Challenges of Ghana's Health System; Akosa & Quashigah Diagnose!*

There was no better demonstration of two truisms captured in the principle of Appreciative Inquiry than during the Golden Jubilee Anniversary lectures of the Ghana Medical Association.

In two separate speeches delivered by Prof Agyeman Badu Akosa, immediate past Director General of the Ghana Health Service and the Honorable Minister of Health, his former boss, the point was brought home forcefully that indeed, your focus becomes your reality and secondly that in any given set of circumstances, there are multiple realities. In between and in betwixt the twain may lie what some might call the truth. Talk of truth then leads me inevitably to Jamaican roots reggae' s Joseph Hill who posits three sides to the lion's story; your side, my side and then the truth!

Originally billed to speak on the current state of Ghana's Health, a topic he varied to include "the state of the health services and the paradigm shift embarked upon as a sector", the Honorable Minister of Health was in his elements in a speech read on his behalf by his deputy, Honorable Dwuma Odoom.

To a large extent, both Major Quashigah and Prof Akosa agreed on the matter of our health indices which they described as either stagnating or declining in recent times. Infant mortality Rate, 133 per 1000 live births in 1957 dropped significantly to 56.6 by 1998 and by the time of the 2006 Multiple Indicator Cluster survey had risen again to 77 per 1000 live births. Over the same period of 1957-1998, under five mortality rates dropped from 147.8 per 1000 live births to 107.6 gradually worsening to 111 by 2006.

The statistics on maternal mortality are less cast in stone, ranging from anywhere from between 214-540 deaths per 100, 000 live births. While the Minister of Health considers these figures "unacceptably high" explaining that "these improvements are slow compared to other countries especially in East and Southern Africa and parts of Asia", Akosa concurs, preferring the phrase "unenviable".

On other matters like the need for a greater role for Community-Based Health Planning Services (CHPS), the changing disease burden from communicable to non-communicable diseases and the urgent need for lifestyle changes, the two are obviously in each other's good books. The emphasis however differs and sometimes, strongly too as we will soon come to appreciate.

But perhaps, these are the only points of convergence of the two giants as far as diagnosing specific maladies in Ghana's health sector and prescribing specific solutions are concerned.

While the Minister makes the insightful linkage between "poverty, inequalities and health" as being the harbinger of the observed overall morbidity and mortality patterns, Akosa fingers "the human resource deficit as probably the greatest challenge in the health sector" going on to list healthcare financing as "another major headache of our healthcare delivery system". Minister Quashigah is also at great pains to establish the woeful lack of multisectoral collaboration as a major challenge stating for example that "many of the determinants of the malaria burden lie outside the direct control of the health sector."

Healthcare Financing The issue of healthcare financing as analyzed by the two makes some striking revelations. The Minister talks about "increasing improvement in revenue generation under the health insurance scheme", marrying this to concerns about diversion of public health resources into public health demands in HIV/AIDS and Tuberculosis. Also, in an answer to a question in plenary, Hon Deputy Minister concedes few challenges in the current NHIS scheme but is quick to point out the phenomenal success achieved by Ghana within the few years of its implementation. This in fact is the reason why some North African countries are at great pains to emulate Ghana.

Major Quashigah then calls for the exploration of alternative sources of funding in view of the rapidly rising cost of providing healthcare. He then bemoans the current status where over 90% of the Ministry of Health's budget goes into "payment of salaries of health workers" and this out of the 10% budgetary allocation.

On the substantive matters raised above however, it is obvious that the immediate past Director-General of the GHS is hardly impressed either by the emphasis of his former boss or his focus on how the critical issues ought to be addressed. On other countries emulating Ghana, Akosa thinks "the Deputy Minister is simply boasting" and reminds us that "Cash and Carry has not been abolished and is still as vibrant in our health facilities seven years on!" Identifying major problems in the management of the NHIS, Prof Akosa calls for a clear separation of the fund management and regulatory functions for the purposes of addressing the following problems; lack of sufficient qualified/skilled personnel in managerial positions, poor supervision of District Mutual health insurance, poor claims management leading to a delay in some cases of over six months and increasing incidence of fraudulent claims.

Akosa then makes reference to "a little assessment done through a sophisticated software system which found fraudulent claims of between 23-55%". He is not finished; he reiterates that NHIL funds should as a matter of urgency be handed over to professional investment companies to invest the funds instead of the situation in 2005 and 2006 where "it was not until a month to the end of the financial year that the NHIS budget was rushed to Parliament for approval, a time when funds had been sitting with the Central Bank uninvested". He suggests that the NHI Authority must concern itself purely with regulation.

Before I deal with Akosa's views on the second part of financing healthcare, I must confess that I am being both a little mischievous and wicked in my analysis. You see, it is not exactly as if Prof Akosa's lecture was in direct response to the Honorable Minister's speech. These were two separate speeches, but because we did not have the privilege of having both speakers simultaneously engage in the follow up discussion, I am simply yielding to the temptation of jointly analyzing their separate analysis of Ghana's Health sector and what it would take to propel it forward.

Alright, having thus cleared my guilty conscience, let us make progress, still on healthcare financing where Prof Akosa all but accuses the Ministry of Health of starving the Ghana Health Service, its service delivery arm of much-needed funds to execute its programs. Now if you find this a tad too hard to swallow, you would have to try harder because it is the considered opinion of the former D-G that something he suffered during his tenure has only worsened since he handed over. In Akosa's words "most of the agencies are on their knees" going on to restate his position that "The Ministry of Health is the rate limiting step in the progress of the Ghana Health Service."!

Of course in a later discussion, Prof Akosa is taken on by some in the audience for probably not doing much during his tenure as the Director General to positively influence the course of the very events he was now complaining about. Akosa explains that he had pursued these concerns with the Minister of Finance and his Chief Director with the argument that since these are subvented agencies, they should be funded directly from Finance especially since they are subject to the Auditor General's audit and answerable to the Public Account's Committee of Parliament.

Till this major funding gap is addressed, it would prove a major obstacle to the GHS's ability to deliver the kind of quality service required.

CONCLUSION Listening to both speakers, I am struck by the startling statistic that all our noise notwithstanding, our orthodox (hospital-based) care caters for only 39% of the people of Ghana! What, who, where, when, why and how are the healthcare needs of the remaining 61% of Ghanaians accounted for-a most unsettling thought?!

Another striking feature of the Minister's speech is his linkage of poverty to inequality and health. Of a number of the indices he identifies, it is obvious that the worst affected areas are the poor rural areas.

Although the 2006 Multiple Cluster Indicator Survey shows an improvement in stunting from 26-22%, other occurrences are less forgiving of these deprived areas. Vitamin A Supplementation Trials in 1992 shows that 65% of children in Northern Ghana (as opposed to 37% in Southern Ghana) have low serum retinol levels. The last Demographic and Health Survey also shows that children in the three northern regions are more likely to be stunted than Ghanaian children elsewhere. We are told of a study in the Kassena-Nankana District of the Upper East Region which reveals that "while malaria care was just about 1% of the income of the rich, it was 34% of the income of poor households". In the area of HIV care the Minister identifies the 9-14 year group as the "window of hope" in view of the low incidence. Even this window with unique opportunities for "education and healthier lifestyle changes" has been shown by recent studies to be fast closing according to the Minister of Health "in some regions, particularly in the north".

On this score of the need to address these inequalities, Prof Akosa is in perfect agreement, himself drawing attention to the current inequitably distributed health workforce where up to about 90% of the workforce is limited to the South leading to a doctor: patient ratio of over 1: 90 000 in a place like Bongo where the only doctor triples as "Medical Superintendent and a District Director of Health Services." The national doctor: patient ratio of 1:10, 500, he then compares to the Kenyan situation of 1 doctor: 5, 200 people. Of course Kenya's 26 million is served by over 5000 doctors while Ghana's 22 million contend with about 2000 doctors.

Beyond inequitable distribution, he also highlights the severe human resource constraints, concluding that simply put, we are not training enough to meet our targets. On the 90% health budgetary allocation being dedicated to salaries etc, the former Director General fingered this as the clearest demonstration of "how small the health budget is" going on to question "What will happen if we increase the numbers of the health workers" seeing the real need to address acute human resource shortages.

Hopefully, my final piece should dwell on concrete solutions proposed by the two on the way forward.

Sodzi-Tettey, Sodzi

* Moving the Health System Forward; Akosa & Quashigah Prescribe!*

The platform of the 50th anniversary lectures of the Ghana Medical Association provided just the right opportunity for some frank talk from major players in the health sector. Today, I intend to take a quick look at the various prescriptions of the Honorable Minister of Health and the immediate past Director General of the Ghana Health Service.

CHPS If Hon Quashigah and Prof Akosa agree on anything more than any other, it is the way forward for the "home-brewed well researched Community-based health planning and services which puts a trained community health officer in all the 6250 communities of this country."

With a current paltry 2% of the population being served by the CHPS even though we swear it is top-priority, Akosa figures we need twice the number i.e. 12 500 in order to provide better service. It is also the reason why he calls for schools-in-waiting in Worawora, Mamapong Akwapim, Yendi, Pantang and Ankaful to be rolled out. Quashigah however encourages multisectoral collaboration and warns against the temptation to "over emphasize health care driven by the health sector."

To quote Prof Akosa, "Every Ghanaian home (urban or rural) will ultimately have a Community Health Officer whose task within the community shall be to provide necessary information on nutrition, safe food and proper food handling, safe water, environmental sanitation, family planning and the management of minor ailments."

Human Resource On our human resource needs, the Hon Minister of Health announced a "recently organized round table conference as part of plans to develop capacity through increased decentralization of services."

Prof Akosa argues that the human resource deficit is probably the greatest challenge in the health sector and cuts across all health professionals. This deficit is further compounded by the maldistribution which has seen "two thirds of the doctors operating in the two Teaching Hospitals of Korle Bu in Accra and Komfo Anokye in Kumasi and in private practice in these two cities."

To achieve Kenya's Dr: patient ratio of 1: 5000 with a population of 29.5 million by 2015, Prof Akosa figures we need to train about 3 800 doctors within the next eight years. He calls for Accra and Kumasi to increase the number of doctors trained to about five hundred a year and to consider running two streams after beefing up faculty. Resources ought also to be massively injected into the medical schools in Cape Coast University and the University of Development studies.

The boost in human resource capacity must touch midwives and Medical Assistants who currently have only one training school in Kintampo and the former D-G asks for the creation of schools in "Navrongo, Dodowa and Hohoe, all with research centers…."

Now considering Prof Akosa's suggestion that the Community Health Officer ought to be equipped with midwifery skills, I am beginning to seriously wonder whether we shouldn't simply train one nurse with competencies in general nursing, midwifery and possibly community health skills. Without enough midwives, we may well never achieve MDGs 4 & 5 by 2015.

Akosa then takes a swipe at the Minister of Health for "not accepting and supporting innovative ideas for improving the conditions of service of health workers." Some of these he listed as "housing policy with flexible mortgages, sabbatical system after ten years of continuous service, vehicle loan scheme and enhanced pension."

Health Promotion & Regenerative Health While both speakers do not dispute what Minister Quashigah calls the "double burden of disease" with its "mix of persistent, new and re-emerging infectious diseases" and what Akosa describes as "the prevalence of hypertension and diabetes in the adult population which are frightening at 1 in 3 and about 1 in twelve respectively", they certainly differ on strategy.

This is an interesting observation especially seeing that they both call for lifestyle changes (regular exercise, diet etc) and advocacy which is why it is poignant when as it turns out, Prof Akosa has major issues with the Ministry of Health's five year plan of work from 2007-2011 dubbed Regenerative Health. His major headache is that the Ministry of Health, a policy formulator, is now implementing policy and worse still, to the total exclusion of trained health promotion professionals in the Ghana Health Service.

"Curiously but against the statutes of the Civil Service which does not implement but formulates, monitors and evaluates policy, the Ministry of Health is the implementer of the health policy and it is done by non-health promotion professionals."

In addition to lifestyle changes, the Hon Minister of Health throws in a new dimension when he states that "Development planning including improved infrastructure such as roads, houses and the provision of key amenities affect the health status in the long run. The lack of enforcement of basic laws including laws on occupational safety and health hazards has led to indiscipline in our society and specifically on our roads which in turn has contributed to numerous occupational and traffic related accidents with high human and economic tolls."

Today we also know that the Ministry of Health has plans to issue directives to facilities to establish resource centers where people may go for advice on healthy lifestyles.

Teaching Hospitals Whoever thought that coming from the Teaching Hospital would soften Prof Akosa's views about them would need a retake. He spared no effort, describing our two major Teaching Hospitals in Accra and Kumasi as anything but "centers of excellence." Accusing them of doing none of the work and research expected of Teaching Hospitals, he stated that "there is nothing that is done there that cannot be done in the Regional Hospitals if they had their fair share of specialists and equipment."

He then proceeded to define what in his view should occupy the energies/exertions of a Teaching Hospital; organ transplantation, bone marrow harvesting, active resuscitation and treatment of medical emergencies such as Acute Myocardial Infarction, Pulmonary Embolism, Strokes from infarcts and hemorrhage and Diabetic coma without giving up so easily on unconscious patients. In addition, he called for the formation of active cardiac arrest teams and the upgrading of neonatal care to the point where 22-24 week old fetuses can survive when delivered while upgrading our treatment of cancers.

The Professor of Pathology accused the Teaching Hospitals of having "a Cash and Carry mentality where the more you see the more money the hospital makes but that is not what a Teaching Hospital does. It makes money from the sale of knowledge and also does heroic things, rescuing people from the thralls or jaws of death."

He ended with a call to the Teaching Hospitals to develop treatment protocols that would be evidence-based and would be available even at the level of health centers.

Prof Agyeman Badu Akosa then condemned doctors and other health professionals who find themselves in a conflict of interest situation by virtue of "running clinics, hospitals, x'ray, laboratory and pharmaceutical services in competition with our employer" supervised by weak and ineffective administrators.

Prof Akosa ended with a call for Ghana to emulate the likes of Thailand, India and South Africa in the field of Medical Tourism that would make Ghana the "preferred destination for the 300 million West Africans when they need medical help."

Research In this area, once again, the Ministry of Health came up for a tongue-lash from its former Director General when he lambasted them for paying lip service to research, an important missing component which according to Prof Akosa should underpin all our policy decisions, NHIS etc. He questioned what had become of the intentions of the Ministry when at the WHO-Tropical Disease Research Joint Committee and Board meeting held in Accra in June 2006, the Ministry of Health had gleefully promised to commit "2.5% of its total health budget to research."!

Public Health While calling for more resources in the area of Public Health, Prof Akosa commended Public Health professionals for doing a good job culminating in the eradication of measles while being on course to eradicate Polio. On HIV/Malaria and Tuberculosis, Akosa asked for public health agencies to work both vertically and laterally to achieve their goals. On Malaria, the Minister calls for Health to team up with other sectors and civil society in fighting the scourge while identifying the 9-14 age group as the window of opportunity in HIV/AIDs prevention in view of the low incidence of the disease.

In conclusion, I believe it would not be out of place having accomplished all the above to achieve what our former Director General of the GHS refers to as tomorrow's indices; Child mortality less than 10 per 1000, infant mortality less than five per 1000 and maternal mortality less than 10 per 100 000 live births from their current rates of 111, 64 and 540 respectively! Perhaps the best way to do this is to reduce the disparities in health status among the rich and the poor and among rural and urban communities as suggested by the Honorable Minister of Health.

Well, so there you have the solutions. All that is left I guess is bold and committed leadership at all levels to see them through.

Tall order, wouldn't you say?