targets the individual, we must always drill down to the spend per individual. With an efficiency score of 27%, we invariably spending $231.41 out of the $317 spent on each of us wastefully. To put it another way, we waste more per individual in health spending than Rwanda ($189) has used to achieve an efficiency score of 49%. Clearly, there is still scope to do better with our current budgetary allocation. The problems associated with an inefficient health delivery system is not entirely due to lack of funding, a lack of infrastructure or an acute shortage of health personnel but a gross failure of effective leadership; a typical case of the fish rotting from its head.






Edited by Winifred Awa

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