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Opinions of Wednesday, 19 October 2011

Columnist: Yeboah, Kwame

The Gods And Sick-Care System Of Health In Ghana

In life, there are few entities and institutions that can be said to have God-like powers over life and death. In a developing country like Ghana, mothers and doctors are high on this list. In a society where people have no recourse to health but only seek treatment when they get sick, we don’t have a health-care but are saddled with a “sick-care” system. Chronic diseases such as heart disease, cancer, diabetes and hypertension are gradually taking a greater percentage of the morbidity and deaths among Ghanaians. We still have over 90 percent of the causes of diseases in our society being preventable.
But too many Ghanaians fail to get the screenings and visits they need to help them prevent these conditions and stay healthy in the first place. We are able to live as long as we do now because we exercise everyday by walking long distances to farms, to the tro-tro stations, and walking all day in the streets of the cities selling things. The truth is our country doesn’t really have a health-care system. We have a sick care system. Our system is not primarily designed to keep us healthy; it’s organized to get us well when we get sick.
In such a society, doctors who take care of the sick are regarded as Gods. They are the first professionals who see the ailing person and has the ability to help the one overcome his pains, and the society gives them the respects they so deserve. Unfortunately, on many occasions these Gods put up some behaviors that sometimes are seen as unethical, betraying and down-right blackmail.
Since the 8th of October, 2011 the Ghana Medical Association (GMA) has called its members out on strike over disagreements with the Fair Wages and Salaries Commission (FWSC) on the salary levels of doctors. In spite of the reports of suffering and death as a result of the prolong absence of these doctors from the consulting room, the National President of the Ghana Medical Association has further urged the striking doctors not to even see emergency cases.
They say in medicine that the real challenge is to get the diagnosis right. If there’s too much focus on the cure before it’s clear what the problem is, the “solution” won’t stick. So what is the problem? From the little I have gleaned from pronouncements on the strike, it does not look like the problem is migrating doctors to the Single Spine Salary Structure. It is about the fact that doctors don't want to accept the level they have been assigned because that will narrow the gap between them and other health and government workers – what the Deputy Minister of Health, Mr. Rojo Mettle-Nunoo described as “relativities in terms of medical doctors and all the other professional bodies.
Secondly, the discussion has involved other non-salary issues. The Ghana Medical Association in a statement said “The Fair wages and Salaries Commission could not resolve the abysmal promotional patterns on the Single Spine Salary Structure. While other health workers are galloping across banks on the spine, the doctors are moving at a snail’s pace with respect to promotions for the same number of years worked.”
These means there are more to the negotiations on migration onto the SSSS than just salaries. The truth is these kinds of negotiations where all concerns will have to be addressed before the migration onto the new scale take time and from the aggressive negotiation stand of the doctors may demand a lot of financial resources to satisfy them. This means the government of Ghana should have the means to pay what they are demanding. If not then people Ghanaians will have to die.
Thirdly, there is a vicious cycle of strike and counter strike by health care professionals in Ghana based on wage disparities amongst the different professions. Dapaah Gyamfi (2011) in his publication on strikes among health care professional stated that statistics from the Ghana Labour Commission in 2008 depicted that out of twenty eight major strikes which occurred in Ghana within a few years period of the data collection, Korle-Bu Teaching Hospital recorded thirteen representing 46 percent. The main complaint of the striking nurses was “the disparity in the pay structure which was skewed to favour the Medical Doctors and the other non medical staff.” They were not asking for equal pay but were complaining about the wide gap between the nurses pay and that of the doctors. This means that if the government yields to the pressure of the doctors and pays their prohibitive demands, Ghana will have another strike on her hands this time from nurses and paramedical staff and other professionals in the public sector. Can we survive that wave of protest?
The striking health-care professionals were of the view that any attempt to segregate and motivate staff differently created disunity within the health sector and led to a perception of discrimination and favoritism which was likely to impact negatively on total patient care. All of them accepted that their strike actions had serious adverse effects on their patients. Most of them also agreed that their strike tarnished the image of the country internationally, led to brain drain, brought about increase in the family expenditure of their patients, reduced their productive time and led to contraction of communicable diseases from the hospital. It should be noted that all these health-care professionals including doctors worked “fulltime” in government institutions with protected salaries. Doctors provide an essential service whose withdrawal is capable of causing great hardship to those they serve, including potential loss of life. For this reason, there is a need for doctors to morally justify any decision for collective action.
The history of health-care delivery is full of heroism. History tells us that for many, or most, of the people who decided to work in the health care sector, the idea of helping or supporting ill or handicapped people is one of the reasons why they chose their particular profession. If they then go on strike, but if they really want to stand by their claims, then someone will get hurt. Inevitably, this is the patient, but hurting patients is contrary to what doctors and nurses normally do or desire. In their case, the key to a successful strike is whether public opinion is on the side of the strikers. To win a strike it is necessary to have public opinion on one’s side and involve the public in raising the pressure. Can you hurt people this bad and expect them to support you from the heart or do you want to force support by withdrawing services even from emergency cases?
According to the World Medical Association declaration of Helsinki, it is the duty of the physician (health worker) to promote and safeguard the health of the people. The health of the patient is the first consideration of the physician (health worker). The main aim of medical practice is to save life, preserve, promote and manage health. It is generally understood that health workers should always desist from harming their patients, and their actions should always be in the best interest of the patient. On the other hand health workers that are employed on agreed remuneration packages have the right to be paid and they have the right to express dissatisfaction and protect themselves from unfair treatment and exploitation. However, their own rights are limited by their responsibilities to save life and promote health as laid down by the medical profession’s code of conduct. It is, therefore, important for the striking doctors to find a better and more humane way of fighting for the demands without endangering the lives of patients any further. Therefore, it is not helpful to hear pronouncements from the GMA that borders on total disregard for life if their demands are not met immediately.
When two rights are in competition or conflict as in this case, the right to be migrated on the SSSS immediately with all the extra demand and the right of the patient to care, the impasse can be solve by resorting to re-evaluation of moral values. You see, not all moral values have the same weight or scope; there is a hierarchy of ethical norms and principle. In our case, I believe the right to care (and implicitly life) on the part of the patient is overriding to immediate satisfaction of demands from government. Therefore, if health workers want to improve their working conditions, let them also fight for care conditions and the life of the patient. For the working condition of the health worker is the living condition of the patient; both are two sides of one coin and one cannot be without the other.
In our society doctors are generally held in high regard particularly in a sick-care system where they have power over life and death. But if doctors in Ghana don’t take care, a time will come when the high regard with which the public holds the medical profession will not be a given. That it can be lowered.
A great writer once asked these questions. Why is the medical profession respected? Why is it intrinsically meaningful when doctors have something to say? What is that added meaning? Understanding the answers to these questions is essential to gaining an accurate sense of the boundaries of doctor’s behaviours within social and political spheres, including public protest. Public regard for the medical profession is the residuum of daily patient-physician encounters, especially in those times when a patient trusts in the doctor’s integrity, is soothed by the doctor’s knowledge, and accepts doctor’s honest, calm, and methodical approach when they reach their individual professional limitations. Are the current doctors’ strike actions threatening this standing?
If care is not taken, the medical profession in Ghana will erode away through the democratic process if doctors undermine its standing. The quickest way to that end is abusing the public's understanding of the physician (health worker) narrative. The physician narrative is the default credibility a doctor is given by doing nothing more than entering the profession -- it is that collection of concepts, generally positive, that people think they know about doctors the moment they learn that they are doctors. Doctors trade on it to do their jobs and also when they advocate for any issue they believe in. So when the matter prompting protest is explicitly in a doctor's personal financial interest, public protest is never the appropriate avenue.
Doctors have achieved their standing in society through the delivery of highly skilled services to those in dire need. So when you engage in hotheaded public protest and civil disobedience, you must have a reason that rises to the level of endangering your ability to practice medicine at all, and a clear explanation for how your actions fit into the medical narrative. If you do not manage your messages well, others will interpret your actions for you, and you cannot expect their version to be favorable.
First and foremost many people think that doctors are paid too much, but cannot do anything about it lets they go on strike and let innocent people die. A section of the public has already started impugning political motives to this strike action and already, there are speculations in Ghana that about 95 percent of materials and equipment supplied to government hospitals end up in private clinics own by doctors. A very serious charge to all those doctors who toil day and night to save lives with limited resources and under harsh conditions.
The fact is that physicians provide an essential service whose withdrawal is capable of causing great hardship to those they serve, including potential loss of life. For this reason, there is a need for physicians to morally justify any decision for collective action. The most effective moral justification occurs when the central issue of the strike relates to the quality of health care or to the doctor–patient relationship. When collective action is taken solely to further the interests of the profession or its members, strikes are probably not morally justifiable.
I will, therefore, plead with the doctors to find an alternate way to fight for their rights without creating problems for the patients and sacrifice the trust of the public which they need to be successful in their profession. I will also plead with them not to treat public outcry over their strike with contempt and ignore calls from society to resume work.
I am also calling on the traditional and religious leadership of the country to get involve in bringing this impasse to an amicable settlement before further harm is done to innocent citizens of the country.
Wishing you all a successful but peaceful negotiation.

Kwame Yeboah