The in-depth interview revealed that, private for-profit healthcare facilities were virtually not taking part in public health policy design. According to the respondents, there was a body that represented private health facilities at the Ministry of Health, so if a consultation was going to be made to have the input of private healthcare facilities on policy formulation, that body was consulted. The body was Private Health Sector Advisory Group. However, members of the body were appointed by minister of health. The respondents believed that members of the body represent the minister not private healthcare facilities. They said these:
Every government tries to implement its own policies. So, Private Health Sector Advisory Group only concentrate on non-policy making aspect of its mandate prescribed for it by the Minister of Health. Besides, the minister does not consult private health facilities before appointing members of the Group.
However, the mission healthcare facilities believed they were making impact in designing public health policy in Ghana. The responses indicate that, the Christian Health Association of Ghana (CHAG) served as a stake holder in the health sector which was sometimes consulted when policies were going to be designed in the health sector. These are some of the responses:
CHAG is a proactive group, the leadership always thinks ahead of time. So, it does not relax when a public health issue needs attention at the national level. Sometime the association is consulted by the government on health issues and its inputs are included when a policy is going to be designed.
The total number of daily attendance by individuals for public services private healthcare facilities attended to within the period under study (2015 – 2019) was 347456. These services included antenatal care (ANC), postnatal care (PNC), family planning activities (FAMPLAN), immunization/vaccination (IMM) and HIV counselling and testing (HIVCT). Table 1 below shows the number of attendance for public health services at the private health care facilities within the period under review.
Table1: Number of Daily Public Health Services from 2015 to 2019
Year
|
Number of Daily Services
|
2015
|
37399
|
2016
|
38700
|
2017
|
37432
|
2018
|
40447
|
2019
|
39500
|
Total
|
347456
|
Source: Authors’ compilation from the field
In terms of public health services undertaken by the two categories of private healthcare facilities, the study indicates that total averages of 25935 (SD 2544) and 12760 (1514) public health services were rendered to individuals by mission and private for-profit healthcare facilities respectively within the five-year period. Statistics on daily public health services base on types of private healthcare facilities from 2015 to 2019 are shown in table 2 below.
Table 2: Statistics on Public Health Services Base on Type of Private Healthcare Facilities.
Shapiro – Wilk normality test was conducted at 0.05 level of significance to verify if public health services rendered by private healthcare facilities under study were normally distributed. The test shows the following results: W= 0.70827, P-value = 0.001. The results show that the data was normally distributed. This paved the way for Welch two sample t-test to find out if the difference between the averages of public health services undertaken by the private for-profit and mission health care facilities was significant. Table 3 below shows the test results.
Table 3: Welch two sample t-test
t DF
|
P-value
|
Mean (M) Mean (PFP)
|
-38.194 5.3717
|
0.000
|
25935.2 12760.4
|
Source: Computation by the authors
The P-value (0.000) for the t-test results indicate that there is a significant difference between the number of public health services rendered by mission and private for-profit healthcare facilities. The results further indicates that mission healthcare facilities rendered more daily public health services than the private for-profit healthcare facilities within the period under study.
The in-depth interview revealed that, private for-profit healthcare facilities did not undertake many public health services compared to mission healthcare facilities within the period under study due to the reasons for their establishments and delay in reimbursement of funds for the facilities by the National Health Insurance Authority (NHIA). The following is what was said by some respondents from the private for-profit healthcare facilities:
Our primary motive is to make profit. So, we concentrate on the curative services. However, when people come with public health issues, we attend to them. Besides, there are certain public health services like immunization which we are mandated to carry out. Also, some of the curative services we undertake also go with public health services. Our major problem is the delay in reimbursement of our money by NHIA. This is because a lot of the public health programs are covered by the National Health Insurance Scheme.
As a result of the challenges faced by private for-profit health facilities in taking up public health programs, they try to cope by infusing revenue generation in the public health programs. A respondent said this:
We used to render antenatal care services absolutely free but this time we take GHȻ10 [US$2] on every visit by the pregnant women to sustain our health facility.
The study revealed that the pharmacy departments of some of the profit-oriented health care facilities sold nutritional supplements to pregnant woman as if it was part of the basic required medicines for pregnant women. According to some of the respondents, their facilities set up ultra-scan facilities to render those services to pregnant women as a way of raising revenue. In addition, some health facilities sold ‘weighing sacks’ to mothers who attended healthcare facilities for examination of their children. It was also observed that, some of the private for-profit healthcare facilities charged fees for the services rendered to the National Health Insurance Scheme (NHIS) subscribers after taking their health insurance records.
4.1 Discussion
It is clear that profit-oriented health facilities do not take part in designing public health policies. This could be due to the fact that their focus is on how they can meet the objectives for which they are established, that is to maximise profit. So, they remain competing with each other instead of collaborating to have a solid front to represent them. Even though there is Private Health Facilities Association of Ghana, the members only complain when their facilities are not reimbursed within the expected time by the National Health Insurance Authority (NHIA). The association is mostly silent on public health issues which do not directly affect their revenue generation effort. According to Ministry of Health [MOH] (2013), a unit has been established to co-ordinate the private healthcare providers, but that unit is ineffective because it is far down the top echelon of the ministry’s administrative structure. The unit is also under-resourced and under-staffed. World Bank (2011) noted that, there is no overall representation of the private healthcare providers in Ghana. In effect MOH admitted that the private healthcare facilities are not sufficiently represented in policy formulation at any level.
In contrary, since mission facilities are not profit oriented, they do not compete with each other, they rather collaborate to make sure that their objectives are met. This makes CHAG strong enough to present one voice. Besides, CHAG has an indirect voice through which its grievances can be channeled to policy makers. There are churches CHAG members are affiliated to, the stakeholders that represent those churches at the national level, like Christian Council of Ghana and Catholic Bishops Conference among others may be speaking the voice of their health appendage (CHAG) on public health issues in Ghana. As a result, they are recognised in the policy making process. That is Ministry of Health can easily ear mark them for consultation as stakeholders during policy making. Even though their participation is described as being insufficient by MOH.
Immunisation services happens to have the highest average in this study. This confirms a study by Levin &Kaddar (2011) that private healthcare institutions undertake immunisation in their facilities which provide access to health services to the people. It also confirms a study in Cambodia by Soeunget al (2008) that private health care facilities are playing vital role in combating the transmission of vaccine preventable disease. The high number of immunisation cases is understandable, this is because there are a lot of people who go in for different kinds of immunisation for various reasons.
The Welch t-test indicates a significant difference between the private for-profit and mission healthcare facilities in terms of the number of public health services rendered by those facilities. The averages indicate that mission healthcare facilities render more public health services than the private for-profit healthcare facilities except family planning. This confirms studies by Hanson et al (2008) that preventive and public health services will be under – provided by private for-profit market as they are not valued in the market transactions. The relatively low number of family planning services rendered by mission healthcare services may be due to religious-base objections to certain family planning services. Especially those which are under Catholic Church (Barden-O’Fallon, 2017). This study supports other studies (Murray, et al, 2005; Campbell, et al, 2015 and Peters, Mirchandani & Hansen, 2004) which indicate that, many young people prefer the private (for-profit) sector for their family planning services due to their accessibility, availability on time, less waiting time and privacy. Due to the profit motive nature of the private for-profit healthcare facilities, they try to raise revenue from all the public health programs some of which are rendered free of charge at the mission healthcare facilities. This will certainly compel a lot of people to attend mission healthcare facilities for certain public health programs which brings about congestion in those facilities.
The study indicates that, CHAG facilities are in a high munificent environment due to the reasons behind their operations. The critical resources that determine the performance of a healthcare facility are human resource and equipment. CHAG healthcare facilities receive funds from government to support payment of their personnel and for personnel training. They also receive equipment and subventions from the government (MOH, 2013). This makes the environment very conducive enough to ensure higher performance by CHAG facilities.
The study illuminates the fact that, both mission and profit-oriented facilities are in a form of collaboration with the state. The collaborations that are common between the state and the private healthcare facilities are attending to the National Health Insurance subscribers and supply of vaccines that are supposed to be administered free of charge. However, the collaboration between the state and CHAG facilities goes further to include financial support, subventions and provision of equipment by the government. The kind of collaboration between CHAG facilities and the state makes it possible for the CHAG facilities to undertake more public health services. Besides CHAG facilities receive support from external development partners (MOH, 2013). This increases the resource bases of those facilities. This study confirms studies by Okeyo (2004), Eisenhardt and Schoonhoven (1990) and Goll and Rasheed (2004) which indicate that if there are high-quality resources (munificence) in an environment, the organisation is likely to perform better.
In a contrary, the collaboration private for-profit facilities have with the state does not help much in boosting their resources. The National Health Insurance Scheme (NHIS) removes the barrier that prevented a lot of people from attending private for-profit healthcare facilities. Ideally, the more NHIS patients they attend to, the more revenue they should be able to generate through the reimbursement of their funds. This is not the case; the reimbursement is always delayed which affect the resource base of those health facilities. As a result, private for-profit facilities find themselves in low munificent environment. This compels some of them to engage in certain coping strategies. This study again supports a claim by Staw and Swajkowski (1975) that organisations that are in low munificent environment will try to conserve their resources and sometimes engage in certain unconventional acts in order to continue functioning. This study supports the conceptual model that if private health care facilities form partnership with significant others, it will create a munificent environment which will lead to increase in performance in public health programs.