Taking care of the nation's health
Poku Adaa
"...I have noted the appalling conditions of Ghana's Health Services... and the World Health Organisation (WHO) is ready to assist," said Dr T.A. Lambo, an official of WHO on a recent four day visit to Ghana. Our correspondent, POKU ADAA reports on the nation's health.After four days of talks with govern-ment officials and representatives of the Ministry of Health aimed at finding ways to improve the country's health service, the Deputy Director General of the World Health Organisation (WHO), Dr T.A. Lambo, said he has taken note of the appalling conditions of the country's health service which are primarily due to lack of funds and a depletion of several highly skilled medical personnel. He assured the nation that the WHO is ready to assist Ghana to improve the system. As a first step, he promised to offer substantial assistance to the Ghana Medical School to its training pro- gramme with recruitment of additional teaching and research staff.
He said that his organisation would provide medical consultants and equipments to assist in a major reorganisa- tion of the service and to evolve a comprehensive medical care system that will meet the total health needs of the country especially for the rural population. Citing environmental sanitation and immunisation as the key factors in the country's health service, the Deputy Director General promised WHO assistance to look at improving and expanding these aspects of health. Several factors militate against the operation of an efficient health service. Indeed, over the past twenty years, there have been many recommendations and attempts at reorganizing the health service, viz, the Easmon Committee of 1968, the Okoh Com- mission of 1978, the National Health Service Commission of 1979-81 and the recent National Health Policy of 1982 incorporating what has come to be known as the Primary Health Care (PHC) programme. Nothing concrete has so far been achieved to regulate and deliver an efficient system that will benefit the ordinary citizen.
In fact, the situation has deteriorated as the years go by. According to available information from the National Planning Unit of the Ministry of Health, the incidence of communic- able diseases has been on the increase: measles from nearly 9,500 cases in 1971 to nearly 130,000 in 1976; malaria from 75,000 cases in 1971 to 440,000 cases within the same period. The epidemic of cholera which erupted in 1970 has never been completely eradicated and still plagues the population from time to time.
Yellow fever epidemics of 1979 and 1983 killed thousands of people and recently the outbreak of Cerebrospinal meningitis is being fought. At the same time, the number of skilled medical personnel and facilities for delivering the health care system have fallen, for instance, nearly 1,500 doctors were within the public system in 1971, but now only about 500 are remaining in the service.
In trying to figure out how this situation has arisen, it will be best to look at a number of factors, i.e., the organisational and management structure of the system, the financing of the service, and the development of the relevant components implementation process of a sound health programme.
Ghana's Secretary for Health, Mr Tandoh.
In Ghana, the health service is administered by the Civil Service through the Ministry of Health and although there are ten regional branches of this Ministry, the overall administration is highly centralised and bureaucracy and complexity tend to be an obstacle in the provision of an efficient service. Drugs procurement and distribution are directed from the Accra end only. In general, the result of this is that supervision of essential programmes and services get hampered and delayed. Evaluation of the service as a whole and the machinery of main- taining public health laws are virtually non-existent. Policy has often favoured curative programmes instead of preventive ones.
Control and retention of skilled manpower within the system is generally poor and ridiculous. Maintenance of the available resources have never been properly handled and one can see the deteriora- tion of drug depots in the regions.
The cost of providing health services in a developing country could be fantastically high and in our case most especially where existing facilities have been run down, there have been no scheme of expansion for several years in the and the quality of care is at an all time low. The government's ability to finance the health service is from the 'Pay-as-you-heal-yourself' system where the patient pays for the cost of medical treatment he gets.
The pity is that although the fee bears no proportion to the cost of running the service and that in theory, government subsidy should shoulder the largest portion of the burden, this subsidy has run dry. Consequently, private health care centres which charge 'realistic fees' are making good business as the public confidence in the public health system keeps falling, being replaced gradually by a practice of self-medication with all its inherent dangers. Many people in Ghana, including professionals in the medical field, tend to look for alternative ways of financ- ing, such as an insurance scheme, though none of such suggestions have revealed a practicable scheme other than the ABIDO recommendation published in the Mirror of August 11, 1984.
In that publication, Dr Moses Abido wrote: "The health insurance scheme is still better than any other method of financing health services in developing countries. There is no doubt whatso- ever that an efficient national health insurance scheme would relieve the government of a considerable financial burden. In Ghana, for instance, look- ing at our environment and society, the introduction of a conventional form of health insurance scheme could mean the exclusion of nearly 70-80% of our population. “It also behoves us to evolve our own health insurance system using existing socio-economic institutions such as credit unions, consumer co-operatives, susu groups and social clubs. Instead of these organisations paying out all the dividends to their members, part of it deducted at source could be used in paying for members contributions to the insurance scheme.
"This would require the development of an efficient co- operative system such that every community would have to establish one and membership could be legislated by law. This system to my knowledge, has not been tried anywhere in the world and I hope our planners will give a due consideration in future."
That apart, an effective health service need to work out a strategy that is made up of definite components as (i), Health education and information/ statistics on health; (ii), Environmental sanitation and immunisation; (iii), Fight against local endemic diseases; (iv), Family hygiene and nutrition; (v), Family planning, maternal and child health facilities; (vi), Drug procurement and distribution, and (vii), Manpower training for middle level person- nel, i.e., nurses, midwives, hospital attendants, caterers, laboratory technologists, etc, etc.
Self-reliance is a first step to an endeavour to look after the health of the entire population, including the elderly and infants. External assistance like that promised by the WHO representative is welcome but should not be seen as a panacea to all our ILLS.
Without the effective programming and implementation of all aspects of the above-listed components, health service will not be worth a penny. The apparent stagnation in the PNDC Primary Health Care (PHC) programme has been due to a number of problems among which are the lack of a definite programme of action, the failure to have medical doctors to work in rural areas, a loose, weak administrative structure to monitor the PHC in towns and villages, lack of finance and, finally, the full emphasis that has been placed on developing infrastructure such as buildings instead of the quality of the care received.
As in most spheres of socio-economic activity in Ghana, the PNDC has woefully failed the nation in its Primary Health Care programme and like the fated PDC/WDC fiasco, may soon crumble to the dust.
Admittedly, it is parochial for anyone to look at a health service system from an isolation point of view, for going by the WHO definition of Health (not merely the absence of disease, but complete social, physical and mental well being), it needs an integrated governmental approach to good housing, clean and safe environ- ment, clean water, nutritious food, good education, community involve ment, to achieve an effective status of health.
Self-reliance is a first step to an endeavour to look after the health of the entire population, including the elderly and infants. External assistance like that promised by the WHO representa- tive is welcome but should not be seen as a panacea to all our ILLS.
Our nation has a long way to go in building a 'healthy' nation, and all governments, present and future, should not overlook these facts.
