UNIVERSITY OF GHANA INSTITUTE OF STATISTICAL, SOCIAL AND ECONOMIC RESEARCH ASSESSING PRIVATE AND GOVERNMENT PARTICIPATION IN HEALTH SERVICE DELIVERY AT ABOKOBI IN THE GA EAST MUNICIPAL ASSEMBLY BY SHAMSIYA ABDUL-RAHMAN (10508835) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF ARTS IN DEVELOPMENT STUDIES DECEMBER, 2015 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I, hereby declare that this submission is my own original work towards the award of Master of Arts degree in Development Studies. To the best of my knowledge, this is not material previously published by another person for the award of any degree of the University or any other institution or for public consumption, except where due acknowledgement has been made in the text. Signature……………………………. Date………………………………… CANDIDATE: Shamsiya Abdul-Rahman Signature……………………………. Date………………………………… SUPERVISOR: Dr. Rev. Adobea Yaa Owusu University of Ghana http://ugspace.ug.edu.gh ii DEDICATION This work is dedicated to the Almighty Allah (SWT) for His numerous blessings and guidance throughout my life. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT I will like to extend my unconditional gratitude to some individuals for their contributions and efforts throughout this dissertation. To Rev. Dr. Adobea Yaa Owusu, my supervisor, thank you for your guidance and support. To Dr. E. N. Appiah for his tremendous contribution and assistance to the success of this work. To Ga East Muncipal Health Management Team for their time and assistance. To my respondents without whose support this work will not be complete. Thank you! To my mother Miss Esther Amadieh, I appreciate your encouragement and support. University of Ghana http://ugspace.ug.edu.gh iv ABSTRACT Accessibility is very critical to health service delivery. It includes financial, geographical and cultural accessibility. These factors inform the utilization of health services. The importance of accessibility and utilization of health services have been established in various studies globally. Yet in most developing countries and Ghana for that matter, accessibility to health care is limited in one way or the other. In Ghana, the implementation of the National Health Insurance Scheme in 2005 increased accessibility. However, accessibility and utilization of health services still remain a challenge for the country. This study seeks to explore how accessible health care is at Abokobi in the Ga East Municipality and to what extent the service is used. The study design was a cross sectional survey using both quantitative and qualitative data with the use Questionnaires and in-depth interviews respectively. The target population were health service providers on one hand and the residents of Abokobi on the other hand. A purposive sampling was employed to sample the health service providers and stratified sampling was used to sample the respondents. The researcher collected all quantitative data with the help of one trained assistant. In depth interviews were conducted by the researcher only. The taped interviews were transcribed and the resulting texts analysed by using thematic analysis. The study revealed that limited public facilities, inadequate health personnel like doctors, midwives and pharmacist at the Abokobi health center were major factors hindering accessibility and utilization of health service delivery. The income and educational status of respondents also affected accessibility and utilisation. University of Ghana http://ugspace.ug.edu.gh v Below are some recommendations for the study; an effective monitoring and supervision of the operations of health facilities; the improvement of the NHIS services at the health facilities in Abokobi; the improvement and upgrade of equipment and logistics to ultra-modern in the health centres ones and the improvement of performance indicators to help the DHMT define and measure progress towards achieving its goals. University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENT Contents DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENT ............................................................................................................. iii ABSTRACT ................................................................................................................................... iv TABLE OF CONTENT ................................................................................................................. vi LIST OF TABLES ......................................................................................................................... ix LIST OF FIGURES ....................................................................................................................... xi ABBREVIATION/ACRONYMS ................................................................................................. xii CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION .......................................................................................................................... 1 1.0: Background to the study....................................................................................................... 1 1.1: Problem Statement ............................................................................................................... 4 1.2: Aim ....................................................................................................................................... 7 1.3: Objectives ............................................................................................................................. 7 1.4: Research Questions .............................................................................................................. 7 1.5: Significance of The Study .................................................................................................... 8 1.6: Organization of the Study .................................................................................................... 9 CHAPTER TWO .......................................................................................................................... 10 LITERATURE REVIEW ............................................................................................................. 10 2.0: Introduction ........................................................................................................................ 10 2.1: Definition of Terms ............................................................................................................ 10 2.2: Global Trend of Health Service Delivery .......................................................................... 13 2.3: A Review of The Health Sector In Ghana ......................................................................... 17 2.4 Public Private Partnership (PPP) ......................................................................................... 19 2.5: Private Sector Health Care in Developing Countries ......................................................... 25 2.6: Conceptual Framework for the Structure of Health Care Delivery in Ghana .................... 26 CHAPTER THREE ...................................................................................................................... 32 METHODOLOGY ....................................................................................................................... 32 University of Ghana http://ugspace.ug.edu.gh vii 3.0: Introduction ........................................................................................................................ 32 3.1 Profile of Ga East Municipal Assembly Area ..................................................................... 32 3.2 Demographic Characteristics .............................................................................................. 32 3.3 Research Design .................................................................................................................. 36 3.4 Population............................................................................................................................ 37 3.5 Sampling.............................................................................................................................. 37 3.6 Sample size .......................................................................................................................... 38 3.7 Data Collection .................................................................................................................... 39 3.8 Data processing/Analysis .................................................................................................... 40 CHAPTER FOUR ......................................................................................................................... 42 PRESENTATION AND DISCUSSION OF DATA .................................................................... 42 4.0 Introduction .................................................................................................................... 42 4.1 Socio-demographic Characteristics of Respondents ........................................................... 42 Table 4.1.1: Socio-demographic characteristics of respondents in Abokobi ........................ 44 4.2 Profile and contribution of both government and private health service providers at Abokobi ..................................................................................................................................... 45 4.3 Frequency of Illness and Disease Prevalence ..................................................................... 49 4.4 Sources of Health Care ........................................................................................................ 50 Table 4.1.2: Percentage distribution of sources of health care by gender of respondents ..... 52 Table 4.1.3: Percentage distribution of sources of health care by age of respondents. ......... 53 Table 4.1.4: Percentage distribution of sources of health care by the prevalent diseases in Abokobi. ................................................................................................................................ 54 Table 4.1.5: Percentage distribution of sources of health care by the frequency of falling sick of the respondents .................................................................................................................. 55 Table 4.1.6: Percentage distribution of sources of health care by marital status of respondents ............................................................................................................................ 56 Table 4.1.7: Percentage distribution of sources of health care by the educational level of respondents ............................................................................................................................ 57 Table 4.1.8: Percentage distribution of sources of healthcare needs by the range of monthly income of respondents ........................................................................................................... 58 4.5 Health Care Financing ......................................................................................................... 58 Table 4.1.9: Percentage distribution of NHIS usage and income status of respondents ....... 60 University of Ghana http://ugspace.ug.edu.gh viii Table 4.1.10: Percentage distribution of sources of health care by the adoption of the National Health Insurance ..................................................................................................... 60 Table 4.1.11: Percentage distribution of orthodox/professional facilities visited by the reasons for the choice of facility (%) ..................................................................................... 62 4.6 Availability, Accessibility, Utilization And Quality Of Service ......................................... 64 Table 4.1.12: Percentage distribution of orthodox facilities visited by respondents by the perceived attitude of service providers .................................................................................. 64 Table 4.1.13: Performance distribution of orthodox facilities visited by respondents by the perceived performance of the health facility ......................................................................... 65 Table 4.1.14: Percentage distribution of orthodox facilities visited by respondents by the services available at the health facility .................................................................................. 66 4.7 Challenges Encountered In Accessing and Delivering Health Care ................................... 66 Table 4.1.15: Constraints faced by respondents in Abokobi in accessing health service in health facilities ....................................................................................................................... 67 Table 4.1.16: Reasons ascribed to the ineffectiveness of the NHIS ...................................... 68 Table 4.1.17: Range of amounts spent by respondents the last time they visited the health centre ..................................................................................................................................... 69 Table 4.1.18: Health services on which the money was spent on by respondents during their last visit to the health centre .................................................................................................. 69 4.8 Proposed Solutions by Respondents ................................................................................... 72 Table 4.1.19: What respondents are most likely to change about health service delivery in general in Abokobi if given the chance ................................................................................. 72 Table 4.1.20: In the view of respondents, what must be done to ensure efficient and effective health service delivery in Abokobi ........................................................................................ 74 4.9 The Findings And The Conceptual Framework .................................................................. 74 CHAPTER FIVE .......................................................................................................................... 76 SUMMARY, CONCLUSION AND RECOMMENDATIONS ................................................... 76 5.0 Introduction .................................................................................................................... 76 5.1 Summary of findings ...................................................................................................... 76 5.2 Conclusion of the Study ................................................................................................. 79 5.3 Recommendations ............................................................................................................... 80 REFERENCES ............................................................................................................................. 83 APPENDIX ................................................................................................................................... 87 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Table 4.1.1: Socio-demographic characteristics of respondents in Abokobi................................ 44 Table 4.1.2: Percentage distribution of sources of health care by gender of respondents ............ 52 Table 4.1.3: Percentage distribution of sources of health care by age of respondents. ................ 53 Table 4.1.4: Percentage distribution of sources of health care by the prevalent diseases in Abokobi......................................................................................................................................... 54 Table 4.1.5: Percentage distribution of sources of health care by the frequency of falling sick of the respondents.............................................................................................................................. 55 Table 4.1.6: Percentage distribution of sources of health care by marital status of respondents . 56 Table 4.1.7: Percentage distribution of sources of health care by the educational level of respondents ................................................................................................................................... 57 Table 4.1.8: Percentage distribution of sources of healthcare needs by the range of monthly income of respondents .................................................................................................................. 58 Table 4.1.9: Percentage distribution of NHIS usage and income status of respondents .............. 60 Table 4.1.10: Percentage distribution of sources of health care by the adoption of the National Health Insurance ........................................................................................................................... 60 Table 4.1.11: Percentage distribution of orthodox/professional facilities visited by the reasons for the choice of facility (%)............................................................................................................... 62 Table 4.1.12: Percentage distribution of orthodox facilities visited by respondents by the perceived attitude of service providers ......................................................................................... 64 Table 4.1.13: Performance distribution of orthodox facilities visited by respondents by the perceived performance of the health facility ................................................................................ 65 University of Ghana http://ugspace.ug.edu.gh x Table 4.1.14: Percentage distribution of orthodox facilities visited by respondents by the services available at the health facility ....................................................................................................... 66 Table 4.1.15: Constraints faced by respondents in Abokobi in accessing health service in health facilities ......................................................................................................................................... 67 Table 4.1.16: Reasons ascribed to the ineffectiveness of the NHIS ............................................. 68 Table 4.1.17: Range of amounts spent by respondents the last time they visited the health centre ....................................................................................................................................................... 69 Table 4.1.18: Health services on which the money was spent on by respondents during their last visit to the health centre ................................................................................................................ 69 Table 4.1.19: What respondents are most likely to change about health service delivery in general in Abokobi if given the chance ........................................................................................ 72 Table 4.1.20: In the view of respondents, what must be done to ensure efficient and effective health service delivery in Abokobi ............................................................................................... 74 University of Ghana http://ugspace.ug.edu.gh xi LIST OF FIGURES Figure 1: A Conceptual Framework of the Institutional Arrangements and Supervisory Structure of the GHS and Health Service Providers..................................................................................... 28 Figure 2: Percentage of disease prevalence among respondents in Abokobi ............................... 50 Figure 3: Various sources of health care needs for respondents in Abokobi................................ 51 Figure 4: Professional/orthodox health facilities visited by respondents in Abokobi .................. 61 University of Ghana http://ugspace.ug.edu.gh xii ABBREVIATION/ACRONYMS AIDS Acquired Immune Deficiency Syndrome CHAG Christian Health Association of Ghana CHPS Community-based Health Planning and Services DHMT District Health Management Team ENT Ear Nose and Throat FDB Food and Dugs Board GEMA Ga East Municipal Assembly GIPC Ghana Investment Promotion Centre GHS Ghana Health Service GSS Ghana Statistical Service HNP Health, Nutrition and Population HIV Human Immune Deficiency Virus ISSER Institute of Statistical, Social and Economic Research KATH Komfo Anokye Teaching Hospital KBTH Korle Bu Teaching Hospital MDGs Millennium Development Goals MHD Municipal Health Directorate MoFEP Ministry of Finance and Economic Planning MoH Ministry of Health NAS National Ambulance Service NGOs Non-Governmental Organisations NHIS National Health Insurance Scheme University of Ghana http://ugspace.ug.edu.gh xiii OPD Out-Patient Department POW Program Of Work PPPIRC Public-Private Partnership PSPs Private Sector Providers RHA Regional Health Administration SPSS Statistical Package for Social Sciences STI Sexually Transmitted Infections TBA Traditional Birth Attendant TTH Tamale Teaching Hospital UN United Nations UNDP United Nations Development Program USAID United States Agency for International Development WHO World Health Organization WIFA Women In Fertility Age University of Ghana http://ugspace.ug.edu.gh xiv University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.0: Background to the study From time immemorial, the lives of a vast number of people have depended on health systems. Right from the point of delivery, to the point of providing quality care for the elderly, health has been of major relevance to society and its development. Existing literature has even proven that the general well-being of a populace determines the overall progress and development of a national economy as an enhanced quality of life means higher productivity. According to the Ministry of Health (MoH) in Ghana, improved productivity, a higher gross domestic product and sustainability in growth is only as a result of a healthy population (MoH, 2007). This has necessitated the espousal of various human rights provisions at the national and international levels to safeguard and enhance the basic needs of human kind including the right to adequate and quality health care. Article 25 of the United Nations’ Declaration of Human Rights says among other things, “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing ,medical care, and necessary social services”. According to the World Health Organization (1948), “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (p.100). This implies that, health is concerned with more of the psychological and social aspects of a person rather than the usual absence of illness or sickness. However, other definitions have also emerged and focused on other dimensions. Two scholars stand out. J. Bircher and R. Sarracci. Bircher (2005) for instance, defines health as “a dynamic state of well-being characterized by physical and mental potential, which satisfies the demands of life commensurate with age, University of Ghana http://ugspace.ug.edu.gh 2 culture and personal responsibility”. Sarracci (1997) sees it as “a condition of well- being, free of disease or infirmity and a basic and universal human right”. Bircher (2005) is concerned with the changing health needs, placing emphasis on how age, culture and personal responsibility strongly influence a person’s health status, while Sarracci (1997) reiterates the WHO definition, but links it to contemporary issues of human of rights, equity and justice. Health service delivery is an immediate output of the inputs into the health system, such as the health work force, procurement, and supplies and financing. Increased inputs should lead to improved service delivery and enhanced access to services (WHO 2010). This implies that the availability of health services to ensure a particular quality standard and the creation of access to them are key functions of a health system. Mental Health, child health and maternal health and child nutrition are some of the key areas captured within a health system. Nonetheless, the precise organization and content of health services differ from country to another. The health system in Ghana is an elaborate network made up of three sectors; “the popular sector, the folk sector and the professional”. The professional sector encompasses the organized and legally sanctioned healing professions such as modern western scientific medicine or allopathy (Buor, 2004). The Ghana Health Service has been established with autonomous powers to administer the professional health services in the country. Health service delivery in Ghana is organized at three levels: primary, secondary and tertiary levels with four levels of management: central or national headquarters; regional; district and sub-district (WHO 2014). At the regional level, the administration of this level is in the hands of the Regional Health Management Team. And the regional health director is the chairman. The highest health institution at this level is the regional hospital which is supposed to be the final referral point within a region. There are three teaching hospitals in the country currently which serve as final University of Ghana http://ugspace.ug.edu.gh 3 referral points; The Korle Bu Teaching Hospital (KBTH) in the Greater Accra region, the Komfo Anokye Teaching Hospital (KATH) in the Ashanti region and the Tamale Teaching Hospital (TTH) in the Northern region. Nonetheless, the facilities at the KBTH are more advanced and in more complicated situations, referrals are made from KATH and TTH to KBTH. The district level is under the administration of District Health Management Team (DHMT). The district is divided into sub districts or zones with a health center catering for the zone. All health facilities in the district are under the supervision of the health directorate which is headed by a district health director Buor (2004). Furthermore, in March 2014, the Cape Coast regional hospital was fully transformed into a Teaching Hospital to support the University of Cape coast School of Medical Science (UCCSMS). In Ghana, there have been recent developmental interventions to eradicate factors that impede on adequate health service delivery. These impediments translates into high levels of ill-health, poor economic activities and production and poverty among others. In view of these challenges, Private Sector Providers (PSPs) role towards quality service delivery is recognized. PSPs of health care contribute to achieving public health goals in developing countries. According to Smith, Brugha and Zwi (2001), they are not under any form of control by the state and they are either for profit or non-profit. They include formally or informally trained pharmacists, doctors, nurses and midwives who provide health delivery services. Ghana has also witnessed both international and national commitment to improving health service delivery for quality care. One of such commitments by the Ghanaian government is the implementation and encouragement of the concept of the Public-Private Partnership (PPP). The core principles of partnership according to Raman & Bjorkman (2009) are;  Relative Equality between partners University of Ghana http://ugspace.ug.edu.gh 4  Mutual Commitment to Health objectives  Autonomy for each partner  Shared decision-making and accountability  Equitable Returns / Outcomes  Benefits to the Stakeholders Raman (2009) quickly notes that not all partnerships are PPP. This distinction helped to identify the type of partnership available in the research environment and how it affects the health delivery service there. Generally, the provision of public sector infrastructure and services has been portrayed as the sole responsibility of the government. However, the huge deficit in infrastructure cannot be met by the public sector alone through budget allocation. According to the Ministry of Finance and Economic Planning, Ghana’s infrastructure deficit in general could require sustained spending of at least US $ 1.5 billion per annum over the next decade (MOFEP 2011). The PPP intends to close the already existing gap and efficiently deliver infrastructure and services, especially those exclusive to promoting health service delivery. Strengthening health services have also been mentioned by the World Health Organization as the third objective among its five objectives with regards to PPP in health. 1.1: Problem Statement Health is now a striking issue on the international agenda than ever before, and concern for the health of people is becoming a central issue in development. It is therefore not surprising that three out of the eight Millennium Development Goals (MDGs) declared by world leaders University of Ghana http://ugspace.ug.edu.gh 5 following the Millennium Summit of the United Nations in the year 2000 are health related. This notwithstanding, many people do not seek health care due to cost of service, the remoteness of the health facility, and quality of service thereby bringing about low patronage of health services. Sociological studies have also revealed non-medical reasons which include financial and geographical access to health care which continue to be key challenges confronting the health sector of Ghana despite the National Health Insurance Scheme and the expansion of Community-based Health Planning and Service (CHPS) (WHO 2014). Regardless of all the efforts by the Ghana Health Services, the Central Government and donor funding agencies to improve quality health service delivery in Ghana, there is still some essential but conspicuously missing elements in the process of quality health service delivery that have resulted in the current health situation in the country. According to Buor (2004), the population of Ghana has a high capacity to grow with an average annual population growth of 2.9%. This is high even within low income economies which have an average of 2.1% annum. He indicates that the high crude birth rate of 30 per 1000, and a relatively low crude death rate of 11 per 1000 reveal a high rate of natural increase. By virtue of these statistics, there is a high momentum for population growth which will further put pressure on the already inadequate health facilities. The World Bank (2002) also reports that health facilities with regards to physicians and beds are poor. The proportion of physicians per 1000 population is as low as 0.1 as against the average of 0.5 for low income countries and 2.9 for high income countries. Furthermore, health expenditure per capita is $19 as against $21 for low income countries with a Gross Domestic Product (GDP) per capita of $400 for the year 1991. Ghana used 3.5% of her GDP on health for the same period. And this fell below the linear regression line (World Bank, 1993). Though in 2005, Ghana spent 6.2% of GDP on health care, approximately 34% of government expenditure, there is still University of Ghana http://ugspace.ug.edu.gh 6 relative pressure on the sector. The sector’s resource envelope also increased in absolute terms from GH¢ 439.23 million in 2007 to GH¢763.02 million in 2008 (MoH 2007). Buor (2004) has indicated that the increasing threats of health hazards are as a result of poor access to facilities to promote good health. Poor and inadequate health delivery translates into alarming health conditions of people. The trend in Abokobi is not different as it is recognized as one of the 216 districts in Ghana. According to the Ga East Municipal Assembly profile (2013), the Doctor to population and Nurse to population ratios are 1: 40,246 and 1: 2,012 respectively. Even though Tuberculosis is one of the priority diseases in the Ghana, the case detection rate is low due to reasons like stigmatization and misconceptions about the disease among others. It is important to note that malaria continues to be the major cause of Out-Patients Department (OPD) attendance in the Ga East Municipality. It accounts for about 40.8% of morbidity. Frequent outbreaks of cholera in the municipality are also of great concern. Poor environmental sanitation is a major contributory factor. The health sector is challenged by lack of office accommodation for the Municipal Health Directorate. It is accommodated in rented premises, lack of a municipal hospital to cater for cases referred from the poly Clinics and Health Centres, Lack of public facilities at Dome and Taifa sub municipalities, lack of NHIS secretariat in the municipality, inadequate space in the facilities, inadequate logistics, lack of some caliber of staff and low maternal health indicators. It is worth noting that the polyclinics in the Ga East Municipality which were health centres, were elevated to the present status in 2008 without any infrastructural expansion. These structures can no longer cope with the ever increasing population who access services from them. In today’s world of complication and haste, it is almost impossible to do anything unaided. This is particularly evident in health where constantly rising prices, changing disease patterns, and University of Ghana http://ugspace.ug.edu.gh 7 increasing use of sophisticated technology for diagnosis and treatment have made it virtually impossible to imagine any single party providing services without some type of established partnership. The engagement of the private sector by the state to help in infrastructure and service provision is the remedy to the existing deficits. It is therefore in this light that, the study attempts to assess the participation of private agencies and government in health service delivery. Generally, efforts to address the health situation have not been encouraging. This study hopes to make contributions to fill up the gaps regarding health delivery in Abokobi in the Ga East Municipal Assembly. 1.2: Aim The study aimed at exploring and assessing the level of participation of both the private and government facilities with regards to adequate health service delivery and how to improve the service delivery at Abokobi in the Ga East Municipal Asssembly. 1.3: Objectives 1) To determine the availability and accessibility of health facilities in Abokobi. 2) To assess the contribution of the government and the private sectors in health care delivery at Abokobi. 3) To identify the factors that impede the delivery of quality health services at Abokobi. 1.4: Research Questions Some questions that the study attempted to answer included University of Ghana http://ugspace.ug.edu.gh 8 1) How accessible and available are the health facilities at Abokobi to the average inhabitant? 2) What is the proportion of both private and public participants in health service delivery in Abokobi? 3) What is the level of partnership between the government and private participants with regards to health services delivery in Abokobi? 4) What are the barriers to the delivery of quality health care in Abokobi? 1.5: Significance of The Study The availability and accessibility of health service delivery is a prerequisite for attaining a quality health status. Everyone needs to be healthy for a sound life without any form of inequities and deprivation. Therefore, no one should be denied of a quality health service as being healthy has been argued by the likes of Sarracci (1997) as a basic and universal human right. This study revealed how both the private and the government participants interplay in achieving the ultimate goal of the provision of efficient health service delivery as well as how the relationship between both parties has evolved over time. The results of this study attempts to assist stakeholders and policy makers in the health sector to identify the strengths and weaknesses in health service delivery of government and private facilities that are engaged in service and possibly build on the weaknesses to ensure quality health care. Furthermore, this study also attempted to add on more knowledge to already existing knowledge in the field of health. University of Ghana http://ugspace.ug.edu.gh 9 1.6: Organization of the Study The study is divided into five chapters. Chapter one includes the general introduction to the study, the problem statement, objectives, research questions and significance of the study. Chapter two is concerned with existing and relevant literature to the study as well as the conceptual framework, while chapter three includes the profile of the study area and the methodology. The analysis and discussions are presented in chapter four. And the last chapter covers the findings and conclusions. University of Ghana http://ugspace.ug.edu.gh 10 CHAPTER TWO LITERATURE REVIEW 2.0: Introduction Like many countries across the globe, health delivery in Ghana and in Ga East to be specific appears to be minimal as a result of several factors. However, certain indicators have shown that this could get better. The big idea in this research is to assess how the Government on one hand participates together with the private sector on the other to promote health delivery. Relevant literature on how the government and private sectors participate to facilitate accessible health care delivery and quality services is critically reviewed. The research issues arising from these reviews informed the formulation of the objectives of the study. 2.1: Definition of Terms Participation Participation, in the development context, is a process through which all members of a community or organization are involved in and have influence on decisions related to development activities that will affect them (Chambers, 1994). For the purpose of this study, participation is concerned with recognition of power differentials between the private and government service providers and how power is redistributed to promote the mutual goal to provide quality health services. University of Ghana http://ugspace.ug.edu.gh 11 Public-Private Partnership (PPP) According to the Public-Private Partnership (PPP) in Infrastructure Resource Center (PPPIRC) of the World Bank (2014), PPP refers to “arrangements between the public and private sectors whereby part of the services or works that fall under the responsibilities of the public sector are provided by the private sector, with clear agreement on shared objectives for delivery of public infrastructure and or public services”. Private Sector Providers (PSPs) PSPs are health care providers who work outside the direct control of the state. In developing countries, those describing PSPs often include both for-profit and not-for-profit providers. PSPs may be formally trained (pharmacists, doctors, nurses, midwives and even some Non- Governmental Organisations (NGOs)) or informally trained; they may work on their own or in institutions, and they may provide health care or other products such as drugs and contraceptive supplies (Smith et al. 2009). Health System It consists of all the organizations, institutions, resources and people whose primary purpose is to improve health care. This includes efforts to influence determinants of health as well as more direct health-improvement activities (WHO, 2010). Availability It is an aspect of comprehensiveness and refers to the physical presence or delivery of services that meet a minimum standard. It is usually tailored towards the needs of the target population. University of Ghana http://ugspace.ug.edu.gh 12 Services delivered include preventive services, curative services and health promotion services (WHO, 2010). Accessibility It is the comprehensive measurement of access that requires a systematic assessment of the physical, economic, and socio-psychological aspects of people’s ability to make use of health services. Services are directly and permanently accessible when there are no undue barriers of cost, language, culture, or geography. Health services are close to the people when there is a routine point of entry to the service network at the primary care level (not at the specialist or hospital level). Services may be provided in the home, the community, the workplace, or health facilities as is appropriate (WHO, 2010). Coverage Coverage of health interventions is defined as the proportion of people who receive a specific intervention or service among those who need it. Service delivery is designed so that all people in a defined target population are covered, i.e. the sick and the healthy, all income groups and all social groups. Universal health coverage is defined as ensuring that everyone has access to needed preventive, curative and rehabilitative health services of sufficient quality. It also means safeguarding that people do not suffer financial constraints when paying for these services. Universal health coverage has therefore become a major goal for health reform in many countries and a priority objective of WHO (WHO, 2010). University of Ghana http://ugspace.ug.edu.gh 13 Utilisation It is often defined as the quantity of health care services used. It is related to the availability and accessibility of health services as well as the culture of users (WHO, 2010). Quality Health Care The meaning of quality healthcare can be cladded in so much controversy. Quality in health care takes many dimensions. According to Gill (1993), medical quality consists of a mixture of hard technical elements such as correct diagnosis, appropriate intervention and effective treatment as well as soft elements such as good communication, patients’ satisfaction and consideration for the patients’ preferences. Quality is the ultimate goal for any service performance. And it is no exception for health delivery service. It has been argued that there is a structural connectivity between quality health care services and other sectors of the economy. “Thirty years ago, an important World Bank (1975) policy paper on health demonstrated a clear link between economic growth and the health and nutritional status of the labour force” (Midgley, 2014, p.96). This has necessitated the need for a system of continuous quality improvement committed to providing better medical services as a surest way of ensuring quality health care delivery. 2.2: Global Trend of Health Service Delivery According to Berman et al. (2011), effective, equitable, and efficient health service delivery is a priority for the World Bank and its clients working in human development. The World Bank’s (2007) Health, Nutrition and Population (HNP) Strategy emphasizes the importance of strengthening health systems. Service delivery is universally acknowledged as one of the core University of Ghana http://ugspace.ug.edu.gh 14 instruments through which health systems produce better health, financial protection, and client satisfaction. In recent years there has been a significant increase in global and national attention toward improving health outcomes; thus, there has been dramatic progress in a number of areas. However, in many low and middle-income countries there is evidence that progress could be greater and more rapid. Many countries are not on the pathway to meet the health-related global objectives such as the Millennium Development Goals 1. To eradicate extreme poverty and hunger, 4. To reduce child mortality, 5. To improve maternal health, and 6. To combat HIV/AIDS, malaria, and other diseases (UNDP 2015), which include outstanding HNP-related targets. Funding for these priorities has increased, and efficacious technologies that can rapidly improve health have been made available. However, weak performance in service delivery affecting access, quality, and cost is often a cause of lagging health system performance. Health systems are one of the key instruments created by human societies to help achieve the above stated goals. Health systems help raise and channel resources and manage the service delivery mechanisms that bring effective health-improving technologies to the people who need those (Berman et al, 2011). Service delivery is a critical link in this chain; the locus at which money and technology are transformed into health-improving interventions. Despite much progress, the gap between need and effective action is still enormous. More resources, further development of cost-effective interventions, and better health financing schemes are certainly needed. But it is also striking that even the funds and technologies that are available are often not being used effectively. Berman et al. (2011) further indicate that, in many countries one encounters health facilities with shockingly few patients, communities with low levels of coverage in life-saving services even where capacity exists to provide that coverage, or trained University of Ghana http://ugspace.ug.edu.gh 15 workers missing from their assigned posts and empty shelves for drugs and supplies when workers have been paid and supplies purchased. Clearly, having money and technology are not sufficient conditions for impact. Even with more money and better technologies, a major challenge remains: improving the delivery of health services. Without improvement in the performance of the organizations that deliver health services, potential gains in health outcomes from increased funding and better technologies will not be achieved. In India for example, the government is the major financier for the child immunization program at relative levels across the states. Yet, according to a recent national survey, the level of coverage with DPT3, a good indicator of overall immunization, ranged from 28.7 in the lowest performing state to 95.7 percent in the highest (WHO, 2013). Within states across this performance range one can also find similar large variations across districts; within districts, differences persist across the catchment areas of health facilities. With relatively similar levels of resource availability, what accounts for these differences? In Kenya, procedures of service volume for three main services were collected for public health centers, a facility type suggesting similar levels of infrastructure and staffing. The average number of these services delivered in each facility was approximately two thousand visits per year, or five to ten visits per day. Yet some health centers reported almost no delivery of these important services, while others reported output levels five-to-six times the average (Berman et al. 2011). In many low and middle-income countries, the overall level of health service delivery performance is not what it ought to be. For example, the Countdown to 2015 on Maternal, Newborn, and Child Survival in its decade report (2000–10) by the World Health Organization and United Nations Children’s Fund (2010) noted that, out of the sixty- eight countries monitored for progress in priority infant and young child mortality goals, nineteen were on track University of Ghana http://ugspace.ug.edu.gh 16 to achieve Millennium Development Goal 4. But forty-nine countries were not on track, and twelve countries had experienced slowdown in their progress. And even within an existing average performance level for a particular country, performance gaps across organizations and facilities are also widespread. In many settings, substantial differentials exist between low- performing health service delivery organizations and their high-performing peers. Berman et al. (2011) posit that in rural India, most antenatal care is delivered by government workers in district-level, health service delivery organizations. Across the country, district coverage with full ANC averaged 18 percent but ranged up to 94 percent. In the Tigre region of Ethiopia, high-performing health service delivery organizations provided eight times more family planning services and treated about eight times more malaria cases than average-performing organizations. In Serbia, high-performing health centers reported more than four times as many outpatient visits per capita per year as low-performing facilities. In Egypt, higher-output urban health units report treating more than six times more sick children annually than the average for similar facilities. In Namibia, inpatient occupancy rates in district hospitals ranged from 18 percent to well over 100 percent. Even in well-performing Sri Lanka, inpatient occupancy rates in a sample of medium- size government hospitals ranged from 21 to 95 percent. Around the world, high- performing health service delivery organizations demonstrate the better outcomes their peers could achieve within the same health systems and with similar resource levels. If the overall performance of health service delivery systems were raised and performance gaps between the higher-performing and lower-performing organizations were closed or reduced, health outcomes in low and middle-income countries could improve significantly. The observation that health outcomes would be better if the delivery of health services were improved is widely shared University of Ghana http://ugspace.ug.edu.gh 17 (Berman et al. 2011). All these bottlenecks accounted for in health service delivery translates to inaccessibility of the service delivery. 2.3: A Review of The Health Sector In Ghana The Ministry of Health is responsible for stewardship of the entire health sector and ensuring equity and efficiency in the sector activities in Ghana. It exercises this function by providing overall policy directions, institutional development, coordinating the activities of agencies, partners and stakeholders involved in health and ensuring performance and accountability within the sector (MoH, 2007). In addition, MOH coordinates planning, resource organization, budget implementation, human resource development and the overall monitoring and evaluation of the health sector performance. The Ghana Health Service (GHS) was established under Act 525 to promote access to health services at the community, sub-district, district and regional levels (MoH, 2007). Christian Health Association of Ghana (CHAG) is an umbrella group of faith based organization that contributes in improving the health status of the people of Ghana. Member Institutions are mostly situated in the interior with a few in urban slums and are therefore positioned to provide services to the poor and marginalized in fulfillment of Christ’s Healing Ministry. There are One Hundred and Eighty-three (183) member institutions located in all the ten regions of Ghana. Our members are involved in the provision of health care and training of health professionals. Established in 1967, the Association currently consist of sixty-one hospitals and a polyclinic, 113 health centres, clinics and primary health care centres and nine health training health-training institutions. Membership has gone up from 25 in 1967 to 183 in 2011 (CHAG 2012). Regulatory University of Ghana http://ugspace.ug.edu.gh 18 Institutions such as the Food and Drugs Board (FDB), Pharmacy Council, are mandated to regulate the activities of the various collaborators and stakeholders in the health sector. Training Institutions are charged with the production of health professionals and it is the shared responsibility of the Ministry of Education, the Ministry of Health and the private sector and quasi government organizations. The National Ambulance Service (NAS) has the mandate of providing transportation and pre hospital care. Actually it promotes access to emergency care. The Private Hospitals and Maternity Homes Board was established to assist in the provision of appropriate regulations relating to private health care practice and the delivery of appropriate services by approved private hospitals and maternity homes. However, the laws and acts governing health service provision and public health protection are disjointed and insufficient in promoting quality and efficiency in the private sector. According to the Ghana Health Service, the ultimate goal of the health sector in Ghana is to ensure a healthy and productive population that reproduces itself safely (GHS, 2007). ISSER (2014) indicates that in spite of all the significant attention given the health sector by the state in Ghana, the question of access to health is still very problematic. However more efforts are still invested by both the government and donor organizations towards achieving quality health delivery services, one way to arrive at this is the National Health Insurance Scheme. Out-patient utilization of healthcare services increased from 0.6 million in 2005 to 25.5 million in 2011. However, in 2012, outpatient utilization decreased to 23.9 million (NHIS, 2012). For the past decade, financing the annual Programme of Work (POW) within a budget constraint whilst managing the hope of rapidly scaling up the delivery of health interventions to meet the MDGs remains a big challenge for the health sector in Ghana. Moreover, the sector will have to take a critical look at the relatively high wage bill without concurrent increases in resources from University of Ghana http://ugspace.ug.edu.gh 19 the consolidated fund for services and investments. At the same time financing through the National Health Insurance system is increasing (MoH, 2007). Currently, the health sector is faced with urban and peri-urban areas as well as deprived rural areas increasingly demanding for health services. At the same time existing health infrastructure are deteriorating and equipment are fast becoming obsolete thus undermining quality of care (GHS 2007) The development within the health industry has not been recognized and analyzed. The capacity of the local manufacturing industry is under-utilized and the potential of Ghana’s herbal and traditional medicines is largely untapped. The role of this industry in wealth creation is in sustaining health services and creating jobs. The national health vision is to attain middle income status with 1000 USD per capita by the year 2015 by creating wealth through health (GIPC 2014). 2.4 Public Private Partnership (PPP) PPPs are typically medium to long term arrangements between the public and private sectors whereby some of the service obligations of the public sector are provided by the private sector, with clear agreement on shared objectives for delivery of public infrastructure and/ or public services. Tain and Bendamane (2001) indicated that in the context of health, a wide variety of initiatives can take the form of Public-Private Partnerships (PPPs). These include:  private sector involvement in product development or distribution programs within public health systems  joint initiatives by a government and the private sector to strengthen specific health programs University of Ghana http://ugspace.ug.edu.gh 20  contracting by the public sector of private sector service delivery organisations. Public-private partnerships (PPP) can achieve positive public health results and at the same time meet the individual organizational goals of the partners. Such partnerships allow considerable leveraging of each partner’s resources and unique strengths, and results are often attained in less time, at lower cost, and with greater sustainability than efforts by any single partner. Between 1996 and 1999, public, private, and donor organizations in Guatemala, El Salvador, Costa Rica, and Honduras formed the Central American Handwashing Initiative. Together, four soap companies and two projects supported by the U. S. Agency for International Development (USAID) designed an advertising and promotional campaign for effective hand washing with soap aimed at reducing diarrheal disease in children. They collaborated with ministries of health and education and other development organizations in the region to carry out the campaign. These efforts led to improvements in hand washing behavior and decreases in diarrheal disease. Ten percent of mothers in the study sample in Guatemala improved their hand washing practices, and the percentage of mothers using optimal practices doubled. Another result was that a sustained involvement of the private sector in social programs emerged (Tain and Bendamane, 2001) In many parts of Africa faith-based organisations are responsible for delivering essential health services to large proportions of the population. Ghana is one country in which this is the case. Here, the Christian Health Association of Ghana (CHAG), which comprises a number of member institutions, caters for the health care needs of an estimated 35 to 40 per cent of the population. Established in 1967, CHAG has evolved over the last 40 years to become a major player in Ghana’s health sector. Its accomplishments to date mean that it is widely viewed within University of Ghana http://ugspace.ug.edu.gh 21 Sub-Saharan Africa as being the best-performing organisation in the faith-based health sector (CHAG, 2012) 2.4.1: Private Sector Providers In many developing countries, when people first seek diagnosis and treatment for an illness they visit a private pharmacist, nurse, midwife, a drug seller or traditional practitioner. People use these private sector providers (PSPs) because they are often nearer, open for longer hours, and are seen as more considerate and sometimes less expensive than their public sector counterparts. PSPs are often a significant part of the health system in developing countries. Consequently they are an important focus for governments which aim to improve the performance of their health system. Poor people in particular visit PSPs for diagnosis and treatment of illness, including those illnesses which contribute most to the population disease burden, such as malaria, sexually transmitted infections, diarrhoea and tuberculosis. They often pay out of their own pockets for health services and products from PSPs as they are not generally members of pre-paid health schemes. Poor people are thus both vulnerable to draining their resources resulting from ineffective treatment and to the sometimes catastrophic costs of serious illness. Both may lead to further impoverishment (Smith, Brugha and Zwi 2001). Aljunid (1995) argues that the reasons for consulting PSPs are ease of geographic access, shorter waiting periods, longer or more flexible opening hours and greater availability of staff and drugs. New anti-malarial such as the artemisinisms, on which future malaria control strategies will rely on are widely found in private retail outlets long before reaching the public sector. Greater confidentiality in dealing with diseases such as tuberculosis (TB) and sexually transmitted infections (STIs) which carry social stigma, especially where notification of STIs by public University of Ghana http://ugspace.ug.edu.gh 22 sector services is mandatory, perceptions are that PSPs are more considerate, caring and sensitive to client concerns. Smith et al. (2001) argued that both informal and formal user charges may be levied in the public sector, making public sector services equally or more expensive. Perceptions in some settings are that private sector services are technically superior continuity of care and in the case of doctors, a belief in the value of the ‘family-doctor’ relationship. Financial inaccessibility is not the only challenge to accessing healthcare but also the nature of the health service must be acceptable by the social structure of the setting to promote utilization. Swan and Zwi, (1997) advice that there is the need to study the nature of Private Sector Providers (PSPs). They argue that the technical quality of care provided by private providers is often poor. PSP practices have been under-researched and few of the available studies compare public and private sector quality of care. However, the available evidence reveals serious technical weaknesses in the services supplied by many for-profit providers. Shortcomings in private sector TB care include failure to test sputum, reliance on X-ray diagnosis alone, use of incorrect drugs or drug dosages, and failure to educate patients. In India, almost half of the TB patients attending private health facilities failed to complete the treatment (Uplekar et al. 1998). Recent studies in Vietnam have shown similar patterns of health care provision for TB by PSPs: little use of appropriate diagnostic tests, delays in establishing the diagnosis and commencing treatment and poor referral to the best available public sector services (Lönnroth 2000). Studies of pharmacy, general practice and specialist Sexually Transmitted Infections services have shown poor quality management of STIs by for-profit PSPs. In a study University of Ghana http://ugspace.ug.edu.gh 23 from Thailand, even where users recognised that government services were technically superior, they sometimes chose a PSP to minimise embarrassment (Benjarattanaporn et al., 1997). Inadequate information and failure to make decisions about the technical quality of the accessible types of health care information asymmetry is a major limitation when people acquire care. They may find PSPs more responsive, but may not recognise their inadequacies. Poor prescriptions, dispensing and self-medication practices waste scarce resources, harm individuals and contribute to the spread of infectious diseases. Where incomplete courses of drugs are dispensed or people fail to complete the treatment, resistance to the drugs that are essential for controlling infections is promoted (Smith et al. 2001). According to Venkant (2009), the virtual breakdown of public health system and unfettered rapid expansion and dominance of private health sector have translated into the poor being forced to seek services from expensive and unregulated private sector. And 80% of expenses from Out-of- Pocket by the service beneficiary resulting in debilitating effects on the poor in India. This attracted the Concern regarding unbridled commercial behavior of the private sector. Juxtaposing the respective strengths and weaknesses, neither the public nor the private sector is in full capacity to deliver health care. Therefore it is by virtue of this circumstance that there is the need for some collaboration between the two. While this study is concerned with the four concepts mentioned earlier (availability, accessibility, utilization and coverage) to assess the service delivery, Venkant (2009), extends his study to financing health delivery. Hypothetically, he outlines the intended benefits of the collaboration between the public sector and private sector in health care. And they include improved access and reach , improved equity (reduce out of pocket expenses), better efficiency , opportunity to regulate and accountability, improve quality, University of Ghana http://ugspace.ug.edu.gh 24 rational practice, imbibe best practices and augment Resources and Funds, technology and human resource. By the end of my study I hope that some of these outcomes will be obtained from the study area. According to a review on China’s health care delivery by Eggleston et al (2008) in a paper submitted to the World Bank, the study looked at the factors that underpin the poor performance of the health sector and revealed that there was more work to be done with regards to cost, equity, personnel, efficiency and urban bias. However, they indicated that it did not really depend on the efforts of either the private or the public sector. The outcomes of the study indicated that the poor performance of the health sector in China was as a result of the following factors: some inappropriate interventions by the government which includes poor regulation, the issue of advertising hazardous products to health and the behaviour of insurance. Other factors were the health care markets such as pricing mechanisms, confidentiality with regards to patients and the issue of not making necessary information available to tackle market failure problems like information asymmetry. Another problem was the quality of the health workforce in China especially in the rural areas. China found it relevant to increase the health workforce however the major challenge that emerged was the issue of the quality of the personal. Eggleston et al., (2008) posit that, a study conducted in 2001 revealed that about 70% of health workers in the rural areas had high school education as the highest level obtained and had just gone through medical training for about 20 months only. The health sector also fell short of management and other key groups necessary for the course on quality health care delivery. University of Ghana http://ugspace.ug.edu.gh 25 2.5: Private Sector Health Care in Developing Countries The huge and mostly unregulated private health sector in low-income countries raises serious concerns. According to a review in the latest issue of the Bulletin of the World Health Organization, the quality of drugs, advice and care sold privately is often dangerously poor. Especially for major diseases such as tuberculosis, malaria, and sexually transmitted infections, this has consequences for the individuals treated, for disease transmission and the development of drug resistance (WHO, 2002). An article by Professor Anne Mills and colleagues in the Health Policy Unit at the London School of Hygiene and Tropical Medicine indicates how the private sector functions, and how it could be influenced in order to help meet national health objectives (WHO 2002). Though it contains extreme diversity, ranging as it does from large commercial companies to shopkeepers and itinerant drug sellers, private enterprise has a strong common characteristic: it needs to sell its services and products profitably. In order to do so, it may ignore good technical standards of treatment such as correct drugs and dosages, especially where these are not readily affordable to its customers. For poor people such services are often the only option. In Sierra Leone, for example, the price of purchased drugs was almost a third of the cost of treatment at a public health centre. Private services are often more easily accessible as well, with drugs sold in general shops with convenient opening hours (WHO 2002). People in low-income countries often lack knowledge about effective means of treating and preventing illness and are dependent on providers for information such as an interpretation of their symptoms (WHO, 2002). This can make them vulnerable to inadequately qualified University of Ghana http://ugspace.ug.edu.gh 26 practitioners providing care of very poor quality, with little chance of redress when they have been victims of malpractice or negligence. Direct consumer education could help inform patients about what constitutes good quality care for many common medical procedures. Price information could help patients when they seek providers, and social marketing could prove useful in publicizing such information. Governments should use a range of approaches when working with private providers rather than relying on single strategies. The improvement of knowledge and skills is a necessary starting point. Most private providers receive no guidance from the public sector on diagnosis and treatment. Consequently, their practices are determined by biased information from pharmaceutical companies. Therefore, training is central to most approaches (WHO, 2002). It has improved the diagnosis and counseling practices of informal providers in India, the provision of antimalarials by shopkeepers in Kenya, and the management of diarrhoea and acute respiratory infections by private medical practitioners in Mexico (WHO 2002). Governments should regulate the private sector, but putting regulation into effect has proved extremely difficult, especially in sub-Saharan Africa. For example, at present, many antibiotics and antimalarials, including those most recently released, are readily available from shops and peddlers, hence, ways must be found to influence the private sector in favour of public health. 2.6: Conceptual Framework for the Structure of Health Care Delivery in Ghana This section deals with the concepts that underpin the study. Many efforts have been put to study and possibly improve on the health service delivery by numerous researchers. However, WHO (2010) has frequently used some conceptualized outcomes to assess health service delivery University of Ghana http://ugspace.ug.edu.gh 27 globally. According to WHO (2010), these concepts are relevant and remain part of the key characteristics of a health service delivery system. This study attempted to adopt some of these concepts. Among them are accessibility, availability, utilization and coverage. Figure 1 gives an over view on how health care is organized, regulated and delivered by the various service providers. University of Ghana http://ugspace.ug.edu.gh 28 Figure 1: A Conceptual Framework of the Institutional Arrangements and Supervisory Structure of the GHS and Health Service Providers. Source: Author’s construct, 2015 Ministry of Health (MOH) GHS Council NDHS RDHS REG Health Committee Public Sector Faith-Based Private Sector Supervising, Monitoring, Regulating, Training and Contracting Provision of health service (Coverage) Availability Accessibility Utilisation Through the Director General University of Ghana http://ugspace.ug.edu.gh 29 NB: GHS – Ghana Health Service NDHS- National Directorate of Health Services RDHS- Regional Directorate of Health Services DHD- District Health Directorate This conceptual framework looks at the various health service providers considered for this study and the institutional arrangement that binds them in executing the common goal of delivering quality health care services. With a mission ‘to contribute to socio-economic development and the development of a local health industry by promoting health and vitality through access to quality health for all people living in Ghana using motivated personnel’, the MoH is tasked by the government with the provision of effective and efficient policy formulation, resource mobilization, monitoring and regulation of delivery of health care by different health agencies in Ghana (MoH, 2012). The MoH is headed by the Minister of Health. The Ghana Health Service is an independent Executive Agency in-charge of the implementation of national policies under the control of MoH through its governing Council - the Ghana Health Service Council. The GHS depends largely on public funds and thus remain within the public sector. At the regional level, the regional hospitals, the District Health Management Team (DHMT) as well as the Public Health division of the regional hospitals provides curative services and public health services respectively. The Regional Health Administration or Directorate (RHA) provides supervision and management support to the districts and sub-districts within each region (GHS, 2015). At the district level, curative services are provided by district hospitals many of which are mission or faith based. Public health services are provided by the DHMT and the Public Health unit of the district hospitals. The District Health Administration (DHA) provides supervision University of Ghana http://ugspace.ug.edu.gh 30 and management support to their sub-districts (GHS, 2015). The situation is not different in Abokobi as the community health center delivers curative services under the supervision of the Municipal Heath Directorate (MHD). The MHD delivers preventive services within the community through programmes such as disease control and nutrition. As mentioned earlier, the arrangements that bind these partners and agencies are contracts, supervision and monitoring as well as regulation. In the case of the private participants, there is a limit to the extent at which the Municipal Health Directorate (MHD) can supervise their work. For example the MHD is limited to only clinical areas of a private facility where as administrative, financial and procurement area no go areas for the MHD. According to the Municipal Health Directorate in Abokobi, the Abokobi Health Center is public and automatically falls under its authority, it also supervises all the private facilities within the catchment area to ensure that the required standards are met. Among the standards checked, supervised and monitored are; a nominal role, procurement, triage desk and all implemented programmes among others. Aside supervision, available nurses are also contracted to the private facilities that at any point in time fall short of nursing personnel. The study then revealed that partnership between government and private health service providers is not a regulated one. However, there is some sort of collaboration existing between the aforementioned categories of service providers that help in promoting health care services for the utilisation of the people of Abokobi. However three key interrelated concepts in the provision of health care are availability, accessibility and utilisation as outlined in the conceptual framework. As it is arranged in the conceptual framework from left to right, each concept needs to be fulfilled and achieved before the next one can be conceived and achieved. According to WHO (2010), availability refers to the physical presence of the facility. However it is not enough for facilities to be available but they University of Ghana http://ugspace.ug.edu.gh 31 should be sufficiently enough in regard to numbers, locations and proximity for them to be accessible to the people. It is only in these regards that the people are enabled to utilize the facilities. Other concepts have been captured by literature in promoting quality service delivery. For example Tanahashie (1978) includes affordability and acceptability in the concepts mentioned above. He posits that a health facility or health service should be affordable and acceptable. Which means that services provided should be reasonably priced. In other words it should be inexpensive to the recipient of the service. He argued that for a health facility or service to be acceptable, the nature of the service should be suitable and satisfactory to the recipient. Or social, cultural, religious and ethnical factors do not discourage the recipient from acquiring healthcare. University of Ghana http://ugspace.ug.edu.gh 32 CHAPTER THREE METHODOLOGY 3.0: Introduction Both quantitative and qualitative methods were used for the study. The Abokobi township was chosen as the study area because of the presence of the District Health Directorate (DHD), the Community Health Center and the presence of some private sector providers which include two pharmacies, some herbalists and a Traditional Birth Attendant. Various instruments were employed to assess the accessibility and utilization of health care delivery in the municipality. 3.1 Profile of Ga East Municipal Assembly Area The Ga East Municipal Assembly (GEMA) is one of the eight (8) districts in the Greater Accra Region of Ghana. The area is located to the north eastern part of the region and is one of the newly created districts carved out of the former Ga District (GEMA 2015). 3.2 Demographic Characteristics The 2010 National Population and Housing Census put the Municipal Assembly’s population at 198,220 with an inter-censal growth rate of about 4.2%. Women In the Fertile Age (WIFA) (15- 49 years) formed 28.5% of the total population. The 2010 population figure yields a density of 1,214 persons per sq km much higher than the national density of 79.3 and the regional density of 895.5 persons per sq. km. This indicates a great pressure of population on land and resources or what the land can generate (GSS, 2014). University of Ghana http://ugspace.ug.edu.gh 33 Abokobi in particular had a population of 1,095 as at 2010 but was projected to reach 1,764 by 2013. Abokobi is the capital of the Ga East District. The district is bordered on the north by the Akwapim South District in the Eastern Region and on the west by the Ga West district, on the south by Accra Metropolis and Ga South and on the east by the Adenta Municipal area. There are thirty four (34) communities in the Ga East Mnicipal Assembly comprising mixed settlements, urban, peri-urban and rural areas with about 82% of the entire Municipal Assembly settlement being urban (GEMA, 2013). The Ga East Municipal Assembly has a great deal of opportunities for both private investment and joint ventureship with the public sector. This is due to the enabling factors for development coupled with the infrastructure set-up and the district’s proximity to the nation’s capital, Accra. There are four main economic activities in the District which are commerce, agriculture, service and industry. The economic activities include Public Services and trading, these are the dominant occupations in the municipality, followed by craftsmanship or artisanship with few engaged in subsistence farming. There are a few who are employed in small and medium scale enterprises as factory hands or casual workers. Some are engaged in hawking in goods for companies for some form of daily commission (GEMA, 2013). About 63.6% of the population of the Ga East Municipality falls within the economically active age group. The dependency ratio shows the relative predominance of persons in dependant ages (persons less than 15 and those above 65) and those in the productive ages (i.e. 15-64 years). The 0-14 year group is the children population; 15-64 constitute the working population and 65 plus forms the aged group. The current dependency ratio is estimated to be 1:0.52 or 52%, which means that for every 100 people aged 15-65 years, there are approximately 52 people depending University of Ghana http://ugspace.ug.edu.gh 34 on them for survival. In other words, each person within the working age group has less than one additional person to cater for Dependency ratio in the Municipality is less in urban localities (52.0) than in rural localities of (53.3). This translates into the high poverty level and for that matter their inability to pay for the health care services offered (GSS, 2014). The district is a Ga community but could be said to be heterogeneous since it is made of a mix of many of ethnic groups in Ghana but with Ga –Adangbes, Akans, Ewes and people from the three northern regions of Ghana forming the majority. Two major festivals are celebrated in the district, namely Dokobi which is celebrated by the inhabitants of Sessemi and Homowo celebrated by the people of Boi, Teiman and the other Ga communities in conjunction with the people of Teshie and La. The Ga East Municipal Health Management Team (MHMT) is responsible for all health service delivery in the entire municipality. The municipality is divided into four sub municipals for the organization and distribution of primary health care services. These sub municipals are Abokobi, Dome, Taifa and Haatso. Each sub municipal health management team has the responsibility for the delivery of health services to defined areas and has a center with either one or two community clinics. There are trained Traditional Birth Attendants (TBAs) and other care providers such as chemical shop dealers, maternity homes and traditional healers in the municipality. The doctor to population and nurse to population ratios are given as follows:  Population to doctor ratio is 1 : 40,246  Population to nurse ratio is 1 : 2,012 University of Ghana http://ugspace.ug.edu.gh 35 One important fact worth noting is that Abokobi is one of the initial settlements of the Basel missionaries in Ghana and is therefore an important landmark of the Presbyterian Church of Ghana. It is the political seat of the district and therefore has the Municipal Assembly as well as other decentralised departments including the Municipal Health Directorate (MHD). The town is well planned with quite good environmental sanitation and has a serene environment. The Ghana Atomic Energy Commission is located at Kwabenya (Taifa sub-district); the largest Psychiatric Hospital in Ghana is located at Pantang (Abokobi sub-district) which has two Nurses Training Schools (GEMA, 2013). The district has a total of about forty-three (43) health facilities made up of 6 public facilities (13.3% ), One (1) quasi government, Ghana Atomic Energy Commission (GAEC), one (1) faith based hospital, Christian Health Association of Ghana (CHAG) and the remaining 35 (81.4%) are private facilities. There is one Community Health based Planning and Services (CHPS compound) located at Akpormang-Boi in the municipality. All these health facilities render outpatient curative care services but only eight (8) have skilled delivery facilities. There is collaboration between the Distri