1. Access to Health Care in Old Fadama
An Urban Informal Settlement in Ghana
Master’s Thesis
Department of Society and Globalisation (ISG),
Roskilde University (RUC)
Submitted 6th of July, 2015
By
Sofie Yung Mitschke
2. Research area
Old Fadama is one of the
largest urban informal
settlements in West Africa
Grown into a local community
with numerous of shops,
private schools, mosques
and public toilets and baths.
Estimated 80.000 residents
who have migrated from
other parts of country mainly
Northern Ghana
Electronic dumpsite causing
a significant health threat to
the people
3. Problem statement
How do economic, social and cultural characteristics of the
local residents, living in the urban informal settlement in
Ghana, influence their access to health care services? And,
how are medical care providers able to address the local
residents’ health needs?
Sub-research questions
1. How do the local resident’s health knowledge, attitude and
beliefs influence their willingness to seek health care?
2. How do social and financial conditions of the local residents
influence their ability to use health services?
3. What types of services do conventional health care
practitioners provide for the local residents?
5. Preparations before fieldwork in Ghana
Research on study area
Applied for travel grants (Danida Travel Grant, Africa Nordic, Oticon
Fond, Dansk Tennis Fond)
Developed a plan/schedule for field work (time-period, interviews,
deadlines etc. ) and budget
Contacted relevant organisations and people in my network,
announcing my arrival
Contacted local translator
Contacted journalist at Globalnyt (ulandsnyt.dk)
6. Data collection in Old Fadama
Meeting with local
translator before going to
the field
Consulted with community
chiefs and other local
authorities
Walk around and got an
overview of the area
7. Focus Group Discussions
10 focus group interviews (five male groups and five female groups)
Selection of participants
Introduced myself in the local language
Ethical considerations
8. Class exercise
In the three scenarios below, you are conducting a focus group discussion with local residents in Old
Fadama. You want to find out how the residents behave/act when they get sick. What health providers
do they seek and why?
1. Scenario
During the focus group discussion, there is one person who dominate the conversation and the rest
are not participating. How would you involve the rest of group in the discussion?
2. Scenario
During the focus group discussion you ask the questions below, but the participants do not understand
your questions. How would you rephrase them?
What diseases do you think most people here in your community get infected by?
Are you familiar with any organizations, NGO’s or associations that work with health issues in
your community?
3. Scenario
During the focus group discussion one of the participants starts talking about the on-going conflict
between traditional tribes in Northern Ghana where he/she has migrated from. You wish to lead the
conversation back to your topic about health care in Old Fadama. How would you do that?
9. Advantages (Successes) Limitations (challenges)
How groups of people think, feel and react about
a particular topic
The group dynamic generated new perspectives
on a topic
It provide an idea of shared views or not shared
views
I was able to interact directly with respondents
(allows clarification, follow-up questions)
Reaching more reluctant people who are often
the most vulnerable
Ensuring active participation
Covering in depth perceptions on a particular
issue
Risk of power hierarchies among the participants
Social tensions between the participants
Moderator bias
10. The moderator role
Short and specific questions
Not too many questions – keep it
simple!
Make the conversation as ’natural’
as possible
Body language and energetic tone
of voice
Memorize the questions and try
not to look at the interview guide
A good relation and collaboration
with the local translator
11. Time-line of data collection in Accra, Ghana
11th-
18th of
February
: Focus
group
interview
s with
local
resident
s of Old
Fadama
19th-20th
of
February:
Interviews
with drug
store
owners in
Old
Fadama
26th of
February
:
Interview
with
Medical
Doctor
2th of
March:
Interview
with
NGO,
Housing
the
Masses
3th of
March:
Intervie
w with
Ministr
y of
Health
12th of
March:
Interview
with Social
Service
(A.M.A)
16th of
March:
Observati
on study
of Poly-
clinic in
James
Town
12. Unpredictability in the data-collection
process
The importance of local drugstores also called chemical sellers
Trust in traditional health practitioners
Low tendency to use formal health institutions
Local drugstores are the link between the local residents in Old Fadama
and the formal health system
Change in the direction of my research
13. More findings…
Illness level is an important factor for the local residents’ willingness
to seek health care
“You only go to hospital when you cannot get up... When you can’t do
things on your own. For here, you go to hospital when you don’t have any
control over your body… Because people here don’t like hospital... Some
say the hospitals are not good others say they waste time...“(Annex 6, p.
4)
Social network enables the local residents to gain financial access to
health care service
“…as we come to a place like this we are all one...“ (Annex 8, p. 3)
The low tendency to seek health care increase health care expenses
14. Reflections after the fieldwork and submission of my thesis
Too much data! Data-collection is very time-consuming
A different theoretical framework
More critical towards the local residents in Old Fadama
(validity)
Only few focus group interviews were very useful
More focus on gender perspective and traditional medicine
Informal settlements means that they are not legally permittted to live and build
The local residents have on their own initiative without support from the government build school, shops ect.
Northen Ghana poor than the Southern part. Most of them are economic migrants who have come to area looking for better oppotunities. They send money back to their families.
HUSK induktiv – deduktiv
Afprøver teori i praksis
5. A local translator are very imporant if you want to conduct field work with poor and vulnerable groups, because they often don’t speak English. I knew Mohamed through a former Intern at the Danish Embassy in Ghana.
6.I had two agendas: 1) Made my work more important and I could use when I wanted to get interviews with ’important people’.
I met with my local translator Mohammed at a quite place, where we could prepare for the fieldwork. I informed him about the what 1) the purpose of our work, 2) what specifically and practically we should be doing in Old Fadama, 3) What was his role as a local translator, 4) What was my role. I also wanted his advice from him. He was the one who are knows the local community and conditions… I have these ideas, do you think its possible? I also had some question, which I could not find answers home in Denmark. Fx. Where they any health clinics in Old Fadama.
As you all probably know, traditional authorities and non-state actors often have more legitimacy among the population than the government. Old Fadama is no exception, traditional leaders and local authorities have control over the area, and therefore my local translator Mohamed took me to see some of the local leaders.
I explained why I was here. I made it very clear that I was only a student and not able to contribute with any financial support. However, I emphasised that my presence in Old Fadama was an opportunity to draw attention to the challenges in their community. As an example, I told them that I was going to write an article in a Danish newspaper about my work in Old Fadama, and thereby inform people in Denmark about Old Fadama. I also mentioned that I was going to interview government officials in the Ministry and confront them with the problems in Old Fadama.
1. The division of men and women in the focus group interviews was based on previous field work experience and existing research challenges of engaging women in active participation and in consideration of gender perspectives. Men and women may see things differently due to gender roles.
2. Selection of participants and organizing the focus groups
- By approaching either women or men sitting in groups on benches, in front of the local shops or in other locations in Old Fadama.
I considered it to be too difficult to organize groups in a narrower age group and I decided to apply a broad age group from 18-50 years when searching for participants.
3. Presentation before starting the interviews. I told them I was here to learn from them.
4. Ethical Considerations:
- We informed aboyt the conditions of the interview: 1) they would not receive any financial payment for their participation, and 2) we made sure that all participants approved an audiotaping of the conversation
3) they were entitled to leave the conversation at any point they felt the need to do so. This led to participants left the conversation before the interview was finished due to work or other errands, which affected the size of the groups.
3. As you just told me… you have all migrated hre because of the conflict at home… so when you come here to Old Fadama… how is the health conditions affecting your lives here?
Pros and cons of the applied method.
The group dynamic - advantage
1. And 2. During my first focus group interview, I realized that I had too many questions and the particpants found it difficilt to understand my questions. When I came back. I listened to interview, and then I cut down on the number of questions and made the question shorter and more specific.
If you have time – find question from your interview guide
3. It was a challenges for me to make the discussion natural. Sometimes I felt like they were waiting for me to give ask them a question. I tried to address this may telling them that this a just like a normal conversation, you are free to tell everything you want…. We are here to learn from you.
I was very active during the focus group. We joked and fun , but that also fit my personality! I reccomend that you find your own style, cuz that will come out more naturally.
I felt very safe with Mohamed. I trusted him. We were team. Evert morning we said ”SO-MO”. I also had to correct Mohamed somtimes. He was very tried some days and I got the feeling that we sometimes added his own lines to the translation to make it more
Before and after every interview we elaborated.
-Bottom-up. The views and perception should shape the following work. This led to unexpecting findings The local drugstores
I began the field study in Old Fadama where the aim was to learn from the local people. It was important that it was the perceptions and experiences of the local residents in Old Fadama that “shaped” the further fieldwork process, and not interviews with other stakeholders such as politicians, NGOs or other professionals. However, a data collection is not a linear process but instead dynamic in the sense that ideas are used to understand data, and data are used to change our ideas.
Because my fieldwork took unexpected directions and I found out many things that would be interesting to further examine, I ended up with too much data.
Before I went to Ghana, I wanted to examine the political challenges, which is why I interviewed government offcials and NGOs. When I came back to Denmark and began wrtiting my report, I realized that it was not possible. There were simple not enough ’space’ in my report to cover this subject.
Had an idea before going to the field that I was going to undertake a examination of the formal health institutions
- The importance of local drugstores
As I have told before, I had too many interviews. I did not have a realistic
2. There were only few focus group interviews that where really useful.
