Ghana@63: a preview of the health sector

 

No nation can rise above the quality of the health status of its people, and Ghana is no exception. The positive correlation between economic productivity and health is well documented. Ghana has made certain strides in its health sector in its six decades as a sovereign state; there is however, a lot more work to be done in this most vital sector.

Background

There has been a shift in the dynamics of the health burden of the nation over the years. From the turn of the last century leading up to Independence, most of the incidences of diseases recorded were infectious diseases such as cholera, tuberculosis and malaria.

Today, many of the diseases faced are chronic non-communicable diseases. Many of these would be described as lifestyle diseases, they include: hypertension, obesity, stroke, diabetes, some forms of infertility and cancer.

There is also an upsurge in public health concerns such as deaths and injuries resulting from road accidents.  These can be attributed to a change in some demographic factors such a rapid urbanization as well as the rise of the middle class which has resulted in a more sedentary lifestyle, the consumption of more processed food, exposure to harmful emissions from cars and factories.

A study by professors A.D Aikins and K. Koram, indicates that the World Health Organisation (WHO) proposed a model of building blocks of health systems that has been widely adopted in global health. In this systems building blocks model, emphasis is laid on the interaction among the blocks. These are

  1. Health Service delivery.
  2. Health Labour force
  3. Medicines and technologies Supply Structure.
  4. Health Data and Information
  5. Financing Mechanisms and robust Governance Structures.

These must interact in a manner that provides accessible, equitable, responsive and quality health services to the general population.

Health service delivery

Ghana inherited facilities – which prior to independence – were set up primarily to cater to her colonial masters. These were principally government and mission structures, skewed in location to regions along the coast. There were:

  • Three hospitals in the capital city – Accra, Korle Bu and Ridge
  • From Independence until 1966, there were 35 new health facilities built across the country
  • During the period from 1969 to 1972 there were a further 12 health centers built.
  • In 1965 and 1975, two new psychiatric hospitals were built in Akanful and Pantang respectively, to supplement the Accra Psychiatric Hospital built in 1906.
  • The 70s and 80s, which were characterized by political unrest, resulted in the stagnation of development in the sector. They however witnessed interventions such as the ‘Health for all’ by 2000 agenda, the Bamako Initiative of 1987 – which was geared towards “supporting and strengthening primary healthcare services in Africa, through donor support and a variety of mechanisms including community financing”. Unfortunately, resource and administrative constraints led to the abandonment of the initiative in Ghana by 1990.
  • Supplementing the efforts of government, private institutions – especially religious and traditional – have contributed significantly to the number of health facilities in the country, especially, in areas beyond the coasts. The number on such facilities have increased exponentially in the last 3 decades, with some additional 100 facilities built across the nation from about 28 in the 60s.
  • There has always existed mutual suspicion between the traditional medical practitioners and the proponents of standardized “western”, orthodox medical practices. However, for a people largely steeped in culture, abandoning the traditional practices has never been an option. To this end, successive governments have sought to incorporate both streams.
  • In 1961, the Ghana Psychic and Traditional Healers Association (GPTHA) was established.
  • In 1975, the Centre for Scientific Research into Plant Medicine (CSRPM) was also established.
  • 1991 saw the Ministry of Health (MOH) establishing the Traditional and Alternative Medicine Directorate, as a unit to coordinate the Traditional Medicine sector.
  • Then in 1992, the Food and Drugs Board (now the Food and Drugs Authority (FDA)) was established to test and approve a variety of food and medicinal products including herbal medicines and supplements.
  • However, poor regulatory enforcement as well as a lot of misinformation has stifled progress in incorporating Traditional medicine with Orthodox medicine.
  • Faith-based healers – Christian, Muslim and others – are also largely patronised. The establishment of many so-called prayer camps across the country bears testimony to this. However, the same mutual suspicion for orthodox medicine and the assumption that faith-healers are cheaper has resulted in many fatalities.
  • There has also been a rise in demand for eastern medicine, particularly Chinese.
  • The Community-Based Health Planning and Services (CHPS) project, which piloted in Navrongo in the early 90s, with the purpose of bringing health services to deprived sub-districts, led to the building of additional facilities. It has been replicated in other parts of the country.

Unfortunately, in spite of the many milestones achieved, Ghana still lags behind in the number and quality of health care facilities.

Health Labour Force

The public health focus during the first decade after independence was on infectious disease prevention and control. Investments were made in building capacity for healthcare professionals with the establishment in 1964 of medical training at the University of Ghana Medical School, nursing training at the University of Ghana and pharmacy training at the University of Science and Technology, now Kwame Nkrumah University of Science and Technology (KNUST). The West African College of Surgeons (WACS)founded in 1976.

  • Whilst the aforementioned turbulent 70s and 80s saw the training of lower skilled (allied) health workers to supplement the higher skilled professionals, it also witnessed emigration of the latter en mass.
  • Ghana’s first Health Human Resources Policy (HRPS) was developed in the early 2000s to address the crisis with the health workforce. The HRPS recommended education and other incentives the stem the brain drain.
  • The sector has faced a two-fold problem of low health professional to patents ratio, with data from the NHIA strategic plan (2015 – 2018), indicating an average doctor: patient ratio of 1:15,423 in 2006. In addition, there is a disproportionate distribution of these healthcare professionals. Few are willing to work in deprived communities. The ratio has improved over the last 2 decades as there has been a decentralization of the training institutions for allied health workers, especially the lower skilled allowing for the training of more individuals. Also, the introduction of incentives such as training allowances has resulted in many more professionals being trained. There however still persists the problem of distribution. Recent news has been inundated with stories of nurses protesting as a result of non-deployment.
  • Data from the GHS shows a reduction in patient visits to public hospitals. Whilst there are many contributing factors such as doctor/nurse to patient ratio, perceived incompetence and time considerations, one major factor is that many public healthcare professionals run parallel healthcare provision privately, where they can charge a premium of their services.
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Medicine and technology supply structure

A well-functioning health system is one which at the barest minimum ensures individuals have access to essential medicines “at all times, in adequate amounts, in the appropriate dosage, with assured quality’, at an affordable price and in public or private health facilities situated within one hour’s walk of need.”

Ghana’s healthcare delivery system, from its colonial roots, has been characterized by disproportionate distribution. This is evident in the location of the facilities as well as the distribution of personnel but also in the provision of vital medicine.

  • Around Independence, due to the citing of major health facilities along the coast, most of the access to medicine was accordingly skewed. Compounding the problem was the poor road network in many parts of the country, which largely limited access and increased time required to deliver vital medicines.
  • The 70s and 80s and disruption caused by political unrest resulted in the reliance on a few outlets for the procurement f medicines, significantly increasing the cost of vital medicines.
  • The 90s scarcely fared better as the cash-and-carry system resulted in hoarding, undercutting and nepotism in the access to medicine.
  • The Central Medical Stores (CMS), which were tasked with the procurement and distribution of medicines have been saddled with instances of late procurement of medicines in the inappropriate quantities; they are poorly distributed, run out of stock, or expire due to poor stock taking, monitoring, and evaluation as well as alleged instances of direct sabotage such as arson.
  • The current administration has taken some steps in the provision of vital medicines and emergency supplies using medical drones. However, the jury is still out on its economic prudence in light of the absence of basic facilities.
  • 307 ambulances were commissioned in January 2020, bringing the national total to approximately 500 ambulances. The decision to ensure that 275 of these are allocated to each constituency is commendable. However, with a population of approximately 29 million, this translates to upwards of 55,000 Ghanaians to 1 ambulance.

Health data and information

The role of accurate data in health care delivery cannot be overemphasized. According to the WHO, “The health information system informs decision-making by collecting ‘data from health and other relevant sectors, analys(ing) the data and ensur(ing) their overall quality, relevance and timeliness, and convert(ing) the data into information for health-related decision-making’ for a range of users”. The collating and adequate storage and usage of health data has been a mixed bag.

  • A wide range of data has been collected by research-driven, community-based health surveys as well as national surveys. These include the Demographic and Health Survey (DHS), Ghana Living Standard Survey (GLSS), and the Multiple Indicator Cluster Survey (MICS) as well as work done by academia. However, this good work has been undermined by poor record keeping and storage, failure to take advantage of technology.
  • Furthermore, the information is largely lop-sided with abundance of information on some variables and close to none for others, as such; making evidence-based decisions, especially for policymakers has been cumbersome.
  • Additionally, there has been weak standardization of institutional records on disease incidence, morbidity and mortality such as death registration.
  • Also, struggles with aligning similar data across institutions (e.g. utilization of services as captured by GHS and NHIA, health workforce statistics captured by GHS and WHO),
  • As well as poor health financing record keeping and accountability.
  • There is a new focus on e-health with emphasis on technology-based record keeping and dissemination of information. However, there are challenges such as poor infrastructural support, a lack of comprehensive long-term funding, as well as inadequate and irregular supply of electricity to facilities and the high cost of internet data services.
  • It must be noted that these challenges are not peculiar to the health sector but are symptomatic of systemic challenges with information management across the policy sectors in Ghana.
  • Hopefully, with interventions such as the National Identification Authority’s Ghana Card, data collection, storage and dissemination will improve drastically. But if the historical is anything to go by, it might remain a hope and nothing more.
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Financing mechanisms and robust governance structures

Finance is probably the biggest public health issue. The challenge of providing equitable and affordable healthcare has been at the heart of healthcare reforms over the last sixty years.

  • The Nkrumah regime, in the 60s, favored the socialist-leaning approach of providing free services in key sectors such as healthcare and education. As laudable as it was, it wasn’t sustainable in the long run and the economy was made worse off. Actions such as import restrictions affected the procurement of capital intensive equipment, essential drugs and supplies, which in turn affected the quality of service delivery.
  • The 70s and 80s saw the implementation of more inadequate policies.
  • In 1968, a statutory dispensing fee was introduced. It was abandoned after strong public uproar.
  • In 1971, the Hospital Fee Act of 1971 – which sanctioned nominal charges for drugs dispensed for outpatient care – was introduced. The charges were too low to effect full cost recovery of hospital services. The NRC/SMC government maintained the hospital fees imposed by the previous administration.
  • The 80s were even more turbulent as there was a political crisis, resulting in the aforenoted emigration of skilled medical professionals. The Structural Adjustment Programme (SAP) sought to ensure full cost recovery for drugs by imposing user fees in healthcare facilities. Poor monitoring and evaluation led to massive abuses.
  • In reaction to this, the cash-and-carry system was introduced in the 90s.
  • The post-1995 reforms began with the establishment of the Ghana Health Service in 1996.
  • The NHIS was established in 2003 to ‘provide financial risk protection against healthcare services for all persons resident in Ghana’. The Scheme is funded by the state and donor partners. However, as funding from development partners will invariably reduce, the burden will be borne by the State. Over the last decade, the NHIS has become a major contributor of health funding. However, when compared to similar lower middle income in African countries, government spending on health in Ghana is low.
  • The NHIS, however, does not cover HIV medications, thoracic, neuro- or plastic surgery (except after trauma), other elective surgery, infertility evaluations, transplant medication or surgery, and many other ex-pensive items, such as hemodialysis. Among cancer treatments, only those for cervical and breast cancer are included.
  • The Government will need to increase revenue collection, reconsider NHIS premiums and exemptions, improve strategic purchasing as well as prioritize preventive/public healthcare service.

Summary and recommendation

In spite of numerous limitations, Ghana has made tremendous strides in promoting medical care in a moderately large and very complicated country. It is a leader in Sub-Saharan Africa. However, whilst successive governments must be commended for their efforts with regards to the health sector, it is obvious that the sector has suffered as a result of the lack of a coherent plan, as well as those ills which are systemic in every sphere of our national life.

Whilst the merits of a purely capitalist approach to healthcare delivery might be debated, there is no deny that healthcare delivery is expensive, and the cost must be borne, not by cutting corners.

As we mark the event of our 63rd Independence Day, we must commend the men and especially women, who hazard their lives to serve and save others. We must also call on all stakeholders, to practice proper hygiene, enforce punitive measures where applicable, one can only imagine, if public servants, especially those elected to serve the people (and are paid from the public purse in multiples of the nation’s GDP per capita) would pool a fraction of their emoluments into a fund for very specific national projects, perhaps, we might see some more advancement. But perhaps that might only remain within the realm of imagination for the foreseeable future.

God Bless Mother Ghana.

God Bless us all.

 

 

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