How and why is the role of government in health service provision changing? This question and the problems of change are being examined by London School of Hygiene and Tropical Medicine researchers in the case of Ghana. Their work forms one of several country case studies on the health sector undertaken as part of a wider research programme on the Role of Government in Adjusting Economies. They focused on four specific health policies - user fees, autonomous hospitals, contracting out, and regulating and enabling the private sector. Lack of a well developed market sector and the health status of the population are among the critical factors that lead them to conclude that direct government involvement in the health sector should continue in order to provide safeguards over the new practices.

Reform in Ghana's health sector has taken place against a background of structural adjustment and public service reform programmes running since the 1980s and through the 1990s. Key components of the reform agenda include introduction of user fees, full cost recovery for drugs, creating 'autonomous' hospitals, restructuring and strengthening health organisation and management at central and district levels and, more recently, legislating for the creation of a Ghana Health Service as an executive agency. Reforms have by and large been introduced step-by-step rather than as a comprehensive package. The focus has been on improving the organisation and management of official health services rather than transforming the scope and nature of government involvement in the health sector. Government remains the dominant service provider in terms of facilities, whilst informal providers have a bigger share of the market in terms of number of clients or volume of expenditure.

The report offers evidence for the view that in Ghana's case, there is a case for major continuing government involvement in health care financing and provision, especially for the poorest people, including women and children. It notes that:

• despite progress in strengthening the capacity of the health ministry, its ability to undertake more fundamental reforms is affected by a combination of internal and external factors, including lack of internal skills, resources, political backing, and private sector capacity
• the design and management of user fees/cost recovery policy has been weak
• implementation of the concept of autonomous hospitals is behind schedule due to vested interests in centralised control and capacity problems in the autonomous hospitals themselves
• capacity to design and manage contracts is constrained by a number of factors, including skills, resistance, and limited private sector development
• capacity on the part of government to regulate and enable the private sector is weakened by inconsistent, fragmented and incomplete legal frameworks, and lack of information.

Policy-relevant recommendations in the report include the following:

• Radical new roles for government need to be approached and adopted with caution.
• The capacity to perform traditional roles needs strengthening while improving the capacity to diversify roles.
• The private sector needs to be courted over time but, in the meantime, contracting for service provision may be easier to develop with public and quasi-public providers (such as mission hospitals).
• Prerequisites for the government performance of new roles such as improved regulatory frameworks, information, and internal skills need to be developed.

Source(s):
The Case of the Health Sector in Ghana. Role of Government in Adjusting Economies, Paper 26, P. Smithson, A. Asamoah-Baah, & A. Mills (1997)

Funded by: DfID, UK (1994-98)

id21 Research Highlight: 1998-Mar-24

Further Information:
Paul Smithson
Health Policy Unit
London School of Hygiene and Tropical Medicine
Kepell Street
London
WC1E 7HT
UK

Tel: +44 (0)171 927 2354
Fax: +44 (0) 171 637 5391
Contact the contributor: A.Mills@lshtm.ac.uk

Health Policy Unit, London School of Hygiene and Tropical Medicine, UK