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Health News of Thursday, 7 February 2008

Source: Public Agenda

Inconsistent Funding is Hurting the Health Sector

Anthony Robbins once said "The higher your energy level, the more efficient your body. The more efficient your body, the better you feel and the more you will use your talent to produce outstanding results."

Thus, the importance of a healthy populace, which serves as a pool from which efficient human resource can be drawn, cannot be over-emphasised.

At the Millennium Summit in September of 2000, the members of the United Nations resolved to address lapses in global development efforts, as well as, the persistence of poverty around the world, and consequently adopted the eight Millennium Development Goals (MDGs).

Three of the MDGs bother on health. The fourth goal is to reduce by two-thirds, between 1990 and 2015, the under-five mortality rate; goal five is to reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio; and goal number six seeks to halt the onslaught of HIV/AIDS, malaria, and other diseases by 2015 and eventually begin to reverse the spread of HIV/AIDS in particular.

In its 2006 review of the health sector's programme of work (2002-2006), the Ministry of Health noted: "Basic health systems are a prerequisite to achieving the MDGs and other priority health outcomes."

The Ministry, however, acknowledged that "A main challenge is to increase overall coverage and to reach the poor more effectively." In addition, it observed that the task requires more careful planning of health facilities and taking into consideration current utilization of facilities, the availability of human resources and core support systems.

Furthermore, the district level remains the key focus of attention as well as efforts to deploy and motivate productivity among health workers and demand better accountability for service results from managers, the Ministry stated.

"It appears, however, that despite the policy of focusing on primary health care, most of the increased spending in the health sector in recent years has gone into other sectors, as the primary health component of overall health sector budget has declined from 70.5% in 2001 to 63.9% in 2006", according to a recent report titled "Review of Trends in Public Spending for Education and Health in Ghana (2002 - 2006)."

The November 2007 document is the result of a joint effort by the Brookings Institution Transparency and Accountability Project (BITAP) and the Integrated Social Development Centre (ISODEC). It examines expenditures in two major social sectors, education and health, at the national and local levels. It looks at the national policies in the education and health sectors by analysing resource allocations to these sectors over time, with particular emphasis on transparency, and accountability.

The report calls upon the Ghana government to commit itself to allocate more funds to investment expenditure in the health sector. This will ensure some stability in development project implementation even when there is donor apathy.

The call is against the backdrop that despite the overall increase in health-sector expenditures, the 2006 sector review spoke of the "persistent under-achievement in terms of targets", blaming the situation in part on a decrease in "flexible funding at district and sub-district levels"

With respect to the MDGs, the review observed that Ghana's performance and progress toward MDG five (5) was deemed visible, but slow. To reduce maternal mortality by three quarters by 2015, it prescribed: invest in measurement of trends in maternal mortality; promote institutional deliveries in health centers for normal deliveries by making them more acceptable to women, ensuring basic obstetric services are provided and by improving health centre to hospital referral; improve clinical quality of care in hospitals; and target the poorest and most disadvantaged sectors of society to provide better access to services, especially for intrapartum and emergency delivery services, as inequities are greatest in these areas.

That notwithstanding, inadequate funding seems to threaten the implementation of these prescribed solutions. As the BITAP/ISODEC report reveals, "Most of the public sector informants interviewed at the regional and district levels complained of inadequacy of funding for their respective sectors. As a result, they lamented about inadequate infrastructure, staffing, and equipment in some areas."

Besides, "Some public sector respondents were of the opinion that resources from the central government level are not allocated equitably, especially when it comes to poor regions and districts."

The case in Ghana has always been that funding for the health sector mainly comes from the central government. It must be mentioned here that donors play a key role in the funding of the health sector but the bulk of the funding comes from the central government. For the period 2001 to 2007, the Ghana government, on the average took about 72 percent of the total budget of the Ministry of Health (MOH) while donors took about 28 percent.

On the average, about 77.5 percent of the MOH's budget was used on recurrent expenditure, while about 22.5 percent was spent on capital expenditure over the period. Personal emoluments, administration and service are classified as recurrent expenditure while investment is classified as capital or development expenditure.

In most instances, however, donors preferred to fund the capital expenditure of the sector. Apart from 2001, the bulk of capital expenditures of the MOH were funded by donors to the extent that in 2006 the central government planned to take only 6 percent of the capital expenditure.

It can be recalled that in 2001, as part of measures to contain the run-away inflation that characterized the previous year, government drastically scaled back spending. In the process, total discretionary expenditures, which include health and education spending, declined by 10.5% and health-sector spending fell by 6.6%. As a share of Gross Domestic Product (GDP), health expenditures in 2001 were 1.1%, down from 1.3% and 1.6% in 2000 and 1999, respectively. Subsequently, with the restoration of macro-economic stability and a relaxation in spending, the health sector's share of GDP has risen steadily, reaching 2.7% in 2006.

The increase in health-sector expenditures was due in part to the government's introduction of the Ghana Poverty Reduction Strategy (GPRS), the local version of the IMF-World Bank Poverty Reduction Strategy Papers (PRSPs), which was a pre-requisite for accessing debt relief under the Heavily Indebted Poor Country (HIPC) Initiative.

In 2003, the government began the implementation of GPRS, which contained a human development module that focused on health and education. The government's medium-term priority since the beginning of the implementation of the GPRS in 2003 has been the expansion and the improvement of the quality of the delivery of basic services, while addressing issues of geographical and gender equity in access to these services. The key priority measures are in the areas of education and health.

In the health sector, priority measures included enhancing access to and delivery of health services; increasing access to safe drinking water in rural areas; and improving access to adequate sanitation.

According to the 2003 Annual Progress Report (APR) on the implementation of the GPRS, the achievements of poverty-targeted health interventions with regard to these objectives have so far been mixed. Key indicators like infant mortality, under-5 mortality and child malnutrition have increased in recent years.

The APR suggests that this is occurring in the context of increasing investments in the health sector.

On the contrary, the BITAP/ISODEC study reveals that available data at the regional and district levels indicates that the amounts received do not show any consistent pattern towards addressing the development needs of the health sector.

"In a certain year the amount received increased, in another year it reduced drastically."

BITAP and ISODEC therefore hold the view that "Policy implementation cannot be coherent if resource flow is not consistent."

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