CHAPTER 14

When you follow the path of your father, you learn to walk like him.

—Ashanti proverb

14.1 INTRODUCTION Ghana is a relatively small developing country nestled along the coast of West Africa that has a weak economy. Formerly known as the Gold Coast, it is sometimes called The Black Star of Africa. It is bordered by Burkina Faso on the north, Cote d’ Voire on the west, and Benin and Togo on the east. It has a population of over 18 million, 70% of whom are women and children living in rural areas. Fifty-nine percent of the population is between 15 and 64 years old, and 39% are 15 years old or younger (WHO, 2005). Ghana’s land area is 238,000 sq. km. Ninety percent of Ghana’s residents are native African, but there is a strong Dutch and Chinese presence in Ghana. The largest religious groups in Ghana are Christian, Indigenous religions, Catholic, and Muslim (WHO, 2005).

Life expectancy in 1997 was 58 for women and 47 for men. In 2000, life expectancy was 60 for women and 58 for men, an improvement of two years for women and an approximate ten year

jump for men, and today it is 61.31 for women and 58.92 for men (CIA, 2010). There is a low divorce rate, and a high, but improving infant and neonatal mortality rate which has steadily decreased over the past 50 years. For example, the infant mortality rate based on 1,000 live births was: in 1965 (120:1,000), in 1989 (86:1,000) in 2005 (57:1,000) and in 2010 (52:1,000) (CIA, 2010). Ghana’s literacy rate is 70% for men and 30% for women. Uneducated women in the Ghanaian system are relegated to a life of petty selling in the market working from sunup to sundown.

14.2 HISTORICAL Since its independence in 1957, Ghana has been a two tier healthcare system, a system administered by the Ministry of Health and one entrenched in a highly respected system of traditional medicine. The Ministry of Health has traditionally funded maternal and child health with little funding for teen, adolescent, older adult, and trauma care.

Many challenges, not the least of which is a failing economy, include the inability to mass immunize, environmental hazards, unclean water, cross contamination of crops, and diarrheal diseases which result in a large number of infants dying before their first birthday. Complications of pregnancy are common.

14.3 STRUCTURE Ghana has a dual system of health care that includes a Ministry of Health (government) controlled, funded, and operated hospital and clinic system, and an equally respected traditional (folk) system. Many Ghanaians use both systems, sometimes simultaneously. Under the Ministry of Health’s primary care initiative, promising “Health for all by 2000,” the government established polyclinics in the nine major regions of Ghana. The expectation was that when people became ill they would visit the polyclinic is their region first, and would be referred to hospitals only when necessary, thereby making health care accessible to all Ghanaians, even those in rural Ghana. However, soon after Ghanaians began using these clinics, they quickly learned that the clinics were poorly staffed, and equipment was substandard. Many stopped coming, and today the well-conceived polyclinics remain underutilized. Instead Ghanaians continued to travel longer distances to hospitals.

Korle Bu Hospital is the only major medical center in the entire country of Ghana. It has a state-of-the-art intensive care unit (again, the only one in the country), theatres known to the western world as operating rooms, and it has a rather distinguished reputation. Korle Bu, like all facilities in Ghana, must contend with unstable water and electricity supplies.

Of the approximately 22 million people making up the Ghanaian population, 12.6 million live in rural areas where only 30% of the allopathic (scientific, mostly hospital-based) physicians practice. The majority (70%) of health practitioners in rural Ghana are traditional healers who practice folk medicine combining the use of herbs, rituals, and sacrificial offerings in their practice. The remainder of those practicing in abundance in rural Ghana are community health nurses and traditional birth attendants (TBAs) who are trained to serve in roles similar to midwives, although they are unprepared to handle complicated deliveries. The majority of Ghana’s physicians (70%) practice in urban areas, where only 30% of traditional healers practice.

Poorly staffed and equipped polyclinics in the nine regions of Ghana have well-educated physicians; however, most physicians choose to practice in the larger cities. Physicians rule in Ghana and the health system honors a Physician’s Bill of Rights . Nurses in Ghana enter the profession by either completing a diploma or baccalaureate degree. They work in hospitals, clinics, and in the community. Their role is subservient to physicians rather than collegial. Nurses prepared at the master’s degree level teach other nurses or are directors of nurses in hospitals and various community-based programs. There are no nurse practitioners in Ghana other than those working at the United States Embassy.

The well-trained medical and nursing professionals are experts at doing the best they can despite the lack of resources and infrastructure to support technology needs and maximization of outcomes. The government’s “health for all” policy, although philosophically a good one, lacks the financial resources to fund it. It is doubtful that the polyclinics will ever be sustained and their benefits fully realized.

Columnist Quainoo (2003, February 22) calls physician salaries in Ghana “slave wages.” In 2002, junior doctors at government hospitals in Ghana are paid 1.6 million cedis ($178.00) a month, while senior doctors receive a little over 2 million cedis ($230). Quainoo goes on to say that doctors with cars are given a mere 150,000 cedis ($17.00) maintenance allowance and 30 gallons of petrol worth 600,000 cedis ($66.00). Doctors without cars are not entitled to these extra allowances. Dissatisfied physicians leave Ghana in high numbers.

High attrition of skilled employees, such as physicians and nurses, can result in an understaffed public healthcare system that is often seen in developing countries. In addition, according to a Ghanaian Conference Report, of the approximate 2,800 nurse midwives practicing throughout Ghana, approximately 90% will be retiring in the next four years. This is expected to create a gap of 3,500 midwives needed to assist in addressing the critical issues of infant and child mortality and morbidity (Daily Graphic, November, 2007).

Wage differentials often account for physicians, nurses, and other skilled healthcare workers migrating to other countries to practice. Migration of Ghanaian physicians and nurses to countries where they could be better compensated has become a workforce supply and demand problem (Chen and Boufford, 2005). Frimpong (2002) reveals that in 2002 there were 600 Ghanaian medical practitioners practicing in New York alone. Another 62% of those still practicing in Ghana intended to emigrate (p. 47), despite the fact that Ghana was, and still is, in dire need of their services. Seventy percent of the physicians trained between 1993 and 2002 left the country after graduating (Antwi & Phillips, 2011; Okeke, 2009; Safo, 2003; Loewenson & Thomson, 2002; Dovlo et al., 1999). The exodus of medical professionals is mirrored in other health sector professions. Out of 944 pharmacists trained between 1995 and 2002, a total of 410 were presumed to have left the country by the end of 2002. The number of nurses and midwives immigrating to foreign countries exceeded that of other health professional categories. Of the 10,145 nurses trained during that same period, 1,996 were deemed to have left Ghana by the end of 2002 (Safo, 2003). Similarly, the Ghana Nurses Association reported in 1999 that, “over a four year span from 1999 to 2002, Ghana lost approximately 2,500 nurses to Europe” (Awases, Gbary, & Chatora, 2003, p. 35). With an annual 328 yield of nurses in 1999, Loewenson and Thomson (2002) reported Ghana’s net loss of its nursing workforce in 1999 as equivalent to its yield. This is an incredible blow to service demand.

In most regions, the ratio of physicians to Ghanaians is 1:12,000, but 1:36,000 in the Volta River Region, as compared to traditional healers who number 1:400 in most regions, and 1:185 in the Volta River Region (Republic of Ghana, 1995). The higher ratio of traditional healers to physicians throughout Ghana makes them far more accessible to the people, especially those in rural areas. Traditional healers are popular in Ghana because they are located in both cities and in rural communities. They are also more available, acceptable by many, and affordable. Traditional healers are typically well-known, accepted members of the community and generally will provide services in exchange for a commodity or foodstuffs such as cloth, chickens, goats, and auto repair services.

Reproductive health remains a challenge for Ghana’s health sector particularly as very few (35%) of all deliveries are attended by a qualified medical practitioner; rather the overwhelming majority of women either deliver at home or seek assistance from a traditional helper such as traditional birth attendants (TBAs) (IRIN, August 5, 2008). The WHO estimates that “560 pregnant women will die out of every 100,000 that go into labor” (IRIN, August 5, 2008). Also, over 214 Ghanaian women will die in the process of delivery (Modern Ghana, August 7, 2008). The use of traditional birth attendants and birthing centers, although helpful in providing some of the care of women mostly during the delivery period, is not always the right care solution as illustrated in the case scenario discussed later.

14.4 FINANCING Ghana is a developing country that has a severely devalued Cedi (Ghanaian currency). Although rich in timber, gold, and diamonds, the country has no infrastructure to manufacture or export any of these. The Ministry of Health, financed by the government, funds the health system that includes the hospitals and salaries of health professionals, including physicians. Physicians receive housing and small transportation stipends. Seventy percent of the healthcare budget is for curative versus health promotion and disease prevention. Ghana’s healthcare funding priority is maternal child health. Little funding is allocated for older adult and long-term care. Older adults are generally cared for at home by close family members until death.

There is a cash ’n carry system that requires that the person pays for medications and hospital services upfront. With the exception of a certain number of indigent patients cared for and written off under a special bad debt program, hospital admissions and the medications administered during hospitalization are based on a patient’s ability to pay for services. Those who have the ability to pay will get the bed and the medications, those without the resources do not. Prior to implementation of the Cash ‘n Carry system January 1992, the Ministry of Finance and Economic Planning provided initial seed capital for free drugs to patients with the expectation that the hospitals would sell the drugs to patients and use the resources to purchase additional drugs to replenish their supplies (Aseno-Okyere et al., 1998). For example, if family fails to purchase needed medications such as antibiotics and narcotic analgesics for their hospitalized family member the patient goes without. I can recall a burn patient having her burns debrided without analgesics because the family did not make it from the chemical store in time with her narcotic analgesic (pain medication).

Many have argued for developing countries such as Ghana to move toward universal health coverage by utilizing a prepayment financing mechanism especially as user fees and direct payments present a hardship for the poor. However, evidence shows that simply removing user fees, as some have advocated, is not a sustainable solution to healthcare financing (Akazili, Gyapong, & McIntyre, 2011). Hercot and colleagues (Hercot, Meessen, Riddle, & Gilson, 2011, p. ii5) propose that “more attention should be paid by researchers to the production of knowledge that meets the needs of people managing policy changes in low income countries.” The authors state that, “good practice hypotheses derived from existing public policy and health financing policy later can assist in a review of removing user fees for health services reforms in low income countries” (Hercot et al., 2011, p. ii5).

There are systematic problems in financing of health care such as the untimely, and unpredictable, methods of processing payments to various districts. Asante et al. (2007) argue that, “first quarter

government allocations to districts are often not received until second quarter… and fourth quarter payments may not be received at all.” The results of a peer reviewed evaluation of the NHIS revealed that routine data treated as confidential information on the DMIS rarely filters up to the national level and there is untimely disclosure of annual and financial reports (Witter et al., 2007).

14.5 INTERVENTIONAL There are few emergency vehicles. Usually, when an accident occurs someone puts the individual in their car or truck and races them to the nearest hospital where there is usually little or no major emergency or trauma care available and the person dies anyway. The is also no reliance on technology except radiology at hospitals other than at Korle Bu Hospital which even there is limited to the theatres and intensive care units. Providers in the Ghanaian system must respect the values of the people they serve. Physicians, however, often openly disrespect patients who vacillate between traditional healers and hospital doctors. Hospitals provide two meals a day for hospitalized patients and the family provides one meal a day. The family also provides linen.

The majority of healthcare funding is allocated to maternal and child health. Many interventions and campaigns focus on healthy childbearing practices, and child health and development. Ghanaians of all ages actively walk long distances. Their diet routinely includes vegetables (including yams), stews, soups, and rice. Obesity is rarely seen. Younger Ghanaians, influenced by foreigners who smoke, are beginning to experiment with smoking. Recent interventions by nurses and physicians are aimed at discussing the associated health risks of smoking and discouraging the practice.

Perhaps one of the greatest interventional assets among the Ghanaian healthcare workforce is that, despite low wages, Witter et al. (2007) report findings from a survey of health workers showed a strong commitment despite long work hours, and morale was not affected.

14.6 PREVENTIVE Ghana has many environmental challenges due to it tropical climate, rainy season, dry season, malaria breeding mosquitoes, unclean drinking water (especially in rural areas), piped in water in some areas of larger cities, poor sewage, pit latrines everywhere, cross contamination of crops, burning of rubbish, unstable electricity in urban areas, often no electricity in rural areas, and no refrigeration.

Other challenges that interfere with preventive health measures include the market culture and women’s work which is from sunup to sundown and includes heavy lifting; numerous older

vehicles releasing exhaust into the atmosphere; and the burning of rubbish despite that the fumes are chronic irritants to the lungs when inhaled.

A major problem making prevention difficult is that Ghanaians tend to self-treat until the health problem gets out of hand before seeking professional care. Also, almost every meal begins with palm oil additives which probably contribute to blood pressure related deaths. However, autopsies are not routinely done in Ghana; therefore, causes of death are not well documented.

14.7 RESOURCES Children are revered in Ghanaian culture. Ghana is a society that values women for the number of children they have. They are considered a major resource. Consequently, Ghanaian women are rarely childless by choice. African reproduction is considered a way of replenishing the family lineage and building the community. People strive to have large families to fulfill their role in society and to build up the strength of constituent groups (Addo & Goody, 1977). To complicate this value, the infant mortality rate is unusually high (CIA, 2010). Many children do not survive beyond their first birthday and they die from preventable problems such as diarrhea. Women, as a consequence, attempt to have many children hoping that some will survive, and attempt to conceive a boy as male babies are preferred. Girls, although not preferred, are later appreciated for the love and assistance they render around the home especially when the parents become older adults or ill. Among most ethnic groups of Ghana, prolific childbearing is honored. For example, a mother of ten children may be given a public congratulatory ceremony. In most regions of Ghana, a woman has no social status until she becomes a mother.

The role of family is very important in Ghana. We-ism demonstrates a valuing of family, nuclear and extended. This strong kinship tie makes the strong statement suggesting that, I am because we are, and we are because I am, translating to we are all responsible for one another. If you become successful it is your responsibility to help other family members. In a typical Ghanaian home you will find nieces, nephews, and cousins living with a family who is paying their school fees and living expenses. They are also assisted to attend high school and sometimes college. Chiefs, elders, and folk traditions are all resources for the ill and make significant contributions in assisting people to stay in their communities while maintaining their health. Male elders are particularly respected and are often among the first with whom people consult when they are ill.

When a patient is hospitalized, family members must purchase and deliver to the hospital many of the prescribed medications to be used during their care. They must also provide one meal a day but may choose which meal.

Organized religion is prominent. Religious symbols and messages are literally everywhere (on buildings, vehicles, bridges, billboards). The formal religions are primarily Christian, particularly Roman Catholic and Protestant, and there is a strong Muslim presence. The Anglican Church still has a notable presence in Ghana (Kirby, 1993).

The grieving experience in Ghana is traditionally somewhat lengthy, with weekly, monthly, and yearly tributes to the deceased, and it is characteristically reflected by massive community support. Wakes are typically held in the family residence. Women are critically important in the care and preparation of the repast feast that often spans more than one day.

14.8 MAJOR HEALTH ISSUES Health problems endemic to Ghana are polio, cholera, yellow fever, guinea worm, and C-Resistant malaria. Although improved over the last 20 years, Ghana’s piped water and electricity are still unstable and in some village communities non-existent. There are illnesses for which Ghanaians will not consult an allopathic (scientific, hospital) doctor because such problems are considered conditions that defy scientific understanding. These include boils, rashes, and headaches. There are also problems creating such urgency that Ghanaians are lead to only consult an allopathic doctor; these include respiratory and heart problems and malaria.

Typical of most developing countries, infections lead the way as the top killers annually. The top ten causes of death and the years of life lost in Ghana according to the WHO (2006) are outlined on Table 14-1 . Each of the diseases listed are preventable, and many can be successfully treated when diagnosed early and

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