GHANA’S HEALTH CARE DELIVERY SYSTEM
All over the world, the way a country’s health care services are delivered is influenced among others by economic, historical, politico- legal, socio-cultural and epidemiological factors .
As to be expected therefore, the health care delivery system of the US should be different from that of Ghana to the extent that these two countries have different economic, historical and political traditions.
How a country delivers its services has impact on the health of its people.
For instance, if a country’s health facilities are not accessibly to the majority of the population then the people will carry heavy disease burden that in turn will impact on their productive capacity.
Again, the ability of a nation to invest adequately in health care is dependent on its economic resources.
Therefore in all cases, every nation recognizes the critical relationship between health and economic productivity and development.
The health care delivery system of Ghana has the following characteristics:
Poor quality and expensive.
The case of Ghana is similar to that of other former British colonies in West Africa, (Nigeria, Sierra Leone, and The Gambia).
In order to appreciate the origin and causes of these characteristics, it is necessary to turn to history.
We shall, therefore deal with history in three (3) phases:
Pre-colonial ( before colonization in 1844)
Post-colonial: 1957-1966: 1966-71:1971-1985; 1985-2003; 2003 to date
Before the Portuguese (the first Europeans) arrived on the shores of this country in 1471, there were healers who took care of the health needs of the community.
There were others who were specially assigned to operate in the courts of chiefs.
Of course, given the rudimentary nature of healing at the time, it might well be that successful outcomes of their diagnosis and treatment were few. Nonetheless, they were highly respected in their communities.
Historical records show that the several European explorers, traders and missionaries who visited the coast between 1471 and 1878, did not interfere with the customary and healing practices of the people.
In any case, most of them died in the first 6 months of their arrival. Europeans in other parts of the West African region suffered the same fate giving the region the accolade ‘Whiteman’s Grave.’
THE COLONIAL PHASE
When Britain formally took over the administration of the Gold Coast from the Dutch in 1844, they first established a health system that administered to the medical needs of Europeans only.
A European health officer was thus stationed in the Elmina Castle for this purpose.
THE PERIOD OF COLONIAL EXPANSION.
From the 1870s onwards, the British abandoned their separatist care policy and extended medical services first to indigenes in the colonial civil and security services and later to the local population.
This new policy was necessitated by the expansion of European commercial and missionary activities into the hinterland. The thinking at the time was that promoting the health of Europeans was not possible as long as the local people were not covered by the health service.
However, the indigenes resisted their incorporation into the new medical system.
They opposed being taken of by ‘strangers’ instead their kinsmen and women in times of ill health.
They also opposed being quarantined far away their homes as was done in cases of contagious diseases.
THE PERIOD OF COLONIAL EXPANSION
Thus, in 1878, the colonial administration issued the Native Customs Regulation Ordinance banning traditional medical practice and other local customs that offended European sensibility. These included firing of musketry at a chief’s funeral and initiation rites such as dipo practised by the Krobo.
The missionaries supported the move by the colonial administration and threatened to ex-communicate all members who visited traditional healers.
To supervise the converts, the missionaries resorted to ‘salemization’ where Christians lived separately in or outside the community.
The first hospital was built in Cape Coast around 1878. Cape Coast was the capital of the colony before the capital was relocated to Accra.
As European missionaries and traders travelled inland, they established schools, churches and health posts. They gained many converts through these facilities.
They also spread new diseases such as venereal diseases and tuberculosis.
The height of the expansion occurred in 1901 when Asante was defeated in the Yaa Asantewaa War leading to the exile of Prempeh I to Seychelles Island.
Most importantly, however, the defeat of Asante extended the territories of the colony and this was followed by the annexation of the northern territories in 1901.
By 1901, Western medical culture had gained roots in the colony. This was because:
Western education and Christianity had been accepted by a fairly large number of people;
Western medical treatment had proven more effective in the treatment of malaria and other parasitic and infectious diseases.
A few health centres had been established in parts of the country to deal with health problems
THE NORTHERN PROVINCE
The colonial expansion did not benefit the northern regions because basically the colonial administration did not find any resources worth their while.
Consequently, the region was designed to produce labor for industrial concerns in the south.
The shape of the country’s rail network attests to this ‘northern neglect’ which has continued to this day.
The first World War (1914-1918) slowed down the activities of the colonial administration in the Gold Coast. However, within the period a few rural health posts/dressing stations were established in the rural areas, mainly in the south.
Mining and a few logging companies also established their own health centres.
These health centres were often located in areas with considerable number of Europeans.
Eventually, these areas also became urban centres for which reason, they were provided with social infrastructure such as markets, waste disposal sites, storm drains, roads, etc.
The early beginnings of the current Ministry of Health may be traced to 1901 when the colonial administration began to focus on environmental issues in the colonies.
Although colonial medical health care was meant to address the health needs of the people, its main focus was on public health because it was felt that most diseases had their origin in the poor environmental conditions prevailing at the time.
In 1909, therefore, a ‘Sanitary Branch’ was established with wide-ranging responsibilities.
Inspecting markets and abattoirs;
Clearing bushes and larviciding stagnant waters with DDT as part of mosquito control;
Cleaning public latrines and clearing waste;
Nuisance abatement, etc.
This period saw a large scale provision of public toilets and water stand pipes in various communities, especially in the urban areas. These were provided free of charge.
Unfortunately, this dept died soon after independence because the nationalist gov. was more interested in building health centres which were in short supply. More on this when we discuss sanitation issues in Ghana.
EXPANSION OF HEALTH FACILITIES
Between 1920 and 1957 health centres were built all over the country increasing the number of gvt hospitals from 17 to 40.
Most of these centres were in the urban areas of the Gold Coast.
The health problems at the time were mainly environmental, parasitic and infectious – malaria, yellow fever, worm infestation, yaws, tuberculosis, sexually-transmitted diseases, leprosy, cholera and malnutrition, measles and whooping cough among children.
The most remarkable achievement in health in the colonial era was the building of the Korle-Bu Hospital in 1923 to serve as the model for a general hospital for the Gold Coast and a research centre for tropical diseases. It was meant for use by Africans, mainly.
Korle-Bu attracted people like the famous Japanese researcher, Hideyo Noguchi who arrived in the Gold Coast to research into yellow fever. Unfortunately he died of the disease in 1928. Today his statue stands in the Hospital.
EXPANSION OF HEALTH FACILITIES
By 1951, the Ministry of Health had taken root and had begun to put colonial health policies and practices in their right perspectives.
These included mass vaccination, environmental sanitation and curative care.
Today, the Ministry of Health is one of the important arms of Ghana government with overlapping roles which extend to other departments and ministries.
At independence, Ghana inherited the colonial health infrastructure but built more health centres.
The new state placed more emphasis on curative medicine although like the colonial administration, it continued with public health measures such as mass vaccination and domestic mosquito spraying and larviciding of stagnant waters.
It became clear to the new nationalist gvt that although the nation had the economic capacity to expand its health services, its colonial capitalist orientation was preventing many from accessing health care.
Therefore, a massive health infrastructural development was to follow while the responsibility for environmental sanitation was given to the Ministry of Local Government.
INDEPENDENCE AND AFTER
So, in 1964, the socialist government declared education and health services free of charge
With respect to health services, gvt medical practitioners were prevented from engaging in private practice; they were paid allowance in lieu of that.
Although private practice not banned, the gvt did not encourage it either.
The new health care policy placed heavy burden on the national economy. And coupled with the fact that the gvt had declared itself socialist , the economy was sabotaged by the NATO pact allies championed by the USA. Cocoa price on the world market drastically fell. In no time, the nation’s economy began to suffer and the health sector began to deteriorate. In 1966, the first gvt was overthrown as a result of mass discontentment and political repression.
However, the state’s policy towards free health care remained unchanged till 1969 when a new civilian administration (Busia) was voted into office. This new administration proposed a graded system of payment for health care.
However, this system was not implemented because the government was also overthrown in 1972.
THE LOST DECADE
In development circle, the period between 1970s and 1980s is known as the ‘Lost Decade’ for Africa because the period was characterized by severe economic difficulties and near collapse of national economies following a steep rise in the price of crude oil on the world market .
Consequently, in Ghana, almost all sectors of the economy collapsed. Thus, on the advice of the World Bank and IMF, the government sought to revive the sector by introducing cost recovery measures.
In the economic logic of the IMF and World Bank, it is foolish for a nation to invest in any sector if no profit can be shown for that. Investing in health and education, for instance is therefore a foolish venture!
Secondly nations have no business running economic enterprises; these must be left to the private sector while govt provides the necessary political and social space for private businesses to operate.
For Ghana, this new development meant that over 350 state owned enterprises (SOEs) had to be sold to private individuals or be made public-private partnerships (PPP).
Consequently, industries such as State Hotels Corporation; State Gold Mining Corporation; Ghana Publishing Corporation; Ghana Meat Marketing Corporations; Ghana Airways, etc were all sold.
THE ‘DEATH’ OF A NATION
Therefore, in 1985, the ‘Cash and Carry’ system was introduced. This had severe negative impact on utilization of health services and on the health of the people leading to the introduction of safety-net measure known as PAMSCAD.
This was meant to assist children under-5, the poor and the elderly who had no means to address their health needs.
From 1985 to date, the most radical health policies have been the introduction of the NHIS and the free maternal care for women in Ghana. However, due to political and economic reasons, these policies are not fully on the ground.
However, what is important to note is that since the colonial period, how much the state should spend on health care has been a debatable issue. Even the Constitution is not very explicit on this. Following the fall of the Wassaw Pact countries led by the Soviet Union in 1989, the world is now witnessing unipolar economic system based on market forces.
This in turn has given rise to unprecedented economic liberalization with huge private participation in every sector of the economy. For instance, before 1990, private universities were unthinkable in Ghana. In a way, this has also affected the traditional medicine sector.
With regard to traditional medicine, the first gvt departed from the colonial position by actively encouraging practitioners to form a national association which came to be known as the Ghana Psychic and Traditional Healing Association (GPTHA).
This association was so close to the corridors of power that when Nkrumah was overthrown in 1966, the association was sidelined.
Today, the state is actively promoting the use of herbal medicines and private individuals – both charlatans and non-charlatans- have taken advantage of the situation.
The global economic changes affected not only the quantum of resources a nation must spend on health, but also how it must structure its heath care delivery system.
In 1978 WHO and UNICEF organized a meeting at Alma-Ata (in the former USSR but now in Kazakhistan) to discuss how to assist developing countries to provide health care to their people. This meeting led to what came to be known as ‘Primary Health Care.’
To bring health care to the doorstep of the people;
To make health provisioning cheaper by infusing local resources;
To allow local people to participate in health provisioning; and
To empower people to deal with their own health problems.
HIGHLIGHTS OF HEALTH POLICIES
These historical developments have led to a situation where the state is the main health care provider.
It is assisted in this regard by
Many missionary hospitals
Private medical facilities
A chain of private pharmacies, chemical shops, medical laboratories; and
THE STRUCTURE OF GHANA’S HEALTH CARE DELIVERY SYSTEM
LEVELS OF PUBLIC HEALTH CARE
Another development is that public sector health service is classified into levels as follows:
Level A refers to regional hospitals
Level B refers to district hospitals
Level C refers to sub-district hospitals
Level D refers to Community-based Health Planning and Services (CHPS). These are compounds built in communities where nurses stay to provide health care to the local population.
Teaching hospitals, private hospitals and specialized health care centres such as leprosaria, communicable diseases hospitals, etc are not part of the classification.
LINKAGES AND SUSPICIONS
The link between public health care system and private practitioners is weak because of the socialist policies of the first republican government.
Gvt doctors cannot officially refer patients to private health care facilities but the vice-versa is permitted.
There is weak linkage among private practitioners
There is no formal link between public and private medical practitioners on one hand and traditional healers on the other because of antagonism shown by doctors towards healers.
There is no networking among traditional healers beside their membership of their national associations.
Two important effects of this weak linkages is the underutilization of health facilities and the lack of adequate and up-to-date statistical figures to enhance policy formulation
It has also led to poor supervision of health facilities.
The structure of the present health care system can be understood against the backdrop of history and political and economic factors.
The weak linkages among the various health care systems can also be explained in similar ways.
Ultimately, the poor health status of Ghanaians can be traced to historical, political, economic and to the demographic characteristics of the people.