Rethinking Our Strategy Towards Health Investment and Delivery: The 2020 Budget

On November 13, 2019, the Finance Minister, Mr. Ken Ofori-Atta presented to Parliament, the Budget Statement and Economic Policy of the government of Ghana for the 2020 financial year. The budget which was themed; “Consolidating the gains for growth, jobs and prosperity for all” highlighted the government’s program and policies for the year.

On government programs and policies for the health sector, several positive developments were highlighted in the budget such as the intention to extend the use of Electronic Medical Records to all Teaching, Regional, District and Psychiatric Hospitals as well as Polyclinics. This if achieved could enhance significantly the patient experience and also ensure patient safety. However, the cost component is not provided. Another positive development was the commitment that in the next financial year, the Ministry of Health will pursue the health sector decentralization agenda and review the Ghana Health Service Act 1996, (Act 525.) This, if done, would ensure considerable autonomy for district hospitals and allow them to better serve their communities. More importantly, this can only be achieved if the commitment to develop Legislative Instruments (LIs) for the Health Acts that are without LIs is carried through. Also, the need for the realignment of health service delivery and strengthening primary health care and health systems in the country was highlighted. This is long overdue and the intention by government to bring this to completion is gratifying.

Investment in health should always be geared towards improved health outcomes and the achievement of universal health coverage. However, a look at the health sector with regards to investment and healthcare delivery as presented in the budget statement raises several concerns.

1. The statement seems to be heavy on health inputs in the last financial year ranging from how much was spent on nursing allowances, how many health professionals were recruited (though the numbers are disputed) the number of health infrastructure that will be completed in the previous year etc. Though this is intended to show the government’s commitment to health investment as a fulcrum for galvanizing health improvement, it cannot by itself be an indicator of the state of healthcare in Ghana.
2. There is little mention of what health outcomes were achieved from previous years based on the government’s health investments, making it difficult to quantify these investments in value for money terms. For example, though the Finance Minister touches on the country’s improving life expectancy and why the need for specialized services for the aged is becoming paramount, little indication is given of how quickly life expectancy is increasing or what our current life expectancy is. There is a failure to recognize that only 3.38% of the population is 65 years and above, and 1.81% above 70 years. Meaning of all those who live past 65 years, 50% of them die before they reach 70 years.
3. The statement was thin on year-on-year health investment growth rate of decline, let alone an explanation of what may have informed these trends. This flaw makes it difficult for trends of health investment to be correlated and the commitment of the government to be judged.
4. With regards to the National Health Insurance Scheme (NHIS), the budget indicates that it would target to enrol 430,000 Ghanaians in 2020. This accounts for 1.43% of the population. With our current population growth rate of 2.2%, that target is not ambitious enough. The net effect could be a reduction of the current NHIS coverage of 36.3%.
5. Information on total health expenditure from previous years and any growth rate in this sector are not indicated. Therefore, it is difficult to determine whether health investments in the next financial year will be adequate for the current population, let alone cater for projected population growth of 2.2%.
6. The government would have benefited from informing us on what their strategy for health investment was, as well as their primary focus. Additionally, should have given an estimate of how much they expect to spend on health in 2020, in total and in per capita terms. This would have allowed for an informed discussion on the government’s ambition or the lack thereof.
7. The government indicates that it will continue to pay allowances to nurses, it estimates that 49,000 nurse trainees in public institutions will benefit in the 2020 financial year. Though we are given information on what was paid in previous years (GH¢210,840,800, GH¢198,200,000 and GH¢57,800,000 to 49,000 nursing trainees in public nursing institutions for the 2017/2018, 2018/2019 and 2019/2020 academic years respectively), no projections or estimates are provided for the 2020 financial year. More importantly, considering that there is a backlog of trained nurses to be employed and the mandatory bonding of nurses has been removed, is this expenditure one that can be justified?
8. The budget seems to suggest that the government is still investing more in infrastructural development and construction of health facilities and less on human resource training and upskilling. Though many health infrastructures started in previous years are yet to be completed, the Finance Minister indicates that there will be the commencement of the construction of twelve new health structures across the country including, the reconstruction of the Central Medical Store.

Overall, the health aspect of the budget does not suggest that we are taking our quest to obtain universal health coverage seriously. It gives little indication that as a country we are prepared to rethink our strategy towards health investment and delivery or that we are purposeful in our approach to address our huge healthcare disparities. This is of grave concern, as Ghana currently has a Health Access Coefficient of 39.3% meaning 69.7% of our citizens are without adequate health access. This could be worsened by the projected reduction in NHIS coverage based on the stated targets for 2020. It would have been informative if the budget highlighted health outcomes that were trending positively to help improve the health access coefficient annual growth rate from its current 1.8%. As without this rate changing significantly, it will take us another 39 years to achieve universal health coverage assuming our population growth rate remains unchanged.

Kwame Sarpong Asiedu is a Democracy & Development (D&D) Fellow in Health at CDD-Ghana. He is a pharmacist by profession, with 19 years of practice, including lecturing in Ghana and the United Kingdom. He previously held various senior leadership roles at Alliance Boots, now Walgreens Boots Alliance, rising to the position of Head of Pharmacy Operations for East Anglia. Dr. Sarpong Asiedu is a member of the Royal Pharmaceutical Society of Great Britain, Institute of Pharmacy Management International, and The Pharmaceutical Society of Ghana.