Ghana has a mixed record in terms of health outcomes. While there have been improvements in access to health services, with a dramatic increase in the number of health facilities, this is not reflected in progress on health indicators, which has been ‘worryingly slow’ (UNICEF, 2013). The sector is underfunded, with allocations declining from 16% of the overall national budget in 2006 to 7.6% in 2011. Wages dominate the government component of the budget, leaving limited resources for actual service delivery. In addition, there are frequent deviations between allocations and actual spending, as well as significant leakages at various levels.
Research in this brief suggests that these outcomes reflect the character of politics in Ghana as well as the interaction of politics with the governance arrangements for the health sector. Ghana can be characterised as a ‘competitive clientelist’ type of political settlement, in which two political parties have consistently challenged each other in national elections and where patron-client forms of politics continue to prevail. In this context, the incentives of the ruling elites are loaded towards the use of public institutions in securing short-term political gains.
Key findings:
- Ghana has a mixed record in terms of health outcomes. Despite some gains and a dramatic increase in the number of health facilities, healthcare – and particularly maternal healthcare – has not improved as much as it should. This is partly because the health sector has become politicised in ways that undermine the technical dimensions of policy formulation and implementation
- quantity is prioritised over quality: politicians are incentivised to make investments in visible aspects of the health sector, rather than the less visible, long-term factors that promote quality health outcomes
- the inequitable allocation of resources and distribution of health workers is linked to deepening regional inequalities – politicians prefer to spread resources thinly to increase their influence on voters, rather than focus on more deprived areas
- in the absence of system-wide drivers of improved performance, sub-national variations in the quality of maternal health services are strongly shaped by the capacity and commitment of regional and district health management teams in instituting and enforcing top-down accountability measures