My first indication that this trip would be a long and bumpy one was when the District Director said he’d need to borrow a truck from St. Martin’s Hospital to get us there. We were traveling to the Keniago sub-district to visit the Nunipankyeremia Community Health Planning and Services Zone (CHPS pronounced “chips”). A CHPS zone is a health facility that is located “at the door steps of clients” and is either staffed by a nurse, midwife, or medical assistant trained to provide basic health care and know when to refer patients to the hospital if necessary. The Amansie West District has seven sub-districts and each sub-district has an average of three community health facilities.
Everyone at St. Martin’s hospital has said that the roads to Agroyesum were terrible. However, they neglected to mention that a lot of the people coming to their hospital do not have the luxury of even dirt or rocky roads. I discovered a new level of terrible on Wednesday. These roads were not just unpaved, but at least thirty percent of the trip was driving through a riverbed that was nearly all dried up. Every time we approached a large puddle, I’d begin to picture myself standing behind the truck and pushing it with my weak little arms. Thankfully, those images remained images. I’m a relatively healthy young woman. Though after two and a half hours of being tossed up, down, and every which way to get to Nunipankyremia, I felt rattled and exhausted. Just imagine an eclamptic pregnant woman in labor seizing on that same journey in the middle of the night. Health care, it’s really not easy to come by.
Along the way to Nunipankyremia, we passed through several other villages. Some of them had some sort of community health post like a CHPS zone and some were completely without. But, nearly every village had at least one tiny convenience store that carried Coca-Cola and Guinness. Does this strike anyone else as strange? I bet access to a reliable source of electricity and water is not as reliable as finding Coca-Cola and Guinness whenever you want it. How did Coca-Cola and Guinness manage to penetrate every remote village in Ghana? Is it their marketing strategy (they do have the best World Cup commercials) or is it the product itself? If Coca-Cola and Guinness can reliably be transported to these remote villages, why can’t quality health care follow suit?
Our arrival at Nunipankyremia prompted a town meeting. Leaders and citizens of the village all gathered in the “main square” of the village to voice their concerns and grievances about the CHPS zone health facility. Some of these included more trained staff who could treat trauma cases and increase the amount of cases that don’t need to be referred to St. Martin’s Hospital and transportation support for emergency transport. My impression from the exchange at the meeting is that one of the major challenges that Ghana’s health care system faces is one of human capacity (topic of my research). There simply are not enough trained mid-level providers (nurses, midwives, medical assistants) and higher-level providers such as physicians and specialists at the district level and rural communities. They are still concentrated in teaching hospitals of the bigger cities. While in the US we are facing a supply generated problem of too much heath care (a conclusion of the Dartmouth Atlas Study), Ghana’s current human capacity building strategy tries to leverage the supply-driven economy of health care to its advantage. If you build a community health facility, staff it with at least one trained provider, then the patients will come and the overall health of the community will improve. But, it’s not that easy to recruit trained providers to work in these community health facilities.
I think the reason why access to Coca-Cola and Guinness is so easy to come by in relative terms is due to the product’s self-sufficiency. Bottles of the beverages require a minimum amount of infrastructural support to be spread and maintained at the rural villages. Health care providers are a completely different story. What kinds of incentives are there for a health care professional to move and work in a rural community where basic aspects of daily life become prohibitive challenges? Here’s what would go through my mind as a physician if I was asked to practice in Nunipankyremia:
Poor Roads
- Will I be able to travel to and from the village safely and in a timely way?
- Will my patients be able to travel to and from the village in case of an emergency?
- How far away is the hospital I will send difficult cases to?
- How far will my patients be traveling to see me?
- Do I have a car?
Electricity
- How often do power outages occur and how long is each episode?
- What kinds of electricity dependent medical equipment and accessory equipment (i.e. computers) will be able to withstand daily power outages? In other words, what kind of damage and electrical equipment turnover will I have to manage due to the power outages?
Accommodations
- Where will I live? If in the village, how close will I be to the health facility so that I can rush to handle emergencies?
- What kind of amenities will my living accommodation have?
Water
- How can I maintain a level of sanitation that I am comfortable with if access to water is inconsistent?
Personal Life
- Will my family move with me to this village or will I commute back to Kumasi (4 hour + journey) to see my family?
- Where are food and other daily living products purchased? Are they readily available in the village?
- Is there a competitive school nearby for my “children”?
- How well will my family and I integrate with the village?
- Is compensation for my work at minimum competitive to working in big cities?
- Will a job that is both fulfilling and competitive be available for my “husband”?
Medical Practice - Will I be able to provide the same type of quality care that I was trained to provide my patients given the lack of resources?
- Will I have enough experience to treat the disease burden of the village?
- What kind of medical and administrative support will I have in my practice in terms of staff?
- Will I have access to necessary medical equipment and pharmaceuticals?
- What is the literacy level of the population? Will a significant portion of my work include community outreach work to educate the village on how to recognize when to seek care?
- How will I be able to stay current with best practices and emerging medical knowledge?
- What kind of support will I have from the village and the Ghana Health Services in my work?
- What will the patient load be like? Can I take care of them all on my own?
- Will I have access to professional development opportunities?
And those are just the first few things that come to mind. Coca-Cola and Guinness as products sometimes don’t even need a fridge (depending on your beverage preferences). Until these infrastructural and professional considerations can be addressed, simply training more health care providers will not be enough to improve the health of the entire country. This is not a problem unique to Ghana. The US also faces difficulties in recruiting providers to practice in rural communities.
As a global community, we need to design a training and employment structure that not just provides incentives to work in rural communities, but also the infrastructural foundation to make health care in rural communities as self-sufficient as Coca-Cola. Then, as the Coca-Cola song Wavin’ Flag” says, the people of the world will be equipped with quality health care in their pockets and will have freedom…”just like a wav’in flag.”
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Your list is valid, but the questions are also relative to some extent. Some would not be considered by most Ghanaians, some have very simple solutions and others can be resolved over time.
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