Access, Bottlenecks, Costs, and Equity (ABCE)

1. Access, Bottlenecks, Costs, and Equity (ABCE)
Understanding the costs of and constraints to
health service delivery in Ghana
On behalf of the ABCE research team
Institute for Health Metrics and Evaluation | Ghana Health Service | UNICEF
January 2015

2. Overview
• Overview of the ABCE project in Ghana
• Key findings
o Facility capacity and service provision
o Efficiency and costs of care
• Using ABCE work and findings for
policymaking
• Conclusions

3. Overview of the ABCE project in Ghana

4. Overview of the ABCE project in Ghana
ABCE study design and implementation
• Collaboration between
Ghana Health Service
(GHS), UNICEF, and IHME
• Primary data collection
took place June-October
2012.
• The ABCE Facility Survey
was used to collect primary
data from health facilities.

5. Overview of the ABCE project in Ghana
ABCE Facility Survey
• Primary data collection from a
nationally representative sample
of 240 facilities
• Collected data on a broad range
of indicators
o Inputs, finances, outputs, supply-
side constraints, and bottlenecks
• Randomly sampled a full range of
facility types
o Referral hospitals, district hospitals,
maternity clinics, health centers,
CHPS, drug stores or pharmacies,
and DHMTs

6. Key findings from the ABCE project in Ghana
Facility capacity and service provision

7. Facility capacity and service provision
Human resources for health: overall trends
• The average number of facility personnel grew 69% across facilities
in Ghana, from 49 in 2007 to 82 in 2011.
• The most dramatic growth was observed among public hospitals,
followed by private clinics and maternity clinics.
• The average number of internally funded personnel at publicly
owned facilities substantially increased between 2009 and 2011.

8. Facility capacity and service provision
Average number of facility personnel, 2007–2011

9. Facility capacity and service provision
Average number of internally funded personnel, 2007–2011

10. Facility capacity and service provision
Human resources for health: facility composition
• Types of personnel working at facilities substantially varied by
facility type, but non-medical staff generally accounted for the
largest proportion of facility personnel.
• Growth in personnel types varied by platform from 2007 to 2011:
o Regional referral hospitals: the number of nurses or midwives rose 24%
o Public hospitals: non-medical personnel nearly doubled
o Health centers: the average number of nurses or midwives increased 65%.
o CHPS: on average, an additional nurse or midwife was added to each facility.

11. Facility capacity and service provision
Average percent of personnel type, by platform, 2011

12. Facility capacity and service provision
Average number and types of personnel, 2007–2011

13. Facility capacity and service provision
Outputs, 2007–2011
• Most facility types saw gradual growth in both outpatient and
inpatient volumes between 2007 and 2011.
o Private clinics were the exception, recording rapid growth in both outpatient
and inpatient visits.
• These results somewhat contrast with previous reports of quickly
escalating patient volumes across facility types
o Past reports attribute such rapid rises to heightened affiliation with Ghana’s
National Health Insurance Scheme (NHIS).

14. Facility capacity and service provision
Outputs: average outpatient visits, by platform, 2007–2011

15. Facility capacity and service provision
Outputs: average inpatient visits, by platform, 2007–2011

16. Facility capacity and service provision
Drug procurement sources
• Facilities generally obtained pharmaceuticals from a mixture of
private and public sources.
o E.g., over 70% of hospitals used both public and private suppliers to procure
pharmaceuticals.
• The majority of surveyed private clinics, maternity clinics, and
pharmacies reported obtaining all drugs from only private sources.
• Health centers were the only facility type where at least 50% of
facilities reported using only public sources for pharmaceutical
procurement.

17. Facility capacity and service provision
Average drug procurement source, 2011

18. Facility capacity and service provision
Availability and stock-outs of antimalarials
• Most facilities stocked some kind of artemisinin-based
combination therapy (ACT) and did not experience stock-outs
during the previous quarter.
o Some facilities still stocked chloroquine, despite policies calling for its
discontinuation.
• Fansidar, the main drug for intermittent preventive therapy during
pregnancy (IPTp), was also widely available for most facilities.
o Compared to other facility types, CHPS and pharmacies generally had
slightly lower availability of ACTs and Fansidar.
• Of the two types of ACTs stocked in Ghana, artemether-
lumefantrine (AL, or Coartem) was generally more available than
artesunate-amodiaquine (AS+AQ).

19. Facility capacity and service provision
Availability of antimalarials for the previous quarter, 2012

20. Facility capacity and service provision
Availability of ACTs for the previous quarter, 2012

21. Facility capacity and service provision
Availability of ACTs and ACT stock-outs for the previous quarter, 2012

22. Facility capacity and service provision
Capacity to test for and treat malaria
• Facility capacity varied for being able to both diagnose and treat
malaria (i.e., have lab testing or rapid-diagnostic tests [RDTs] and
stock ACTs).
o 100% hospitals, 77% of private clinics, 53% of health centers, 23% of CHPS
• Availability of malaria testing was the primary constraint for most
facility types, with 47% of health centers and 68% of CHPS lacking
malaria diagnostic capacity.
• CHPS and pharmacies experienced a similar proportion of facilities
that lacked both malaria diagnostic capacity and treatment (just
under 10% of facilities).

23. Facility capacity for service provision
Capacity to test for and treat malaria, 2012

24. Facility capacity and service provision
Availability and stock-outs of antiretroviral drugs (ARVs)
• Of surveyed facilities, only regional referral hospitals and public
hospitals carried ARVs.
• On average, regional referral hospitals had a higher availability of
ARVs than public hospitals and experienced slightly lower levels of
stock-outs.
• Tenofovir (TDF), nevirapine (NVP), and lamivudine (3TC) were
generally more available at all hospitals, and experienced lower
levels of stock-outs, than efavirenz (EFV) and zidovudine
(AZT/ZDV).
• In terms of stocking all first-line ARVs, 60% of regional referral
hospitals and 33% of public hospitals had all five.

25. Facility capacity and service provision
Availability of ARVs for the previous quarter, 2012

26. Facility capacity and service provision
ARV stock-outs for the previous quarter, 2012

27. Facility capacity and service provision
Diagnostic capacity for a subset of infectious diseases
• Facility capacity to diagnose two infectious diseases that affect
Ghana – malaria and HIV/AIDS – varied by facility type.
• 100% of hospitals had malaria testing capacity, and about 90% of
hospitals had HIV/AIDS testing.
• Facilities generally had a higher availability of malaria testing than
HIV tests; CHPS and maternity clinics were the exceptions.
o 23% of CHPS had malaria tests; 29% had HIV testing
o 50% of maternity clinics had malaria tests; 69% had HIV testing

28. Facility capacity and service provision
Diagnostic capacity for a subset of infectious diseases

29. Facility capacity and service provision
Laboratory testing capacity
• Laboratory-based diagnostic capacity varied across facility types
but largely diverged by level of care (hospitals vs. primary care).
• All hospitals had lab capacity for malaria testing and urinalysis, and
over 90% of hospitals had blood draw capacity.
• Primary care facilities had much lower levels of laboratory
capacity, which generally reflects their infrastructure and
organization.
o Privately owned or specialized facilities had much higher availability of lab
testing. Among maternity clinics, for example, 63% of facilities provided
urinalysis, an important component of antenatal care.

30. Facility capacity and service provision
Laboratory equipment availability for the previous quarter, 2012

31. Facility capacity and service provision
Vaccine storage capacity and monitoring efficacy
• Of the facilities that routinely stored vaccines, only 64% of facilities had
temperature-monitoring systems in place.
• Among facilities reporting routine vaccine storage, 25% stored vaccines
out of the recommended temperature range (colder than 2° C or warmer
than 8° C).
• The majority of facilities with a temperature-monitoring chart stored
vaccines within the recommended range.
o 90% of hospitals
o 80% of CHPS
o 25% of private clinics
• The majority of facilities that stored vaccines outside of the
recommended temperature range did not have a monitoring chart.

32. Facility capacity for service provision
Vaccine storage capacity and monitoring efficacy, 2012

33. Key findings from the ABCE project in Ghana
Efficiency and costs of care

34. Efficiency and costs of care
Estimating efficiency: Data Envelopment Analysis (DEA)
• DEA: quantifies the relationship between a facility’s resources
(medical staff, beds) and its production of services (outpatient
visits, inpatient bed-days, and births) relative to comparably sized
facilities in the ABCE sample.
• Efficiency score: a value between 0% and 100%, reflecting the
alignment of facility resources to service production.
o 100% = maximum use of facility resources for output production
• Outpatient equivalent visits (OEV): weighting different outputs in a
standardized way to allow for direct comparisons across facilities.
o Average across facilities:
 Inpatient bed-day = 3.8 outpatient visits
 Birth = 10.9 outpatient visits

35. Efficiency and costs of care
Average production of outputs across facilities
• Across platforms, facilities averaged a total of four outpatient
equivalent visits per medical staff per day, ranging from 2.2 visits
at CHPS to 6.8 visits at maternity clinics.
• Outpatient visits accounted for the largest proportion of patient
visits experienced per medical staff per day at primary care
facilities.
• Inpatient bed-days accounted for the largest proportion of patient
visits produced per medical staff per day at regional referral
hospitals and public hospitals.

36. Efficiency and costs of care
Average production of outputs across facilities, 2011
Note: All visits are in outpatient equivalent visits, with an average of one inpatient bed-day
equaling 3.8 outpatient visits; and one birth equaling 10.8 outpatient visits.

37. Efficiency and costs of care
Efficiency scores varied across and within platforms
• Across all facilities, the average efficiency score was 27%.
• More than 80% of facilities had an efficiency score at or less than 50%.
• Average efficiency scores declined in parallel with decreasing levels of
care.
• Private facilities averaged higher efficiency scores than public facilities at
similar levels of care.
• Tremendous range in efficiency scores within platforms:
o At least one facility had an efficiency score of 100% for nearly all platforms.
o Multiple facilities had efficiency scores close to 0% for most facility types.
• Urban facilities generally had higher levels of efficiency than rural
facilities, but this relationship was not as clear-cut at lower levels of care.

38. Efficiency and costs of care
Efficiency scores across platforms, 2007–2011

39. Efficiency and costs of care
Estimated potential for expanded service production
• We estimated that facilities had substantial potential for increasing
output production, especially among lower levels of care.
• An average of 13 additional visits, measured in OEV, could be
added across facilities, based on observed resources.
• This potential for expanded service production does not reflect
the quality of services delivered; it shows the alignment of facility
resources and output production.

40. Efficiency and costs of care
Estimated potential for expanded service production, 2011

41. Efficiency and costs of care
Cross-country comparison of efficiency
• Ghana showed more potential for expanded service
provision, given observed resources, than other sub-Saharan
African countries involved in the ABCE project.

42. Efficiency and costs of care
Facility expenditures: overall trends
• Average facility expenditures grew 38%, largely driven by increases
in service and personnel expenditures.
• Hospitals spent the most among facility types, and private clinics
documented the strongest growth between 2007 and 2011.

43. Efficiency and costs of care
Average annual facility expenditures, 2007–2011

44. Efficiency and costs of care
Average annual expenditures, 2007–2011

45. Efficiency and costs of care
Facility expenditures: spending composition
• Spending patterns by facility type were largely similar, with
personnel expenses generally accounting for the bulk of spending
at the facility level.
• Expenditure growth varied by platform from 2007 to 2011:
o Regional referral hospitals: moderate increases, largely driven by service
increases (a 41% rise)
o Public hospitals: overall average expenditures increased 62%
o Health centers: spending on services more than doubled
o CHPS: average spending on personnel increased by 35%, but percent of total
spending on personnel decreased over time

46. Efficiency and costs of care
Average percent of expenditure type, 2011

47. Efficiency and costs of care
Average levels and types of expenditures, 2007–2011

48. Efficiency and costs of care
Facility revenues: overall trends
• Average facility expenditures grew 30% between 2007 and 2011,
largely driven by expanded NHIS reimbursements and continued
growth in government spending.
• Facility revenue growth generally kept pace with spending.
• Private clinics recorded the largest and most consistent increases
in revenues from 2007 to 2011.

49. Efficiency and costs of care
Average annual facility revenues, 2007–2011

50. Efficiency and costs of care
Average annual revenues, 2007–2011

51. Efficiency and costs of care
Facility revenues: funding composition
• Funding patterns by facility type widely varied, largely diverging
along facility ownership (public vs. private).
• Most hospital revenues were composed of government funds and
NHIS reimbursements, whereas publicly owned primary care
facilities were largely funded by the government.
• Revenues at private clinics and maternity clinics were largely
drawn from NHIS or cash and carry.
• Funding trends and composition varied by facility type, but across
a subset of platforms, the overall revenue composition generally
shifted with the expansion of NHIS funds and small declines in
cash and carry.

52. Efficiency and costs of care
Average percent of revenue source, 2011

53. Efficiency and costs of care
Average levels and types of revenue sources, 2007–2011

54. Efficiency and costs of care
Estimating costs of care
• Using information produced through DEA, output-specific
spending by facilities was divided by outputs produced by each
facility.
• All cost data were adjusted for inflation and reported in 2011
Ghanaian cedi.
o All US dollar estimates were based on the 2011 exchange rate of 1.60
cedi per $1.

55. Efficiency and costs of care
Average facility cost per visit, across outputs and by platform
• Facility costs per patient visit varied across platforms and by
output type.
• Based on average facility costs, outpatient visits were generally the
least expensive to produce, and births were the most expensive.
• Regional referral hospitals generally spent the most per patient
visit produced, whereas maternity clinics generally produced
patient visits at the lowest facility cost per output.

56. Efficiency and costs of care
Average facility cost per visit, across outputs and by platform

57. Efficiency and costs of care
Cross-country comparison of output costs
• Ghanaian facilities generally averaged higher production costs
per visit than the other sub-Saharan African countries involved
in the ABCE project.

58. Using ABCE work and findings for policymaking

59. Using ABCE for policymaking
Identifying health system progress and challenges
• Provides policymakers with the evidence to pinpoint areas of
success and for improvement as linked to national goals and
priorities
• Enables direct comparisons across facility types and
ownership, allowing policymakers to contrast facility capacity
in the public sector with that of the private sector
• Supports the timely use of data to inform policy dialogue

60. Using ABCE for policymaking
ABCE Ghana policy report
http://www.healthdata.org/dcpn/ghana

61. Conclusions

62. Conclusions
Facility capacity for service provision
• Ghana recorded substantial growth in facility personnel, but composition of staff
varied widely by facility type.
• Facilities generally had a high availability of ACTs for treating malaria, but the
concurrent availability of malaria diagnostics was much lower, particularly
among primary care facilities.
• Hospitals appeared to be the only type of facility that stocked ARVs for HIV
treatment, but HIV testing was generally available across levels of care.
• The majority of facilities in Ghana procured pharmaceuticals from both public
and private sources, which has implications for the country’s regulatory capacity.
• While 25% of facilities that routinely stored vaccines had storage temperatures
outside of the recommended range, the presence of a monitoring chart was
related to better storage practices.
o 90% of facilities with monitoring charts had proper thermal conditions for vaccine storage.

63. Conclusions
Facility production of health services
• Average patient volumes gradually increased across
platforms, except for private clinics, which recorded rapid
growth.
• Shortages in human resources and facility overcrowding have
been viewed as problems in areas in Ghana; in the ABCE
sample, most facilities averaged fewer than four visits per
medical staff per day.
• Given observed facility resources, facility service production
could potentially be increased by an additional 13 outpatient
equivalent visits per day, on average, per medical staff.

64. Conclusions
Facility costs of care
• Average facility spending increased over time, often driven by
heightened spending on personnel.
• Growth in facility revenue generally kept pace with spending,
with increased spending by the government and NHIS largely
accounting for growth.
o For a number of facility types, the percentage of facility revenues coming
from cash and carry – or out-of-pocket expenditures – has declined.
• Average facility cost per patient visit differed substantially across
platforms and types of visits.
• In comparison with a subset of other countries in the ABCE
sample, average facility costs in Ghana were generally higher.

65. Conclusions
Priority considerations for future work
• Updated analyses across indicators to assess progress and to
identify areas that may require more investment
• Targeting a broader set of facilities to capture a clearer picture of
levels and trends in facility performance
• Linking estimates of efficiency to quality of the services produced
at facilities, as well as other factors.
o e.g., expediency with which patients receive care, demand for increased
services
• Generating estimates of cost-effectiveness based on facility
delivery of services and costs of production, and linking to ongoing
work on estimating trends in health outcomes and disease burden

66. Thank you
http://www.healthdata.org/dcpn/ghana