Ghana faces a dual burden of both communicable and non-communicable diseases. While malaria and diarrhea remain problems, non-communicable diseases like hypertension, stroke and diabetes are increasingly common causes of death. Ghana's health system struggles to address this growing disease burden due to underfunding and understaffing of the National Health Insurance system. Policy changes are needed to improve sanitation, health education, and ensure universal access to healthcare through increased funding from taxes and the formal sector.

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Policy Brief 2: The Burden of Disease in Ghana
A look at the growing number of NCDs in an underfunded health system still battling Malaria.
!
Abstract
Ghana is a low-income country facing a
disease burden of both communicable
and non-communicable diseases. After
instituting a National Health Insurance
system in 2003, the system has
remained largely underfunded and
understaffed, unable to meet the needs
of Ghanaians and forcing many people
to seek the services of traditional
medicine. The system fails everyone,
but above all those in the informal
sector and in rural areas. To solve these
problems, the costs for the informal sector must be eliminated, and be better funded through
increased taxes and payroll deductions in the formal sector. Furthermore, many communicable
diseases could be prevented through improved sanitation standards.
Ghana has a dual burden of disease that is
increasingly affected by non-communicable
diseases while still facing communicable
diseases. In total, 39% of mortality in Ghana
is attributed to NCDs. (WHO, 2014) Today the
top ten causes of death include hypertension,
stroke, diabetes, and cancer. (Abiiro &
McIntyre, 2012)
In the next 20 years Ghana’s burden of
disease will continue to shift to more chronic
non-communicable disease due to a
population that is living longer and in more
urban environments, with poor diets and
decreasing physical activity, especially
around the major city of Accra and the
Ashanti region. (Addo, Aikins, Bosu, & Ofei, 2012) Almost 29% of the adult population is considered
overweight and that is increasing at a rate of 1% per year, while 33.7% of the population is
between the ages of 25 and 54. This means that we can expect to see an increasing burden of
NCDs in the forceable future as a large portion of the adult population begins to enter old age,
when they are at a greater risk for NCDs. (World Bank, 2014)
Meanwhile, Ghana continues to face communicable diseases such as Malaria, and Diarrhoea a
common symptom and the ultimate killer of many communicable diseases. Many of these
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diseases and symptoms result
from poor water sanitation,
which provides breeding
grounds for vectors and other
pathogens. While data
surveys from the WHO (2014)
show that improved water
standards have increased,
only 18% of the population
has access to improved
sanitation standards. There is
continued growth in access
to improved water and
sanitation, but the rate at which improved sanitation is
growing is much slower. More striking is the difference in
these standards between urban and rural areas. In general,
urban areas have higher improved water and sanitation
standards, whereas open defection has increased in rural
Ghanaian. (WHO, 2014)
In 2003 Ghana passed the The National Health Insurance Scheme Act. While this system is a
contributory National Health Insurance system, it functions as a hybrid of a National Health
Insurance system and a Pluralist system. This is largely because the informal sector is expected to
make out-of-pocket contributions and also because the public sector is unable to meet the needs
of the people, and so the private sector has begun to fill the gap for those who can afford it. As
such, medical facilities are owned by the public and private sectors. There is both public and
private insurance and the system is financed through a VAT, employers and employees payroll
deductions, and income generated by out-of-pocket expenses. In 2005 the NHIS had about 7% of
the population enrolled and that had increased to 66.4% in 2010. Even though enrolment is
increasing, this does not mean that the medical needs of the population are being met. (Abiiro &
McIntyre, 2012)
Approximately 70% to 75% of the the system is tax funded, but only 1/3 of members actually
contribute to the system. There are exemptions for children, core poor, and the elderly. Those in
the informal sector are supposed to pay annual premiums indexed to their incomes, but it can be
difficult to obtain true earnings, so usually a flat rate is asked for. As a result, many in the
informal sector choose not to contribute to the system and there are inadequate funds to pay for
both resources and medical staff, which explains the shortage and understaffed facilities
throughout the country. This is especially true in rural areas and at the tertiary level of care.
(O’Connor, 2010) There are approximately .15 medial personnel per 1000 Ghanaians, which is far
too few to meet even the most basic needs of the people. Nearly 75% of Ghanaians seek
traditional care initially, while those who can afford to, go to private hospitals or self medicate.
(Baidoo, 2009)
The Ghanian healthcare system is not properly staffed to handle the burden of disease for today
or in the future, as it does not have the necessary funds to pay for trained medical staff, drugs,
and other resources. In the future, as the burden of disease shifts increasingly to NCDs, more
resources and funds will be needed as these diseases are more complex and require more
Essentials of Global HealthJuly 4, 2014David Dingus: 11403109
Urban
sanitation
trends
Coverage(%)
0
20
40
60
80
100
1990 2012
10 7
31
1
46
72
13
20
Improved facilities
Shared facilities
Other unimproved facilities
Open defecation
Rural
sanitation
trends
Coverage(%)
0
20
40
60
80
100
1990 2012
29 33
47
15
20
44
4
8
Improved facilities
Shared facilities
Other unimproved facilities
Open defecation
(WHO, 2014)
(WHO, 2014)

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expensive drugs. Every year newly qualified graduates who would normally choose to enter the
medical field, choose instead to go abroad. Resulting in a brain drain and robbing the country of
its ability to provide for its own medical needs. (Addo, Aikins, Bosu, & Ofei, 2012)
While all Ghanaians regardless of gender or socio-
economic status are being increasingly affected by NCDs,
the wealthy groups generally have better access to care
through private insurance and hospitals. On the other
hand, the poorest Ghanaians who usually work in the
informal sector with no insurance or funds, rely on
alternative methods to meet their basic medical care
needs. Because of the structure of the healthcare system,
those working in the informal sector are the most
underserved and make up 80% of the population. They
are unable to pay for the premiums that would grant them
access to the NHIS and thus do not receive the care they
need. Those in middle and middle-low income groups, who work work in the formal sector, are
served by the NHIS, but because of improper funding there is a deficit of hospital staff,
accessibility, and overall healthcare can be slow and ineffective. In sum, the wealthy quartile is
the most targeted and biggest benefactor of the healthcare
system in Ghana, the same group which contributes most
of the taxes that fund this healthcare system. Nonetheless,
all income quintiles and the entire population is being
underserved. (O’Connor, 2010) However, Ghana has seen
positive results from previous policies that have granted
free health care to pregnant mothers and children. Today
most Ghanaian women visit the doctor at least once
during their pregnancy across all income quintiles. On the
other hand, as income decreases, the rate of care by
trained medical staff decreases, yet immunisation remains
high and relatively uniform across all income quantiles.
(WHO, 2014) (Baidoo, 2009)
Policy changes must address the challenges Ghana faces in communicable and NCDs. First, a
focus on improved sanitation standards across the country and especially in rural areas would
greatly help reduce the risk for communicable diseases such as Malaria and deadly symptoms
such as Diarrhoea, which impact the poor the most, and at the same time this would free up
resources for the growing number of NCDs.
Furthermore, current public campaigns and additional ones should be implemented to educate the
public on the importance of healthy food and an active lifestyle. Overtime, these campaigns
positively influence preferences and would reduce the number of people requiring medical care
for the growing number of chronic NCDs.
Finally, structural reform should first and foremost focus on the funding and accessibility
shortage, and the cost barrier for the informal sector. In order to be effective in the prevention and
treatment of communicable and non-communicable diseases, health insurance and care must be
universal. Essentially, the NHIS should move away from being contributory and Pluralistic. It is
Essentials of Global HealthJuly 4, 2014David Dingus: 11403109
(WHO, 2014)
(WHO, 2014)

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especially important that there be no out-of-pocket or premium costs for
the informal sector, and that all funding come from employer, employee,
and tax based payments. However, it is not feasible to switch the country
entirely to a National Health Insurance system, because the costs would
be too great and would require much higher taxes. (Abiiro & McIntyre,
2012)
While many opponents argue that any increase in taxes is not possible,
the current funding system simply does not provide enough money.
Furthermore, Ghana continues to be dependent on foreign aid and this is
not sustainable in the long-run. Instead, the current system can be
adjusted incrementally to include free access for the poor and correct the
funding deficit through a combination of increased payments from the
formal sector and taxes, especially the VAT. By focusing on the VAT, the
NHIS would be funded through consumption, which would be higher for
wealthier individuals and have a a negligible effect on the poor given
how little they consume in the market. Furthermore, funding for NHIS
will grow as the country continues to develop and incomes increase,
because people will consume more, which will increase revenues from
the VAT. (Abiiro & McIntyre, 2012)
Private hospitals and insurance companies should remain, because they will ensure continued
access to healthcare for some individuals, and closing these facilities would only place further
burden on already strained public facilities. Private hospitals would also help attract more
medical personnel in staying in Ghana and eventually lead to spill over effects into the public
sector.
Concluding, improved sanitation standards
in combination with public awareness
campaigns and an adjustment in the
funding structure of the current NHIS, will
help the health system of Ghana better
meet a growing number of health
challenges. Above all, these policies will
help better serve the poor who work in the
informal sector, the most underserved
group, by reducing the risk for the most
common communicable diseases, and
removing the prohibitive costs of medical
care. This will become increasingly important as the country’s disease burden continues to shift
towards NCDs. Only a well funded system will be able to provide greater access to care and
drugs that are essential in combating the growing rate of NCDs.
!
!
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Essentials of Global HealthJuly 4, 2014David Dingus: 11403109
!
“Health care is an
essential
safeguard of
human life and
dignity and there
is an obligation
for society to
ensure that
every person be
able to realise
this right.”
-Joseph Bernadin

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References
Abiiro, G. A., & McIntyre, D. (2012). Achieving universal health care coverage: Current debates in Ghana on covering those
outside the formal sector, BMC International Health and Human Rights. Retrieved from
http://www.biomedcentral.com/1472-698X/12/25
!Addo, J., Agyemang, C., Aikins, D., Bosu, W. K., Ofei, F. (2012). GHANA’S BURDEN OF CHRONIC NON-
COMMUNICABLE DISEASES: FUTURE DIRECTIONS IN RESEARCH, PRACTICE AND POLICY. GHANA
MEDICAL JOURNAL, 46 (2). Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3645141/
!Baidoo, R. (2009). Toward a Comprehensive Healthcare System in Ghana. Retrieved from
https://etd.ohiolink.edu/!etd.send_file?accession=ohiou1237304137&disposition=inline
!O’Connor, F. D. (2010). An Evaluation of the National Health Insurance Scheme in Ghana. Retrieved from:
https://www.academia.edu/1873350/An_Evaluation_of_the_National_Health_Insurance_Scheme_in_Ghana
!WHO. (2014). Proportional Mortality [Chart]. Retrieved from
http://www.who.int/nmh/countries/gha_en.pdf?ua=1
!WHO. (2014). Improved water and sanitation [Chart]. Retrieved from
http://www.who.int/gho/countries/gha.pdf?ua=1
!WHO. (2014). Health services equity [Charts]. Retrieved from
http://who.int/gho/health_equity/countries/gha.pdf?ua=1
!WHO. (2014). Sanitation trends [Charts]. Retrieved from
http://www.wssinfo.org/fileadmin/user_upload/resources/Ghana.xls
!World Bank. (2014). Ghana: Prevalence of Overweight. Retrieved from
http://api.worldbank.org/countries/GHA/indicators/SH.STA.OW15.MA.ZS?per_page=1000
Essentials of Global HealthJuly 4, 2014David Dingus: 11403109