Government should take bold and decisive actions to transform the healthcare landscape

Introduction
Ageing populations in the western world is putting unbearable pressure on their healthcare facilities and workforce to an extent that they are effectively bursting at the seams. The response over the years has been to throw in ever larger sums of money and import workers from poorer countries. Even that is becoming unsustainable as waiting lists just to see a healthcare professional are breaking all available records, putting lives at risk. One way of providing a solution to a growing western problem is for emerging economies to develop their healthcare systems to very high standards and attract health tourists for comparable, if not superior care than they would receive in their own countries. Some Eastern European countries, Türkiye, India and China have benefited significantly from this health tourism over the last decade or two. Can Ghana, or Africa do the same?

Prepare to pay more
Healthcare does not come cheap and raising standards several notches up will bite. However, that is a bitter pill we must all swallow in exchange for ‘better health’ of our healthcare facilities, personnel and systems. However, if done well the benefits would be huge and the investment will pay for itself several times over; we will improve healthcare for our own citizens, turn our infamous brain drain into brain gain, improve job prospects and increase our foreign exchange earnings.

Invest in modern healthcare facilities and technologies and above all, personnel

Who would have thought that Ghana, a country so endowed with natural and human resources would have a healthcare system that is itself on life support? Ghana’s healthcare situation leaves many deep thinkers scratching their heads and wondering what happened to the sparkle of the black star!

Compared to her peers, healthcare in Ghana is not doing too badly. However, we could do a lot better, reverse the brain drain and turn the ‘Gold Coast’ into a health tourism destination.

It starts with education. We must educate our workforce, especially healthcare workers to very high international standards and adopt a continuous self-improvement mindset. At the same time regulators should set standards of care and monitor compliance through staff appraisals, patient satisfaction surveys, unannounced inspections and mystery shopping.

Respect for oneself is the key that turns on the engine of attracting respect from yonder. If we can put our house in order, live in a clean environment, have basic facilities that meet minimum international standards and show that we are serious about changing our own image, the world will gradually begin to respect us and gain confidence in using our services, generating much needed tourism revenue. But is it enough to just keep building hospitals?

Developing a good maintenance culture.

Ghana has a notorious reputation of allowing a poor maintenance culture to take hold in all aspects of our lives. Brick and mortar infrastructure, like machines is prone to wear and tear through repeated use. Buildings develop cracks with time, taps malfunction, wastewater pipes lose their structural integrity and become clogged, air-conditioning systems fail, surgical instruments become blunt, lightbulbs burn out, etc. That is why right from commissioning, all buildings and equipment must be assigned a visual inspection and maintenance schedule with mandatory compliance oversight by management. We must not wait until any facility starts falling to pieces before we think of refurbishments; regular inspections for functional and structural integrity must be weaved into our culture. If we did that our flagship hospital, Korle Bu Teaching Hospital wouldn’t be the eyesore that it is today. In fact, it is now a danger to workers and patients alike and possibly poses more danger to life than any disease that forces patients there. I think it is time to demolish it and put up a brand-new replacement structure.

As part of this agenda, we need to learn to take BOLD initiatives. For example, come up with a definite plan and timetable to eliminate malaria by 2035 and/or an ambitious goal to add 10 years to the current average lifespan within 10 years (Agenda 10 in 10) through improved healthcare, better nutrition and wiser lifestyle choices. These must be entrenched in a healthcare charter and be binding to subsequent governments.

It is time Ghana embraced preventative medicine; it will save us money, time and heartache in the long run. To make this happen, healthcare must come to the people, not wait for sick people to seek healthcare. What does that mean in practice? Instead of waiting for people who are sick enough to seek healthcare, every Ghanaian must be made to register with a healthcare practitioner. This would signify the birth of the family doctor concept in Ghana. At registration each practice must capture certain basic personal data of every Ghanaian and store them securely on purpose built, secure National Health Service Records Computer Systems. These must include blood pressure (if adult), blood group type, blood cholesterol level, sickle cell genotype, dental records, basic eye tests and a full blood count as a minimum. Anyone whose parameters are outside the expected normal range must be prioritised for further investigations and referred to secondary or specialist care if needed.

Doing this will have high initial costs but will bring down overall healthcare expenditure in the long run. It will create much needed employment but most importantly, it will IMPROVE THE HEALTH OF THE NATION DRAMATICALLY, as conditions that cause serious morbidities and mortalities will be picked up early and have higher chances of successful resolution with early initiation of treatment. Our current model is failing us as incidence of hypertension, diabetes, kidney disease, cancer and many other serious diseases is shooting through the roof. We must change direction and do something drastic if we want to arrest this growing trend.

We must be super ambitious if we want to occupy a top spot as a healthcare tourist destination. Ghana is blessed with more than her fair share of highly competent healthcare professionals dotted around the globe. It is estimated that nearly 3400 doctors of Ghanaian origin work in the UK alone (BFT, 2021). Though no official scientific study has been carried out in this regard, a snapshot of some of these professionals in the diaspora may be interested in returning home to serve their motherland if conditions of service improve, most importantly the existence of opportunities to learn and progress in their chosen professions. Indeed, I am aware of a team of highly qualified senior Ghanaian nurses in the UK who are willing to volunteer their services, nurture and transfer much needed skills to their younger colleagues back home in Ghana. We can develop schemes that will attract them back to the motherland with the aim of reversing the brain drain that has bedevilled us for so long.

It all starts with the concept of excellence and standards. It is no use trying to be ordinary or average if we want to develop world class healthcare systems. We must aim for excellence at all levels. At whatever point a patient accesses healthcare they are entitled to receive care that is effective, empathetic, evidence-based and professional. This is where standards come in. How does one know what excellence looks like if there are no standards to compare with? Minimum standards of care must be developed and enforced at every stage of healthcare with gradual but systematic improvements introduced with the aim of attaining excellence through consistent application of international best practices. With that in place, excellent or any degree of improved practice needs to be rewarded whilst consistent poor practice must not go unpunished; a carrot and stick approach if you like.

I understand this is an enormous task that will require a high level of commitment of human and material resources but with determination and effective leadership nothing is beyond our reach. To make the workload a little lighter for all we must embrace the concept of skill mix, where various healthcare professionals work ever more collaboratively with the aim of improving every patient’s experience and treatment outcomes. This means we must redesign our healthcare models to make better and more efficient use of highly qualified but often under-utilised professionals like pharmacists. This model is proving very successful in many industrialised countries and Ghana can learn valuable lessons from such practices. We don’t need to reinvent the wheel.

We may continue to construct more hospitals and other healthcare facilities but if we don’t adopt a new and innovative approach in the ways we work, we may not achieve very much out of that colossal investment. Instead, we will continue to lose young people prematurely as a direct result of skill shortages, outdated practices and our unwillingness to embrace change. We need to ensure every Cedi spent on healthcare stretches as far as it possibly can. There must be a good value for money approach in our healthcare spending, enhanced productivity and a culture of ongoing learning with demonstrable improved outcomes.

Is our funding model fit for purpose?
During the Covid-19 pandemic the World Health Organisation (WHO) popularised a saying which is as true now as it was then. That is “no one is safe until everyone is safe”. Some may argue this only applies to infectious diseases. Nothing could be further from the truth. About time we welcomed the philosophy that every Ghanaian is a valuable microcosm of our entire population. Read through that last sentence again and ponder over it. A few Ghanaians are trying hard to make a lasting impression and ensure their country assumes her rightful place in the global community. Would it be easier and more tangible if every single Ghanaian had the opportunity to play their part towards achieving that goal? This philosophy has guided today’s developed nations for decades, if not centuries. We must begin to accept that the most valuable asset we have as a nation is our Human Resource, not gold, diamond, manganese, copper, cocoa or indeed any non-human natural resource. With that mindset we will begin to see our collective value in each other more than in any inanimate thing found above or beneath the surface of our territorial land. Our gold is valueless in the ground unless someone can bring the ore out of the ground, refine it and turn it into the shiny, expensive mineral that it is. We will begin to see the health, personal development and potential contributions of every Ghanaian as assets rather than liabilities or anything else.

With the above understanding ingrained in all of us it would make sense to argue that those with broader shoulders should do all they can to lift everybody else to a certain minimum standard. After all, “he who wishes to secure the good of others has already secured his own” - Confucius. Isn’t that one of the goals of taxation? Specifically, I would want to propose a model of funding which includes an element of taxation and an element of individual contributions to a national health service pot (NHIS contributions, currently in place). Apart from insurance premiums, we need to introduce a form of tax in the way of prescription charges, where everyone contributes something towards each item of medication they’re prescribed. This will only apply at the point of need when someone is prescribed some medication. The quantum should be small enough that everyone can afford to pay it and should be large enough to achieve say, 40% of overall average cost of each medicinal item, and the remaining 60% covered by insurance contributions. It could be tiered according to one’s level of income. My reasons are numerous, but I would mention just two:

1. That stream of income will help improve procurement of medicines and medical devices that improve overall healthcare. Informal conversations with some Ghanaians suggest many are willing to pay higher insurance premiums to access better healthcare for themselves and their families.
2. It will improve adherence to treatment. The rationale is this. People generally don’t value freebies and will not appreciate any medicines given to them free of charge, unless they’re in severely poor health states, where their very survival is dependent upon taking their medicines correctly. However, if they contribute a small percentage of the cost of the medication, it serves as an incentive to ensure they extract the necessary benefit from it and minimises the likelihood of requesting items that they do not take regularly or may no longer need. A case in point is Scotland where some Counties are now calling for re-introduction of prescription charges that were abolished almost a decade and a half ago. Costs to the taxpayer have risen astronomically and strong evidence is emerging of medicine wastage.

There is a cohort of people who will be exempted from such contributions due to an inability to earn an income either because of age, certain illnesses or disability.

Health institutions need to be given autonomy to generate funds internally through their services at controlled margins. In return government must empower healthcare providers with modern technology for data collection, data processing and record keeping by digitising healthcare at all levels. This must be done swiftly within a deadline of no more than 2 years. No aspect of healthcare delivery should still have paper records after that deadline.

Additional Measures:
Current estimates suggest the doctor: patient ratio stands at around 1:7000. Each doctor is responsible for approximately 7000 patients. What kind of care can Ghanaians expect with such a huge ratio? New thinking is required to improve the health of the nation and ensure there is a physically fit and mentally sound workforce to lift the country up to a more globally competitive status. To achieve that I propose the following:

1. We must bring health to the people, not wait for sick people to seek healthcare.
2. Every Ghanaian and any other national living in Ghana for a period exceeding 6 months must register with a healthcare provider that must have access to a doctor, some nurses and pharmaceutical services (pharmaceutical services should be expanded beyond supply of medicines). That will form the basis of primary care.
3. No practice shall register more than 6000 patients, to ensure there is equitable access to doctors. Each patient registered should automatically attract a patient premium paid to the practice monthly as long as they remain registered at the practice. Each patient should also be assigned a unique identity number linked with their Ghana card to prevent duplication of registration.
4. No patient should have to travel for more than one hour (to be reduced to 45 minutes when transport infrastructure improves) using any form of motor transport to reach a hospital (secondary care). This must inform siting of any new hospitals.
5. All existing tertiary hospitals should be reconfigured to specialise in aspects of healthcare needs that are most prevalent in their catchment areas, with capacity to receive patients from adjoining areas, or indeed from any part of Ghana.
6. All quaternary hospitals must be elevated to teaching hospitals with research facilities and capabilities.
7. The ministry of Health must have a more hands-on, field approach in overseeing and monitoring effectiveness as well as quality and timeliness of care provided to Ghanaians. Penalties should apply where there is evidence of consistent failure to meet standards of care.
8. Expand and improve telemedicine to increase access to quality healthcare, especially in difficult to access rural areas.
9. Reduce red tape and incentivise the pharmaceutical industry to ramp up local manufacturing to meet at least 80% of local demand for medicinal products and facilitate export.
10. Make acquisition of health insurance a mandatory requirement to permit entry into Ghana by foreign nationals.

There is a lot more to propose but I hope this will kickstart conversations that will unlock more ideas towards making Ghana a popular health tourist destination!

Elijah Tiimob
(MSc, Pharmacy; Member GPhC, UK)