Wed, Nov

Ghana’s Health Social Contract; Are We Getting More Benefit?

Thoughts From Afar
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“The word ‘slavery’ and ‘right’ are contradictory, they cancel each other out. Whether as between one man and another or between one man and a whole people, it would always be absurd to say: “I hereby make a covenant with you which is wholly at your expense and wholly to my advantage; I will respect it so long as I please and you shall respect it as long as I wish.” Jean-Jacques Rousseau, The Social Contract

Over the past few weeks, we have tried to review several health outcome parameters that pertain to Ghana. We undertook this exercise because we want to understand what we have benefitted based on the investments public office holders make in health on our behalf. Having read many of the manifestos that have been published by those seeking our mandate to govern, it is abundantly clear that many of the pledges they make are inputs that ultimately should ensure the overall improvement in our society’s health outcomes. Twenty-eight years after this democratic experiment, it is important for us to know the benefit we have derived from such documents in the past. We will thus look at a few mortality statistics for Ghana.

Ghana’s female adult mortality rate (the probability of women dying between the ages of 15 and 60 years), as of 2019, was approximately 214 deaths per 1,000 female adults. This indicator has improved by 16.38% since 1990 (approximately 0.58% yearly). Globally, this ranks Ghana the 29th country in the world where females die earlier than their predicted life expectancy at birth. In 1990, Ghana was ranked 46th. This means that though the number of female deaths has been decreasing, seventeen countries have had better improvements than we have had over the period. Examples of African countries that have surpassed Ghana since 1990 include, Rwanda which decreased their female mortality rate by 68.27%, Ethiopia by 48.05%, Malawi by 40.23% and Sudan by 31.18%.

The male adult mortality rate at 255 deaths per 1,000 male adults is higher for men compared to women. In 2019, males in Ghana were the 37th most likely to die before their sixtieth birthday amongst 156 countries ranked globally. This represents an improvement of 16.50% since 1990 (approximately 0.58% annually). In 1990 Ghana was ranked 57th. This means that, twenty countries had decreased their male adult mortality rate better than Ghana did in the last twenty-nine years. Countries that had outperformed Ghana on the African continent include Rwanda (62.45%), Tanzania (43.17%), Liberia (32.04%) and Botswana (26.06%).

Another statistic that was of interest to us was the infant mortality rate (the number of infants dying before reaching one year of age, per 1,000 live births). In 2018, Ghana’s infant mortality rate was 35 deaths per 1,000 live births. Between 1990 and 2018, Ghana moved three places up the rankings, where we were ranked the 45th amongst 193 nation-states. Again, though infant mortality in Ghana has decreased by 56.08% since 1990, the country has been outperformed by many of the previously named countries in this category too. For example, Malawi moved from the 5th country in 1990 to 51st in 2018. Here too, the fortunes of the very vulnerable have worsened.

Other health outcomes have trended in a similar fashion since 1990. The irony, however, is that Ghana spends more per capita on health in comparison with many of the countries that are achieving better health outcomes. Whilst the health expenditure per capita for Ghana in 2018 was $71, Rwanda was $49, Liberia was $57, and Tanzania was $34. More importantly, Ghana between 1990 and 2018 spent more on health as a percentage of its gross domestic product (GDP) than most of the countries achieving better health outcomes. In 2018, whilst Ghana spent 3.3% of GDP on health, Malawi spent 3.0%, Liberia spent 2.5%, Rwanda spent 2% and Botswana spent 1.9%. Thus, when it comes to the size of the health funding envelope, because Ghana has a larger economy ($ 65.52 billion, 2018) the funds committed to health are much bigger (US$ 2.16 billion, 2018).

How then can it be that when it comes to how much we invest in health, we seem to be doing much better than these countries, but when it comes to how much benefit we derive from health, our health outcomes are comparatively much worse? The data suggests that at 0.27, health efficiency scores for Ghana are poor. This is to say for every $1 spent on health, $0.67 is lost. We hold the view that this is a result of the level of attention we pay to the content of the manifestos of those seeking our votes. These documents, in our view, are the social contracts we are choosing amongst; once of which will become the contract we sign for the duration of the next government.

By definition, a social contract is an implicit agreement among the members of a society to cooperate for social benefits, for example by sacrificing some individual freedom for state protection. On the basis of the health outcome data we have shared, can readers honestly claim that over the period of this Fourth Republic, Ghanaians have been signing and benefiting from the numerous health social contracts we have entered? On the basis of one’s answer, can you honestly claim that there is enough in the political party manifestos you have seen so far to make an informed choice and thus consent either explicitly or tacitly that we mandate any political part to improve our health outcomes?

The point is we cannot continue engaging in the same political behaviours and expect these outcomes to change significantly. The rhetoric our politicians provide, appealing as they may be to our ears do not seem to have transformed our health fortunes or provided us with adequate health security. As we write, the country’s Health Access and Quality Index score is 39.3%; implying that 60.7% of all the mortality categories we focused on in this article are preventable. Putting it bluntly, of the 214.3 deaths in every 1,000 females that occurred between ages 15 years and 60 years in 2019, 130 of them were avoidable. If we extrapolate this data to the entire population, about 1.9 million of these deaths were avoidable. These women could be our mothers, sisters, daughters or wives. Now let that sink in for a bit and ask yourself, is this is the sort of social contract you deserve? Try the calculation for infants and estimate how many families are grieving for the loss of their toddlers.

We will end by reminding readers that as long as we continue to accept the terms of these social contracts and live with the poor benefits we derive, irrespective of which political party or individuals we have in government, our fortunes as far as health is concerned will only appreciate marginally. We need to let our politicians know that we are not prepared to respect this mediocrity for as long as they wish. Now, we ask, who will bell the cat?

Featured Image Courtesy of EpicTop10.com

Edited by Winifred Awa


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