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GHANA – MEDCOI REPORT

Acknowledgements
The EUAA acknowledges International SOS as the drafter of this report.
The report has been reviewed by International SOS and EUAA.

3

EUROPEAN UNION AGENCY FOR ASYLUMContents
Acknowledgements........................................................................................................................ 3Contents .......................................................................................................................................... 4
Disclaimer ........................................................................................................................................ 6
Glossary and abbreviations ........................................................................................................... 7
Introduction ................................................................................................................................... 10
Methodology ....................................................................................................................................... 10
Terms of reference ........................................................................................................ 10
Collecting information ................................................................................................... 10
Currency ........................................................................................................................... 10
Quality control ................................................................................................................. 10
Sources .............................................................................................................................. 11
Maps ...................................................................................................................................................... 12
1.

General information ..........................................................................................................13
1.1. Demographic and Economic context ......................................................................................13
1.2. Burden of disease ......................................................................................................................142.

Healthcare system ............................................................................................................15
2.1. Health system organisation ..................................................................................................... 15
2.1.1. Overview ................................................................................................................. 15
2.1.2. Public sector ......................................................................................................... 21
2.1.3. Private sector ....................................................................................................... 222.2. Healthcare resources .............................................................................................................. 23
2.2.1. Human and technical resources .................................................................... 23
2.2.2. Finance resources ............................................................................................. 25
2.3. Pharmaceutical sector............................................................................................................. 26
2.4. Patient pathways ....................................................................................................................... 27

3.

Economic factors .............................................................................................................. 30
3.1. Risk-pooling mechanisms ........................................................................................................ 30
3.2. Private health insurance schemes ....................................................................................... 32
3.3. Out-of-pocket health expenditure ........................................................................................ 33
3.3.1. Cost of consultations ......................................................................................... 35

4

HEALTHCARE PROVISION IN GHANA

3.3.2. Cost of medication ............................................................................................. 37
4.

List of useful links............................................................................................................. 38

Annex 1: Bibliography .................................................................................................................. 39
Oral sources ....................................................................................................................................... 39
Public sources.................................................................................................................................... 40
Annex 2: Terms of Reference ...................................................................................................... 45

5

EUROPEAN UNION AGENCY FOR ASYLUM

Disclaimer
This report was written according to the EUAA COI Report Methodology (2023). The report isbased on publicly available sources of information, as well as oral anonymised sources whoare based in Ghana. All sources used are referenced.
The information contained in this report has been researched, evaluated and analysed withutmost care. However, this document does not claim to be exhaustive. If a particular event,person or organisation is not mentioned in the report, this does not mean that the event has
not taken place or that the person or organisation does not exist.
Furthermore, this report is not conclusive as to the determination or merit of any particularapplication for international protection. Terminology used should not be regarded asindicative of a particular legal position.
‘Refugee’, ‘risk’ and similar terminology are used as generic terminology and not in the legal
sense as applied in the EU Asylum Acquis, the 1951 Refugee Convention and the 1967
Protocol relating to the Status of Refugees.
Neither the EUAA, nor any person acting on its behalf, may be held responsible for the use
which may be made of the information contained in this report.
On 19 January 2022 the European Asylum Support Office (EASO) became the European Union
Agency for Asylum (EUAA). All references to EASO, EASO products and bodies should beunderstood as references to the EUAA.
The drafting of this report was finalised on 5 April 2023. Any event taking place after this dateis not included in this report. More information on the reference period for this report can befound in the methodology section of the Introduction.

6

HEALTHCARE PROVISION IN GHANA

Glossary and abbreviations
Term

Definition

CHAG

Christian Health Association of Ghana

CHPS

Community-Based Health Planning Service

COI

Country of Origin Information

CT

Computer Tomography

DHMT

District Health Management Team

ECG

Electrocardiograph

EEG

Electroencephalograph

EHSP

Essential Health Service Package

EML

Essential Medicines List

ENT

Ear Nose and Throat

EU

European Union

EU+ countries

Member States of the European Union and associated countries

EUAA

European Union Agency for Asylum

GDP

Gross Domestic Product

GHS

Ghanaian cedi (national unit of currency)

GHS

Ghana Health Service

7

EUROPEAN UNION AGENCY FOR ASYLUM

TermDefinition

GLSS

Ghana Living Standards Survey

GSS

Ghana Statistical Services

HDU

High Dependence Unit

HeFRA

Health Facilities Regulatory Agency

HIV

Human Immunodeficiency Virus

HSMTDP

Health Sector Medium Term Development PlanIDSR

Integrated Disease Surveillance and Response

IGF

Internally Generated Funds

IHR

International Health Regulation

KII

Key Informant Interview

MDAs

Ministry/Department/Agencies

MedCOI

Medical country of origin information

Member States

Member States of the European Union

MOH

Ministry of Health

MRI

Magnetic Resonance Imaging

NAS

National Ambulance Service

NCD

Non-communicable Disease

NHIA

National Health Insurance Authority

8

HEALTHCARE PROVISION IN GHANA

Term

Definition

NHIF

National Health Insurance Fund

NHIS

National Health Insurance Scheme

OPD

Outpatient Department

PCHIS

Private Commercial Health Insurance Scheme

PHC

Primary Health Care

PHIS

Private Health Insurance Schemes

PMHIS

Private Mutual Health Insurance Scheme

RHMTRegional Health Management Team

SDHMT

Sub-district Health Management TeamSSNIT

Social Security and National Insurance Trust

TB

Tuberculosis

TH

Teaching Hospital

UHC

Universal Health Care

URI

Upper Respiratory Tract infection

UTI

Urinary Tract Infection

WHO

World Health Organisation

9

EUROPEAN UNION AGENCY FOR ASYLUM

Introduction
Methodology
The purpose of the report is to provide information on access to healthcare in Ghana. This
information is relevant to the application of international protection status determination(refugee status and subsidiary protection) and migration legislation in EU+ countries.

Terms of reference
The terms of reference for this Medical Country of Origin Information Report were developedby EUAA.
The terms of reference for this Medical Country of Origin Information Report can be found in
Annex 2. The drafting period was finalised on 2 March 2023, peer review occurred between
3-17 March 2023, and additional information was added to the report as a result of the quality
review process during the review implementation up until 11 April 2023. The report wasinternally reviewed subsequently.

Collecting information
EUAA contracted International SOS (Intl.SOS) to manage the report delivery including datacollection. Intl.SOS recruited and managed a local consultant to write the report and a publichealth expert to edit the report. These were selected from Intl.SOS’ existing pool ofconsultants. The consultant was selected based on their experience in leading comparable
projects and their experience of working on public health issues in Ghana.
This report is based on publicly available information in electronic and paper-based sources
gathered through desk-based research. This report also contains information from multiple
oral sources with ground-level knowledge of the healthcare situation in Ghana who wereinterviewed specifically for this report. For security reasons, all oral sources are anonymised.

Currency
The currency in Ghana is the Ghanaian cedi (GHS). The currency name, the ISO code and theconversion amounts are taken from the INFOEURO website of the European Commission. 1

Quality control
This report was written by Intl.SOS in line with the European Union Agency for Asylum (EUAA)
COI Report Methodology (2023) 2, the EUAA Country of Origin Information (COI) Reports

12

European Commission, Exchange rate (InforEuro), n.d., url
EUAA, Country of Origin Information (COI) Report Methodology, February 2023, url
10

HEALTHCARE PROVISION IN GHANA

Writing and Referencing Guide (2023) 3 and the EUAA Writing Guide (2022) 4. Quality control of
the report was carried out both on content and form. Form and content were reviewed by
Intl.SOS and EUAA.
The accuracy of information included in the report was reviewed, to the extent possible,
based on the quality of the sources and citations provided by the consultants. All thecomments from reviewers were reviewed and were implemented to the extent possible, undertime constraints.

Sources
In accordance with EUAA COI methodology, a range of different published sources have been
consulted on relevant topics for this report. These include governmental publications,academic publications, reports by non-governmental organisations and internationalorganisations. All sources that are used in this report are outlined in the Bibliography section.
Key informant interviews were carried out between January and March 2023. Interviews wereconducted mainly with officers who work within organisations of Ghana’s healthcare system. A
complete anonymised list of interviewees can be found in the bibliography.

3
4

EUAA, Country of Origin Information (COI) Reports Writing and Referencing Guide, February 2023, url
EUAA, The EUAA Writing Guide, April 2022, url
11EUROPEAN UNION AGENCY FOR ASYLUM

Maps
Map 1. Ghana, © United Nations 5

5

UN, Ghana - Map No. 4186 Rev.3, February 2005, url
12

HEALTHCARE PROVISION IN GHANA

1. General information
1.1. Demographic and Economic context
Ghana is a democratic middle-income nation situated on the West Coast of Africa bordered by
the Atlantic Ocean, Togo, Cote d’Ivoire and Burkina Faso. The official language is English. It
covers an area of 238 535 square kilometres, has a population of approximately 32 million
people 6 and an annual population growth rate of 2.0 %. 7 Between the years 2000 and 2020,
Ghana’s population age structure shifted from one dominated by children (0-14 years) 35.3 %,to one dominated by young people (15-35 years) 38.2 %. 8 Females generally outnumber malesby 2.8 % and in urban areas by 5.0 %; however, in rural areas males outnumber females by
0.3 %. 9 The total fertility rate is 3.1, higher in the rural areas (3.8) than the urban areas (2.7). 10
Life expectancy at birth is 64 years. 11
Between 2011 and 2019, Ghana’s economic growth showed an average increase of 4 % in
GDP per capita. Government expenditure, as a share of GDP, increased from 13 % in 2000 to
21 % in 2019. 12 The World Bank estimates that, in 2022, GDP growth slowed to 3.2 % froma 2021 figure of 5.4 %. The poverty rate in Ghana was estimated to be 25.5 % in 2020.13
The official language of Ghana is English. Moreover, there are at least 50 indigenous
languages with the major ones being Akan, Ewe, Ga, Dagaare, and Dagbani. 14 70 % of the
population is literate (can read and write with understanding) 15. Literacy rates are higher inmales than females and also higher in urban against rural areas. 16 Of the literate population
about 46 % are literate in English and in a Ghanaian language. 17 Formal education is provided
in English. 18

BBC, Ghana Country Profile, 17 January 2023, urlWorld Bank (The), Ghana, n.d., url
8
Ghana, GSS, Ghana 2021 Population and Housing Census General Report, Volume 3B, Age and Sex Profile,
November 2021, url, p. 26
9Ghana, GSS, Ghana 2021 Population and Housing Census General Report, Volume 3B, Age and Sex Profile,
November 2021, url, p. 30
10Ghana, GSS, Ghana 2021 Population and Housing Census General Report, Volume 3H, Fertility and Mortality,
February 2022, url, p. 28
11World Bank (The), Ghana, n.d., url
12
JLN DRM Collaborative, Public Expenditure on Health in Ghana: A Narrative Summary, 2022, url, p. 4
13World Bank (The), The World Bank in Ghana, 28 September 2022, url
14
Sadat M et al. Views from the streets of Accra on language policy in Ghana, 2017, url, p. 185
15
Ghana, GSS, Ghana 2021 Population and Housing Census General Report, Volume 3D, Literacy and Education,
December 2021, url, pp. 24, 25
16
Ghana, GSS, Ghana 2021 Population and Housing Census General Report Volume 3D, Literacy and Education,
December 2021, url, p. 26, 27
17Ghana, GSS, Ghana 2021 Population and Housing Census General Report Volume 3D, Literacy and Education,
December 2021, url, p. 32
18USA, U.S. Embassy in Ghana, Educational System of Ghana, n.d., url
6
7

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EUROPEAN UNION AGENCY FOR ASYLUM

1.2. Burden of disease
Ghana has a complex burden of disease, present across different age, gender, location, andsocio-economic status groups in the country. The major health conditions affecting children
are communicable diseases, with malaria prevailing. Moreover, maternal and neonatal healthconditions remain challenging, especially in rural areas and amongst poor women. Noncommunicable diseases (NCD) such as hypertension, strokes, diabetes, eye disorders, oral
health conditions, cancers, genetic diseases; injuries, mental health disorders, andsubstance/medicine abuse are increasing in prevalence. This complex disease burden is
influenced by risk factors such as the physical environment, education level, socio-economic
situation, and demographic characteristics of the Ghanaian population. 19

19Ghana, MOH, National Health Policy: Ensuring healthy lives for all (revised edition), January 2020, url, p. 14
14

HEALTHCARE PROVISION IN GHANA

2. Healthcare system
2.1. Health system organisation
2.1.1. Overview
Ghana has a pluralistic health sector in terms of ownership (public and private), and in terms ofhealthcare models (orthodox, traditional and alternative medicine). 20 Ghana’s National Health
Policy 21 and Universal Health Care (UHC) Roadmap 22 jointly set the policy direction for thehealth sector until at least 2030. The health sector sets out to provide an Essential HealthService Package (EHSP) that covers Family and Reproductive Health; communicable diseases;
non-communicable diseases and their risk factors, as well as mental health; healthemergencies; and rehabilitative and palliative care service. 23
The institutional structure of the health sector is made up of the Ministry of Health (MOH) as
policy maker and regulator. Healthcare services are provided by two public sector institutions,
namely the Ghana Health Service (GHS) and the Teaching Hospitals (TH), as well as by private
sector service providers made up of for-profit providers and non-profit faith-based healthfacilities. 24
The MOH delivers its mandate through 26 specialised agencies and affiliated organisations.
These include regulatory bodies responsible for establishing and enforcing standards andguidelines for the training of health professionals, regulations on professional standards ofconduct and practice, and standards for accreditation of health facilities in order to get
qualified to provide health services. 25

Ghana, MOH, National Health Policy: Ensuring healthy lives for all (revised edition), January 2020, url, p.23
Ghana, MOH, National Health Policy: Ensuring healthy lives for all (revised edition), January 2020, url, p.7
22
Ghana, MOH, Ghana’s Roadmap for Attaining Universal Health Coverage 2020 –2030, url, p.1
23
Ghana, MOH, 2022-2030 National Essential Health Service Package Ghana, August 2022, not available online,p. 17
24
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December, 2021, url, p. 11
25
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December, 2021, url, p. 11
20
21

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EUROPEAN UNION AGENCY FOR ASYLUM

Figure 1. The health system of Ghana, MOH 26

Figure 1 above shows how the system is organised in three levels: the primary level, with afocus on Primary Health Care (PHC) services, includes the district hospital, the sub-district
health centre, and the community-based health planning service (CHPS) compound. The
secondary and tertiary levels have regional, and teaching, hospitals respectively. 27
Table 1. Health facility type, expected service capacity and quantity 28
Facility type

Comment

Expected Service Capacity

Number*

PRIMARY LEVEL
Community-based
health planning
service (CHPS)

All are public
facilities locatedwithin communities
and are part of the
primary level.

Has the capacity to deliver
essential community-based
health planning and services
such as basic emergency
services, treatment of minor
ailments (such as simple
malaria, acute diarrheal
diseases, upper respiratory
tract infections (URI), urinary
tract infections (UTI), asthma),

5 876

Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 12
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 11
28
Ghana, Health Facilities Regulatory Agency, Requirements, 2022, url; Ghana, MOH, Health Sector Medium Term
Development Plan, 2022-2025, December 2021, url, p. 15
26
27

16

HEALTHCARE PROVISION IN GHANA

Facility type

Comment

Expected Service Capacity

Number*provide basic laboratory
services (rapid diagnostic tests(RDT’s) only), dispensary (level
A medicines), andobservational services as wellas public health services(including health promotion,disease prevention andsurveillance); and reproductive
and child health services
involving health planning with
community members. Headed
by a Community Health Officer
or a midwife.
Maternity home

Health centre

These are primarily
private facilities.

These are public
facilities and are partof the primary level.

17

In addition to services at
CHPS, can provide care ofpregnant women and children
under five years including
antenatal, delivery, postnatal,family planning and dispenses
level M medication and hasaccess to ambulance services.

1 403

In addition to services at CHPS
can provide emergency
resuscitation, minor
procedures (for example
wound care, minor suturing),
primary laboratory services,
dispensary (level B1),
observation (23-hour unit),
immunisation and healthpromotion, as well as publichealth services like child andadolescent health services,disease control andsurveillance, home/school
visits to the general public. It is
headed by a Physician
Assistant.

992

EUROPEAN UNION AGENCY FOR ASYLUM

Facility type

Comment

Expected Service Capacity

ClinicThese are primarily
private for-profit
facilities

Provide general or specialized(medical, surgical or dentalcare) outpatient services,laboratory services and aminimum of level B2
medicines to the generalpublic. It is headed by anorthodox trained medical ordental practitioner.

Polyclinic

These are public
facilities and are partof the primary level.

Has the capacity to provide
general outpatient andinpatient services in at least
two or more general/specialty
areas. The services include
basic emergency services,
observation, surgicalprocedures, reproductive &child health, adolescent,mental and public health(social & behavioural change
communication, outreach,disease surveillance & control,
nutrition, special programmessuch as TB/HIV/malaria); and aminimum of level C pharmacy.
It is headed by an orthodox
trained medical/dental
practitioner.

Primary Hospital

These are the district
hospitals, public andprivate (CHAG)
facilities. There aresome private-forprofit primary
hospitals and arepart of the primarylevel.

Has the capacity to provide
services in at least five main
specialized areas which are
24-hour accident andemergency (trauma/surgical,
medical, obstetric, paediatricand psychiatric emergencies),
internal medicine, generalsurgery, medical, anaesthesia,
paediatrics and obstetrics &gynaecology services. It also18

Number*

478

HEALTHCARE PROVISION IN GHANA

Facility type

Comment

Expected Service Capacity

Number*must provide the following
services: high dependency
unit (HDU), mental health,imaging (electrocardiograph(ECG), computer tomography(CT) scan, magnetic resonanceimaging (MRI),
electroencephalograph (EEG),
primary eye, ear, nose andthroat (ENT), dental and publichealth, dispensing up to level
C pharmacy, primarylaboratory, health information
unit/medical records services
to the general public. Headedby an orthodox trained
medical or dental practitioner.
SECONDARY LEVEL CARE
Secondary Hospital

These are theregional hospitals,
public facilities.

Have the capacity to provide
services in at least 10
specialty/sub-speciality areas,
inclusive of those provided in
the primary hospitals. They
have the required staff
complement, laboratory,
diagnostic imaging andmedicines resources.

7

TERTIARY LEVEL CARE
Tertiary Hospital

These are theteaching hospitals.

Like a secondary hospital but
has the capacity to support theprovision of services in at least
20 speciality/sub-specialty
areas.

19

5

EUROPEAN UNION AGENCY FOR ASYLUM

Facility type

Comment

Expected Service Capacity

Number*Quaternary facility

The University of
Ghana Medical
Centre is the only
hospital designatedas quaternary.

It provides an advanced formof medical care, beyond thetreatment offered by tertiarycare health facilities.

1*

Number of facilities as of December 2020

Table 1 shows that service provision covering prevention, promotion, curative, rehabilitation,and palliative care, as well as diagnostics services, are provided by both the public and private
sector institutions to differing extents, at the different levels of the health sector.
Timely access to services remains inequitable with respect to healthcare facilities andpackage of services (preventive, promotive, curative, rehabilitative and palliative). Rural areas
are more disadvantaged on account of the generally limited and poor infrastructure and themore acute shortage of health personnel to provide the services. Services are further not
appropriately designed for populations with unique needs such as the disabled, aged,
persons with genetic disorders, accident victims, people affected by natural and man-madedisasters, adolescents, as well as people with mental health vulnerability. 29
Table 2. Health facilities in Ghana by ownership type, MOH30
Ownership Type

Facilities
Amount

%

7 137

80.9

Quasi-government

79

0.9

Private not for profit

280

3.1

Private Self-financing

1 331

15.1

Government

29
30

Ghana, MOH, National Health Policy: Ensuring healthy lives for all (revised edition), January 2020, url, p. 18
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December, 2021, url, p. 15
20

HEALTHCARE PROVISION IN GHANA

Ownership Type

Facilities

Total

Amount

%

8 827

100.0

2.1.2. Public sector
PHC services are delivered through interconnections between district hospitals, healthcentres, maternity homes, clinics and CHPS compounds. 31
The CHPS compounds provide a minimum package of service for the universal coverage of
Reproductive Health Services (maternal, neonatal and child health services), management ofminor ailments, and provision of health education, sanitation and counselling on healthy
lifestyles and good nutrition for community members. 32 As of December 2020, there were
5 876 CHPS compounds,33 of which 80 % are functioning. 34 This ensures service provisionboth at the compound and via household visits, that covers the most impoverished andvulnerable families. 35
Regional hospitals provide both public health and clinical services, and serve as referral points
for facilities from the district level and below. 36 Tertiary and specialized care is provided
through five public teaching hospitals: one each in Accra (Greater Accra Region), Cape Coast(Central Region) and Ho (Volta Region) all in the Southern part of the country; Kumasi (Ashanti
Region) in the Middle; and Tamale (Northern Region) in the Northern part of the country.
Additionally, three psychiatric hospitals are all located in the southern part of the country (twoin Accra and one in Cape Coast). 37
The public sector service delivery institutions primarily provide orthodox medical care, notlocal traditional or alternative medical care. The major strength of the public sector service
provider is the availability and accessibility to essential health services, at a cheaper cost, inboth urban and rural areas across the country. 38
The Ministry of Health identifies challenges facing the public sector, for example:•

increasing population with varied disparities between urban and rural areas;

Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 11
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 11
33
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 15
34
Ghana, MOH, Health Sector Annual Programme of Work, 2021 Holistic Assessment Report, April 2022, url, p. 59
35
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 11
36
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 11
37
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 11; KII16. KII16
is a Medical Director of a public secondary hospital, February 2023. The person wishes to remain anonymous.
38
KII16. KII16 is a Medical Director of a public secondary hospital, February 2023. The person wishes to remain
anonymous.
31

32

21

EUROPEAN UNION AGENCY FOR ASYLUM•

inequitable distribution of human health resources;•

inadequate health infrastructure, logistics and equipment;•

suboptimal quality of care at all levels of the healthcare system;•

weak collaboration among government Ministries/Departments/Agencies (MDAs)
whose functions impact on the health of the population;•

the lack of nationally representative data on mental health services and NonCommunicable Diseases (NCD); and•the lack of a national database for health data.39

2.1.3. Private sector
The private sector complements government efforts in service delivery. The private sector isdefined as any non-government health actor such as self-financing (also referred to as forprofit), mission faith-based facilities (referred to as not-for-profit) involved in the delivery ofhealth services; input suppliers (medicines and medical equipment), health research andtraining institutions; traditional and informal providers of health services; health promotion andeducation; and health financing organizations. 40 The private sector is also regulated by the
MOH through licensing by the Health Facilities Regulatory Agency (HeFRA) and the legal
compliance requirements to other regulatory bodies, national healthcare standards andpolicies. 41
The private sector provides a mix of types of healthcare models including orthodox, traditional
as well as alternative medicine practitioners. 42
While government facilities and services are available and accessible in both urban and rural
areas across the country, the private service providers are concentrated in urban and periurban areas, with the faith-based organisations providing primary and secondary carecomplementary to the government’s 43
Anecdotally, the quality-of-service provision in the private sector (both faith-based not-forprofit and the private self-financing institutions) is generally considered to be of better quality
than the public sector healthcare. The cost of care is more expensive than that provided by
the public sector. Significant areas of better service quality are acknowledged in the provisionof patient centred care, availability of medicines/medical supplies, and better access tomodern technology. Increasingly more private-for-profit institutions are providing highly
specialised care, comparable to or better than that provided in the public teaching hospitals. 44
In general, more people (51.7 %) seek consultations at facilities in the private health sector as
against 45.7 % in facilities in the public health sector and 2.6 % seek care in facilities providing

Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 17
Ghana, MOH, Private Health Sector Development Policy, 2013, url, p. 8
41
Ghana, MOH, Private Health Sector Development Policy, 2013, url, pp. 6, 20
42
Ghana, MOH, National Health Policy: Ensuring healthy lives for all (revised edition), January 2020, url, p. 10
43Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 12
44
KII01. A Facility Assessment officer from the Health Facilities Regulatory Agency. Interview February 2023. The
person wishes to remain anonymous.
39

40

22

HEALTHCARE PROVISION IN GHANA

alternative medical care (these are traditional and unorthodox medical practitioners). 45 The
challenges faced by the public sector, especially the inadequate health infrastructure, logistics
and equipment and the suboptimal quality of care at all levels of the healthcare system makes
utilisation of private healthcare services the preferred choice irrespective of the higher cost ofcare. 46 Anecdotally, it is known that many people resort to the use of traditional medical
practices prior to accessing or in addition to accessing orthodox medical services. 47

2.2. Healthcare resources
2.2.1.

Human and technical resources

The World Health Organization (WHO) recommends that the ratio of doctors and nurses to thegeneral population is 1:1 000. In 2021, the MOH stated that the national ratio of doctors andnurses to the general population stands at 1:5 705 and 1:530 respectively. 48 There arevariations across the regions, with better ratios in urban than in rural areas. 49
Table 3. Comparison of density per 1 000 population of different occupations of the healthworkforce as at 2018 in the WHO African Region and Ghana. 50
Category

Density per 1 000 population
Ghana

AfricaPhysicians

0.15

0.31

Nurses and midwives

1.80

1.23

Dentists and technicians

0.02

0.05

Pharmacists and technicians

0.07

0.09

Environ. And public health

0.00

0.04

Ghana, GSS, Ghana Living Standards Survey (GLSS 7), Main Report, June 2019, url, p. 48
KII02. A client of a private healthcare facility. Interview February 2023. The person wishes to remain anonymous.
47
KII02. A client of a private healthcare facility. Interview February 2023. The person wishes to remain anonymous.
48
Ghana, MOH, Health Sector Annual Programme of Work, 2021 Holistic Assessment Report, April 2022, url, p. 59
49
Ghana, MOH, Health Sector Annual Programme of Work, 2021 Holistic Assessment Report, April 2022, url,
pp. 18 and 19
50
WHO, The state of the health workforce in the WHO African Region, 2021, url, pp. 18 and 66
45

46

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EUROPEAN UNION AGENCY FOR ASYLUM

Category

Density per 1 000 population
Ghana

AfricaLaboratory technicians

0.05

0.35

Community health

0.53

0.46

Administrative and support staff

0.89

0.43

Other technicians and health cadres

0.59

0.40

Ghana has the capacity to manage both public health emergencies as well as pre-hospital andemergencies. 51
Ghana is a signatory to the International Health Regulations (IHR) 52 and uses the third editionof the Integrated Disease Surveillance and Response (IDSR) strategy 53 as a vehicle for its IHR
implementation. This is done within the legal framework of the Ghana Public Health Act 2012
(Act 851). 54 The country uses event-based surveillance, indicator-based, and all-hazard
approaches to prevent, detect and respond to all potential public health threats of biologicalchemical, and radio-nuclear origins, as well as natural and man-made disasters. 55
Pre-hospital emergency services is provided by the National Ambulance Service (NAS) which
was first set up in 2004 as an agency of the Ministry of Health in collaboration with the Ghana
National Fire Service of the Ministry of Interior. 56 In 2020, the National Ambulance Service Act
established NAS and its mandate to provide effective and efficient administration andmanagement of emergency care services and to provide for related matters. 57 As of 2022, theNAS has a national head office based in the national capital Accra with regional dispatch
centres, one for each region, located in the respective regional capital and 297 district
stations covering all 216 districts in the country (some districts have more than one station on
account of their size). 58

Ghana, NAS, About National Ambulance Service, 2022, url; Ghana, Parliament of the Republic of Ghana, Ghana
Public Health Act 2012 (Act 851), art. 169, url
52
WHO, International Health Regulations (2005) Third Edition, 2016, url
53WHO, Integrated Disease Surveillance and Response Technical Guidelines, Booklet One: Introduction Section,
3rd ed., 2019, url
54
Ghana, Parliament of the Republic of Ghana, Ghana Public Health Act 2012 (Act 851), url
55
Ghana, MOH, 2022-2030 National Essential Health Services Package Ghana, August 2022, not available online,p. 66
56
Ghana, NAS, About National Ambulance Service, 2022, url
57
Ghana, Parliament of the Republic of Ghana, Act 1041, The National Ambulance Service Act, 2020, url, p. 3
58
KII03. An officer in the National Ambulance Service in Accra. Interview, February 2023. The person wishes toremain anonymous.
51

24

HEALTHCARE PROVISION IN GHANA

NAS has the capacity to carry out both scheduled and unscheduled services. In its 2019
Annual Report NAS lists its main functions as being:•

emergency medical response and out of hospital care;•emergency medical transport by road;•non-emergency patient transport;•

major incident management and response;•

retrieval of critically ill patients;•

provision of ambulance coverage during public events;•

support for other health services in communities where the full range of services are
not easily accessible; and•community education on first aid.59

In terms of performance the national average for ambulance response time to a call is 22
minutes; the average case holding time is 2 hours whilst that for vehicle engaged was around
4 hours. 60 The ambulance service is available and accessible to individuals, organisations andany public or private health facility. 61

2.2.2.

Finance resources

Ghana’s health sector is financed from four main sources: central funding by the Governmentof Ghana, internally generated funds (IGF) from health facilities, the National Health Insurance
Fund (NHIF), and external financing from development partners. 62
The Ministry of Health obtains its revenue from various sources. Some of the sources include
general government appropriation from the central government, internally generated funds,
technical assistance from bi-lateral and multilateral sources, and from local authorities. 63
Per capita public spending on health increased on average by 8.7 % over the 2000-2019
period. The health share of public expenditure decreased from 8 % to 7 % of total government
budget between 2000 and 2019, suggesting a de-prioritisation of health. Ghana is within ahealth financing transition phase with an increasing per capita public spending on health (of8.7%) and a decreasing per capita out-of-pocket pending on health (3.7 %). 64
In 2018, Ghana’s health expenditure was 4 % of GDP or approximately USD 70 per capita.
Government prioritisation on health fell from 12 %, or USD 58.4 per capita in 2011 to 6 % in2018, or approximately USD 30 per capita. An important source of health financing is via the
National Health Insurance Levy of 2.5 % of VAT, 70 % to 80 % of which is usually allocated to
Ghana, National Ambulance Service 2019 Annual Report, n.d., not available online, p. vii
Ghana, MOH, Health Sector Annual Programme of Work, 2021 Holistic Assessment Report, April 2022, url, pp. ix,
x61
KII03. KII03 is an officer in the National Ambulance Service in Accra. Interview, February 2023. The person
wishes to remain anonymous.
62
Ghana, MOH, 2022-2030 National Essential Health Service Package Ghana, August 2022, not available online,p. 11
63
Ghana, MOH, Health Sector Annual Programme of Work, 2021 Holistic Assessment Report, April 2022, url, p. 34
64
JLN DRM Collaborative,Public Expenditure on Health in Ghana: A Narrative Summary, 2022, url, p. 4
59

60

25

EUROPEAN UNION AGENCY FOR ASYLUM

the National Health Insurance Scheme (NHIS). 65 Health sector budget support throughDevelopment Assistance for Health has decreased from 48 % in 2004 to 9 % in 2020. 66 The
share of national budget to the health sector saw a decline to 6.6 % in the 2021, a decrease ofnearly 2.4 percentage points between the base year (2020) and target year (2021). 67

2.3. Pharmaceutical sector
The Ghanaian pharmaceutical market is made up of approximately 30 % locally produced
drugs and 70 % imported products, which originate mainly from India and China. 68 Ghana is a
net importer of medicines with the private sector supplying about 70 % of medicines within the
supply chain. 69
Ghana has had Essential Medicines Lists (EML) since 1988. The list is reviewed on average
every 4-5 years. The current 7th edition of the EML was issued in 2017. 70 The EML for Ghana
has been derived from its companion document Standard Treatment Guidelines 2017 71 toensure harmony in treatment, procurement, and NHIS re-imbursements. 72 It is guided by the
WHO Model Lists of Essential Medicines 73 and it reflects medicines that are required toaddress the disease burden of the country and are safe, efficacious, and cost effective. 74
Public sector procurement of medicines, primarily for public sector facilities, is guided by the
EML. The medicines listed have been coded according to the Health Commodity Codes
Catalogue of the Ministry of Health (2008) and their levels of use. Based on the type of healthfacility, the appropriate medicines from the EML are stocked. The list is for use by both public
and private service providers, 75 though private sector providers are responsible for their own
procurement of medicines and are at liberty to purchase medicines outside of the EML. 76
The country promotes the use of generic medicines, and these are readily available for mostformulations. To encourage the use of generic medicines, subscribers of the NHIS are reimbursed for the cost of only generic medicines found on the EML. This notwithstanding,branded products are available on the market. 77
The supply chain for medicines involves both the public and private sector. Public sector
procurement is led by the MOH and the Ghana Health Service (GHS) for the specific use of
public sector service providers across the country. Central procurement by the procurement
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 16
Ghana, MOH, Health Sector Medium Term Development Plan, 2022-2025, December 2021, url, p. 17
67
Ghana, MOH, Health Sector Annual Programme of Work, 2021 Holistic Assessment Report, April 2022, url, p. 34
68
Goodman AMC LLC, Ghana’s Mergers & Acquisitions Report 2017, 2017, url, p. 14
69
Ghana, MOH, Pricing Strategy for Pharmaceuticals and other health technologies in Ghana, 2022, not available
online, p. 16
70
Ghana, MOH, National Drugs Programme (GNDP), Essential Medicines List, 2017, url
71
Ghana, MOH, National Drugs Programme (GNDP), Standard Treatment Guidelines, 2017, url
72
Ghana, MOH, National Drugs Programme (GNDP), Essential Medicines List, 2017, url, p. ix
73
WHO, WHO Model Lists of Essential Medicines, 22nd list, September 2021, url
74
Ghana, MOH, National Drugs Programme (GNDP) Essential Medicines List, 2017, url, p. x
75
Ghana, MOH, National Drugs Programme (GNDP) Essential Medicines List, 2017, url, p. ix
76
KII04. An officer of the Pharmacy Council. Interview, February 2023. The person wishes to remain anonymous.
77
KII05. An officer of the Pharmacy Council. Interview, February 2023. The person wishes to remain anonymous.
65

66

26

HEALTHCARE PROVISION IN GHANA

units of the MOH and the Ghana Health Service is restricted to registered products. Tertiary
hospitals procure about half of the essential medicines themselves, mostly through private
wholesalers. Teaching Hospitals occasionally import specialist drugs directly through medical
representatives of the manufacturers. 78 The current systems, mechanisms, and inspection
resources do not seem to be adequate to ensure that inferior medicines and medical devices
and supplies do not enter the public sector supply chain system. 79
Medicine availability in public health facilities is restricted by the level of care. The higher thelevel of care, the more varied and specialised the medicines they can carry. Whereas
pharmacies, called ‘chemical shops’ in Ghana, managed by dispensing technicians or
pharmacy assistants can stock only over the counter (OTC) medicines, private registeredpharmacies managed by licensed pharmacists have no restriction as to the medicines type or
category they can stock. Quite often, medicines that hospitals (public or private), for various
reasons, may not stock, can usually be purchased by clients from private pharmacies. There isno medicine in particular that is consistently in shortage or particularly vulnerable to shortages
and as well there is no pattern to when any particular medicine will be in shortage. In general
medicines are more available and accessible in the urban as against rural areas and in private
health facilities and pharmacies as against public ones. 80
Non-registered medicines cannot be imported into the country. However, on an individual
basis, patients can bring un-registered medicines for personal use into the country, supported
by a prescription. 81

2.4. Patient pathways
Information about where to access, and the quality of healthcare services to expect at bothpublic and private health facilities, is informally available primarily through friends and family
and to some extent individual facility social media posts and websites. 82 The Health Facilities
Regulatory Agency has a register of facilities it has accredited and licenced to provide
different types of service at different levels of care. The list of accredited and licensed facilities
can be found in the Ghana Gazette HeFRA. 83
As described above, in section 2.1., Ghana has three levels of care. This informs the typicalroute/patient’s pathway to accessing care. To reiterate, the primary level of care consists of
CHPS zones, health centres, and primary hospitals (including the district hospitals). The
secondary level of care consists of secondary hospitals (including the regional hospitals)
which provide specialized services and receive referrals from the primary level. At the tertiarylevel of care are the Teaching Hospitals which provide highly specialized healthcare services
and receive referrals from the secondary level, and sometimes the primary level hospitals. A
Ghana, MOH, National Medicines Policy, 2017, url, p. 24
Ghana, MOH, National Medicines Policy, 2017, url, p. 26
80
KII06. A pharmacist in a public health facility. Interview, February 2023. The person wishes to remain anonymous.
81
KII07. An officer in the Food and Drugs Authority. Interview, February 2023. The person wishes to remain
anonymous.
82
KII02. KII02 is a client of a private healthcare facility. Interview, February 2023. The person wishes to remain
anonymous.
83
Ghana, HeFRA, Gazette, 2022, url
78

79

27

EUROPEAN UNION AGENCY FOR ASYLUM

quaternary level of care, e.g. The National Cardiothoracic Centre, the National Plastic Surgery
and Reconstruction Centre, and the University of Ghana Medical Centre, also exist. 84
Care can be accessed at the nearest primary or secondary level health facility by directly
walking in. Patient assessments are done and if the facility has the capacity and is licensed toprovide the full range of care (diagnostic investigations, treatment, and medicines) necessary it
does so. Where the facility is unable or not licensed to provide the full range of care required
the patient is provided with what is possible and then referred to a higher-level facility tocontinue care. Access to the tertiary and quaternary level health facilities is only by referral
from the public and private PHC or secondary level service providers. These tertiary facilities
have a polyclinic (PHC service) attached to them and serve as the first point of care for clients
who reside in the vicinity and use the tertiary as their PHC facility. These clients are managed
at the polyclinic and the decision to refer to the tertiary facility is made and facilitated. The
PHC and secondary facilities serve as a gatekeeper, ensuring that, as practical as possible,
only appropriate cases requiring tertiary level care have access to such care. 85
Patients can access care from private health facilities, at all levels, by directly walking in. The
public and private health facilities maintain a professional relationship that facilitates referral
from one to the other as necessary. 86 In Ghana, health care services are sought from different
types of facilities. The majority of people visit the hospital (35.1%), pharmacies (28.8%) andclinics (19.1%) for health care services. The pattern is the same in all ecological zones except
Accra where the majority accessed clinics (54.9%) and about one-fifth visited the hospitals(20.4%). 87
For the public sector facilities, medical laboratory services, diagnostic imaging and medicines
availability and accessibility, is regulated by the level of care. The least and less complicatedare available at the CHPS level and the most comprehensive at the tertiary and quaternary
levels of care. Medical laboratory services range from the use of test strips for simple
investigations to more complex and advanced investigations requiring sophisticatedequipment and technology. Diagnostic imaging services are available ranging from X-ray andultrasound to Computer Tomography (CT) Scans and Magnetic Resonance Imaging (MRI).
Electrocardiograph (ECG) and Electroencephalograph (EEG) services are also available.
Medicines availability ranges from over-the-counter medicines to specialist only prescription
medicines at the different levels of care. 88
The range of services, infrastructure and equipment and the staff needs are standardised foreach level of care and is expected to be the same anywhere in the country. Table 1 shows theservices expected at each type of facility. The challenges facing the public sector (see 2.1.

KII08. An officer from the Ghana Health Service, Institutional Care Division. Interview, February 2023. The person
wishes to remain anonymous.
85
KII08. An officer from the Ghana Health Service, Institutional Care Division. Interview, February 2023. The person
wishes to remain anonymous.
86
KII08. An officer from the Ghana Health Service, Institutional Care Division. Interview, February 2023. The person
wishes to remain anonymous.
87
Ghana, GSS (Ghana Statistical Service), Ghana Living Standards Survey (GLSS 7) 2019, url, p. 48
88
KII01. A Facility Assessment officer from the Health Facilities Regulatory Agency. Interview, February 2023. The
person wishes to remain anonymous.
84

28

HEALTHCARE PROVISION IN GHANA

Health system organisation Sector) mean that, in practice, there is a wide variation in thecapacity of facilities at the same level in the health system to provide the expected services.89
In general, at the PHC level, the facilities that are located in urban areas are better resourced(especially with staff) and better able to provide the expected services than those in rural
areas. At the secondary and tertiary levels, all of which are located in urban areas, there isminimal variation amongst respective facilities regarding resources and service provision.
There are instances where, at the tertiary level, certain laboratory investigations andspecialised medicines (mainly for the confirmatory diagnosis and treatment of cancers) aresourced outside the country in South Africa, England, United States of America and India,
amongst others. 90
The private sector faces similar challenges to the public sector but to a lesser degree andoften the public sector relies on the private sector to provide laboratory, diagnostic imaging,and medicines support where they fall short. Patient out-of-pocket payment is required tocover the cost of these services. These costs are not reimbursed by the NHIS. 91

KII08. An officer from the Ghana Health Service, Institutional Care Division. Interview, February 2023. The person
wishes to remain anonymous.
90
KII09. An administrator at one of the teaching hospitals. Interview, February, 2023. The person wishes to remain
anonymous.
91
KII10. A district claims officer of the NHIS. Interview, February 2023. The person wishes to remain anonymous.
8929

EUROPEAN UNION AGENCY FOR ASYLUM

3. Economic factors
3.1. Risk-pooling mechanisms
There is both public and private health insurance schemes available in Ghana. Approximately
70 % of the population have health insurance coverage, women having a higher coveragethan men, 72.6 % and 64.5 % respectively. 92 The public scheme, the National Health Insurance
Scheme (NHIS) is available to all Ghanaians for use at all levels of care. In all 16.8 million(57.3 %) of the population has an active NHIS membership. 93
Enrolment in the NHIS scheme is open to all residents, including non-citizens, in Ghana. 94
Registration with the scheme can be done at any time. To register, a prospective member of
the NHIS must contact the nearest NHIS office to enrol. Enrolment is either as an annual
premium paying member, who pays a processing fee of GHS 8 [EUR 0.6] and an annual
premium of GHS 30 [EUR 2.33], or as an exempt member who does not pay any premium orprocessing fee.95 Both categories need to renew annually, either by physically visiting thenearest NHIS office or by using an online application. The categories of exempt groups are:
•
•
•
•
•
•
•
•
•

children under 18 years of age;pregnant women;
indigents;
categories of differently abled persons determined by the Minister responsible for Social
Welfare;persons with mental disorder;
Social Security and National Insurance Trust (SSNIT) contributors;
SSNIT pensioners;
persons above seventy years of age (the elderly); andother categories prescribed by the Minister. 96

Individuals who register as exempt members are required to provide evidence of theirstatus. 97
Persons under the age of 18 years is the largest category of active members (41.6 %) in thescheme, followed by the informal sector workers (36.4 %), who pay direct premiums.
Enrolment of the aged (70 years or older) has proportionally remained at less than 5 %.

Ghana, GSS, Ghana 2021 Population and Housing Census. General Report Volume 3C, Background
Characteristics, November 2021, url, pp. 26, 35
93
Ghana, MOH, Health Sector Annual Programme of Work, 2021 Holistic Assesment Report, April 2022, url, p. 9
94
Ghana, Parliament of the Republic of Ghana, National Health Insurance Act, 2012 (Act 852) Part two, Article 27, 1,
2012, url ; Ghana, NHIS, Home - Faqs, 2023, url
95
Ghana, NHIS, Home - Membership, 2023, url
96
Ghana, NHIS, Home - Membership, 2023, url
97
Ghana, NHIS, Home - Membership, 2023, url
9230

HEALTHCARE PROVISION IN GHANA

Between 2017 and 2020 the proportion of female to male active members has consistently
been approximately 3:2. 98
The NHIS is designed to cover 95 % of diagnosed conditions, also to cover all outpatient,
inpatient, emergency care costs, as well as the cost of the medicines in the NHIS medicines
list. 99 NHIS members are not liable for out-of-pocket payments for these covered services fromservice providers (both public and private) who accept the NHIS card as a means of
payment. 100 The conditions excluded from the benefit package include:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

rehabilitation other than physiotherapy;
vision, hearing, orthopaedic and dental aids and prostheses;
elective cosmetic procedures except reconstructive surgery;
antiretroviral drugs for treating HIV/AIDS and other programme medicines for example
for Tuberculosis;
assisted reproduction, including artificial insemination and hormone replacement
therapy;echocardiography;
medical photography;
angiography;
orthoptics;
dialysis for chronic kidney failure;
heart and brain surgery, except to repair trauma;
cancer treatment other than cervical and breast cancer;
organ transplants;
medicines not included in the NHIS Medicines List;
diagnosis and treatment abroad;medical examinations for purposes of employment, school admissions, visa
applications, driving licenses, etc.;
VIP ward accommodation; andmortuary services.101

Some health conditions, such as for tuberculosis, are not included in the NHIS list above,instead those affected and registered on the relevant programme receive free care. 102
With respect to funding for the NHIS, Ghana has earmarked funds to support the financing ofhealth care through the NHIS. The earmarked funds comprise the National Health Insurance
Levy which is 2.5 % consumption tax on goods and services and Social Security Contributions

Ghana, MOH, Health Sector Annual Programme of Work, 2021 Holistic Assessment Report, April 2022, url, pp. 10,
11
99
Ghana, NHIS, Home - Benefits Package, 2023, url
100
Wang, H. et al, Ghana National Health Insurance Scheme: Improving Financial Sustainability Based on
Expenditure Review, 2017, url, p. 20
101
Ghana, NHIS, Home - Benefits Package, 2023, url
102
KII21. KII21 is an officer of the National Tuberculosis Programme in Accra. Interview, March 2023. The person
wishes to remain anonymous.
98

31

EUROPEAN UNION AGENCY FOR ASYLUM

which is 2.5 percentage points of each person’s payroll contributions to the National Social
Security Scheme. 103
There is insufficient allocation of collected earmarked funds to the NHIS, from central
government, to pay service providers and there are delays in NHIS payments to service
providers, averaging 4-6 months. 104 In addition, according to both the public and private
service providers, the NHIS tariffs are considered uneconomical in that they are below current
market prices for the respective goods and services, making cost recovery and the provisionof continued services a challenge. This situation makes accepting the NHIS card, as a mode ofpayment, unattractive to service providers. 105
In practice, many private health facilities, who have signed on to the scheme, do not accept
the NHIS card as means of payment, indicating that the tariffs do not cover their costs. Some
private health providers are not signed up to the scheme at all. In either situation the
cardholder will have to pay out-of-pocket for services rendered. 106 The costs of these services
are not reimbursed by the NHIS to the cardholder. The private sector is at liberty to refuse the
NHIS card as a mode of payment and to set its own fees for services provided, which mosthave done to varying degrees. 107
In public health facilities similar practices prevail and cardholders may be asked to go to theprivate sector for services (such as laboratory and pharmaceutical) where they pay out-ofpocket without reimbursement from the NHIS. In public facilities, card holders may be asked to
pay unofficial additional fees out-of-pocket directly to service providers before services areprovided. This may be for consultation; for emergency diagnostic services; ward fees for
inpatient care or fees for surgical and other clinical intervention procedures. This practiceoccurs at all levels of care. 108 The public sector is mandated to accept the NHIS card as ameans of payment and any revision of fees requires parliamentary approval, thus it faces
frequent disruptions in service delivery due to lack of funds and consequent lack of required
inputs for the provision of continuous services. 109

3.2. Private health insurance schemes
There are licensed Private Health Insurance Schemes (PHIS) in Ghana, regulated by the
National Health Insurance Authority (NHIA). There are two types, namely the Private Mutual
Health Insurance Scheme (PMHIS) and Private Commercial Health Insurance Scheme (PCHIS).
There is 1 PMHIS and there are 12 PCHIS schemes, 19 health insurance brokers, and 1 licenced
JLN DRM Collaborative, Public Expenditure on Health in Ghana: A Narrative Summary, 2022, url, p. 10
KII11. An officer of the National Health Insurance Authority (head office). Interview, February 2023. The person
wishes to remain anonymous.
105
KII12. The finance manager of a private hospital in Accra. Interview, February 2023. The person wishes to remain
anonymous; and KII13. The finance manager of a public district hospital in the Eastern Region. Interview, February
2023. The person wishes to remain anonymous.
106
KII10. A district claims officer of the NHIS. Interview, February 2023. The person wishes to remain anonymous.
107
KII14. An active card holder of the NHIS. Interview, February 2023. The person wishes to remain anonymous.
108
KII15. An active card holder of the NHIS. Interview, February 2023. The person wishes to remain anonymous.
109
KII16. A Medical Director of a public secondary hospital. Interview, February 2023. The person wishes to remain
anonymous.
103

104

32

HEALTHCARE PROVISION IN GHANA

health insurance adjuster that are licensed up to 30 June 2023. 110 Service providers also, attheir discretion, accept international private health insurance cards from schemes that are notoperating in Ghana. 111
These private schemes are completely financed by their respective subscribers and provide atleast the same but often more coverage benefits than the NHIS in terms of types of healthservices the beneficiary can access and a higher ceiling of cost. The annual premiums forthese schemes range from GHS 1 200 to GHS 4 500 [EUR 88 to EUR 330] for an individual,
and for family schemes of a family of 4 persons the premium ranges from GHS 12 000 to GHS
15 000 [EUR 880 to EUR 1 100]. The differences in premiums for both individual and family
schemes are based on the range of services to be covered. Where subscribers have preexisting conditions, the premiums are accordingly reviewed upward. Prospective clients are
not refused insurance. 112
The tariffs by the private health insurance schemes are set at their discretion while changes to
the NHIS tariffs requires government approval. Tariffs of the private health insurance schemes
are higher than that of the NHIS, making private health insurance more attractive to service
providers. In the private sector frequent changes in fees are common as they are often
reviewed to accommodate changes in the country’s economic environment. Fees charged in
the public sector are the same at respective levels of care while those in the private sector
vary from provider to provider. 113
These private schemes are predominantly subscribed to by corporate bodies for theiremployees. It is estimated that 350 000 people have active memberships of private healthinsurance schemes. 114

3.3. Out-of-pocket health expenditure
Out-of-pocket health expenditure will occur for people who have no form of healthinsurance. 115 Based on ecological zones, more people in the urban forest areas (70.6 %)compared with those in the urban coastal (62.4 %) and urban savannah (63.1 %) pay out-ofpocket for their health expenses, an indication that health insurance is not prevalent in theseareas. 116
Figure 2 shows out-of-pocket expenditure as a percentage of current health expenditure andhow it has fluctuated but reduced between 2000 and 2019. 117

Ghana, NHIS, Home - Private Health Insurance Scheme, 2023, url
KII17. KII17 is an officer in a Private Health Insurance Scheme. Interview, February 2023. The person wishes toremain anonymous.
112
KII10. A district claims officer of the NHIS. Interview, February 2023. The person wishes to remain anonymous.
113
KII11. An officer of the National Health Insurance Authority (head office). Interview, February 2023. The person
wishes to remain anonymous.
114
KII17. An officer in a Private Health Insurance Scheme. Interview, February 2023. The person wishes to remain
anonymous.
115
KII10. A district claims officer of the NHIS. Interview, February 2023. The person wishes to remain anonymous.
116
Ghana, GSS (Ghana Statistical Service), Ghana Living Standards Survey (GLSS 7) 2019, url, p. 51
117
World Bank (The), Out-of-pocket expenditure (% of current health expenditure) – Ghana, 2023, url
110
111

33

EUROPEAN UNION AGENCY FOR ASYLUM

Figure 2. Out-of-pocket expenditure (% of current health expenditure), 2000 to 2019 118

Private-for-profit service providers have the highest cost of care, followed by private non-profit
with the lowest cost of care in public service providers. Cost of care in the public service
providers is generally uniform across the country. For the private sector cost of care is higher
in urban than in rural areas. 119 The GLSS surveyed people in different ecological regions
across Ghana and recorded their expenditure on health in the two weeks preceding thesurvey. Table 4 shows the average health expenditures per household that were reported.
Care was found to be more expensive in urban areas as against rural areas and again more
expensive in the urban forest zones compared to the rural savannah. 120
Table 4. Average health expenditure in a two-week period for outpatient services 121
Cost item

Average cost of service

Registration (card/folder fees)

GHS

[EUR]

15.12

[2.69]

World Bank (The), Out-of-pocket expenditure (% of current health expenditure) – Ghana, 2023, url
Ghana, GSS (Ghana Statistical Service), Ghana Living Standards Survey (GLSS 7) 2019, url, p. 51
120
Ghana, GSS (Ghana Statistical Service), Ghana Living Standards Survey (GLSS 7) 2019, url, p. 51
121
Ghana, GSS (Ghana Statistical Service), Ghana Living Standards Survey (GLSS 7) 2019 url, p. 51
118

119

34

HEALTHCARE PROVISION IN GHANA

Cost item

Average cost of service

Consultation fees

66.03

[11.76]

Diagnosis (x-ray, Lab etc.) fees

36.94

[6.58]

Drugs and treatment

51.03[9.09]Overall treatment or services

114.18[20.34]

Transport

13.39[2.39]

Any other services

65.04[11.58]3.3.1. Cost of consultations
Medical fees, including consultation, are regulated for public sector service providers but notfor the private sector. The public sector service providers require parliamentary approval forthe fees charged, while private sector service providers have no such regulatory mechanism
and are at liberty to charge any fee, at their discretion, for services they provide. 122 By default,
health insurance schemes indirectly regulate medical fees for service providers who upon
acceptance of the schemes tariffs and terms of payment are bound to that until such a timethat these are re-negotiated or the schemes present revised rates. 123

KII09. KII09 is an administrator at one of the teaching hospitals. Interview, February 2023. The person wishes toremain anonymous.
123
KII17. KII17 is an officer in a Private Health Insurance Scheme. Interview, February 2023. The person wishes toremain anonymous.

122

35

EUROPEAN UNION AGENCY FOR ASYLUMTable 5. A comparison of public and private sector consultation and inpatient fees 124
Public Primary
Hospital

Public Tertiary
Hospital

NHIS

NHIS

Cost item

Private Sector Hospital

NHIS tariffs

Private Sector
pricing

GHS

[EUR]

GHS

[EUR]

GHS

[EUR]

GHS

[EUR]

Generaloutpatient
consultation- adult

19.44[2.72]

86.37[12.74]28.70[3.13]

95 - 180[26.55 3.92]

Specialist
outpatient
consultation- adultn/an/a

121.77[17.96]n/an/a

200 380[56.05 8.27]

Inpatienttreatment /day - adult

72.94[10.76]128.59[18.97]108.54[11.84]250 500[73.75 10.88]

The private sector hospitals providing the information in Table 6 are primary level service
providers. Table 6 shows the difference between the NHIS tariffs 125 and the fees that theprivate service providers levy. Most private sector facilities do not serve NHIS card holders

Public Primary Hospital: Ghana, NHIS, National Health Insurance Scheme Tariffs for Public Primary Care
Hospitals (Catering Inclusive), February 2023, not available online, pp. 22 and 27; Public Tertiary hospital: Ghana,
NHIS, National Health Insurance Scheme Tariffs for Tertiary Hospitals, February 2023, not available online, pp.
26, 27, 28; Private Sector Hospital: Ghana, NHIS, National Health Insurance Scheme Tariffs for Private Primary
Care Hospitals (Catering Inclusive), October 2022, url, pp. 24, 26; Interviewees: KII18. Hospital Administrator of a
private hospital in Accra. Interview, March 2023. The person wishes to remain anonymous; KII19. FinanceManager of a private hospital in Kumasi, Interview, March 2023. The person wishes to remain anonymous; andKII20. Finance Manager of a private hospital in Accra, Interview, March 2023. The person wishes to remain
anonymous. It is noted that the NHIS prices in the above table are derived from the cited documentation, while
the private pricing is derived from the cited interviews.
125
Ghana, NHIS, National Health Insurance Scheme Tariffs for Public Primary Care Hospitals (Catering Inclusive),
February 2023, not available online; Ghana, NHIS, National Health Insurance Scheme Tariffs for Tertiary
Hospitals, February 2023, not available online; Ghana, NHIS, National Health Insurance Scheme Tariffs forPrivate Primary Care Hospitals (Catering Inclusive), October 2022, url, p.26
124

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and this difference in the NHIS tariffs is why the private sector states that the NHIS tariffs are
not economical. 126

3.3.2. Cost of medication
The pharmaceutical sector as described in section 2.3 above is the context within which
medicines prices prevail. Medicines prices are not regulated in Ghana. As 70 % of all
medicines are imported into the country, their prices are susceptible to foreign exchange rate
fluctuations. For many medications, their price is higher in the private health facilities than in
the public. 127 The cost of generic medicines in the private sector ranges from 0.99 to 34 times
the international reference price whiles same in the public sector ranges from 0.88 to 27
times. 128
This notwithstanding, a form of regulation exists on account of the NHIS medicines list 129
where generic medicines are listed, their prices fixed and often cheaper than prices in theprivate sector. It is important to note that the cost of purchased medicines that are not on the
NHIS medicines list are not reimbursable to the individual. As well, when the market prices of
medicines are higher than the NHIS tariffs, service providers will not accept the NHIS card for
payment and will request the cardholder to pay out-of-pocket. 130
Medicines for certain condition such as Tuberculosis and HIV are given free of charge topatients; these are referred to as programme medicines. Access to these programme
medicines, for free, is only available in the public health facilities. There are instances where
programme medicines are out of stock and not available in the public facilities, and in thissituation, clients may have to resort to private pharmacies. Often though, clients wait for
stocks to be replenished thus discontinuing treatment. These programme medicines, whenavailable in the private sector, are expensive. 131

KII18. Hospital Administrator of a private hospital in Accra. Interview, March 2023. The person wishes to remain
anonymous; KII19. Finance Manager of a private hospital in Kumasi, Interview, March 2023. The person wishes toremain anonymous; KII20. Finance Manager of a private hospital in Accra, Interview, March 2023. The person
wishes to remain anonymous.
127
WHO and Health Action International (HAI) Africa, Medicines Prices in Ghana, 2015, url, p. 5
128
WHO and Health Action International (HAI) Africa, Medicines Prices in Ghana, 2015, url, p. 3
129
Ghana, NHIA, Home – Medicines List, 2023, url
130
KII19. Finance Manager of a private hospital in Kumasi, Interview, March 2023. The person wishes to remain
anonymous. KII10; A district claims officer of the NHIS. Interview, February 2023. The person wishes to remain
anonymous.
131
KII16. A Medical Director of a public secondary hospital, February 2023. The person wishes to remain
anonymous.

126

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4. List of useful links
Organisation

Web address

BBC Ghana Country profilewww.bbc.co.uk/news/world-africa-13433790

Ghana Statistical Service

www.statsghana.gov.gh

Health Facilities Regulatory Agency

www.hefra.gov.gh

Ministry of Health, Ghana

www.moh.gov.gh

National Health Insurance Authority

www.nhis.gov.gh

The World Bank Ghana data

www.data.worldbank.org/country/GH

The World Bank Ghana country profilewww.worldbank.org/en/country/ghana/overvi
ew

38

HEALTHCARE PROVISION IN GHANA

Annex 1: Bibliography
Oral sources
KII01, interview, February 2023. KII01 is a Facility Assessment officer from the Health Facilities
Regulatory Agency. The person wishes to remain anonymous.
KII02, interview, February 2023. KII02 is a client of a private healthcare facility. The person
wishes to remain anonymous.
KII03, interview, February 2023. KII03 is an officer in the National Ambulance Service in Accra.
The person wishes to remain anonymous.
KII04, interview, February 2023. KII04 is an officer of the Pharmacy Council. The person
wishes to remain anonymous.
KII05, interview, February 2023. KII05 is an officer of the Pharmacy Council. The person
wishes to remain anonymous.
KII06, interview, February 2023. KII06 is a pharmacist in a public health facility. The person
wishes to remain anonymous.
KII07, interview, February 2023. KII07 is an officer in the Food and Drugs Authority. The
person wishes to remain anonymous.
KII08, interview, February 2023. KII08 is an officer from the Ghana Health Service, Institutional
Care Division. The person wishes to remain anonymous.
KII09, interview, February 2023. KII09 is an administrator at one of the teaching hospitals. The
person wishes to remain anonymous.
KII10, interview, February 2023. KII10 is a District Claims officer of the NHIS. The person
wishes to remain anonymous.
KII11, interview, February 2023. KII11 is an officer of the National Health Insurance Authority(head office). The person wishes to remain anonymous.
KII12, interview, February 2023. KII12 is a Finance Manager of a private hospital in Accra. The
person wishes to remain anonymous.
KII13, interview, February 2023. KII13 is a Finance Manager of a public district hospital in the
Eastern Region. The person wishes to remain anonymous.
KII14, interview, February 2023. KII14 is an active card holder of the NHIS. The person wishes
to remain anonymous.

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EUROPEAN UNION AGENCY FOR ASYLUM

KII15, interview, February 2023. KII15 is an active card holder of the NHIS. The person wishes
to remain anonymous.
KII16, interview, February 2023. KII16 is a Medical Director of a public secondary hospital. The
person wishes to remain anonymous.
KII17, interview, February 2023. KII17 is an officer in a Private Health Insurance Scheme. The
person wishes to remain anonymous.
KII18, interview, February 2023. KII18 is a Hospital Administrator of a private hospital in Accra.
The person wishes to remain anonymous.
KII19, interview, March 2023. KII19 is a Finance Manager of a private hospital in Kumasi. The
person wishes to remain anonymous.
KII20, interview, March 2023. KII20 is a Finance Manager of a private hospital in Accra. The
person wishes to remain anonymous.
KII21, interview, March 2023. KII21 is an officer of the National Tuberculosis Programme in
Accra. The person wishes to remain anonymous.

Public sources
BBC, Ghana country profile, 2023, https://www.bbc.co.uk/news/world-africa-13433790,
accessed 9 February 2023
European Union Agency for Asylum, EUAA Country of Origin (COI) Report Methodology,
February 2023 , https://euaa.europa.eu/sites/default/files/publications/202302/2023_02_EUAA_COI_Report_Methodology_Rebranded.pdf, accessed 5 April 2023
European Union Agency for Asylum, EUAA Country of Origin Information (COI) Writing andReferencing Guide https://euaa.europa.eu/sites/default/files/publications/2019-EASO-COIWriting-Referencing-Guide.pdf https://euaa.europa.eu/sites/default/files/publications/202302/2023_02_EUAA_COI_Writing_and_Referencing_Guide_Rebranded.pdf, accessed
5April 2023
European Union Agency for Asylum, The EUAA Writing Guide, April 2022,
https://euaa.europa.eu/publications/euaa-writing-guide, accessed 5 April 2023
European Commission, Exchange rate (InforEuro), n.d., https://commission.europa.eu/fundingtenders/procedures-guidelines-tenders/information-contractors-and-beneficiaries/exchangerate-inforeuro_en, accessed on 3 April 2023
Ghana, GSS (Ghana Statistical Service), Ghana 2021 Population and Housing Census General
Report Volume 3B, Age and Sex Distribution, November 2021,
https://statsghana.gov.gh/gssmain/fileUpload/pressrelease/2021%20PHC%20General%20Rep
ort%20Vol%203B_Age%20and%20Sex%20Profile_181121.pdf, accessed 17 January 2023

40

HEALTHCARE PROVISION IN GHANA

Ghana, GSS (Ghana Statistical Service), Ghana 2021 Population and Housing Census. General
Report Volume 3C, Background Characteristics, November 2021,
https://statsghana.gov.gh/gssmain/fileUpload/pressrelease/2021%20PHC%20General%20Rep
ort%203C_revised%20print_281121a.pdf, accessed 17 January 2023
Ghana, GSS (Ghana Statistical Service), Ghana 2021 Population and Housing Census General
Report Volume 3D, Literacy and Education, December 2021,
https://statsghana.gov.gh/gssmain/fileUpload/pressrelease/2021%20PHC%20General%20Rep
ort%20Vol%203D_Literacy%20and%20Education.pdf, accessed 17 January 2023
Ghana, GSS (Ghana Statistical Service), Ghana 2021 Population and Housing Census General
Report, Volume 3H, Fertility and Mortality, February 2022,
https://statsghana.gov.gh/gssmain/fileUpload/pressrelease/Volume%203H_Fertility%20and%2
0Mortality_240222a.pdf, accessed 17 January 2023
Ghana, GSS (Ghana Statistical Service), Ghana Living Standards Survey (GLSS 7), Main Report,
June 2019,https://www.statsghana.gov.gh/gssmain/fileUpload/pressrelease/GLSS7%20MAIN%20REPORT_FINAL.pdf, accessed 17 January 2023
Ghana, HeFRA (Health Facilities Regulatory Agency), Gazette, 2022,
http://hefra.gov.gh/index.php/licensed-facilities/, accessed 3 April 2023
Ghana, HeFRA (Health Facilities Regulatory Agency), Requirements, 2022,
http://hefra.gov.gh/index.php/requirements/, accessed 3 April 2023
Ghana, MOH (Ministry of Health), 2022-2030 National Essential Health Service Package
Ghana, August 2022, not available online
Ghana, MOH (Ministry of Health), Ghana’s Roadmap for attaining Universal Health coverage
2020-2030, https://www.moh.gov.gh/wp-content/uploads/2021/08/UHC-Roadmap-20202030.pdf, accessed 17 January 2023
Ghana, MOH (Ministry of Health), Health Sector Annual Programme of Work, 2021 Holistic
Assessment Report, April 2022, https://www.moh.gov.gh/wp-content/uploads/2022/08/2021Holistic-Assessment-Report_v1.7.3.pdf, accessed 5 April 2023
Ghana, MOH (Ministry of Health), Health Sector Medium Term Development Plan, 2022-2025,
2021, https://www.globalfinancingfacility.org/sites/gff_new/files/Ghana-GFF-InvestmentCase.pdf, accessed 1 February 2023
Ghana, MOH (Ministry of Health), National Drugs Programme (GNDP) Essential Medicines List
Ministry of Health, Seventh Edition (7th), 2017, https://www.moh.gov.gh/wpcontent/uploads/2020/07/GHANA-EML-2017.pdf, accessed 10 February 2023
Ghana, MOH (Ministry of Health), National Drugs Programme (GNDP), Standard Treatment
Guidelines, Seventh Edition (7th), 2017, https://www.moh.gov.gh/wpcontent/uploads/2020/07/GHANA-STG-2017-1.pdf, accessed 5 April 2023

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EUROPEAN UNION AGENCY FOR ASYLUM

Ghana, MOH (Ministry of Health), National Health Policy: Ensuring healthy lives for all (revised
edition), 2020, https://www.moh.gov.gh/wp-content/uploads/2020/07/NHP_12.07.2020.pdf13072020-FINAL.pdf, accessed 17 January 2023
Ghana, MOH (Ministry of Health), National Medicines Policy, 3rd Edition, 2017,https://www.moh.gov.gh/wp-content/uploads/2020/07/NMP-book-file-1.pdf, accessed
10 February 2023
Ghana, MOH (Ministry of Health), Pricing Strategy for Pharmaceuticals and other healthtechnologies in Ghana, 1st Edition, 2022, not available online
Ghana, MOH (Ministry of Health), Private Health Sector Development Policy, 2013,https://www.moh.gov.gh/wp-content/uploads/2016/02/Private-Health-Sector-DevelopmentPolicy.pdf, accessed 17 January 2023
Ghana, NAS (National Ambulance Service), National Ambulance Service 2019 Annual Report,
n.d., not available online
Ghana, NHIS (National Health Insurance Scheme), Home - Benefits Package, 2023,
https://www.nhis.gov.gh/benefits, accessed 17 January 2023
Ghana, NHIS (National Health Insurance Scheme), Home – Medicines List, 2023,
https://www.nhis.gov.gh/medlist, accessed 17 January 2023
Ghana, NHIS (National Health Insurance Scheme), Home - Membership, 2023,
https://www.nhis.gov.gh/membership, accessed 5 April 2023
Ghana, NHIS (National Health Insurance Scheme), National Health Insurance Scheme Tariffs
for Private Primary Care Hospitals (Catering Inclusive) National Health Insurance, October
2022, Version 2.0,
https://www.nhis.gov.gh/files/Private%20Primary%20Care%20(Catering%20Exclusive).pdf,
accessed 5 April 2023
Ghana, NHIS (National Health Insurance Scheme), National Health Insurance Scheme Tariffs
for Public Primary Care Hospitals (Catering Inclusive) National Health Insurance, February
2023, Version 1, not available online
Ghana, NHIS (National Health Insurance Scheme), National Health Insurance Scheme Tariffs
for Tertiary Hospitals, National Health Insurance, version 1.0, February 2023, not available
onlineGhana, NHIS (National Health Insurance Scheme), Home - Private Health Insurance Scheme,
2023, https://www.nhis.gov.gh/phis, accessed 17 January 2023
Ghana, Parliament of the Republic of Ghana, Act 1041, The National Ambulance Service Act,2020,
http://ir.parliament.gh/bitstream/handle/123456789/1919/NATIONAL%20AMBULANCE%20SER

42

HEALTHCARE PROVISION IN GHANA

VICE%20ACT%2c%202020%20%28ACT%201041%29.pdf?sequence=1&isAllowed=y,accessed 5April 2023
Ghana, Parliament of the Republic of Ghana, Ghana Public Health Act 2012 (Act 851),
https://www.moh.gov.gh/wp-content/uploads/2016/02/Public-Health-Act-851.pdf, accessed 5
April 2023
Ghana, Parliament of the Republic of Ghana, National Health Insurance Act, 2012 (Act 852),
https://www.nhis.gov.gh/files/ACT852.pdf, accessed 3 April 2023
Goodman AMC LLC, Ghana’s Mergers & Acquisitions Report 2017, 2017,https://goodmanamc.blogspot.com/2017/04/ghanas-mergers-acquisitions-report-2017.html ,accessed 10 February 2023
JLN DRM Collaborative, Public Expenditure on Health in Ghana: A Narrative Summary.
Domestic Resource Mobilization Collaborative, Joint Learning Network for Universal Health
Coverage, 2022, https://www.jointlearningnetwork.org/wp-content/uploads/2022/12/GHANANarrative-Summary.pdf, accessed 2 March 2023
National Health Insurance Scheme Tariffs for Tertiary Hospitals, National Health Insurance,
February 2023, not available online
Sadat, M. and Kuworno, A.A., Views from the Streets of Accra on Language Policy in Ghana.
Journal of Education and Practice, In Vol: 8, No 2, pp. 185-192, 2017,https://iiste.org/Journals/index.php/JEP/article/view/35087/36090, accessed on 3 April 2023
United Nations, Ghana - Map No. 4186 Rev.3, February 2005
https://www.un.org/geospatial/content/ghana, accessed 2 December 2022
USA, U.S. Embassy in Ghana, Educational System of Ghana, n.d.,
https://gh.usembassy.gov/education-culture/educationusa-center/educational-system-ghana/,
accessed 5 April 2023
Wang H, Otoo N, Dsane-Selby L., Ghana National Health Insurance Scheme : Improving
Financial Sustainability Based on Expenditure Review, Washington, DC: World Bank, License:
CC BY 3.0 IGO, 2017, https://openknowledge.worldbank.org/handle/10986/27658, accessed
2 December 2022
WHO (World Health Organization), International Health Regulations (2005) Third Edition.
Geneva, 2016, https://www.who.int/health-topics/international-health-regulations#tab=tab_1,
accessed 2 December 2022
WHO (World Health Organization), World Health Organization Regional Office for Africa,
Integrated Disease Surveillance and Response Technical Guidelines, Booklet One:
Introduction Section, 3rd ed, License: CC BY-NC-SA 3.0 IGO, 2019,https://apps.who.int/iris/handle/10665/325015, accessed 3 April 2023

43

EUROPEAN UNION AGENCY FOR ASYLUM

WHO (World Health Organization), World Health Organization Regional Office for Africa, The
state of the health workforce in the WHO African Region. Survey report, Brazzaville, Congo,
2021, https://apps.who.int/iris/bitstream/handle/10665/348855/9789290234555eng.pdf?sequence=1, accessed 1 February 2023
WHO, (World Health Organization), World Health Organization Regional Office for Africa and
Health Action International (HAI) Africa, Medicine Prices in Ghana, https://haiweb.org/wpcontent/uploads/2015/07/Ghana-Summary-Report-Pricing-Surveys.pdf, accessed 5April 2023
World Bank (The), Ghana, https://data.worldbank.org/country/GH, accessed 7 February 2023
World Bank (The), Out-of-pocket expenditure (% of current health expenditure) – Ghana, 2023,
https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?end=2019&locations=GH&start=2000&view=chart, accessed 5 April 2023
World Bank (The), The World Bank in Ghana
https://www.worldbank.org/en/country/ghana/overview, accessed 7 February 2023

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HEALTHCARE PROVISION IN GHANA

Annex 2: Terms of Reference
General information
Avoid general COI, focus on aspects that have an impact on healthcare.
This section is devoted to the geographic, demographic, political, and/or economic contexts
which are relevant to analyse the health system in the country in question. If possible, explain
the impact of these factors on the accessibility of healthcare. Ensure that in this section are
included all particular aspects that can have an impact on the provision of healthcare in the
country. (e.g., security situation, IDPs / refugees, ethnic tensions, etc.).

Healthcare system
Health system organisation
Overview
How is the healthcare system organised (e.g., organised as primary, secondary and tertiary
healthcare)? If so, could you explain who provides care at each level and what type of care isprovided at each level? Does a system of referrals and counter referrals exist?
Is the healthcare system centralised, decentralised or federal? How are the healthcare
jurisdictions distributed between the levels of power? How is the health sector financing
distributed between the levels of power? In the cases of states with federal / confederal
structure, if the care is not available in the state / region/republic of residence of the patient,
but is however available in another federated state (region / republic) of the same country, isthere a possibility for the patient to be transferred there? Is there a mandatory referral system?
What are the conditions?
Is there recent data on the geographical distribution of the health structures? If so, could you
give an overview? Is there a difference in the care supply, in respect to the different
healthcare levels, in the urban and rural regions? Do the patients in the urban and rural zones
have equal access to healthcare? Are there regions / provinces particularly affected by a lackof hospitals or health centres? Ensure that there is Information on the number of healthcare
facilities at each level of healthcare.
Use links to existing documents online for more detailed information.
Public sector
How is the public sector structured? What are the strengths? What are the weaknesses?

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Private sector
Does a private health sector exist? How is it structured? Is there a difference (quantitatively
and qualitatively) between hospitals and health structures in the public and private sector?
What are the main differences, for the patient looking for medical care, between the statefinanced healthcare system and the private sector?

Healthcare resources
Is there recent data on the number of healthcare personnel in the country (e.g., cardiologists,
psychologists, etc. per number of inhabitants)? If so, provide a brief overview (context /comparison with other similar countries or Europe)?
How is the distribution of human resources in health care in the country? Are there regions /provinces particularly affected by a shortage of healthcare professionals? Is the distribution of
the healthcare personnel equal between the public and private sectors?
Are there any specific needs with regards to human resources for health? Are there any
under-represented professional categories? Could you specify?
Is there an emergency healthcare service, e.g., ambulances? How is it organised?
Health expenditure / GDP.

Pharmaceutical sector
Is there a national essential drugs list for the country? What does it mean in terms of access to
drugs for patients? How often is the list updated? If generic drugs are not widely available, dopatients have access to generic drugs? Are they accessible to patients and how?
Is there a supply system for drugs? Does the country experience regular stock shortages? If
so, does it affect the patients’ access to medication? What drugs and diseases are mainly
affected by these stock shortages? What organisations regulate / control the market? Are
there many illegal medications in circulation?
Are the drugs accessible both in urban and rural areas? Are the drugs accessible
geographically in all the country's regions?
Are any medications only available in hospitals, not pharmacies? If so which ones?
Can non-registered medication be imported (parallel import)? How?

Patient pathways
In general: when in need of medical treatments and/or medicines, where and how can patientsfind information? What is the ‘typical route’ of a patient who needs healthcare; treatments
and/or medicines? What does he/she do and where does he/she go primarily and what

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happens next? What are the main obstacles in general to access medical treatments /medicines in the country?

Economic factors
Risk-pooling mechanisms
Include only the mechanisms which are relevant to the country in question. Remove section if
there are none.
Is there a national health and social insurance system / certain state coverage in the country?
How is the Public Health / Social Insurance system organised?
How is health insurance financed? Is it financed by the employer and/or employee
contribution or by taxation or by OOP (out of pocket payments)? What is the patient's financial
contribution?
What does it consist of? Who is entitled to public health insurance (or other form of public /state coverage)? Is the entire population entitled to this insurance? If not, what are theadministrative procedures that should be undertaken and/or the conditions that are necessary
in order to be registered with health insurance? Are the procedures identical for the entire
population? Is being employed one of the conditions to qualify for health insurance? Does thehealth coverage target certain groups of the population (pregnant women, children, seniors,etc.)? What are the criteria in order to be covered by public health insurance? Is a patient’s
financial participation necessary for the registration? If so, how much should they pay? What
percentage of the population is covered by public health insurance?
Does the country have a complementary system to protect the most vulnerable and those
who cannot contribute or be enrolled in the National Health insurance?
Are returning migrants / citizens covered by public health insurance?

Public health insurance, national or state coverage
Note for drafters: the aim of this section is to make clear to the reader what is covered bypublic health insurance and to what extent it is covered. Below are guiding aspects to take
into account.
What type of healthcare / what diseases does health insurance cover? Is maternity carecovered by health insurance? Where is the healthcare provided (in which healthcare facility orat what level of the health pyramid structure)?
Are medicines covered by health insurance? Does it cover all medicines or only some of themor only a percentage of the cost? What are the conditions to benefit from drug coverage?

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Are there cash benefits in case of illness for employees? If so, in which cases and conditions
and what is the amount of these benefits?
In case a patient needs medical care and does not have the means to pay, are there any
governmental measures allowing them access to healthcare? Is there a difference between
emergency care and non-emergency care? What are the solutions for patients without
financial resources?

Community-based health insurance schemes
Are there community-based health insurances in the country? What are the conditions toregister? Which are the practical steps to register? How much must an average person / family
pay to become a member? Do all community-based health insurances offer the same
coverage and have the same mechanism?
Which risks are covered? What type of healthcare, what diseases do the community-based
health insurances cover? Where is the healthcare provided (in which healthcare facility or atwhat level of the health pyramid structure)? Are the drugs covered by community-based
health insurance? Does the insurance cover all drugs or only some of them or only apercentage of the cost? Are there conditions to benefit from the coverage? Does the patient
have to participate financially in order to have access to care (co-payment)? What is therecovery rate for the medical costs?
What is the percentage of population’s coverage by the community-based health insurances?

Private health insurance schemes
Are there private health insurance systems? What are the main health insurances in the
country? What are the conditions necessary to benefit from them?
What do these health insurances cover? What type of healthcare, which diseases arecovered? Where is the healthcare provided (in which healthcare facility or at which level of thehealth pyramid structure)?
How much must a person / family pay to obtain a private insurance on average?
What is the percentage of the population’s coverage by private health insurances? Who hasaccess to this type of insurance?

Out-of-pocket health expenditure
Average total of out of pocket payment on total health expenditure.
Information on the frequency of health expenditure events that may bankrupt a person /family.

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Cost of consultations
Provide a range of prices for consultations with a general practitioner and different specialists
as well as for a hospital stay. What is the price of a consultation / hospitalisation in an
emergency department? What is the share of financial participation by patients?
Is there a difference in respect to prices between the private and public facilities? Are there
any geographical disparities?
Is there a practice of overcharging medical fees? Is it common? If so, could you explain thecontext? How much does it amount to?
Cost of medication
General information about the prices of medication: Are the prices regulated? Is there an
inflation problem, price variation, etc.?
Are there medications provided for free (e.g., are certain medicines covered by the state)? If
so, could you specify which ones and in what facilities or at what health level?
In general, what share of the health budget per person / family goes to the purchase of drugs?
Does the price of medication vary between pharmacies? Is there a difference in respect toprices between the private and public facilities? Are there any geographical disparities?

List of useful links
Include links that provide long-term value and are likely to be kept updated, such as websites
detailing epidemiologic data, national disease programmes, Ministry of Health website, certain
large hospitals, online pharmacies, etc. Not e.g., individual research articles or other ‘static’material.

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50