Fri, Oct

Unpicking our way out of Health Delivery Stagnation

Thoughts From Afar
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As it is said, countries don’t attract what they want but what they are. Therefore, though we claim to want quality health care, we as a people have failed to invest our thinking into how to convert this wish into a need.

 According to A.A. Milne, “The third-rate mind is only happy when it is thinking with the majority. A second-rate mind is only happy when it is thinking with the minority. A first-rate mind is only happy when it is thinking.” Throughout history, it has been known that thoughts and not our wishes, build a nation. In “As a man thinketh” James Allen argues, “A man is literally what he thinks, plans and acts upon.” In essence, outcomes are indicative of plans, actions and or inactions of yesteryear.

Last week, the Director of Policy Planning Monitoring and Evaluation (PPME), Ministry of Health, Dr Emmanuel Odame, revealed that a holistic assessment of Ghana’s health sector over past three years (2014, 2015 and 2016) shows a stagnating performance. For some of us, who have been looking at the health data for Ghana over the years, this wasn’t a surprise. In fact, coming from a technocrat involved in our health policy, I for one saw this as a tacit acceptance that we were retrogressing and radical measures based on a change in direction are needed.

For a country with a population growth rate 0f 2.2% and improving life expectancy, if care is not taken we will find in the next decade that we are incapable of managing our disease burden. Since 2010, many who work in the area of international public health have been raising red flags about the failure of countries in sub-Saharan Africa to invest in primary health and the inherent risk this carries. Yet, we have failed to heed this advice preferring instead concentrate our resources on secondary and tertiary care whilst politicising the provision of primary care.

Every situation in life is a culmination of thought, planning, action and effort. A look at our approach to primary healthcare provision indicates that our thought process has been hit and miss. To start with we have failed to harness technology as a leverage to reach the furthest parts of our country. We have continued to rely solely on mechanical and pseudo-analogue models and limped on in the process. Concepts like the Community-Based Health Planning and Services (CHPS) were politically exploited to the point that some were even built without adequate involvement of the Ghana Health Service and local communities. Consequentially, many have been abandoned with some becoming zones for open defecation, hideouts for hoodlums or shelters for squatters.

With those in operation, a failure of a linked in thinking to ensure that there was adequate communication using at least the mobile phone to liaise with better-resourced district hospitals meant they are stand-alone facilities with extremely limited ability. This coupled with a lack of health human resource numbers and little by way of motivation means our action and effort have failed to match up with the initial thoughts. Hence, primary health care has seen marginal benefit from this concept.

Unfortunately, we cannot continue this way. An article in The Economist Magazine in August 2017 highlighted the changing face of Africa’s disease burden. It indicated that whereas in 1990 only 47% of this was due to chronic disease, by 2020, this would have changed to 70%. This shift can be seen with data on Ghana’s disease burden too with conditions like hypertension, diabetes, arthritis, coronary health disease etc. becoming increasingly common. The financial implications of this and the impact on our personal quality of life cannot be underestimated. To start with, these diseases required lifelong treatment and a commitment by individuals or the nation to monthly expenditure on medicines. There also has to be a commitment to routine medical reviews, lifestyle adjustment and exercise regimes all of which cost money. These costs will be in addition to the cost of treatment of infectious disease like malaria that will continue to affect us.

To deviate from our current approach will first require an understanding of how we got here. For over sixty years our health strategy has been based on improving life expectancy based on dealing with infectious diseases and the leading causes of mortality and morbidity. Hence most donor support was channelled towards programs like decreasing childhood mortality and roll back malaria. To some extent, we have achieved some success in these areas. Between 1988 and 2014 infant and under five years mortality was virtually halved from 77 death per every 1000 births to 41 per 1000, with the biggest decreases occurring in the rural areas. Likewise, diseases like guinea worm were eradicated in 2011 and malaria though still prevalent is not as devastating as it used to be. All these have been achieved with a ballooning wage bill in the healthcare sector with over 58% of the total health expenditure spent on staff remuneration. In essence, we seemed to have thrown most of our healthcare financial resources at our problems without pausing to look at the relevance of some job roles in this era of technological abundance. Hence till this day, positions like typist, messengers etc. are still found in the health sector. This cannot be sustained and must be curtailed.

Important as these successes may be, they exposed us to a new reality too of more people in the rural areas especially living past age 40. A point at which wear and tear of body organs, sedentary life and dietary changes led to the emergence of disease that hitherto was believed to be the preserve of the urban dwellers. Thus, there opened a new medicines procurement avenue for chronic disease products which also lacks transparency and is subject to considerable sleaze, putting further strain on merger financial resources.

Unfortunately, our public health planners seemed to have been oblivious of this and have paid little attention to the need to innovatively invest in primary care to ensure these new diseases were identified early and managed properly at the outset to prevent complications later. Not even the occurrence of many unexplained sudden deaths amongst the middle age population raised alarm bells. In fact, a lot was superstitiously blamed on witchcraft and sorcery. Being a country that frowns on postmortems, it was very difficult to educate the population on the actual cause of these deaths. Hence the failure of planning was covered up by a mirage of supposed lack of informed knowledge.

As it is said, countries don’t attract what they want but what they are. Therefore, though we claim to want quality health care, we as a people have failed to invest our thinking into how to convert this wish into a need. In effect, the quality of our healthcare has teetered on the brink and not matched up to our wishes. This is what has to change and pretty soon. If we accept our current circumstances is a culmination of failure of thought, failure to act, over politicisation of the health sector and a failure of effort; then we should be able to reverse these components and ensure that the generation that comes after us inherit a healthcare system that reflects today’s aspirations and is devoid of the mediocrity many aspects of our lives have become characterised by.

We should not be scared of embracing technology. In my view, it is where the missing link is.

With the help of public-private partnership, encouragement of social entrepreneurship in the area of health and a positive drive to automate most of our health systems we would considerably decrease the wage burden, improve healthcare access, cut down procurement sleaze and waste, improve health efficiency, improve health and safety at work, minimise risk, upskill health sector human resource and create more jobs than what will be lost that are more reliant on the private sector.

To the likes of Dr Odame, my parting comments will be, speak up more, think more, encourage citizen and patient participation in any discussions to reverse the identified stagnation and be prepared to embrace ambitious blue sky thinking. That we are where we are should be the best indicator that officialdom is not the custodian of all knowledge in improving the quality of health for Ghanaians. My belief is we have more than enough to what it takes to think and act our way out of this cul-de-sac.


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