Sunday, July 25, 2010

Public Health in Ghana

As Dr. Howard Koh, U.S. Department of Health and Human Services (HHS) likes to say, public health is defined as: "When you wake-up in the morning and take in a breath of clean air, that's public health. When you brush your teeth and the water coming out of the faucet is fluoridated, that's public health. When you eat breakfast and you pass up the donuts for a healthier alternative, that's public health. When you drive to work and you put on your seatbelt, that's public health. Better yet, you ride your bike to work, that's public health. When you get into an accident and an ambulance arrives and takes you to the nearest hospital in a timely manner, that's public health. When you receive great care at the hospital, that's public health....."

Despite this universal definition, the role public health plays seems to locally adapt to each country’s needs and greatest concerns. In the US, I think public health sits in a nebulous and unglorified third space where it encompasses and tirelessly pushes causes such as seasonal flu, diabetes, hypertension, drug and alcohol abuse, abstinence, food poisoning outbreaks, obesity, hospital-acquired infections like MRSA and C. diff, and pandemic scares like the H1N1 flu. Public health in the US monitors and accomplishes much, but we often take it for granted and don’t notice their presence unless something goes wrong. In the US, the coordination between public health and medical institutions where care is being provided to individuals also does not seem to be well-defined.

In Ghana, public health appears to have a much greater and more coordinated role with medical institutions. The Ghana Health Services (GHS), part of the Ministry of Health, is the public health arm of the country. While the GHS’s main concern is population health through various visible public health campaigns both through passive public service announcements and active direct outreach into the communities against malaria, tuberculosis, HIV/AIDS, and now H1N1 (affectionately referred to as “HeeNee” at the medical school) the GHS’s role as a centralized governing body that oversees medical institutions from rural health posts to teaching hospitals allows it to have a direct impact on individual care through a population health lens. The GHS collects population health measurements from provider medical institutions such as maternal mortality statistics and infection rates and uses these statistics to determine the population need for medical personnel, equipment, and skills.

At the skills level, this form of centralized coordination is a huge benefit. With a system of nested medical provider institutions, the GHS helps to keep each level in close and standardized communication from community health centers all the way up to tertiary medical centers. In several districts, the GHS organizes district wide continuing education workshops to teach the nurses and midwives managing the community health posts relevant skills such as a refresher course on eclampsia including signs, treatment, and indications for referral. These workshops are usually held at the district health office or the district hospital thus physically connecting the staff at the community outposts with their district hospital referral point staff. The GHS also sponsors leadership skills workshops for the health services administrators and physicians in the districts. One of the leadership development workshops I was able to sit in on was a demonstration meeting showcasing the results of a 90 day project that select districts undertook to practice using the model of improvement: setting an aim, determining how to measure progress, assigning group responsibilities and feedback channels, implementing an intervention, evaluating the intervention, and setting steps for the next PDSA cycle of work. Isn’t it fantastic that all leaders are provided with these essential quality improvement skills in Ghana? As an aside, I am convinced that this course that was borrowed from the US was in fact borrowed from IHI!

However, one significant disadvantage of the GHS’s centralized system is seen in its role as the main allocator of medical staff and equipment. The district hospitals and community health centers are completely dependent on the GHS to provide them with medical staff and equipment and do not have the flexibility to seek necessary support through other available supply channels. Because each district usually has a population of over 100,000 people with at least a dozen health centers, the GHS is unfortunately placed in a position of a much needed mother with more children than she can handle.

For example, H1N1 has arrived in Ghana and the GHS is now busy administering the H1N1 vaccine and educating the public about the importance of getting vaccinated against H1N1. This message was not easily communicated in the US, so just imagine how difficult it is in Ghana when the belief that HIV/AIDS was introduced to the continent of Africa via Western vaccines is not uncommon. Reports of death due to the vaccine blared on the radio also complicate the situation. However, all in all the risk of the Ghana’s population being crippled by H1N1 is minimal. With several other pressing health demands like more midwives to staff maternity wards, better distribution of emergency vehicles, and community education on the dangers of taking herbal concoctions during delivery, perhaps less resources should be devoted to the H1N1 flu. Examples such as this leads to significant delays in providing the population with quality health care.

So, can public health and the GHS’s role in Ghana be redesigned to better meet the country’s need? This situation is actually a question that all industries around the world face: how to strike the right balance between regulation and standardization in order to allow the system to operate flexibly and meet the needs of the population.

Although I admit that I do not have the clearest picture about the relationship between GHS district offices and the district hospitals or how this all works on a regional or even country-wide level, if the current centralized system were to be maintained, I’d recommend stronger channels of communication. This will allow the needs of a district hospital to be more clearly understood and will allow the GHS district office to better communicate the process and progress made to meet those needs. With stronger communication, the GHS district offices and hospitals can work together to set aims and develop plans to achieve those shared goals—better health care for all.


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  5. Did you learn whether the Ghana Health Service deals with volunteers? I mean if they are in charge of staffing health centers, then I imagine volunteers would be included? I ask because I am concerned about the fact that severely underqualified volunteers are able to do medical procedures that they could only do with certification in their own countries. This puts the population at unnecessary risk.