Tue, Feb

The Strong Link Theory; The Heart of Our Healthcare Equality Failure

Thoughts From Afar
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In defence of our current strong link approach, some keep saying health care professionals are unwilling to go out of Accra or Kumasi but fail to realise we skew the law of natural selection towards attracting them to the centre by taking a strong link approach towards healthcare policy.

In 23 Things They Don't Tell You about Capitalism, this favourite quote caught my attention, “Equality of opportunity is not enough. Unless we create an environment where everyone is guaranteed some minimum capabilities through some guarantee of minimum income, education, and healthcare, we cannot say that we have fair competition. When some people have to run a 100 metre race with sandbags on their legs, the fact that no one is allowed to have a head start does not make the race fair. Equality of opportunity is absolutely necessary but not sufficient in building a genuinely fair and efficient society.” Ha-Joon Chang

In football what matters is how good your worst player is compared with the number of star players a team has. If your worst player gifts a goal, as happened twice to Liverpool in the recent UEFA Champions League final, you are toast. Football is a weak link game. Hence irrespective of how versatile Messi is, in a weak link team he will be mediocre. A similar situation occurs in the aviation world. It is often better to correct the anomalies at the weak link hub airports where the most airline delays occur, than to improve the sleekness of the well-oiled hub airports. Aviation efficiency is limited by how good the worst hub airports where the most delays occur are.

This weak link principle can be applied to healthcare too, especially in less endowed nations like Ghana. Data on our life expectancy indicates that we seem to have stalled in the mid-sixties since 2000. Though the life expectancy of the upper middle class seems to be increasing, the rate of mortality for the middle class and lower middle class has stalled. Even worse is the fact that the working class are tanking and their life expectancy is stalling or even depreciating. Hence on the law of averages, our life expectancy is failing to improve significantly. If anyone wants evidence of this, have a look at the unsightly obituary ”gone too soon” posters that litter many gyratories in our villages, towns and cities.


Though Ghana’s healthcare problems are a weak rather than a strong link phenomenon, our healthcare policy and expenditure indicates we do not appreciate this reality. Data available from the Human Development Report indicates that though our total health expenditure as a percentage of GDP has increased since 2010 to the current 7.2% in 2017, the percentage spent on teaching, regional and district hospitals has been 55% with more rural hospitals receiving 45%. This indicates that we are still keen on upgrading the superstars without realising our current healthcare problem lies with the worst players in our healthcare delivery team, facilities in the hinterland.

More importantly, our health mortality and morbidity statistics have also undergone a paradigm shift in the last two decades too. Gone are the days when the leading causes of mortality and morbidity were communicable diseases like malaria, dysentery and tuberculosis. Current evidence indicates that strokes and coronary heart disease are the top two causes of mortality and morbidity. On the world stage, Ghana ranks eleventh as the most likely place to die from a stroke. This situation needs urgent addressing, especially when most who get these conditions in the hinterland stand little chance of getting to the district or regional hospitals, let alone teaching hospitals before they pop their clogs. Addressing this will require a significant investment of expenditure that will challenge the strong link theory.

Capitalism and Reverse Healthcare

This change in mortality data is the best indication that our strong link approach towards healthcare expenditure is madness. We seem too fixated in the belief that catering for the glamour of Accra, Kumasi, and Takoradi etc. makes us look good. However, this only indicates our lack of understanding of the changing face of healthcare and its overall impact on our countries development. This call for a change in expenditure approach will not be easily accepted by the strong link institutions though. Especially when they have the most health professionals with clout and have the loudest voices too.

But wait a minute, should loud noises drown the evidence? Surely not if you ask me. Let’s not forget that healthcare outcomes are dependent on early intervention, diagnosis and clear treatment plans. In a country where the majority of the population are rural dwelling, it is thus not rocket science to identify where the most money should be spent, at the point of intervention. Ironically, we still concentrate on the quality of consultants in our leading teaching hospitals. Ignoring the defenders, midfielders and second strikers who ensure the Messi’s and Ronaldo’s of our country’s healthcare delivery get the right through pass that results in them delivering the needed lethal finishes which in healthcare is treatment outcomes.

Our current President has been on the right side of the debate identifying our country and its problems can only be solved by dealing with our weakest links. Hence his zeal to introduce Free SHS. However, that approach needs to be extended to healthcare and other sectors too. Sadly, this seems not to be the case. In fact, even as the expenditure on health as a percentage of GDP has appreciated, areas like mental health have seen nothing by way of funding appreciation. They are actually worse of year on year. A recent report attributed to Dr Akwasi Osei, Chief Executive of The Mental Health Authority, psychiatric hospitals are likely to start "Cash and Carry” by July this year. Considering that mental health is known to be one of the areas where countries compromise GDP growth due to stigmatisation, this surely can’t be smart.

In defence of our current strong link approach, some keep saying health care professionals are unwilling to go out of Accra or Kumasi but fail to realise we skew the law of natural selection towards attracting them to the centre by taking a strong link approach towards healthcare policy. It’s this obfuscation that leaves us in twists as to how to deal with rural healthcare access. No one should try soliloquising this conversation, for healthcare in our country has evidence of drifts to the hinterlands when the healthcare opportunities are right. The drift to Kokofu and Agogo Hospitals to seek quality ophthalmic care in the 80’s and 90’s when ophthalmic specialist came from abroad points clear to how concentrating on weak links can yield the desired results. Fact is, capitalism doesn’t champion reverse healthcare mobility or the weak link approach because it’s not profitable. Thus the lobbyists who influence our healthcare policy won't highlight the need for this drift. Simply put, such a move doesn't ensure, "it's our time to chop."

I will end by reminding readers that, a criminal society is not only one in which people rob, steal, embezzle and plunder; it is also a society that thanks to inept healthcare expenditure prioritisation, loses its best middle-class workforce just when they are at their prime to contribute their optimum. This is what the strongest link approach has brought to us, people die in their forties and early fifties long before they have contributed their bit and helped with succession planning. Resulting in a perpetual training of new experts and significant losses of human resource. Simply put our model makes us a classic criminal society.

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