Health News of 2013-12-03

Reflections on first Health Quality Forum

The above ended Thursday in Accra. As a physician trained in quality, I followed it keenly. While commending Ghanaweb, convener Dr. Boateng and the speakers, I think the forum underachieved. If quality was a disease, one could say that there was a lot of talk about diagnosis and little done about treatment for the disease.

Candidly, it would have benefited from a few other speakers—like the very practical Dr. Kwabena Opoku Adusei, President of Ghana Medical Association, Dr. Appiah Denkyira of the Ghana Health Service and a representative of the nursing profession.

Dr. Boateng started by cautioning that the health forum was not meant to criticize anyone and then went on to chastise doctors by stating that, “we are not meeting the needs of patients, having effective communication to help uplift healthcare delivery in the nation and for this to happen, doctors should be responsible for what they do to patients.”

Dr. Atikpui of the Medical and Dental Council outlined how the council keeps out of practice unqualified doctors and quacks and did a fine job. However, given the forum and its purpose, he should have addressed how the council can help increase the number of practitioners in the country.

Prof. Frimpong Boateng was, perhaps the most substantive of the speakers. He made 3 crucial and valid points:

Expenditure on health per capita as at 2011 is USD 90 while the global average per capita spending on healthcare spending on health is USD 948.

Currently, Ghana has 2,700 doctors and this leads us to a doctor to patient ratio of 1 to 10,000. It is a fact that we need 48,567 doctors to have a ratio of one doctor to 500 patients.

Basically, system failure is responsible for Ghana’s poor healthcare delivery. It is a fact that Ghana is technologically challenged and therefore, it will continue to have a ripple effect on the nation’s healthcare system.

To buttress those points, despite a promise by African leaders in 2001 to commit 15% of their budgets to healthcare, Ghana will spend just about 4.8% on its 2014 budget.

Furthermore, the ratio of Doctors to patients that the professor cited is worsened by the skewed distribution of doctors-with just about half of them in Accra and Kumasi.

The Minister of Health, Honourable Sherry Ayittey, expressed her disappointment at the ill-equipped hospitals, unaccommodating nurses and undisciplined healthcare specialists who often get away with their unprofessional actions.

According to Ghanaweb, the Minister stated that, “The lack of assurance of quality stems from several factors, some of which do not fall directly in the health sector. Neglect of road infrastructure, lack potable water and the general lack of appreciation of basic principles of health and diseases, contribute a great deal towards the low levels of quality in healthcare delivery.” The Minister concluded by charging participants to help design a “workable solution” to help improve healthcare. She had nothing to say about government inaction and no bold solutions of her own to offer.

Frankly, I wish that in addition to the ideas he offered, Prof Frimpong Boateng had answered the following questions for the audience: What quality initiatives did he launch during his tenure as CEO of Korle-Bu? What were the outcomes? What did he learn from the process?

I would love to hear similar answers from Prof. Akosah about his tenure as Director General of Ghana Health Service.

It would appear that one of the fundamental obstacles to quality healthcare is that we do not have enough doctors and nurses. Yes, nurses. Without enough nurses and lab techs and other staff, it will be difficult to improve anything. With apologies to Minister Ayittey and Dr. Boateng, it is hard to get high quality professional service from overworked and underpaid doctors and nurses.

While working in Cape Coast, I learned that while the three hospitals there lack sufficient nurses to staff them, there are about three hundred or so nurses who are studying for advanced qualifications at the University of Cape Coast. Requiring ten hours of nursing work per week from each of these nurses would provide 3,000 hours of nursing per week and solve the nursing shortage in the Cape Coast area overnight.

On the physician side, most people agree that there are probably between 5 and 10 thousand highly qualified Ghanaian physicians in the Diaspora. Whenever they attempt to offer services on a temporary basis, they are met with bureaucratic obstacles by the Medical and Dental Council.

Registering them en mass and mobilizing them to volunteer for short periods will significantly improve the care we provide patients. If in a year, one can get 1000 Ghanaian doctors abroad to volunteer for two weeks each, it would amount to 80,000 physician hours per year in addition to whatever our local doctors can do. It will help the local doctors learn and encourage the diasporans to think more of home.

Certainly, if we can let Cuban doctors who are not as well-trained and do not speak our language to work in Ghana, we can find ways of getting our own to work. This is what the government and the Medical and Dental Council should be discussing. What I just described can be applied to nurses and pharmacists and indeed many other professionals in the Diaspora.

Our labs, which were hardly mentioned, are unreliable and poorly supervised. Labs that in the US can be done in hours take days to do and to result in Ghana. I once received labs containing Sodium of zero for a living patient, reported two days after the sample was taken. To compound this, there are frequent breakdowns of lab equipment with repairs from a company contracted by the Ghana Health Service taking weeks at a time.

While technology matters, we should focus on appropriate technology. In Cape Coast, it was routine to find patient charts missing within weeks of their discharge. It was rare to obtain any records from other health facilities. Supplying fax machines to every hospital and circulating the numbers would significantly improve communication and the quality of care while costing very little.

While on technology, sometimes we can spend a lot of our scarce resources unwisely. While the Cape Coast Teaching Hospital lacked a mobile X-ray machine to take X-rays of critically ill patients in bed, plans were far advanced to procure a CT scanner and an MRI. While a CT scanner would improve care, it must be preceded by a mobile X-ray and a Pulse Oximeter for every ward. That would be applying prudence to the issue of quality.

In addition, while technology improvements are needed, they must be maintained. A couple of years ago, 9 out 11 Ventilators acquired for the Komfo Anokye Teaching Hospital were allowed to break down and lead to deaths before a crisis meeting was called. In the end nobody was reprimanded or sacked. It does not matter how good the equipment is if it cannot be maintained responsibly.

A journey of a thousand miles begins with one step. We can and should start tackling quality now.

By Arthur Kobina Kennedy, MD, MSc, BSc.