Structural Adjustment and Ghanas Health Care System

1
Structural Adjustment and Ghanas Health Care
System

• Joseph R. Oppong
• Department of Geography
• University of North Texas
• Denton, TX

2
SAP - the diagnosis

• Over-bloated public service
• unwarranted state intervention in the market
• state ownership of manufacturing
• investment in social welfare programs
• crippling disease clogging wheels of market
  efficiency

3
SAP - prescription

• Massive currency devaluation
• Liberalization of interest rates, prices and
  trade
• Salary and wage freezes
• Credit ceiling and money supply controls
• Privatization of public enterprises
• Reduction of public expenditure
• Withdrawal of real or imagined government
  subsidies

4
SAP - prescription.

• Cost recovery - particularly health and education
• Reduction of civil service size through
  retrenchment
• Increased revenue mobilization - direct and
  indirect taxes

5
Main Argument of Paper

• SAP is producing irreversible changes in health
  care -- new forms of care are emerging, public
  health is suffering and expensive private care is
  booming.
• Decreased use of formal health system due to user
  fees makes estimating disease burden extremely
  difficult, prevents effective early intervention
  and compounds health problems.

6
Headline News Poverty diseases are increasing

• Cholera kills 48 after north Ghana flooding
• 0801 a.m. Sep 14, 1999.
• Cholera outbreak hits Kumasi (Oct. 11,1999)
• Suhum hospital records 106 cases of T.B. last
  year
• 19 May 99
• Cholera breaks out again in Accra
• 22nd June 99

7
Cholera outbreak hits Kumasi (Oct. 11,1999)

• FORTY-TWO people have been admitted to the Komfo
  Anokye Polyclinic suspected to be suffering from
  cholera.
• Presently, the recovery ward is congested with
  some of the patients sharing beds whilst others
  are sleeping on the floor and on benches.
• A visit to the ward by a Graphic team revealed
  the shortage of drip stands thus forcing some of
  the patients to bear theirs in their hands.

8
Cholera outbreak in Kumasi (Oct. 11,1999)

• Affected areas include Sabon Zongo, Moshie Zongo,
  Roman Hill, South Suntreso, Bantama, Ashanti
  Newtown, Aboabo, New Tafo, Asafo and Atonsu.
• Two nurses at the ward are being supported by
  three of their counterparts from the Komfo Anokye
  Teaching Hospital.
• Dr. E. Appiah-Denkyirah, Regional Director of
  Health Service, who has visited the ward,
  directed the nurses to concentrate on providing
  treatment first before asking the patients or
  their relatives to go through the procedures for
  treatment and admission to forestall fatalities.

9
Cholera outbreak in Kumasi (Oct. 11,1999)

• Currently, no other patients, other than those
  suffering from cholera are admitted at the
  Recovery Ward.
• The cholera ward near the Center for National
  Culture is temporarily closed down following the
  use of a park near the facility as a lorry park.

10
Cholera breaks out again in Accra22nd June 99

• 3 dead and 49 on admission at the Korle-Bu
  Polyclinic.
• Affected areas include Palladium, Chokor, James
  Town, Korle-Gonno, Agbobloshie and parts of
  Ablekuma.
• The patients, lying on benches on verandas and
  corridors, and officials of the polyclinic said
  there is no ward for cholera patients who need to
  be isolated.

11
Cholera cases in Upper East 15, Oct. '98

• Cholera cases in Upper East region, which was
  hardest hit by the recent outbreak of the
  disease, are on the decline, Dr Samuel Sackey,
  head of Disease Control Unit, Ministry of Health,
  said yesterday.
• The region recorded 1,439 cases from August 12 to
  October 3, with 38 deaths.

12
Ghanaians Urged To Adopt Healthy Lifestyles

• ACCRA, Ghana (PANA) - Professor Agyeman Badu
  Akorsa, Chief Pathologist at the Korle Bu
  Teaching Hospital, has said 80 percent of deaths
  that occur in the country are preventable.
• He said bacteria infection, hypertension, motor
  traffic accidents, cancers and tuberculosis which
  are the leading causes of deaths in that order,
  could be prevented through good dietary habits,
  education
• He said one of the biggest problems in the
  country is adult malnutrition

13
Suhum hospital records 106 cases of T.B. last
year 19 May 99

• The Suhum Government Hospital recorded 106
  tuberculosis cases last year.
• Between January and March this year, the hospital
  has already recorded 40 cases, Dr. Harry Opata,
  district director of health services in charge of
  the Suhum/Kraboa/Coaltar said that more cases are
  expected before the end of the year.
• Dr. Opata said only six TB cases were reported at
  the hospital in 1991 and that between 1992 and
  1997, 92 cases were reported.

14
Cutbacks in health sector spending have produced

• Retrenchment - large layoffs of public service
  workers.
• 60,000 between 1987-92, and continue at about
  10,000 per year (Sahn, Dorosh and Younger,
  1997).
• Salary freezes significant salary reduction due
  to inflation.
• 2nd jobs to make ends meet produced absenteeism.
• Closure of health facilities in rural areas,
  poorer health care.

15
Devaluation of the cedi produced

• Increased cost of imported drugs and medical
  supplies.

16
Poverty has increased

• In 1997, more than 6.5 million people (30 of
  total population) lived in absolute poverty and
  the poverty of 1.8 million was described as
  hard-core (World Bank, 1997.
• Proportion of poor increased from 43 in 1981 to
  54 in 1986 and 55 in 1997.
• Poverty in Accra tripled from 7 in 1988 to 21
  in 1992.
• Real wage reductions, rising food prices, and
  subsidy cutbacks

17
Malnutrition has also increased

• Reduced diet intake.
• Avoiding expensive foods such as meat, milk, and
  protein foods that are high in protein.
• The decreased buying power of households reduces
  the amount and quality of food purchased.
• Increased avoidable diseases.

18
Increased health problems but reduced access to
health services

• Cost recovery, Cash and Carry system
  dramatically reduced usage of formal health
  facilities (by 50-80).
• Increased use of illegal providers.
• Proliferation of new, profit maximizing , mobile,
  versatile groups of providers (drug peddlers,
  fringe dispensers, IDVs).
• Increased, high quality, private care for the
  affluent.

19
Extremely low morale of health workers

• Low staff morale ... is as a key cause of the low
  service quality in the health sector. This
  maybe in direct response to the service
  conditions which to a lot of health workers are
  far below that of other sectors. Another
  contributing factor is the limited number of
  skilled staff which tends to create a high work
  load for most health workers. Supervision,
  monitoring and regulation of staff and service
  delivery, is also inadequate (Ministry of Health
  1999).

20
Decaying public health facilities

• Poor maintenance of public health care
  facilities.
• Leaking roofs, cracked walls, faulty plumbing and
  sewer systems.
• Obsolete health equipment with no spare parts or
  preventive maintenance programs.
• (Ministry of Health 1999)

21
SAP may be promoting HIV/AIDS

• Poor hygienic practices due to reduced funding
  may be spreading HIV.
• Limited funding for STD control increases HIV
  since STDs facilitate HIV spread.
• Increased poverty increases risky behavior (e.g.
  commercial sex work). Malnourished, poor women
  extremely vulnerable.
• Increased rural urban migration may be spreading
  HIV.

22
Buruli Ulcer

• Ulcer with undermined borders, necrosis of the
  underlying subcutaneous tissue, and a shiny hyper
  pigmented patch of skin surrounding the ulcer.
• Caused by Mycobacterium ulcerans.
• First identified in Accra in1971 but now in all
  10 regions
• 96 cases in 1989, but in 1993, 1,300 cases were
  reported.
• Nationwide case search mid-1999 revealed a much
  higher than expected, rapidly increasing
  occurrence. 256 cases in Western Region alone.

23
Beginning - Nodule Stage
24
Advanced stage of Buruli ulcer
25
Late stage ulcer
26
Late stage Buruli ulcer
27
(No Transcript)
28
The true extent of Buruli Ulcer disease in Ghana
is unknown

• In the Western Region, an endemic area, inability
  to walk to the Asankrangwa Hospital (about 10-14
  miles away) or pay the 1,000 cedis fee (then
  about 0.30 US) for daily wound dressing kept
  patients away.
• The cash and carry system not only deprives the
  sick of much needed care, but makes it difficult
  to get a true estimate the burden of disease.

29
Physician are getting frustrated

• After examining a very sick patient, I requested
  that he should go and get a chest x-ray. The
  patient told me Doctor, I have no money to pay
  for that x-ray. Just give me some medicine, any
  medicine to help me. Please dont let me die.
  How do I provide effective treatment? I feel like
  Im shooting in the dark, my hands are tied
  behind my back because of this Cash and Carry
  system. (Physician, Chest Clinic, Korle Bu,
  Accra).

30
Short gun therapy is increasing

• In the absence of appropriate laboratory tests
  due to patients inability to afford them, I end
  up prescribing several different drugs, shot-gun
  therapy, in the hope that one of them will work.
• Several times my patients tell me Doctor, I
  cant afford to buy all these medications. Please
  select the most important one for me so that I
  can get that one. In fact, sometimes, they ask
  me to prescribe partial dosage because they
  cannot afford the full dosage of even one drug.

31
Some physicians are becoming cynical

• How do I treat the effects of poverty and
  under-nutrition? I cant feed them three times a
  day!
• District Medical officer.

32
Conclusion

• Structural adjustment is producing irreversible
  changes in Ghanas health care system leading to
  the emergence or escalation of new treatment
  forms and reduced access to quality health care.
• Second, SAP is compounding the disease burden in
  Ghana, exacerbating the existing health problems,
  and increasing the difficulty of disease control
  in the country.