The health status of Ghanaians has evolved over time, from predominant inflictions from infectious diseases and negative maternal and child health outcomes that prevailed at the time of independence in the late 1950s, to the addition of non-communicable diseases (NCDs) such as hypertension, stroke, diabetes, cancers, etc. that prevail in present times.

1. EminentPanelConference,Accra,August7th -9th,2020
HEALTH ACCESS INTERVENTIONS IN GHANA
Nkechi S. Owoo*, Monica P. Lambon-Quayefio* and Brad Wong+
*Department of Economics, University of Ghana
+Copenhagen Consensus

2. INTERVENTION AND RELEVANCE FOR GHANA
• Changing landscape of disease in Ghana
- Double burden of disease (infectious e.g. malaria, diarrhoea, etc + NCDs e.g. diabetes,
stroke, etc)
- Disease patterns also often differ across age, gender, location and socioeconomic
status
• Consensus in Ghana, and in many other developing country contexts, that
majority of health problems observed experienced by the poor (Bukhman
et al., 2015).
- Experience the most catastrophic healthcare expenditures (Surhcke et al., 2006);
- live in less safe and sanitary environments with increased likelihoods of disease
infestations;
- limited social support systems (de-Graft Aikins and Koram, 2017);
- lack participatory power in changing community and health systems (Greif et al.,
2011; Capewell and Graham, 2010).

3. INTERVENTIONS AND RELEVANCE FOR GHANA
• Interventions focus on rural and poor section of population
- Expanding insurance coverage by transferring the cost of premiums from the
poor to the non-poor
- Expand and maintain terrain appropriate ambulance networks in rural areas
- Incentivize health care workers to move to remote areas via deprived area
allowance schemes
• All interventions prevent significant adverse health outcomes

4. INTERVENTIONS AND RELEVANCE FOR GHANA
• Removal of premiums likely to increase demand for healthcare by the
poor
- Avoid 1,728 deaths and 25,500 years lost to disability per year across Ghana
• Incentivizing health care workers to move to remote areas via
deprived area allowance schemes
- Avoid 75 to 360 deaths per year in rural northern region
• Access to terrain-suitable emergency transportation systems in rural
communities likely to reduce incidences of mortality and morbidity
- Avoid 1,918 deaths per year in rural Ghana, mostly from avoided neonatal
deaths

5. IMPROVED TARGETING OF NHIS PREMIUMS

6. Introduction and Suitability of Intervention
• NHIS introduced to eliminate high user fees of accessing health care
- Focus on the poor
• Recent assessments indicate that poor households not adequately
covered (Aryeetey et al., 2011; Kotoh and Van der Geest, 2016).
• One reason is that poor cannot afford premiums
• Intervention calls for the abolishment of user fees and annual
premium payments in deprived communities and among poor
households
- Expected outcome: increase in demand for healthcare among the poor

7. Improve targeting of NHIS premiums: Costs
• Target population = 2.7m uninsured poor in
Ghana (GSS,2016) or 9% of population
• Total costs comprise:
• an initial registration drive (Ghc26.9m)
• increased payments by NHIA on the
newly insured (as a result of increased
claims) (Ghc213.6m)
• increased premiums for the non-poor
(Ghc603.2m)
Total Costs in first year = Ghc 844 million
(Ghc5.8bn over 10-year period at 8% discount
rate)
Premium payment of GHS 30 and renewal fees of GHS 6 will be transferred
from the 23% of Ghana’s population that is poor to the non-poor segment of
the population.
Increased
healthcare
utilization by
poor
Increased
premiums for
non-poor
Registration
drive
0
100
200
300
400
500
600
700
800
900
Ghana
Cedi
(millions)
Cost in first year

8. Improve targeting of NHIS premiums: Benefits
Summary of benefits
• ~1,700 avoided deaths among poor per
year (GhcGhc813m)
- 9% of the estimated 19,433 deaths in Ghana due to non-
utilization of health services (Kruk et al. 2018)
• ~25,500 avoided years lost to disability
per year (Ghc348m)
- YLD is an aggregate measure of illness where 1 YLD = 1
year of life lost
• Ghc213m premiums saved from poor
- 4.3m already-insured + 2.7m newly-insured
Total benefit in first year: Ghc1,374 m
(Ghc 12.2bn over 10-year period at 8% discount
rate)
Avoided
deaths
Avoided
illness
Avoided
premium
cost
0
200
400
600
800
1000
1200
1400
1600
Ghana
Cedi
(millions)
Benefits in first year

9. TOTAL COSTS, TOTAL
BENEFITS AND
COST-BENEFIT
RATIO
• Summary of Costs and Benefits (in
millions GH¢) 10-year intervention
period
Discount rates
5% 8% 14%
Total costs 6,801 5,848 4,471
Total benefits 14,361 12,175 9,066
BCR 2.1 2.1 2.0

10. DEPRIVED AREA INCENTIVE ALLOWANCES

11. INTERVENTION AND RELEVANCE FOR GHANA
• Adequate delivery of health care would be difficult without an adequate
health workforce.
• Recognized difficulty in retaining health care staff in SSA
- Staffing of rural health care facilities particularly challenging
• In Ghana, concentration of health staff in urban areas and southern regions
- 82% of mothers in urban Ghana access maternal health service; 43% in rural Ghana
(MoH,2011)
- Close to 50% of Ghana’s population resident in rural areas
- Implications for (equity in) health outcomes
• Intervention assesses cost-effectiveness of providing various incentives (salary
increases, comfortable accommodation and education scholarships) to attract
and retain health workers in deprived and rural areas of Ghana.

12. Deprived Area Incentive Allowance: Costs
• Incentives applied to new and 116
existing doctors
• Assume incentives encourage
movement of doctors from urban to
rural areas (Prust 2019)
• Interventions
- 30% salary increment - Ghc2.3m
- Superior housing- Ghc13.4m
- Education scholarship- Ghc4.9m
• Housing has the greatest annual cost
because it is both more expensive per
doctor, and encourages more doctors
to move
Target population: 3 Northern regions in Ghana (rural areas)
Currently, 116 doctors (2018 GHS Factsheet) serving population of 2.3 million
0
2
4
6
8
10
12
14
16
30% boost to
salary
Superior
housing
Education
scholarship after
4 years
Ghana
cedi
Millions
Cost per year
Cost for existing doctors Cost for new doctors
44 new doctors
207 new doctors
76 new doctors

13. Deprived Area Incentive Allowance: Benefits
Total benefit
• Analysis across countries
shows the presence of 1
doctor is associated with 0.27
maternal deaths avoided and
1.45 child deaths avoided
(Saluja et al. 2020)
• Housing has largest absolute
impact because it incentivizes
the most doctors to move
• Inclusion of morbidity effects
would likely increase benefits
by about 30%
0
50
100
150
200
250
300
350
30% boost to
salary
Superior
housing
Education
scholarship
after 4 years
Ghana
cedi
Millions
Benefits per year
Child deaths avoided Maternal deaths avoided
• 12 maternal deaths avoided
• 63 child deaths avoided (59.4)
• 56 maternal deaths avoided
• 301 child deaths avoided
(281.7)
• 21 maternal deaths avoided
• 110 child deaths avoided (103.3)

14. TOTAL COSTS, TOTAL
BENEFITS AND
COST-BENEFIT
RATIO
Summary of Costs and Benefits (in millions
GH¢)
Discount rates
5% 8% 14%
Total costs
Salary 2.3 2.3 2.3
Accommodation 11.9 13.4 16.9
Education Scholarship 4.7 5.0 5.6
Total benefits
Salary 59.4 59.4 59.4
Accommodation 281.7 281.7 281.7
Education Scholarship 103.3 103.3 103.3
BCR
Salary 25.8 25.8 25.8
Accommodation 23.7 21.0 16.7
Education Scholarship 22.1 20.8 18.6
All incentives have
large benefits
relative to costs

15. Maintain Rural Emergency Transportation
Systems

16. Introduction and Background
• Efficient ambulance and emergency systems are critical for reducing
morbidity and mortality
- Most rural areas in Ghana lack such timely health systems
• Emergency health care in Ghana is mostly informal in both rural/urban
areas
- Use of commercial vehicles (taxis, mini buses, private cars; bicycles, motorcycles,
animal driven carts)
- Existing adverse health outcomes are further compounded
• Recent events around the poor emergency infrastructure generated keen
public interest and political debates
- distribution of 300 previously purchased ambulances to 275 consituencies

17. The Intervention
• Initial intervention modified - exclude purchase of ambulances since
this is a sunk cost
• Current analysis focus:
- maintenance and continued operation of the entire ambulance system in the
rural areas of the country
• Main Consideration (44.5% of total population= 13m people)
- Direct costs: fuel, maintenance; repairs, ambulance stations, training and
remuneration of drivers and paramedics
- Indirect costs: increased health care cost due to improved access

18. Expand emergency transportation systems: Costs
Target population - women in the reproductive
age group, non-maternal and non-children
population in rural Ghana
Total Cost over 10 years: Ghc 646
million
Per unit cost of intervention: Ghc 50
• 206 ambulances for rural population based
on distribution model
• Ghc 385m for the first year
• GHc 46.5m annually for subsequent years
- Robust cost estimates based on similar intervention in
Ethiopia (Accorsi et 2017) and the Ghana National
Ambulance Service
• Ambulance station required costing GHc 1.6m
per ambulance as one-off cost
0
50
100
150
200
250
300
350
400
450
2019 2020 2021 2022 2023 2024 2025
Ghana
cedi
Millions
Cost of intervention over 5 years
Increased health system utilization Operations cost Ambulance station

19. Expand emergency transportation systems: Benefits
BCR: 21
Total Benefit over 10 years: Ghc
13.3 billion
Annualised benefits: Ghc
1.9billion
• Total Deaths averted per year = 1918
- 218 Maternal deaths
- 1101 Neonatal deaths
- 599 deaths from trauma and injuries
• Evidence on benefits limited due to the lack of consensus
from RCTs – main effect sizes based on Indian context
Neonatal
deaths
avoided
Trauma and
injury
deaths
avoided
Maternal
deaths
avoided
0
200
400
600
800
1000
1200
1400
1600
Ghana
cedi
Millions Benefits per year

20. Benefits, costs and benefit cost ratios over 10 years
Discount rate
5% 8% 14%
Benefit (GHS,
millions)
15717 13297 9861
Cost (GHS,
millions)
710 646 551
BCR 22 21 18

21. SUMMARY

22. The Health Access Intervention BCRs range from 2.1 to 26
• The Deprived area Incentive
interventions have the highest BCRs
between 21 and 26
• Rural emergency transport has the
highest absolute benefit and a BCR of
20.6
• Costs of NHIS premiums have the
highest costs and the lowest BCR of 2.1
• Quality of evidence: limited
• Few experimental studies available
• Reliance on studies outside the
Ghana context
0
500
1000
1500
2000
2500
NHIS Premiums Rural Emergency
Transport Systems
Deprived Area Incentive
millions
of
Ghana
cedis
Annualized Costs and Benefits of Interventions
Costs Benefit
BCR= 2.1
BCR= 20.6
BCR= 21-26