Strong PHC is a cornerstone of an effective and responsive health care system and is a vital vehicle in achieving universal health coverage (UHC). Ghana has long been recognized for its high-performing PHC system, with its Community-based Health Planning and Services (CHPS) system often cited as best practice in delivering health services and engaging the community. However, a survey conducted in 2016 showed significant gaps in access to affordable, respectful, and high-quality primary health care, including:1
- Wait times for eligible health facilities to receive reimbursements from the National Health Insurance Scheme (NHIS) are extremely long (average 278 days).
- Availability of essential drugs is inconsistent across health facilities. On average facilities had only 70% of essential drugs.
- Only half of the respondents sought care for themselves or a family member in the last six months; 80% of them went to a public facility, particularly a public hospital, indicating bypassing of PHC facilities.
- 65% of respondents had insurance coverage, mostly through the NHIS. However, over one-third of women who sought care in the last six months found it difficult to afford their visit and around one-fifth of them had to borrow or sell something to afford the cost of their visit. The average out-of-pocket cost was approximately 141 Cedi ($37 USD in 2016).
In 2016, the Alliance for Reproductive Health Rights (ARHR), the lead for this IC, partnered with PAI to advocate for stronger PHC in Ghana by promoting the development, adoption, and financing of an Essential Package of Health Services (EPHS). In 2017, ARHR and PAI developed the PHC Advocacy Strategy which focused on developing the EPHS and lobbying for a higher budget for PHC.
The Implementation Case
Ghana Learning Questions
Stakeholder Buy-In: What are the most effective advocacy strategies for ensuring government buy-in to civil society organization (CSO) work around the EPHS?
- How can we adapt and implement the JLN Strategic Communications guidance to advance our advocacy agenda related to the EPHS and increased financing for PHC?
- How can this information be best packaged to communicate effectively to various audiences (community, providers, local leaders, national leaders)?
- What are some effective strategies to engage with the media to better advocate for the EPHS?
- What advocacy strategies are most effective in ensuring governments fulfil stated commitments (i.e., the Abuja commitment)?
Root Causes: How can we overcome challenges such as securing funding to better advocate for a cost-effective national EPHS?
Research: What are some key documents/policies to consult when developing materials?
The Implementation Case team, consisting of Nii Ankonu Annorbah-Sarpei, Leonard Shang-Quartey, and Vicky Okine from ARHR, presented the following problem:
Community members continue to bypass CHPS for higher-level facilities because most of the CHPS facilities are under-resourced and frequently report stockouts of essential medicines and equipment. Currently, Ghana also has multiple packages of health services in various government programs—CHPS, NHIS, Newborn Health, Maternal and Reproductive Health, and Adolescent, Sexual & Reproductive Health—which contribute to vertical programming within the health sector and erosion of citizens’ trust of the current PHC system. Efforts to establish an EPHS have stalled since services defined in the package will require financing, by the government or individuals.
The Implementation Case team envisioned a “strengthened and well-functioning primary health care system supported by a consolidated national essential health service package that is well funded (including, but not limited to, COVID-19 health levy and adequate share from oil proceeds) to cater to the health needs of the residents of Ghana.”
Through this implementation phase, the Ghana Implementation Case team pursued learning objectives around creating stakeholder buy-in, adopting strategic communications strategies using the JLN Strategic Communications and Advocacy Tool, identifying strategies to address the root causes of low funding for PHC, and identifying resource materials that they could use in their advocacy efforts (see Ghana learning questions).
During the kick-off meeting, the Implementation Case team laid out the causal chains by identifying critical steps that would lead to their target outcomes:
- Develop a research tool with Ghana Health Service partners at the district health directorate.
- Draft a report on gaps in PHC service delivery.
- Complete a five-year trend analysis on health care financing with a focus on PHC spending.
- Expand stakeholder/partner engagement to share the results of service delivery gaps and trends in financing, including meetings with one or two partners to align advocacy strategies.
Key Lessons and Insights
The Implementation Case team set out to contribute to efforts to address PHC issues in Ghana by generating evidence on service delivery gaps in PHC services and analyzing how the government could mobilize resources to improve the country’s PHC services. The Learning Exchange was instrumental in the development of the policy briefs on service delivery and financing PHC, by providing the following lessons and insights:
- Evidence is critical in making a case for higher funding for PHC and to prompt the review of EPHS. The Implementation Case team reported gaps in PHC service delivery in four districts and completed a five-year trend analysis of funding for Ghana’s health sector (2017-2021). These findings were shared through policy briefs and presented in various forums as part of ARHR’s advocacy for better packaged and well-funded EPHS.
- Multisectoral stakeholder engagement is also vital. Through the process, the Implementation Case team found that building relationships with health technocrats was not enough when advocating for higher health funding, and that it was equally important to cultivate relationships with political leadership. During this Learning Exchange, the Implementation Case team established new and significant relationships with state and non-state actors to support advocacy, which they intend to continue beyond this learning platform. Strategically communicating with these stakeholders is important in galvanizing support for actions.
- The facilitation approach adopted in this Learning Exchange contributed to the advancement of the work of ARHR, including:
- Timely and relevant technical feedback from peer learners and facilitators. The team found the inputs of peer learners and facilitators timely and useful in developing the service delivery survey and the implementation framework that laid out the problem statement, causal chain, and short-term outcomes. The facilitators also reviewed and provided suggestions to improve the draft technical reports on service delivery gaps and the five-year health funding analysis. Peer learners and facilitators provided the Implementation Case team advice on alternative routes and other opportunities to secure health financing data.
- Learning with and from other Implementation Case teams. Through bi-monthly virtual exchanges, the Ghana Implementation Case team was able to connect with the other Implementation Case teams to learn how they were addressing other implementation challenges, including how to engage in strategic communication for priority stakeholder groups to create demand and ensure commitment in the delivery of PHC, how to engage in strategic communications for domestic resource mobilization, and how to establish effective and integrated referral systems.
- Availability of useful resources. The Implementation Case team utilized resource materials like the PHCPI’s vital signs profile and JLN’s Messaging Guide for domestic resource mobilization and the Strategic Communications Resources.
- Contribution of peer learners in implementation Learning Exchange. The participation of peer learners in the process was essential. One peer shared how a coalition of CSOs became effective partners in pursuing health reforms in Nigeria, while another peer suggested reaching out to other stakeholders outside the health sector to secure budget data. Another peer based in Ghana volunteered to assist the Implementation Case team in data analysis. Given the valuable contributions of peer learners to the Ghana case, the technical facilitators sought to engage peer learners more purposively in future endeavors.
The Ghana Implementation Case team will finalize the policy briefs and use them to continue engaging policymakers, make a case for increased funding for PHC in Ghana, and lobby for the development of a more responsive EPHS. They also used the same evidence to further engage with sub-national stakeholders in the first quarter of 2022.
The Implementation Case team found the Learning Exchange useful in implementing their work, particularly the technical feedback they received from peer learners and facilitators. PHCPI and JLN products like the Vital Signs Profiles, domestic resource mobilization, and strategic communications and stakeholder engagement toolkits were also useful. The Implementation Case team looks forward to continuing to build on the tools and skills to advance its work.
The PHCPI-JLN Learning Exchange would like to thank the Ghana Implementation Case team members, including Nii Ankonu Annorbah-Sarpei, Leonard Shang-Quartey and Vicky Okine of ARHR. Special thanks to peer learners who joined the Ghana learning checks and provided useful insights: Marion Subah, Menyanga Abu, Ibrahim Duah Kwaku, Dr. Obioma Obikeze, Dr. Elizabeth Oele, and Camlus Odhus.
The Implementation Case teams were supported by technical facilitators: Dr Leizel Lagrada-Rombaua, Dr. Belinda Nimako, Muchiri Nyaggah, and Dr. Luis Gabriel Bernal Pulido. Linda Arogundade, Dany Chhan, Amanda Folsom, Chloe Lanzara, Tania Mathurin, and Emma Stewart at R4D provided technical and operational support to the teams. The development of this Learning Exchange was supported with funding from the Bill & Melinda Gates Foundation.
1. Started in 2016, PHCPI partnered with Kwame Nkrumah University of Science and Technology, Johns Hopkins Bloomberg School of Public Health, and Performance Monitoring and Accountability 2020 to conduct a survey of 142 health care facilities in Ghana along with a nationally representative survey of 3,694 women.