“Nothing is more harmful to the service than the neglect of discipline; for it is discipline more than numbers that gives one army superiority over another” George Washington
Discipline is the quality of being able to behave and work in a controlled way which involves particular rules or standards. In other words, discipline is the practice of making people obey rules or standards of behaviour and meting out approved penalty or punishment to those who go against such rules. The 1992 Constitution of the Republic of Ghana in Article 190(1) provides for the establishment of the Ghana Health Service (GHS) to improve efficiency in health care delivery in Ghana. Pursuant to that, the Ghana Health Service and Teaching Hospitals Act, Act 525 of 1996 was enacted to pave way for the establishment of the Ghana Health Service (GHS) and the Teaching Hospitals (THs) as major implementing arms of the public health service in the country. The GHS was officially launched in 2003. Other subsidiary instruments and regulations passed to improve efficiency and discipline by the GHS include the Code of Conduct and Disciplinary Procedures (2003), the Code of Ethics (2003), the Patient Charter (2003), the Employee Handbook (2008), Handbook on Customer Care (2009) etc. But has the Ministry of Health/Ghana Health Service been able to stem the tide of indiscipline with these regulations and instruments? Consistent with the general practice in Ghana, GHS is very good at making excellent rules and regulations but very weak at enforcing them. If as little as twenty percent (20%) of all these rules were enforced rigidly as intended by their framers, the country would have been experiencing some modicum of discipline in the Service.
Indiscipline in Ghana Health Service has manifested itself in many ways. It is an open declaration that some staff of Ghana Health Service have very poor attitude in service delivery. Though the staff of GHS are highly skilful, their attitude toward work and notably patients is undesirable. Ironically, the logo of GHS portrays the handling and treatment of patients by GHS staff like the way one would handle an egg (delicately). The GHS motto reads; “Your Health: Our Concern”. Wow! Do we see or experience largely these intentions or values in GHS facilities? An emphatic no would be the answer! And do not think the poor attitude exhibited by the GHS staff is targeted at only non-GHS staff. There are many examples where both senior and junior level personnel of GHS have suffered in multiple doses of the poor attitude from their own colleagues. The poor attitude or client service, which is systemic and inherent, is exhibited at all levels of the Service. There is evidence where a former Director of the Regional Hospital of the Eastern Region, Koforidua introduced himself and pleaded with a nurse to try and find a bed for his mother at the Korle-Bu Teaching Hospital. The nurse retorted, “So do you want me to go to my house and bring my bed to give to your mother because you are the Medical Director of the Koforidua Regional Hospital?” The man was reported to have wept uncontrollably in the full glare of other patients and staff because of this highly insensitive remark. An African proverb says that “if a crocodile eats its own eggs what will it not do to frogs and fishes”. Therefore, what happens to the ordinary patient like you and me is left for you to imagine.
But what do you think happened to this nurse? Nothing! Would the same nurse have said the same thing at a Private or Christian Health Association of Ghana (CHAG) Hospital and walk away freely? She would not dare! So why would this happen freely in the nation’s premier Hospital? Meanwhile the Patient Charter; which espouses the rights and responsibilities of patients states inter alia “All staff shall treat all patients humanely” Were these documents made to gather dust on our Medical Superintendents’ and Administrators’ desks?
Another clear manifestation of indiscipline in MOH/GHS is refusal of some staff to accept posting to needy and deprived communities in the country. In Ghana today, the issue is not about inadequate number of staff, it is about inequitable distribution of staff. Indeed, Accra and Kumasi alone have about 71% concentration of all public service medical doctors (GHS Annual Report). The GHS Code of Conduct and Disciplinary Procedures (2003), states that “Refusal to accept posting” is a major offence. Meanwhile, every year staff notably doctors posted to regions (not only the Northern and Upper regions) refuse to accept posting and virtually nothing is done to them. Early in 2012, seven doctors were posted to the Eastern Region and only one reported. When the one who reported was told she would be posted to the Oda Government Hospital, she was reported to have said she would go and consider it. As at the time of writing this piece (August 2012), I assume she is still considering it and collecting salary for only thinking about whether to accept the posting or not. As for the other six doctors, I presume they are still in Accra if they had not left the country and getting all the niceties just like a doctor in Zuarungu in the Northern Region. It will be naive to think that these doctors will all leave for the private sector; they certainly will find a place in Accra or Kumasi on government payroll because they know someone who knows someone in high places and will sacrifice the utility of these doctors if they had gone to the places where their services would be most needed.
I do admit that there are challenges in accepting posting to certain areas in the country. But would such officers refuse to accept posting if they were working for the banks, military, private hospitals, churches, etc? No! Because, discipline is hallmark of such facilities.
It is noteworthy that recent proliferation and mushrooming of private clinics, diagnostic centres, maternity homes and pharmacies could partly account for the high level of indiscipline in MOH/GHS. Following the implementation of the National Health Insurance Scheme (NHIS), there has been an unprecedented increase in the creation of private health facilities in Ghana most of which are poorly regulated in their location and operations. The MOH/GHS has an objective to have a health facility within an eight kilometre radius. The government and the churches have been very complementary in this direction. As a matter of fact, government does not create any district hospital where there is a capable mission facility. Examples include Holy Family Hospitals in Nkawkaw and Techiman, Presby Hospitals in Agogo and Berekum.
Lately, however many private hospitals and clinics have sprung up, some as close as 50 metres to government health facilities. Worst of all, most of them are accredited by the NHIA. Whilst this development generally could lead to apparent increased competition with the patients being the greatest beneficiaries due to improved service, it also comes with its concomitant indiscipline which could manifest in pure conflict of interest situations involving GHS staff. Most of these private health facilities are owned and operated by government health professionals. Whilst an employer does not and cannot determine how an employee should use his/her spare time, it can be said without any dispute that some of these facilities are run at the time these professionals are required to be at post in the government facilities. Additionally, most of these professionals direct and refer patients to their private facilities which would benefit them personally.
Similarly, other staff gravitate toward these nearby private facilities in the name of locum service. Government loses in two main respects; first, loss of time in respect of professionals who should have been performing their duties in government hospitals as well as divulging of business secrets to private facilities and loss of revenue to government hospitals. Secondly, the National Health Insurance Authority (NHIA) pays more claims because patients hop from one facility to the other frivolously once they are close to each other and he/she does not make any direct payment. Furthermore, tariffs paid to private facilities are generally higher than government health facilities. The questions to ask are: is the Private Hospitals and Maternity Homes Board up and doing its work? Why would the NHIA defy the objective of the Ministry of Health/Ghana Health Service and accredit facilities as close as 50 metres to each other? Is GHS sleeping or pretend to be sleeping on conflict of interests cases which are reaching gargantuan proportions? Or those to take action on staff indulged in conflict of interest offences are by themselves smeared with the same offences?
Most of us thought the introduction of the NHIS would completely ward off illegal fee collection in government Hospitals. This is far from eradication. Whilst it is almost negligible and near extinction in the mission and private facilities, this canker is still seriously gaining roots and festering in government health facilities. Meanwhile, the GHS Code of Conduct and Discipline Procedures (2003) states that “improper demand or collection of unauthorised fees” is not just an offence, but a major offence. Staff brazenly demand and collect illegal fees from both insured and non-insured clients and get away with it. There are instances where health professionals tell the patient that in order to expedite the service he/she will have to charge extra which is not catered for by the National Health Insurance Tariff and they collect these monies for their own selfish gains. More examples abound. Finally, misdirected or wasteful spending or poor prioritisation is also a manifestation of indiscipline in most of GHS facilities. Do not be surprised to walk into government health facility and see an ambulance “on rocks” because there are no tyres and the managers of the facility go to buy laptops to “Facebook” themselves. Oh! Health professionals are fond of laptops. A walk through some hospitals may arrest your appetite for food for hours because some of the facilities are in such squalid condition. In some cases you dare not go to their mortuaries, for you may not sleep for a week. I wish to state without any doubt that if government facilities are run well, they would be as attractive and efficient as private facilities. The margin of difference on the tariffs between government facilities and private facilities is not so huge but the private facilities pay salaries to their staff whilst government facilities salaries are paid by government. So why is it that some private facilities are more efficient than government facilities? Financial indiscipline in government facilities is the answer. There are serious non-prioritization of spending, pilfering of resources, diversion of materials and supplies, and gross abuse of vehicles in state owned health facilities since in Ghana people will be brave to ask “is the hospital for your family?”
What could be the cause(s) of this high level of indiscipline one may ask? I would identify only two but I believe those two causes alone if tackled would address about eighty percent if not hundred percent of all the scenarios of indiscipline cited above and those not even mentioned: i. First is the centralization of hire and fire decisions: Henri Fayol, arguably the doyen of modern management, postulates in his fourteen principles of management, the necessity of authority and responsibility. The manager of a typical government hospital does not have full authority to hire and fire staff except casual and temporary staff. Modern human resource management practice requires that you recruit for attitude and train for skill. In other words, it is easier to train staff who have the right attitude for any skill than to hire staff with the right skill but with the wrong attitude. This makes sense. What use will it be to have a very skilful doctor or nurse who has the wrong attitude? Who walks out on patients because one patient has annoyed him or her? Attitude it is said, is everything. Therefore, as staff are hired and fired (which never really happens) centrally, loyalty and allegiance to local authority is negligible if not difficult. It is said that civil and public servants are like headless nails, because they find it easy to get into the wood but are difficult to remove.
If becoming a service (Ghana Health Service) cannot address a basic human resource principle of decentralizing hiring and firing decisions, then it would be difficult to move forward. Vacancies in Ghana Health Service should be advertised at the local level. In other words the Item One (salary budget) should be decentralized to the district level for decisions on hiring and firing to be taken at those levels. 2. Leadership of Ghana Health Service is very weak especially lately. I have an eerie morbid fear for the future of Ghana Health Service because I do not see evidence of transformational leadership now or in the near future. The above manifestations are sufficient proof of poor or weak leadership in MOH/GHS. An Akan proverb says if a fish would go bad, it starts from the head. It is equally said that “leadership is cause; all other things are the effects of leadership”. Most, if not all the above issues listed would not occur in good leadership environment. There has been no substantive Head of the Service for more than a year and the same thing for almost half of the directors at the GHS headquarters. How would a seemingly headless class of people behave?
It is worthwhile to conclude this piece with George Rathmann’s thinking. According to George Rathmann(1980), the culture and philosophy of every organization is characterized by two main axioms: discipline and ethic of entrepreneurship as shown in the diagram below.
The Good-To-Great Matrix of Creative Discipline
Hierarchical organization
Great organization
Bureaucratic organization
Start-up organization Low High Ethic of Entrepreneurship
This diagram shows that if you have low culture of discipline and low ethic of entrepreneurship, this gives birth to bureaucratic organization. High culture of discipline and low ethic of entrepreneurship will produce hierarchical organization. Organisations which have high ethic of entrepreneurship and low level of discipline are start-up organizations. But high culture of discipline and high ethic of entrepreneurship would yield great organisation.
From the foregoing discussions, it is easy to say that MOH/GHS is a bureaucratic organization: Low discipline, low ethic of entrepreneurship. Rathmann underscored that, the purpose of bureaucracy is to compensate for incompetence and lack of discipline, a problem that largely goes away if you have the right people in the first place. Most bureaucratic organizations build their bureaucratic rules to manage the small percentage of wrong people in the organizations, which in turn drives away the right people from the organization, which then increases the need for more bureaucracy to compensate for incompetence and lack of discipline, which then further drives the right people away and so forth.
Rathmann also understood an alternative exists: Avoid bureaucracy and hierarchy and instead create a culture of discipline. When you put these two complementary forces together-a culture of discipline with an ethic of entrepreneurship-you get a magical alchemy of superior performance and sustained results. The need for a high culture of discipline is needed now than ever in the history of Ghana Health Service. The public health service is menacingly ebbing into an abyss of no return and the time to act is now. An industry like health service should maintain the highest level of discipline, even higher than that of the military. The decisive, dynamic and purposive leadership provided to the Ministry/Service at some time ago by the likes of Commodore Steve Obimpeh and Prof. Agyeman-Badu Akosa truly moved the Service forward and in the right direction. We need such leaders now, because our health is more important than anything else. We cannot neither meet the health Millennium Development Goals with this inherent high level of indiscipline nor reach the standards of the US, UK or Cuba in health service delivery if things continue this way. Jim Rohn says, discipline is the bridge between goals and accomplishment. So without discipline nothing meaningful can be accomplished.
Writer: Francis Dondomeso-Soglo, francisdondomesosoglo@yahoo.com Boston State University, MA USA.
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