Ghana Health Service 2014 Annual Report

GHANA HEALTH SERVICE 2014 ANNUAL REPORT

GHANA HEALTH SERVICE

2014 ANNUAL REPORT JULY 2015

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FOREWORD

The Ghana Health Service has very elaborate review processes that culminate in the writing of the Annual Report.. Each year, the GHS conducts performance reviews beginning at the District level and ending with the Health Summit at mid-year. These reviews apprise and appraise Health Sector comparative performance overtime, based on the six define objectives of the sector. Achievements in the year form the baseline to set the targets of the following year. The 2014 Annual Report of the GHS highlights the implementation activities, and health service initiatives in the Health Sector Medium Term Development Plan (HSMTDP 2014-2017). Ghana has continued to maintain a ‘polio-free’ status since 2008 and a progressive TB success rate of 86% over 2012 and 2013. Elimination of Maternal and neonatal tetanus (MNT) status has remained at zero since 2011. Mortality from measles has also remained at zero since 2003. Efforts to eradicate Guinea Worm have remained on course in 2014. Topical in our efforts to reduce maternal and newborn deaths are measuring institutional maternal mortality ratio (IMMR) and stillbirth rate (SBR). IMMR in 2014 was 143.8/100,000 live births in comparison to IMMR of 153/100,000 live births in 2013. Stillbirth rate stagnated at 1.8 in the 2014, as was in 2013. Total outpatient department (OPD) attendance in 2014, comprised 83.5% insured clients and less than 17% being out-of-pocket clients. This coverage is comparable to 2013 where 83% of OPD attendants were insured. The proportion of malaria cases tested before treatment at the OPD continued to improve from 42.9% in 2011 to 74.3% in 2014. The malaria case fatality in the under-fives reduced from 0.6% in 2013 to 0.51 in 2014. The proportion of pregnant women who were registered and were administered a second dose of Intermittent Preventive Treatment (IPT2) declined, falling from

55.4% in 2013 to 38.8% in 2014. This is

drastic fall back compared to 60.9% coverage achieved in 2011. In 2014, the continued poor financing of the Service produced noticeably adversely effects on health care services across districts and regions. The inability to address issues of inadequate financing and the pattern of erratic fund flow over successive years is hampering service delivery efforts as well as maintaining and running district, regional and national offices within the GHS. The majority of funds disbursed in 2014 were earmarked for implementing only particular programmes. This is reflected in the inability of the Service to progressively achieve desired service delivery targets. Despite these setbacks, we as a national health service have remained focused and undeterred in our efforts to provide healthcare for all people living in Ghana and contribute to national development and productivity. In the coming year 2015, we would reflect on combined efforts and initiatives that have been implemented to enable Ghana achieve its health-related Millennium Development Goals (MDGs).

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I am grateful to all the staff of the Ghana Health Service, first of all for their resilience in a particularly challenging year, and for their hard work and commitment to achieving the vision of the Ghana Health Service and the accomplishments of the Health Sector. I am also grateful to our health and development partners as I acknowledge their continued collaboration, capacity-building, technical and financial assistance to the Ghana Health Service. I would also like to acknowledge collaboration efforts of other Sectors: Finance, Agriculture and Local Government working with health to make Ghana a better place for all Ghanaians. I say Ayeekoo! Although I acknowledge that Ghana will not be achieving three out of its five MDGs next year, I urge all of us to put our shoulder to the wheel to make the positive change we all want to see in 2015. Thank you.

Dr. Ebenezer Appiah-Denkyira Director-General

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EXECUTIVE SUMMARY The Ghana Health Service has the primary mandate to ensure a healthy Ghanaian population by providing quality healthcare services to all people living everywhere in Ghana. This is a priority achieved through a seamless access to health service from community level to the district level. The Ghana Health Service 2014 Annual Report is organized into ten chapters. Chapter One describes the Ghana Health Service as an organization and its mandate. Chapter Two elucidates its structure, governance and leadership. In Chapter Three we review financial reporting and in Chapter Four, human resource. Chapters Five, Six and Seven cover support services for health, Disease Surveillance and Control, and reproductive and family health activities, respectively. In Chapter Eight we cover activities in clinical and institutional care and highlight some of the community engagements and partnerships in Chapter Nine. Chapter Ten concludes

with

research

activities

and

reporting,

and

the

role

of

the

District

Health

Information Management System (DHIMS2) in strengthening health information management in the GHS. Sector wide indicator figures are covered in the Annexes. Key performance indicators for 2014 are discussed in comparison to previous years. In 2014, 368 additional functional CHPS zones were made operational across all ten regions. This is a slight increase compared to 354 CHPS being made operational in 2013. This brings the total number of functional CHPS zones in 2014 to 2,948; a 14% increase (368 CHPS zones) over the 2,580 figure reported in 2013. Out of this total number, 1,260 CHPS have compounds. In 2014, 2,743 CHPS (93%) were seen to be directly reporting into the DHIMS2, in comparison to 2119 CHPS (82%) reporting into DHIMS2 in 2013. For CHPS not directly reporting, health service data are reported on their behalf by the supervising health centres. CHPS contribution to OPD attendance increased from 6.1% of the total OPD attendance of 2,549,859 in 2013 to 2,407,966, which is 10.2% of total OPD in 2014. The proportion of total OPD attendance that was insured in 2014 was 83.5%, which is almost the same as what was recorded in 2013. Out of the total OPD attendance 62.7% were females. As the efforts to ensure improved maternal and neonatal health continue, there was an observed increase in the proportion of pregnant women achieving the minimum 4 antenatal care (ANC) visits in 2014.

Approximately 76.1% pregnant women made at least 4 ANC visits

in 2014 in comparison to 66.3% in 2013. The supervised delivery rate slightly improved from 55.3% in 2013 to 56.7% in 2014. Family Planning coverage increased from 24.7% in 2013 to 29.1% in 2014. These improvements in maternal care although not conclusive, could be a reflection of the increase in critical workforce, particularly midwives in many districts across the regions. The midwife: WIFA ratio has been slowly improving over the last three years. In

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the last two years, the midwife: WIFA ratio improved from 1:1,400 in 2013 to 1: 1,374 in 2014. Improvement in childhood immunization is measured using the proxy Penta-3. National average of Penta-3 coverage increased from 86% in 2013 to 90% in 2014, however 29% (63) of the 216 districts in Ghana, could not achieve the 80% coverage target for Penta 3 coverage in 2014. The Greater Accra region recorded the highest number (44,487) of unimmunized children. Regional immunization performance is detailed in Chapter Six.

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TABLE OF CONTENTS FOREWORD ......................................................................................................................................................... 3 EXECUTIVE SUMMARY .................................................................................................................................... 5 CHAPTER ONE .............................................................................................................................................. 15 1.0 INTRODUCTION ................................................................................................................................ 15 1.1 GHANA HEALTH SERVICE ORGANIZATION AND MANDATE ............................................................................ 15 1.2 CHALLENGES IN THE GHS: END OF 2013/BEGINNING OF 2014 .................................................................. 15 1.2.1 HEALTH SYSTEM ................................................................................................................................................. 15 1.2.2 HEALTH INFORMATION SYSTEM ...................................................................................................................... 15 1.2.3 HUMAN RESOURCES FOR HEALTH ................................................................................................................... 15 1.2.4 HEALTH FINANCING AND FINANCIAL ARRANGEMENTS .............................................................................. 16 1.2.5 INFRASTRUCTURE AND EQUIPMENT ................................................................................................................ 16 1.3 SUMMARY OF KEY PRIORITIES ACTIONS FOR GHANA HEALTH SERVICE FOR 2014 ................................. 16 CHAPTER TWO ............................................................................................................................................. 18 2.0 LEADERSHIP AND GOVERNANCE ............................................................................................. 18 2.1 THE GHANA HEALTH SERVICE COUNCIL ............................................................................................................ 18 2.2 DIRECTORS’ MEETING ............................................................................................................................................ 18 2.3 HEALTH SUMMIT .................................................................................................................................................... 19 2.4 GHANA HEALTH SERVICE STRATEGIC PLAN ...................................................................................................... 21 2.5 GAVI HEALTH SYSTEMS STRENGTHENING (HSS) ........................................................................................... 21 2.6 CHPS OPERATIONAL POLICY AND GUIDELINES ............................................................................................... 21 2.7 PROGRAMME OF WORK ......................................................................................................................................... 21 2.8 PERFORMANCE MANAGEMENT PROCESSES ....................................................................................................... 21 2.9 MONITORING AND EVALUATION .......................................................................................................................... 22 DATA COLLECTION AND REPORTING: ....................................................................................................................... 22 2.9.1 IMPROVING THE DISTRICT HEALTH INFORMATION MANAGEMENT SYSTEM (DHIMS2) .................... 22 2.9.2 INTEGRATED MONITORING VISITS .................................................................................................................. 23 2.10 AUDIT OF BUDGET MANAGEMENT CENTRES (BMCS) IN GHS ................................................................... 24 2.10.1 FORMATION OF AUDIT REPORT IMPLEMENTATION COMMITTEE (ARIC) ............................................ 24 2.10.2 PERFORMANCE OF REGIONAL INTERNAL AUDIT UNITS ........................................................................... 25 2.10.3 AUDIT RECOMMENDATIONS IMPLEMENTED ............................................................................................... 25 2.10.4 AUDITS FINDINGS ............................................................................................................................................. 25 CHAPTER THREE .......................................................................................................................................... 26 3.0 FINANCE ................................................................................................................................................ 26 3.1 PERFORMANCE IMPROVEMENT ............................................................................................................................ 26 3.2 2013 FINANCIAL REPORT .................................................................................................................................... 27 CHAPTER FOUR ............................................................................................................................................ 28 4.0 HUMAN RESOURCES FOR HEALTH ....................................................................................... 28 4.1 ANALYSIS OF PAYROLL DATA ............................................................................................................................... 28

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4.2 NOMINAL ROLL AND PAYROLL RECONCILIATION ............................................................................................. 34 4.3 REVIEW OF STAFFING NORMS .............................................................................................................................. 34 4.3.1 SUMMARY OF STAFFING NORMS OUTPUT ...................................................................................................... 35 4.3.2 HUMAN RESOURCES (HR) GAP ANALYSIS BASED ON THE STAFFING NORMS ........................................ 36 4.4 HUMAN RESOURCE DATA ...................................................................................................................................... 36 4.5 RECRUITMENTS ....................................................................................................................................................... 36 4.5.1 MEDICAL OFFICERS ............................................................................................................................................ 36 4.5.2 DENTAL SURGEONS ............................................................................................................................................. 37 4.5.3 GENERAL NURSES ............................................................................................................................................... 37 4.5.4 REGISTERED MENTAL HEALTH NURSES ........................................................................................................ 37 4.5.5 REGISTERED MIDWIVES ..................................................................................................................................... 37 4.5.6 COMMUNITY HEALTH/ ENROLLED NURSES .................................................................................................. 37 4.6 HEALTH ADMINISTRATION AND MANAGEMENT (HAM) PROGRAM ............................................................ 38 4.6.1 EVALUATION OF THE HAM PROGRAM ............................................................................................................ 38 4.7 TRAINING/DEPLOYMENT OF MEDICAL PERSONNEL TO FIGHT AGAINST EBOLA VIRUS PANDEMIC ...... 38 CHAPTER FIVE ............................................................................................................................................... 40 5.0 ADMINISTRATION AND SUPPORT SERVICE ...................................................................... 40 5.1 TRANSPORT .............................................................................................................................................................. 40 5.0.1 CONSTRUCTION OF CHPS COMPOUNDS AND HEALTH CENTRES ............................................................... 41 5.0.2 UPDATING AND VALIDATING DATA ON HEALTH FACILITIES IN THE REGIONS ..................................... 41 5.0.3 REVAMPING BOAT FLEET AND MANAGEMENT ............................................................................................. 41 5.0.4 INCREASE FLEET SIZE AND IMPROVE VEHICLE AVAILABILITY .................................................................. 41 5.1 EQUIPMENT .............................................................................................................................................................. 42 5.1.1 ESTABLISHING THE EQUIPMENT MAINTENANCE FUND .............................................................................. 42 5.2 ADMINISTRATION ................................................................................................................................................... 42 5.2.1 DEVELOPMENT OF ADMINISTRATORS DASHBOARD ..................................................................................... 42 5.3 ESTATE ...................................................................................................................................................................... 42 5.3.1 UPDATING THE PROGRESS AND STATUS OF GHS CIVIL WORKS .............................................................. 42 5.3.2 GHS 2014 CIVIL WORKS BUDGET .................................................................................................................. 43 5.3.3 APPROVED BUDGET ............................................................................................................................................ 44 5.3.4 GHS CIVIL WORK PROJECTS ............................................................................................................................. 44 5.3.5 TREND OF PROJECT IMPLEMENTATION FROM 2012 – 2014 .................................................................... 45 5.3.6 PROCESSING AND PAYMENT OF CLAIMS ........................................................................................................ 45 5.3.7 SECTOR BUDGET SUPPORT ................................................................................................................................ 45 5.3.8 CHPS PROJECTS .................................................................................................................................................. 45 5.3.9 CERTIFICATES PROCESSED ................................................................................................................................ 46 5.4 CLINICAL ENGINEERING ........................................................................................................................................ 46 5.4.1 ACCE/HTF 2014 INTERNATIONAL ACEW AWARD .................................................................................. 46 5.5 PROCUREMENT ........................................................................................................................................................ 46 5.5.1 COMPETITIVE TENDERING / SOLE SOURCING CONTRACTS ........................................................................ 46 5.5.2 FUNDING SOURCES FOR PROCUREMENT FOR YEAR 2014 .......................................................................... 47 5.6 STORES AND SUPPLY .............................................................................................................................................. 47 5.6.1 EARLY WARNING SYSTEM ................................................................................................................................. 47 5.6.2 INTRODUCTION & TRAINING OF SUPPLY CHAIN MANAGEMENT IN PRE-SERVICE INSTITUTION ......... 48

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5.6.3 INVENTORY MANAGEMENT SOFTWARE .......................................................................................................... 48 CHAPTER SIX ................................................................................................................................................ 49 6.0 DISEASE SURVEILLANCE AND CONTROL SERVICE ....................................................... 49 6.1 DISEASE SURVEILLANCE ............................................................................................................................................ 49 6.1.1. ACUTE FLACCID PARALYSIS (AFP) SURVEILLANCE ........................................................................................ 49 6.1.2. MEASLES-RUBELLA SURVEILLANCE ................................................................................................................... 52 6.1.3. NEONATAL TETANUS SURVEILLANCE ................................................................................................................. 55 6.1.4 YELLOW FEVER ........................................................................................................................................................ 56 6.1.5 MENINGITIS SURVEILLANCE .................................................................................................................................. 57 6.1.6. CHOLERA SURVEILLANCE ...................................................................................................................................... 59 6.1.7. INFLUENZA-LIKE ILLNESS (ILI) SURVEILLANCE ............................................................................................... 60 6.1.8. NATIONAL VIRAL HEPATITIS SURVEILLANCE AND CONTROL PROGRAMME (NVHCP) .............................. 60 6.2 NATIONAL MALARIA CONTROL PROGRAMME ......................................................................................... 63 6.2.1 KEY ACTIVITIES ........................................................................................................................................................ 63 6.3 GUINEA WORM ERADICATION PROGRAMME ........................................................................................... 68 6.3.1 MAJOR ACTIVITIES .................................................................................................................................................. 68 6.3.2 MAJOR ACHIEVEMENTS .......................................................................................................................................... 68 6.3.3. SOCIAL MOBILIZATION AND HEALTH EDUCATION ........................................................................................... 68 6.3.3. CAPACITY BUILDING (TRAINING, MEETINGS) .................................................................................................. 68 6.3.4 LOGISTICS SUPPORT ................................................................................................................................................ 69 6.3.5. WATER INVENTORY IN FORMERLY ENDEMIC COMMUNITIES ........................................................................ 69 6.3.6 GUINEA WORM PROGRAMME REVIEW MEETING ............................................................................................. 70 6.3.7 GUINEA WORM FREE PRE-CERTIFICATION: ICT VISIT TO GHANA ................................................................ 70 6.4 NON COMMUNICABLE DISEASE CONTROL PROGRAMME .............................................................. 71 6.4.1 POLICY REVIEWS ................................................................................................................................................. 71 6.4.2 MONITORING ........................................................................................................................................................ 71 6.4.3 ESTABLISHMENT OF ADDITIONAL WHO-PEN SITES ....................................................................................... 71 6.4.4 CERVICAL CANCER SCREENING IN ASHANTI AND GREATER ACCRA REGIONS ............................................. 71 6.4.5. PARTNERSHIP FOR CERVICAL CANCER ............................................................................................................... 71 6.4.6. TRAINING ON WHO-PEN PROTOCOLS AND TOOLS ........................................................................................ 72 6.4.7 SUPPORT SERVICES ................................................................................................................................................ 72 6.4.8. DISEASE BURDEN ................................................................................................................................................... 72 6.4.9. HEALTH RESEARCH ................................................................................................................................................ 74 6.5 NATIONAL YAWS ELIMINATION PROGRAMME ................................................................................... 74 6.5.1 ACTIVITIES ................................................................................................................................................................ 74 6.5.2 RETURNS AND INDICATORS .................................................................................................................................... 74 6.5.3 REMARKS ON ENDEMIC COMMUNITY BASELINE SITUATION ............................................................................ 75 6.5.4 INNOVATIONS ........................................................................................................................................................... 76 6.6 NEGLECTED TROPICAL DISEASES ............................................................................................................. 76 6.6.1 LYMPHATIC FILARIASIS ...................................................................................................................................... 76 ONCHOCERCIASIS ........................................................................................................................................................... 77 6.6.2 ...................................................................................................................................................................................... 77 TRACHOMA ..................................................................................................................................................................... 79 6.6.3 ...................................................................................................................................................................................... 79

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6.6.4 SCHISTOSOMIASIS ................................................................................................................................................ 79 6.6.5 SOIL-TRANSMITTED HELMINTHS ..................................................................................................................... 79 6.7 NATIONAL TUBERCULOSIS CONTROL PROGRAMME ........................................................................ 80 6.7.1 KEY ACTIVITIES .................................................................................................................................................... 80 6.7.2 PERFORMANCE INDICATOR TRENDS ............................................................................................................... 80 6.7.3 COMPLETION OF NATIONWIDE TUBERCULOSIS PREVALENCE SURVEY .................................................... 82 6.7.4 DEVELOPMENT OF NEW STRATEGIC PLAN ..................................................................................................... 82 6.7.5 ON SITE COACHING FOR LABORATORY STAFF AND QA ASSESSORS ........................................................... 82 6.7.6 CONTINUOUS ON SITE DATA VALIDATION AND DATA QUALITY AUDITS ................................................. 82 6.8 THE EXPANDED PROGRAMME ON IMMUNIZATION (EPI) .............................................................. 82 6.8.1 EPI-RELATED HEALTH INDICATORS ............................................................................................................... 82 6.8.2 GLOBAL COVERAGE GOALS FOR NATIONAL IMMUNIZATION PROGRAMME ............................................. 83 6.8.3 PROGRAM OBJECTIVES FOR 2014 ................................................................................................................... 83 6.8.4 KEY STRATEGIES FOR 2014 ............................................................................................................................. 83 6.8.5 MAIN INTERVENTIONS CARRIED OUT IN 2014 ............................................................................................. 84 6.8.6 SERVICE DELIVERY STRATEGIES ...................................................................................................................... 84 6.8.7 EQUITY IN VACCINATION COVERAGE .............................................................................................................. 86 6.9 OCCUPATIONAL HEALTH ............................................................................................................................... 88 6.9.1 ACTIVITIES ................................................................................................................................................................ 88 6.9.2 POISON CONTROL .................................................................................................................................................... 89 6.10 NATIONAL LEPROSY ELIMINATION PROGRAMME ......................................................................... 90 6.10.1 LEPROSY ENDEMIC DISTRICTS IN GHANA ........................................................................................................ 90 6.10.2. PRIORITY INTERVENTIONS ................................................................................................................................. 91 6.11 NATIONAL YAWS ELIMINATION PROGRAMME ................................................................................ 91 6.11.1 ACTIVITIES ......................................................................................................................................................... 91 6.11.2 INNOVATIONS ........................................................................................................................................................ 92 6.12 NATIONAL AIDS CONTROL PROGRAMME (NACP) ........................................................................... 92 6.12.1 HIV TESTING AND COUNSELING SERVICES (HTC) .................................................................................... 92 6.12.2 PMTCT SERVICES ............................................................................................................................................ 92 6.12.3 EID SERVICES .................................................................................................................................................... 93 6.12.4 CLIENTS ON ANTIRETROVIRAL THERAPY .................................................................................................... 93 6.12.5 CONDOMS ........................................................................................................................................................... 93 6.12.6 HIV TEST KITS AND ACCESSORIES ................................................................................................................ 93 6.12.7 INFORMATION AND COMMUNICATION MATERIALS .................................................................................... 93 6.12.8 CAPACITY BUILDING FOR HEALTH CARE WORKERS ................................................................................. 94 6.12.9 CDC COLLABORATION ..................................................................................................................................... 94 6.12.10 MONITORING & SUPERVISION ..................................................................................................................... 95 6.12.11 RESEARCH ....................................................................................................................................................... 95 6.12.12 RESOURCE MOBILIZATION ........................................................................................................................... 95 6.13 PUBLIC HEALTH LABORATORIES ............................................................................................................ 95 6.13.1 BACTERIOLOGY, MEASLES/RUBELLA/YELLOW FEVER BENCH .............................................................. 95 ACTIVITIES UNDERTAKEN ............................................................................................................................................ 95 6.13.2 ................................................................................................................................................................................... 95 CHAPTER SEVEN .......................................................................................................................................... 97

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7.0


REPRODUCTIVE HEALTH, MATERNAL, NEWBORN AND CHILD HEALTH

(RMNCH) ........................................................................................................................................................... 97 7.1 ADOLESCENT HEALTH AND REPRODUCTIVE HEALTH SERVICES ................................................................... 97 7.1.1 POLICY AND PLANNING IN ADHD PROGRAMMING ...................................................................................... 97 7.1.2 ADOLESCENT HEALTH SERVICES ..................................................................................................................... 97 7.2 FAMILY PLANNING .................................................................................................................................................. 98 7.3 SAFE MOTHERHOOD AND CHILD HEALTH ......................................................................................................... 99 7.3.1 ACCELERATED REDUCTION OF MATERNAL MORTALITY ............................................................................. 99 7.3.2 NEWBORN CARE .................................................................................................................................................. 99 7.4 NUTRITION ............................................................................................................................................................. 100 7.4.1 VITAMIN A SUPPLEMENTATION ..................................................................................................................... 100 7.4.2 DEVELOPMENT OF GUIDELINES & PROTOCOLS ........................................................................................... 100 7.4.3 INFANT AND YOUNG CHILD NUTRITION PROGRAM (IYCN) ..................................................................... 100 7.4.4 NMCCSP/GROWTH PROMOTION ................................................................................................................. 100 7.4.5 COMMUNITY MANAGEMENT OF ACUTE MALNUTRITION (CMAM) ........................................................ 100 7.4.6 NUTRITION ASSESSMENT COUNSELING AND SUPPORT (NACS) FOR PLHIV ....................................... 101 7.5 HEALTH PROMOTION ........................................................................................................................................... 101 7.5.1 HEALTH PROMOTION SUPPORT FOR PROGRAMMES .................................................................................. 101 CHAPTER EIGHT ......................................................................................................................................... 103 8.0 CLINICAL CARE SERVICES ........................................................................................................ 103 8.1 EBOLA CASE MANAGEMENT AND INFECTION PREVENTION AND CONTROL TRAININGS ....................... 103 8.1.1 EBOLA CASE MANAGEMENT SIMULATION EXERCISE ................................................................................. 103 8.2 DEVELOPMENT OF DRAFT POLICY ON ANTIMICROBIAL USE AND RESISTANCE ....................................... 103 8.3 CATARACT SURGERIES ......................................................................................................................................... 104 8.4 FIGHT AGAINST EPILEPSY INITIATIVE .............................................................................................................. 104 8.5 CUSTOMER CARE PROGRAMME (PHASE 2) ..................................................................................................... 104 8.6 GUIDELINES ON THE DISPOSAL OF DEAD BODIES ........................................................................................... 105 8.7 DISTRIBUTION OF SEVERAL QA DOCUMENTS .................................................................................................. 105 8.8 PATIENT SAFETY SITUATIONAL ANALYSIS ........................................................................................................ 106 8.9 TRAINING OF TRAINERS IN PAEDIATRICS IN DISASTERS ............................................................................... 106 8.10 QUALITY IMPROVEMENT WORK WITH PROJECT FIVES’ ALIVE .................................................................. 106 8.10.1 DESIGN AND IMPLEMENTATION ................................................................................................................... 107 8.10.2 SOME RESULTS ON THE INTERVENTIONS MADE BY HEALTH STAFF ....................................................... 107 8.11 NEONATAL MORTALITY RATES ....................................................................................................................... 108 CHAPTER NINE ............................................................................................................................................ 112 9.0 COMMUNITY ENGAGEMENT AND PARTNERSHIPS ................................................................ 112 9.1 COMMUNITY-BASED HEALTH PLANNING SERVICES (CHPS) ....................................................................... 112 9.1.1 CONTRIBUTION OF CHPS TO SERVICE DELIVERY ....................................................................................... 113 CHAPTER TEN ............................................................................................................................................. 114 10.0

HEALTH INFORMATION, ICT AND HEALTH RESEARCH .......................................... 114

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10.1 DATA MANAGEMENT AND INFORMATION TECHNOLOGY TO IMPROVE HEALTH INFORMATION MANAGEMENT AND SERVICE DELIVERY ...................................................................................................................... 114 10.1.1 DATA QUALITY IMPROVEMENT ................................................................................................................... 114 10.1.2 GHS PERIODIC PERFORMANCE REPORTS .................................................................................................. 114 10.2 HEALTH RESEARCH ........................................................................................................................................... 115 10.2.1 ACTIVITIES ....................................................................................................................................................... 115 10.2.2 DATA MANAGEMENT SUPPORT FOR RESEARCH STUDIES ...................................................................... 115 10.2.3 RESEARCH CENTRES ...................................................................................................................................... 115 ANNEX ............................................................................................................................................................. 116

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ACRONYMS & ABBREVIATIONS ACTs ACSM AEFI AFRO AMFm ANC AusAID BCC BMCs CBAs CDR CDTI CFR CHO CHPS DANIDA DFID DHIMS DHMT DHS DTS EmONC EMD EPI EQA GAVIHSS

GHS GIS GMA GoG

Artemisinin-based Combination Therapies Advocacy, Communication and Social Mobilization Adverse Events Following Immunization African Regional Office of WHO Affordable Medicines Facility for Malaria Antenatal Care Australian Agency for International Development Behavior Change Communication Budget Management Centers Community-based Agents Case Detection Rate Community-directed Treatment with Ivermectin Case Fatality Ratio/Rate Community Health Officer Community-based Health Planning and Services Danish International Development Agency UK Department for International Development District Health Information Management Systems District Health Management Teams Demographic Health Survey Dried Tube Specimens Emergency Obstetrics and Neonatal Care Epidemic Meningococcal Disease Expanded Programme on Immunization External Quality Assessment Global Alliance for vaccines and Immunization Health Systems Strengthening Ghana Health Service Geographical Information System Ghana Medical Association Government of Ghana

GWEP HASS HIA HMM HPV RDD HRDD HSMTDP HTC ICD ICOH ICT IDSR IE&C IHR IGF IMCI IPHU IPT IRS ITNs JHU CCP

KATH KBTH CoHS LDP LF LLINs MAF MDA

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Guinea Worm Eradication Programme Health Administrative Support Services Division Health Impact Assessment Home Management of Malaria Human Papillomavirus Research Development Division Human Resource and Development Division Health Sector Medium term Development Plan HIV Testing and Counseling Services Institutional Care Division International Commission on Occupational Health Information Communication Technology Integrated Disease Surveillance and Response Information Education and Communication International Health Regulation Internally Generated Funds Integrated Management of Childhood Illness International Public Health Unit Intermittent Preventive Treatment Indoor Residual Spraying Insecticide-treated bed nets Johns Hopkins University Centre for Communication Programs Komfo-Anokye Teaching Hospital Korle-bu Teaching Hospital KintampoCollege of Health Sciences and Wellness Leadership Development Program Lymphatic Filariasis Long-lasting insecticide treated bed nets MDG 5 Acceleration Framework Mass Drug Administration

MDAs MDBS MDSC MICS MNT MSD NACP NCD NFP NGOs NHIA NHIS NHRC NIDs NMCCSP NMCP NPHRL NSSCD NTB NTDs OHS OHS OPC OPD PCR PMDT PMTCT POD PoW PPME/D QA


Ministries Department and Agencies Multi-Donor Budget Support Multi-Disease Surveillance Centre Multiple Indicator Cluster Survey Maternal and Neonatal Tetanus Measles Second Dose National AIDS Control Programme Non-communicable Diseases National Focal Person Non-Governmental Organizations National Health Insurance Authority National Health Insurance Scheme Navrongo Health Research Centre National Immunization Days Nutrition and Malaria Control for Child Survival Project National Malaria Control Programme National Public Health and Reference Laboratory Newborn Screening for Sickle Cell Disease National Tuberculosis Control Programme Neglected Tropical Diseases Occupational Health and Safety Occupational health strategy Onchcocerciasis Control Programme for West Africa Out Patient Department Polymerase Chain Reaction Programmatic Management of Drug Resistant TB Prevention of Mother to Child Transmission Prevention of Disease Programme of Work Policy Planning Monitoring and Evaluation Division Quality Assurance

RDTs SBS SCD SCFG SHEP SOP SP SSDM SSTH STH TBCAP ToT TTH U5 UNICEF USAID WHO WIFA

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Rapid Diagnostic Test kits Sector Budget Support Sickle Cell Disease Sickle Cell Foundation of Ghana Social Health Education Project Standard Operating Procedure Sulphadoxine–Pyrimethamine Stores, Supply and Drugs Management Division Schistosomiasis and SoilTransmitted Helminthes Soil-transmitted Helminthes Tuberculosis Control Assistance Program Trainer of Trainers Tamale Teaching Hospital Under Five year olds United Nations Children’s Fund United States Agency for International development World Health Organization Women in the Fertile Age


CHAPTER ONE 1.0

INTRODUCTION

1.1

Ghana Health Service Organization and Mandate

The Ghana Health Service (GHS) was established in 1996 as a Public Service body under Act 525 as required by the 1992 constitution. The GHS is an autonomous executive agency of the Ministry of Health (MoH) and responsible for the implementation of all national health policies. GHS’ independence is designed primarily to ensure that the agency has greater degree of managerial flexibility to achieve its responsibilities, in contrast to what would be permissible within the civil service. The GHS is also independent of the Teaching Hospitals, Private and Mission Hospitals but collaborates to ensure the health of the nation. The Ghana Health Service is mandated “To provide and prudently manage comprehensive and accessible quality health services with emphasis on Primary Health Care in accordance with approved national policies.” The Ghana Health Service has the shared vision to ensure “A Healthy population with Universal Access to Quality Health Service.” 1.2

Challenges in the GHS: end of 2013/beginning of 2014 1.2.1

Health System

a) Weak sub-district structures .There are inadequate public health programmes both at the sub-district and community levels resulting in weak community engagement for routine health activities, particularly EPI and operating CHPS. Progress made in improving immunization coverage in previous years was not maintained in 2014. Progress in CHPS implementation also slowed in 2014. b) Inadequate sector collaboration The weaknesses at the sub-district level were more evident during the cholera outbreak early in 2014 and the inadequate collaboration with other sectors, particularly transport and sanitation, that contribute significantly to the health of Ghanaians contributed in an immense way to the care of cholera cases in the country. 1.2.2

Health Information System

There is low commitment among some senior managers at the district, regional and national level in supporting the use of the DHIMS data for reporting and decision-making. This apathy by managers poses a challenge to improving the data quality at all levels. 1.2.3

Human Resources for Health

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There has been the gradual improvement in the increasing the numbers of skilled staff nationwide in efforts to close the ever-widening equity gaps. Despite these efforts, there has been little impact on rural and remote facilities. Many rural areas lack the minimum number of skilled staff needed to enhance service delivery and quality of care. 1.2.4

Health Financing and Financial Arrangements

The withdrawal of Government of Ghana funds to the Service over the last few years continues to adversely affect service delivery, particularly public health promotion and prevention activities across the country. This is further exacerbated by the continued delayed reimbursement of health facilities by the Nation health Insurance Scheme at all levels. There has been some efforts to collaborate with the National Health Insurance Authority, but this has not yielded much improvement in the late reimbursement of all facilities. Many facilities are unable to sustain their drugs component of the health financing as a result of severe funding constraint. 1.2.5

Infrastructure and Equipment

The health sector has a backlog of uncompleted projects that not only hampered the provision of adequate office space and accommodation for staff across all regions, but also efforts to draw in more clients because of overcrowding in facilities. There is inadequate and in some case a lack of means of transport at health facilities to undertake outreach services into hard-to-reach communities and for health service monitoring activities. In cases where vehicles are available these are either overage or carry a high burden of cost to repair or operate. In some regions there is notably a a poor culture of planned preventive maintenance (PPM) of equipment and facility buildings. This may be in part due to little or no funding for PPM activities. 1.3

Summary of Key Priorities Actions for Ghana Health Service for 2014

There are six broad health sector objectives that underscore the implementation of priority actions in the Sector Programme of Work for 2014: Table 1.0 Health Sector Objectives of the Health Sector Medium-Term Development Plan (HSMTDP) 2014-2017 HO1

Bridge Equity Gaps in Geographical Access to Health Services

HO2

Ensure Sustainable Financing for Health care Delivery and financial protection for the poor

HO3

Improve Efficiency in Governance and Management of the Health System

HO4

Improve Quality of Health Service Delivery including Mental Health Services

HO5

Enhance National Capacity for the attainment of health-related MDGs and sustain gains

16


HO6

Intensify Prevention and Control of Communicable and Non-communicable Diseases

These Health objectives require certain priority actions by the Ghana Health Service. Below is a summary of the priorities for 2014 that will cover report of activities in Chapters Six to Nine. Table 2.0 Summary of Priorities for 2014 1.

Accelerate scale-up of Community-based Health Planning and Services (CHPS) under the ‘close-to-client’ service delivery policy;

2.

Continue implementation MDG 5 Acceleration Framework and related emergency services.

3.

Finalize

staffing

norms

and

implementing

the

Human

Resource

for

Health

(HRH)

deployment plan to provide skilled middle-level health workers for deprived areas 4.

Increase strategic use of Information Communication and Technology to improve health outcomes, especially related to DHIMS2

5.

Step-up disease control activities, particularly surveillance.

6.

Explore avenues for alternate source of funding for implementing key activities in the 2014 Programme of work

17


CHAPTER TWO 2.0

LEADERSHIP AND GOVERNANCE

Leadership and Governance within the Ghana Health Service involve several partners, with differing roles depending on their level of authority. One of the most important players in the governance of the GHS is the Ghana Health Service Council established by the Act 525 with key duties, which are to: ü

Ensure the implementation of the functions of the Service; Submit recommendations on health care delivery policies and programmes to the Minister for Health

ü

Promote collaboration between the Ministry of Health, the Teaching Hospitals and the GHS

ü

Advise the Minister on qualification for post in the Service; and on such matters as the Minister may request.

2.1

The Ghana Health Service Council

A new GHS Council was sworn into office in 2014 chaired Dr. Paul Enin, a private Consultant Gynaecologist. This new Council succeeds the previous one that was chaired by Professor J. Oliver-Commey. The Council held a briefing with Divisional Directors and Programme Managers at the Headquarters. Among some of the activities it undertook during the year were: to clear the backlog of staff promotions in the Service and appoint Divisional Directors to the Family Health and Public Health Directorates. The Council has tasked itself to address issues of professional misconduct, negligence and unethical behavior of certain staff of the Service.

As part of these activities there were

punitive actions taken against individual who were guilty of financial malfeasance reported by the Internal Auditors of GHS, the Auditor-General’s Department and Special Forensic Audits. Named individuals at various levels were found guilty of theft, misappropriation and embezzlement of funds and appropriate disciplinary action taken against them according to the GHS Code of Conduct and Disciplinary Procedures. There are measures in place to retrieve the embezzled funds. In 2014, there were fewer reported cases of payroll irregularities. In the coming year the Council will make visits to the regions to hold briefings with the regional management teams. 2.2

Directors’ Meeting

GHS Divisional Directors hold weekly meetings to update the Office the Director-General on their implementation activities under the agreed programme of work for the year. In 2014,

18


43 of such meetings were held at the Headquarters and a Directors’ Retreat to summarize the holistic progress over the year, while planning for the next year 2015. The Directors’ Retreat provides a forum to discuss implementation of the health sector policies and strategic direction, and is attended by all Divisional and Regional Directors, and Deputy Directors. The theme for the 2014 directors’ retreat was: “Thinking Strategically and Acting Tactically: the Last Push for Achieving the Health MDGs.” At this meeting the DirectorGeneral reaffirmed his vision and engaged the directors to build consensus on performance management in GHS and to deliberate on the best approaches to engage with the Coalition of NGOs in Health, to achieve Ghana’s MDGs. The Director-General reiterated the motto of the GHS: “Your health – Our concern.” he enumerated his vision for the GHS as: 1. All children shall survive beyond five years 2. All Pregnant women shall have a safe delivery and healthy babies 3. All

people

shall

be

educated

to

live

healthy

life

style

and

avoid

unwanted

pregnancies, Communicable and Non-communicable diseases 2.3

Health Summit

The Health Summit is the zenith of annual performance reporting in the Health Sector. It presents a holistic assessment of the progress made or deficits in the Health Sector. In 2014, the health summit was held in May from 12th to 16th at GIMPA-Legon. Among key issues from the holistic assessment are summaries presented in Table 3.0. Table 3.0 Holistic Assessment: 2014 Health Summit 1 2

LEADERSHIP AND GOVERNANCE 1 FDA to look for GSA’s draft Bill, identify areas of conflicts and inform the . Parliamentary Select Committee on Health through MOH

Sept. 2014

FDA/ MOH

MoH will review the formats for presentations to bring out strategic and 2 policy issues during reviews and business meetings. This will be shared at . the Sept. sector working group meeting for consensus.

Aug. 2014

Sept. 2014

PPME, MOH

4

3 MOH to work and complete the LI for HIFRA by end of year 2014 .

Aug. 2014

Dec. 2014

PPME, MOH

5

4 MOH to identify and earmark specific funds towards the completion of . the uncompleted and abandoned projects within the sector.

Aug. 2014

Dec. 2014

MOH

6

5MOH to submit the required information to the Office of the President to . facilitate the transfer of monies accrued from salary cuts of the Executives for the construction of CHPS compounds.

Aug. 2014

Sept. 2014

MOH

7

6 MOH to finalize all requirements and sign the MOU with DANIDA for the . SBS before September sector working group meeting

Aug. 2014

Sept. 2014

MOH

19

Responsibility

Aug. 2014

3

Timeline


8

7 MOH to constitute the adjudication committee for the National Health . Insurance Scheme by end of December 2014

Aug. 2014

Dec. 204

MOH

9

8MOH to work with Parliamentary Select Committee on Health to amend . the NHIS Act, Act 856 to allow direct transfer of the NHIL to the NHIA through MOH

Aug. 2014

Dec. 2014

MOH

Aug. 2014

Dec. 2015

MOH/ KATH

Aug. 2014

Sept. 2014

PPME, MOH

Aug. 2014

Dec. 2014

MOH/ NHIA

Aug. 2014

Sept. 2014

PPME, MOH

Aug. 2014

Sept. 2014

MOH

Aug. 2014

Jan. 2015

MOH/ NAS

Aug. 2014

Sep. 2014

Aug. 2014

Dec. 2014

Aug. 2014

Dec. 2014

Aug. 2014

Sept. 2014

DG, GHS

Aug. 2014

Sept. 2014

HRHD, MOH

Aug. 2014

Dec. 2014

HRHD, MOH

Aug. 2014

Wk.2 Feb. 2014

10 9 MOH should earmark funds to support KATH’s IGF for the completion of . KATH’s Maternity and Children’s Block by December 2015 11 1 MOH to make provision for funding primary health care in the 2015 0 sector budget . 12 1 MOH to work with NHIA and make provision for funding preventive health 1 care . MOH to organize a meeting in September to brainstorm on ways of 13 1 mobilizing financial resources internally. This will be presented at the 2 September HSWG meeting 14 1 MOH should coordinate the Ebola Preparedness and Response, bring all 3 stakeholders along esp. NAS, THs, NBS, Private Practitioners . 15 1 MOH to work with MOF to secure Financial Clearance for the training of 4 200 EMTs by January 2015 . 16 1 NBS to share a concept paper on the NBS and its contribution towards 5 the country’s Ebola preparedness. . FDA and TMPC to sign MOU in areas of safety testing and safety 17 1 monitoring herbal preparations. The two agencies will jointly develop a 6 framework for safety testing and monitoring of such products. MOH will . facilitate the process 18 1 MOH to address all the issues causing the delay in implementing the 7 Supply Chain Master Plan and roll out the plan by Dec 2014 . 19 1 DG - GHS to develop a re-deployment plan for the re-distribution of 8 health staff through out the country. . 20 1 The plan and analysis of current distribution of staff will be presented at 9 the September HSWG meeting . 21 2 MOH to identify critical HR needs by December 2014. This will be the 0 basis for Recruitment and Training of Health staff going forward. . 22 2 MOH to always arrange for MOF to participate in the review and 1 business meetings .

20

NBS

MOH, FDA, TMPC

MOH/ PS


2.4

Ghana Health Service Strategic Plan

The Ghana Health Service Strategic plan outlines key interventions under the sector objectives. This begins with the preparation of the Service’s plans and budgets at district and regional level and summarizing these into a single composite plan for the Service that will be submitted to the Ministry of Finance (MoF) through the Ministry of Health (MoH). In 2014, funding constraints did not permit this procedure, as such all plans and budgets for 2015 were molded on the 2014 plans and budget. 2.5

GAVI Health Systems Strengthening (HSS)

Immunizations in Ghana have been immensely supported by the Global Alliance for Vaccines and Immunization (GAVI). GAVI has also supported health systems strengthening through its GAVI-HSS component. In 2014 Ghana submitted a new proposal for GAVI support, having completed the activities under the previous funding support. The proposal has been accepted and funds are to be disbursed over the course of next year. Ghana however has begun preparations towards graduation off GAVI support, because of the attainment of middle-income status. The Ghana of Ghana will as such be fully responsible for funding vaccine procurement and management of the EPI programme. 2.6

CHPS Operational Policy and Guidelines

The CHPS Operational Policy was reviewed to intensify capacity building at the community (CHPS) level and to advocate for accelerated CHPS implementation by re-orientation of DHMTs, MDAs, Area Councils, Sub-districts, Community Health Committees and Volunteers on CHPS concept. 2.7

Programme of Work

Preparation of the Ghana Strategic plan continued throughout the year in 2014. The strategic objectives for the plan were agreed upon. These have been aligned to the sector objectives in the new Health Sector Medium Development plan (2014-2017) and also aligned to the 9 health systems strengthening pillars of the Ouagadougou Declaration. 2.8

Performance Management Processes

Performance Appraisal All managers within the service signed performance agreements with their supervisors to deliver on some set objectives during the year under review. They were assessed on these objectives during the half-year. It is expected that in the early part of the year 2015, all managers will give an account of their stewardship. The performance appraisal was cascaded down to the other staff of the service during the year under review.

21


2.9

Monitoring and Evaluation

2.9.1 Data Collection and Reporting: Improving the District Health Information Management System (DHIMS2) a) Orientation and training DHIMS2 regional, administrators, regional focal persons and MOH staff were introduced to the newer version of the analysis module and the tracker in DHIMS2. Some staff were also trained to support the management of DHIMS2 at the regional and district level to sustain the gains of DHIMS2 in the GHS. Although this is in place, facilities, regions and districts are still reaching out directly to the National Technical team for troubleshooting, bypassing the district and regional administrators and DHIMS2 focal persons. Some of this was attributed to inadequate orientation on the current versions of DHIMS and has since been addressed by the Technical team. A five-day workshop was organized for the GHS HQ DHIMS2 regional focal persons and staff of MOH. CHNS/CHOS, midwives, and maternity in-charges were trained on the DHIMS2 mobile application for data management and tracking of the MAF (MDG5) indicators. The MDG Acceleration Framework (MAF) – Ghana Action Plan

developed by the Ministry of

Health and Ghana Health Service in collaboration with development partners focuses on improving maternal health (MDG 5) at both community and health care facility levels through the use of evidence-based, feasible and cost-effective interventions to accelerate the reduction of maternal and new born deaths. The MAF key priority activities include; −

Procurement of smart phones for data capture at the community level and in health facilities, and reporting on the family planning programme using the DHIMS2 mobile application.

−

Training of CHNs/CHOs, midwives, and maternity in-charges in the use of these smart phones for data management and supportive supervision

−

Development of an MDG5 indicator dashboard on the smartphones for CHNs/CHOs, midwives, and maternity in-charges to support monitoring and supervision

A

total

of

560

smartphones

(Samsung

Galaxy

Tab

3)

were

procured

through

the

Procurement Department of MOH with specifications provided by the Ghana Health Service – Policy Planning Monitoring and Evaluation Division and ICT Department. Training on the use of the DHIMS2 mobile application on the smartphones was done jointly by the DHIMS2 technical team, the ICT departments of GHS and MOH, staff of the Family Health Division and the Regional Health Directorates. The training covered 60% of subdistricts in across all regions. The target participants were the health centres at the subdistrict level that were submitting their health service reports to their respective districts for entry into DHIMS2 and health centres with limited internet connectivity.

22


The outcome of the training was that these target groups were now conversant with the DHIMS2 mobile app and were given the Samsung Tablets to use in their respective facilities. b) DHIMS2 Governance and Data Access DHIMS2 Governance and data access structure for users and system administrators has been and developed and approved for adoption by the Service. Upon consensus, the PPME and Family Health Divisions, and the EPI Programme tasked the DHIMS2 technical team to develop and deploy an electronic register for capturing individual child health case management data. This is now known as the DHIMS2 eTracker system, a system designed to collect, manage and analyze transactional case based records at the community level. c) The

Ghana Health Service Report periodic

reports

of

the

GHS

published

on

the

organization’s

website

at:

www.ghanahealthservice.org/publications or upon request from the PPME-GHS. Publications include GHS Annual Reports, Ethics Guidelines, GHS Quarterly Performance Bulletin and GHS Half-year Reports, Regional and Programme reports. 2.9.2 Integrated Monitoring Visits The GHS instituted an integrated monitoring system to undertake monitoring and oversight of the implementation activities in the regions. An Integrated Monitoring Tool is developed for this purpose and a league table updated to reflect individual regions’ performance at the end of the year. The first integrated visit was held from May 13 to July 5 2013. Some general observations from the visit are summarized below: a) Monitoring Plan with Access Coverage and Poor Information Dissemination Culture Only one (1) region i.e. UER, has some data on access coverage for health care, clinical care and outreach services. Some regions do not have capacity in using the GPS to capture the coordinates of their facilities

The

b) Infrastructure old asbestos roofing

sheets

on

staff

residential

accommodation

which

needs

replacement in Ashanti Region; RHD office block in Ho which is made up of 70% wood in this era of rampant fire outbreak; Sea effect on equipment in the Central Region e.g. air conditioners, ceiling, hospital beds; Poor sewerage system in Sunyani Hospital c) Operational Research Poor generation of information through relevant Operational Research d) NHIS reimbursement Delays in reimbursement with an average of 4 months arrears; Errors on claims forms leading to arbitrary claim cuts; High accreditation fee; Inability to recover cost; Low Tariffs; Cheques not separated into drugs and services.

23


e) Occupational Health and Expired Drugs in some of the regional stores Occupational Health activities are not regularized in the regions. Regions will have to operationalize the DHIMS 2–based OHS surveillance system to provide data for decision making. 2.10

Audit of Budget Management Centres (BMCs) in GHS

In 2014, three hundred (300) health facilities were scheduled for auditing. Out of these 78% (233) were audited. The facilities audited were Regional Health Directorates, District Health Directorates, Regional Hospitals, District Hospitals, Polyclinics, Health Centres and some CHPS compounds. The number of audits conducted in 2014 in the Central region fell in comparison to numbers in 2013. The Brong-Ahafo, region maintained similar audit coverage in 2014 as for 2013. Audits increased in all the other regions with the highest being in the Volta and Eastern regions. (Figure 1.0) Figure 1.0 Audits of BMCs by Region (Regional Coverage)

2014" 2013" 100" 282723

2012"

Covera ge"(%)""

2.10.1 Formation of Audit Report Implementation Committee (ARIC) All

Regional

Health

Directorates

have

formed

Functional

3823

544446

Audit

Report

Implementation

2827 31 12 12 18 16 13 13 12 12 11

Committees (ARIC). At the District Health Directorates, Regional Hospitals and other category

16 18 16 17 13 14

16

of BMCs, 80% of health facilities visited in 2014 had also formed their Audit Report Implementation Committees (ARIC). Of these ARICs formed at the District level, 61% are active.

0"

24


2.10.2 Performance of Regional Internal Audit Units All ten Regional Internal Audit Units were assessed in the areas of Annual Plan, Functional ARICs, Submission of reports and BMCs audit coverage. Six regions comprising Eastern, Ashanti, Northern, Upper East, Greater Accra and Western scored above the set average (9/12) while remaining four regions –Volta, Central, Upper West and Brong-Ahafo performed below average. 2.10.3 Audit Recommendations Implemented There was improvement in the implementation of audit recommendations made in both internal and external audit reports. Out of one thousand, one hundred and twelve (1,112) observations raised in the 2011/2012 Ghana Audit Service report to Public Accounts Committee of Parliament (PAC), one thousand, and seventy four (1074) were resolved, representing (97%) with thirty eight (38) representing (3%) are still pending. 2.10.4 Audits Findings Though there was improvement in compliance with laws and regulations in respect of financial operations, there were few other areas that were a source of concern. The following were the observations made at the BMCs visited in 2014: −

61% reduction in misappropriation of funds by the Health facilities visited.

−

23% decrease in overdue staff advances over 2013.

−

9% decrease in unretired advance.

−

Non-remittances of advances however increased by 23%.

−

11% reduction in unearned salaries over 2013

−

17% decrease in non-acquitted PVs as compared with 2013.

−

16% reduction in items not routed through stores.

The above occurrences may be attributed to the weaknesses in the internal control environment that includes; −

Weak budgetary control system

−

Management override of laid down procedures

−

Weak monitoring and supervision at all levels

25


CHAPTER THREE 3.0

FINANCE

3.1

Performance Improvement

A number of activities were carried out in in 2014 that resulted in the implementation of a Resource Tracking Tool (RTT), which was developed in 2013. A training of trainers was held for of some regional managers and selected district managers on the RTT in all ten regions. This will enable a regional cascade of training on the RTT for finance and non-finance managers in all BMCs to ensure full utilization of the tool. However because there was no release of MAF funds in 2014, the rollout of RTT is limited. The transaction model of the ACCPAC accounting software implemented at the Greater Accra Regional Health Directorate (GRHD) was monitored and any challenges encountered were documented to provide learning for a smooth rollout in the other regions. There was the need to build capacity of regional finance managers (2 per region) to provide constant and sustainable support for smooth implementation. There were quarterly validations of BMCs financial statements across all ten regions. The first was to validate the 2014 financial data for the 2013 financial statements. The last three were to validate the financial data for first three quarters of 2014. There were no visits by the Headquarters to the third quarter validation exercise at the BMCs. An excel-based transactional tool has been developed for BMCs below the Region to minimize

paper-based

financial

transactions,

processing

and

reporting.

A

hospital

transactional tool was been developed in 2014. The tool was piloted in the Volta Region in November 2014 after a series of stakeholder acceptance tests.

If the pilot is successful the

there will be scale up to other hospitals in the country. The feasibility of utilizing the Accounting model in the Logistics Management Information Systems (LMIS) software being used in the Volta, Greater Accra and Eastern Regions was conducted. The outcome so far shows that the Accounting module can be used with some tweaking of the system. There was the audit of the 2013 financial statement by the Ghana Audit Service and Ernst & Young as part of the cycles in Public Financial Management. There were fewer observations on procurements, incompleteness of fixed asset register, unearned salaries and some recommendations to strengthen internal controls in 2014 in comparison to 2013. These cleared by both auditors after deliberations.

26


There was a review meeting with all regional accountants, financial monitors and other senior finance managers of the Service. There was financial monitoring and supervision visits in Greater Accra, Eastern and Volta Regions. The numbers of accounting staff are inadequate; there are a total of 1000,although the estimated adequacy is 5000 accounts staff. However, even for the number available, there is an issue of inequitable distribution. Compilation of a comprehensive data on all finance staff in the Service has been planned to facilitate the redistribution of staff. At the end of 2014 data has been obtained on 9 regions. A re-distribution exercise will be scheduled for 2015 based on the outcome. 3.2

2013 Financial Report

Ghana Health Service un-Audited Financial Reports for year ending 31st December 2014 Ghana Health Service Consolidated Balance Sheet

(Ghana Cedis)

As At: 12/31/2014 Current Assets Cash and Bank Balances

104,685,416.25

Accounts Receivable

237,373,958.98 342,059,375.23

Current Liabilities Accounts Payable

86,696,555.07

NET CURRENT ASSETS

255,362,820.16

Consolidated Statement of Revenue and Expenditure For the year ending 12/31/2014 Income Net Operating Income

542,568,606.93

Non Operating Income

770,654,512.17

TOTAL INCOME

1,313,223,119.10

Expenditure Employee Compensation

674,120,617.13

Goods & Service

463,826,877.44

Assets (Purchases)

12,850,891.92

Programme Expenses

128,787,549.06

TOTAL EXPENDITURE

1,279,585,935.55

INCOME SURPLUS

33,637,183.55

27


CHAPTER FOUR 4.0

HUMAN RESOURCES FOR HEALTH

4.1

Analysis of Payroll Data

Analysis of data from Integrated Personnel and Payroll Database (IPPD) indicates that as at December 2014, the total number of health workforce on the MOH payroll was Eighty-Four Thousand and Eight (84,008) which is about 25% increase over the previous year. The corresponding Net Salary of the Health Workforce is Seventy-Three million, Two Hundred and Forty-Six Thousand, Seven Hundred and Seventy Ghana cedis (GH¢73,246,770.07) representing about 14.5% increase over the previous year. This figure excludes trainees within the health training institutions. The distribution of the health workforce by staff category and agency is presented below. Figure 4.1 Distribution of Health Workforce by Agency, 2014 NAS, 962 , 1%

PsyHosp, 1,901 , 2%

Ghana Health Service (GHS) has the highest number of health workforce

TH, 9,260 , 11%

MOH, 133 , 0%

CHAG, 11,579 , 14%

MDC, 917 , 1% HTIs, 5,174 , 6%

of Fifty-Five Thousand and Eighty-Two (54,082)

representing

64%

of

the

total workforce in the sector. This represents a 4% increase in GHS staffing level over the year 2013. The

GHS, 54,082 , 65%

Christian Health Association of Ghana (CHAG) also has 14%, followed by the Teaching Hospitals with 11%.

Trend analysis of Health Workforce distribution by Agencies revealed that all Agencies except Health Training Institutions and Health Trainees are making steady increase in the number of health workforce. The number of Health Trainees on payroll has reduced significantly because trainees allowance has been curtailed even though the intake into Health Training Institutions has rather witnessed massive increases over the years. The Human Resource for Health (HRH) situation on payroll as at December 2014 stands at 84,008 (excluding Health Trainees). Of this, Greater Accra Region has the highest number of HRH (20.77%) with Upper West and Upper East Regions having the lowest.

28


Figure 4.2 Regional Distribution of HRH (Per cent) - 2014 (All Agencies) 25.00

20.77

Percentage Distribution

20.00

18.17

15.00

10.00

7.85

8.49

8.55

8.62

BAR

VR

CR

9.31

9.95

5.04

5.00

3.25

-

UWR

UER

WR

NR

ER

AR

GAR

Regions

Trend analysis of HRH distribution of health workforce by region indicates that Greater Accra region maintained similar proportion of HRH from 2010 to 2012 with an increase of 0.81% in 2012 but reduced by 1.2% in 2013. In 2014, the region made a net gain of 0.24% in in their HRH strength. On the other hand, Brong Ahafo, Eastern and Volta Regions recorded declines in the number of HRH. Northern and Ashanti Regions have shown steady increases over the years. The increase in Northern Region is due to massive production of enrolled nurses in the region and expansion of the Tamale Teaching Hospital, which continues to attract significant number of HRH into the region. Figure 4.3 Trend of Distribution of HRH by Region (All Agencies) 25.00

Percentage Distribution

20.00

2010

15.00

2011 2012

10.00

2013 2014

5.00

UWR

UER

NR

WR

CR

BAR

VR

Regions

29

ER

AR

GAR


Figure 4.4 Trend of HR Distribution in GHS, 2010 – 2014 12,000

Number of Workforce

10,000 8,000 2010 2011

6,000

2012 4,000

2013 2014

2,000 AR

BAR

CR

ER

GAR

NR

UER

UWR

VR

WR

Regions

Trend analysis shows that all regions with the exception of Central and Greater Accra, all regions had steady rise in health workforce over the last five years. Even though Greater Accra experienced a decrease in their staff strength, the region continue to be the most endowed in terms of HRH followed by Ashanti, Eastern, Western, Volta, Northern, Central, Brong-Ahafo, Upper East and Upper West Regions in descending order. Even though the three regions in the north recorded some increases in the HRH due to the numerous initiatives to bring about equity in HR distribution, they are still below expectation. Figure 4.5. Trend of Midwives Distribution by Region in GHS, 2010 – 2014 800 700

Number of Workforce

600 500

2010 2011

400

2012 300

2013 2014

200 100 0

AR

BAR

CR

ER

GAR

NR

UER

UWR

VR

WR

Regions

In 2014, Ashanti region recorded the highest increase in the number of midwives even though Greater Accra Region still has the highest number of midwives in the GHS having consistently over 600 Midwives at post in the five-year period. There has been some improvement in the number of midwives across the regions even though Central and Volta regions are yet to fully recover the net losses of midwives over the last five years due to

30


retirements. In line with the target set by MDG 5 to reduce maternal mortality ratio by ¾ in 2015 the Health Sector in Ghana has over the years embarked on various interventions and programmes to improve access to quality health services with special emphasis on maternal, neonatal and adolescent health services. The midwives to Women in Fertile Age (WIFA) ratio have recorded some improvement as a consequence increased production of midwives. Figure 4.6 Trend of Midwives to WIFA Population, 2009 – 2014

Figure 4.7 Trend of Midwives to WIFA Ratio by Region, 2010 - 2014

The figure above shows the trend of Midwives to Population ratio by year and region. The trends show that Western Region has the worst Midwives to Population ratio above 2,000 over the four (3) years period but witnessed improvement in 2013 and 2014. Northern Region also witnessed Midwives to Population ratio above 2,000 for 2013 and 2014. All the regions recorded improvement in the Midwives to Population ratio in 2014. The national Midwife to WIFA population ratio has improved from 1:1,400 in 2013 to 1:1,374 in 2014.

31


Figure 4.8 Distribution of medical officers in GHS, 2013 & 2014

As shown in figure 4.8 above, all the regions recorded slight increases in the number of medical officers except Central and Brong-Ahafo regions where many medical officers were upgraded to specialists. Furthermore, doctor to population ratio has improved in many regions but the issue of inequity in doctor distribution continues to linger. There has been a marginal improvement in the Doctor population ratio from 1:10,000 in 2013 to 1:9043 in 2014. Figure 4.9 Trend of Doctor to Population Ratio by Region, 2010 - 2014

Distribution of the skill-mix of nurses Figure 4.9 depicts the current skill mix of professionals and enrolled nurses. Grossly, the GHS has 44.8% of clinical nurses being professionals as against 55.2% who are auxiliary. There are huge inter-regional variations with the widest in northern region where only 22% of the nurses are professionals. No region except Greater Accra region meets the norm of 60% professional nurses to 40% auxiliary nurses. The situation has huge implications for

32


quality of care and therefore requires a critical look at the number of enrolled nurses being produced. Figure 4.10 Skill-Mix of Clinical Nurses by region 2014

Age distribution of health workforce on payroll: Analysis of the age distribution of the health workforce on payroll shows that those in the 25 to 35 age bracket constitute 66.24% of the total workforce. This indicates that the health workforce is largely young. This has implications for training and capacity development. On the other hand, those in the 56 – 60 age bracket constitute only 6.22% and would be retiring from the within the next 5 years, majority of whom are nurses and midwives. Mentorship and succession planning need to be strengthened to ensure that few experienced staff who would be retiring enhances the competencies to take up the mantle of leadership and service delivery without compromising quality. Figure 4.11 Age Distribution of the total Health Workforce 12,000 2010

Number of RGNs

10,000

2011

2012

8,000

2013 2014

6,000 4,000 2,000