Gabon is an upper middle income country, with reasonable spending on health, however, its health outcomes resemble that of a country that is low / low-middle income. Where has Gabon gone wrong, and what are the challenges that Gabon is facing in improving health outcomes? Gabon is an emerging economy, while it has achieved high economic development it still has not achieved living standards and health outcomes seen in upper middle income countries. Gabon faces low life expectancy (63 years), levels as seen in other low income countries. It is in an early stage of an epidemiological transition. Fertility rates remain high, and mortality rates are starting to decline. It has a high burden from communicable diseases. While HIV incidence and tuberculosis incidence has started to show positive results, Malaria incidence continues to remain high. There are cost-effective interventions available to prevent many of the communicable diseases the country faces. These interventions require multi-sector approaches, behavioral change programs, outreach services, community development, and a primary health care focus.

This book was produced to support the policy dialogue on Human Resources for Health (HRH) in Ghana. Despite some recent successes, further improvements in health outcomes are in part hampered by the lack of skilled service providers, or human resources for health (HRH), particularly in rural areas, that prevent critical health services from being accessed and adequately delivered to those that need them most. To address the lack of information to guide the development of policies and programs on HRH, the book aims to paint a comprehensive picture on HRH, consolidating new and existing evidence on stock, distribution and performance of health workers to focus on the "what", as in "What is the situation on HRH?" and the "how", as in "How is this situation explained?" . The book highlights in particular new evidence on some of the underlying determinants impacting stock, distribution and performance of health workers in Ghana, including health worker production and attrition, management and accountability structures, the capacity of health training institutions, and health worker compensation. As is made clear, any potential policies to improve the situation on HRH need to be well targeted, and take into account some of the fiscal and political challenges that are specific to the health labor market in Ghana. The data and findings presented in this book are the result of extended and close collaboration between the Ghana Ministry of Health, and the World Bank's Africa Region Technical Team on HRH and will provide a better basis for Ghanaian decision makers and external partners to dialogue on HRH and related policies, resulting in concrete HRH actions. More broadly, it will be of interest to all those working to improve Human Resources for Health in Africa and beyond.

Ghana is one of only several African countries to enact legislation and earmark financing for universal health insurance coverage for its entire population. Seven years into its implementation the Ghana National Health Insurance Scheme (NHIS) has made significant progress in transitioning to universal coverage, but faces significant fiscal and coverage challenges. This study reviews Ghana's health financing system with a special emphasis on its National Health Insurance Scheme. Such an assessment is important because Ghana is often considered a global 'good practice' in terms of earmarking significant amounts of its general revenues for health insurance coverage, providing formal coverage to its vulnerable population groups, and extending coverage by transitioning its existing community health insurance schemes into a national health insurance program. In addition to the global interest in the Ghana 'model', this review is timely in view of recent critiques of the system and questions about its financial sustainability. The study is also unique in terms of evaluating Ghana's NHIS in terms of basic health system goals of health outcomes, financial protection, consumer satisfaction, equity, efficiency, and financial sustainability. The strengths and weaknesses of Ghana's health financing system are assessed on the basis of these performance goals to provide the current health policy reform baseline. The assessment is also based on several new and updated sources of information on: total health spending, inputs, outcomes, household spending, and the macro economy. It also undertakes for the first time an extensive international benchmarking analysis; assesses the financial protection/equity of the system at both macro and micro levels; and, contains an extensive fiscal space analysis based on Ghana's new macroeconomic realities (i.e., the revaluation of Ghana's Gross Domestic Product (GDP) upward by some 60 percent in November 2010, making Ghana a lower middle income country). The study concludes with an assessment of potential structural and operational reform options to assure NHISs long-term efficacy and sustainability in the context of its future available fiscal space.

Ghana s demographic profile is changing, and demographic, epidemiological, and nutrition transitions are well underway. However, several of Ghana s health outcome performances, especially in terms of child health and maternal health, are worse than the levels found in other comparable lower middle income and health spending countries. The volume is timely, given the stage of the Ghana's development. It briefly discusses some of the debates in Ghana s health sector: decentralization and governance, private sector partnership, strengthening health systems, and health financing. It brings together several elements of health system development and challenges and links it to health financing and delivery performance. The volume reviews the situation among human resources for health and pharmaceuticals. The private sector is growing and attention is required on its development. The volume benefits from health service delivery assessments in the public and private sectors, and finds large variations in distribution and weak incentives to improve productivity and performance. It also reviews the demand side financing reform, its coverage of the population and its effect on service use and the financial sustainability of the National Health Insurance Scheme. There is fragmentation in financing of public health, and inefficiency in health spending, and there is need to improve spending in areas that provide a higher value for money. Data overall has been a constraint, however, the study benefits from various household level surveys to disaggregate the analysis by income quintiles. It also reviews the household s vulnerability to health shocks and their financial protection against illness costs. There is inequity in health access, health service use, and health outcomes. The Northern regions have poorer results. Finally, the volume highlights the range of policy options needed to improve health system performance and health outcomes. At this stage of the country s development, and taking the agenda for reform to the next level, the Government of Ghana could embark on significant reforms in the areas of (a) decentralization and governance, (b) health service delivery, (c) public health, and (d) health financing. Further it should set up a holistic and accountable health reform process as it transitions to universal coverage along with its concomitant service delivery, public health, and governance reforms."