Links in Developing Country Health Systems

1
Links in Developing Country Health Systems

• By
• Dr Edward Addai
• Director Policy Planning Monitoring and
  Evaluation
• MOH, Ghana
• eddieaddai_at_yahoo.co.uk

2
In this Presentation

• Snap of the Ghana context including health system
  challenges
• Position links in the national health response
  suggesting potential areas for Links
• Share some experiences with Links in Ghana
• Suggest some conditions for success

3
Ghana Country Context

• Small country with about 23 million population
• Rapid urbanization gt50 population will be living
  in urban areas by 2010
• Population growth outstripped infrastructure and
  social services development
• Small economy
• GDP of about USD 460 to 500 and health spending
  about 22 USD per capita
• But hopes to become a middle income country by
  2015
• We have discovered oil (Black gold) in addition
  to the real gold!!!! and cocoa
• Young democracy of almost 16 yrs
• Open media, vibrant Parliament and increasingly
  empowered civil society
• Challenge of balancing short term visible results
  with long term sustainable development
• Effects of Globalization seen in the country
• Food crisis, Energy crisis, climate change
• Globalization of ideas and lifestyles sometimes
  disrupting traditional institutions and practices
• Free movement of people and goods without strong
  regulation

4
Health System

• Burden of diseases
• High burden of Communicable disease
• High pregnancy related morbidity and mortality
• Malnutrition and rising obesity
• Rising non communicable diseases including road
  traffic accidents and mental health conditions

5
Male life expectancy by GDP per capita, 2004, WHO
AFRO countries
Life expectancy by level of economic
developmentGhana 2004
Female life expectancy by GDP per capita, 2004,
WHO AFRO countries
Ghana
Ghana
Within the African Region, life expectancy in
Ghana is higher than expected on the basis of its
GDP per capita only (PPP Int. ).
(Source WHO, 2006)
6
Changing Risk Factors

• Environmental sanitation getting worse
• Risk factors that can be changed are worsening
• Cigarette smoking, alcohol, diabetes, obesity,
  behavioural factors, etc
• Factors that promote peoples health are not
  popular
• Exercise, fruits, vegetables, rest, etc.
• Certain practices are not helping either
• Funerals, RTA, etc.

7
Risk factor transition
Prevalence of adult females who are obese and
children under 5 stunted for age
Prevalence of tobacco use among adults aged 15
and over in AFRO countries
Although still in an early phase, nutrition
transition (decreasing underweight and increasing
obesity) is under way.
Ghana's adult tobacco smoking prevalence is among
the lowest in AFRO countries.
(Source WHO, 2006)
(Source WHO, 2006)
8
Child survival interventions immunization
coverage
Average DTP 3 and measles immunization coverage,
Ghana, 1980-2004
Children who have received all their vaccinations
(BCG, measles, DPT-3 and three doses of polio
vaccine), Ghana, DHS, 1988-2003
Average levels of DTP3 and measles immunization
coverage have been continuously improved over the
last 2 decades.
DHS data also confirm the substantial progress in
childhood immunization.
(Source DHS WHO, 2006)
(Source WHO/UNICEF, 2006)
9
Child survival interventions
Skilled birth attendance and children with ARI
taken for treatment, Ghana, DHS, 1986-2003
Coverage of ORT, fever with antimalarial drugs
treatment and Vitamin A supplementation, Ghana,
DHS, 2003
However, skilled attendance at delivery continues
to lag behind. There was very little progress
since 1988. In general, there is an improvement
in treatment seeking for ARI between the 1988 and
2003 surveys, but the progress was modest.
Other child survival interventions are also in
place. On average their coverage is relatively
high.
(Source DHS WHO, 2006)
(Source DHS WHO, 2006)
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TB control
DOTS status in AFRO countries, 2004
Ghana
Ghana has achieved the DOTS targets of treatment
success rates 70 or over and DOTS detection
rates 50 or over.
(Source WHO, 2006)
11
Health System Challenges

• Over-focused on delivery of medical technology
  with little attention to behavioral, nutritional
  and environmental interventions
• Brain drain and huge gaps in access to services
  and in staffing of frontline health facilities
  make reliable, quality services difficult to
  attainable, particularly in rural and peri-urban
  areas.
• Shortage of equipment, consumables supplies and
  some essential drugs
• Weak regulation of public and private sector.
• Inadequate financing of the health sector
• The introduction of the National Health Insurance
  Scheme presents new opportunities.

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Summary of our response

• We have a new health policy and 5 Year Program of
  Work to guide investments and actions of
  stakeholders
• We are expanding training institutions and have
  increased salary of health workers to ensure that
  we have adequate health workers
• We have introduced a national health insurance
  scheme
• We are focusing on scaling up investments towards
  achieving MDGs
• We are promoting health literacy and adoption of
  healthy lifestyles through our regenerative
  health and nutrition program
• We have committed leaders and staff to help us
  focus on what matters

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Our Limitations

• Inadequate resources limit
• the scope of our efforts
• Major gaps are in district level surgery and
  psychiatry
• Middle level training
• Medical rehabilitation
• the scale of our efforts
• Rural and peri-urban areas loose out
• Maternal and new born care????
• Rehabilitating the backlog of deteriorating
  health infrastructure and the need to construct
  new ones
• Replacement of Obsolete equipment
• Staffing and equipping training institutions
• Postgraduate placements, internet, books and
  other teaching materials

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Links present opportunities

• Fill gaps in training and service delivery
• Service delivery links should always be linked to
  capacity development
• Standalone training links
• Fill resource and sometimes financing gap
• Should never be standalone
• Cultural and knowledge exchange and learning new
  ways of service provision and management

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But links can be disruptive

• When the links equation is not respected
• National priorities International Opportunities
  Coordination
• Links Model
• Not an AID instrument but a true partnership
• Starts as an individual initiative but moves
  quickly into institutional links to ensure
  sustainability
• Is dynamic starts small, evolves and takes time
• Is mutually beneficial

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What we have done

• Set up a Links desk to be a facilitator rather
  than a gate keeper for Links
• Developed a Code of Practice for Links
• Conducting a survey leading to database of Links
• Consolidating existing Links and looking at
  forging new ones
• Bolgatanga NTC
• Kintampo Medical Assistant Psychiatry training
• ?University of Cape Coast Medical Assistant
  Training
• ??Pantang Mental Hospital
• ???? Scaling up middle level training
• ????

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Lessons on Conditions for Success

• Moves quickly from individual initiatives to
  institutional links
• Focus the links on clearly defined objectives
• Balance short term objectives and long term
  sustainability
• Integrate activities into the program of work and
  results package of countries and institutions
• Genuine commitment to dialogue and work together
  based on mutual respect
• Create a forum for information sharing and joint
  learning
• Needs to be facilitated

18
Thank you