CHAPTER 14 When you follow the path

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 improveme nt 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 the appropriate
intervention applied.
Table 14-1 Top 10 causes of death (all
ages) in Ghana, 2002, with the number and
percent of
years of life lost by disease.
https://content.uagc.edu/books/Lovett.9124.18.1/sections/i150#t
ab_14.1
Data From: Death and DALY estimates by
cause, 2002.
http://www.who.int/entity/healthinfo/statistics/bodgbddeathdaly
estimates.xls
14.9 DISPARITIES
Ghana’s poorest residents are women and
children. The majority of women and children
live in
rural areas where there are few
scientific/allopathic physicians. Care in rural
Ghana is primarily
provided by community health nurses, traditional
birth attendants, and traditional healers. The

majority of physicians live and practice in
urban areas. The cash ’n carry system of
operation
favors patients who can afford care. Kirby
(1993) suggests that delivering better health
care may be
impeded by an individual’s religious orientation,
traditional beliefs, and practices.
SUMMARY
A major strength of the system of healthcare
in Ghana is that the country has many
well-qualified
physicians and nurses dedicated to practice.
Major weaknesses in the system are many.
The
majority of Ghanaians (70%) live in rural
areas but the majority of well-educated
physicians live in
the cities. There is a serious need for
physicians in rural areas. Although the
polyclinic concept is a
good one, it just does not work because
the clinics are not well staffed or equipped.
The Ministry
of Health’s lack of necessary resources, a
Physician’s Bill of Rights and a cash ’n
carry system are
also major weaknesses.
http://www.who.int/entity/healthinfo/statistics/bodgbddeathdaly
estimates.xls

CHAPTER 14 When you follow the path

CHAPTER 14 When you follow the path

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