Medical sociology

PART I: S E T T I N G THE SCENE C H A P T E R 1. I N T R O D U C T I O N So it is only on rather different grounds that it is possible to sustain the argument that the reduction of illness has to await the reduction of poverty and underdevelopment in the Third World today. These It is now widely accepted that in most countries of grounds are that poverty and underdevelopment inAfrica, Asia and Latin America the government evitably affect the working of the health services as health services have failed to meet the needs of the they affect every other aspect of society, preventing rural masses. Far too many children, in particular, die them from being effective. Low budgetary resources of preventable illness. This is also true of Ghana. limit the amount that can be spent on health services, There is little agreement over what should be done. and more important, underdevelopment implies all There is a common if not ubiquitous expression of the inefficiencies which lead to poor use of the intent to pay more attention and devote more resources available. Some would point particularly to resources to rural areas, but it is rarely translated into the tendency at all levels for the resources to be misalaction to the extent, for instance, of rural areas receiv- located, favouring the better off. Even so, all that may ing the greater part of increases in health service bud- still lead to one of two conclusions: either that action getary allocations. Currently in vogue, also, is the can and should be taken against the features of underconcept of community participation in health activi- development within the health services as part of the ties, or "'health by the people"; again, what has so far effort to overcome underdevelopment in the society; been put into practice in most countries is meagre or that nothing of any significance can be achieved beside the weight of advocacy of the approach, par- until more decisive changes take place in the overall ticularly in international circles. Many conceptual organisation of the society and economy. problems remain inadequately explored. The context, then, is one of uncertainty as to It is broadly agreed that poverty and underdevelop- whether health services can achieve much, something, ment are at the root of the problem. But this is only or virtually nothing to improve health, depending on the starting-point of the discussion. For some, the the extent to which it is feasible to overcome the definext step is to say that since poverty and underdeve- ciencies of the services themselves. In this context, the lopment are the cause, the only cure is their eradica- idea that radical new approaches need to be adopted tion. One set of evidence supports this conclusion: the to rural health problems has gained wide assent. evidence that the reduction in mortality from the These new approaches centre on the involvement of great infectious diseases in the advanced industrial the community. There is an obvious danger that the new approach countries of the West predated effective drug treatment and was related rather to improvements in gen- may be adopted uncritically as a reaction against past eral standards of living. However, there are some failures. The "community participation" approach to leaps in this argument which may not be justified. rural health services supposedly overcomes the failure While drugs were not effective before these diseases of the conventional health services to meet the real had been largely conquered, specific public health needs of the rural population, by being based on conmeasures had been taken: it was not necessarily just a sultation with rural communities concerning their matter of people being able to afford a better diet and needs. It also supposedly deals with the fact that traa healthier home environment. Furthermore, even if it ditional health services do not have the resources to should turn out that, in the history of Western reach all the villages, by harnessing the willingness of Europe and North America, what most counted were the villagers to do things for themselves, thus tapping the actions taken by individuals as their incomes and new resources. But were these the major causes of their educational levels rose, there is no justification failure, and will they really be solved in this way? Or for generalising that it must be so in all places. In the were there other causes, and can they be solved in socialist countries advances in health can be said to other ways? have been made more rapidly than general advances These are the broad questions to which the present in development, the health of the whole population research is addressed. having been treated as a priority and an area in which It is impossible to give a complete or an uncontrorapid strides could be made in a short time. From versial answer to the question of why the health sertheir experience the conclusion might be drawn that a vices have failed to meet the needs of the rural masses, drastic reduction in infectious and communicable dis- in any country. But the differing interpretations exist ease is easy. once the commitment is there. Also, the primarily at the level of generalisation. It is possible weapons of contemporary pharmacology do now to collect data at local and district level, on the inadeexist: the)' can be (and are being) applied to bring quacies which can be observed and on the immediate, about reductions in mortality which, in Western obvious or reported, reasons for these inadequacies. Europe. had to await improvements in living stan- These data form part of the essential background for dards. any analysis, although knowledge of the wider socioI. T H E STATE O F U N C E R T A I N T Y OVER R U R A L H E A L T H SERVICES IN T H E T H I R D W O R L D : T H E G H A N A H E A L T H P R O J E C T IN THIS C O N T E X T

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political context and of higher level decision-making processes is also a requirement for an informed interpretation (Chap. 3:1 ). Empirical research is also possible at village level on the problems and achievements of "'community participation", even though in Ghana at present only two experiments with this approach are under way. Ways of involving communities in consultations about their (health) needs can at least be simulated, in order to assess the likely response of the villagers, their representatives and their leaders. The potential village resources for a health programme can be assessed by examining current forms of organisation and by identifying those features of village society which offer obvious possibilities or obvious constraints. Findings can be compared with the experience in the two experimental projects. They must, however, be somewhat hypothetical: only a wider variety of experimental approaches could confirm them. There have, of course, been other evaluations of primary health care. and our work needs to be seen in the context of a growing concern with the issues here examined. We have not made reference to such other work in the body of this report. What needs emphasising at the outset, however, is that this stud), cannot be used to arrive at a.judgement on the Ghanaian health care system in comparative perspective. No health care

system, we assume, fully conforms to the ideal embodied in our norm. The findings suggest that the health care system is not doing the right things and not meeting the needs it is supposedly set up to meet; the findings do no more and no less. 2. COMMUNITY DIAGNOSIS AND M A N A G E M E N T OF HEALTH PROBLEMS

Much attention has recently been focussed on the question of "'basic needs" and on the importance of development strategies and policies being concerned in the first place, and perhaps above all, to meet the basic needs of a country's population. Those are the set of needs that must be satisfied to ensure a "'certain minimum standard of productive survival" and the now suggested "'core" list comprises five basic needs, the first three of which are directly relevant to the concern of this study: food and nutrition, drinking water, basic health, shelter and basic education (World Bank, 1977). Our research design was formulated before "basic needs" had become a new organising concept for issues of development. However, the approach adopted here is entirely consistent with that concept: this should become evident in the following pages. It is essential at the outset to have a well-defined statement of just what the needs are which are currently not being met, as a yardstick against which to measure actual performance and in order to specify the goals for change. At the present time. health needs in Ghana are regarded as almost exclusively the concern of health service personnel: only in a very few isolated projects is the potential contribution of vii* This accounts for the overlap in different areas (e.g. malaria prevention has a place in four out of the five areas: tuberculosis is mentioned as a priority problem in all but the maternal health area, etc.).

lagers to the promotion of their own health taken seriously. In a sense our work has been hampered by this: where community involvement does not exist, its workings cannot be evaluated, and the extent to which health needs can be met by activities undertaken outside the health services becomes in part a matter for conjecture. However, the very specification of the tasks required to be undertaken if basic health needs are to be met, illustrates the fact that many of them do not require professional health workers to perform them: of the hundred or so tasks identified as basic requirements (Appendix IA), probably around 8~,o could be performed by a member of the village community with minimum health training, or even by families or organised groups of villagers. Nevertheless. given the overwhelming predominance in Ghana of the conventional "health to the people" model, it was inevitable that much attention would have to be paid to the workings of the health services and to their limitations and that a large part of our evaluation had to deal with assessing their effectiveness, and their potential for coping with health needs. To identify those health needs we turned to such epidemiological information as was available; we used currently "accepted" medical views to indicate how, technically, those needs identified would best be dealt with through the health system, and organised the different tasks in the same broad way as has been done conventionally, i.e. by health service areas--maternal health, child health, curative (polyclinic) care, environmental sanitation and communicable disease programmes.* Much research effort was devoted to establishing the tasks that would give the minimal acceptable (basic) health service that was realistic within Ghana's resource constraints. We then looked at the current allocation of resources within the health care system, and at alternatives which would be more consistent with the basic health needs of the population. Finally, taking account of Ghanaian resource availabilities and constraints, we drew up a specification of the resources required for the proper performance of the minimum tasks and formulated an organisational framework within which that performance was likely to be smooth and efficient. We called these specifications "implementation targets"; they deal with such matters as supplies (especially drugs) and equipment, transport, efficiency of clinic organisation, staff and staff training, or supervision. The methodology used in this connection is set out in detail in the next chapter. And yet our village work has provided us with an additional perspective. As virtually no health care reached the villages, there was no question of evaluation at the village end. So we tried to supplement the work done at the health units by beginning to document how priority health problems present themselves in villages. In doing so, we could initiate a discussion of what might eventually be done in villages to cope with the diseases and other health problems which predominate in rural Ghana. While there is. indeed, a medical consensus on the causes of the diseases and on the best way to cope with the problem, that consensus is not always based on a deep knowledge of the" actual life situation of villagers, or of the precise chains of causation of disease insofar as they

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often being a contributory cause of death), and to perinatal conditions and complications of pregnancy. Deaths in children under five account for about half of all deaths. Measles continue to be a major cause of death. Maternal mortality is high, especially in the rural areas, where it is reported as being over 14 deaths per 1000 deliveries. Communicable diseases remain a major problem (malaria, tuberculosis, yaws. polio). Some of our own findings confirm this general picture. In the area of maternal and child health two findings especially deserve to be mentioned. Though we have no data on maternal mortality, we found that the stillbirth rates were high, especially in Birim District, where it reached 4.3~o of supervised births (double the Jasikan figure). As for child health, we concentrated our village studies on questions of child nutrition. Malnutrition, though not as acute in the districts studied as in the North of Ghana, appeared to affect between a fifth and a quarter of almost 300 children examined in six villages (IDS, 1978b: App. l la), and at one health unit studied about 30~o of children between 1 and 2 years of age were malnourished (Chap. 5:2). More generally, faecally-borne diseases appeared to be a significant problem in most villages, largely caused by poor latrine provisions (especially for children) and the frequent use of contaminated water (Chap. 5:6b). In a special study undertaken at four health units in Birim District, fever (which can be assumed to be mostly malaria) accounted for between a third and a half of all consultations (IDS, 1978b: Appendix 7). The picture, then, should not be in doubt. The basic health needs of the majority of Ghana's people (those living in the rural areas still make up around 70°~ of Ghana's population) require a health system which prevents their children from contracting easily preventable diseases, and dying from them; which ensures that their pregnant women have adequate antenatal and delivery care. widely and locally avail3. AN OVERVIEW OF T H E able; which gives adequate and accessible curative MAIN F I N D I N G S O F T H E STUDY care for their common ailments: which helps build them a healthier environment through appropriate This overview, together with the final chapter on sanitation measures; which is capable of controlling Recommendations, is intended to show the reader the the communicable diseases rampant among them: main lines of the work undertaken. It provides an which can utilise their own approach to health, disoverall picture, some background material not further ease, and death to the best effect, and transmit such elaborated later, and a quick guide through the study "'modern" knowledge as seems to be indispensable to as a whole. create a basis for healthy living. Finally, account must be taken of the factors which determine whether la) The health needs Ghana's rural people will have at their disposal sufAs could have been expected, the priority health ficient resources to feed themselves, to raise their stanproblems of the two districts studied (Jasikan, in the dard of living, and to emerge from the poverty that Volta Region and Birim, in the Eastern Region) distinguishes them from their better-off fellow Ghapresent a pattern similar to that of other African de- naians who live mainly in the towns: these factors the veloping countries.* High infant mortality rates in health system cannot affect by itself. both regions (reported rates per 1000 live births are We did not start with the presumption that health respectively l l3 and 100)result from largely prevent- needs are solely, or even predominantly, served by able diseases: 55"o of all reported deaths are due to conventional health care services. But these clearly infective and parasitic diseases (with malnutrition have a contribution to make. Moreover. the resources devoted to them are so large (in Ghana some 8°0 in 1974,/5 of total government expenditure alone) that their role cannot be ignored. Our research was. then. * See Chap. 3:3. We did not do an~ systematic research aimed primarily at documenting how far the existing on the health status of the populations in the districts stud- health care system addresses itself to these basic ied, but relied on published accounts. health needs.

occur during the daily activities in villages. Often it also takes account only of the resources directly available to the health services: when a broader view is taken, which incorporates the resources available within villages, the range of possible health actions is considerably enlarged (Chap. 3:1). By close observation of village reality, by assessing in particular localities the factors involved in the incidence of diseases that are predominant and widespread (e.g. child malnutrition, malaria, diarrhoea, worms), and by taking account of people's own understanding of problems, it is possible to develop a fresh approach to possible solutions. This approach starts by focussing on what actually might be done in the villages, and asks what factors are likely to make this easy or difficult; those interventions that are clearly beyond the capacity of the community will then be identified as tasks for which the community needs the help of the health service---or, possibly, of other government departments. This kind of exercise is firmly based on the idea that it is priority needs that should be dealt with first, and its result would be the preparation of a set of priority "target interventions" against crucial points in cycles of disease transmission or in the causation of health problems. As has been stated earlier, we have not had the time or resources fully to work out this approach, but in a number of substantive areas of enquiry (e.g. those dealing with child nutrition, environmental sanitation, or communicable disease control), we should be able to show its usefulness in indicating so far untried "interventions" at the village level to complement, or even supplant, those undertaken from the primary health care unit. Specifically, it should make it possible for some of the general tasks listed in Appendix 1A (the vast majority of which do not require a qualified health worker) to be spelled out in greater detail. and for priorities to be established for action.

IDS HEALTHGROUP (b) The health care system, and what it achieves

As far as the health services were concerned, the districts studied were generally accepted by the Ghanian health authorities as lacing broadly representative of the situation in the country.* While the "modern" health care system is by no means the only source of care to which rural Ghanians have recourse when they are ill (Chap. 4:1), it is clearly the preferred option for most common ailments which cannot be dealt with in the home. Even so, utilisation is limited. In the districts studied even polyclinic care (the most widely offered service) was not utilised by a significant proportion of the population: a special study of a 1% sample of patient cards at all health units studied, compared with census data of population by location, suggests that between a quarter and a fifth of the districts' populations did not register at a health facility for polyclinic care (Chap 4:3 and IDS, 1978b: App. 6). The only other service utilised by a similar proportion of the relevant populations was that providing antenatal care: about 80°/O of pregnant women appeared to have been seen at least once in an antenatal clinic (Chap. 5:1). All other basic health needs were catered for to a much lesser extent. In the districts studied only about one fifth of births appeared to be supervised (Chap. 5:1c). One fifth or less of under-fives were seen by the child health services, and the vast majority of these were under 1 year of age, and not in the much more vulnerable 1-3 years age group (Chap. 5:2). Child immunisation coverage was very poor in both districts. No more than a third of the population of the one district for which data were obtained appeared to be covered by the environmental sanitations services. Figures such as these result from a combination of scanty provision of services, difficulties of access, and low utilisation even where services are formally available. We will return to the latter issue shortly. Another finding goes some way towards explaining this low "coverage" for all but polyclinic and antenatal health care. Of the 17 units studied, 40% did not provide child health clinics at least once a week; home visiting for MCH was undertaken only by half the units, while over two-thirds of the units did not engage in any type of personal care activity in surrounding villages, i.e. MCH home visits or satellite clinics. Only a quarter of the clinics had provided at least two kinds of ~-aintir/isa--ii--~, to however small a number of children, at any time, over the past year (Table 5). Compared to the (full) range of services provided at the Danfa project, which we studied for comparison, no unit reached two-thirds of the Danfa range, and only four provided between 50 and 60% of the minimally required services. All the others were less than half "complete" in what was provided-many, indeed, very much less (Table 6). In the districts studied an important cause, therefore, of the low coverage/utilisation figures reported above was the fact that the health care units do not make provision for the minimum package of services required to meet the population's basic health needs. * Workshop discussions at Ministry of Health in Aeera, November, 1977.

But low utilisation may well be related to another issue on which we concentrated a good part of our research effort. That issue is the quality of care. Health services are likely to have a beneficial effect only to the extent that they reach a minimum level of quality, i.e. when the actions and interventions undertaken correspond to those which current knowledge designates as proper practice. And that applies to health work done in villages just as much as to curative care provided higher up the line of referral. As the body of this report will show, the method of evaluation used enabled us to form a view about the host of "specifics" which together make or break a health care service. We have looked in turn at the five areas which are supposed to cover the basic health needs of the population. In each of them we found some excellence, much that was indifferent, and also much that was downright poor and even harmful. There was no relationship between the size of the unit, and the resources it used, on the one hand, and the quality of care on the other. In fact, for quality of care one of the district hospitals scored only about one third of the total possible, and the other scored half; they both gave poor quality polyclinic care, and at one of them the quality of child care was very poor indeed (Figs 2 and 4). History taking and examination in the polyclinics were generally poor, perfunctory or altogether absent. The uncontrolled and unrestrained use of drugs stood out as an area where drastic and early corrective measures could bring major benefits, especially in economic terms (see below). The main problem with maternal health care, where the quality of care was on the whole higher than in the other areas, lay in the failure to recognise at risk cases among pregnant women and to arrange for their supervised delivery. This again, was related to poor history taking and examination, but also to the absence of clearly specified criteria on what constitutes a risk factor. Moreover, even if risk factors were identified, mothers were apparently not sufficiently convinced, or found it impossible on largely economic grounds to have their deliveries supervised at health institutions. (In a special study of maternal referrals from seven units, around 90% of the 131 referrals during labour appeared to have been for conditions for which the mother could have been identified during the antenatal period as being at risk: see Chap. 5:lb.) As for child care, its quality was on the whole considerably lower than that of either maternal or even polyclinic care. Only limited curative care was available at child welfare clinics, malaria prophylaxis was on the whole absent, and poor quality was evident in the poor supervision of growth, deficient nutrition education, the frequently impractical advice given on feeding practices, and the absence of attention to the procurement of foodstuffs or the growing of food crops. Environmental sanitation activities displayed at times a preference for over-sophisticated solutions, and frequently a lack of concern with the problems for the villagers of implementing the sanitation advice given. Communicable disease control activities suffered mainly from lack of coordination, and poor organisation of follow-up for specific disease control programmes, notably tuberculosis. Much of Chap. 4 and 5 is taken up with the presen-

Health needs and health services in rural Ghana tation of an "'itemised'" evaluation of Ghana's health care services, and the reader will encounter details on such matters as poor history taking, unsterilised injection needles, ineffective immunisation or malaria prophylaxis, confusion in the reporting and recording of communicable diseases, and a better than average quality of maternal care. But it is important that the main lines of the argument are kept clearly in sight. This part of the report is meant to show with some precision for each area of the health services how the tasks necessary for the management of basic needs were being handled. Many of these tasks tended not to be performed in a manner likely to have the desired and expected effect: in some cases, interventions were not just ineffectual, but downright prejudicial. The causes for these shortcomings can lie in "'implementation failure", where misdirected training, insufficient supervision, or lack of support can be held responsible. In this situation remedies may be found by correcting the relevant operational deficiencies. But shortcomings may also have deeper causes, which relate to the basic conception, to the "model" of the health services. Where changes such as better supervision, new refresher courses, or improved supply procedures are not likely to remove the problems identified, their cause must be sought in "'model failure"-and only reformulated basic concepts and a restructuring of the health care system around them are likely to lead to improvement. In the last few years the Ghanaian health authorities have themselves done much work that has pointed to major areas of "'model failure". The Health Planning Unit's working document A Primary Health Care Concept for Ghana (Ghana HPU, 1977) leaves no margin for doubt that what is needed is not just better implementation of existing procedures, but rather a rethinking and restructuring of the health services with much greater emphasis on village level work and an easily accessible first line of referral. By documenting how the present system fails to meet basic health needs, this report aims to complement the work already done in Ghana itself: and by presenting quasi-anthropological material on health needs as seen from and experienced in the villages, and on the operation of traditional and modern village institutions and organisations, the report aims to be relevant to the building up of a health care system responsible to the needs of the rural people. As for the village work. our findings on social organisation will be dealt with later in this section. With respect to health needs, we concentrated on (child) nutrition and faecal transmission of disease. A quarter of the children in four villages studied appeared to be tat least marginally) malnourished. There was some reason to believe that mothers paid less attention than they should to the feeding of the sick and recently sick children. In general, however, where sufficient food was available, feeding practices in the villages did not appear to be major causes of ill health in children, though our evidence is limited in this respect. Less open to doubt were the findings on the neglect of food crop production as compared to the time and effort spent on cash crops, and the general lack of advice and aid to food crop farmers--perhaps especiall3 to women (Chap. 5:6a).

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Environmental sanitation formed the focus of much of our village work (see also IDS, 1978b: App. 11). We attempted to specify which points in the potential cycle of disease transmission appear to present the greater dangers and see where the best chances lie for successful intervention. Two related findings only are mentioned here. In the first place, exogenous "modern", and technically relatively complex solutions to the latrine problem tended to be preferred by villagers, as well as by environmental sanitation personnel, over those (e.g. pit latrines) which were within the capacity of villagers to build and maintain. This preference existed in spite of the fact that in present Ghanaian circumstances the former are giving unreliable service at best. Secondly, lack of attention to the needs of toilet-trained younger children appeared to create major sources of potential infection almost everywhere (Chap. 5:6b).

(c) The allocation and use of budgetary resources In common with so many other countries, Ghana's health services have been using their financial, physical and human resources in ways unlikely to have much impact on the basic health needs of the population. Health planning is relatively new to Ghana. Hitherto the response to incompatible demands for resources must have been determined more by the relative power and influence of the different sectors of the health service, than by the intrinsic merit of the proposals for expenditure, and least of all by the extent to which those proposals were cost effective in meeting basic needs. This much can be concluded from the pattern of resource allocation which has prevailed in Ghana's health care system {Chap. 3:1), characterised in the current Plan as one that has favoured the urban few and denied resources to the rural majority. In 1974/5 over a third of all budgetary allocations went to Korle-Bu Hospital and Greater Accra, directly serving only just over a tenth of the populations. Per capita expenditures varied greatly by Region: even excluding Korle-Bu and Greater Accra, Ofosu-Amaah's figures for 1974/5 showed a range where the best-off region spent more than twice the resources per capita of the worst off. At the District level resources were concentrated at the hospital end of the spectrum: over half of all health expenditures in both districts studied were for "'medical" costs (i.e. excluding salaries, wages and other expenditures on environmental sanitation and public health) at the hospitals, and these costs constituted over two-thirds of all "'medical" costs in both districts (Chap. 6:3 and 4). Overall pressure on resources remained great. Despite considerable population growth (in recent years between 2.5°0 and 3°° p.a. at least), the total resources available to the health services in real terms had not grown by more than about 2°; in all over 7 years, and per capita expenditures had fallen, As a result of heavy inflation health personnel had seen their real incomes diminish rapidly, and even after a salary award their position was still very difficult. Almost 85Qo of the Ministry of Health budget was for recurrent expenditures on existing services. For these and other reasons short-run reallocation of resources between town and countryside, hospitals and rural

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services, could not be achieved without major upheavals. But the extent of improvement possible within the rural (primary health care) services by a more costeffective use of resources, or perhaps by minor but strategic additions to them, was an altogether different matter. As tends to be the case in most countries, personal emoluments make a large claim on total resources. In Jasikan District (excluding the MFU) they represented 46~o of all expenditures. Medical personnel at the District and Mission hospitals together received just under half of all personal emoluments. More surprising, perhaps, is the fact that the sanitary and conservancy labourers accounted for 31~o of all personal emoluments in Jasikan District, and for 61~ of the personal emoluments paid to health workers not employed at the hospitals (IDS, 1978b: Table A39). These figures need to be seen in the context of the fact that only about one third of the district's population were estimated to be receiving environmental sanitation services. Even more striking and thought-provoking was the very large proportion of medical costs taken up by drugs and other stores: well over half in both districts. At all M O H primary care facilities in Jasikan drugs and other stores accounted for three quarters and over of medical costs. At all but one of those units in Birim that proportion was two thirds or over (IDS, 1978b: Tables A35 and A36). A special study of prescribing confirmed the over-prescribing already noted in the polyclinic care evaluation, and a comparison with a set of "best practice" patterns made it possible to attribute a cost to this (Chap. 6:5). The waste involved can only be termed monumental. At the p r i m a r y care units studied, appropriate prescribing patterns could have reduced expenditures on pharmaceuticals to less than one third of current drug costs. Of course, one cannot generalise with a great deal of confidence from such limited data. But they suggest that the introduction of controls based on appropriate prescribing regimens might lead--in the Volta Region, at least, the only region for which full stores costs were available (for 1975/6)--to savings of the order of one-fifth of the total stores budget (which stood at ¢3m. in the Volta Region for 1975/6). Even a 105~, reduction in the national bill for unallocated stores would make available ¢3.2m. annually, at 1976/7 cost levels. The importance of this for the financing of a better support system (see below), or for a reorganised primary care system rooted in the villages, cannot be overestimated.

(d) Availability and disposition of material and human resources, and organisation of the primary health care services Greater control over drug use could, then, make considerable sums of money available from within the primary health care sector itself. This has particular relevance in view of the finding that existing resources are often inadequate, or ineffectively used, to meet the population's basic health needs. Physical facilities were, on the whole, quite good, given the organisation of Ghana's primary care services. But there were considerable problems with supplies and equipment. Most noteworthy was the paradox that all primary care units, though in general

overflowing with drugs, including ample supplies of sophisticated drugs for rare conditions, were short of two or more basic drugs. Similarly. essential (and cheap) supplies for the environmental sanitation services such as disinfectants, soaps, antiseptics, were scarce or absent everywhere. Vaccines did not seem to get ;hrough to the primary care units, while considerable stocks appeared to be kept. often approaching their expiry dates, at the hospitals or M F U units (Chap. 7: 2). The latter problem appears to be related mainly to the absence of' adequate transport---one of the main resource failings of Ghana's health services today. Over and above interfering in a major way with supplies, lack of transport diminishes the effectiveness of outreach, supervision and referral. The absence of simple procedures to claim for the reimbursement of travel and transport (T & T) expenses only exacerbated an already critical situation, and impeded its alleviation by the use of health workers' own vehicles or public transport. Liberality, even licence, in the provision of drugs had as its counterpart tightfistedness in the provision of transport: both are items for which (scarce) foreign exchange needs to be made available (Chap. 7: 3). As far as human resources were concerned, the evaluation brought to light inadequacies of a quantitative as well as qualitative nature. Quantitatively one problem resembled (and was related tol the incomplete service provision at many of the units studied, reported above: at many units staff trained in one (or more) of the basic skills--polyclinic curative care, midwifery, child care and environmental sanitation-were missing. All four skills were in fact, available at no more than one third of the units studied. Another problem noted was that of short effective working hours, and of very limited time spent on preventive activities, especially in maternal and child care (Chap. 8:1). Qualitatively we found that staff at a considerable majority of the units were performing tasks inconsistent with their training, either by engaging in activities for which they had never been properly trained, or by performing duties which could be done effectively by less trained personnel. This, together with poor support in material terms (inadequate supplies and equipment; non-existent transport etc., and to some extent also pay inadequate in relation to historical norms) as well as in human aspects, seemed to be the main reason for fairly widespread low morale (Chap. 8: 2). These human aspects of poor support manifested themselves in various ways. In-service training appeared to be non-existent in Ghanaian primary care units. Except for the environmental sanitation service, the frequency of supervision was low and its level poor: supervising visits tended to be one-off affairs, which focused on fault finding ("inspections") rather than on training and the provision of technical or moral support. Referral procedures were largely unspecified, and health workers almost invariably lost sight of the patient referred (for whom usually no record was kept anyway). In general, there were major problems with records, both in their preparation and more importantly in their use. There was widespread duplication and lack of coordination: for example,

Health needs and health services in rural Ghana record cards made out at the child welfare clinics were never used at the polyclinics and antenatal records not transferred if the mother moved to another town. Overall, the level of material and human resource inputs was evaluated as adequate at only two units: a district hospital (providing on the whole care of poor qualityl and a mission hospital Iwhere the quality of care was generally good). The rest of the units had inadequate resources--some of them grossly inadequate. Nevertheless. quality of care did not show a clear positive relationship with adequacy of resources. Whilst there were units which did conform to the expected relationship, some with good resources performed poorly and some with inadequate resources gave health care of good quality (Chap. 8:6at. Beyond resource adequacy, we believe that factors related to the organisation of the primary health care services have a major effect on the quality of care provided. These organisational issues are largely matters related to the structure of the health care system, and they tend to point to "model failure" rather than to mere problems of implementation. Many organisational issues have been mentioned above torganisation of physical facilities and supplies, especially transport, staff utilisation, records, referral). Selection and training is another area we looked at (Chap. 8:3): in those areas problems are closely connected with widespread and critical lack of health service integration: within health units, between branches of the services, between the health unit and the community, and between the health service and other agencies. It is in this area that "'model failure" was most apparent (Chap. 8:6). The Medical Field Units play a potentially important role in Ghana's health system, though in the districts studied they have been hampered by lack of transport. There was, however, no mechanism for coordinating their activities with the health units for the health inspcctoratel of the areas in which they operated. This resulted in duplication and, more seriously, in fragmented reporting and recording, and a complete lack of follow-up on an individual basis. Mutatis mutandis similar considerations applied to the health inspectorate. Within most health units the different clinics all seemed to go their own way, "'do their own thing", and this lack of integration had particularly detrimental effects in the area of child health. Curative and preventive care for children was provided separately by different personnel, at different times, using different records. In fact, under-fives were seen to a much greater degree in the polyclinics, where no preventive care was available, than in the child welfare clinics. For many mothers child welfare clinics offered so little that they could not afford to attend them: at two units studied the attendance ratios of polyclinic to child welfare clinic were 10:1 and 24:1. Moreover. children seen for preventive care appeared to be mainly under one year of age. or even under 6 months, the child welfare clinic often being little more than a post-natal baby clinic. Children from the more vulnerable age group 1-3 years tended to be seen only in the polyclinic, when they were already sick. Nor was there any integration of the maternal services with those for children. In short. mothers and their children, sick or well. were

403

expected to attend at different times and see different people; everything seemed to be organised to make utilisation of the services as difficult and time-consuming for them as possible. All this was intimately connected with the narrow specialisation of field staff, trained in separate schools for separate tasks (community health nurses, midwives, health centre superintendents, health inspectors, health inspection assistants, MFU officers, enrolled nurses, SRNs, or QRNs, etc.), eaeh incorporated into vertical hierarchical structures within the Ministry of Health. These imply rigid career patterns, parallel supervising responsibilities and fragmentation at the primary unit and even at the district level, where no effective integrated supervisory and support system exists for the primary health care services. This pattern of organisation was "'built in" to our evaluation as it was only possible to evaluate such tasks as were expected to take place and to study such activities as staff undertook within the existing division of labour. As the research progressed, however, evidence accumulated to confirm that many of the problems of the health care system, specifically in terms of the quality of care provided, could be directly attributed to this fragmentation and hyperspecialisation all the way down the line: the workshop of Ministry of Health officials called to discuss this report in November 1977 explicitly recognised the implications of these findings and made perhaps its most basic proposals for changes in this area (see Chap. 11L

(el The potential for a shift towards villaye level health care The other main thrust of the reorganisation proposals put forward by the workshop was for a determined downward and outward shift of the focus of primary health care towards the villages where over two-thirds of Ghana's people still live. It arose from the work done by the Ghanaian authorities (especially the Planning Unitl at least as much as from the findings of this report. Our village work suffered, as has already been stated, from the major disadvantage that active community involvement in health and health care is found in Ghana in no more than a few experimental projects. The village research had to take as given what we found, just as the evaluation of the health services themselves had to focus on the existing specialised roles and the prevalent fragmented structure. At best, the issue of community involvement could be raised hypothetically, and the traditional and modern village organisations examined for their relevance to possible developments in the health field. At that hypothetical level, in all villages studied there was a willingness to co-operate with future health programmes, and everywhere village leaders were conscious of health problems as "felt needs" and were able to give examples of diseases and other health problems which might be mitigated with outside help (or by village effortsl. However. understanding of the immediate causes of these problems was often limited. and solutions to them were (not surprisingly) seen in conventional terms: a hospital or health centre, piped water system, or the services of existing categories of health personnel. Above all, the felt need was for ad-

4O4

IDS HEALTH GROUP

equate and accessible treatment of the limited range of simple but widespread conditions that necessitate curative care (Chap. 9:2 and 3). Traditional (authority) institutions retained their strength in virtually all villages studied. Chieftancy, the chief's court, sometimes clan organisations or women's councils, could all give support to certain kinds of innovations. These organisations tended to be closely integrated with the "modern" village or town development committees, which in all cases had undertaken a development project with the help of communal labour (Chap. 9:4). Communal labour had been used for environmental sanitation projects, especially, and this is an area of activity which could well be widened. It is questionable though, whether the resources to remunerate a full-time village health worker could be raised through communal labour. There are various social and cultural reasons for this. At least in the villages studied, the village authorities usually called for communal labour only to help with "finite projects" considered worthwhile by the villagers: the idea that it should be given on a regular basis to provide for someone's regular livelihood was alien, and likely to meet with problems of indifference and hence poor attendance (Chap. 9:6). In general, it did not seem likely that villages could generate the funds necessary to renumerate full-time village health workers. It is conceivable (but not necessarily desirable) that certain curative activities could be paid for on a fee for service basis; the arrangements for this might be supervised by the village development committee. (There are, of course, precedents in the fees paid to the TBAs and to other traditional practitioners.) But as village health workers

would have to concern themselves with preventive and sanitation activities perhaps even more than with curative care, much of their work could not be dealt with in this way. So if is as at all possible within existing resources, there are many reasons why village health care should be paid for by the government (through the Ministry of Health or the District Councils), perhaps especially because the inequalities between those who are relatively well-off and live in towns, and the rural poor, would be merely accentuated if the former were to have health care paid out of general revenues, while the latter had to raise the funds themselves (Chap. 10:3). Finally, in trying to see what issues might arise if health work were seriously extended to the villages. we briefly looked at matters of training, supervision and phasing (Chap. 10:4 and 5). Given that our village research pointed clearly in the direction of one or more multi-purpose village health workers, it would be difficult to imagine that their training and supervision (in the villages) could be successfully undertaken by any one of the health cadres as at present trained and constituted. Phasing issues, which relate to how to start, with what range of activities, and where, will be taken up in the recommendations: from the point of view of the villages studied, a number of alternatives seemed worth considering and developing side by side. As for those recommendations, developed in the final chapter of this report, they will not be summarised here. They discuss broad proposals rather than details, and we believe them to be of sufficient general interest to be read in their entirety together with this summary.

C H A P T E R 2. C O N C E P T S A N D M E T H O D S

I. A C O N C E P T U A L FRAMEWORK FOR THE ASSESSMENT OF EFFECTIVENESS OF PRIMARY H E A L T H CARE SERVICES

The approach to evaluation used in this study conforms to the newer concepts of evaluation described by W H O (1977). Evaluation is seen as a continuing process of making informed judgements about a programme. Indeed. as W H O states, "The very process of carrying out the evaluation can be just as important as the conclusions drawn." This is particularly relevant in this study. The process and methods described in detail in this report, are themselves one of the objectives of the research--namely the development of planning and management tools for improving primary health care in Ghana. Ideally, the effectiveness of a health service should be measured by its impact on people's health. But health, however it is defined or measured, is the outcome of complex interactions in the social and biological milieu, of which health systems and their programmes are themselves a part. Health programmes which have the reduction of specific diseases as primary objectives can be evaluated using indicators of disease incidence as a measure of effectiveness. Primary health care. as it has come to be defined, cannot be evaluated in this way, because its goals are the satisfaction of basic health needs--a much more comprehensive and intangible objective. Reduction in the incidence of and mortality from the major diseases in the community is a necessary but not sufficient indicator of effective primary health care. In this study, therefore, we do not concern ourselves with the impact on people's health of the primary health care services, but with their operation. Our objective is to assess how effectively and efficiently they function and the quality of care provided. (a) The primary health care concept The concept of primary health care involves the recognition of the principle that a number of different interventions need to be carried out together as part of a package; that to implement only a part of the package reduces the effectiveness even of the interventions which are implemented. This is because the factors which cause different diseases are closely interrelated, and because the effectiveness of one intervention or activity is usually dependent on the presence (or absence) of another. Increasing nutritional intakes in young children will be more successful in improving nutritional status if simultaneous improvements in sanitation are implemented or vaccination programmes carried out. An improvement in water supply will be of little benefit where people drink from dirty containers or do not wash their hands after using the latrine or before preparing and eating food. * The designing of such a package of activities is sometimes referred to as "'norm setting" or "microplanning".

An analogy may be helpful--though, as with most analogies, it must not be taken too literally. The image we have in mind is that of a barrel composed of vertical planks, each plank representing a group of health interventions, some more, some less sophisticated. For the barrel to hold any water, all planks should be present, even though some may be rotten and others not very big. The individual planks represent the least sophisticated activities at the base. building up to the more sophisticated at the top. A plank with a sound top but no base is useless. It is the base of the planks in which we are most interested. What are the minimum essential activities that constitute the primary health care package? Clearly there is no single recipe which is universally applicable. The disease pattern and resource constraints will be the main determinants of what constitutes such a minimum package for a given country.* The specification of these activities for Ghana's primary health care system provides the starting point for the evaluation strategy used in this study. The definition of required tasks, in relation to the priority health problems, constitutes a framework or "benchmark" against which to compare actual performance. We consider primary health care to be a functional concept embodying the following principles (WHO, 1965; King, 1966: Morley, 1973): (a) Activities should be relevant to priority health needs; the interventions should be effective against the major disease problems of the country. (b) Services should reach priority population groups such as those most at risk, e.g. mothers and young children, and those for whom health must be maximised to ensure productivity and economic development. (c) Services consist of an integrated package of interdependent activities including preventive and curative health care at the personal level, and also directed towards the general environment. (d) Health services are provided in liaison with other sector programmes, especially those sectors whose responsibilities include activities which have a major impact on health. (e) Communities participate in the organisation and control of health activities as well as. being involved directly in health actions. (f) Health services are efficient in operation; a given health output is achieved at the lowest possible cost. To maintain an acceptable quality of care there should be: (a) Defined work norms (manuals, standardised drug regimens, etc.). (b) Correct and economical use of drugs. (c) A good support system--both administrative and technical, e.g. supplies, transport, etc. regular inservice training and supervision. (d) An efficient system of record keeping which pro-

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IDS HEALTHGROUP

I.

IDENTIFICATION OF PRIORITY HEALTH PROBLKMS

2.

Specification of Requirements - the ~road interventions needed to deal with health problems (curative and prevent ire)

3.

Selection of Requirements which could feasibly be undertaken by a health care system

4.

DEFINITION OF FUNCTIONS OF HEALTH CARE SYSTD4 (Primary care level only)

5.

SPECIFICATION OF TASKS TO BE PERtrORMED IN RELATION TO FUNCTIO qS (select ion based on judgement about 'best practice' methods) (Appendix IA)

6.

SPECI, ICATION OF RESOURCES REQUIRED AND ORGANISATIONAL OBJECTIVES

(Appendix IB)

7.

CONSTRUCTION OF OBSERVATION SCHEDULES to describe performance of tasks~ resources and organisation of health services

8.

ANALYSIS AND INTERPRETATION OF INFORMATION GAINED IN 7

9.

USE OF C R I T ~ I A of ut ilisat ion

OF EFFECTIVE PERFORMANCE and indicators (Appendix 2)

Fig. 1. The evaluation process. vides accurate information on morbidity, coverage and achievements, which is used by staff and supervisors as a guide to decision making and which facilitates high quality and continuity of individual patient care.

(e) A satisfactory level of morale amongst health workers, facilitated by having well-defined staff policy, acceptable to all levels, and which includes specific prospects for career development and promotion. Finally, primary health care services should be responsible for: (a) Disseminating correct and relevant health education. (b) Promoting the provision of adequate basic health requirements, especially in the area of water, sanitation, nutrition and housing. While provision of, or increasing, food supply may not be a direct responsibility of the health sector, the primary health care concept includes promotional activities related to the provision of services to meet these basic health needs. 2. THE EVALUATION PROCESS

The steps that were taken in constructing the evaluation instrument and interpreting the results are summarised in Fig. 1. * This is further discussed in Chap. 3 : 3. t A list of priorities is given in IDS, 1978b: Table AI, together with the factors associated with these disease problems, where relevant. The main rationale for their selection is based on a mixture of severity, prevalence, and feasibility of management. + In practice, these functions of the health care system were derived directly from the identification of health problems, recognising that a range of other interventions which are outside the responsibilities of the health system is possible. The functions of the health care system are shown juxtaposed with priority health problems in IDS, 1978b: Table AI.

(a) Identification of priority health problems Although there are few reliable epidemiological data available, the general problems in Ghana are well known. Unpublished data on mortality obtained from the Centre for Health Statistics (1973) and published reports provided enough information to make reasonable assumptions about the relative prevalence and severity of diseases.* In addition, special studies from the Danfa Project and elsewhere (Ampofo, 1971) provided further data on which to select the priority health problems. To relate them more specifically to the districts studied, information was also obtained from interviews with health personnel in the field during the early phases of the field work, and some morbidity data were collected as part of the field work.t

(b) The definition of functions of the health care system and specification of tasks The definition of functions of the primary health care system in response to disease problems in theory requires at least two intermediate steps involving choices (steps 2 and 3 in Fig. 1). Firstly, because there is a chain of factors in the causation of individual disease problems, there are a number of possible interventions which could be made to interrupt this chain at different points. Some possible interventions at the village level, to interrupt such casual chains, are discussed in Chap. 5:6. Many of the possible interventions are socio-political or economic, or involve changes in individual or community behaviour; however, though often of immense potential benefit to health, such changes may be beyond the sphere of influence of a health care system. It is the selection of those requirements which can be met by a health care system that constitutes the next step (4 in Fig. 1).:~ These functions, and the diseases they must manage or prevent, are grouped organisationally to provide a framework for listing tasks (step 5 in Fig. l). Many of the tasks and interventions will have to be performed by a health worker of some kind--any-

Health needs and health services in rural Ghana thing from a part-time volunteer in the village to a doctor--but some can perfectly well be undertaken by a family member such as the mother, or even by patients themselves, given the means to do so. It does not matter who does the task as long as it is done, and done correctly. This is a centrally important point. It means that we can look again at the conventional task-allocations in a health care system, and the need ior indeed usefulness) of any particular set of tasks being performed by particular cadres, such as professionals or sub-professionals, for example. Concretely, it means that it is possible to allocate tasks and interventions to be undertaken by new types of health workers who have not yet been trained, e.g. at the village level, or indeed by villagers themselves. About four-fifths of the tasks we have identified do not require a qualified health worker. Although there is usually no one correct method of management or prevention of a specific disease, for most common conditions there is a general consensus amongst experts about what, in broad terms, constitutes good practice. It should be emphasised that it is not lack of knowledge about what needs to be done that is the main problem in developing countries, but rather a failure to implement existing knowledge. The definition of tasks also includes quantitative and time dimensions. It should, for example, specify the numbers of people for whom the tasks should be performed, and how often. It thus states the minimum level of care necessary to meet the basic health needs, a concept which is elaborated by King as "human rights for health" (King, 1974). The necessary tasks are listed in Appendix 1A. They were drawn up in consultation with colleagues in Ghana, both in the Ministry of Health and in the Community Health Department of the University of Ghana Medical School, Accra. (c) Spec!lication of resources and organisation necessary Having defined the tasks, the next step is the specification of resources required and the organisational framework necessary for the optimum performance of tasks. These "implementation targets" are designed to establish norms for the implementation of primary health care in the Ghana context. The implementation targets are not simply based on current practices, forms of organisation, and existing policies--that would not make possible the identification of the shortcomings of the PHC system as a whole (though problems in the performance of individual health workers might be highlighted). We have tried to formulate the necessary organisational and resource inputs with sufficient flexibility for these to be relevant to various policy options--as long as the option gives priority to primary health care and the satisfac* The Danfa and Kintampo projects and Bawku District services were used as reference projects. + It was not possible to eliminate subjectivity altogether. Ideally. it would have been desirable to test for replicability using different observers at the same units to estimate the degree of observer variation. Unfortunately we did not have time to do this. ~.The observation schedules shown in IDS, 1978b: App. 2 are the result of several modifications after experience with their use.

407

tion of basic health needs. In general terms the targets listed in Appendix IB were seen by Ghanaian advisers with experience of primary health care to be relevant to local circumstances. Some experimental, pilot and voluntary agency projects* in Ghana served as useful guides or models of what can be achieved, given appropriate resources and using relevant organisational principles. We believe that these "implementation targets" are not unrealistic objectives. However, as will be apparent from the research findings, current practices. policies and resource provision in the primary health care system are themselves major constraints to implementing these objectives. In other words, to achieve some of these objectives within the existing pattern or model of health services and manpower would require a level of resources which is unrealistic. The cause of the problems, therefore, should not be sought only in the malfunctioning of the "model" (though this does play a par0; even if the model were functioning optimally, it could not achieve the basic primary care objectives. So the evaluation tries to show where "implementation failure" is responsible for shortcomings, and where these are due to "model failure". It also attempts to highlight the structural changes which are required in the system for it to function more effectively. (d) Construction of observation schedules It is at this point that the tasks and implementation targets have to be specifically related to current practice in Ghana, because this is what is to be observed. In order to ascertain whether or not a task is being performed, we need to know who is likely to be performing it; to find out whether an organisational principle like the integration of preventive and curative child care is being implemented, we need information about the types of clinics. The data collected will relate to existing types of health units and staff categories, and to current systems of organisation and record keeping. The aim was to record observations which did not require medically qualified observers, and by specifying some observations in detail to eliminate subjectivity as far as possible.t In the event, some indicators had to be dropped and others substituted in the light of field experience, and after discussion with colleagues in Ghana.:~ These observation schedules and the criteria for effectiveness could be adapted where necessary to fit changed policies, and provide a basis to guide supervisors or those responsible for health worker training_ programmes. (e) The criteria and indicators of effective performance A list of criteria for judging effectiveness (Appendix 2) was developed to assess how far the information collected on current performance matched the tasks and implementation targets. In addition, indicators of utilisation (for MCH services in particular) were devised and used to assess the extent to which risk groups are reached, and how often. The following summarises the criteria and indicators used. Altogether 175 criteria were used, 93 of which reflect the quality of "output" from the health care system, 46

408

IDS HEALTHGROUP

the adequacy of resource "inputs", and 36 the organisational efficiency. These are categorised as follows: 1. Criteria for range and balance of service provision, including penetration into community (15). 2. Indicators for MCH utilisation or uptake of services (10). 3. Criteria for the quality of: (a) child care (20) (b) maternal care (17) (c) polyclinic care (15) (d) environmental sanitation service (16). 4. Criteria for amount and quality of resource provision (46). 5. Criteria for organisational efficiency of services (36). Criteria for resource adequacy are separated from other aspects of organisation in order to gain an understanding of how much resource inadequacies alone are responsible for the shortcomings. Although there is some merit in illustrating the size of this problem, it cannot really be separated from organisational problems. It is the way resources are organised and utilised in the health care system as a whole which determines their adequacy at the health unit level. The main value of the criteria was to use them as a checklist to provide a framework for identifying the major problems in the primary health care system as it is currently operating in Ghana. The use of a scoring system made it possible to "quantify" the results. By applying scores to each of the criteria in the above five groups, it is possible to derive an index of "quality" for each of the various components of the primary care system. An important problem in using a scoring system of this nature is that of weighting different criteria or groups of criteria. How much weight, for example, should be attached to transport as opposed to supervision, or how does one compare the prescribing of useless, ineffective drugs to not taking a proper history from a patient? We attempted to deal with this problem by having a panel of four doctors with experience of primary health care in Ghana. plus the medical doctor on the IDS team, individually place the criteria for quality of care in the polyclinic, child clinic and maternity clinic in three groups of decreasing importance. In the event agreement on the importance of these criteria was relatively high among the panel members.* Virtually all were placed in one of the two more important groups; those few which were ranked by the majority as of least importance have been excluded from the analysis. So each of the criteria used for assessing quality of care for these clinics has been given a weight of I or 2 points, based on the majority view of the panel. The criteria for assessing the quality of environmental sanitation services, the * For the polyclinic there was disagreement on only 3 out of 14 criteria. ~"Also the polyclinic indicators were only ranked by three panel members. Where health centre superintendents receive much of their practical training. Two dressing stations were evaluated (together, as one unit) where dressers had received recent inserviee training and received a high level of supervision.

quantity and range of service provision, resource and organisational efficiency and indicators of utilisation were not ranked in this way and have been given equal weighting. Appendix 2 shows how each of the criteria or indicators was scored. The resulting scores should, however, be used with some caution. In retrospect it appears that panel members had difficulties in deciding on relative weights to attach to individual criteria in the absence of clearly defined and agreed principles or objectives (e.g. patient satisfaction versus cost effectiveness versus contribution to community health), and as the panel never actually met, this issue was left unresolved.t Further, in more general terms, the use of simple additive scores gives an impression of greater precision in evaluation than is warranted; an item given the score of 2 points (e.g. the proper sterilisation of syringes) may be more than "twice as" important as an item which scores 1 point (e.g. not using expensive drugs). 3. A BRIEF DESCRIPTION OF THE RESEARCH METHODS USED

The research on the existing rural health care system required detailed assessment of the practice of primary care facilities together with an examination of the resource allocation to these institutions, the training and supervision of their personnel, and in general the support provided from higher levels of the health service. It was decided to undertake the assessment of all the primary care facilities in each of two districts (Birim and Jasikan) in different regions of the country, in order to obtain the maximum sample of institutions permitted by our resources of time and personnel, while also collecting data on coverage of the population of the two areas concerned, and gaining some understanding of the variables involved at district (and regional) level.

(a) The medical aspects Several days were spent at the majority of the sixteen health units studied in the Jasikan and Birim Districts, observing activities, collecting data from records and interviewing staff. The period of time required to complete the evaluation varied from one to five days, depending on the size and complexity of the unit. The following table gives the number of locations where different aspects of the health service were studied:

Health sector

Number of locations studied

Polyclinic Child health clinic House visits, etc. by CHNs Maternal health Environmental sanitation areas MFU teams Training schools

15 11 4 15 9 2 2 I + 3 brieflyl

In addition, polyclinics were observed at Kintampo Health CentFe,.* one of the newly operating village community clinics in Kintampo District, Danfa, and Bawku.~ MCH activities were observed at Danfa and

Health needs and health services in rural Ghana Bawku. These units provide some comparative data from innovative projects enjoying a good reputation, with access to more resources and, in some instances, an alternative organisational framework. Observation. One day was devoted to the observation of each of the following activities: polyclinic, child welfare clinic, antenatal clinic, home visits and outreach activities of the community health nurses, and the daily activities of the health inspectorate. As far as possible the observation was done on a "typical" day at each location. As part of the assessment of polyclinic care, all consultations of patients seen by the consulting health worker were recorded during a minimum of one hour's observation. For most units this represented between 15 and 20 patients, except for the smaller units which only see around 10 patients during the morning. Other activities involved in polyclinic care, e.g. the giving of injections, were observed as well as the general organisational features of the running of the unit. Some time was spent with the person responsible for records and registration at all clinics, to assess their reliability. All activities taking place at the child welfare clinic were observed, including weighing, nutrition and health education, vaccination and food distribution. Consultations were observed for at least one hour. Wherever possible the community health nurses were accompanied on house visits, chop bar and school inspections. Antenatal clinics were observed in the same way as the child welfare clinics, with at least one hour devoted to consultation. If there were any deliveries during the stay at the unit these were also attended by the observer. The Health Inspector or Assistant was accompanied on his daily work to observe house visits and the procedure for inspecting and supervising refuse dumps, latrines, chop bars. child care centres and communal labour activities. Four days were spent at the community health nurses" training school and one day at the health centre superintendents' course observing training activities in the field and classroom. Unfortunately it was not possible to observe the field activities of the Medical Field Unit because lack of transport confined them to their District Offices. Records. Data providing information on utilisation, coverage, disease incidence, the activities of health workers and the quality of individual patient care were collected from registration books, monthly, quarterly and annual reports, and individual patient records, at all clinics. Details on sample sizes are given in the text on each section. A special study of accessibility of polyclinic care was undertaken by plotting census data. and the findings Of a 1°o sample study of registration cards at all health units, onto large-scale maps. In the maternity section the delivery and referral books and the family planning records were also studied. Records of the daily activities of the health inspecrotate were examined where available, and monthly and annual reports were studied in the Oda District Office. An attempt was made to collect data relating to

409

communicable disease control, in particular of yaws, tuberculosis, measles and malaria. Records pertaining to these diseases were sought from the MFU. the health centres and posts, the health inspectorate and the district hospitals. Interviews. Information was obtained by interview rather than observation in areas where time was against direct observation, e.g. health inspectors were interviewed for information on water and sanitation projects and the provision of environmental health services in the whole of the area for which they were responsible. Information on supervision, training, supplies, transport and referral was elicited by interview. as well as by observation, whenever possible. All categories of health worker were interviewed on their perceptions of reasons for observed inadequacies, personal problems and aspirations, morale, and relationships with other b~alth staff and related Government departments, as well as the community.

(b) The economic aspects Data were collected on the allocation of resources at the national, regional and district level. The costs of individual institutions, and therefore the geographical distribution of resources is not known routinely in Ghana. Hence the research had to establish where resources were located in relation to the geographical distribution of the population. We analysed such published land unpublished) data as were available for national patterns of resource allocation. For our work in the Districts, the procedure was to aggregate the expenditure of each health facility from the accounts of the various payment centres for 1975/6. In the case of the Ministry of Health and District Council facilities this involved establishing the name of each individual health worker at each facility and finding their salaries and other expenses entered in the accounts of a number of payment centres. Expenditures on central and regional administration were not included, nor were the costs of the Medical Field Unit. The most important payment centres were the Central Medical Stores, the Regional Medical Stores (in the Eastern Region only), the Regional Headquarters and the District Hospitals. In Chapter 6:1 and 2 we set out these procedures in more detail, and also discuss their limitations. As the study proceeded it became increasingly apparent that the expenditure on drugs was so wasteful and so easily rectified that it overshadowed all other "implementation failures" from the point of view of the allocation of resources. To establish just how large the waste was, a special study on prescribing patterns was undertaken by means of a 1% sample of all consultations at one health centre in Birim District, supplemented by smaller samples at two further units. We priced the prescriptions given to patients in the four major diagnostic groups which accounted for between two-thirds and three-quarters of all cases, and compared these with prescriptions that constituted a "best practice" pattern, as established with the help of the Community Health Department of the University of Ghana Medical School. Further details are given in Chapter 4:4f and Chapter 6:5.

(c) The sociological aspects The village-level research (which also took place,

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IDS HEALTH GROUP

for reasons to be explained, in a third district-Tongu) had three main purposes. First, to aid the specification of target interventions, complementing the available data on mortality and morbidity and earlier studies of the causes of malnutrition and ill health, by investigating health problems and the way they are currently tackled in the villages. Second, to examine more generally the features of village society which bear upon the potential of a "community participation" approach. Third, to see "from both ends" some problems at the interface between the health services and the population. In each area where the studies were carried out, with minor variations, a number of villages were visited once, and one or two were studied in detail. Thus, a total of some 30 villages have been visited for periods ranging from two hours (with one formal interview with village representativesl to three weeks. Both formal questionnaires or schedules and free probing were used. A schedule of questions to ask village representatives and leaders at formal meetings was drawn up at the start of the research (in the course of pilot visits to two villages near Koforidua) and used throughout the work in Jasikan and Tongu Districts. It explored the formal aspects of general and health-related village organisation, but encouraged probing on informal aspects when circumstances

permitted. A questionnaire on health and nutrition practices was also drawn up at the start of the research proper in Jasikan District, to be used with a representative sample of village mothers of young children. This questionnaire was altered in the course of the research, as more was learnt both about the subject matter and about appropriate questions, and in Tongu District was divided into three: a Health Schedule (enquiring into health problems and how they are tackled, including environmental sanitation}; a Nutrition Schedule; and a Utilization Schedule (enquiring into 'the use made of various health institutions including the traditional ones}. In all areas key individuals were interviewed concerning their roles without any prepared schedule. In Birim District free probing of questions of interest largely replaced the use of formal schedules. In certain cases other, more appropriate methods were used. At Koru a census was undertaken, largely to throw light on the stratification pattern. In several villages, arm circumference or weight for age measurements were taken of under-fives, in an attempt to identify undernourished children before determining their social characteristics. Everywhere, informal conversation arose spontaneously, providing valuable leads. In half a dozen villages, the researcher stayed in the village during the course of the work.

HEALTH

CARE

PART II: IN JASIKAN AND BIRIM

DISTRICTS

P A R T II: H E A L T H CARE IN JASIKAN A N D B I R I M D I S T R I C T S C H A P T E R 3. T H E D I S T R I C T S T U D I E S A N D T H E I R C O N T E X T

i. THE WIDER CONTEXT OF THE EMPIRICAL STUDY: RESOURCE ALLOCATION AND HEALTH SERVICES EXPENDITURE IN GHANA

Although there is widespread recognition that government health services have failed to meet the needs of most people in developing countries, very few have managed to do much to alter this. In Ghana, the latest Five Year Development Plan is particularly specific and states that "... the coverage of the health services is still inadequate. The modern health services appear to reach not more than a third of the total population" (Plan, Volume II, p. 366); "the pattern of resource allocation has tended to favour the upper end of the institutional hierarchy thereby increasing the health resources that have been available to the urban few and denying resources to the rural people who form the majority of our population" (Plan, Volume II, p. 370). The extent of the inequity of the distribution of resources has been demonstrated recently by the researches of Professor Ofosu-Amaah (1975). Here the 1974/5 Budget estimates were re-worked to show the Regional breakdown of health expenditure and the division between curative and preventive services; the per capita medical care resources allocated to the Greater Accra Region were, for instance, nearly three times the allocation to Brong-Ahafo Region (¢7.84 as opposed to ¢2.81) and eight and a half times if the massive expenditure on the Korle-Bu Teaching Hospital* were to be included as part of the services of Greater Accra (see Tables 1, 2 and 3). The Government has committed itself in the Plan to correcting the situation; "the Government... will emphasise.., the expansion of the primary care segment by extending the distribution of health centres and health posts to as many settlements as possible and by developing the promotive and preventive services. Government will seek the involvement of the local communities in efforts to satisfy their own simple needs" (Plan, Volume II, p. 371). It is not possible to see from the recent budgets the extent to which regional disparities in health expenditure have actually been corrected, because many large items such as drug costs are incorporated under the heading of General Administration. and are not shown on a regional basis. We therefore had to look at figures that excluded those items (which Professor

Ofosu-Amaah actually allocated by region after a detailed investigation). But the situation still seemed to be similar: by the 1976/7 Budget the Greater Accra Region received over three times the per capita expenditure on "Medical Care" (excluding drugs) of BrongAhafo (¢3.93 as opposed to ¢1.22), and there was no reason to expect the picture to be very different for other categories of expenditure. By the end of 1975 in the Government Services 12% of doctors, 36% of professional midwives and 24% of senior nursing staff were serving 82% of the population living in localities of less than 20,000 people.t The future looks particularly bleak when even the Plan's commitment to reallocate resources was contradicted by the actual allocations within the Plan. For in the Capital Budget- 1.86 times as much was to be spent at Korle-Bu and other hospitals as was to be spent on health centres and health posts, thus worsening still further the imbalance between primary and secondary/tertiary health care institutions. But it is hardly surprising that the maldistribution that persists and the Government's attempts are contradictory. Firstly, the proportion of the health budget in any one year that is effectively not committed by past decisions, and could therefore be used to finance new policies, is miniscule. Over 80?/0 of Ministry of Health Funds have been for recurrent expenditure and presumably quite a high proportion of the remaining 16% for capital expenditure was committed to finishing projects started in previous years. Secondly, the apparent growth in the health expenditure from the 1970/71 budget estimates of ¢107.6 m is over 300% but when these figures are corrected for inflation and expressed in 1973/4 prices, the growth is a mere 2% in seven years, with population growth running over 2% every year (see Table 4). In fact, the health budget has fallen in "real" per capita terms in recent years, further reducing the ability of Government to allocate resources to the places where the people live. Thirdly, the bias in the distribution of health services is similar to the bias in other goods and services. Power resides in Accra, and other urban centres and resources are concentrated there. Furthermore, the kind of service that exists in the urban area Table 1. Functional allocation as a percentage of health budget Recurrent

(%)

* There has, however, been a decrease m the inequality

of resource distribution on a per capita basis in the 1977/78 budget estimates, as a result of new budget estimate procedures initiated by the Health Planning Unit. + See 1970 Census and Table 1B of untitled mimeographed tables produced by the Centre for Health Statistics. 411

Capital

Total

(%)

(%)

Headquarters Medical care

2.7 78.6

2.1 84.9

2.6 79.6

Public health Training

13.0 5.7 100.0

4.7 8.3 100.0

11.7 6.1 100.0

IDS HEALTHGROUP

412

Table 2. Allocation by region (¢) Region Korle-Bu Hospital Greater Accra Volta Region Eastern Region Central Region Western Region Ashanti Region Brong Ahafo R e g i o n Northern Region Upper Region Headquarters

Medical care

Public health

17,960,407 8,766,807 4,317,803 6,737,832 5,461.555 5,032,039 7.905,942 2,464,891 3,719,263 3,473,912 325.114 66.215,565

is predominantly hospital-based and curative in nature, that is, required by people whose nutritional and sanitation requirements are already satisfied. It is this minority who dominate the society and are also pressing for "'standards" to be improved in the hospitals, even if the consequent expenditure is at the expense of others who as yet do not have basic health care. Within the straitjacket imposed by power, inflation and the inertia of past decisions, it is to be expected that change will be slow and hard won; for in these circumstances redistribution of resources will involve the relocation (and retraining) of people already employed in towns or the running of the urban facilities which currently absorb such large proportions of the recurrent budget. Biat resource~ for the expansion of the health care services to those tens of thousands of people denied access may still be found in the short term, and within the current distribution of resources, because these resources are both underutilised and used inefficiently. It is for this reason that this study concentrates on the rural areas, where the mass of people live and where the changes will have to take place. It is also for this reason that new ways of doing things are sought, in order to break out of the conventional constraints of ideology and resources to the provision of health care to the mass of people. As we shall see, even at the District level, Ministry of Health resources were concentrated at the hospital end of the health care spectrum (Chap. 6:4), and in the Districts resources existed which could be far better utilised. The simplest way to save money would seem to be from the substantial waste of drugs,* but considerable "savings" of human resources, both inside and outside the Government system, could also be made and used to extend a more appropriate service to many more people. For instance, the resource contribution which communities can make to their own health care has been largely ignored until recently in Ghana. as in most other non-communist developing countries. The resources now being considered from this source throughout the world largely consist of contributions in the form of cheap labour teither as village health workers or in mass actiont, * 80°., of some institutions" costs went on drugs and other stores, and a "best practice" prescribing pattern would appear to cost only one-third of the current practice.

-1,340,306 1.216,986 1,100,779 1,351.614 1,147,374 907,932 740,014 759,588 814,706 490,795 9.870,094

Training

Total

-2,141,758 519,675 495,096 363,597 218,438 648,686 190,556 ' 286,296 211,898 28,660 5.104,660

17,960,407 12,248,871 6.054,464 8.333,707 7.176,766 7,260,058 9,462,560 3.395,461 4.765,147 4.500,516 884,969 81.190.319

and these possibilities are explored in the research. But however large the contribution from the people themselves, the case is not diminished for the government to redistribute its own resources more equitably and more efficiently. The research then explored at the local level the inefficiencies and inadequacies of the existing health system from both the economic and medical point of view. In addition it examined the sociological context of the villages in which health care must be provided in order to identify those aspects of village life that can be utilised by the people and the health services. There are clearly a number of levels at which inadequacy and inefficiency can be "explained" in the health care and resource allocation systems. Much of this research concentrated on the most "micro" levels of explanation: explanations in terms of individuals' perception of their tasks, or the lack of complementary resources of supervision, supplies and training at the point of contact with the public. But it is important to set this level of explanation in the wider context of the overall forces operating throughout the society. As we explored problems at the District level we were continuously being led back "up" the system, to decisions made by people in Accra and to more Table 3. Allocation per capita for regions--medical care (¢1

Korle-Bu* Greater Accra Volta Region Eastern Region Central Region Western Region Ashanti Region Northern Region Brong Aha[o Region Upper Region Mean

Recurrent

Capital

Total

14.41 6.35 3.19 3.91 4.95 4.85 3.80 3.38 2.22 2.93 5.65

1.65 1.49 0.94 1.07 0.69 1.10 0.83 1.01 0.59 0.82 1.14

16.06 7.84 4.13 4.98 5.64 5.95 4.63 4.38 2.81 3.76 6.79

* Assuming that only the people in Greater Accra had access to Korle-Bu. If on the other hand it is assumed that 20°0 of all the people of Ghana had equal access to Korle-Bu Hospital. the per capita allocation for these persons at Korle-Bu would be ¢9.25. Tables 1-~ have been reproduced from Ofosu-Amaah S. Reflections on the health budget. Ghana Med. J. 14, Tables 6. 7. 8, 1975.

413

Health needs and health services in rural Ghana Table 4. Current account health expenditure at constant 1973/4 prices*

Financial year July-June 1970/71 actuals 1971/72 actuals 1972/73 revised estimate 1973/'74 estimated 1974/75 estimated 1975./76 estimated 1976/'77 estimated

Expenditure in current prices (¢ million)

Consumer p r i c e index 1963 = 100 (mid-yearJ'l

Consumer price index converted to 1973/74 = 100

Expenditure in constant 1973.74 prices

34.5 34.0 44.0 54.4 66.9 93.0 107.6

197.25 216.35 226.6 270.9 362.1 506.5 604.1,+

72.8 79.9 83.6 100.00 133.7 187.0 223.0

47.4 42.55 52.6 54.4 50.0 49.7 48.3

* These figures are based on budget estimates, and the effects of inflation may have been countered by overspending. and supplementary votes. Indices converted from calendar to financial year by taking midpoint. 1976/77 index is that for January to October 1976. Sources: Brooks R. G. Issues in the Financing of the Ghanaian Health Sector (mimeo). Government of Ghana: Annual Estimates, 1974/75 to 1976/77. Central Bureau of Statistics: Statistical Newsletter 37/76.

"macro" levels of explanation. We have not, in our work, been able to devote more than passing attention to those macro-factors, and we see this as a regrettable limitation to the contribution we may be able to make to the understanding (and overcoming) of these problems. But some issues can be identified. The most immediate impact of these larger forces was felt in the massive cuts in the real income of the health service employees due to fixed wage levels and rapid rates of inflation. The salaries operating in the health service, at least until August 1977, were at rates set on July 1st, 1974 (see budget Estimates 1976/7, Vol. X). By November 1976 the real value of these salaries had been cut by over half, so that by the end of 1976 the purchasing power of a health centre superintendent's salary at ~:2178 p.a. was reduced to ~'946 at 1974 prices.* Such a fall in real purchasing power was likely to have a considerable negative effect on the morale of the Service and to encourage people to supplement their incomes by other activities, both legal and illegal. Indeed one health supervisor was observed encouraging community health nurses to supplement their incomes by petty trading and farming, even though this could only have been done by reducing the time and effort devoted to their health work. This level of inflation clearly affected all aspects of the health service by making budget allocations insufficient to cover the cost of particular activities. This was seen not only in capital projects running out of funds before work was completed, but also in inadequate allowances for travel expenditure or the purchase of vehicles. More indirectly, such levels of inflation have a tendency to lead to financial indiscipline and they undermine attempts to tighteia up budgeting procedures. The Plan document identifies overspending by Government Departments on recurrent account as a major cause of inflation (pp. 4 and 20, Vol. I) and "'measures [will be taken in the Plan Period] for strict

control of Governmental expenditures.., to eliminate remaining areas of waste" (p. 21). If such control were effective and nothing else were to change, the Ministry of Heaith's activity would be considerably disrupted, as the effective result in a continuing inflationary situation would be a lowering of available resources in real terms. The second cause of inflation and another dominating influence in Ghanaian society was the over-valuation of the local currency against world currencies. The Plan describes how there was in Ghana "'a process of continuing over-valuation of the Cedi which is generating pressures that are becoming extremely difficult to contain in spite of exchange controls, fairly high import taxes, quantitative restrictions and export subsidies" (Plan, Volume I, p. 40). At the general level, the over-valuation meant that non-government exports became impossible to sell abroad with subsequent harmful effects on the growth of the economy and dependence on (government controlled) cocoa exports. On the import side it meant that foreign goods appeared excessively cheap, and had therefore to be controlled by import licences. The authors of the Plan regretted that under those economic conditions in Ghana people were more interested in "commercial" transactions rather than "direct, physical production" (Plan, Volume I, p. 20). The over-valuation had direct and contradictory effects on the health sector. On the one hand, those imports for which the Ministry of Health managed to get import licences appeared excessivelY cheap. This meant that expenditures on drugs appeared to take up a much smaller proportion of the budget than would be implied by the real cost of foreign exchange to the Ghanaian economy. At the time of the study the allocation for drugs and other '~unaliocated'" stores was about 22~d of the recurrent budget at ¢24m (see 1976/'7 Budget estimatesk but their "real'" cost might be something nearer twice that amount. On the other hand, the import controls and lack of foreign exchange from exports meant that the health * Price Index 1974 = 315.3: November 1976 = 725.8 service was starved of vehicles, spare parts and equipwith 1963 = 100. Source: Newsletters of Central Bureau of ment. Indirectly, the over-valuation added to the rewards Statistics and the monthly Economic Bulletin of the Ghana Commercial Bank. Februar) 1977. to be had from smuggling goods out of the country in

414

IDS HEALTH GROUP

return for "hard" convertible currencies; these goods one government hospital (but not more). Since the might include food, cocoa and items, such as drugs, research concerned rural health care, districts containing a regional capital or located near the main cities stolen from the health system. A third factor which seems to have had a pervasive were avoided, as were districts which were unusually influence on the working of the health care system rich. The choice fell upon the Volta and Eastern Regions was the apparent reluctance to delegate responsibility in Ghana. In the health care system this resulted in (not uninfluenced by the suggestion of the HPU and even district medical officers not having the power to of ISSER, and by the interest shown by the Regional switch funds between accounts without an elaborate Medical Officers of Health), and on the Jasikan and clearance procedure. Huge amounts of time Birim Districts within these regions. Village-level and effort were wasted at the lower level units research was also done in Tongu District, Volta because of claims for reimbursement for amounts of Region. Jasikan could not serve exactly as a substitute for a money trivial to the overall health budget but most significant to the individuals concerned. This general district in the north of Ghana, but it has something of lack of trust (which also seems to operate in the the North's remoteness and poor development of inreverse direction) stifled innovation and reinforced frastructure, while nevertheless having a full complepeople in doing tasks that they knew to be inappro- ment of health facilities. Birim, on the other hand, is priate just because some instruction had been issued more typical of southern Ghana in terms of accessifrom "higher up". Nowhere was this effect more bility, infrastructural development, and the urban noticeable than in the filling in of inappropriate forms character of its district capital, Akim Oda. Both districts are, however, in the forest zone with (often wrongly) and in the accounting procedures. This section has outlined a number of "macro" cocoa planting the most important economic activity. forces which constituted constraints to effective health Cocoa has brought a certain comparative prosperity, services (and many other kinds of change). How im- at least to some sections of the population. For these mutable these constraints are perceived to be largely reasons, it was desirable to look also at village-level determines what is considered an appropriate strategy problems elsewhere. The district chosen was Tongu, a of action in Ghana. Some considered major changes relatively dry, flat savanna zone in the south of the to be impossible, and the appropriate action was seen Volta Region, where there are no cash crops of any in terms of a large number of small actions taken over importance. Cattle are reared, but not by the indigentime. But there were others who would see even small ous population. Agriculture is confined mainly to subchange as impossible, or pointless, and for them more sistence crops, with what is surplus to household redrastic and fundamental action was the conclusion. quirements being sold. While migrants (especially Part of this difference of opinion was a matter of the fishermen) remit funds back to the district, much of it time horizon chosen for the policy frame, and much is poor; apart from the Accra-Lome highway, there heat was generated by a confusion of short- and long- are no surfaced roads, and many villages become term strategies. In our research we have tried to strike inaccessible to vehicles in the rainy season. Other ina balance by exploring the possibility of change frastructure is also poorly developed: for instance, within the existing constraints, and then examining there is no domestic water supply in the district capithe possibility for change over a longer period, during tal, Sogakope, the residents going to the banks of the which time such constraints might be modified by Volta river for their water. Electricity pylons carry other actions and developments. But the decision as power through the District from Akosombo to Togo, to what can and should be done, and when, ultimately and Benin, but do not serve the villages near their must be made in Ghana, and by Ghanaians alone. We path. Ethnically the district is homogeneous, comprising merely hope that we may have made the choices somewhat clearer, and thereby perhaps the decisions the Tongu sub-group of the Ewe. There is little stratification within villages, and in this context of homsomewhat easier. ogeneity and relative equality the system of hierarchical chieftaincy is also poorly developed. The choice of 2. THE CHOICE OF DISTRICTS Tongu for some further village level work also meant that the representation of ethnic groups (with differThe limitations of time and resources meant that the research on health facilities had to be confined to ent social organisational features) was improved: just two districts (village-level work was extended to a Tongu has a purely Ewe population while Birim is a third). Representativeness had to be achieved, as far typical matrilineal Akan area, and Jasikan a heterogeneous area with much new settlement and several as possible, by the choice of "typical" districts. The limitations mentioned precluded working in a district small ethnic groups. But only in the latter two disin the north of Ghana as well as one in the south, so tricts did we study the coverage, quality and econthe problem was one of choosing two districts in the omics of the primary health care service, as well as south, which between them could be considered as issues of primary health care as seen from the villages. typical as possible of the country as a whole. At the same time we wanted to choose districts which could (a) General characteristics of Birim District Birim District is the most westerly district of the be seen to represent if not best current practice, at least fair current practice in the field of health care (as Eastern Region, and lies in the heart of the "golden triangle", the area bounded by Accra-Tem& we saw no point in studying areas generally conKumasi, and Sekondi-Takoradi. This is the area of sidered below average). So we decided to look for districts relatively well endowed with the range of generally greatest all-round "modernisation" in Ghana, and Birim is a representative rural part of it. government health facilities of primary care level and

Health needs and health services in rural Ghana

415

The economy is founded on cocoa, but there is also town of Worawora" Buems in much of the south, inextensive forestry and open-east diamond mining. The cluding the town of Jasikan, together with other even District was formed in 1975 by the amalgamation of smaller groups. In general, the indigenous population three former local councils--Abirem, Oda and Birim groups maintain their political and numerical dominAnafo. The total population at the 1970 census was ance in the towns and larger villages, while the in168,068, and projecting a 2°o p.a. rate of population migrants predominate in the smaller villages and growth would give a 1976 population of around hamlets newly established during the expansion of 189,000. cocoa cultivation. In general, also, members of the The principal town is Akim Oda (Oda), population indigenous population have taken advantage of their 21,000 (1970 census), located about 130km from rights to the land and are better off than the inAccra and 120km from Koforidua, the Eastern migrants. Region capital. Oda is now an important timber and The largely Akan population, who were displaced cocoa town. Communications in the District are rela- from their fertile valleys by the formation of the Volta tively good: main roads through Akroso--Manso- Lake, were resettled in lakeside settlements where the Oda-Achiase are surfaced and the railway runs land, generally of poorer quality, was insufficient for through Oda itself and the southern part of the Dis- their needs as well as those of the existing population trict. Rains from May to July regularly make the there. Little has been done to solve this problem and laterite roads impassable to most vehicles. the lakeside settlements are among the poorest in the The indigenous population of the District belongs District. The lake also brought other settlers: Ewe to the Akim subgroup of the (matrilineal) Akan. fishermen from the south (where the dam damaged Numerous in-migrants from a variety of places are fishing on the lower reaches of the Volta River and scattered among the indigenous population, having associated lagoons) come to take advantage of the been attracted by the economic opportunities. There fishing prospects of the lake--with only mediocre is very considerable stratification in economic terms. results to date. The traditional hierarchy is highly developed, as is Despite the unusual ethnic and linguistic heterogeneral in the Akan area, with strong emphasis on geneity of the area, there are cultural similarities formality and respect of dignity. The typical size of between the groups, probably as a result of long village settlements is larger than in the Jasikan or contact and interaction. Ewe is the lingua franca of Tongu Districts, though in all three districts the main the District, though it is by no means spoken by all, villages tend to have smaller hamlets in their vicinity. particularly in the northern Akan towns. However. the area's ethnic heterogeneity has caused certain (b) General characteristics of Jasikan District problems, for example, in towns of mixed ethnic Jasikan District is located in the north of the Volta composition, where traditional authority is extremely Region, between the Volta Lake and the Togolese weak because there is no consensus to recognise one border. It was formed by the amalgamation of four authority. local councils: Biakoye, Buem, Akan Bowiri and Akan Wawa. The population in 1970 was 170,876 (approx 192,000 in 1976 assuming an annual increase 3. A HEALTH PROFILE OF THE DISTRICTS of 20/o). To the north is the relatively underdeveloped Data for establishing the health status of the people and sparsely populated Nkwanta District. To the south is Kpandu District, and it is in the southerly of Ghana are incomplete and of doubtful validity. The direction that Jasikan District is oriented in terms of overall picture, however, is relatively clear. Infant the movement of people and goods: in particular to mortality is estimated to be ll3/1000 live births for the marketing centre of Hohoe, which lies some the Volta Region and 100/1000 for the Eastern 35 km away from Jasikan Town, just south of the Region, as compared with 63/1000 for Accra (Gaisie, boundary in Kpandu District. Within Jasikan District 1968-69). Maternal mortality is broadly estimated at roads between towns were not in good condition at over 14 per 1000 deliveries in the rural areas (NHPU, the time of the research. The District capital is Sept. '77, pp. 11-72). There are thus wide differences Jasikan Town (population 6403 in 1970), which is in health status between the population in the capital some 120km from the Regional capital at Ho. The and those who live in rural areas of Ghana. district hospital and the DMO's office are situated at Deaths due to infective and parasitic diseases, perithe western side of the District, at Worawora (popula- natal conditions and complications of pregnancy tion 4499 in 1970). account for 559~, of all deaths (GIMPA2 1975). Deaths The social characteristics of Jasikan District are de- in children under five account for approximately 50% termined largely by the spread of cocoa cultivation to of all deaths. The main causes of certified deaths the area in the first half of this century. Cocoa is (which represent only 15~o of deaths in Ghana) were extensively planted and is by far the major source of given in 1973 (in descending order of importance) as cash income. It has attracted predominantly Ewe in- respiratory infections, perinatal disease and birth migrants from further south in the Volta Region and injuries, diarrhoeal diseases, measles and malaria. from Togo, together with smaller numbers from the These are followed in importance by a second group ethnic groups to the north. The indigenous popula- comprising tuberculosis, malignant neoplasms, tion was already heterogeneous, consisting of Akans tetanus, anaemias, meningitis, cerebrovascular and in the northern half of the District and including the heart diseases, and typhoid. A third group of important causes of death are infective hepatitis, overt mal* Source: Analysis of Causes of Deaths, 1968-73 from nutrition and complications of pregnancy and childCentre for Health Statistics. birth.* The most important causes of maternal m o r -

416

IDS HEALTHGROUP

tality are ruptured uterus, post partum haemorrhage, toxaemia and puerperal sepsis. The incomplete data we have on morbidity in Jasikan and Birim districts* suggests that the problems common to (southern) Ghana as a whole are found in these districts also: fever/malaria, gastrointestinal disorders, respiratory tract infections, measles, injuries and accidents. Of the diseases which are more focal, being dependent on a vector with a limited habitat, three are of some importance in these districts: onchocerciasis, schistosomiasis, and guinea worm. Onchocerciasis is particularly prevalent in the northern part of Jasikan District, where one village visited had a high percentage of blind people; schistosomiasis is prevalent along the lake-shore in Jasikan District, but is not an important problem elsewhere in the two Districts (though it is in other areas including Tongu District); guinea worm is highly focal to particular villages, at least in Jasikan District, but here it may also be a severe problem. Other diseases are not focal to the same degree, but incidence varies. Of these, there is some indication that tuberculosis may be particularly prevalent in Birim District (200 new cases were diagnosed in the six-month period November 1976--May 1977). Anaemia, particularly during pregnancy, is very cornmort, especially in the northern parts of Jasikan District. Yaws is prevalent in Jasikan District but not in Birim. It may be presumed that diseases such as polio and sickle cell disease are as common as in southern Ghana as a whole. Meningitis appears to be an important problem in Jasikan, as the third most common condition recorded at the outpatients department of the district hospital. 4. T H E P R O V I S I O N O F H E A L T H SERVICES IN T H E DISTRICTS

Ghana is administratively divided into nine Regions which are subdivided into Districts. At District level there are four agencies which may be involved in the organisation of health services: the Ministry of Health, the Distruct Council the Missions and private individuals. The Ministry of Health is responsible for the operation of government hospitals, health centres and posts, the Medical Field Unit, and training programmes. The District Council organises environmental sanitation services and may be involved in running health units. The Missions tend to set up hospitals, maternity units and polyclinics in response to felt needs in their parochial areas. They hold the majority of the satellite clinics because of their greater access to transport. The most common type of western style private health unit is the mater* These data derive from the monthly HOP.I.C. returns, which provide some information about reasons for outpatient attendances. However, differences in diagnostic ability, confusion on the part of health workers about the most appropriate diagnostic category to use, given the large number of disease categories listed, and differences in methods used to complete the returns {i.e. new attenders only, or both new and old) make these data of doubtful value.

nity home, although one or two private polyclinics were seen.

In theory the District Medical Officer is responsible to the Regional Medical Officer for all aspects of medical services in the District. In practice he does not perform such a universal role, and the administration of the District from the Region is carried out through a series of line relationships linking professionals such as the pharmacist, public health nurse and health inspector with their regional counterparts. There is no management team at District level, and regular contact between District and Region seems to be mainly restricted to the forwarding of statistical returns and the ordering of drugs and equipment. Interactions between the agencies concerned with primary health care in the District were minimal. At District level there was little consultation or co-ordination between Mission and Ministry of Health and neither had a common forum with the District Council health workers. At District level there was no obvious source of overall control of health institutions.

(a) Birim Ministry of Health, Mission and privately operated health units existed in Birim District, as well as the District Council environmental sanitation service and the Medical Field Unit. There were five Government units: one 125 bed hospital (Oda), three health centres (Achiase, Brenasi and New Abirem) and one health post (Anyanase). In addition there was a completed but unopened health centre at Akrose. There was a training school for community health nurses and enrolled nurses in Oda. The units at Brenasi and Anyanase were built at District Council initiative and were subsequently taken over by the Ministry of Health. There were Mission health units at Swedru, Ofoase and Ntronang. Swedru, in addition to its orphanage, ran a daily polyclinic and satellite clinics at Aperade and Akrose. Ofoase and Ntronang were maternity units providing child-care and polyclinic services. Ofoase held a daily polyclinic and satellite clinics at Ntronang, Chia, Nwateng, Akokoaso, Adwaro, Ayirebi and Asabadee. There were private maternity units in Oda (two) and Pankase, and a private polyclinic was held at Ayirebi.

(b) Jasikan Jasikan District differs from Birim in that it had four District Council units, as well as Ministry of Health, Mission and private units. There were five Government units: one 157 bed hospital (Worawora), two health centres (Kadjebi and Dodo Amanfrom) and two health posts (Jasikan and Ahamansu). The District Council was responsible for two maternity units providing daily polyclinics (Nkonya Wurapong and New Ayoma) and two dressing stations (Abotoase and Lolobi Kumasi), as well as environmental sanitation services. A Medical Field Unit team operated from Jasikan. There was a Mission Hospital of approximately 50 beds at Dodi Papase, which also held two satellite clinics. There was a private maternity home in Jasikan.

CHAPTER 4. HEALTH NEEDS AND HEALTH SERVICES IN THE DISTRICTS S T U D I E D - - P A R T A I. T H E VILLAGERS" RANGE OF O P T I O N S FOR H E A L T H CARE

Our information regarding the villagers" own response to the existence or non-existence of modern health care facilities, obtained in the course of the village field work,* is presented here, before we deal with the provision of health care services. Poor modern health service provision merely reinforces such modes of response as villagers have traditionally had to ill health (Twumasi, 1975): it is proper that we give these due consideration in this discussion too. Rural Ghanaians have recourse to a wide variety of sources of treatment when they are ill.* Among the features we have found apparently influencing where people go for treatment are the following: type of illness, age of patient, ease of access to the facility, reception given at the facility, and educational and religious background of the patient. These influences can best be seen in terms of two types of factor operating when a decision has to be made about (i) the categorisation of the treatment needed by the patient and/or his family, neighbours and friends: and {ii) the effort (including the expense and unpleasantness} involved in obtaining treatment.

(a) Factors affectin9 the categorisation of the treatment needed Age of patient. The common diseases of very young

suspect they have caused any illness by magical means (juju) and will have recourse to fetish priests. Madness and psychosomatic diseases are particularly often ascribed to witchcraft and taken to fetish priests for treatment. Chronicity of illness. Chronic diseases which are not cured but are adeviated by a variety of treatments call naturally for an eclectic approach in which a variety of therapies, including those offered by the spiritual churches, are tried. Herbalists often specialise in particular kinds of chronic disease, such as rheumatism. Seriousness of illness. The seriousness affects, o f course, the lengths to which the patient or his family will go in the search for treatment. A case which is considered serious but curable will be taken to hospital rather than to primary institutions. Similarly, people will travel,considerable distances to see herbalists with a reputation in curing certain types of illness. or to a supernatural healer with a wide reputation. The dimension of seriousness may lead from one mode of treatment to another, however. In particular it may lead at one level from the local nonprofessional herbalist to the modern medical system. while at a higher level, for those whom the techniques of modern medicine cannot help, it may lead back to the indigenous practitioner, this time the professional

children in G h a n a are generally amenable to modern medicine. Respondents uniformly reported taking such cases to government institutions (health centres, etc.). It is considered that the younger the baby the more vulnerable it is to such disease. From one year of age self-treatment is usually regarded as satisfactory. If the child does not recover after initial treatment with herbal or other commercial home remedies, the next recourse is to the modern facility, specifically the health centre or post. Superficiality of complaint. C o m m o n skin infections. superficial cuts, etc. will be treated with self-administered herbal remedies. Urgency of complaint. Snakebite and convulsions are generally taken to the traditional practitioner in the village. This is also the case with childbirth, especially when the labour commences at night. In some areas traditional birth attenda.nts are older women in the village: in others, the local traditional practitioners, including males. Suspected cause of illness. Illness in G h a n a is often ascribed to witchcraft. Pregnancy is a particularly susceptible period, but at any time those who suspect others of envy or evil intent will be inclined also to * The quotations in the text are from our field notes andor interview schedules. + See IDS. 1978b: App. 4 for a more precise typological exercise, 417

one.

Such conditions as hernia, childbirth complications and TB are said to be taken to hospital. In the case of bone fractures in particular, traditional bonesetters are often recognised as being able to deal with even the serious cases well. Infertility, impotence and venereal diseases. There is some indication that because of the shame attaching' to these conditions, or just because their intimate nature may require less social distance between patient and doctor, they may be taken to indigenous practitioners in preference to modern ones. At any rate, they figure in the lists of complaints which the traditional healers claim to heal. Characteristics of the patient. It is not the case in G h a n a that educated (or Christian) people always seek modern medicine or shun the indigenous mode of treatment. However, there is a strong tendenc) for formal discussion about medical need to concentrate upon modern medicine, even at village level, indicating the lower esteem in which the other modes of treatment are apparently held within what might be called the "'educated universe of discourse". It would follow that the more familiar the individual is with this universe of discourse the more likely he is. on the whole, to prefer Western medicine.

(b) Factors affectin 9 effort invoh'ed in obtaining treatment Distance. The most important factor affecting access is. of course, distance in terms of time spent in

IDS HEALTHGROUP

418

travel, and the cost involved in travel. This is reflected in the strong demand (or felt need), voiced in all the villages visited, for some form of health facility to be available on the spot. The demand for Western medicine is greatly obscured by the lack of access which prevents it from becoming effective. The effect of this constraint is greater on the poorer sections of the village community than on the better off. It also leads to a situation where cases are not taken to health facilities until they become severe, by which time it may be too late. Fees. The choice of facility used is sometimes affected by fees, or at least this is said by villagers to be influencing their choice. However, this effect is overlaid by the one discussed below. Speed and attentiveness in treatment. Complaints were frequently made at the delays involved in treatment at the government facilities. Sometimes they were unfavourably compared with mission clinics in this respect, although there seems to be little objective basis for this contrast: perhaps it is an indirect way of referring to the greater attentiveness or better reception which was also frequently mentioned as a characteristic of the mission institutions. Indigenous healers are also held to be more attentive and understanding towards the patient. (c) Conclusion The felt need for modern medical facilities to be located within easy access in the villages is not in contradiction with the continuing use of indigenous herbal and supernatural modes of treatment. The availability of modern medical institutions for primary care would displace largely the currently prevalent self-treatment with herbs or with drugs purchased from drug peddlers, and the herbal treatment by local non-professional herbalists within villages. It is acknowledged in the villages that it would replace amateur or inexpert forms of treatment by forms which are more reliable, rather than constituting competition for the professional herbalists and fetish priests. In the villages we have visited, there has been no indication that indigenous practitioners would oppose the introduction of modern medicine. 2. THE RANGE OF SERVICES OFFERED FROM THE HEALTH UNITS

We now turn our attention to the modern health services. Our criteria (Chap. 2:1) assume that proper * Details of the criteria used here can be found in IDS, 1978b: Table A2 which also gives the overall scores for each unit. These scores were arrived at by adding the scores on the separate criteria (not weighted in this case), which represent the different areas of activity needed for a minimally satisfactory primary health care service in Ghana. ¢ We did not include environmental sanitation services in this overall score, because in most cases these are not provided from the health unit, but from a separate office in the town, or from a nearby town. Some environmental sanitation services were provided in all towns where health units were situated--but see text. :~In order to compare the health units studied with this "best feasible" situation, we have also expressed the score for each unit in relation to that of Danfa, on a scale of 0-100.

primary care involves providing a certain minimum range of services to a certain minimum standard. This section deals exclusively with the former problem--in terms of our earlier analogy, it assesses the completeness of the barrel, i.e. whether all the planks are there, but does not deal with the state of those planks that are found. Thus, the actual activities undertaken under each heading, as well as the quality of care, will be discussed later. In Ghana today there are considerable differences in the range of activities which different kinds of health units are expected to undertake, even though all are seen as being concerned with primary care, or some aspect(s) of it. A large health centre supposedly providing an adequate range of services to the local population is more fairly tested against our criteria than a small dressing station with no such pretensions. So in the following analysis we have grouped the units by nature/size. None apart from the Danfa health centre provided the full range embodied in the criteria--currently the "best feasible" range of primary care services in Ghana.* In Table 5 we now give in broad terms the main areas of activity~"carried out in 17 units for which data are reasonably complete, and the proportion of each type of unit providing them.:~ As can be seen from Table 5, while virtually all units provided polyclinic (i.e. curative outpatient) care, only just over half of the units carried out weekly child health clinics and half did some home visiting. Less than one-third of the units had some kind of outreach activity beyond the town where they are located: these units were the three hospitals, one of the !ar~er health POSTS_,and a small mission clinic. Only Oda Hospital achieved fairly wide outreach (one-third of all MCH contacts outside the town), because this activity was part of their community nurses training programme. Only four units had had any programme involving TBAs--and two of these had been unsuccessful. Perhaps most surprisingly only a quarter of the units had given two or more immunisations to some children in the past year, viz. the three hospitals and only one further unit. In all this it must be remembered that we were only recording whether an activity occurred at all, not how many people it reached, nor how well it was carried out. The differences in the range of activities between different types of units is also evident from Table 5, which leads us to the presentation of overall scores for each of 17 units in the two districts. These are given in Table 6, which also includes the score for the Danfa Health Centre, and a column showing the score for each unit as a proportion of the score for Danfa ("best feasible" range of services). Table 5 had already suggested that the hospitals were the units giving the widest range of primary care services and this is confirmed by the output scores shown in Table 6. Even so, the hospitals only provided 55-70% of the Danfa range, and this suggests that there are factors other than the availability of resources (e.g. transport, vaccines, staff) which contribute to the range of services provided (see Chap. 7 and 8). Environmental sanitation services. These have not been included in Table 6 because most health units did not actually provide these services from the unit.

Health needs and health services in rural Ghana

4t9

Table 5. Main areas of activities carried out by primary health care units studied

Hospitals HCs and HPs Polyclinic care+ more than 3 times per week Maternal care IA~'Nweekly and deliveryl Weekly child health care Home visiting (MCHI Individual health education and/or group discussion (mainly MCH) Monthly family planning services Home visiting in surrounding villages and/or satellite (outreach) clinics At least 2 kinds of immunisations in past year Contacts with TBAs

Dressing Stations and Small Mission Clinics

All (17 unitsl*

3/3 3/3 3/3 2/3 3.'3

10/10 10/10 6/10 6/10 7,'10

2/3 3/3

4/10 1/10

1/4

35",, 30",,

3/3 0

1/10 4/10

0 0

25°0 25"o

3/4 1/4

1/4 0 0 0

Virtually all 80" ,, 60",> 50'),, 45".

* Rounded to nearest 5°o. t Curative outpatient care.

the primary health care level are best made on a regular basis (such as screening children and pregnant women) and this can only be achieved adequately where people are in close proximity to the providers of the service. The distribution of health services is important on grounds of equity, effectiveness and efficiency. The procedure in this part of the study was to locate on large-scale maps both census populations and data about health service clients obtained from a l~o sample of health facility polyclinic patient registration cards. The huge problems of obtaining these data and consequent large margins of error are de3. PHYSICAL ACCESSIBILITYAND scribed in detail in IDS, 1978b: App. 6. However, UTILISATION OF POLYCLINIC CARE certain broad conclusions can be drawn and the areas Having found the range of services offered by the indicated in which the data would have to be imunits to be quite limited in most cases, we now look proved if meaningful distributional planning were to at the extent to which the existing system is physically take place. accessible to the population for primary health care. The initial but somewhat misleading conclusion We have approached this problem in two ways. In was that there was quite a high density of curative this section we present the main results of a special care institutions in the areas (Table 7). In Jasikan study of accessibility undertaken on the basis of a District only 6 ~ of the population lived more than six' sample of health facility registration cards at all units miles from a health unit, if District Council facilities studied.t These cards were for the patients attending were included. In Birim the proportion was 35~, but for polyclinic care. the type of service most widely a proportion of these people lived near a satellite provided. We have also looked in a less systematic clinic, while others lived within six miles of facilities in way at the utilisation of other services (maternal care, neighbouring districts. Jasikan District is, by contrast, child health, etc.). That information will be presented bordered on one side by Togo and on the other by the Volta Lake. However, if District Council dressing in the following sections. The physical ease with which the population can stations are excluded from the analysis of Jasikan get to the health service units is a particularly impor- District,+~ the proportion of the population living tant dimension in the choice between models of more than six miles from a facility in this district rose health care. The majority of health interventions at to 48% and the proportion living more than four miles away was 61~o. We also looked at the patients actually registered. * Environmental sanitation workers who have had no Rather complex estimated corrections have had to be formal training. These two were acting as health inspection made to the data in view of double registration of assistants. patients whose cards have been lost. Table 8 presents -I-A more detailed presentation will be found in IDS, in a simplified way the average of the results based on 1978b: App. 6. two alternative assumptions regarding card duplica$ The object of this study was to use polyclinic care as an tion. indicator of accessibility to units which could provide the The data suggest that in Jasikan District about range of primar~ health care services. District Council dressing stations can well be excluded from this analysis three-quarters of all registered patients came from and in any case the3' are presently attended by far fewer within four miles of health units and that over 90°o of people living within four miles did in fact register at a patients than Ministry of Health facilities. They were, however, usually provided in the towns. Only four health units themselves provided environmental sanitation services. Including these units, 12 places had resident health officers, although two of the latter were health overseers.* A further four places received regular visits at least weekly from health officers based elsewhere. We have less complete data on the service provision for the surrounding villages, but that it was low can be surmised from the fact that only about one-third of the districts' population appeared to be "covered'---see Chap. 5:4a.

420

IDS HEALTH GROUP Table 6. Range of services provided by individual health units* Health Unit Danfa Hospitals: (B) Oda (J) Dodi Papase (M) {J) Worawora HC's + HP's: (B) Ofoase (M) (J) Nkonya Wurapong (DC) (J) Kadjebi (B) Achiasc (B) New Abirem (J) New Ayoma (DC) (J) Jasikan (J) Dodo Amanfrom (J) Ahamansu (B) Brenasi

General scorer

Satellite score +

14

6

20

100

10 8 9

2 4 2

12 12 11

60 60 55

7 9 9 9 8 7 5 5 5 4

4 ----------

11 9 8 8 8 7 6 5 5 4

55 45 45 45 40 35 25 25 25 20

4 1 1 1

-2 ---

4 3 1 1

20 15 5 5

Dressing Stations and Small Mission Clinics: (B) Ntronang (M) (B) Akim Swedru (M) (J) Loiobi Kumasi (DC) (J) Abotoase (DC)

Total °o of (max = 20) Danfa§

* Excludes environmental sanitation services which, for most units, are provided separately from the health unit (see text). t See Appendix 2 for method of scoring. :~This is scored separately to illustrate differences without satellite clinic provision. Scores for satellites are up to a maximum of 2 for each type of service provided at satellite clinics, e.g. if a health unit holds one satellite clinic where child clinics and polyclinics are held, the score would be 2. If it held 2 or more such satellites the score would be 4. If antenatal care is also provided at 2 or more satellites, the score would be 6 (i.e. maximum score is 6). § If Danfa health centre score is taken as the optimum or model for primary health care service provision, other health units' scores are shown as a percentage of Danfa (i.e. Danfa is assumed to be I00% ). Abbreviations: B -- Birim District; J -- Jasikan District; M

DC

-- Mission unit;

= District Council unit.

health unit. However, registration d r o p p e d off quite sharply for those living further away, a n d only a b o u t o n e - t e n t h of the p o p u l a t i o n living m o r e t h a n six miles from a health facility appeared to be registered at all in Jasikan. In Birim the situation a p p e a r e d quite different. T h e data suggested that less t h a n 60*/0 of all registered patients came from within four miles a n d as m a n y as 35~o of those registered lived over six miles away.

However, the findings were complicated by the fact that the registration cards of those w h o attended satellite clinics were kept at the main clinic, a n d this m a y well explain the large p r o p o r t i o n of registered patients living m o r e t h a n six miles from m a i n units. This explanation is supported by the finding that a b o u t three-quarters of those living less t h a n four miles from a m a i n unit and of those living over six miles away appeared to register; only of the small

Table 7. Distribution of population in relation to health facilities, 1970 census data Jasikan All health facilities No. ~o Population living at 0 < 4 miles from facilities 4 < 6 miles from facilities > 6 miles from facilities

95,700 32,500 9200 137,400

Sources: IDS, 1978b: Tables A6 and A7.

70 24 6 (100)

Birim

Excl. District Council dressing stations No. %o 52,800 18,600 66,000 137,400

39 14 48 (1001

All health facilities No. og

73,500 15,600 47,000 136,100

54 11 35 (100)

Health needs and health services in rural Ghana

421

Table 8. Gross estimate ('!olof population registered by residential location lexcluding District Council units)

Jasikan Proportion of all registered patients living at given distance Proportion of total population living at given distance actually registered at health facility Birim Proportion of all registered patients living at given distance Proportion of total population living at given distance actually registered at health facility

Within 4 miles

445 miles

Over 6 miles

76

15

9

96

57

9

58

7

35

76

43

71

(100)

(100)

Source: IDS, 1978b: Tables A8 and A9. Best average of two alternative assumptions presented there. group (7?/0 of all population) who lived four to six miles away did less than half actually appear to register. Of course it needs to be noted that registration is only a broad indicator of utilisation: a person may have happened to be in town on one occasion when he needed curative care, but have gone without help many other times in his village. Data on the total number of outpatient contacts at each institution imply that the number of contacts per patient registered was of the order of 1.8, though this figure would rise to 2.5 if the patients registered were reduced by 25~o to account for the possible duplication of lost registration cards. The number of contacts per patient registered is likely to decline as distance increases from the facility; in the case of Anyanase (Eastern Region) the sample showed that registered people living within four miles of the facility visited 1.86 times in the year, while those living between four and six miles came, on average, 1.4 times (IDS, 1978b: Table A10). The siting of the various health units seems on occasion to pay little regard to the location of other institutions or to the distribution of population. The worst cases of overlapping occurred when Government and Mission facilities were located very close to each other; this probably reflected an uncertainty over the future contribution of Missions and/or a lack of co-ordination between the public and voluntary sectors. 4. ASSESSMENT OF POLYCLINIC CARE The following analysis is based on observations of outpatient sessions at 19 health units. Most of the units were in Jasikan and Birim Districts but, for * At the four units where larger numbers of patients were recorded for longer periods of observation, little additional information was gained about the consulting and prescribing practices at the unit in question, as the morbidity pattern is fairly uniform. + The precise criteria used for assessing quality of care and scores are shown in IDS, 1978b: App. 3. ,+The details of how the different types of health units performed on each of the criteria used are shown in IDS, 1978b: Table All.

comparison, four additional health units at Danfa, Kintampo and Bawku have been included for the assessment of polyclinic care. The methods used have been described in Chap. 2:3. Our objective was to gain information about a large number of different units. In this way we hoped to obtain an overall assessment of the quality of care from primary care institutions, which was unlikely to have been gained from an in-depth study of a smaller number of units.* It was not possible to assess the appropriateness of examination, or the effectiveness of management for particular health problems. Not enough cases of individual health problems were observed to draw valid conclusions about their separate management. The quality assessment and scoring is, therefore, based on general observations which size up the overall use of drugs, and whether the level of history taking and examination would be likely to lead to correct diagnosis.t

(a) Overall results Assessment of the performance of individual health units is summarised in Table 9.:[: Possible total scores ranged from 0-34. Scores from 0-11 were deemed poor and those from 23-24 were considered good. Total scores for individual units are shown in Fig. 2. Although any one unit may not have been assessed with precise accuracy because of the possible unrepresentativeness of the patient sample, the over-aU grouping does give a clear picture of the situation: seven out of 19 units provided good quality care, seven were classed as fair, and five units were rated as poor. It is noteworthy that the two district hospitals were in the poor group. No units with health centre superintendents at their head were in the poor category; the hospitals' polyclinics were mostly conducted by ward-masters. The category of staff conducting clinics is shown for each unit in Table 9; the clinics in the best group were conducted by a range of different types of personnel, including dressers and QRNs.

(b) History taking and examinations A number of health units, especially those where large numbers of patients were being seen, adopted the practice of using untrained personnel (e.g. the records clerk) to take the patient's history. This did

422

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Health needs and health services in rural G h a n a

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424

IDS HEALTHGROUP

not really work satisfactorily. In some cases, where the main consulting health worker bothered to probe, a different history was elicited from the one recorded on the card. This procedure therefore only saves time at the expense of the quality of care, which is precisely what happened in the district hospitals. Examination of patients was poorly performed at most of the health units. Examinations of some kind were performed on 60°0 or more of the patients at only five health units. Less than 20°0 of patients were examined at three health units, including a district hospital. It is worth stressing that we were quite generous in our assessment of whether or not an examination was performed, and in most cases examinations were very perfunctory indeed. For example, a sick child with fever hardly ever had the throat or ears looked at and chests were almost never examined even when cough and fever were the chief complaints. Even when probing did take place in the history taking, or when a patient was examined, there was often little rationality in the questions asked or selectivity in examinations performed. Routine questions tended to be asked or examinations performed regardless of the complaint, or of the answers to the previous questions. it} Treatment Table 9 summarizes the scores for treatment and prescribing practices of the units, grouped according to total scores. All health units in the good and fair categories treated patients with some drugs likely to be effective for their probable conditions: in the poor category only the two district hospitals did so. All units except for a mission clinic and dressing station used drugs in correct doses and prescribed the appropriate course of treatment. At the mission clinic large quantities of different drugs were being used in improper (frequently too largel dosages, in an apparently indiscriminate manner. At almost all units, however, large quantities of unnecessary drugs were being used.* Only the mission hospitals and three of the four units included for comparative purposes did not do so, and neither did the two dressing stations at Bawku and Kintampo, probably because of strict controls over their drug supplies. We believe that this pattern reflects inadequate training, inexperience, and lack of confidence of the health workers. Also, large quantities of expensive drugs were being dispensed, which are of doubtful cost-effectiveness and some of which are dangerous. Many health units were observed to be using large quantities of "'Novalgin" and "'Baralgin'" injections for routine analgesia. drugs which are known to have serious side effects.

* Some examples of the unnecessary use of drugs were: ta~ antibiotics when no suggestion of infection, tbt injection of "'Novalgin'" as a routine analgesic le.g. for muscle aches and painsl, (cl one dose of crystalline penicillin given with each injection of chloroquine. [dl unnecessary use of more than one antibiotic, e.g. penicillin and "'Sulphatriad'" for simple cough, (e) use of vitamins (e.g. Vitamin B Co., Vitamin C and B 121 without indication.

Ampicillin for upper respiratory infections, gammaglobulin for established measles, and "'Largactil" for headaches, are some examples of what was observed at primary care units other than hospitals. Fewer than half of the health units were not using unnecessarily expensive drugs.

td) Use of injections Injections were given to more than 80% of patients at nine units and to 58-72°J0 of patients at four other units. Chloroquine injections especially were used far too frequently. The two most common explanations for the excessive use of injections were that patients demanded it and, particularly in the case of chloroquine, the shortage of tablets. There was certainly evidence of the latter at a number of units, which is not surprising given the vast quantities of tablets prescribed for large numbers of people for long periods. As far as public demand is concerned, some health centres do not use many injections. These units do. however, provide higher quality of care than average and it is likely that there is enough public confidence in their medical care to compensate for the lack of injections.

le) Sterilisation of syringes and needles Six of the health units did not sterilise syringes and needles adequately. There was widespread re-use of disposable syringes and a number of health units merely rinsed them out with "'sterile" water after use. Some kept them in methylated spirit as the only method of sterilisation. Inadequate facilities for boiling instruments and the use of disposable syringes seemed to be the main reasons for inadequate sterilisation. Another widespread malpractice was the failure to change the injection needle for each new patient. observed in 9 out of 14 units.

(f) A special study of prescribiny The economic studies on resource allocation to primary care tsee Chap. 6) indicated that the cost of drugs accounted for most of the resources going to this level. To analyse this further, and parallel to the quality of care analysis described above, a special study was carried out on prescribing patterns. The main analysis was of a 1°o sample of all recorded consultations during 1976 at Achiase Health Centre, Birim District. A total of 193 record cards was transcribed, containing details of 305 visits, an average of 1.6 visits per person in the sample. Almost all patients (96°0) were treated with at least one injection, the average number of injections per consultation being 0.99. There were two common prescribing responses for the majority of s y m p t o m s - - o n e involving an antimalarial injection and the other a penicillin injection, given together with tablets. The most common tablets were antimalarials and analgesics. Antimalarial injections, tablets and syrups were prescribed in 80°0 of all consultations, though only 51°o of the diagnoses were for fever or malaria. An average of 3.9 items was given on each prescription. Smaller samples of prescriptions for the most common symptoms were taken at two other health centres to ascertain the extent of variations in pre-

Health needs and health services in rural Ghana

425

'fable 10, Outpatient consultation patterns, Birim District, 1976 Proportion of consultations by symptom/diagnosis 1 ~4 as o

Institution Achiase HC id.. from 1", sample Anyanase HP Brenasi HC New Abirem HC

Fever,malaria

Cough/catarrh

Diarrhoea

Measles

of total

42 51 37 44 33

20 17 12 6 16

3 3 5 7 14

15 4 8 3 1

80 75 62 60 64

Akim Oda Hospital OPD--recent data not available. Sources: HOP.I.C. returns. 1976: Study sample. scribing habits, but the picture was strikingly similar.* At each of the health centres, fever/malaria, cough/ catarrh, and diarrhoea accounted for well over half of the total cases seen (Table 10). The pattern of symptoms recorded was very similar to that on the outpatient returns sent monthly from all institutions in the district to the Centre for Health Statistics, confirming the representativeness of the sample. A "best practice" set of prescribing recommendations is, of course, difficult to define, since the severity of the illness has to be taken into account. In addition there are likely to be differences of opinion within the medical profession. A first step towards an "'appropriate prescribing response" was, however, made with the help of public health specialists in the Department of Community Health at Korle-Bu. For the four most common conditions the likely proportions of more severe and complex cases were estimated, and dosages were defined for adults and for children of specified age. Martindale's Extra Pharmacopoeia and the Korle-Bu Pharmacopoeia were used for this exercise.+ There was evidence of over-prescribing in two main ways. More expensive options were used on many occasions when a cheaper alternative was possible. Paracetamol tablets, for instance, are 3.5 times as expensive as aspirin (IDS, 1978b: Table A14). Injections are usuall) more expensive than the therapeutic equivalent in tablet form (in terms of pharmaceutical cost alone--i.e, excluding the extra time and the cost of maintaining the necessary sterile conditions). Syrups are also more expensive than the tablets of the same drug. A number of proprietary products were used instead of their generic equivalents. For example, chloroquine injections were often given as Nivaquine or Resochine (IDS. 1978b: Table AI3). A Nivaquine injection is 30°,) more expensive than generic chloroquine (IDS. 1978b: Table AI4) and the cost of some proprietary chloroquine tablets may be as much as three times greater than generic tablets, Larger quan-

* Examples of prescriptions from each of the health centres are given in IDS. 1978b: Table A13. + The prescriptions are given in IDS. 1978b: App. 7. Figs AI A4. We shall return to this issue in Chap. 6:5 dealing with resource allocation, where the cost differences between actual and "'appropriate" practices will be discussed, and where the Tables are displayed containing the data of this analysis.

tities of drugs than necessary were also frequently prescribed.++ The pattern of excessive prescribing identified at three health centres in the Birim District bore some resemblance to the prescriptions which, in a "best practice" situation, would be appropriate for the most severe cases. This might be because the health centre superintendent lacks the diagnostic skill to distinguish a serious case and so covers himself against undertreating. It might also be that, recognising mildness, he nevertheless decides to give the maximum prescription, for example to insure against the need for a return visit of patients who live far away. Contrary to a commonly held belief, the lack of fees for drugs within the Government system did not appear to contribute to the level of overprescription: in the Mission clinics in Birim District, where fees are charged at a level that covers drug costs, the extent of overprescription was similarly excessive. In our discussions at these three health centres both providers of drugs and patients seemed to be united in a preference for larger prescriptions and inject i o n s - a s was the case at the other units reported on before. This undoubtedly influences prescribing habits. The provider may collude with the patient's preference for injection in order to be certain that the medication has been properly given. There is widespread, though anecdotal, evidence of patients rejecting treatment which does not include at least one injection and the provider might feel that his own status is reduced if he is seen simply as a dispenser of tablets. Senior (regional and national) health service personnel tended to accept this situation as "inevitable". Nevertheless, at the Danfa project injections are given only when oral treatment is inappropriate, and there appears to be no evidence of patients rejecting this approach. Overprescription is a major element in the inefficient use of scarce resources at the primary care level. We shall deal with economic arguments for the control of drugs and drug expenditure in detail in Chap. 6:6. But, there are good medical reasons for control as well, from the avoidance of adverse drug effects and the development of resistance to anti-infective agents to reducing the negative side-effects of injections, such as the spread of hepatitis and the provocation of paralytic poliomyelitis. (g) Other aspects of polyclinic care Health education is very rarely given at outpatient clinics. At only two health units did the health worker

426

IDS HEALTHGROUP

give the patients advice about diet and disease prevention as part of the consultation. However, the time available for such advice was clearly insufficient, the entire consultation, including completing the records and giving the advice, lasting an average of 4 and 3.3

minutes per patient at these two health units. Generally, the average time per patient contact was less than five minutes (see also Chap. 7:5) and there was too short a time for health worker patient contact at almost all units.

CHAPTER 5. HEALTH NEEDS AND HEALTH SERVICES IN THE DISTRICTS S T U D I E D - - P A R T B

Table 11 also shows two further indicators of the utilisation of antenatal services: the average number of antenatal visits and the time of first registration. In Jasikan as a whole, the average number of antenatal visits per birth was 3.7~ in Birim 3.3. If adjustments are made to account for double registration the average n u m b e r of attendances would be much higher. At three units in Jasikan District and at all units in Birim District for which data are available, over one-fifth of expectant mothers first registered during the last trimester of pregnancy, the figure for most of the units being around 31Y'/0.One reason why so many mothers appear to register late in pregnancy, making antenatal care less effective, is the fact (reported particularly in Birim District) that mothers tend to return to their home villages near the time for delivery, where they register (again) for antenatal care. The system of keeping antenatal records at clinics, rather than using a

I. MATERNITY UTILISATION AND QUALITY O F M A T E R N A L H E A L T H CARE

(a) Antenatal utilisation

For antenatal care, utilisation was high for all units and for the districts as a whole (Table 11). The figures at face value suggest that in Birim 85~ of births in the district are preceded by at least one antenatal visit, while in Jasikan the figure is 89%. However, many mothers, while being registered "locally", also attend a larger antenatal clinic in the district once or twice-this was observed especially at Worawora. There, double registration may have involved as many as one third of the mothers. In Jasikan District the actual coverage for antenatal care was therefore perhaps no more than about 80%. Double registration presumably also applies to Birim District, but we have no data to confirm this.

Table 1I. Antenatal care utilisation

New Population New antenatal Total no. of in "catchment" Expected antenatal visits as antenatal area* births~ visits % of births visits

Av. no. of antenatal visits per patient registered

% of mothers first registering in last 3 months of pregnancy

dasikan District

Worawora Hosp. Dodi Papase Hosp. } Dodo Amanfrom Ahamansu Jasikan Kadjebi Nkonya Wurapong New Ayoma Selina's Maternity (Jasikan) Jasikan District

7679

369

2227

6177

2.8

23,003

1104

1914

9980

5.2

21,989 18,807 Not calculated Not calculated

1055 903

1057 1289 250 364

4310 6047 510 1538

4.1 4.7 2.0 4.2

NA { NA 9% 21% 13°o 16% 35°,0 13°o

1141

2200+*

1.9

33°,o

Not calculated 192,440

9237

8242

Oda Hospital Achiase Anyanase Ofoase } Brenasi

47,283 23,251 12,388

2269 1116 595

10,176

Ntronang "~ New Abirem J Edith's Maternity (Oda) Paulina's Maternity (Oda)

11,085

89~§

30,762

3.7

2550 776 548

8908 2630 1535

3.5 3.4 2.8

31°,o 35°/, NA

488

1935

4813

2.5

300o

532

1385

4879

3.5

2700

1121 1859

4.2 7.2

NA NA

25,745

3.3

Birim District

Birim District:

---

---

268 260

189.278

9085

7722

85%~

NA--Not Available. * Catchment area is taken as a radius of 4 miles around the health unit. Assuming a birth rate of 48 per 1000 population. .+Approximate estimate only. Records of total attendances not kept. Involves double counting. Possibly overestimates real figure by some 10°o. See text. 427

428

IDS HEALTHGROUP Maximum Score Good

Fair

Ix)o¢

17

~sll5 Ii4 14

GOOD (14-19]

8 I

Ilill

K

z

•

7

7

FAIR (7-13)

n

Key = Disl'ricl Council -h= Mission ®

;

POOR (0-6}

~ ] = Comporative ul~t

Motet nily clinics

Fig. 3. Summary of scores for quality of antenatal care. ~. For these two units, one or two indicators were not observed or recorded. The dotted line indicates the alternative possible score had they been recorded positively. home-based system, makes it difficult to provide continuity of care for these mothers, and the recording system also makes it difficult to evaluate coverage achievement when so many mothers are registered twice.

(b) The quality of antenatal care Fifteen units providing antenatal care were studied in the Jasikan and Birim Districts. Two dressing stations which provide "'outstation'* antenatal clinics were also studied, for comparative purposes only, at Bawku in the Upper Region. The assessment of the quality of care at antenatal clinics is based on observations of the activities shown in Appendix 2 and used the scoring method described there: scores are based on 12 of the activities listed. Figure 3 shows how units scored overall.* With the maximum possible being 18 points, the range of scores was between 2 and 15. A score of 0-6 was deemed "'poor", 7-12 was considered "'fair", and 13-18 was "good". There were five units in the good range, four were judged fair and six were poor. The quality of the antenatal care was not clearly related to the type of unit. District hospital scores ranged from 7 to 14, the score for the MOH health centres and health posts ranged from 4 to 15, the district council units were fair to good, and the private maternity homes scored 11. Two of the small mission units studied did exceedingly badly, while the mission hospital scored well. Of the comparative units, one of the Bawku mobile clinics did very well. Half of the units studied took a careful history for new antenatal attenders. Apart from the identification of risk factors, the effectiveness of antenatal care is dependent on some action being taken for those * IDS, 1978b: Table AI6 shows how the different type of units scored on individual criteria.

mothers found to be at risk. At none of the units were criteria for referral clearly specified. Records of patients at risk were separately identified only at four units and referral records were usually kept only for emergencies. Midwives recognised the unwillingness of patients to be referred for delivery in hospital or even to come to the local health unit for a supervised delivery. Consequently they did not seriously attempt to refer them, All they did was give the occasional piece of advice about the desirability of having the baby in hospital or at the health centre. We collected data on referrals from seven units, but because of the problems discussed above and the likely under-reporting of antenatal referrals in particular, the results should be interpreted cautiously. Out of the total of 216 referrals recorded over the past year at the seven units, 85 were antenatal referrals, while 131 patients were referred when in labour. Of the 85 antenatal referrals, one quarter were for antepartum haemorrhage, often an unpredictable complication; one fifth were referred for unspecified sickness, while a third were referred because of identified risk conditions arising during pregnancy (preeclamptic toxaemia, malpresentation or twins, and anaemia). Only 7°o were referred on the basis of their obstetrical history: primigravid patients were said to be referred routinely at only I of these units. Table 12 shows the most common reasons for referral for antenatal complications and during labour. Half of the 131 referrals during labour were for delay in the second stage or obstructed labour, complications which can often be foreseen as likely during the antenatal period. One-fifth were referred because of post partum haemorrhage (PPH) and/or retained placenta, complications often associated with risk characteristics, such as a previous PPH or high parity of the mother, which might have been picked up dur-

Health needs and health services in rural Ghana

429

Table 12. Reasons for referral (data based on records from 7 health units)

Reasons recorded.lot referral from antenatal clinic Antenatal haemorrhage Patient sick (undiagnosed) Pre-eclamptic toxaemia ~or oedema) Anaemia Malpresentation or twins History of stillbirths, Caesarian section. PPH. or twins Other Total number of A N referrals

c~

19 14 13 9 7 10 85

Reasons recorded fi~r re&rral durin.q labour Delayed second stage (including obstructed labour) PPH and retained placenta Malpresentation or twins APH. signs of PET. history of CS, PPH or high parity Foetal distress or cord prolapse Other Total labour referrals

ing antenatal care. Malpresentations, or twins, represented 12°o of the indications and other factors identifiable during the antenatal period accounted for a further 9°0 of reasons for referral in labour [see Table 14). Thus about 90°0 of patients referred during

labour might hare been preriously identified as at risk. It is not known how many of these referrals in labour were for patients who had attended antenatal clinics or who had been advised to deliver in hospital but had not gone in time. The rate of antenatal referral in the different units varied from 0.3°0 to 2.6°0 of first antenatal attendances and for labour referrals from 6.4°0 to 20.0°,, of births. If screening was being carried out effectively, one might expect a low rate of referral during labour with a higher referral rate from the antenatal clinics. However. no correlation was found between the scores for quality of antenatal care and the rate of labour referrals. This might suggest that other factors outside the control of health units [such as transport availability and costs, or facilities for mothers to stay in the vicinity of the referral centre prior to the onset of labour) may be more important contributing factors to the obviously inadequate screening achieved by the maternity services.

(c~ Delivery utilisation The data for assessing the utilisation of services for delivery are less problematic--at least multiple recording of births can be excluded. Only about one fifth of births were supervised* in both Birim and Jasikan Districts. Excluding the hospitals, which are expected to function as referral units, most primary health units supervised less than half of the births in their catchment areas.+ Only one group of two units (grouped * Supervised births are those which are attended b? trained personnel either in health units or at home. The) may include births supervised by trained TBAs if these births are recorded: in this instance no TBA-attended births are included. + It is more appropriate to relate supervised births to a defined population around the health units than it is for antenatal care. because most women are unlikely to travel far for delivery care unless complications occur Isee Referral. Chap. 7:4).

51 21 12 9 4 9 131

because they are close together and serve the same catchment area) supervised between them 6600 of estimated births, while at two units at the other end of the scale only 12~o and 15% of births were supervised. / The stillbirth rate was high in Birim District (4.3 oJo), almost double that in Jasikan (2.2~ol. The main difference between the districts, however, was the exceptionally high rate in Oda Hospital, where 9.6~ of supervised births resulted in a stillbirth (comparable figures for Worawora and Dodi Papase were 4.8% and 6.3% respectively). This suggests either that mothers at risk were not being identified for hospital delivery and/or that they were not reaching the hospital in time.

(d) Family planning coverage Coverage for family planning was minimal in both districts. In Birim, services were provided by Oda and Achiase units only, and in 1976 there was a total of 622 acceptors. This represents 1-2°o of the women in the district (aged 15--45 yearsl. In Jasikan District the 465 acceptors were recorded, some I°o of the fertile women.

(el General conclusions Utilisation of antenatal services appeared to be relatively high in both districts---even allowing for some duplication of registration. The main problems in antenatal care were found to be perfunctory history taking, no special concern for primiparous patients, poor identification and treatment of anaemia, inadequate tetanus and malaria prophylaxis, and non-existent or irrelevant health education. One of the reasons for differences between health units in the quality of antenatal care appeared to be the availability of supplies. Suitable haemoglobingreeters, even simple ones, were not provided at most units. Health units that had no scales could not weigh mothers. There was also a shortage of tetanus vaccine and anti-malaria and iron tablets. History taking was poor because it was frequently carried out by untrained personnel. Only one fifth of births were supervised, even by a trained TBA. For those births which were supervised the standard of delivery care seemed to be relatively good.

430

IDS HEALTHGROUP

Perhaps the most important problem in maternity care was the absence of effective screening and referral based on the "at risk" concept. Risk factors are not clearly defined and when identified in individual patients relevant actions were not taken. There were no criteria for referral and no means of referring patients effectively, even when clearly indicated. The high rates of referral in labour, especially in Birim District, and the high stillbirth rates at O d a Hospital, reflect this problem. M o r e efforts should be directed towards finding ways to make it easier and less expensive for patients really needing a supervised delivery to have one (see Referral, Chap. 7:4), and more attempts should be made to create a better understanding of the at risk concept in midwives. All mothers were encouraged to come for delivery. It might be more appropriate to concentrate on those who really need it. 2. CHILD HEALTH: COVERAGE. UTILISATION

AND QUALITY OF CARE Assessment of coverage and utilisation of the child health services was particularly difficult, because the

records kept at most clinics did not provide the number of children seen in a year. So in most cases the assessment had to be made roughly from rather poor data. At a few clinics it was possible to calculate the number of registered children from record books. but for most of the others an estimate had to be made. This was calculated by using the total attendance figure (recorded at all clinics) and using the typical number of attendances per child in a year from samples of records and/or a one-day clinic sample. The size of the former samples was between 5% and 20% of.the estimated number of children seen in a year. Eleven units providing a child health service were observed in Jasikan and Birim Districts. A satellite child welfare clinic at Danfa (managed by community health nurses) and two satellite clinics at Bawku (run by an SRN and an enrolled nurse) were studied for comparison. Emphasis was placed on observing practices related to weighing of children, growth and nutrition, health education, curative care and prophylactic therapy. Sixteen criteria from the list in Appendix 2 were chosen for the quality of care and total scores on the

Table 13. Child health coverage Under-5 populationt in catchment area~: Worawora* Apesokubi/ Abotoase* (Worawora satellites) Kadjebi Jasikan* Dodo Amanfrom } Ahamansu Dodi Papase* Mempeasem Ampeyo (Dodi Papase satellites) Nkonya Wurapong New Ayoma Jasikan District Oda Manso/Swedru/ Awisa* Asene/Aboabo Achiase* Brenasi l, Ofoase* J NewAbirem } Ntronang* Amoano Praso* Birim District

% of under-5 No. of children population in seen in 12 catchment area months seen in 12 mths

Total attendances

Average no. of attendances per child/year

% attendances under 1 year

7396

878

63

6492

7.4

74

--

320

--

1600

5.0

50

21 14

4501 4182 2592 -6168

6.4 7.7 4.9 -5.6

81 74 75 -NK~

3423 4002 4187

707 545 523 } -1107

33

--

549

2298

4.2

NK

---

54 180

163 1156

3.0 6.4

100 94

35,024

4863

14

29.152

6.0

8606 __

2190 2168

25 --

5806 6245

2.7 2.9

66 43

-17

--

1914 2914 -1182 295 2052 2108

3.0 4.2 -3.9 1.9 7.9 4.5

52 67 -NK 100 NK NK

20

22,516

3.3

-4232 1852 2017 -34,448

622 702 -- ~ 301 f 153} 260 472 6868

16 20

- - : Not calculated. NK: Not known. * Clinics participating in CRS food programme. t Population figures taken from the 1970 census and adjusted to 1976. The number of under-fives is taken to be 18.2% of the population {calculated on the basis of % aged 0-5 years in the total population for Ghana in the 1970 census). + Catchment area - 4 miles radius around unit. The total under-five population for each district is also given. Mission health units did not complete the Ministry of Health returns showing age groups of total attendances.

Health needs and health services in rural Ghana basis that reliable information was available from the majority of units. In addition, some further criteria which were not included in the total scores are discussed in the text.

(a) Overall coverage and utilisation It was estimated that in Birim District approximately 200° of the under-five children are seen by the child health services at least once a year, while in Jasikan District this figure is 14"o (Table 13). The large number of satellite clinics run by Oda are part of the CHNs" training programme, and the fact that two of the missions in Birim also run M C H services with satellite clinics, probably accounts for the somewhat better coverage achieved in Birim. Some data were collected from the samples in nine clinics to establish where the children lived. In five of these nine clinics some 80°0 or over came from the town in which the unit was located: in one clinic the figure was around 70°0 and in a further two between 50°0 and 60°o. The average number of attendances per child per year (calculated from the total attendances and divided by the estimated number of children seen) was much higher in Jasikan District (6.3) than in Birim (3.3). All clinics in Jasikan saw children on average more than three times per year, while some saw them as often as 7.7 times per year. Thus concentrated care was being given to a relatively small number of children, i.e. those who did use the clinic came very often. The proportion of children estimated to come only once was between 10% and 30~o for most clinics in Jasikan District and between 10~o and 20% at two clinics where samples were taken in Birim District. In Jasikan District most attendances were of children under the age of one year. Some clinics were really only postnatal clinics. Even those run by CHNs, who were at least trying to reach the vulnerable group between one and three years of age, on the whole had more than 70% of attendances under one year of age. In Birim District a slightly higher proportion of children being reached by the child health service are over one year. The child health clinics, therefore, were not reaching most of the children at risk. This is illustrated by the fact that at one health centre 30~o of the children aged 1-2 years attending the clinic had weights for age below the third percentile, while in the age group under one year only 18 ° o were malnourished. Distance from the clinic is obviously a major reason for non-utilisation. It has been found at Danfa that mothers generally do not bring children to a child clinic from more than a two mile distance, and * Public health nurses at Oda and Worawora thought that mothers with newborn babies could be persuaded to come for immunisations: but if these were not available they would stop coming after a few months. The attendance at Aboabo clinic fell from 140 to 69 in one month when mothers realised that there were no "'nutrients", medicines or vaccines. "t The food--3 lbs of sorghum. 2 lbs of WSB, 1 lb of milk powder and ½lb of oil--is worth ¢ 11.50 (£5.75 at the official exchange rate}, i.e. 20°o of the minimum monthly wage. which is available to the mother at a cost of 5p and one morning's loss of labour. ~. IDS. 1978b: Table A17 shows how each type of unit scored on individual criteria.

431

our data support this. Equally important in the view of the C H N s are the very limited services offered at the clinics.* Food distribution, good curative care and immunisations were considered to be the most important incentives to attract mothers of older children. The cost of living was so high that women were most reluctant to leave their farms or trading to come and listen to advice if the child was not sick. It was noticeable that clinics involved in the food programme {these are indicated in Table 13), achieved significantly higher attendances of children over the age of one year than did those not involved. The community health nurses were unanimously agreed that the economic incentive of food distribution is crucial in clinic attendance.¢ The pattern at clinics without food run by the C H N s was regular attendance to the age of six months to one year, after which it dropped off rapidly in the second year. Those attending after the first few months tended to be higher income mothers with more leisure, e.g. wives of salaried workers. Women engaged in earning a living attended a few times for the postnatal check, but as soon as they felt strong again and felt that the baby was safe, they returned to their normal occupations. Nevertheless, the experience at Bawku child health clinics and Kaneshie Health Centre would seem to suggest that if good curative and preventive care are provided, mothers will attend the clinic regularly, even without the distribution of food. (b} The quality of care: curative care and prophylactic therapy Total scores for the quality of child health care were obtained for the 11 units studied in Jasikan and Birim Districts and for the Bawku and Danfa clinics. The units were then ranked according to their scores: 0-9 was deemed "poor", 10--18 "fair" and 19-28 "'good". Figure 4 summarises the scores for each unit.~ Overall, child care was of poor quality, as even the best units scored well below the total possible. Apart from the two comparative units which were scored "good", only the mission hospital provided good quality child care. Most units were fair and three were poor. In general, the health centres/health posts had higher average scores than the district hospitals. which, together with the district council units, scored less than a third of the total possible score. The three units providing good quality care all enjoyed staffing and supply inputs better than those of the typical government health unit. All the units had a senior staff member (either a SRN or a PHNI closely associated with, or in, the team. Members of the team had periodic inservice training dealing with specific local problems and there was regular supervision by senior staff. Reliable transport and supplies such as for malaria prophylaxis were usually available. In three-quarters of the clinics observed in Birim and Jasikan Districts the children were examined in some way. In clinics utilising C H N s this was some assessment of physical and neurological development. Many of the clinics were for "'well-babies" only and the quality of curative care for children could only be evaluated in the polyclinic service. Causes of fever other than malaria were never looked for at any

432

IDS HEALTHGROLP

B M0ximum score

28

FAIR

GOOD

POOR

GOOD (19-28)

8

13

13 13 12

tc

12.

, II

-1-

FAIR (10- 18)

I0= --9._o-----

2

i ~N

STAFF EN

EN

PHN EN PHN R-IN PHN CHN Mid- CHN PHN MidCHN d-IW CHN Q'IN Q'IN wife CHN wife

PHN PHN CHN CHN

The health units

POOR (0-9)

I

%is,r,c, coup,, + Mission

]

Comoorotive units

Fig. 4. Quality of child care--overall scores. clinic. Only one-third of the clinics studied in Birim and Jasikan Districts distributed tablets for malaria prophylaxis to over 80% of the attenders. Health workers at both child welfare and polyclinics seemed generally to be unaware of the signs and dangers of dehydration; they did not usually examine for it or have a rehydration mixture available.

(c) The quality of child care: the supervision of growth and nutrition Children were weighed at all the clinics observed, but in one-third the scales were not checked for accuracy before use. Weight charts were used in just over half the clinics for at least some children. The proportion of mothers with weight charts for their children ranged from 10°/0 to 50°/0. At the comparative clinics the weight chart was used as a home-based record for all children. O n the whole charts were correctly filled in, but they were rarely referred to at most of the clinics which used them. Only at Dodi Papase and Danfa were they looked at as a matter of routine. The various uses to which a weight chart may be put were not understood by most health workers and the system was not included in the training programmes of community or public health nurses. In the majority of clinics observed the weight chart cannot have been understood by the mother, as she never looked at it.

* This was partly the result of a misleading poster, distributed by the Ministry of Health, which reads "Breastfeed Your Baby for One Year". In a society where it is the norm to breastfeed for 18-24 months, this will inevitably be interpreted as an instruction to ,stop breastfeeding at 1 year.

There was a considerable variation in the competence of health workers at any one clinic, so that one C H N might pick up 80°;; of the children with falling growth counts and give their mothers correct advice, while her colleague on the other side of the table might only recognise 30°•0 of such children. Advice recorded on clinic cards tended not to be specific enough to be useful. Third degree malnutrition~ identifiable by physical examination, weight loss or zero weight gain was picked up at all clinics. The difficulties of recognising faltering growth without graphic representation were clearly demonstrated in those clinics not utilising or referring to the weight chart. The majority of children with unsatisfactory weight gain were not identified as special risk cases in any clinic, although dietary advice--usually based on the stages of the child's development rather than the risk situation--was given to most mothers at some time during the clinic. But reasons for unsatisfactory weight gain were rarely discussed with the mother• The health worker usually gave the mother an instruction on feeding, sometimes after an enquiry into the present diet. In only half the clinics in the two districts was individual health education given sufficient attention as defined by the criterion that one-third or more of the consultation time was spent on it. Many instructions given by C H N s were not relevant and in some cases were actually incorrect: C H N s instructed mothers to give fruit juice to one-month old babies, an unnecessary practice with the risk of diarrhoea: often supplementary feeding was recommended too early [at two months or even before): mothers were advised to stop breast feeding after one year (as opposed to advised to breast feed for at least one year)* : toddlers with minor

Hcalth needs and health services in rural Ghana ailments were put on a "'light diet" which does not satisfy their caloric requirements. Health education in priority areas such as the home management of measles, diarrhoea, high fever and coughs was rarely' given. In all but three of the clinics the health workers" attitude was reasonabl3 cordial, if not sympathetic. The social distance between health worker and mother obviously varied with the status of the mother, but the teacher,pupil relationship was always adopted. Although dialogue is encouraged during theoretical training, the student nurse copies other health workers in establishing a one-way flow of information. Health education was more satisfactory at the comparative units, particularly as regards content. although at the Bawku clinics time for individual health education was short. A third of the clinics in the study districts were observed to hold group health education sessions. Other clinics said they did so regularly, but our impression was that in most of these this happened at best occasionally and they tended to be based on rather academic lectures. A cooking demonstration was observed in only two clinics (Bawku and Dodi Papasek although eleven others recorded cooking demonstrations in their quarterly returns. We observed that although health workers in classroom discussions appeared to appreciate the need to recommend cheap local foods, in practice they still tended to recommend milk, a very scarce commodity, with cheaper additions as an afterthought. Seven of the clinics which recorded group health education sessions included at least one session on nutrition in the last quarter. The importance of breast feeding, weaning, and toddler diets 'were most frequently, discussed. All clinics advised mothers to introduce solid foods before six months and the majority advised 3 months or even earlier. The major emphasis in all nutrition education was on the increased use of protein-rich foods. Health workers were unaware of the importance of calories from total food intake and staple foods were considered to be of very, marginal value. The frequent recommendation to give a "'light" diet is a further example of ignorance of the role of "'compact calories". In only one clinic in the study' districts was advice given to feed a child three times daily' or more frequently if he is sick and anorexic. Only' at Bawku were mothers advised to use more fat or oil in the diet, although low calorie intake due to a bulky, low fat diet and irregular meals is likely to be a major cause of undernutrition all over Ghana. Information on food production was said to be given at one health centre, but we did not observe it. Though health workers might encourage mothers to grow more legumes and leaves, they were not trained in the specifics of increasing food production and it is unlikely that they had any knowledge to impart to women attending the clinic, many of whom were farmers or gardeners. They did not see this as part of their job: it is for the agricultural extension agent, as environmental sanitation is for the health inspector (see also Chap. 5:6a. belowk (d) General conclusions Despite the fact that so much of the community

433

and public health nurses' time was spent "'doing records", the most important data on population coverage and utilisation could not be obtained from them. However. it was estimated that coverage of children under five years was very low in both districts. particularly of the vulnerable 1-3 years age group: as few as 14-20°,, of under-fives were receiving preventive health care. The limited and ineffective use of the weight chart was a major reason for the unsatisfactor3; supervision of growth observed in all but the three "good" quality clinics. The value of the chart for diagnosis and education appeared not to have been appreciated by policy makers, trainers or health workers. Individual natrition and health education were considered to be unsatisfactory in half of the clinics studied. Group education sessions were held infrequently and health education was given a low priority during house visits. The pedagogic approach tended to be didactic rather than a problem-solving dialogue. and the content was frequently inappropriate and not related to priority health problems. These inadequacies are related to deficiencies in training, motivation. supervision, and access to relevant information and teaching materials (see Chap. 8:4). In some clinics the health workers did not have sufficient knowledge to give sound advice (e.g. in those run by midwives). In others, motivation was so low that only the minimum tasks necessary were carried out, to the detriment of health education. The child health clinic was considered to be a purely preventive rather than a comprehensive preventive.curative service. This is reflected in the inadequate training given in the diagnosis, treatment and management of common childhood diseases and in the poor curative care provided by the majority of clinics. Even so. malaria prophylaxis was effectively carried out at only one quarter of the clinics, mainly because of inadequate supplies, and an immunisation service was not provided at most clinics (see Table 5). 3. SPECIFIC COMMUNICABLE DISEASE CONTROL

Health service activities on communicable disease control were very fragmented. They involved almost all branches of the rural health services, but with no one taking overall responsibility for co-ordination. The MFU of the district is the service which deals exclusively with communicable disease control, but it had limited responsibilities and resources, and there was little or nor co-ordination of its activities with those of the health units. The following evaluation. based on information obtained from the health units. is presented for the two districts together. There was very little difference amongst the various units with respect to th~s work. Table 14 presents an overview of the different tasks in communicable disease control and the current activities of the personnel involved in the different branches of the health service. In sub-section {aj we give a brief description of the MFUs. Then three aspects of communicable disease control are evaluated: in (b) the immunisation programmes: in lcl the collection of statistics and reporting. and health education: and in Idj the control pro-

IDS HEALTHGROUP

434

Table 14. Communicable disease control: tasks and personnel involved Tasks 1.

Information retrieval--collection of statistics and reporting

2.

Diagnosis and treatment of those seeking curative care; recording numbers diagnosed and treated and village of origin; and routing of information to appropriate personnel (supervisors or field staff) Active case finding and screening of vulnerable population

4. 5. 6.

7.

Treatment in villages of those found during case finding campaigns Investigation of outbreaks of disease and epidemics and taking appropriate measures for their containment Routine follow-up of contacts and those diagnosed at health units, and taking appropriate actions to prevent spread of disease Environmental sanitation and vector control

g.

Immunisations

9.

Distribution of prophylactic drugs to vulnerable population Mass treatment programmes, e.g. for intestinal worms, or bilharzia Follow-up of registered patients with communicable diseases on long-term therapy (TB, leprosy) Health education

10. 11. 12.

grammes of tuberculosis and yaws. Section 6 of this chapter deals with the needs for communicable disease control from the village perspective.

(a) The Medical Field Units These are specialised units set up by the Ministry of Health to deal with communicable disease control, and they function on a mass campaign basis. The M F U s developed from the successful mass campaigns for the treatment of sleeping sickness of the late 1930s, and in 1944 they turned their attention to yaws, carrying out field surveys and using mobile treatment units visiting remote areas. Around this time they started to undertake mass immunisation programmes, but during the 1950s the emphasis was on the investigation and epidemiology of some of the important endemic diseases of Ghana. Each district has an M F U team and at the present time their programmes are decided annually at the regional level. They have

Personnel involved Health unit curative staff (HCS nurses or dressers engaged in polyclinicl Health inspectorate MFU Public health nurses (TB) Curative health unit staff, including hospital OP personnel MFU at district treatment centres (Yaws and VD). MFU Health inspectorate (very occasionally during house visits) Public health nurses could do so, but home visiting not usually concerned with case finding of communicable diseases MFU MFU Health inspectorate (occasional--only one health officer in study districts did this) People take actions themselves with some stimulation from health inspectorate. Latter do some spraying or oiling of mosquito breeding sites, but vector control activities minimal MFU Public health nurses Public health nurses Not performed Public health nurses District hospital Minimal activity in this area. No personnel particularly responsible. One lecture by public health nurses at an out-patient clinic dealt specifically with TB been mostly concerned with campaigns for case-finding and treatment of yaws; mass immunisation against smallpox, measles and in some cases tuberculosis; and with investigating outbreaks of communicable disease. During the year prior to the study they had been heavily involved in "fire-fighting" activities against cholera, of which more than 3000 cases were reported in 1977. In theory M F U s operate by moving from one area to another within the district, visiting all the villages and screening the entire population. In fact their activities appeared to be limited, primarily due to lack of transport but also from lack of direction. The Technical Officers are trained to carry out a limited number of functions and to operate under the direction of a medical officer. In the absence of such a director (as in the districts studied) they are unable to respond to requests for an investigation of many diseases, nor are they able to initiate investigations and

Health needs and health services in rural Ghana control programmes themselves, on the basis of reported increases in incidence of disease.* The overall result of these problems was that the effectiveness of the MFUs in both of the districts studied was quite limited. They were undertaking treatment of yaws in the main towns and of venereal disease in Oda. Some immunisations had been carried out in both districts during the previous 12 month period, the MFUs having achieved a much higher coverage than the static units, but still well below the required level (see belowj. At the time of the research no immunisations were being carried out in either district by the MFU because of lack of transport.t {b) lmmunisation prograrnmes and coverage Children in Ghana may receive immunisations against smallpox, measles and tuberculosis from the MFUs or from child welfare clinics, which may also give DPT and poliomyelitis vaccines. Overall. probably less than 25,~ of children in the target age-group in each district were protected with at least two doses of DPT vaccine. Over a period of 18 months in Jasikan District 16.5~o of children under five years received measles vaccine; the corresponding figure for Birim was 4.30/o. The child welfare clinics played an insignificant role in measles immunisations, which were given mainly by the MFUs. Immunisation against poliomyelitis was not given in either district in the year under consideration in spite of the high incidence of the disease in Ghana (Ofosu-Amaah et al., 1977). BCG vaccinations were given to children up to 15 years by the MFU in Jasikan District. In Birim District the MFU gave no BCG and not more than 1.3°, of the children under five years in this district received BCG from child welfare clinics. Smallpox vaccinations were given to 20°0 of the total population of Jasikan District and only 1.3°o of the population in Birim District. Using data from (approximately 10~o) samples of clinic cards or of patients who had attended clinics for more than a year, no child was identified as being fully immunised except at Worawora, where this was achieved in 5~o of children of the appropriate age. Five child welfare clinics gave no immunisations. There was no co-ordination between the child care services and the MFUs. The former did not have enough vaccines: the MFUs on the whole had the vaccines, but not the transport to implement a mass programme. If there were more liaison between the two branches of the service, at least the children reached by the child health service could have been immunised, even though the coverage would have been small. In addition, the MFUs did not issue cards to record the immunisations they gave in the villages and neither did they use the child welfare cards issued by clinics. So with all the lack of coverage it is still possible that duplication of immunisation was occur* In the Volta Region even the Regional Office had no medical officer responsible for communicable disease control. the responsibilit3 being carried b~ the Regional Medical Officer in addition to his other functions. "i For a summary of the resources available and programmes carried out in the two districts, see IDS. 1978b: Table A 18. ~.See also IDS. 1978b: Appendix 10.

435

ring, or could occur if the programme were expanded on both sides. (c) Other services provided Collection of statistics and reporting. The system of reporting on communicable diseases was in considerable confusion. It was impossible to unravel the complicated channels of communication, which vary between units and districts and which result in much duplication and many inaccuracies. Our izomparisons of different sets of figures, presumably covering the same cases, showed that the figures varied depending on the source of information. Returns originated from different people and followed different routes; reports were made to various district or regional authorities and sometimes seen by different sets of people; statistics were not systematically collected from all units: responsibilities were not well enough defined (or understood) as regards the collection of data, nor with respect to acting on them. Returns did eventually reach the Regional Medical Office, but no reconciliation of discrepant returns appeared to take place. At the health unit level, when a diagnosis was made of a specific disease (e.g. yaws or measles) no records were kept of the patient's address. At some health units, where the diagnosis was not recorded except on the patient's card, only cards of new patients were examined at the end of the clinic by the records clerk, for the purpose of filling in the registration book and the communicable disease returns. Health centre superintendents said that they did tell the MFU informally if they noticed an outbreak of infectious cases (e.g. of measles or yaws), but gradual increase in the incidence of a disease would probably not be noticed. Individual cases of certain conditions such as cerebrospinal meningitis did get reported occasionally, which prompted cables and requests for follow up. In general, surveillance of communicable diseases was poorly implemented. The whole system needed to be tightened up considerably at all levels, and the roles of different personnel needed to be clarified and co-ordinated.~ Health education. Very little health education about. communicable diseases appeared to be taking place. The Jasikan MFU undertook health education when they could reach the villages. The only other health workers visiting villages, the health inspection assistants, usually acted more like health policemen than health educators. Mass health education programmes were not being carried out in the districts studied, nor was there any attempt at informing people through mass media channels. An occasional health education talk was given at some health units, but no group sessions were held in the villages. There was no attempt to persuade people to bring cases of tuberculosis or yaws for early treatment, or to spread information on how to recognise the symptoms of the diseases, their methods of spread or, in the case of tuberculosis, the importance of treatment being continued for a long period. The health system did not seem to have considered the contribution to the control of communicable diseases that can be made by mass and individual actions of villagers. The people were not involved in the programme; and nor was there any awareness of the need for this among the health staff concerned.

436

IDS HEALTH GROUP

(d) Evaluation of two individual disease programmes Tuberculosis (TB). An important indicator of effectiveness of TB control is the proportion of diagnosed active cases who are still continuing treatment, but the recording system does not give the relevant data. The information requested on the monthly return form was confused in that "the number on treatment" was regarded as a running total of the patients registered, whether or not they were still being seen. All diagnoses were made at the district hospitals by sputum examination. The patients were registered at the hospital and at Worawora they might be admitted. For ambulatory treatment they were given a supply of antituberculous drugs (including streptomycin for injection) and told they must attend their nearest health centre daily. At Worawora (where the "number on treatment" for 1976 was 305) only 30 patients, including 19 inpatients, were receiving regular treatment. The majority of patients discharged themselves from hospital. There was no record of the number in the district continuing treatment from health centres, because only a few health centres kept a register of TB patients; in any case, they only recorded those receiving injections. At Oda, the names and card numbers of all newly diagnosed patients were recorded and used to complete the monthly return on the n-umbers-0f-new-cas-es. In the period November 1976 to May 1977, 286 cases were diagnosed.* It was extremely difficult to find the cards of patients, but we managed to trace the cards of 17 out of 36 cases diagnosed during the month of December 1976. Of these 17, only three had returned for new supplies of drugs in the two months prior to our visit in May 1977. Interviews and discussions with those concerned confirmed that few patients were continuing treatment from the hospital. The reasons given for this were that patients cannot or will not return to the hospital every two weeks for supplies of drugs, while even monthly trips are too much to expect for patients living far from the hospital. Patients do not accept that a daily injection is a necessity, and a trip to the nearest health unit may mean going some distance from their homes. They also see no need to continue treatment after the first few months when they feel better and little was being done to make them and their relatives aware of the importance of continuing treatment. There is still considerable stigma attached to TB and people are afraid to be labelled with this disease; for this reason no special TB clinics were being held. At the mission clinic at Akim Swedru, near Oda, a somewhat different picture of follow-up emerged. Here records were kept of the patients who had been * If this figure includes all new TB cases occurring in Birim District (which is unlikely), it represents an incidence of over 2.6 new cases per 1,000 population per year, which is very high. However, an unknown number of the patients are likely not to have been new cases but merely new registrations, because cards were lost due to the poor recording system. On the other hand, this number probably represents only a small proportion of the total TB cases occurring in the district. ~"Performance on individual criteria by types of organisation of environmental sanitation services is shown in IDS, 1978b: Table A20.

diagnosed and treated at Oda Hospital, and who were still continuing treatment from the clinic. Of the 36 patients who were registered with them in 1976, 29 were still coming regularly, one had died and six had defaulted. This suggests that when the peripheral health unit assumes responsibility and keeps accurate records, it is possible to achieve quite good results in terms of follow-up. It is likely that many TB cases attending health centres remained undiagnosed until their condition was serious. The general level of history taking and examination, and the time available for consultation, made it likely that many cases were not being identified (Chap. 4:4). We saw little evidence of any health education programme concerning T B - - n o campaigns, village discussion groups, mobile vans, radio programmes, or lectures (apart from one outpatient lecture given at Worawora on the recognition of TB). Yet people were clearly unaware of the importance of continuing treatment, and the fact that it was still very much seen as a stigma to be a TB patient also suggested that much more education needed to be done. No follow-up of contacts was carried out, partly because of lack of transport and of contacts between health workers and villagers in general. Much could be done, however, by those health workers who do visit villages regularly, such as health inspection assistants, provided information reached them about newly diagnosed patients. Similarly, if records were available to indicate who had not returned for treatment in a particular month, such a health worker could take the drugs to him. Community health nurses did some follow-up of patients in the vicinity of a health unit but they had no formal responsibility for the treatment or progress of the patient. Yaws. The organisation of yaws control was another example of the lack of integration referred to above. Many cases of yaws were seen and diagnosed at health units. Treatment is usually with daily injections of procaine penicillin, for which the patient may or may not return. The long-acting injection of penicillin (PAM) was not made available to health units by the MFU, as the health unit staff were not thought to be able to give the injections properly. If the M F U office is elsewhere in the town (e.g. as in Jasikan District) yaws cases were refei'red to it, but no one knew how many patients actually found their way there when diagnosed at health units. No-one was routinely informed of the number of cases, and no record was made of the patient's village of origin. There was no mechanism for follow-up and treatment of contacts. The M F U ran their own programmes of mass casefinding and treatment independently, without regard to the cases being seen at the health units. 4. ENVIRONMENTAL SANITATION

(a) Overall coverage and quality The population of the villages covered by the health inspectorate in the Jasikan District was estimated from the 1970 census (IDS, 1978h: Table A19). The figures show that only 32% of the district population was covered by environmental sanitation services. Overall scores for the quality of environmental sanitation are shown in Fig. 5.+ Out of a total score of

Health needs and health services in rural Ghana 18 FAiR

I

POOR

Moximum Score

16-

14

o

GOOD (13 - 17)

12

I0

0

9 8 o

7. 6

FAIR (7-12)

6

U

-1-

o

4-

3-i Y"

"

,,

POOR (0-6)

Environmentol sonitotion oreas studied Key

= District Council

1

I i

Fig. 5. Quality of environmental sanitation--overall scores.

18, 13-18 was rated "good", 7-12 "fair" and 0-6 "'poor". Only one unit was considered to provide a good quality service, six units were fair and two were considered to be poor. Services provided by health inspectors were on average better than those provided by health inspection assistants. Places where only a health overseer provided environmental sanitation services had a significantly lower quality of service. (b) Tasks involvin9 the public Health education by health inspection personnel was not observed anywhere, neither were visual aids seen. Group sessions were reported to take place in five areas, usually if a specific need arose, e.g. the building of an unfamiliar type of pit latrine. Health inspectors and their assistants were not observed giving health education at clinics anywhere. House visits were carried out in all the areas studied, with around 100 visits per month recorded by health inspection personnel in Birim District. The number of visits varied a great deal; the same was true for the approach used and the content of the message. House visits were considered to be satisfactory in only one-third of the areas studied. Only three health inspectors were observed to give reasons for recommended actions. The "policeman approach" adopted in the majority of home visits is obviously effective in many cases, where a specific

437

action (such as digging a soak-away pit) is required, but unhelpful in producing behaviour changes, such as hand washing. To follow most of the environment a l health advice would require considerable effort, which would probably not be made if the health in, spectors merely voiced a mild recommendation. Lack 'of statutory powers was seen by the CHNs as a i reason for the often ineffectual advice. In fact, in Birim District only 4% of the 13,148 health inspection contacts recorded were served statutory notices, while 1% were prosecuted. The majority of prosecutions were for inadequate protection of foods on sale, which indicates that the threat of prosecution is sufficient to produce action. All the health inspection personnel interviewed saw a need for changes in personal habits regarding defaecation, refuse disposal and use of water, but they had not been successful in motivating people to make these changes. Uncovered water containers, and insanitary refuse and excreta disposal were seen in the majority of areas, in spite of years of "health education". Many of the health inspection personnel lacked the teaching and communication skills necessary for this activity. In the majority of areas studied the health inspectors were not able to identify priority problems and to suggest appropriate and relevant technical solutions to them, either in the household or the village. Although advice given was correct in the formal sense, we witnessed impractical advice being given in the majority of areas studied. Suggestions tended to be vague and theoretical, and the health inspectors themselves could not translate them into actions (e.g. "Get the cooking pot off the floor", but no idea how to build a stand). At other times the advice could not be put into practice because the necessary materials were not available locally or because the cost of following the advice was prohibitive (e.g. "Build a concrete gutter", but there was no cement; "Scrub the latrine and bathroom with Izal or Omo", where neither was available, even for conservancy labourers). In general, there were very few places where the health inspection officers seemed concerned with the problems of implementing the advice they were giving. One indication of this is the fact that in fewer than half the places studied did health officers appear to know the cost to householders of the actions they were recommending. At the village level, the health inspection personnel were aware of obvious problems, such as inadequate or unsafe water supplies, poor latrine provision or indiscriminate dumping. They frequently were also aware of feasible solutions using local materials (e.g. mud incinerators, thatched latrines), but were not able to motivate the community to translate them into action. This is in part due to a predilection, probably shared by all concerned, for a more "modern" solution to be provided by the government. However, the fact that in most of the areas health inspection personnel had managed to motivate at least one community to undertake sanitation projects involving communal labour over the past year, demonstrates that this attitude can be overcome. It presents a considerable challenge to the health inspectorate to steer the priority interest of Village Development Committees from a health facility providing

438

IDS HEALTH GROUP

sophisticated curative care, towards less appealing sanitation projects involving communal effort. The health inspection personnel contact the District Council and the Water and Sewerage Corporation for the supplies needed for sanitation and water projects (e.g. water pumps, cement and other building materials). In the majority of areas the health inspection officers had brought a problem to the appropriate authority, and most expressed dissatisfaction and even bitterness over the negative outcome. In this situation it is not surprising that a certain amount of apathy and lack of motivation was observed regarding liaison with these organisations. In most of the areas studied, some water sources were considered by the health inspectorate to be unsafe for drinking. Out of 23 villages or townships in Jasikan District, 14 had unsafe supplies from streams or ponds, six had boreholes which had either broken down or suffered frequent breakdowns, and only three villages had a safe supply (although in one of these many people also regularly used a polluted stream). The health inspectors and their assistants did not undertake water testing, but used the rule-of-thumb method that slow-flowing streams are likely to be unsafe, while faster flowing rivers will be reasonably uncontaminated. The role of the health inspectors in the improvement of water supplies is to make a report to the Water and Sewerage Corporation and District Council and to organise health education. In many cases the health inspectors do make a report, but there are difficulties in implementing improvements. The decision to improve water supplies appears to rest on the size of the population of a village and on social influence rather than on need. The use of communal labour for "intermediate technology" solutions to water problems (e.g. wells, protected water sources) does not seem to have been explored in most areas. lc) Inspection and other activities In all the areas observed villages, houses and the environment around the houses were reasonably clean and tidy, and health inspection personnel appeared to be routinely visiting refuse dumps and latrines. In general, village latrines were in a reasonable condition and invariably much better than their counterparts in the urban areas. There was great variety in the standard of care of refuse dumps. The limited powers of the health inspectorate to change either behaviour or environmental situations resulting from lack of resources renders these routine visits rather fruitless when a major problem exists. The inspection of markets and bars was observed to be thoroughly done with a satisfactory outcome. The cooperation of the villages in refuse control, keeping latrines clean and communal sweeping varied widely. Supervision of conservancy labourers was performed regularly: in fact it was one of the main (daily) tasks of the health inspectorate. Problems that arose with the work done by the conservancy labourers were related more to shortages of protective supplies and tools than to poor work performance. There is also a shortage of conservancy labourers because

* See also Section 6, below, and IDS, 1978b: App. I 1.

people are unwilling to take on such work when possibilities of more attractive employment exist. For vector control no spraying was reported in Jasikan District because insecticides were not available. Less than half the health officers reported environmental activities to reduce the number of mosquitoes. The Birim District returns recorded that in 1976, 329 sites were oiled and earth drains regraded to reduce mosquito breeding. Evidence of this was not actually found anywhere.

(d) Communicable disease control In only one third of the places were both casefinding and contact-tracing for communicable diseases done routinely and efficiently by health inspection personnel. In most areas affected people were picked up during the course of routine house visits and advised to go to the nearest health unit. Cases of measles, chickenpox and yaws were reported in the monthly returns. In one instance a health inspection assistant was observed to give advice intended to prevent the spread of tuberculosis.

(e) Some general conclusions The environmental sanitation services depend on the District Councils rather than on the Ministry of Health, and their effectiveness is much reduced by the lack of material support from these two entities. The health inspection assistants were generally aware of the problems and often had feasible solutions to them. but they were not able to translate them into action. The preference in Ghana for more modern constructions to be provided by the government over simpler constructions made locally with available materials and using communal labour, is another barrier to appropriate and relevant solutions to village sanitation problems. These two factors are perhaps responsible for the lack of liaison of health inspection personnel with other agencies to request assistance, or even just to report sanitary hazards. In their experience, nothing was likely to come of repeated representations to District Councils. Very few villages had adequate supplies of water, and very little was being done about this most important issue by anyone in the two districts studied.* On the whole, the health inspectorate have been successful in organising communal labour, in most cases for latrine building. Relations with the VDCs were generally cordial and it appeared that there was scope for expansion in this direction, especially as many of the activities involved can be undertaken with minimal extra expenditure. The inspection of markets, bars, public latrines and refuse dumps was done routinely, but the effectiveness of this activity depends to a large extent on back-up support and the ability to change behaviour. Effective and routine case finding and contact-tracing for communicable diseases was seen only in three areas. The normal practice was to advise affected people picked up during routine house visits to attend the nearest clinic. The need for a more formalised system is obvious. 5. THE QUALITY OF CARE-A QUANTITATIVESUMMARY In Table 15 we have attempted to give an overall summary for each health unit of the quality of the

Health needs and health services in rural Ghana

439

Table 15. Summary table for quality of care assessments* Final grading Health unit A

C

Polyclinic

Maternity

Child health

Dodi Papase Mission Hosp. Achiase HC New Abirem HC Nkonya Wurapong DC.HP

2 1 2 1

2 2 2 2

2 1

Fair

Kadjebi HC Oda Hospital New Ayoma DC.HP Worawora Hospital Jasikan HP Ahamansu HP Brenasi H P

2 0 2 0 1 1 1

Poor

Ofoase Mission Unit Dodo Amanfrom HC Abotoase DC Dispensary Ntronang Mission Unit Lolobi Kumasi DC Dispensary

1 0 0

Good

- -

0

Environmental sanitation

Total

1

-0 --

6/6 4/6 4/6 4/6

1 2 1 1 0 1 0

1 1 0 0 1 ---

1 1 0 2 I 0 1

5/8 4/8 3/8 3/8 3/8 2/6 2/6

0 0 -0

-1 0

-1 --

- -

- -

1/4 2/8 0/4 0/2

- -

- -

- -

--

- -

0/2

* For each area of activity health units have been given '0', T or '2' according to whether the quality of care score was graded as poor. fair or good in the previous assessments. To arrive at a total we have added the points for each unit, but used a denominator related to the possible total for each unit, e.g. if environmental services and child care were not provided, the total possible for that unit would be 4, where units providing all four types of service would have a total possible score of 8. From these totals percentages of overall quality were calculated and classed as A, B or C, as follows: 67*, or above = A. 33°, or above = B and less than 33% = C.

Figure 6 shows that those units providing the best quality of care were by n o m e a n s the m o s t expensive in terms of cost per patient contact.

activities in polyclinic, child and m a t e r n a l care a n d e n v i r o n m e n t a l sanitation. T w o health units in Birim District (Achiase H.C. a n d New Abirem H.P.) and two units in Jasikan District (Dodi Papase Mission Hospital and N k o n y a W u r a p o n g District Council H e a l t h Post) were assessed as providing a good overall quality of primary care. Five health units (one health centre, two district council dressing stations a n d two mission clinics) were assessed as providing p o o r quality of care and the remaining seven were graded as fair (five close to the dividing line with the p o o r group).

6. N E E D S F R O M T H E V I L L A G E P E R S P E C T I V E

The strategy we have adopted to assess the existing health services, namely, to evaluate them against an acceptable s t a n d a r d of performance as defined by medical consensus, suffers from the limitation that the medical consensus itself has been built up o n the basis I. A d ~ s e 2. Ofoase 3. Brenasi 4. N t r o n a n g

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IDS HEALTHGROL'P

of an established organisational framework. While, therefore, the method provided a yardstick for the performance of the health care system operating within that framework, our study of the needs from the village perspective allowed at least some investigation of health priorities independent of it. The village study thus gave some possibility to ask the following types of question. la) To what extent are the priority health needs of villages those conventionally attended to by health services, or to what extent are activities in other sectors, or indeed other changes that government could introduce, more important? The medical consensus assumes that primary health care services are priority means to improve health, i.e. they are costeffective and feasible. An independently-based study of village needs, and the feasibility of various ways of meeting them, could throw light on the justification for this assumption. (b) To what degree do particular interventions, whether or not they are among those identified as tasks in the medical consensus, have greater priority in terms of cost-effectiveness or feasibility than others'? It is one of our assumptions, as set out in the Introduction. that various different interventions need to be carried out as part of a "'package". But we should not assume that all interventions are equally indispensable if the full package cannot be offered immediately. Some interventions may be both especially easy to implement in comparative isolation from others and of considerable effect by themselves. (c) Would it be possible for certain tasks, especially those necessarily mentioned in general terms in the medical consensus, to be further specified in organisational terms'? And how easy would it be for any health workers in the village situation to do this? The starting point for this part of our research had to be independent of the organisational framework of the health services but it did not intend to be independent of medical knowledge. The study investigated from the villagers' perspective the various processes known to be associated with particular diseases or health problems, mainly using a questionnaire survey supplemented by some probing and observation. We investigated the causal processes involved in two important health problems of Ghanaian villages: nutrition, especially of young children, and the faecal transmission of disease. These problem areas correspond approximately to the organisational categories of child health and environmental sanitation, but the correspondence is not exact. (a) Nutrition There are two important aspects to nutritional problems in rural Ghana. as in most of the Third World : the problems of poverty and inequality, which limit the access which large sections of the population have to food: and the problems of feeding practices,

* See IDS, 1978b:Tables A22 and A23: The final version of the questionnaire, as used in Tongu District. is given there in Appendix l la. + Our data on nutrition status are given in IDS, 1978b: Table A24.

which may not be optimal in making use of the food. or the potential food sources, to which the household does have access. Acceptance of the general socioeconomic and political situation leads to a concentration on the changes in feeding practices which might be obtainable without greatly improving overall access to food. Focussing attention on feeding practices means that the structural changes in society required to reduce social inequality need not be faced, although some increase in food production, or diversification in types of food grown by individuals, is usually considered within the existing social structure. In Ghana there has been this tendency to discuss nutritional problems mainly in terms of feeding practices and of crop mix in food production, rather than in terms of poverty and inequality. Economic differentiation has often been assessed positively in terms of the entrepreneurship of the successful, while the associated (or at least concurrent) impoverishment of the unsuccessful has been relatively ignored. Our view of this situation and its effect on nutrition may have been exaggerated by the fact that our research coincided with a period of two consecutive very poor harvests. But frequently comments were heard of a longer term worsening of the food situation. We shall return to these important issues. The intention in the present research was to gather data both on feeding practices and on the most obvious determinants of household access to food. Data-gathering, mainly by questionnaire, was structured by a checklist of the types of influences which have been postulated as affecting nutrition in other countries, and another on the particular points raised in other work on nutrition in Ghana.* The questionnaire method suffers from drawbacks: it is confined to reported rather than actual practices and quantitative measures of intakes are excluded. It was supplemented by discussions in the villages and by some assessment of the nutritional status of children aged between their first and fifth birthdays, using weightfor-age and arm-circumference measurements. The findings are suggestive, not definitive, but they provide a basis for commenting on the types of interventions which may be indicated. Nutritional status. Of some 200 children in four villages of Jasikan District. 4°0 were found by the arm circumference method to be severely malnourished and a total of 24°0 were suffering from some degree of malnutrition. In two villages of Tongu District. at least 15°; of 81 children were found to be significantly below the expected weight for age. There was considerable variation between the different villages.'l" Feeding practices. The great majority of mothers replied to open-ended questions that they breast fed their children for at least one year: introduced supplementary food in the form of a porridge by six months: introduced the staple with soup or stew well before withdrawal of the breast and had no problems when the breast was withdrawn: gave their children three meals a day: did not have prejudices against giving eggs. meat or fish to children: and said that there was no problem with feeding when they go to work in the fields. Those who have received nutrition advice reported that-they were able to carry it out and that it was useful: this included the inclusion of groundnut or other sources of protein in the child's porridge.

Health needs and health services in rural Ghana These replies do not necessarily reflect the reality of actual feeding practices, but they do suggest that childhood malnutrition is not due mainly to mothers' ignorance about what they should be doing. Local health workers, including any future VHWs, will need to elucidate the real situation about feeding practices in their areas. One aspect of feeding which may well require special attention by a VHW, possibly helped by part-time neighbourhood "health monitors", is the nutritional care of children during and after episodes of acute infections, which can precipitate serious nutritional problems. A VHW may need to ensure that particular attention is given to feeding during this time, including in the "'catch-up" period on recovery; this would appear to be pre-eminently a "monitoring" function, to be performed by a person living close to the families and able to devote considerable time to them (rather than just calling in briefly with a piece of advice). Surveillance of children's growth with the help of weight charts or by periodic screening of arm circumference could be another monitoring function at the village level. On the points where majority practice in a village is unsatisfactory within local resource possibilities (e.g. concerning the use of green vegetables or cheap sources of protein or compact calories), what appears to be required are discussions led in the village by its health worker, rather than sessions of "nutrition education" at which an educator lectures groups of individuals. Such discussions could help to overcome problems people may have in growing or using important foodstuffs. A summary of some nutritional interventions which appeared to be indicated at village level, and of the kinds of village organisation which might play a part in implementing them, is given in Table 16. We are not suggesting it will necessarily be easy to implement these interventions. We shall return to the question of feasibility in Chap. 9. Food production and access to food. Nutritional problems may, however, have to be traced beyond the more conventional issues of feeding practices raised so far, to questions of food production and access to food.* Productive resources of all kinds (notably land suitable for cash crops) tended to be concentrated in relatively few hands, rather than spread more or less evenly amongst the population of an area. Where the research was carried out there were many people whose ability to produce (and hence feed their families) above the minimum level necessary for survival was very limited by their lack of access to productive resources. Share-cropping in which the produce is divided 50--50 between the landowner and cultivator was normal in cocoa farming in Jasikan District, and even for foodcrop farming this was the arrangement under which some people had access to land in some villages. Access to equipment such as tractors, was probably even more concentrated. Attention thus needs to be directed towards those

* This is set out at some length in IDS, 1978b: Tables A22 and A23. ;- For further details, see IDS, 1978b: Appendix 1la. SSMI~.,~

15 4

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441

who are not favoured by this pattern of commercial agriculture and who are finding that the use of land by others for cash crops reduces the amount remaining to them for traditional agriculture. This situation is also shortening periods of fallow, reducing soil fertility, and forcing a shift into crops which survive under such conditions (especially cassava). Moreover, it was found in Jasikan and Birim Districts that land was becoming an increasingly scarce resource. The traditional right of any indigenous person to cultivate land (and in practice also the traditional freedom for in-migrants to do so against token payment) was giving way to a concentration of land rights in relatively few hands.t We ecneluded that it was becoming crucial that the government take measures to ensure that every Ghanaian farmer had access to enough land, reasonably close to home, to absorb his or her capacity to work. High on the list of factors affecting the time and effort put into food production, as compared to other activities, was the neglect of this activity by many men, who favoured cash-cropping or out-migration in search of more remunerative employment. Although at the immediate time of the research the prices of food crops should have been high enough to attract them back to food production, the response was very limited, as doubtless decisions on such matters are made on a longer-term basis. Our data for four villages in the Volta Region show that between one quarter and one half of the children aged between 1 and 5 years had fathers who were absent. In this situation the day-to-day responsibility for providing food for the children falls even more completely on the mother. It was found, at least in Tongu, that relatively few such mothers could afford to employ labour and that mutual aid amongst families was declining. So these mothers had to rely on their own efforts, which were limited by their strength and time. The following interventions at village level may therefore be considered: (1) provision in each village of a day care centre which could simultaneously increase the productive time available to mothers and provide at least one good meal a day for the children; (2) paying special attention to providing detailed advice on cultivation to women as farmers, together with necessary material inputs such as seeds and integrating advice on cultivation with advice on nutritive foods; (3) provision of help in clearing land for women, who can perform the less strenuous tasks in cultivation themselves. Turning to factors affecting productivity in farming, it was found in the Guaman area that there were problems with the traditional practice of bush-fallowing. Growing pressure on the land, due to a combination of the extensive cultivation of cocoa, flow of in-migrants and population growth, has resulted in shorter periods of fallow, giving the soil less time to recover its fertility. In such areas there is a need for some intensification of farming practices. In Tongu District, though there was not the same problem with bush-fallowing, intensification was also necessary. Special attention should, therefore, be paid to ensure that small farmers, including women, have the information and support necessary for any feasible intensification of their farming, including where appropriate

442

IDS HEALTH GROUP

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Health needs and health services in rural Ghana support for irrigation, and information and support for soil fertilisation. There appeared to be a need also for measures to encourage the growing of nutritious vegetables, perhaps in a kitchen garden near the home. For this, the interventions needed are the dissemination to all farmers, both men and women, of the necessary information on such vegetables, as well as to prevent the destruction of the crops by animals, such as by penning them in or fencing the crops. The interventions to overcome the problems of food production and access, and farming productivity, go well beyond the jurisdiction of the M O H as conventionally defined. Some of the interventions would normally be regarded as within the area of "community development" and hence in the province of the village development committees. Others would be more clearly the responsibility of the Ministry of Agriculture. The role of the health authorities would be to draw attention insistently to the interrelations amongst health, nutrition, food production, poverty and inequality, and to point to the limitations of their own technical activities in the absence of appropriate actions by the government and its other sectoral departments. The need to ensure more equal access to land, capital equipment, productive inputs, etc. is fundamental and goes well beyond the technical fields of particular departments. It requires a focusing of attention on the processes which generate the present inequality of access, and the adoption of policies to reverse the situation.

(b) Faecal transmission of disease The village-level research on environmental sanitation and personal hygiene was centred around the cycle of faecal transmission of disease.* The findings are summarised below, together with the interventions that might follow from them. Observation was made of village practices (mainly in the Volta Region) in respect of each of the likely routes of transmission, and common sense conclusions were reached about the points in the cycle which appeared to be most critical. These common sense conclusions could be regarded as hypotheses for further testing of a more exact kind. There seemed to be a preference, both among villagers and local authorities, for a septic tank type of latrine, emptied periodically by a mobile suction tanker. This appeared to be inappropriate to the present circumstances of rural Ghana, if only because of the frequent breakdowns of the tankers. Generally there was a preference for exogenous solutions to the sanitation problem, rather than making local solutions more effective, for example, by ensuring that the village latrines were kept covered with lids to keep out flies. Many villages still had no sanitary facilities at all. a clear indication for the construction of pit latrines. However, where modern latrines were already built, more attention needed to be paid to their hygienic maintenance. Perhaps the most widely encountered problem concerned the place of defaecation of children too young to use the adult latrine. Whereas considerable atten* The research and findings are set out in detail in IDS, 1978b: Appendix 11.

443

tion had been paid to latrine building, comparatively little systematic thought appeared to have been given to solving the special problems of children's defaecation. One possibility appeared to be the construction of special latrines, but in any case it should be possible to develop--in cooperation with the villagers themselves--some effective means or other for the safe disposal of excreta of young children. Another problem concerned a particular aspect of personal hygiene. Whereas general cleanliness was habitual, the washing of hands often appeared to be inadequate, even when water was available. Only one hand might be washed and soap, often scarce in the villages, was frequently not used. Soap was difficult to obtain in many villages owing to problems of price control and administrative distribution. This situation is potentially resolvable, although we are aware that it would involve grappling with the basic causes of scarcity of many essential commodities in Ghana. As for hand-washing, the identification of the problem could lead to a concerted effort of health education in the villages. The necessary interventions are presented in Table 17.

(c) Conclusions In the villages the major felt need was for curative care, and certainly improved curative activities would have a rapid and significant impact on health, especially of children. In addition to the work of the regular health care service in this field, many of the therapeutic actions are quite simple (e.g. the early treatments of fe~'er, respiratory symptoms, and diarrhoea) and could be within the competence of VHWs. The fulfilment of this curative need, not requiring much community participation, would be relatively easy to organise within the prevailing socio-political context and as such could be a priority for action by the governme_nt. With regard to preventive work, we also identified a number of relatively simple and practical actions a VHW or a "monitor" might do under the guidance of health service personnel. Some possible interventions in the fields of nutrition and the faecal transmission of disease were discussed above. In addition, village health personnel could make valuable contributions to bringing people into contact with the health care service for immunisations and the control of communicable diseases such as yaws and tuberculosis, as well as to ensuring that treatment (where they do not give it themselves) is sought, given and continued until it is effective. When indicated they could also distribute tablets for malarial prophylaxis. Once an organisation exists to carry out such tasks in villages, it hopefully might be expanded to cover a wider "package" of integrated curative, preventive and promotive activities. There are other village interventions which would require a degree of community mobilisation and a commitment to health-related action greater than exist currently in Ghanaian villages. To some extent they might be organised in the context of a programme centred on VHWs, and we shall return in Chapter 9 to the feasibility of the kinds of community involvement required. However, it could also be argued that it is this community mobilisation which is

444

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445

transformation in some of the basic socio-economic conditions for health. As this issue obviously goes well beyond the health system as such, we can do no more here than place it on the agenda for discussion.

PART III: INPUTS

P A R T Ill: I N P U T S

C H A P T E R 6. P A T T E R N S O F R E S O U R C E A L L O C A T I O N

I. INFORMATION ON RESOURCE ALLOCATION TO HEALTH IN GHANA In an earlier section we noted that reallocation of resources within health care systems from tertiary to primary care is proving difficult to implement, particularly where health budgets are not rising in "real" terms. This has been true in Ghana, in spite of the government's stated intention to redistribute resources to the rural majority of the population. For these reasons we concentrate in this section on the use of resources within the primary care sector. The government health care system in Ghana, like many other such services in the Third World, hitherto has been administered but not planned. The setting up of the National Health Planning Unit both recognised this distinction and made a valuable start in changing the situation. But the costs of particular institutions are currently not routinely known--though the work by R. G. Brooks (1975) is beginning to fill this gaty--as costs are not kept for planning purposes but only for administrative purposes. Accounts record the expenditures of"payment centres'" which often add together the expenditures of many (but not always all) health facilities in a district. Similarly. data on the deployment of staff and other resources are not routinely kept at District. Region or Central administrations. Against this background it became clear that a necessary, but massively time-consuming, part of the research would be to establish the ,qeooraphical distribution of resources within the health service. The distribution of budget resources had already been established at a general level through the work of Professor

Ofosu-Amaah (1975) and R. G. Brooks had undertaken an exercise on the actual costs for 1974/'75 for the Eastern Region and much of the Northern Region. But to bring these data up to date and to match the work carried out by the medical and sociological teams, it was necessary to establish the costs of health service institutions and activities in Jasikan and Birim Districts. 2. PROCEDURES FOR THE RESEARCH

There are four basic types of "modern" health services in Ghana: the Ministry of Health's services, the services of the district councils in their dressing stations (though these do not exist in Birim District), the services of the missions, and those in the quasipublic and private sectors including the quasi-government Mines and Cocoa Clinics, and private practitioners. Of these types three were studied: Ministry of Health and mission facilities in both Birim and Jasikan Districts and district council dressing stations in Jasikan District, in addition to the activities of the sanitary and conservancy labourers who deal with the night soil and other public health measures. There were no quasi-government units in the two districts studied. Of the 11 health facilities in Jasikan District and the eight facilities in Birim District, 11 are Ministry of Health, three are Mission and five are District Council. The Ministry of Health facilities are financed through a variety of payment centers, which all had to be separately researched. For Jasikan District the, details are given in Table 18.

Table 18. Jasikan District health service costs, by source 1975'76 i¢) Ministry of Health Worawora Ho Hohoe Worawora Hsp. Jasikan H.P. Dodo Amanfrom H.C. Ahamansu H.C. Kadjebi H.C. Nkonya Wurapong D.S. New Ayoma D.S. Abotoase D.S. Kwamekrom D.S. Lolobi Kumasi D.S. Dodi Papase Mission Total: Oo:

296.106 16.769 16.571 7641 23,589

10.843 965 1639

9005 9260 4693

480

6053

Central Medical Stores

District Council

335.799 60.199 69.091 50.464 68,006

Mission

17.392 24.550 6826 13.667 26.587 19.925 6015 15.867

Total 642.145 111,743 98.820 71.771 124.715 91.925 6015 15,867

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2586 15.082

22.891 356.567 3000

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IDS HEALTHGROUP

448

Table 19. Cost and patient-contact data, selected institutions, Jasikan District. 1975 76 1¢) A

Medical costs*

B C D Drug and Health stores costs Inspectors, included in sanitary & medical conservancy Out-patient costs+ labour contacts+

E "o Drugs etc. in medical costs (B,A)

F Medical costs per patient contact ¢ (A.D)

1. Hospitals

Worawora District Hsp. Dodi Papase Mission Hsp.

622,375 76,606~

335,799 18,361

19,770 15,082

66,198¶ 20,758

54 24

NA NA

60,211 91,886 86,789 79,398

50,464 68,006 69,091 60,199

I 1,561 32,829 12,031 32,345

22.563 53,418 30,246 48.610

76 74 80 76

2.67 1.72 2.87 1.63

3779 3018 3942

(551) NA

1575

NA

2. M o l l Primary Facilities

Ahamansu H/C Kedjebi H/C Dodo Amanfrom H/C Jasikan H/P 3. District Council Facilities

Nkonya Wurupong H/P New Ayoma H/P Abotoase Dressing Station Kwamekrom Dressing Station Lolobi Kumasi Dressing Station Other Total Jasikan District (incl. non-government expenditure at Dodi Papase Mission Hospital)

1,029,579

601,920

16.146 3.286 2997 NA 11,925 3968 Not functioning 1011 NA 47,361 203,058

249.074

IA5 0.99

58

A reraye :

Non-Hosp.: 2.0,1

(53,715)~

* t ~ ~ II~ See Table 20 footnotes.

District Council expenditures are met from central government allocations to local government and recorded at the District Headquarters; the Missions keep their accounts at each facility. The procedure was to aggregate the expenditure of each health facility from the accounts of these various Payment Centres for 1975/6.* The data combined by this procedure contained a number of limitations. The most important are: firstly, as the district hospital is the source of supplies (and occasionally staff) for the other institutions in a district, it is likely that the distribution of costs between hospitals and other institutions is biased towards the hospitals. Secondly, the costs of drugs and other stores were taken from the Central Medical Stores and, in the case of the Eastern Region, from the Regional Medical Stores (though checks were made in the records of the individual health facilities). This means that the amounts entered as the cost of drugs at any facility in any one year were in fact the costs of the stores supplied and not necessarily the * In the case of the Ministry of Health and District Council facilities this involved establishing the name of each individual health worker at each facility and finding their salaries and other expenses entered in the accounts of a number of payment centres. Expenditures on central and regional administration were not included nor were the costs of the Medical Field Unit. Although this was a very tedious and time-consuming exercise (many accounts staff said that it was not possible), there was a considerable "learning effect" in that once the various accounts and procedures became familiar, the speed of data collection rapidly increased. t Hospital accounts should be redesigned to show such an important functional breakdown; meanwhile, it would be worthwhile to undertake a special study on this issue.

costs of stores used. We do not know if institutions changed the level of their stocks over the year. As stock changes are not recorded in this approach, our analysis might erroneously suggest that drug use rose (or declined), whereas in reality the drugs supplied merely changed the stock of drugs held at the unit. 3. THE ANALYSIS The first step in the analysis was to establish recurrent costs by facility and by "'activity". This is shown in Tables 19 and 20. The cost data were manipulated to distinguish between what might be called "medical" costs and the costs associated with public health activities. "Medical" costs included expenditure from the Ministry of Health, the Missions and the District Council sources for all personnel, drugs and equipment shown in the accounts, but excluded the salaries, travel and transport and other expenditures of the health inspectors, health inspection assistants, sanitary and conservancy labourers: these latter costs are shown separately in Column C of Tables 19 and 20. The second step was to distinguish between that part of medical expenditure which was taken up by drugs and other stores. In order to compare the costs of the individual institutions an index of their size and level of activity was required. For this, the total number of outpatient contacts per year was taken as a first approximation. We then calculated the cost/out-patient contact as the main instrument of comparison. From data at the hospitals it is not possible to separate out expenditure associated with hospital in-patients and those relating to hospital out-patients# Early in the research it became clear that drugs constituted a very large proportion of total recurrent costs at the

Health needs and health services in rural Ghana

449

Table 20. Cost and patient-contact data, selected institutions, Birim District, 1975/6 1¢) A

Medical costs* 1. Hospitals Akim Oda Hsp. 2. M o l l Primary Facilities Achiase H.C. Brenase H.C. New Abirim H.P. Anyinase H.P. 3. Mission Clinics Akim Swedru Ofoase Ntronang Other

Total Birim District

B C D Drug and Health stores costs Inspectors. included in sanitary & medical conservancy Out-patient costs+ labour contacts+

E "o Drugs etc. in medical costs (B/A)

F Medical costs per patient contact ¢ (A/D~

775,763

388,056

114,778

106,394

50.0

NA

79,926 65,135 51,671 39,379

52,906 44,691 29,368 31.272

17,310 14,846 66.355 --

44,878 18,493 34.484 25,889

662 68.6 58.6 79.4

1.78 3.52 1.50 1.52

71,573 70, I 13 7809

39,077+++ + 39,077.+~. 4000+'I"

713 -7i3 50.346

66,155"* 46,320"* 7879

54.6 55.7 72.4

1.08 1.51 0.99+

54°o

A veraoe: Non-Hosp. : 1.70

1.161,369

628,447

265,061

350.492

Notes to Tables 19 and 20..

* Medical costs include the costs of salaries, drugs, travel and transport and other costs associated with all the staff of the health facilities excludin# health inspectors, health inspection assistants, sanitary and conservancy labourers. These latter costs are shown in column C. "i-The Drugs and Stores costs which are included in column A are shown separately in column B. $ Outpatient data refer to polyclinic, antenatal and child clinic contacts. They are taken from data supplied by Centre for Health Statistics, from analysis by use of records at facilities, and by guesstimate for dressing stations. The guesstimates are based on records of new patient registration multiplied by an assumed level of patient contacts per registration of 1.7--a number derived from institutions where such data are available. Two figures in column A for Dodi Papase Mission Hospital: ¢76,606 is the total expenditure recorded by the Institution. ¢53,715 is the amount received from non-Government sources. Dodo Amanfrom's relatively low attendance figures were caused by the illness of the Health Centre Superintendent. $ Excluding child clinic contacts at satellite clinics run from Worawora. ** Including out-station contacts. t t Rough estimate for drugs expenditure. ~+. Divided equally between mission clinics. Sources Hospital, Health Centre and Health Post costs were obtained from four sources:

(it the District payment centre, usually the District Hospital; (ii) the Regional Headquarters of the Ministry of Health: Off) the Central and Regional Medical Stores; (iv) certain staff costs are paid from the cadre headquarters', for example, some staff in Jasikan District, such as some health inspectors and community health nurses, are paid via the office in Hohoe. District Council Dressing Stations, sanitary and conservancy labourers land their expenses) are paid through the District Council's offices. Most salaries for all Government employees are now paid via payment centres Isuch as those listed above) from computerised records produced by the Accountant General's Office, Accra.

primary health care level. T o explore this p h e n o m enon, drug costs were estimated for all institutions in the Volta Region, a n d a special study o n prescribing patterns was u n d e r t a k e n in the Eastern Region to establish the extent of "wastage" in drug use. 4. THE RESULTS The most 'striking result of the analysis was the very large p r o p o r t i o n of recurrent costs t a k e n up by drugs and other stores, which made up 54°0 a n d 58°,0 of the "'medical" costs in Birim and Jasikan Districts re-

spectively (see Tables 19 a n d 20). We shall return to this issue in detail later in this section. The cost analysis confirmed that the overwhelming p r o p o r t i o n of medical expenditure in the Districts went o n hospital care; in Jasikan District 685~o of medical costs went o n W o r a w o r a District Hospital and the Dodi P a p a s e Mission Hospital; in Birim District 67% of medical costs was t a k e n up by O d a District Hospital. T h e medical costs of the hospitals, moreover, represented respectively 57% and 54% of all health expenditures in the two districts, The m a l d i s t r i b u t i o n of health resources between Accra

450

IDS HEALTHGROUP Table 21. Summary table of 'medical' costs only by type of institution and patient contacts, 197576 (¢)

"Medical" costs* Jasikan Birim 1. District Hospitalst 2. Mission Hospitals'l" All Hospitals (1 + 2)'t" 3. M.O.H. Health Centres and Posts 4. District Council Units 5. Mission Clinics Total: Total excluding non-government sources

622.375 76,606 1698,981) 318,824 12,314 -1,029,579 975,864

Average "'Medical" cost per patient contact Jasikan Birim

775,763 9.40 -3.69 (775,763) (8.03) 236,111 2.06 -Incomplete outpatient data 149,495 --

7.29 -t7.29) 1.90 --

1,161,369 Incomplete 1,011,874

Incomplete

1.24

Source: Tables 19 and 20. * Defined in * to Tables 19 and 20. "I"Includes in-patient costs. and the rest of the country was therefore repeated within each .District. A summary presentation of medical costs can be found in Table 21. The total cost of all medical and public health activity in the Districts was about ¢1.2 million and ¢1.4 million respectively in Jasikan and Birim, or ¢6.40 and ¢7.54 per capita. The salary and wages cost of the health inspectors and their labourers constituted around one-third of total personal emoluments, but they paid for about 50% of the people employed because of the large numbers of sanitary and conservancy labourers (IDS, 1978b: Tables A39 and A40). The quite large sums of money spent on wages and salaries and on stores were in marked contrast to the other expenditures, particularly on travel and transport. The shortage of funds for travel and transport was noticeable everywhere and seemed considerably to hamper the activities of health inspectors and their assistants as well as community health nurses. Lack of transport was further aggravated by the small number of vehicles available in both Districts for health work (IDS, 1978b: Tables A37 and A38). Only two out of six official vehicles in Jasikan District and four out of ten in Birim District were adequate, though the situation was even worse if one took account of time spent off the road over the last 12 months (see Chap. 7:3). It is difficult to place much reliance on the differences between particular institutions in terms of medical costs per patient contact (Tables 19 and 20). There might have been variations in the cost of drugs because of different timings for drug deliveries (those institutions which got, say, six deliveries a year would clearly have been more costly than those that only got five---but the number of deliveries would be determined more by events at the Central Medical Store than by the extent of prescribing). In addition to this, the wide variation in cost per patient contact seemed to be more a function of variations in out-patient attendance than of the level of medical costs. This

* This is set out in detail in IDS, 1978b: Figs AI-A4.

would explain the high cost per out-patient for Dodo Amanfrom, Ahamansu and Brenasi: total costs (and total personnel) were of the same order of magnitude as at comparable units, but total out-patient contacts were very much fewer. 5. THE QUESTION OF DRUGS We have already dealt with drugs in various earlier sections, particularly in the discussion of the polyclinic care (Chap. 4:4). There we presented evidence of gross over-prescribing in terms both of the prescription of larger quantities (and more items) than is desirable, and in terms of the choice of more expensive options, particularly injections. We now relate that evidence to the economics of the health service, and demonstrate how great is the burden which health workers, in collusion with patients, impose on the service, and what could be achieved if drug use moved closer to a rational pattern. It will be remembered that at all the health units studied fever/malaria and cough/catarrh accounted for half or more of the total cases seen, and if diarrhoea and measles are added the four major symptom groups accounted for between 60% and 80°o of all cases (Table 10). We priced each individual prescription given to patients in these four major diagnostic groups for our 1% sample at Achiase Health Centre, and thus arrived at an actual cost per 100 patients for each major symptom group. Then, we compared this actual cost with the cost of the appropriate prescribing response for cases of different degrees of severity and different ages again per 100 cases.* This is shown in Table 22, which demonstrates that the potential savings per 100 cases ranged from about ¢25.00 in the case of diarrhoea to about ¢125.00 in the case of coughs, and that for malaria cases, by far the most important single disease, an attack on over-prescribing could mean savings of up to 60°0 of the cost at the time of our study (almost ¢35.00 per 100 cases). The enormity of malpractice in economic terms will be realised once the total, potential saving per annum is calculated for no more than the one health centre at which our sample study was undertaken. This is

Health needs and health services in rural Ghana

451

Table 22. Actual and appropriate prescription costs from 1% sample of Achiase health centre

Percentage of 1% Sample

Total consultations by disease Itotal 39,334)

Malaria Cough Measles Diarrhoea

51 17 4 3

20,060 6687 1573 1180

Total

75

29,500

Disease

Average prescription cost 1¢) "Actual. . . .

Appropriate . . . .

0.57 1.35 1.38 0.79

0.2295 0.119 0.68 0.5387

Total cost [¢) Actual. . . .

Appropriate"

11,434 9027 2171 932

4604 796 1076 636

23,564*

7106

* Note that total annual stores cost at Achiase = ¢52,906 of which 80% were likely to be drugs (i.e. ¢42,325~. Therefore

56",, drug costs {23.564 + 42.325l were accounted for by 75% of patients. Table 23. Actual and appropriate prescription costs per 100 patients from 1°o sample

Fever/Malaria Cough/Catarrh Diarrhoea Measles

(11

{21

Actual cost

Appropriate cost

3=11-2~ ¢

57.00 135.50 78.60 138.00

22.95 11.90 53.87 68.00

34.05 123.60 24.73 70.00

shown in Table 23. If appropriate prescribing regimes had been used instead of those observed, drug costs would have fallen from ¢23,500 to just over ¢7OX)---a saving of 7000. If the same degree of overprescribing occurs on the 25°0 of consultations not covered by the four major symptom groups, then about 70% of the entire pharmaceuticals budget for primary care might be saved. From this set of appropriate prescribing responses to major conditions a pharmaceuticals entitlement for 75°0 of Achiase's patients can be calculated. The necessary data for this analysis (total patient numbers by symptom} are routinely available for all health centres. For the remaining attendances not covered by the four main conditions, a high and a low cost per prescription can be estimated to give an idea of the likely appropriate drug cost range. If the cost of these 10,000 other cases is assumed to be the average cost of treating the four main conditions, then this would be ¢39.25 per 100 patients or a low estimated total of ¢3925: if it were to be 50°0 more than the average the high figure would be ¢5887. The total pharmaceutical budget for a health centre of Achiase's size would then be between ¢11.000 and ¢13,000. Grossing these figures to allow for 20% "other" stores expenditure---dressings, equipment, stationery, etc.--would give an appropriate stores cost per primary institution of ¢13.200--¢15,600 which is ¢0.34-4:0.40 per outpatient contact compared with the level at the time of the study for the unit studied [Achiasel of¢1.18.* This is a substantially lower figure than that used for planning purposes by the National

* 66.2°0 of cl.78. See Table 20.

Potential savings 4=3+ oo

1

59.7 91.2 31.5 50.7

Health Planning Unit in costing alternative scenarios for primary care (¢1.60), and is also less than the actual drugs cost per contact recorded in the experimental conditions of the Danfa Comprehensive Rural Health and Family Planning Project. The difference-over ¢1.00 in both cases--may be seen as a measure of the wastage entailed by planning on the basis of current practice, rather than evaluating the services and planning on a "best practice" norm. The distribution of diseases, the proportion of people in contact with the service and the severity of their diseases are, of course, related to the existing service structure; modifications such as those proposed by the Planning Unit would change the pattern of demand and hence drugs requirements of primary care posts. For example, if antimalarials were to be distributed widely, as by "health monitors", and used effectively, a higher proportion of the {fewer) fever cases seen at health centres would be serious, thus raising the drug norm for these posts. To generalise from observed prescribing behaviour to the whole primary care budget is, of course, difficult, but on the conservative assumption that onequarter of the drugs used at hospitals are for primary care (i.e. in the out-patients" department), the potential savings (or the existing waste) look very substantial. For the Volta Region, for example, which is the only Region on which full stores costs for 1975/6 exist, the total stores budget was some ¢3 million: ¢2.4 million for hospitals and ¢574,000 for health centres and health posts (IDS, 1978b: Tables A41 and A42). If we assume that 80t~ of this (¢1.92 million for hospitals and ¢460,000 for primary care institutions) was accounted for by pharmaceuticals, the potential savings were approximately ¢658,000, some 20°o of the total stores expenditure for the Region.

452

IDS HEALTH GROUP 6. CONTROLLING DRUGS EXPENDITURE

The reason for the abundance of drugs within the Ghanaian primary care system must have been largely due to the fact that primary care institutions had direct access to the Central and Regional Medical Stores. They were, therefore, not subject to the control found in many other countries in which they are dependent on secondary and tertiary institutions, such as the District Hospital, for their supplies. But this does not explain the general abundance of drugs. While the overall budget allocation to drugs in terms of current health expenditure was largely similar in Ghana to that in Tanzania, i.e. around 22~o in Tanzania (Yudkin, 1977: 14) and 24~o in Ghana, because of its overvalued currency, Ghana's proportion bought around three times more than the comparison would lead one to assume. However, the lack of reliable evidence on actual expenditures in Ghana prevents any firm conclusions being drawn. Certainly the budget allocations to "unallocated stores" {of which drugs are part) have been in decline in recent years, falling from 30% of the recurrent budget in 1974/5 to 22~o in 1976/7. This is possibly also related to the rising foreign exchange cost of drugs. At the time of the study there was no planned limit to the amount of drugs and other stores that any particular institution could have at any level of the health system. It has even been suggested that the physical size of the health institution store rooms is the only limiting factor on the amount of drugs ordered. The lack of control at the central level was repeated at the level of individual institutions. Stores (of which drugs are the major component) were the only item of health service expenditure not individually budgeted at Regional and District levels. There was, therefore, no advantage to the providers of drugs to adopt cost minimisation procedures. The accounting system, which prevented even senior people (such as District Medical Officers) having the delegated power to transfer savings from one account head to another, further undermined any incentive to use drugs sparingly. In fact motivation for the dispensers of drugs to maintain the high levels of drug supply was reinforced by the possibility of theft: although we obtained no direct evidence of the theft of drugs it was widely believed to occur, and sales both inside the country and across the borders were said to represent an increasing source of income for health workers as their wages were dramatically undermined by inflation. The temptation for theft must also have been encouraged by the considerable difference in the prices paid by Government for imported drugs and the prices charged in the private sector. This lack of control over drugs contrasted sharply with the control over other major items of expenditure such as labour and vehicles. The lack of vehicles in the rural health services was as acute and obvious in Ghana as was the contrasting abundance of drugs:

the lack of transport immobilised substantial sections of health workers and represented a large underutilisation of health service capacity. One explanation for the difference in treating drugs and vehicles within the Ghanaian system may have been that in the interdepartmental competition for resources the Ministry of Health's demand for vehicles was weighed against the demands of other Ministries; the lack of vehicles to some extent represented the weak position of the Ministry of Health in this competition. In contrast, drugs were under the predominant control of the Ministry of Health, and the Ministry not only had direct access to import licences for its own drugs, but also controlled the licences issued to the private sector for their importation. Moreover, drugs "were seen to be amongst the most complex commodities and consequently very few people were considered sufficiently qualified to make choices about them. This was, of course, in part correct. But it also reflected the more general professionalisation of medical knowledge, and partly resulted from the efforts of the drug companies to differentiate their products from those of competitors by superficial modifications to the molecular structure, the promotion of brand names and elaborate packaging. In contrast, laymen, particularly politicians and civil servants, appeared far less constrained by lack of knowledge and product differentiation in the selection and purchase of vehicles.

7. THE PAY-OFFS OF ACTION

We have already discussed the medical arguments for stricter control on drugs and prescribing (Chap. 4:4f). The economic argument for control rests on both the ~'opportunity cost" and the inequity of excessive drug expenditure. Excesses in prescribing and drug expenditure cannot compensate for the difficulties of access to care, and the excesses necessarily involve the use of resources that would otherwise be available for the treatment or prevention of disease in someone else. A 10% reduction in the national bill for unallocated stores would make available some ¢3 million for other uses. Of much greater potential importance is the fact that such an amount would be adequate to fund a radically new system of health care delivery, such as those currently being discussed by the W H O / U N I C E F and others which would greatly expand coverage of basic health care to the rural population. Less dramatic reallocation, such as transferring funds saved from drugs into, say, the repair of broken-down vehicles, might also have a substantial effect on both the quality and coverage of the Ghanaian health system. Given present prescribing patterns, the marginal health return to expenditure on drugs is certainly lower than the health returns that could be obtained from a variety of other expenditures both inside and outside the health service.

C H A P T E R 7. THE A S S E S S M E N T OF R E S O U R C E S A N D ORGANISATION--PART A

unreliable for communication between population centres). Most units scored "good", but 7/17 units were rather less well served and only scored "fair". As might be expected, mission units and district hospitals had the best facilities, and the district council units the poorest.

For the assessment of resources and organisation, reference is made to the specified implementation targets noted in Appendix 1B and discussed in Chap. 2:2c. The criteria used to assess effectiveness measure the extent to which existing organisation and resources meet those targets (Appendix 2). These criteria have been divided into "'Resources" criteria and "'Organisational'" criteria, although many are used for both. In fact there is considerable overlap between the availability of resources for primary health care and the efficiency of their use. In the following discussion for some of the items such as staffing, supervision and referral, resource adequacy is discussed together with the effectiveness of utilisation of these resources. Other items such as physical facilities, supplies and transport are largely, but not entirely, a question of resource adequac), while clinic organisation and record keeping are almost entirely organisational questions. In the final section of the next chapter we summarise the problems which are mainly due to inadequacy of resource provision separately from those which are organisational, i.e. essentially management or planning problems. The distinction is important in that the latter could be tackled without requiring a major injection of new resources.

2. SUPPLIES AND EQUIPMENT

The adequacy of supplies and equipment for each unit is summarised in Table 26.f Only three health units scored "good" for adequate supplies. Five health units were particularly badly supplied. (a) Drugs and vaccines

l. PHYSICAL FACILITIES

In general facilities were good at most health units--more than adequate at some of the health centres. The adequacy of facilities is summarized in Table 26, p. 466.* With the maximum score of 10 points, 4-7 was deemed "'fair" and 8-10 "good". All except three units had adequate space for all activities carried out at the units. However. in some places the existing space was not being used optimally. At others there was insufficient waiting space or seating at certain stations where bottle-necks were likely to occur. Still less did the design allow child welfare clinics to be held concurrently with the polyclinic. Water supplies were inadequate--insufficient in volume, unsafe, or both--at around one-third of the health units. Handwashing facilities were inadequate at four units, the state of repair of buildings was unsatisfactory at three units, but all units except one were well kept and clean. Half the he~,lth units for which we have information had no access to telephone communication Itelephones in Ghana are * See IDS. 1978b: Table A43 for scores on individual criteria. + Details of scores on the individual criteria for the different types of unit are shown in IDS. 1978b: Table A44. ++The drug suppl) at the three hospitals was not investigated. ,~Triple. BCG, measles and poliomyelitis.

Most primary health care units$ had large stocks of drugs in their stores, but all were short of two or more basic druos. Not one unit had supplies of glucose/ electrolyte powder (or sugar/salt) for oral rehydration therapy of diarrhoea. There were also shortages of iron tablets, chloroquine and pyrimethamine tablets, and antihelminthics. In contrast, most of the units had (sometimes quite large) supplies of expensive broad spectrum antibiotics such as ampicillin, and non-essential and potentially dangerous drugs such as injectable "Novalgin" and "Baralgin', "Largactil", "Librium", and many other preparations. All the child welfare clinics run by the MCH team at one of the district hospitals were seriously short of drugs for the child clinics because they were not allowed by the pharmacist to use them. In general malaria prophylaxis was in a state of confusion, because doubts had arisen over the suitability of pyrimethamine (imported by the CRS and used, against a fee, by the mission clinics), and the M O H had not issued any directives or guidance. Only three health units out of 17 (including hospitals) had two or more essential vaccines,.~ although most units had adequate supplies of anti-snake venom and ATS serum, and some had tetanus toxoid. The shortage of vaccines in both districts was particularly acute. It was likely that the problem lay mainly in the method of distribution, with vaccines not getting beyond district hospital level because of faulty organisation with regard to collection or delivery, because of the ubiquitous transport shortage, or because of ignorance of the need for cold storage and non-availability of cold boxes for travel. Compartmentalisation of the health service and bureaucratic rigidities also took their toll. Thus, for example, measles vaccine in considerable quantities was in one district found to be stocked in the refrigerator of the M F U , near to expiry but unused, because of the lack of transport. It was not being made available to the community nurses at nearby health posts.

453

454

IDS HEALTHGROUP

Ib) Equipment Five of the 17 units did not have a refrigerator in working order either at the unit itself or, as was the case at Nkonya Wurapong, accessible for use in the town. Seven units had inadequate supplies of syringes or needles and four of these had inadequate facilities for sterilisation. Four health units were short of three or more of the following: thermometer, scales (adult or child), B.P. machine or stethoscope. Scales used for child clinics were either the UNICEF infant basket type weighing up to 24 lbs only, and often old and inaccurate, or an easily damaged and expensive beam balance type supplied by the CRS. Older toddlers were weighed on highly inaccurate bathroom scales. Only in the Bawku clinics did we see the use of hanging scales up to 55 lbs, which are tough, cheap and readily transportable for mobile clinics or house visits, or to demonstrate at village meetings. Arm circumference bands which could easily be used to identify undernutrition, particularly by the health workers in a busy polyclinic, were not seen in use anywhere. At the time of the study weight charts were only available from the CRS, on condition that the pre-school feeding programme was initiated. Even at those clinics where weight charts are used they seemed to be in short supply and tended to be reserved for the regular attenders--precisely those who were less likely to suffer from malnutrition because they mostly came from nearby, in the town.

tion programme which are supposed to be made available by the District Councils. All areas reported inadequate supplies of antiseptics, soap and latrine disinfectants. Only one team had an insecticide sprayer and none had access to insecticides for communicable disease control. There was also a problem in providing materials for latrine construction or repair, such as cement slabs or boards. Cement is in particularly short supply. Tools like spades and grass slashers were also difficult to get for labourers to perform the routine refuse disposal and bush clearing tasks in public places. The reasons for these shortages were, firstly, the same macroeconomic ones that have led to shortages of commodities in all sectors in Ghana and which particularly affected imported goods (cement, insecticides, etc.); secondly, distribution and transport problems, both into the district and out to where they are needed; thirdly, the inadequate budgets of the District Councils for these items; and finally, some inefficiencies on the part of the District Councils themselves. Supplies of equipment for water services are the responsibility of the Water and Sewerage Corporation, which has more resources than the District Councils. However, the flow of materials for maintenance of water supplies was no better than that for environmental sanitation. No pumps, broken down pumps and bore-holes, lack of cement for repairs to tanks or for the building of protected water supplies, were observed universally.

(c) Food CRS food (soya oil and soya fortified sorghum or flour (DSM)). was distributed as a monthly supplement to all regular attenders at approximately half of the child welfare clinics in the two districts (Table 13). In Birim and Jasikan districts transport to outstations was a constraint on supplies being available at satellite clinics. Clinics not operating the CRS programme sometimes gave supplements of tinned or powdered milk, Milo, sugar or tea to malnourished or motherless children.*

(d) Visual aids and teaching matermls Flashcards were available, again from the CRS, the main supply source for the child health programme. These are relevant, printed in Nigeria, and include hookworm and roundworm, scabies, flies, good wells, TB, tetanus and family planning. The ubiquitous Zambian nutrition posters and some posters printed by the nutrition division have been distributed to health units, but they were not observed in use at any teaching session and seemed to serve a decorative function only. There was no allocation of funds for the purchase of local foods for demonstrations of food preparation.

(e) Equipment and supplies for environmental sanitation There were considerable shortages of almost all supplies in connection with the environmental sanita* These are all expensive items with marginal nutritional value which are not normally available locally. They are of no educational value for the child's guardian. +The Missions" access to foreign exchange is clearly related to their ability to maintain vehicles in running order.

3. TRANSPORT

(a) Availability of vehicles Transport was probably the most crucial resource input missing from the Ghana primary health care system. It affected not only the outreach possibilities of services, but also supervision, inservice training (and consequently staff morale), referral and supplies. The effect of the totally insufficient number of MOH vehicles, as well as of the shortage of public and private transport, was to reduce the quality of care as well as the coverage. Overall, only 5 units had good scores; four of these were mission units and one a district hospital (see Table 26). Three units were classed as fair, and nine had poor transport resources. Half of the 17 health units had a 4-wheeled vehicle. These included the two district hospitals, two government health centres, and the four mission units. However, of these, only the mission units and one district hospital had vehicles in running order at the time of the study.t The other units' vehicles had spent more than 8 months of the year off the road because of breakdowns and repairs. The lack of transport also affected the MFU. The District Councils which are responsible for environmental sanitation services also had difficulties with transport for general support and supervision, and in Jasikan the tanker which was supposed to empty septic tank public latrines frequently broke down. Finally, health workers may use their own means of transport for work purposes, especially those who have been able to get a government loan to buy a motorbike or car. Half of the units (excluding the hospitals and mission units) had a staff member with his own vehicle. However, two of these were either in disrepair at the time of the study, or had

Health needs and health services in rural Ghana been in working order for less than 8 months of the year. (b) Maintenance and repair problems For Birim District the nearest maintenance facilities were outside the District at Koforidua, approximately 50 miles away from Oda on poor roads. For Jasikan, maintenance was available at Hohoe, just outside the District, with limited facilities within the District at Jasikan and Kadjebi. It is clear from observations and interviews, however, that preventive maintenance of vehicles was very inadequately performed. Lack of trained mechanics or accessible workshops within the districts, the absence of compulsory regulations about frequency and nature of vehicle servicing, and changes of drivers, were some of the factors responsible. Problems were exacerbated by the multiplicity of different makes of vehicle used by the Ministry, some of which had been given by aid agencies. Each vehicle was supposed to go to the relevant firm in Accra or Tema for servicing and spare parts, and formally could not be dealt with locally. But the overwhelming problem in Ghana at the time of the study was the lack of spare parts. This was due to the shortage of foreign exchange so that the MOH could not import what it needed, and to the fact that, when buying locally, it could only offer the controlled price which was well below the going price in the free market. Spare parts were especially hard to come by in rural areas. The stock of vehicles was at a critically low level, and many of the vehicles in use in the Volta Region were more than 10 years old. At each regional headquarters there was a dump of vehicles in need of repair and waiting for one or more spare parts, not to mention those vehicles at the various car agents' workshops in Accra and Tema. In the financial year prior to the study most of the foreign exchange allocation made available to the Ministry was apparently spent on new vehicles rather than on spare parts. A policy decision has now been taken to standardise vehicles. This should help gradually to build up a maintenance programme, and to plan the spare parts requirements and use of the foreign exchange budget. But action was urgently required to rehabilitate that part of the existing stock that still has a useful working life. Apart from the availability of vehicles, there may be an insufficient budget for running costs. For the community health nurses public transport is the most obvious alternative to having their own vehicle. But they were unwilling to use this because it was unreliable, and they might thus not have reached their destination in time to see the mothers at a clinic, who themselves would often have come from a long distance. They also said that they might not be able to return home on the same day. and many public transport owners refuse to take passengers without luggage. They also reported that Transport and Travel (T and TI claims were not paid. This was a major problem for all health staff, especially in Jasikan District, affecting the willingness of staff to travel by means other than official transport. For some health workers no T and T was budgeted, even though they were expected to carry out work man) miles away from their base. SSML~.~

I "~ 4

F

455

The health inspection assistants and health inspectors also reported problems with the use of public transport, which often did not pass within five miles of the villages they were expected to visit. They, too, reported major problems and long delays with the repayment of transport claims.

(c) Use of bicycles No one used bicycles in the two districts. There was a strong reluctance, particularly on the part of the women, to ride bicycles (which were considered an inferior means of transport by most), although they were taught to do so at the Ho community nurses school. In northern Ghana, however, bicycles are commonly used, even by women. In the south, it is "not done" for Ghanaian women to ride a motor bike, or on the back of one, unless it belongs to their boyfriend or husband.

4.

REFERRAL

(a) Availability and ease of access to referral facilities The adequacy of referral facilities was assessed by two criteria only: whether second opinion referral for non-emergencies was available within one hour's travel and whether, for emergency referral, patients could be transferred in 3 hours or less. Overall, 12 health units had referral facilities assessed as good, 4 fair and one poor (see IDS, 1978b: Table A52). The costs to patients, however, were not taken into consideration as a criterion for assessments of adequacy; had they been, all units (except for one mission unit) would have scored less, and some units considerably less. Excluding hospitals, l0 out of 14 health units had facilities for non-emergency referral to hospital within a distance of one hour's travel (taking into account the likelihood of public transport availability). Because of the infrequency and irregularity of supervisory visits, patients could not routinely be referred to a visiting senior health worker. In some cases the nearest referral centre for government health units was a mission hospital, but lack of integration of mission and government services meant that the health worker was obliged to refer patients to the much more distant district hospital. For emergency referral all but two units reported that patients could reach hospital within three hours from the time that the relatives agreed (which itself might take much longer). Referral problems also arose because of the lack of facilities for maternity patients to stay at a health unit while waiting for delivery. This was found to be an important problem, especially in Birim district. There, expectant mothers identified at the antenatal clinic as at risk, and consequently requiring a hospital delivery, often did not go because of the expense not only of transport, but of staying in the town while awaiting the onset of labour. This problem may also apply to a lesser degree to mothers who should be delivered at a health centre rather than at home--it is worth remembering that the level of coverage of supervised births was very low in both districts {see Chap. 5:1c). Self-care hostels, to which such patients could be admitted free of charge to await delivery, might be considered as a solution to this problem.

IDS HEALTHGROUP

456

(b) Referral practices of health workers Only one health unit sent a note or letter with patients when referring them from the polyclinic for non-emergency care, and often no letter was sent with patients, even when they were sent as emergencies. There were no official guidelines about what cases should be referred, nor were there any identified procedures, administrative or otherwise, to be carried out when referring a patient. Records of referred patients were not well kept at units (in most places they were not kept at all), presumably because no-one ever asked for, or looked at them. Within the health unit referral takes place from the community nurse to the health centre superintendent. When children were referred, no advice was given on home management, either by the nurse or the health centre superintendent, although the type of cases referred (e.g. measles, severe diarrhoea, high fever, etc.t were precisely those where advice on home nursing care was most urgent. At Danfa, which was studied for comparative purposes, the situation was entirely different. There, the community nurse accompanied the mother and child directly to the health centre superintendent, thereby not involving the mother in waiting for a second time in a long queue, and enabling a joint consultation to take place with the health centre superintendent and the community nurse. The community nurse also made sure that the mother was given advice and instructions about home management nursing.

5. CLINIC ORGANISATION In Appendix 2 the criteria used for assessing the efficiency of organisation of polyclinics, antenatal clinics, and child welfare clinics are listed together with the quality assessment criteria. However, in our earlier discussions on quality of care the organisation of the respective clinics was not discussed. This will be done in the present section. In general, apart from mission units, as might be expected, the pattern of clinic organisation tended to be standardised. Health workers follow the routines of clinics attended during their practical learning experience. Polyclinics were on the whole better organised than child welfare clinics. Only two units scored badly for both polyclinic and child clinic organisation. Four criteria for general clinic organisation were examined: whether queues were orderly (no crush or squabbling around the health worker or door): whether there was an efficient line of flow between the various stations of the clinic: whether waiting and seating space was adequate; and the time spent by patients at the clinic (more than three hours for child clinic, and more than two for polyclinic, being unacceptable).

(a) Polyclinics For the polyclinic the most common problem was the long time patients had to spend at the clinic-usually the whole morning. The other most common observation was that lines of flow were poor. often due as much to the design of the buildings as to the inefficient utilisation of existing space. The time for consultation at polyclinics was inadequate (an average of less than 5 minutes per patient)

at most units in the study districts. Of the comparative clinics, only at Kintampo Health Centre was the consultation time less than 5 minutes per patient. The short time spent for consultation has already been referred to as one of the factors likely to contribute to low quality of care (see Chap. 4:4). Two factors of clinic organisation contributed to this inadequate consultation period: the health centre superintendent had to see all patients and no effective screening of patients was carried out; secondly, the hours worked together were less than the expected full day (see Chap. 8: lb). The normal pattern of the working day at most units did not allow the consulting health worker a midday break. It is difficult to see how a health worker, working non-stop for 5 hours and seeing 80--100 patients, can really function effectively. A more efficient way of working would be to close at least some of the clinic stations for an hour or so at midday and continue the clinic during the afternoon as necessary. Longer working hours with an adequate midday break might avoid some of the congestion and rush to "get through" the patients load, allowing a more relaxed consultation and a more refreshed and therefore more efficient health worker. At five clinics some screening of patients was done. This included the taking of temperatures and/or histories by an enrolled nurse or by an orderly. With patients having to wait up to four hours, it is imperative that severely sick patients are identified quickly. The registration clerks usually spotted the adults who were acutely or severely ill, but sick children were often missed.

(b) Child clinics At child clinics, congestion, confusion and a long wait for mothers (usually the whole morning) were observed at five units. There were over 100 attendances at these clinics and all distributed CRS food. By comparison, the mobile clinics held in Bawku at dressing stations, i.e. at facilities equally inadequate as some of the satellite clinics studied in Jasikan and Birim, were well organised and orderly, in spite of huge daily attendances (around 250 attendances each at the two clinics observed). Although these numbers inevitably led to some delays for mothers, lines of flow were efficient and queues orderly. Unnecessary duplication of records, inefficient registration procedures (see below) and the fact that CHNs were not taught to organise clinics efficiently, were the main reasons for the poor organisation observed at child clinics.

(c) Antenatal clinics Because there were usually fewer patients at antenatal clinics at any one time (except at the hospitals), problems with lines of flow and congestion were rare. At most units the antenatal consultations were conducted in a quiet room. At more than half the antenatal clinics, advice was given by a person other than the one conducting the main history taking and examination. While technical procedures (such as urine testing or the taking of blood pressures) can, and should, be delegated, the separating of the main functions of the consultation between different staff members is unsatisfactory and can only lead to a lower quality of care.

Health needs and health services in rural Ghana 6. RECORD KEEPING AND REPORTING

Three kinds of records are needed in an efficient primary health care system. The first are personal, individual records, the main purpose of which is to provide continuity of care for individuals, and to identify patients at risk who need follow-up or special care. Second are those records which provide information to health workers and their supervisors on which to evaluate their work and guide their day-today activities.* Third, there is the keeping of records on health indices--mortality, incidence of specific diseases, etc. All three kinds of records were assessed in the evaluation, as well as the efficiency and effectiveness of the actual recording procedures during clinics. Summary scores for all units together are shown in Table 26, using the scoring methodology for assessing organisational efficiency described in Chap. 8:6.

(a) Personal records and registration procedures At both polyclinics and child health clinics registration procedures were inefficient. At most polyclinics, patients' individual records were held at the clinic, but out of 13 clinics l0 could not trace at least 2~o (and often many more) of the patients' record cards each day. At many places the proportion of cards lost was extremely high--up to 38~o of patients required new cards in one day at Brenasi. Most of this was due to identification cards being lost by patients, but clerks may also be unable to find records and waste much time looking for them. Partly as a result of this, most health units required more than one full-time person to deal with registration--at larger health centres three or four people were required daily and the clerks were supplemented by volunteers, orderlies, drivers or other outside staff. However, at Dodi Papase mission hospital a policy had been introduced 2 months prior to our visit that patients should keep their own records. One clerk was needed to register new patients, make out new cards and record attendances. In this period it was reported that only two patients had lost their records as compared with the previous system where approximately two to four record cards had been untraceable daily. The efficiency of the outpatient clinic was greatly improved as there was no congestion at the registration section and returning patients went straight to the consultation waiting area. There was no continuity of care for the largest atrisk group, the younger children. The system resulted in fragmented information on different records kept in different places and involving much duplication. At most child welfare clinics at least two records were used for each child, and at five clinics three separate cards were used--a "'mother's blue card", the clinic registration card and the weight chart. It was the filling-in of these many cards which took up precious consultation time during the course of a clinic: at five child clinics, completing records and registration procedures took up more than one quarter of total staff * E.g. to provide information on: who has not been seen in the past month though heshe should have been (a TB patient or child due for immunisation, for example): ~hether there has been recent increase in yaws cases from a particular village: whether a TB patient has been diagnosed indicating a need for a follow-up visit to the village.

457

time during the clinic. In addition CHNs spent at least half a day after the clinic sorting out the cards. None of these cards were used at the polyclinic if a child attended when sick. Here he would have two more cards. An individual child may thus have five different calds, at least two of which will be kept in different places at the health centre and which record different information including episodes of illness and drugs prescribed. Home-based records, brought whenever the child attends any health unit, are probably the only effective way of solving the problem. It has been found at Danfa that mothers do not lose cards that are regarded as important by health staff at anything like the rate of loss observed in the existing system. Home-based cards could also be used at the polyclinic. Patients are likely to keep the home-based record for the duration of one episode of illness, even if not for longer periods. The three groups for which continuity of care is particularly important are those with chronic disease, the under-fives and pregnant mothers. If these groups are registered at clinics and have the main risk features identified in the register, home-based records could be used to record their day-to-day progress. They also have the advantage of being available in the home during the course of a home visit. Antenatal registration and recording systems were more efficiently organised than polyclinic and child care records. Individual antenatal record cards were kept at clinics but because a pregnancy lasts only a relatively short time the numbers were much more manageable and cards were rarely lost. Unfortunately, cards were not used for subsequent pregnancies except at one mission hospital. There was, therefore, no continuity of care over the longer period, especially important where complications have arisen in previous pregnancies. At most health units there was evidence that the antenatal cards were used at the time of delivery. At four antenatal clinics cards of patients identified as having some risk factor were separately identified. Home-based records for antenatal patients might be considered to solve the problem of lack of continuity of care when patients return to their home towns for delivery or when they attend another antenatal clinic, at a hospital, for example, on the occasional visit to the market town. Referral records were not well kept at health units except for those of emergency referrals of maternity patients. Second opinion referrals from antenatal or polyclinics were not usually recorded. Apart from the patients referred from maternity, who were given special forms, there was no routine for sending forms or letters with referred patients.

(b) Reporting and on-going eL'aluation Records for evaluation of health activities and as a guide to developing operational programmes were not usually kept or used by health staff when available. Existing recording systems did not provide useful information on utilisation, coverage or simply for epidemiological studies to assess local environmental causes of disease or the impact of specific programmes. It was not possible for health unit staff to identify high or low users of the health unit; who was getting health care and who was not; where patients come from and how often they came. The concept of

458

IDS HEALTHGROUP

catchment area population for individual health units was appreciated by the Directorate and Planning Unit. although it was not understood by most operating personnel. Indeed, staff had no idea what population was being served by any particular unit nor which villages they were supposed to cover. The only records which were well kept. but not utilised, were daily attendance registers. Monthly returns for MCH were complex and involved much duplication. There was a midwives return, a CRS return and a public health nurses return. It was exceptionally difficult to unravel the complexity of the recording procedures at child clinics, because so many registers had to be kept to extract the information required by the CRS and the Ministry of Health. Unfortunately, in spite of the time spent and the complexity and multiplicity of records, the data available did not provide useful information on coverage, changes in nutritional status, which children at risk had not been visited, or who was due for immunisation. We concluded that there was an urgent need to streamline the child care record systems and the kind of data needed for evaluation. Health workers should be taught to use the information themselves.

(c) Records for health indices The system for the collection of morbidity data had been reviewed shortly before our study by the Plan* Only the health centres and hospitals used these.

ning Unit with assistance from a W H O consultant. An experimental system for recording the main morbidity groups was being tried in three areas of Ghana. From our observations on the methods for recording attendances and completing the morbidity (HOP.I.C.) returns, very inaccurate data were being recorded. At those units where HOP.I.C. returns were completed* it appeared that only diagnoses on new patients were used to complete the return. We therefore supported the introduction of an alternative system of recording attendances by diagnostic grouping, using a tally chart. This is completed by the consulting health worker at the time of consultation, rather than by a records clerk from cards at the end of a clinic. With familiarity and practice it should be possible for the health worker to tick off the appropriate box for each patient without taking up valuable consultation time. Finally, there was no systematic collection of vital statistics by health staff, although some health inspection assistants did record births and deaths collected from the registrar, or if "they happened to hear about it" in the village. Such collection of vital statistics obviously grossly under-recorded, because it was dependent on individuals themselves coming forward. Birth registration was often done at child clinics. More outreach and satellite clinics accompanied by the births registrar might encourage more registration of births from villages, but only with closer supervision and health monitoring of identified populations at the village level could more accurate data be gathered.

CHAPTER 8. THE ASSESSMENT OF RESOURCES A N D ORGANISATION--PART B

I. STAFF: QUANTITY

one District Council health post. Six units were rated as fair, a n d three as poor.

F o u r criteria were used to assess the staff inputs which are here referred to as "quantity". They are s u m m a r i s e d in Table 24 a n d relate to different staff skills available to each unit, the average time worked by staff, a staff absence rating and the p r o p o r t i o n of staff time spent o n preventive activities (see footnotes to Table 24 for further details). Overall, seven units h a d adequate staffing inputs (good) which included the hospitals, three health centres or health posts a n d

(a) Health worker skills available It is assumed that for a minimal complete range of services staff skills are required in four areas, namely polyclinic activities, midwifery, child care a n d env i r o n m e n t a l sanitation. In G h a n a , the existing health care system uses health workers who have usually been trained in only one of these skills. Therefore, given present organisational forms, at least one each

Table 24. Staffing inputs: quantity

No. of qualified staff

Health Unit

No. of different types of staff*

Average no. of hours worked ( + if more than 6 per person per day~

Staff absence rating't

°o Staff time on prevention ( + if more than ~ of total time)

Total score (total possible = 7)

4

(7.0~ +

+

NA

(6~+

3

t8.0} +

+

+ (520o)

(6)~.

4 4 2 4

{4.6) (6.6) + (5.0) 15.51

0 0 0 0

{25°0) + 141°o) {30°0) {30',0)

4 6 2 4

3 3 2~ 1

(>6) + (4.6l {4.0) (4.6)

+ 0 0 0

+ (42',,J ÷ (51°ol {13"ol {0°,,)

6 4 (2~ 1

4

(7) +

+

NA

(6)~

4 3 3 1 2 2

(61 + 16) + (4~ 14) (7) + (7) +

+ + 0 + + +

Jasikan District HOSPITALS

Worawora

Not calculated Dodi Papase 8++ H. CENI"RES AND H. POSTS Kadjebi 11 Jasikan 11 Ahamansu 4 Dodo Amanfrom 8 Dlsa-Rtcr COUNCIL UNITS New Ayoma 3 Nkonya Wuropong 2 Abotoase 1 Lolobi Kumase 1 Birim District HOSPITALS

Oda

Not calculated

H. CENTRES AND H. POSTS

Achiase New Abirim Brenase Ntronang Ofoase Akim Swedru

10 6 5 3¶ 5 5

(25°0) (20°ot {14° o) + 163"o) {20°.) 10%1

6 5 3 3 4 4

* Four different groupings are: (i) Health Centre Superintendent. SRN, QRN or dresser: (ii) Midwife or staff nurse midwife: Off) Community Health Nurse or Public Health Nurse: {iv) Health Inspector or Health Inspection Assistant. -I-No qualified staff away from post for average of more than 2 working days per month during previous 6 months and no staff on leave without replacement. ++For hospitals, data are not available for all indicators, although for some, e.g. Dodi Papase. estimates have been made for the hours spent on primary health care activities, and also the °o spent on preventive activities, assuming normal timetables for staff are followed (more likely to be the case at hospitals). Also for staff absences it is assumed that there are enough staff to cover. The bracketed total indicates an estimate only. Community Health Nurses visit once a month for Child Welfare Clinic. As can be seen in IDS. 1978b: Table A.17.I the scoring used was as follows: 1-2 = 0 (poor}. 3-5 = + Ifairl. 6-7 = + + (good). ¶ Only 1 resident midwife but visited weekly by 2 staff from Ofoase for the polyclinic. 459

460

IDS HEALTH GROUP

of these staff members would be necessary for all services to be provided. In fact all staff skills were provided at only a third of the health units.* At a further five units, three of the four skills were present. For those units which might be considered to have the provision of comprehensive primary care as a major objective, health centres and health posts, the commonest deficiency was a staff member trained in child health.

(b) Hours worked by staff It was not possible to assess this accurately for all staff members at all units. During the days that the activities of the unit were being studied, some attempts were made to determine the timetables of staff members, the starting and finishing times of clinics, and the working hours of community health nurses and health inspection assistants. The averages for each staff team are shown in Table 24. For half the units the average was less than 6 hours daily. After 2 p.m. there was very little activity at almost all health units (including hospitals). The most under-utilised staff members were community nurses. Because they were expected to perform a function, a large part of which they were unable to do (i.e. visit homes in villages), they spent much of their time sitting around at the health unit "doing records" or they went home when the outpatient clinic ended, usually around 2 p.m. Some health centre superintendents worked hard: although the unit closed down when the morning clinic was over, they were normally having to see emergencies later in the afternoon and often at night. It was difficult to assess the work-loads of midwives because of erratic hours worked when deliveries occur. However, the number of deliveries was not very high at any of the units (see Chap. 5: Iv), and it was not observed that any midwives had excessive work-loads. They too usually had afternoons off unless there was a patient in labour. The health inspection assistants officially kept the longest working hours. In Jasikan District the time-table was laid down, and there work was expected to start at 6.30 a.m. with a roll-call of labourers and assignment of the day's work. Then came inspection of refuse disposal and/or meat inspections until 8 a.m.; a break for breakfast; and home or village inspections until mid-day. After lunch they would work again on similar duties. However, when on their own, out of the towns, this timetable was not strictly adhered to, and it was hence not possible precisely to determine the number of hours worked by health inspection assistants. Nevertheless, judging by the kind of coverage reported, it would appear that they did in fact spend most of the official working day (8 hours) on the job. Most of the other staff at the larger health units (laboratory attendants, nurses, records clerks and orderlies) were involved with the polyclinic and there* Environmental sanitation skills were considered as provided where the health officer was based either at the unit or in the same town, or visited the town weekly while there was a resident health overseer. f Two working days' absence per month was considered the maximum allowable without disruption of services when the organisation targets were drawn up (see Chap. 2:2e).

fore finished work when the polyclinic ended. qualified staff worked on average some 5 hours (excluding the mission units). None of the units, from one district hospital, was observed to down before all the patients had been seen.

Nondaily apart close

(c) Staff absence rating Over half the health units (excluding the hospitals) had staff members away from their posts for more than an average of two working days a month.* At some units the health centre superintendent had been away (usually .to collect drugs or carry out administrative tasks at the district or regional headquarters), or on sick leave. In other cases a staff member had gone on leave, been transferred, or gone on a course, while no similarly qualified staff had replaced him or her.

(d) Time spent on preventive activities The total staff time actually worked was calculated from observations of each of three kinds of activity: polyclinic care; MCH; environmental sanitation. Table 24 shows the proportion of qualified staff time spent on preventive activities (MCH plus environmental sanitation). For only three units is this over 50?/0, and in 10 units qualified staff spent less than one third of their time on prevention. By adding the hours worked at the separate units we can provide an overview of the situation in each district. In Jasikan District as a whole (excluding the district hospital), polyclinic work took 61% of qualified staff time (with 29% on MCH and 10°/0 on environmental sanitation). In Birim District as much as 75% of qualified time at primary health care units was devoted to polyclinic activities (with 19°/0 on MCH and 6% on sanitation). Despite the lack of full data, especially for Birim, there is no doubt that the resources going to MCH care were quite inadequate in both districts. Moreover Birim District, because of the community nurses training school and the outclinics associated with their practical training, was an untypical district, having a greater than average MCH input. Other districts in Ghana probably had considerably less MCH time inputs. The work done by sanitation labourers was essentially preventive. If we were to include this in the assessment, the picture would be quite different-though, of course, nothing would be altered in respect of the very small proportion of time spent by qualified staff on non-curative activities, and the proportion of time spent on MCH would be even smaller. Unfortunately, in the case of sanitation labourers the only data available were those relating to hours "paid for". These are not strictly comparable to our data for qualified staff, which relate to hours actually "on the job". Villagers have told us on various occasions that local sanitary labourers only work one or two hours per day, but we have not been able to check on this, nor did we explore this issue systematically in interviews. 2. STAFF: QUALITATIVE ISSUES

The most important aspect of staff quality concerns their training. This is discussed in the next section. In addition, three related criteria have been used to

Health needs and health services in rural Ghana

461

Table 25. Staffing inputs: quality

Health unit Worawora Dodi Papase Kadjebi Jasikan Ahamansu Dodo Amanfrom New Ayoma Nkonya Wurapong Abotoase Lolobi Kumasi Oda Achiase New Abirem Brenasi Ntronang Ofoase Akim Swedru

All staff observed to be carrying out tasks appropriate to level and type of training*

Inservice training been given to one of staff in past 5 years¢

0 0 + 0 0 0 0 0 + 0 + 0 + 0 + 0 +

?0 + 0 0 + 0 + 0 0 0 ?0 0 0 + 0 0 0

Staff morale rating~ Team Individuals + + 0 + + 0 + 0 + + 0 + + 0 + + +

0 + 0 0 0 0 0 0 0 0 0 0 0 0 + 0 0

Total 1 3. 1 1 2 0 2 0 2 I 1 2 2 1 3 1 2

* See IDS. 1978b: Table A49 for expected tasks and tasks performed. -t Includes inservice training for staff members carrying out tasks for which they were not originally trained (e.g ENs going to Adidome on course in child care--Dodi Papase) and also more formal courses designed to improve existing skills. See text for criteria. assess some aspects of the quality of staff inputs. These are shown for each unit in Table 25. Only the mission hospital and another mission unit had good scores, two were poor, but by far the majority (14 out of 17) were fair.

(a) Appropriateness of tasks performed At the vast majority of units health staff were performing tasks inconsistent with their training. In some cases the staff concerned had received inservice training for such tasks, either on the job by an immediate supervisor, or through a more formal course. However, if the functions a health worker is expected to perform regularly require skills other than those taught in the basic training, then that basic training is not sufficiently geared to the requirements of the services. This was clearly shown up by the analysis of tasks actually performed, many of which were apparently not incorporated into present training.* The personnel most commonly expected to perform tasks inconsistent with training were community nurses and midwives. Enrolled nurses also have to do a great deal of primary medical care for which they have inadequate training. At almost all units the midwives or enrolled nurses have to take charge of the * it was not possible to get full job descriptions, nor the curricula for all staff training programmes. It is therefore probable that some of these tasks were in fact taught to health workers, especially those of which it is generally assumed by everyone in the health care system that they will be performed. IDS. 1978b: Table A49 summarises the observed tasks performed by different types of staff which ~ere inconsistent with basic training, or for which we had reason to believe they were inadequately trained. Tasks which they should do. but were not doing, are also included-though these have been dealt with more fully in the quality evaluation of each particular service.

outpatients when the health centre superintendent is absent. Community nurses are seeing sick children regularly in the clinic and have to treat them. Midwives assist with child welfare clinics, having had insufficient training in child care and nutrition, while the community nurses assist at antenatal clinics but only in a very limited capacity (giving tetanol injections). Conversely, staff who were relatively highly qualified were performing tasks which could be done effectively by junior (and less trained) personnel. Thus SRNs, for example, distributed medicines, a task which could surely have been undertaken by junior nurses or even orderlies. Public health nurses spent their time during child welfare clinics merely giving immunisations or, worse still, "doing records": leaving no time for consultations with mothers. Hence we felt that there was an urgent need to streamline and rationalise health manpower at the primary care level. The staffing structure at the time of the study was inefficient. The need was not for more staff at each unit, but for more appropriate staff skills related to routine tasks.

(b) lnservice training Very few staff had had any inservice training since qualifying as health workers. This was a particularly important omission in the case of health workers doing outpatient work and prescribing treatment, in view of the many new drugs available and the frequent changes in recommended treatment regimens. The lack of up-to-date information about the use of simple drugs and about the contra-indications and dangers in the uses of some drugs was, in our view, a major factor in the poor quality of care administered at many of the units. Even if the necessary improvements to basic training in this respect were to be

IDS HEALTH GROUP

462

brought about, there would still be a need for inservice training for polyclinic care. Lack of inservice training is also an important contributing factor to low morale.

(c) Staff morale Two aspects of this were considered: firstly, the general atmosphere of co-operation and enthusiasm at the unit as a whole (admittedly based on subjective impressions), and, secondly, whether individual staff members expressed dissatisfaction about their work during interviews. On the first criterion, 12 of the 17 health units were considered to have a good working atmosphere, with evidence of team work and some interest in the work. But the second morale criterion showed a much more serious problem. At all units, except two missions, some staff showed signs of varying degrees of dissatisfaction. By far the most commonly expressed complaint (at 12 out of 15 units) was that support was lacking to carry out their work properly--lack of transport, supplies (drugs, food for child clinics, vaccines or environmental sanitation supplies) and help or interest in their problems on the part of supervisors. This was expressed most acutely by the public health and community health nurses, but also by health inspection assistants, M F U staff and district council employees. Many were very bitter about the work they were expected to do and the totally inadequate tools provided. They often related this to the fact that in Ghana material advantages, in personal or work terms, were more available as one moved closer towards the centre (e.g. Ho or Accra). Also, a move from the periphery to the centre was associated with climbing the promotion ladder, and those who had reached the centre (even at the regional level) have no motivation to move "backwards" to the periphery. A number of health workers also expressed dissatisfaction with their pay and working conditions. 3. STAFF TRAINING

Two aspects of training are relevant to the work done at primary health care units, and we shall deal briefly with both in this section: inadequate training in terms of what is taught, and inadequate training in terms of how students are expected to learn. Where at least some health workers are performing a particular task and performing it correctly, it is probably the case that this is an expected task and that it has been taught, at least to some. But when hardly any health workers are found to be doing a particular task, this suggests that they have probably not been trained to perform it. This applies particu* This gap is seen most clearly at the university level with regard to medical training--which at the time of the research was a long way from focussing on the priority health need~ of the country. t Details of the health centre superintendent and community health nurse courses are given in IDS, 1978b: Appendix 15. The criteria used for evaluation of each of the training programmes, and how each programme scored on individual criteria, are shown in ibid. Table A50. The data are too incomplete to give total scores for training institutions.

larly to aspects of organisation (see below), such as methods of record-keeping, organising clinics, and use of staff time. A more surprising example in the field of child care appeared to be the fact that no health workers used oral rehydration therapy in clinics for the treatment of diarrhoea. Although the list of expected tasks used by us was drawn up in consultation with the Ghanaian authorities, many of the tasks had not been incorporated in Ministry of Health directives, let alone communicated to training schools. Many other tasks which were explicitly accepted either had not been clearly communicated to the district and peripheral health services, or the resources needed for their implementation were not provided. Of course, the required tasks were only formalised at the beginning of this research project. Only after this step had been taken did it become relatively easy to engage in "micro-planning", so that the definition of required tasks could determine the curriculum design for the training of health workers. In future this can be achieved if the gap can be bridged between those who deal with running and administrating the health services, and those who are responsible for training.* We now come to the second major problem in connection with training. Training schools may be teaching the right things. But because of the way in which training occurs the trainees may nevertheless learn bad practices in the field (where they properly spend much of their training period) from field supervisors who themselves are inadequately supervised. Because the practical experience is so much more vivid than theoretical teaching, what is eventually practised is more likely to be based on the experience gained, for example, from the outpatient department of a district hospital than from the health centre superintendent training given at Kintampo. Unless the clinical attachments can be (more) carefully selected, and those responsible for supervising and providing continued training for trainees themselves given guidance and training, bad practices will be perpetuated (for example, in prescribing) in spite of improvements in the training curriculum. It was not possible in the time available to do any detailed study of health worker training. However, in view of the importance of training in relation to performance, some evaluation was made of the training of community health nurses and health inspectors (together with a brief assessment of health inspection assistants' training at the Ho school). The health centre superintendents' training which we also briefly examined was under review at the time of our study, as it was generally recognised as having been inadequate. This has to be kept in mind when reading the comments in the following section. The M F U training is also included in the discussion. We had two main objectives in these evaluations: to establish how closely training related to agreed tasks in primary health care (Appendix IA and B), and to determine the quality and effectiveness of the training given.'t

(a) Trainees The emphasis in selection was on evidence of learning ability, as shown by literacy and verbal skill. In all training programmes, trainees were required to have Middle School Leaving Certificate or General Certificate of Education. In all but the M F U training, an

Health needs and health services in rural Ghana additional written examination in English and mathematics was given. The MFU was to introduce such an exam in the year following our field work, as some students had not been able to cope with the written course content. Success or failure on all courses was based primarily on the results of written examinations rather than on performance of practical skills. This type of selection process tends to identify trainees who are academically brighter than average, and perhaps with higher expectations and a reluctance to work in rural areas. Prior knowledge, skills and experience were taken into account on selection in the health centre superintendents' and MFU training courses. But we do not consider that five years' work in hospital nursing is really relevant experience for someone who is to become a health centre manager in a rural area. With one exception socio-cultural factors were taken into account on all courses. These included, in various combinations, geographical location and language group, motivation and willingness to work in rural areas, and age and marital status. Ethno-geographical factors were not taken into account in the selection for the health inspectorate courses, as trainees were expected to learn any required language during the first three months of posting. But as communication and cultural understanding are so crucial in health education and community development, it would seem more effective to take geographical location into account on selection. The community health nurse selection process had not been successful in recruiting mature women with at least one child, and the inexperience and youth of the majority of community nurses lowered their credibility in the community. The local selection of trainees who have shown themselves to be motivated by some community activity is likely to be the most effective way of selecting rural health workers, as demonstrated in Danfa. The proposed formation of a village health worker cadre should provide a useful pool for the future recruitment of health workers. A further probation period could be used to assess motivation and the personal qualities required to be a successful rural health worker. Such prospects for further training might be a sufficient incentive for part-time volunteers at the village level.

463

[c) Aims and objectives

There was an awareness among policy makers in Ghana of the inadequacy of syllabi for the training of different categories of health worker, and most of them were being reviewed for relevance and the setting out of detailed educational objectives and task analysis. The health centre superintendents' course was to include a substantial section on preventive and MCH activities and was to be integrated with the public health and environmental sanitation sectors. The training of public and community health nurses was moving towards a problem solving approach rather than formal lectures. The intention was to relate skills more closely to required tasks. The syllabus for the health inspectors" training was revised a few years ago. It is impossible to make ant judgement on the relevance of this syllabus, as well as that of the health inspection assistants' course, without more detailed information on the way the topics are dealt with in practice. The training syllabus for. the MFU is not laid down in sufficient detail to allow evaluation. It proved impossible to match the training syllabi with the required tasks defined in Appendix 1A, for two reasons. In most cases the syllabi in use at the time of the study did not lay down a detailed job description. Secondly, unless actual teaching sessions are observed it is impossible to assess whether the treatment of any particular topic is appropriate for the required tasks. In many cases it is not the subject itself that is inappropriate, but the bias given in teaching. For example, house visiting with the objective of monitoring health and giving relevant education may be a required task, but it will not be properly taught if 75~ of the training visit is spent on unnecessary records and only 25~o involves the family. Conspicuous gaps found in all syllabi were: the "community development approach", including community diagnosis: social skills in communication and ways of motivating the community to initiate health activities; and to some extent planning, target setting and evaluation, and organisation of services, especially clinic management. In general all training courses suffered from a middle-class, urban bias, and taught procedures which could be followed in an ideal situation, but were less useful under the constraints found in many rural areas. For example, history-taking and examin(b) Trainers ation were taught along conventional medical lines Most trainers were selected on their field perform- on the health centre superintendents" course and ance and thrown into teaching without further train- assumed that the time for this is unlimited. Real-life ing apart from informal observation. In three of the outpatient sessions in rural Ghana create cortditions training courses the trainers did not like teaching and in which it is totally impossible to follow this method, would have preferred to be involved in their normal and as no alternative had been taught, usually no field duties in the rural areas, where they enjoyed a history-taking or examination was carried out at all more flexible work situation and a lower cost of by health centre superintendents. living. With the exception of the community health nurses training course, where the tutors had had experience (d) Resources Resources were inadequate on all courses, with the in urban areas only, all trainers had had relevant field experience. Nevertheless, in most cases this experience health centre superintendents faring best and the was not effectively passed on in practical training health inspectorate having minimal resources. Relevant recent teaching materials were not availbecause of the absence of guidelines and poor motivation. It is clearly essential that trainers are equipped able on any of the courses. Most textbooks were out with pedagogical skills in addition to technical knowl- of date and irrelevant to the health needs of Ghana. The Kintampo library was reasonably well stocked. edge.

464

IDS HEALTHGROUP

but there was a dearth of tropical public health books in the community health nurses' library (less than 50% of stock). The health inspectorate had no library. Visual aids (e.g. films on communicable diseases) were only used in training at the Kintampo Rural Health School courses.

(e) Field experience At least 40~ of the course was devoted to field experience in all but two courses, but in no observed course was the field training and supervision considered to be satisfactory. Trainees frequently learned poor practices in the field from "supervisors" who were usually peers without guidelines, motivation or supervision in training, and were themselves too occupied to undertake training. Indeed, trainees were often gratefully seized upon as an extra pair of hands for tedious tasks with no training component at all. This was observed at several chaotic child welfare clinics where students were busy serving "nutrients" and finding cards rather than observing consultations and learning skills in communication. Moreover, although the syllabus and class-room training may include the required tasks, these are not always put into practice on the field training--e.g, although visual aids are described in the written exercises on health education, they were never used in practice.

(f) Integration The integrated training of health workers from different sectors of the health service is essential if integration is to be achieved at District level. Field experience should demonstrate integration as an effective way of working rather than a fashionable theory. Some attempt was being made to integrate training on all courses. The revised health centre superintendents' syllabus placed greater emphasis on integrated training, and the new Health Inspection Assistants' School in Ho was to be constructed on the same site as the Community Health Nurses School. The minimal attention given to integration in the classroom was reinforced by the lack of integration of health services experienced by the student during field training.

(g) Attitudes, role models, motivation Most trainees took as their role model their tutor or supervisor. Thus the health centre superintendents modelled themselves on the doctor, the health inspection assistants on the health inspector, and the community health nurses on the public health nurse. These role models are part of the elite urban sector of the society and they tend to be inappropriate for the needs of rural areas. They also tend to be taken from inappropriate Western models (e.g. the community health nurse is the European health visitor). The dead end nature of the careers of the auxiliary health cadres--the health inspection assistants, the community health nurses and the field technicians-had a seriously demoralising effect and resulted in low * Whether a doctor had visited during the past two months; whether any other professional supervisor had visited in the same period: whether the health unit received any feed-back on referred patients lsee Appendix 2-Resource Input Criteria~.

motivation and poor performance. Although in theory they could progress by acquiring GCE qualifications, in practice this was almost impossible to achieve in the rural situation. The low priority and minimal support given by the Ministry of Health and the District Councils to environmental and public health, compared to the curative services, was a major factor in poor motivation in these sectors. 4. SUPERVISION It was difficult to get accurate information about supervisors' visits. Few records were kept, and visits were infrequent and irregular, making it difficult for the health workers to recall when a supervisory visit last occurred. Also, there was no distinction between a visit for supervision and a one-off visit by a senior officer to sort out a problem. On the three criteria used to evaluate supervision,* excluding hospitals, three units were assessed as good, seven as fair, and seven as poor. In general, the level of supervision was unsatisfactory except for the environmental sanitation services. Only one of the primary care units had had a visit from a doctor in the past two months and that was because of the staff problems there and the illness of the health centre superintendent. Two health units in Jasikan District had not been visited by a doctor for approximately two years and for other units the period since a doctor's visit was between three and seven months. Some could not remember when the last visit had occurred. Other supervisors, such as public health nurses or health inspectors, visited more often. In the Eastern region the three government primary care units studied had all been visited by the district health inspector in the past month, and one had been visited by the public health nurse in the previous week. The mission units had not had supervisory visits from anyone in the past two months. For the child health programme, the Catholic Relief Services employed three SRN/midwives in the South and one in the North of Ghana to supervise all CRS pre-school feeding programme clinics. The target was to visit each centre quarterly, although until 1977 they did not have enough transport to visit more than twice yearly. No units we studied had received visits from them during the previous 2-month period. The frequency of supervision for the health inspection assistants was much higher than for the other branches of the service. It was reported by health inspection assistants that the district health inspector visited them regularly, although in fact in Jasikan District only the health post at Jasikan had been visited by the Jasikan-based health inspector within the previous two months. The health inspection assistants, who are more mobile than other health workers, also tended to have regular meetings with the district health inspector at his office; in addition, particular villages were visited with the supervising inspector if problems arose. With the exception of the environmental sanitation services, for most of the "supervisory" visits the main purpose seems to have been to discuss some administrative problems with the staff concerned, and it was

Health needs and health services in rural Ghana only when a particular problem arose that a visit was made. Supervisory visits from public health nurses tended to centre around "'fault-finding'" inspections, e.g. inspection of the cleanliness of the labour ward and records, rather than around constructive discussions of work or problems. Health service supervisors did not usually observe a clinic in operation. This contrasted with the CRS supervisors, who observed the clinic from beginning to end using a supervisory check list.* during the course of which suggestions for improvements were made to clinic staff. Whereas the health inspection assistants felt they were well supported, and the supervising district health inspector was well respected for his practical skills and moral support, particularly in Jasikan, this was not the case with the community health nurses. The reluctance of senior staff to spend any time in the rural areas giving meaningful supervision or support seemed to have been an important factor in the low morale and motivation throughout the health service, but particularly in the public health nursing service. The problems of the district medical officers were also partly motivational. No training or orientation was given to medical officers before taking on the role of administering the district health services, and there seemed to be no guidelines on what was required. Some doctors simply did not have time. Interviews with the medical officers in charge of the districts suggested that they had quite enough problems to deal with at the hospital without going out to look for more at the rural health units: in their view many of the problems there were. in any case, insoluble. Moreover. in many districts--including Birim and Jasikan - - t h e doctor in charge of the district hospital, the senior medical officer, "'doubled up" (acted as) district medical officer. The substantial amount of work involved in properly running a district's health services can only suffer if those formally in charge have their primary responsibilities (and, of course, interest) in the hospital. Lack of transport was obviously another major constraint to effective supervision. 5. COMMUNITY RESOURCES AND INVOLVEMENT The bulk of our research on community resources and involvement was carried out at the village level, and is reported upon in Chapters 9 and 10. From these chapters it should become clear that much remained to be done to mobilize the villagers for the contribution they themselves might make to their own health situation. However. the medical team also * The supervisory checklist included: number of registrations, number of attendances, scale check, weight chart used. filled in correctly and explained to mother, group talk with demonstration or visual aids. member of staff running clinic, individual counselling given, minor ailments treated, number of children above or below the path of health on the card. CRS food supplies and quantities being distributed. + Those aspects of community involvement considered to be resource inputs have been summarised in IDS. 1978b: Table A51 and have also been incorporated in the final assessment for individual units in Table 26 along with the other resource inputs.

465

included a minimal assessment of community involvement as seen from the health unit, and it is that aspect which is discussed in the present section. All except three health units could be said to have some community involvement, but in most cases this was minimal.$ Over all. three health units had good scores, three scored nil or poor, and the rest were assessed as having a fair input from community resources. We would emphasize, however, that these are generous assessments, and for most /Jnits almost the only real community resource used regularly was communal labour. The most active involvement was at a district council health post where the Town Development Committee (TDC) managed and controlled the polyclinic side, while the district council was responsible for the running of the maternity side. Here, a dresser assistant and six volunteer girls (paid "chop money" only) helped in the clinic and received regular training (e.g. to take temperatures) by the QRN and midwife. At two mission clinics volunteers, teachers and catechists helped with varying success in the running of the child welfare clinics. For many villages the TDC took charge of environmental sanitation (though often reluctantly, as it was regarded as properly the district council's responsibility), thus supervising the sanitary and conservancy labourers. This was not always done with great success: in one area it was said that at eight out of 21 villages they did not perform this function very well: refuse dumps were not maintained and latrines were not properly kept. The most common form of community participation was in the form of communal labour. There were eight places where communal labour had been used for health activities in the past 12 months. This included the digging of pit latrines in five villages. improvements to a water supply and erecting a new clinic building at two others. Other activities included the construction of street drains and the digging of a trench for the disposal of night soil. At three places a special levy had been raised for a health project. There was very little co-ordination between health" workers and extension workers from other government sectors. Three units had had some contacts of a tenuous nature with the Department of Social Welfare. At one, the health inspection assistant was liaising with the Agriculture Department over livestock vaccination because of an outbreak of disease among some of the animals in the area. There was no coordination of health personnel with the Water and Sewerage Corporation: relations with the district councils existed only through the environmental sanitation programme, or where units were actually run by the council. 6. R E S O U R C E AVAILABILITY AND O R G A N 1 S A T I O N A L EFFICIENCY: AN O V E R A L L ASSESSMENT

(a) Assessment of resource inputs Table 26 summarises the resource adequacy for all health units, using the foregoing scores for each type of resource input on a 3-point scale (0, 1 or 2). The final score for all resources together is based on a simple addition of points adjusted to a four-point

466

IDS HEALTH GROUP Table 26. Summary of scores for resources adequacy Staffing Quantity Quality Supervision Referral

Transport

Supplies

Physical Community Total facilities resources score*f"

Jasikan District Worawora hospital Dodi Papase hospital Kadjebi HC Jasikan HP Dodo Amanfrom HC Ahamansu HP Nkonya Wurupong DC New Ayoma DC Lolobi Kumasi DC Abotoase DC

+ + + + + + + + 0 + + + 0 0

+ + + + + 0 + 0 + + +

+ + + + 0 + + 0 + + 0 0

+ + + + + + + + + 0 + + + + + + +

+ + + + 0 + + 0 + 0 0 0

+ + + + + + 0 + + + 0 0

+ + + + + + + + + + + + + + +

+ 0 + 0 + 0 + + + + +

+ + + + + + + + + + 21/34

+ + + + + + + + 17/34

+ + 0 + + 0 + 0 13/34

+ + + + + + + + + + + + 28/34

0 + + 0 0 + + 0 + + 13/34

+ + + + 0 + 0 + 15/34

+ + + + + + + + + + + + 27/34

+ + + + + + + + + 17/34

+ + + + + + + + + + + + + + + + + + + + + + + +

Birira District Oda hospital Ofoase Mission HC Achiase HC New Abirem HP Ntronang Mission HC Brenase H P Akim Swedru HC Totals

+ + + +

+ + + + + + + + + + + + + +

* Key for assessing total score: 1-4 = +, 5-8 = + +, 9-12 = + + +, 13-16 = + + + +. i" See text below for limitations as regards interpretation of these totals. scale.* These final scores should be interpreted with considerable caution. They are merely intended to show the differences between units in their access to resources a n d to provide some measure of the overall adequacy of inputs to the primary health care facilities. T h e procedure can give n o more t h a n a n indicative assessment, not least because of the problems involved in a d d i n g together the different scores. Bearing this in mind, only the mission hospital a n d one district hospital h a d a level of resource input which m i g h t be considered adequate. Six health units had rather inadequate resources ( + + +), seven had p o o r resources ( + +), while at two units resources were grossly deficient. W e have also tried to give some a p p r o x i m a t e indication of the adequacy of each different type of resource available to the primary health care units studied. Figure 7 gives a n impression of the availability of each type of resource input for all health units together, based o n the totals from Table 26. These latter totals c a n n o t be read to m e a n that a particular resource is available to "a q u a r t e r " or " h a l f " of what is reasonable: they show no more than that all types of resources in the primary health care system fall short of what might be considered the absolute m i n i m u m for adequacy, a n d that m a n y types are clearly very deficient indeed. Hence, while the height of each bar in Fig. 7 is determined by the total at the b o t t o m of Table 26, we do not show these * The details of how each resource is scored are shown in the relevant tables for each item, except where only two or three criteria were used, in which ease those which scored 2 or 3 scored + + and those with 1 scored +. All items were weighted equally to calculate the total for each health unit. 5"white there is a n overall correlation (r) of 0.4, the coefficients for Jasikan and Birim are 0.55 and -0.11 respectively.

n u m b e r s in the figure. Resources for t r a n s p o r t a n d supervision were lowest (nine and seven health units respectively scored nil for these items). Physical facilities and referral were the least unsatisfactory, a l t h o u g h even these were considered i n a d e q u a t e overall (and one unit scored nil for referral facilities). W e have a t t e m p t e d to explain the reasons for poor quality of care as being, at least in part, due to inadequate resource provision. While this was almost certainly true for some aspects of health care provision, the relationship between the overall quality of care provided by different units a n d the level of resources to which they have access was not a clear one. At one end of the scale, the mission hospital provided a relatively high quality of care a n d was backed by adequate resources, while at the other end one mission clinic with very few resources a n d three o t h e r health units with poor resources, performed badly. O n e district council health unit, however, with p o o r resources, performed relatively well a n d a district hospital with a good resource input gave health care of no more t h a n fair quality. M o s t health units were b u n c h e d together, performing more or less well with marginally a d e q u a t e or p o o r resources. A l t h o u g h resource adequacy clearly plays some role in accounting for p o o r performance within the health system, it is h a r d to interpret the data.i" Obviously there were o t h e r factors responsible for the short-comings, a n d we turn n o w to a n assessment of the organisational problems as distinct from resource questions.

(b) The organisation of theprimary health care system The criteria used to assess the efficiency of organisation of primary health care in the district reflect m a n a g e m e n t a n d p l a n n i n g p r o b l e m s in the health service itself rather t h a n shortcomings at the health unit level. H e a l t h units belonging to the same organisational structure tended to have similar scores for in-

Health needs and health services in rural Ghana

I

467

I

staff quantity

Ii

staff quality

Supervis~on

g_

Referral facilities

Transport

Suppl ies

Physicol Foolities

I

I I

Community resources

Fig. 7. Quantity of different resource components for primary health care. dividual criteria. It was, therefore, not considered particularly useful to compare scores for the individual health units. Instead, we aggregated the information gained from individual units to build up a profile of organisational efficiency for primary health care services in the two districts together, there being no important differences between the districts in the way services were organised. The difference of this pro-

cedure from that used for the other criteria must be kept clearly in mind. The organisational criteria have been used to assess the overall organisational efficiency by allocating one point (to the system as a whole) when half or more of the units for which information was available scored positively for a particular criterion.* For example, if out of 12 units for which information was available seven scored positively for having their drug stores kept in good order and up to date on stock records, the services as a whole scored one point. No attempt

* Because of the difficulties inherent in relating the existing organisational model of primary health care to the organisational targets listed in Appendix B. the criteria for effectiveness had to be derived after the field work had been started. This necessarily resulted in gaps in information from units studied earlier. For each of the criteria used, therefore, there are different denominators and information is complete on all criteria for only a few units. ~"They are shown in detail for each of the criteria used in IDS, 1978b: Table A52. ++The use of vehicles was not evaluated because hardly any vehicles were available.

has been made to give different weights to the criteria used. The results are summarised in Table 27.t They demonstrate the very wide gap between the existing organisation and that which is considered necessary for effective primary health care. We looked at 31 criteria of efficiency. These covered the use of physical and human resources, organisation of clinics including integration of services, records, referral and the organisation of communicable disease control services. The health services scored only eight points. If mission health facilities were excluded (i.e. those not subject to the Ministry of Health's organisational constraints), the total was reduced to only seven out of 31. The management of physical resources did best (four out of five criteria were positive), but most of these criteria reflect management at health unit level rather than the efficiency of management at higher levels. Transport organisation "failed" because there was no efficient system for the reimbursement of travel costs to health personnel.:[: The utilisation of staff was very inefficient at all government health units (none of the six criteria used scored positively when mission units were excluded). The misuse of staff time has been discussed in detail above. The reasons why staff were not properly utilised was primarily due to the mismatch between skills required at the primary care level and skills available. Some categories of staff were underutilised, because at any one place the call upon the services of health personnel with a narrow range of skills (e.g. child care only) was

468

IDS HEALTHGROUP Table 27. Summary of organisational assessment

I. Management of physical facilities and supplies 2. Efficient utilisation of staff 3. Clinic organisation and integration of services 4. Use of records 5. Referral procedures 6. Organisation of communicable disease control

No. of criteria

Health system score+

5

4

6

1 (0)*

6

2

5 4

0 1

5

0

31

8 17)*

( )* = excluding missions. + Score = sum of the number of criteria on which more than half the units scored positively. limited, even though they were available full time. This problem was exacerbated by the severe limitations of transport and supplies in general. Staff were trained not only in too narrow a range of skills, but often also at a level too high for the required tasks. They were also not trained appropriately for the conditions in which they had to work, nor did they learn some of the essential skills needed to perform the required tasks effectively. Record keeping, referral mechanisms and communicable disease control, all of which have been discussed above, were obviously extremely poor.

(c) Integration of services Reference has been made earlier, e.g. in con0ection with the discussion of communicable disease control, to the lack of integration between the various branches of the health care system. There was little or no co-ordination between the health institutions and the M F U on such activities as irnmunisation programmes, recording and reporting cases of infectious disease, such as yaws or measles, or follow-up of individual cases of infectious disease seen in outpatient clinics. There was also very little co-ordination between the health inspectorate and either the M F U or even the health centre staff. Lack of co-ordination between health unit staff and health inspectorate was particularly serious when the latter did not have an office at the health unit. There was also evidence of lack of integration within the health unit itself. The problems of personal records and the fragmentation of child care resulting from this have been discussed in Chapter 7:6(b). The same child may be attending both polyclinic and child clinic, but each of these kept separate records which were not easily accessible to the other. No health units in the study districts provided integrated preventive and curative child care, although elsewhere in Ghana, at Danfa and at Bawku. combined preventive and curative child clinics were held daily at health units or weekly at satellites. At most health units, sick children would attend the polyclinic on a child welfare clinic day and had no contact with a trained child health worker. Only the comparative unit, Danfa, weighed children and gave nutritional advice to mothers on the days when no child welfare clinic was held. At all

other units children seen at the polyclinic were treated in the same way as adult outpatients. However, at the mission hospital steps had been taken to integrate preventive and curative care for children by using the child welfare records at the polyclinic and giving nutrition and health education advice to mothers attending with sick children. At most units mothers of sick children attending the polyclinic received little or no health education. The lack of nutritional surveillance and health education for mothers of under-fives attending the polyclinic was a serious inadequacy for the following reasons: (i) The polyclinic achieved a far greater coverage of under-fives than the child welfare clinics. For example, at one health centre the number of children seen in the polyclinic was l0 times greater than the number seen in the child welfare clinic, while a mission clinic saw 24 times more children at the polyclinic. Records at four units showed that 33-48°o of polyclinic attenders were under five, although this age group represents only 18.2~o of the population. These children were also coming from a greater distance than child welfare clinic attenders. The community health nurses and midwives were constantly complaining about the low attendance rates at their clinics while in the next room many risk cases were going away without any preventive care whatsoever. (ii) The majority of children seen by the child welfare clinics were under l year or even 6 months of age (see Chap. 5:2a). They were also likely to come from the higher income groups. Those most at risk nutritionally were likely to come to the polyclinic only when the child was sick because of time and financial constraints. Preventive child care should be available at the polyclinic if these children are to be reached with the services they need. (iii) Weight for age data collected from seven child welfare clinics and two polyclinics showed that: (a) the incidence of undernutrition was significantly higher at the polyclinic, with 58°0 being below the third percentile (girls), compared to 25°o at the child welfare clinics. (b) the incidence of undernutrition among those attending was higher in the second and third years of life than in the first year.

Health needs and health services in rural Ghana Average for seven clinics (352 childrent Age in months O~ under third percentile

0-5 6-11 12-23 24+ 15°o 19°o 29°~, 35°0

At most health units the majority of children over the age of one year were only being reached through the polyclinics. The integration of maternal care with child care was also assessed. As the recently weaned toddler of the pregnant mother is especially at risk nutritionally, and because it is difficult for mothers to attend two separate clinics, it is important that services for both mother and child are provided on the same day, preferably at the same consultation. The narrow range of skills available from existing staffing patterns in Ghana made this difficult to achieve; and usually both a midwife and a community health nurse were required. Thus two separate consultations were inevitable even if clinics were run simultaneously-which mostly they were not. At most health units the services were run independently by different staff at different times. Some health units utitised the midwives at the child welfare clinics: they might function as assistants to the community nurses at busy clinics, or they might actually run the child welfare clinics where there were no community nurses. But midwives did not usually have training in child care beyond the care of the newborn, so most of these clinics run by midwives were in fact post-natal baby clinics and did not even try to cater for older children as well. Moreover, it was the required presence of the midwife at child welfare clinics that necessitated the provision of antenatal clinics on another day. Daily clinics, like those held at Danfa and jointly run by community health nurses and midwives, would allow both antenatal mothers and young children to be dealt with satisfactorily at a single visit. In summary, there was little evidence of integration of services at the primary care level. This was largely a reflection of the staffing structure of the Ministry of Health. which narrowly delineated responsibilities of field staff and supervisors into vertical hierarchical structures. This made it difficult to develop common objectives at the peripheral level. Staff of each cate* At the time of the study attempts were being made to bring all members of primary health care teams, including community health nurses, under the direction of the health centre superintendent. This was being reflected in their training.

469

gory related functionally to their district and regional supervisors with whom they identified rather than with the primary health care team at local level.* Integration did not even occur at district level because there was no district team leader who could co-ordinate all branches of the service. We felt that there was an urgent need to decentralise to the district level the planning and administration of primary health care services. However, this could not be done in the absence of a team or individual responsible for district primary health care. The setting up of a district primary health care organisation (see Part IV) would provide an opportunity for integration with the district council, and for decentralisation along the lines proposed in the local government reorganisation of 1974. It would also make it possible to broaden the concept of primary health care to take account of necessary activities in other sectors and to contribute to development programmes which have the promotion of health as a primary objective. The experimental project at Kintampo provided an example of how health could be administered in close collaboration with the district council. It is significant that primary health care appeared to be more effectively organised in the two districts where there was a separate real district medical officer--Kintampo and Bawku. The overall picture, then, was one of resources inadequate to support rural primary health care. Inadequacies of management, however, and poor planning of the use of human resources in particular, would seem to be even greater impediments. More transport, vaccines and supervision would undoubtedly make the existing services function more effectively, but these did not appear to be the most crucial determinants of effective performance of the primary health care system. To achieve that aim, fundamental changes would be required in the pattern of staffing, in the leadership at district level, and in the way services were organised. As was already foreshadowed in our initial discussion on specifying the resources and organisational requirements necessary for effective task performance (Chapter 2:2), the problems of the primary health care system in Ghana were inherent in the organisational model--in the way health services were organised, in the pattern of health units and health manpower, and in the services available. The main constraints to the effective operation of primary health care services were to be found not in the health units themselves, but at the district level and in the policies that had been pursued by the Ministry of Health.

POTENTIAL

PART IV: FOR ALTERNATIVE

SYSTEMS

OF PHC

PART IV: POTENTIAL FOR ALTERNATIVE SYSTEMS OF PHC CHAPTER 9. VILLAGE ORGANISATION AND THE POTENTIAL FOR C O M M U N I T Y PARTICIPATION IN HEALTH SERVICE PROVISION

The following sections refer to Jasikan District. The extent to which the situation has been found to be different in the other districts studied, Tongu and Birim, will be discussed separately; but the general observations, which may well apply to most at least of southern Ghana, will be made here. Each village is unique, and it will not be appropriate to present a detailed account of the social organisation in each of the 13 villages of Jasikan District which were visited. Rather, it is proposed to focus the discussion on the possibilities of initiating various forms of community participation in health. Where appropriate, feference will be made to the variation between specific villages. The villages studied in Jasikan District were in three areas: Guameng, in the Buem traditional area and close to Jasikan town; Dodo Amanfrom, in the north of the District, an area where the indigenous inhabitants are patrilineal Akans but there has been substantial Ewe immigration; and Tapa Abotoase, an area on the Volta Lake shore with resettlement villages, and a similar mixture of indigenous Akans and immigrants. I. VILLAGES AND PARTICIPATION: THE QUESTIONS ADDRESSED

It was recognised that the potential for different kinds of activity might well be different. Distinguished at the start of the research were: --Community control: a form of organisation in the village which would be in charge of its health activities, whether as a separate committee or otherwise. --Monitoring activities: monitors would maintain a continuous check on the health of the people in their area (e.g. a small village or the ward of a large one), making sure appropriate action is taken but not necessarily taking it themselves. --Village health workers: persons trained briefly, able to carry out simple curative care and play a central role in preventive activities in the village. ---Communal labour, mobilised for health-related activities. - - H e a l t h promotion through village groups, or the use of the authority of the organised community to achieve changes in individuals' health-related behaviour. ---Cooperation with indigenous practitioners of various kinds. 2. GENERAL WILLINGNESS OF VILLAGES TO COOPERATE IN HEALTH PROGRAMMES

The questions to which answers were sought by sociological fieldwork in villages were those which appeared most relevant to the potential for community participation in health: - - a r e Ghanaian villagers willing to undertake selfhelp activities in cooperation with health services? - - W o u l d they sustain such activities? - - A r e there differences between villages in this respect? - - I f so, what are these differences? Are they a matter of the cultural traditions of different ethnic groups? Or of the extent of urban or modern influences? Or of the degree of factionalism or internal disputes? - - H o w do these influences or background features have their effect? It was proposed to investigate these questions in two main ways: (1) By examining the current features of village organisation and the current state of self-help activities, in a sample of villages broad enough to embrace various dimensions of differences. (2) By discussing with village authorities and other villagers what activities might be undertaken by the village. 471

From the point of view of the villages visited, any interest shown in their health problems was regarded as welcome if not overdue. Difficulties were seen as arising much more from lack of attention by the health (and other) authorities than from any shortcomings in the ability to organise within the village. In all of the villages except the very smallest, Dzolokodzi, cases were recounted in which requests to outside authorities such as the District Council had not been met. Villagers, who pay the District Council levy and other taxes, generally felt that they did not receive enough in return. Nevertheless, in all five villages where the question was specifically put, villagers said that, in the absence of a government salary, they would be willing to support a village health worker financially. At other villages the payment alternative was not specifically put, but the idea of a village health worker was approved. The villagers were extremely conscious of their lack of technical knowledge as far as health matters were concerned, and perhaps over-confident that advice from outsiders would be useful. The advice given by community health nurses and by social welfare personnel was spoken of with appreciation. Similarly,

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any programme promising to increase the pool of health knowledge in the community was regarded with favour. No radical difference was observed between villages which were prepared to do more for themselves and others which expected all services to be provided by government. All the villagers preferred and expected (in the normative sense) government to provide services. But all villages also expressed willingness to co-operate actively (and all villages visited had undertaken some projects, such as the building of school classrooms, themselves). The differences sometimes noted may be a result of different tactics used by village representatives in meetings with officials. Such meetings may best be seen in terms of bargaining. The aim of the village representatives is to achieve the greatest possible advantages for the village from the contact with officials. Usually, this will be seen as the greatest possible disbursement of funds for the village. Village chiefs and other leaders are skilled in impression management: they will seek to create that impression of the village among the officials which will lead them to make as big as possible a disbursement of funds. They will be judged by their fellow-villagers on the success achieved in this, or at least the skill shown in trying. All villages were willing and able to cooperate with outside authorities in programmes in which a significant input was made by both sides. Where two different technological solutions were possible, village representatives on the whole preferred the more "'modern" and expensive one, provided the village did not bear the cost. This was related to what has been called the "'demonstration effect". The more expensive the solution the greater the gain to the village and its leaders, in prestige, and also in work and effort, since in most cases the more modern solution is laboursaving in some way, and the labour saved is the unremunerated labour of villagers. Thus, it would be wrong to conclude in a simple way that some villages were "'unwilling" any longer to dig pit latrines, etc., or expected the District Council to provide everything: it would neglect the element of bargaining in the situation. Larger (and less remote) villages expected more modern solutions: Pampawie expected a pipe-borne water supply and a health post, or at least a dressing station, and was more dissatisfied with talk of merely changing health-related behaviour than were the smaller villages. This would make it easier to propose self-help solutions in small villages, given a certain level of government help towards the projected solution. But it does not mean that serf-help was impossible in large villages.

improved living standards, but it was not focussed on particular changes, apart from the desire to be provided with the facilities seen elsewhere: the health centre, the piped water system, and (to a lesser extent but still welcomed) the services of health inspectors, community health nurses or social welfare personnel. All the villages visited in Jasikan District expressed the desire for a health facility (except the two small hamlets for which it would be completely unrealistic). When the more modest idea of a village health worker was explained, the response was invariably positive. Anything would be better than nothing. But by the same token it proved impossible usefully to discuss what precise form any such programme might take. In the hope of getting something from the health authorities, and aware of their lack of technical knowledge, village representatives were ready to accept almost any suggestions put to them. This applied particularly to such questions as what would be the tasks, the training period, or the criteria for selection of any village health worker: the formation of a health committee and its functions; also to matters of spare-time voluntary work and its organisation. Discussion could be meaningful where it was a question of the resources (in kind, money or effort) which the community or its members could contribute. As already mentioned, in each of the villages in Jasikan District, where the question was specifically asked, the village representatives said that they could pay a village health worker. It was generally recognised that only a modicum of spare-time work could be expected to be given voluntarily, and as the area produces cocoa, money could be raised. Since villagers were largely unaware of the precise causes of diseases, they were also unaware of preventive measures which could be taken, perhaps by communal labour. Water may be taken as an example. It was known in a vague way that pipeborne water supplies were cleaner and healthier than streams, ponds, or lakes. But the only specific diseases which were associated with particular water sources were schistosomiasis and guinea worm (in one village, a few people thought onchocerciasis was caused by bad drinking water too). If these two diseases were absent, and if turbidity was not extreme, the villages in this area did not worry about the purity of their water. The straightforward precept that all drinking water should be boiled is likely, in this situation, to be treated with some scepticism: the danger from the existing source--if indeed it does exist--has not been demonstrated and understood. 4. A L T H O R I T Y AND ITS LIMITS

3. THE QUESTION OF FELT NEEDS" All village leaders were conscious of health needs in a general sense, and had no difficulty in providing a list of diseases in response to probing on "health problems". But the knowledge possessed on disease causation was not specific enough to enable villagers to identify "'felt needs" for particular interventions. They were aware, as another study has documented. that ill health is in general caused by poor living conditions lTwumasi. Yangyuoru and Banuaku. 1977). There was. then. a "'felt need" for better health and for

(a~ Chieftaincy Every village has a chief or headman and elders, representing the formal power structure. In none of the villages studied in Jasikan District was this formal power structure challenged by any other (a religious leader, say, or an independent-minded Town Development Committee). But there were large differences from village to village in the apparent authority of the chief. There were. first, the formal differences. Some villages visited had chiefs with the status of paramount.

Health needs and health services in rural Ghana Of the paramount chiefs, some showed a greater panoply of power than others, and appeared to be more influential. Then, of the other villages, some were headed by divisional chiefs and some by lesser chiefs or headmen. Where the formal status was higher, there was a strong sense of social distance between chiefs and ordinary villagers, but it was much reduced in smaller villages where the chief, or headman, lived among and at a similar economic level to the rest of the population. Until it erupted in an open dispute, disaffection appeared to affect the smooth running of village affairs relatively little. It would be a partial hindrance to a programme of community participation in health, but most problems could almost certainly be circumvented, provided that the health service supervisor (or community development workerl were on hand to help solve them. Disaffection was contained in part because disrespect was not shown openly. It may have had its effect, however, in the failure to perform tasks. All chiefs have to take into account the opinions of elders and, in the final analysis, of their people as a whole, since not to do so is to risk destoolment; and also in the sense that, for instance, asking the population to perform more communal labour than they are prepared willingly to do would lead to absenteeism. Although absentees from communal labour were fined, it would clearly be a difficult matter to fine more than a few individuals. There is also a formal obligation to consult elders: to ignore their advice would be to invite discontent. Certain chiefs impose themselves relatively forcefully. But others do not have strong personalities. It was clearly not regarded as too great a disadvantage that a chief works elsewhere, since the internal affairs of the village can be settled by others--it is representation to the outside world which requires that the world can be met on its.contemporary terms. The smaller the village, however, the less relevant this is.

(b~ Elders the chief's court The chief's court, or council of elders, generally consists of representatives of the wards of the town or village, together with some individuals chosen by the chief. At very small villages there are no divisions such as wards, and the elders are simply individuals chosen for their personal qualities. There may also be a degree of representation of ethnic groups. It is with the group of elders that power and authority mainly lies: there was no sign in these villages of challenges by other groups such as young men, religious leaders, or the group of more educated people on the Village or Town Development Committees.

(c~ Village or Town Derelopment Committees Each of the villages had its development committee. with the exception of two of the small hamlets. The

* Most formal of all is the government-sponsored "'National Council on Women and Development", which is set up to help integrate women in the development process. It has regional and district branches. We did not. however. encounter the organisation during our field work.

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development committees are invariably subordinate to the chief's court. At one village an "'inactive" committee had been disbanded and a new one selected, by the elders. In most cases the committee members represented the same divisions of the village as the elders. but with the important exception that minority ethnic groups, where they existed, were represented. The chairman was, in these villages, the chief or, if he was not resident in the village, the senior elder. Members of the development committees were often younger men with more formal education than the elders: the secretary, in particular, was usually one of the most educated persons. Schoolteachers who were indigenous to the village were often prominent members. In one or two cases the representatives were said to have been "'elected", but in most it appeared that they had simply been chosen by the elders. All development committees reported some development project undertaken recently with the use of communal labour, in addition to periodic sweeping of the village. Communal labour took place on the weekday which, in addition to Sunday, was the day nobody was "permitted" to go to farm. Almost all villages mentioned the building of additional classroom blocks for the school as a development project carried out. Other projects included road construction and the digging of pit latrines. Nowhere did it appear that the gong-gong was beaten every week for communal labour, though some villages claimed the sweeping was done every week: it was more a matter of an occasional project on which work was done intensively over a short period.

td) Women and women's councils In none of these villages were there women members of development committees, nor did queenmothers exercise functions in the affairs of elders, as they do, for instance, in matrilineal Akan areas of Ghana. But in Jasikan District the larger villages had queen-mothers who presided over the women, with a queen-mother's court having representatives from the women of the clans in the same way that the male elders represented the clans on the chief's court. The organisation is, in fact, entirely parallel but is concerned only with women's affairs, primarily in solving disputes, with the queen-mother having formal authority over the women.* The small villages, however, do not have any such formal organisation of women, or queen-mothers,

~e) Other aspects Clan organisation is important only in the larger villages. Here. clans have their own formal councils and the larger ones have three clan "'officers" or formal leaders. The larger clans also have formal women's leaders and councils. Clearly, the authority exercised by older women through these women's councils at village and even clan level is a factor that needs to be taken into account in organisation for health. Stratification and status differences were particularly visible in the larger, old-established towns such as Pampawie. The ownership of cocoa plantations was highly unequal but large owners were not found in

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the small migrant villages which were, therefore, much more homogeneous in economic terms. This was clearly reflected in the degree to which all the population were involved in the processes of decision-making, for instance concerning development projects. To talk with village representatives about possible health activities, the researchers were taken, at two of the larger villages, into internal rooms, and committee members, elders, or prominent individuals were invited to attend. At smaller villages, meetings were held in public places and many villagers, including women and children, were also present. At one of these larger villages there were indications of tensions arising from the scarcity of land and the fact that some clans and individuals had much more than others, but even there communal activities were observed to be in progress (the building of shade for the market area, and of a shed to house a cornmill). The tensions had not, then, disturbed work in the general interest. Nor has the greater wealth of some individuals led to moves to replace communal by paid labour (as in many places in Latin America).

5. VILLAGE ORGANISATION IN TONGU DISTRICT

Most of what has been said about Jasikan District applies also to Tongu. It is proposed to discuss here only those features which are different in Tongu. Tongu is a district without important cash crops or the degree of differences in income within villages which is associated with cash crops. In some of the villages studied, apparent differences in wealth and income were minimal, with few opportunities for the accumulation of capital. In others, one or two individuals stood out as having a considerably higher income (for example, as cattle-owners), but the villages also gave an overall impression of homogeneity and lack of status differences. One village, with sugar as a cash crop, had gone somewhat further in differentiation. On the willin#ness of villages to cooperate in health programme& the remarks made in the context of Jasikan District also apply to Tongu, with the exception that the Tongu village representatives did not think it possible for the village to support a village health worker with a salary. This was the case in all three villages where the more extended field work was done, and the question was discussed. In one of these, a villager had been given a short training in first aid at the mission hospital in Adidome. He was willing to work as a volunteer, and was already assisting at the time of the monthly visits by health staff from Adidome, but the collection of any money was seen as a problem. At a second village, our enquiries led to a request from the village to the District Chief Executive for the payment of a village health worker, and to the hospital at Adidome to train him; a villager volunteered for the job and was approved by the Village Development Committee. The villages were very ready to cooperate by providing buildings. The negative reply to enquiries about providing remuneration for the village health worker was a realistic assessment of the difficulty of raising regular funds in villages without cash-crops,

not a sign of a generally lower willingness to cooperate, either with the health service or one another. The formal structure of chieftaincy is somewhat different in Tongu District as compared with Jasikan. The importance of the clan is greater. The details need not concern us here. What is perhaps more significant, however, is that there is much less insistence on formality and social distance as between chiefs and villagers. This was true in all three villages studied, although the formal status of the chiefs differed greatly in the three cases. In .one, a senior elder was acting as headman after a decision had been taken to cease to obey the constituted headman (instead of formal destoolment); in the second, the person acting as chief of the village was the paramount chief of a small traditional area; in the third there were--simplifying the matter--two rival chiefs. Even the paramount chief dealt with fellow-villagers on non-formal occasions in the manner of an equal, and was in fact employed as an assistant schoolteacher at the school without it being seen as inappropriate. As with chiefs, so also with elders: the extent of their authority appeared to be less strong. The generally small size of villages in Tongu District made it difficult for big differences in status to be maintained. 6. THE NEED AND THE POTENTIAL FOR PARTICULAR ASPECTS OF COMMUNITY PARTICIPATION

(a) Community control From the point of view of those planning a rural health programme involving community participation, it may appear that community control of the programme is a fundamental requirement. Yet from the point of view of the village, in the Ghanaian context at least, the emphasis may be put on the need for health system support and guidance. What are the reasons for this paradox? The central planners may stress community control because this is seen as a kind of guarantee that the interests of the villagers will be served, a n d - - m o r e relevant to the planners--because it is believed that villagers will support the programme and make it work if they themselves are in control. However, from the village point of view, control at the local level is no guarantee that essential support will continue to come from the health service, and it is the failure of that support which is seen as the main danger to the village health programme and hence to the villagers' interests. The question which villagers mainly ask themselves is whether other villagers will make their contribution towards the programme. They fear that there may be apathy, and believe that frequent visits by health system personnel will counteract such apathy. There is no difficulty, however, in having village development committees assume responsibility for the arrangements suggested by health service representatives and agreed by the village. Decisions are readily taken, but they may remain unimplemented if there is no follow-up from the health service. There may be a tendency in the health service to regard a failure to implement a decision as a reprehensible "going back on a promise" when it would be more realistic to

Health needs and health services in rural Ghana regard the original decision as contingent upon further contact with and advice from the health service. Another kind of problem may be presented by community control: the decisions may not be regarded as appropriate by those promoting the village health programme. One area in which this may happen is the appointment of a village health worker. Whereas the interest of the health service is to have what it regards as the most suitable person for the job, villagers will be more conscious of the potential advantages which can accrue to the person appointed. It is difficult to generalise, but it would appear a reasonable policy for the health service outsiders to lay down criteria or otherwise assist in selection.

(b) Monitorin9 of health, and simple care In all the villages we visited, the health need which was most readily and consistently seen by villagers was the need for treatment for simple cases to be available within easy access. Just as the health unit was seen as a source of curative care, so the village health worker was conceived by villagers primarily in terms of curative work, with other functions seen as additional. The need for curative care was seen as pressing both for urgent cases and to avoid unnecessary journeys for simple treatment. If curative care was the most strongly felt need, a case could be made that it was monitoring and ensuring remedial action which was the greatest real need for improving healih. A "monitor" would actively keep a check on the health of the population, particularly those at risk (pregnant women and young children), and not wait to be consulted. The monitor would, for instance, measure and chart the weight of children, and would be responsible for finding cases of specific illness among a defined population, the ward of a larger village or the whole of a small hamlet. Alternatively, the role might be combined with that of a village health worker. A division of functions might be advantageous in that those functions which can be carried out by a volunteer in spare time might be separated off, and the more difficult problem of ensuring remuneration for village health workers would be reduced. Where the roles were separated, of course. the monitor would have to work in close liaison with the village health worker. In most villages of small or medium size, the purely curative workload would not be sufficient to justify the existence of a separate curative worker. Whether or not the curative role is combined with that of the monitor, it seems both natural and desirable that it should be combined with that of pivot and activist for all preventive and promotive health work, if not with a wider "'community development" role. The curative workers will be looked upon in the villages as their "'doctors" lin the sense of the person with modern knowledge in the health field), and attention is likely to be paid to preventive activities which they recommend. Above all, it cannot be envisaged that any village worker separately given responsibility for environmental sanitation or for "community development" would be remunerated by the village. It would. then, probably be best to have a village health worker take on these functions also. while being paid primarily on the strength of the curative work. The vii-

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lage health worker would be oriented to follow up the causes of the illness he sees. in terms both of discussing them with the patient or family, and of initiating wider community action. In any case, it can be argued that curative care, while certainly needed, should be de-emphasised by ensuring that the curative worker does not typically sit in his clinic waiting for patients to come to him ~or hert, but is typically busy with other health work in the community, where patients requiring treatment Iother than, perhaps, at a specified time each dayl will have to seek him out. The question of the remuneration of the village health worker consistently came to the fore as a problematic issue in discussions in villages. Villages in Jasikan and Birim District generally expressed willingness to finance a village health worker in one way or another, while the poorer villages in Tongu District generally said that this would not be possible. No characteristics appeared to distinguish the "willing'" from the "'unwilling" villages, other than this geographical one which also reflected the existence or otherwise of a cash crop. It is not at all surprising that regular payment for work to a villager should be problematic. Villages were familiar with the system whereby dressing station and sanitary/conservancy labourers working in a village were paid by the District Council: some were also familiar with private clinics licensed to charge fees for services [these were found in two villages visited in Birim District). No regular salaries or wages were paid by villages for any other work. Village organisation is, in fact, not geared to making regular payments, though it is very well geared to the occasional collection of funds for a specific expenditure (such as the rehabilitation of a clinic building or improvement of the water supply). The reasons are fairly obvious: when money needs to be collected in villages (once-and-for-alll for a specific purpose, individuals gain status by making sizeable contributions. For the disbursement of small amounts on a single occasion, a decision can be rapidly made and carried out by the village authority. Small amounts of money for such purposes are often at hand through the imposition of fines, etc., while for rather larger amounts a single levy, or a call for a day's communal labour to raise funds, will meet with a good response. But the idea that communal labour should be given on a regular basis to support a regular salary is alien, and likely to meet with problems of indifference and failure to attend. The summons to communal labour may, in fact, not be made when the village leaders know that apathy is general. It seems inappropriate, then, to attempt to use village organisation to generate funds to remunerate village health workers. Village authorities can oversee the charging of fees for treatment, or can pay the health worker out of fees collected, but where this is not enough it may be easier for the salary (or the remainder of it) to be paid by central or local government than to make a system of regular village payment work. Voluntary work is an alternative possibility, especially when the work-load amounts to no more than can be done in spare time. In the course of the village research it was not unusual for villagers to declare their willingness to serve voluntarily as health workers, and this was the position of the seven or

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eight village health workers of the Danfa project. But a'number of instances were recounted to us in which promising work dependent on volunteers had ceased after initial enthusiasm had flagged. It would not be surprising that volunteers lose much of their motivation once they have learnt the skills needed and the work becomes routine, particularly if they are not supported by highly motivated health service staff. The motives of volunteers (especially those who are not just spare-time helpers) are clearly in part those of learning, whether for future use in earning a living or for intrinsic interest.

(c) Communal labour The potential for communal labour to make a contribution to village health appeared to be somewhat more circumscribed than was envisaged at the start of the research. At first sight, it was one of the most promising possibilities. Ghanaian villages, unlike those in many other parts of the world where the custom has tended to disappear with increasing economic differentiation and payment for work, do still frequently perform communal labour. In most of the villages visited, above the level of small hamlets, communal labour was supposedly undertaken by both men and women once a week, but where it was possible to observe actual practice it was clearly by no means so regular. Willingness to perform communal labour was clearly related to a belief that there was a need for the particular work to be done, and village authorities appeared to be reluctant to call for communal labour unless there was a consensus that the work was worthwhile. This is a second limit on the potential. In general people did not refuse to undertake work which was suggested, but they delayed its implementation, perhaps indefinitely. This suggests that there was a need for "animation", for community development work, done by the village health worker or by personnel of the Ministry of Health or the Department of Social Welfare and Community Development. However, villagers may have had good reasons for not being enthusiastic about a particular job. One such reason, a third limiting factor on the potential for communal labour, was that little could be done by the villagers alone without substantial inputs in material and expertise from outside. Larger villages may be able to mobilise help through their members resident in the capital or large towns, or through their home town associations which can often raise money as well as petition for official help. But smaller villages do not usually have this recourse. Provision for support in these cases must be made in any plans for community health work which involve communal labour. For example, in labour-intensive improvements to the water supply, cement and other small items---or the lack of them---are often the crucial determinants of success or failure. The village view at the time of our field work was that these items were far too often not forthcoming. In fact, few of the feasible interventions which are likely to have a substantial effect on the improvement of health require communal labour. A generalised belief that "villages could do a lot for themselves" may lead to a shifting of responsibilities onto villages

which can in fact do little, while simple and effective interventions by the health care system, such as immunisation, are neglected. This was certainly the view expressed in the villages. Of the 40-50 priority interventions tentatively identified in the course of the village fieldwork only the following required communal labour: digging of wells or other water improvement, where necessary and feasible with village-level technology; digging of latrines, replacement latrines, or special latrines for children;provision of lids for latrines; physical/ecological measures against trypanosomiasis, schistosomiasis, or guinea worm (against the vectors or to discourage contact with water). Of these, only on latrines were actions likely to be required and feasible in most or all villages. Communal labour would, then, largely be a matter of environmental sanitation. There is another problem in this regard: villagers are unwilling to do "dirty" jobs connected with excreta. For this reason. the traditional system of periodically digging a new (deep trench) communal latrine may present fewer problems than are posed by more "modern" systems involving some form of removal of excreta. If for the performance of such tasks outside Ioften foreign) labourers are not available, and paid by the District Council, the system breaks down.

(d) Changing individual behaviour To change individual health-related behaviour is one of the most difficult tasks facing a health care system, but if it can be achieved, one of the most rewarding. There is little doubt that in relation to hygiene, at least, changes in behaviour requiring comparatively little effort could have an important impact on health. The question of what can influence villagers to change their habits has not been satisfactorily settled. The present research was not experimental and can only indirectly throw light on the problem. But it suggests that it is useful to distinguish three modes of influence: (1) the use of a respected, authoritative source, such as a doctor, a chief, or even a film shown by a mobile cinema van, as the vehicle to carry a message urging a change in behaviour; (2) the use of multiple reinforcement of the message, so that it reaches the individual villager not from one source but from several; (3) the attempt to convince through logical argument or demonstration. The first of these methods, the use of authority, accords well with the respect for authority, and for persons of higher status and education, found in Ghanaian villages. However, this respect may well be largely a matter of public and outward deference, the result of the sanctions which can even today befall those who openly challenge constituted village authority. The words of the authoritative figure are less likely to be taken to heart and applied in "nonpublic" situations, such as within the home. That is probably why there tended to be a considerable difference between reported and actual behaviour over matters such as infarat feeding practices. Multiple reinforcement of the message might well

Health needs and health services in rural Ghana produce an effect. It could be done through a massmedia campaign, as well as through the local representatives of the health system, through schoolteachers, town development committees, and perhaps also through the traditional hierarchy of chiefs and headmen. To a limited extent, the experience of the Operation Feed Yourself may be said to confirm this. The success of the Tanzanian "Man is Health" campaign (Hall, 1975), using radio and organised listeners" groups, is also an instructive example. The third method, the attempt to convince through logical argument or by demonstration, is the method which village health workers would be required to use. The community participation approach assumes that a villager is best placed to present the case for a change in behaviour to his fellow-villagers, as there is little or no social distance to impede communication. Whether or not this assumption is justified can only be tested in practice, but there are some likely obstacles worth keeping in mind. Thus Ghanaian villagers are accustomed to formal rules embodied in traditional codes of behaviour or laid down by village authorities, but not to a process by which people are convinced in dialogue and through the presentation of arguments. Consequently people who come to villages to influence habits te.g. health workersl tend to fall into the expected pattern of laying down precepts, and they do not find it easy to stimulate dialogue.

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There is a danger that this will also happen with village health workers, especially if they themselves are trained in terms of precepts rather than given a more thorough understanding of the reasoning involved in the recommendations. Finally. there are two kinds of existing institutions which are of potential usefulness in efforts to change health-related behaviour. One is the school and its teachers, not only through health education imparted to children in classes, but through a more active involvement of teachers in other activities in the community. Children can be organised to clean up, fill in puddles, etc., and already did so in many places. A teacher from each village could actively participate in any programmt, that might be instituted for monitoring health or training village health workers. Where teachers were asked if they would be willing to participate as volunteers in such a programme, the response was invariably positive. The suggestion made was that the teacher might attend the initial stages of village health worker training together with the VHW, and then help him with advice and support. The other kind of institution which might be of assistance is the women's council, where it exists, or the more informal group of women. Since the habits of mothers are often the object of attempts at change, the potential of doing this through the existing organisation of women is obviously worth exploring.

C H A P T E R 10. P R O B L E M S IN T H E I M P L E M E N T A T I O N COMMUNITY PARTICIPATION

This chapter aims to draw practical suggestions for the initiation of a programme of primary health care with community participation. It does so both from the general considerations of the previous chapter and from the experience of the health services as we observed them in Jasikan and Birim Districts, and also from discussions and brief observations at Danfa and Kintampo. The Danfa project and the BARIDEP* project at Kintampo are the two important programmes in Ghana which involve experimentation with village health workers. But they differ in starting point and approach. The Danfa projectt (which has other research purposes also) is concerned to bring comprehensive health care to the population of a defined area, with other areas serving as experimental controls having less comprehensive services. Within this framework, village health workers are a relatively minor aspect of the total effort to provide comprehensive care, and the area is well provided with other health services. Other aspects of community participation are encouraged to some degree, especially in activities closely associated with health (e.g. drinking water, day care nurseries). Traditional birth attendants are trained. Even so, the focus of attention is provision for health. In contrast, the philosophy of the Kintampo project, though it was initiated by the Ministry of Health, has been concerned more with awakening, in the communities of the area covered, a will and a capacity to generate development initiatives themselves, not just in the field of health. Health care remains an important component, however: "The health care delivery aim is the improvement of health status of the local population by the provision of important parts of basic health care through community projects decided on. organised and performed by the communities themselves as an integral part of rural community development.",+ There is an emphasis on the involvement of the communities in deciding what they want to do from the beginning: at the same time they are stimulated and helped to do what is decided. In this process, adult education has a prominent place.

*Brong-Ahafo Rural Integrated Development Programme [often called the "'Kintampo Project"). + Of the Community Health Department, University of Ghana Medical School. Started in collaboration with the University of California. and with funds from USAID. ,+Quoted from the plan of operation formulated at the start of the project. Working one day a week to provide community funds. This practice is found elsewhere in Ghana. and is encouraged by government. 479

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I. T H E Q U E S T I O N O F T H E S C O P E O F A PROGRAMME AND COORDINATION WITH O T H E R A G E N C I E S

The BARIDEP project appeared to have been most successful in the narrower health field, and to have experienced difficulties in stimulating initiatives by communities or indeed by other agencies of administration apart from the Ministries of Health and Education and the Department of Social Welfare and Community Development. The most successful health activities were the programme for community clinic attendants (simple curative care) and training of traditional birth attendants. By 1977, about two years after the start of project activities in 1975, some 38 community clinic attendants had been trained and had been or were about to be installed. The programme had clear acceptance and others would be trained. The most successful activity outside the narrow health field and involving active community participation had been the starting of community farms.~ However, this had been achieved, by November 1977. in only 16 or 17 villages (out of 211 in the project area) and on only a small acreage. In that month three tractors, made available through the good offices of WHO, arrived in Kintampo, The availability of tractors should greatly increase the incentive for community farming, but these must be regarded as an exceptional input, difficult to replicate on a national scale. Of other activities outside the narrow health field, shallow well digging had got off to a slow start, though it was expected to expand; and a vocational training school had been established, but at the time of our research had only 10 trainees. With the wide range of developments envisaged, it was considered that every effort should be made to involve many departments of administration at District level, and formal responsibility for the project was transferred to the District Chief Executive. Nevertheless, the project remained identified locally as a Ministry of Health initiative. Although a large number of meetings had been held, other branches of the administration had not become as ~ictively involved as had been hoped. The experience suggested that the extension of the original model to other places should be pursued cautiously, and that it might well be complemented by experimental projects elsewhere based on different conceptions. At the level of dialogue with the community and the stimulation of community initiative, the experience of Kintampo appeared to us to confirm what was said in the previous chapter. The physical resources of available labour--and even money, to some extent--existed for village communities to do more for themselves. In spite of this, there had not been much success in stimulating a qualitative change

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in the degree to which communities were disposed to act autonomously to improve their living conditions. But willingness to cooperate when inputs were made by government agencies---c.g, providing clinics for clinic attendants---certainly did exist. Another consideration is that it may be difficult or impossible for the Ministry of Health to initiate a programme involving other government agencies at the district level. Such an initiative may have to come from the District Chief Executive or Regional Commissioner, at their respective levels, or as a matter of general government policy for rural development. Activities which have conventionally been associated with other government departments are, certainly, essential for the achievement of the minimal conditions for good health. We may identify in particular water supply and inputs into agriculture with their potential direct effects on nutrition. But agencies may have different views with regard to priority needs, and consequently be unwilling or unable to make the necessary resources available. These problems may be overcome if coordination is achieved through political decision at the highest level. Otherwise--by no means an ideal solution, it would seem--it may be necessary for the Ministry of Health to consider expanding its own activity into the relevant areas.

2. PROGRAMME CONTENT A N D

INTEGRATION AT VILLAGE LEVEL In the health field, the BARIDEP programme involved, as separate and unintegrated items, the training of Community Clinic Attendants, of Traditional Birth Attendants, and of Community Nutritional Assistants; of schoolteachers and day nursery attendants in first aid; and the establishment of Health Education Committees. To attempt to introduce such a wide variety of specialised functions in a single village may well be more difficult than to train just one or two village workers who would cover a wider range of activities. These would include monitoring of health (or MCH), which was not included under the BARIDEP programme as initially established. It was apparently proposed to extend in future the role of the community clinic attendant to more of these promotive-preventive tasks, as a result of the early experience. The programme for nutritional assistants was tried in one village where it apparently ran into the problem that the assistants wanted some remuneration, or at least a kit as the TBAs were given; the Health Education Committees, set up in

* Briefly, it was envisaged that each committee member would head a group of households and would pass on health education to the heads of households for transmission within the household. The plan proved unrealistic in expecting health messages to be "passed down the line" in this way, though some of the committees which were set up did function to organise health activities, generally on a village-_wid_e_b_asi_s. _. t This observation about more than one worker does not of course, apply to the training of TBAs: these would not expect to be paid regularly by the community, though they would be likely, after training to demand a fee for their service.

Kintampo town and in six villages, were not working (as it was at one time envisaged) to change healthrelated habits:* the training of the schoolteachers and day nursery attendants in first aid had taken place, but discussion continued over what role (if any) they should play outside their schools, as well as over their supplies. Meanwhile, two areas of this ambitious project for "community involvement in solving local health problems", namely the programmes for community clinic attendants and for TBAs, were proceeding more or less as intended. It is true that the villagers' first thought or "felt need" was for curative care. It would be truer to say, however, that they felt a need for a "mini-doctor", who treats the sick but is also an authority on all matters of health. Although we were made aware of different views on this issue in Ghana, some strongly held, we still believe that a single village health worker should be the pivot of the health system of the village, concerned with monitoring, prevention, and promotional work, but doing minor curative care when required. In a larger village where this may be too much for one person, the best policy for spreading the load might be through giving the monitoring function primarily to voluntary helpers, ideally perhaps with one in each ward. However, experience at Kintampo and Danfa suggests that in small villages (say, up to around 1000 population) a single village health worker can handle the workload very well. Indeed, to have more than one may cause frustration (too little work to share) and possibly rivalry. We do not believe that villages will support more than one worker with any form of regular remuneration----especiallya second person not having a curative function.t The customary division of labour between the sexes in Ghanaian villages puts a far greater burden of work on the woman. Therefore, men normally have more time to perform the functions of a village health worker, and are more likely to come forward and to be chosen as such by their fellow villagers. At Kintampo, all but two of the 38 community clinic attendants who had been trained were men, and the two women had been selected together with men from the same villages. At Danfa, none of the three women originally selected continued to work. Also the more retiring role expected of women in village society (even in Ghana) makes it more difficult for women (other than those, perhaps, of exceptionally forceful personality) to engage in promotional or "community development" work. However, it may be argued that this is a repressive tradition which can only be challenged if it is not allowed to determine the choice of a village health worker.

3. REMUNERATION For the reasons mentioned in the previous chapter, any form of regular remuneration by the village is problematic. A high proportion of the time of the administrative personnel of a project (and its vehicles) may need to be devoted to the task of mediating between the village health worker and his employers, the village authorities, or pressing them for payment on his behalf. Difficulties of this kind had occurred in

Health needs and health services in rural Ghana at least three of the first four BARIDEP project villages with clinic attendants, and the initial experience there did not suggest that ideas such as communal labour on the village health worker's farm offered a better solution than raising money for a simple salary. Those who had to deal directly with the problem at Kintampo were of the opinion that the salaries of village health workers should be paid by the District Council. This was the opinion of many others interviewed elsewhere. Ultimately the choice must be between funds raised in the villages, which are of course relatively poor, and funds supplied by central government from its general revenues, which in the direct sense tax those who are relatively better off. It is these general revenues which support urban hospitals and other health institutions. In terms of distributive justice, villagers have good grounds for expecting that the government pay their health workers. At the time of our research the cost of paying a ¢100 monthly salary to some 3000 village health workers, one for each community in Ghana of between 500 and 5000 inhabitants, would have been of the order of ¢3.5 million---or about 3~o of the nation's health budget at that time.

4. T R A I N I N G A N D S U P E R V I S I O N

Trainers of village health workers tend to reproduce what they learned in their own training, and to inculcate the approach and attitudes of their own occupational group. This means that a village health worker trained by a health centre superintendent is likely to adopt this (primarily curative) role in his or her village, while one trained by a public health nurse may well adopt a more preventive and MCH-oriented role. But. as we said above, what is required in the village is an all-round health worker and stimulator of community initiatives, rather than a specialist in one aspect of health work or in community development. Moreover, what is required is that reasoning be applied to trace the causes of health problems in the village and eliminate them: reasoning not by the village health worker alone, but in consultation both with other villagers and with his or her supervisor. These requirements may conflict with the approach which has hitherto characterised the training of virtually all categories of health worker, professional and non-professional alike. One solution might be the retraining of the staff who will act as trainers and supervisors of village health workers. An obvious problem is the degree of reorientation which can be expected among existing staff: however, this is the solution which would accord best with the aim of adapting an existing primzry health care system to a new emphasis on village needs and community participation. It would also probably ensure the best possible co-operation between the VHWs and health unit staff on referral, supervision and supplies, and bring the health service staff into more direct contact with village reality. Another solution might be to train a new cadre whose work would be exclusively the supervision of village health workers, taking as trainees those from the existing personnel who would be most prepared for the necessary daily travelling to villages.

481

At the least, there is a clear need for training material for village health workers, prepared in such a way as to encourage an all-round approach to the community's health, while not introducing irrelevant or unassimilable detail. A strong case could be made for the training to be in the vernacular, even if the village health workers have, say, completed primary school. Not only are there obvious difficulties of communication in English among persons with this level of education, but it throws upon the VHWs the onus of translating concepts into the vernacular if they are to explain them to their fellow villagers. Perhaps the major problem in the area of training and supervision is that of work satisfaction and motivation among health service staff. A very high level of motivation is demanded of staff who must not only spend most of their time visiting villages, but continuously use initiative to solve the problems they find there. It is not a routine activity comparable to a health centre clinic. Special recognition should probably be given to the greater responsibility of this role. Above all, perhaps, there must be adequate arrangements for transport to villages. The importance of supervision, and of transport to ensure it, has been felt strongly at Kintampo (although, due to problems, it was for a time somewhat neglected). It is the central element of the support system which will determine the success or failure of a programme of community participation, and it must be adequately provided for. The supervisor m u s t be able (and willing!) to gain a first-hand view and contact with what the village health worker is doing, and not rely only, as one of the health centre superintendents in the BARIDEP area told us he did, on a scrutiny of the types of cases that come to the health centre from the villages where the community clinic attendants work. One working four-wheeled vehicle per district, and one two-wheeled vehicle per supervisor (or health centre responsible for supervision of an area) would seem to be an indispensable minimum. A problem which seemed likely to prove at least as difficult as providing adequate supervision in the village is that of arranging the higher tier of supervision, at the level of the District. There might be a coordinator at district level, who might be responsible just for the village programme, or for all primary care in the district, or there might be a true District Medical Officer of Health responsible for all health services but free of any clinic duties at the hospital. Ideally, it should probably be a doctor with community health training or orientation. However, such doctors were not available in large enough numbers in Ghana. One alternative that might be seriously considered is to appoint a non-doctor as "District Health Officer" or "District Primary Care Officer". He would be responsible to the D M O H and able, when necessary, to call upon the authority of the latter. But he would be in direct charge of all aspects of the support for village health work, if not of all primary health care. Such a person might be chosen, as a promotion and with some special training, from health centre superintendents or, if responsibilities were limited to village work, from other categories--public health nurse, health inspector, or Medical Field Unit personnel.

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IDS HEALTH GROUp 5. PHASING

It must be decided whether: (1) the whole programme of changes and innovations which is decided upon is to be carried out in one geographical area first, and then extended to others; or (2) some elements of the programme, which are judged to be higher priorities or are easier to implement, are carried out in one area first, and then extended to others, before the whole programme is implemented in any one place; or (3) there will be some combination or compromise between these two approaches to phasing. The advantage of the first alternative, purely geographical phasing, appears to lie in its simplicity and in the possibility that the "model" area can provide a more complete set of guidelines for other places. The advantage of the second alternative, which includes a degree of phasing of programme content, may be primarily that it allows a more rapid spread of coverage for the most cost-effective innovations; also, it may allow learning from experience to be incorporated in the step-by-step process of programme introduction. If it were to be decided to establish a denser network of smaller units than the existing health centres or health posts, in conjunction with village health workers and other elements of community participation, then it is important that the whole programme is not held back because of a lack of resources to build and staff such health units on an extensive scale. As an eventual goal, the integration of village activities with a denser network of primary care facilities may well be desirable. In the short term and with existing resource constraints, however, village work was required in part as a matter of filling gaps in coverage. For these purposes, a rapid extension of village work would be required.

Within the area of village work, also, it is possible to distinguish two sets of activities. There are those which require a "'fully-fledged village health worker", i.e. a person able to treat a range of simple conditions and be the village's "health expert", and those which can be performed by people with much less training-especially the monitoring work. There is room for much discussion on how much training is required for each activity. There is less doubt that a "small package" of useful work for a person with less training (probably a vo!unteer working in spare time) might be worked out, as well as a "big package" for someone who had been given further training and, probably, some form of remuneration. Already we have made distinctions on these lines in connection with the possibility of having "'health monitors" Ithe "small package") in wards and in small hamlets, working to a village health worker in the larger village as a whole. It is debatable whether it would be best for the "small package" to be implemented first in any village or area, in order to ensure that the simplest interventions were extended as rapidly as possible. Thus, for instance, in any one area it might be possible to implement first a programme involving just, say, two weeks' training for volunteers; these might, as mentioned above, include a schoolteacher as well as another volunteer from each village. Later, some of the latter would expect to go on to further training, assuming satisfactory performance as a volunteer. However, starting from this minimal package may have disadvantages too. If only the simpler interventions or monitoring are provided, this might disappoint the villagers' expectations for curative care, their major "'felt need". Motivation and impetus might drop rather quickly if at least some of the sick cannot be treated. Our earlier suggestion for some further experimentation with different models applies also to the present set of alternatives.

CHAPTER 11. TOWARD ALTERNATIVE STRATEGIES AND STRUCTURAL CHANGES: RECOMMENDATIONS The Ministry of Health has recognised the limitations of the existing primary care system, and over the past few years has taken steps to plan an alternative health care delivery system aimed at extending health services to 8000 of Ghanaians by the year 1990. In November 1977 a workshop was held in Accra, attended by senior personnel from the Ministry of Health including regional medical officers, most divisional heads, and representatives from the university, in which the finaings of this report were presented for discussion, together with a working document containing the Ministry's own proposals, "A Primary Health Care Concept for Ghana". We now set out the recommendations for an alternative strategy which were based on the discussions and proposals arisin Ofrom this workshop. We followed the overall strategy agreed at the workshop, though in some areas we went beyond what was actually discussed, in order to set out in detail some of the implications of the strategy and to present some of the choices which would have to be made in its implementation. The recommendations are presented in their original form. It must be noted that they do not take account of developments which may have occurred since the end of 1977; they represent, therefore, the response to the situation as it existed at that time. I. THE GENERAL STRATEGY PROPOSED A system of health care is proposed which provides three levels of care. The first would be at village level, accessible within one-half to one mile of the population served. This would be organised and controlled primarily by the community itself, supported by the national health system. The second level of care is the first referral unit of the health care system, which should be within four to five miles of the population to be served. The third level of care would be at the district level and consist of both a referral facility (the district hospital) and the district primary health support and supervisory team. Multipurpose village health workers are recommended for the first level and two kinds of basic health workers for the second level. The planning and siting of each unit of care should be based on (geographicl factors related to accessibility rather than on numbers of population. The population density will he the major determining factor for the number and size of the first referral centres and village centres. Decentralised district planning will be necessary to determine the numbers.

* For the purpose of this report, first referral centres will be called health stations, to distinguish them conceptually from existing health posts and health centres. 483

size and mix of village "units" and first referral centres (health stations)* required in each district, so that 80-100% of the population have village level care within one mile of their homes and 80% have health station care within four to five miles. Where communications are poor and there is no public transport, or where terrain or rivers intervene, the geographical area to be covered by a health station should be reduced to take account of these factors. The significance of planning on the basis of accessibility is that each unit of care, both at village and health station level, will cover a different size of population. Village health workers might cover from 500-2000 population. For villages or hamlets of less than 500 population, of which there are many in Ghana, it is suggested that some kind of part-time health worker or volunteer, equipped with a minimum of skills, carry out at least some of the tasks of a village health worker. Health stations might cover 2000-15,000. The actual manpower required would be determined by the population covered by each unit of care. For example, smaller villages might use only one pan-time health worker, larger villages one or more full- or part-time workers, or a mix of these. Health stations might be staffed by three to nine health workers depending on the total population within the catchment area. Although village "units" and health statiohs may be smaller or larger, it is proposed that the level of care be comparable in large and small units of the same level. To achieve such radical structural changes in the pattern of health care delivery will present formidable problems---so much so that we ourselves would probably not have dared to propose them had they not emerged from the Ministry workshop. This report has identified a whole range of issues which militate against the effective functioning of the existing primary health care system. A number of these could probably be overcome without too many dii~culiies by a determined implementation of the new strategy (such as problems of integration, poor coverage and some management/supply problems), but others will not easily be solved, and no doubt further obstacles will emerge. Those social, economic and political factors which in the past have brought about inequality, urban bias, and elitist attitudes will not yield easily to an attack in the health sector alone. In the past many attempts have been made to introduce new ideas; but most of these have come to nought. However much the present recommendations will have to be subsequently modified (they are, after all, only starting points of a lengthy process of discussion with a large number of interested parties), the underlying ideas of the strategy should not be lost from sight. And it is those underlying ideas which first will need to gain acceptance by all concerned. A strong political

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IDS HEALTHGROUP

[District Team Health1

/

DISTRICT LEVEL

Health stationA

ation B

//iS-6 Health I workers l

Health station level

3 - 4 Health wockers l

/ o t ~ l popula "o x / • 13,500 ~ ,

Village level ( population )

2000

4,000

2500

will and commitment to such a strategy is the first target to be achieved in Ghana. 2. FUNCTIONSTO BE PERFORMED AT EACH LEVEL OF CARE

(a) The village level (a) Simple medical care for common conditions (diseases and management regimens, including referral, to be specified). (b) Monitoring of child health and nutritional status surveillance.* (c) Monitoring of maternal health and supervision of births. (d) Organisation of sanitation and assistance with provision and maintenance of a safe and adequate water supply.* (e) Recording and data collection and use of data collected. (f) Health education--as an integral component of all of the above activities.

(b) Functions of the health station as first referral centre (a) Curative outpatient or ambulatory care requiring more skill than is available at village level (again diseases and management regimens, including referral. to be specified). This function might be supported by laboratory services in some instances. (b) Maternal and child care including nutritional surveillance and nutrition education, possibly supported by a minimum of food supplementation where necessary. (c) Environmental sanitation services. (d) Communicable disease surveillance and follow up. (e) Data collection and use. {f) Health education as an integral component of all other activities as well as specific campaigns and com* Regular supervision of growth and screening for signs of nutritional deficiencies. t Identify problems and motivate community to organise communal labour for protection of ponds and streams or the digging of shallow wells. Materials and supplies to be provided by the District team--see below under Supplies.

\

I000 3000

I000

munity health teaching programmes, e.g. group meetings and discussions, women's groups, cooking demonstrations, etc. (g) Community development activities--i.e, activities designed to stimulate development projects in the community which are related to health but are broader than the direct health activities.

(c) Functions of the district level (a) Provide a strong supporting system for the lower levels of care. This would consist of administrative and managerial functions: training and supervision: distribution of supplies: the collection of data and use for health status monitoring: evaluation and functional accounting: the provision of technical and professional support and advice for MCH activities, nutrition programmes, medical care, communicable disease campaigns (including immunisation), and for health education and community development programmes. This would all be done in liaison with the district administrative structure and in coordination with other district sector heads. (b) Provide the referral facilities at the district hospital for patients who cannot be treated at the health stations. This should include ensuring feedback to health stations from the hospital when patients are discharged (or newly diagnosed) for a communicable disease for which some actions would be required in the village. 3. MANPOWER REQUIREMENTS AND TRAINING

(a) Villaoe level The Village Development Committee itself should play a major role in organising sanitation activities and in providing labour for communal projects such as water supply protection or building latrines. It should organise health education meetings and set up women's groups, or other appropriate village groups. all of which can be used as vehicles for the dissemination of health information. The organisation of day care centres should also be taken in hand. The VDC will need some "'training" to undertake these tasks. This would involve at least two kinds of programmes. Initially there is a need for considerable dialogue between health care system personnel or community

Health needs and health services in rural Ghana

"'animators" (see below), so that villagers" real health needs can be identified and their felt needs expressed, and in order to find alternative solutions to the apparent and real problems which exist in villages. Such discussions are themselves learning experiences both for the village leaders and for the health service personnel. Secondly, once the programme is under way it should be possible to arrange seminars for representatives from the village development committees from a number of villages. It might be advisable for the VDCs to appoint one or more of their members to take responsibility for managing the health activities of the village. Guidance from the health care system should be given, especially for the management and financial control of the village health programme, and also for the supervision of the village health worker and in the use of data collected for local planning and action within the village. For the other health care tasks which will have to be undertaken at village level the community should appoint village health workers. Deciding on the numbers and types of workers, and their organisation and selection, would be the responsibility of the VDC assisted by persons from the higher levels of the health care system. A flexible approach should be used, allowing for variation and experimentation according to the size of the community, its needs and resources. There are a number of options which should be tried out, where appropriate, using different mixes of health workers. For example, a small village might decide to select a part-time volunteer, while larger ones might feel that one or more full-time worker(s) would be necessary, perhaps assisted by a number of volunteers. This would be particularly relevant where a full-time worker could "'supervise" a number of part-time "aides" covering nearby hamlets. Different educational levels could be acceptable in different circumstances. Some villages may prefer younger, better educated health workers, others older, less educated but more respected health workers. Men or women may be selected. But in all cases selection should aim at identifying such attitudes and motivation as are likely to lead to a more effective programme. If possible the candidates should have demonstrated their willingness to serve the community by some active voluntary participation in community organised activities. It is strongly recommended that whatever mix of village manpower is decided upon, the emphasis should be on providing a domiciliary service which is not institution based. Village health workers should not operate from a "clinic" but have as their main task the regular visiting of homes. VHWs should keep a "'register" of young children, pregnant women and family planning acceptors in the village, and of persons with special health problems requiring regular follow-up or supervision such as TB patients. They should ensure that all such risk categories in the village are regularly seen for a check up, either at a collecting point in the village (e.g. under-fives for nutritional status check), or in the homes for those who have not attended the group session or who need special advice and help in their home environment. Depending on the size of the village and the demand, a short period might be set aside, possibly in the evening when people return from farming, for seeing any SSMI~,~

15 4

H

485

sick patients. Much of the curative care, however, could be done during the course of other work while home visiting. Problems are likely to arise in introducing the concept of this type of health worker, because existing role models in Ghana are primarily institution orientated. Moreover, people expect health workers to function from a clinic building. The emphasis given in training, the type of training given, and attitudes and roles of the trainers and supervisors will be the main determinants of the successful development of a new model of health worker. The training of these health workers will need careful local planning once the programme comes to be implemented. The district health team should be responsible for planning the training programme, which might be carried out with the involvement of local Ministry of Health personnel. It should be carried out in phases, teaching simple tasks first and gradually increasing skills as experience is gained and particular health problems come to be identified. The initial training phase should include instructions on how to take a census of "their population" and what risk factors to look out for in order to identify the most important health problems. It is suggested that Appendix 1A be used as a starting point to select tasks which could be done by village health workers, expanding or modifying the tasks as appropriate to the level of worker, the resources which can be made available, and the degree of supervision envisaged. Tasks which can be taught quickly and easily and which are effective interventions to priority disease problems should be taught first, but it should not be difficult to build up skills over a period of a few months which would effectively cope with most of the tasks listed in Appendix 1A. The discussion in Chap. 5:6, especially Tables 16 and 17, should also be useful. The selection of priorities may well be determined more by the support system's ability to provide the counterpart resources than by the ability of village health workers to learn the skills, or even by the identified priorities of the villagers. If there is more than one health worker in a village, a decision would have to be taken as to whether there should be a division of labour among them, or whether they would all have the same basic skills. We have seen that there are major problems of integration within the health system as a result of functional dividing lines between primary care workers. Unipurpose village health aides would tend to perpetuate this system into the village. It is therefore recommended that these health aides should function as multipurpose health workers, although bigger villages might well divide the tasks between workers on slightly different functional lines. One exception to the multipurpose health worker, undertaking all tasks, relates to supervision of births, which is already being carried out by traditional birth attendants, who can be trained to carry out their tasks better. They could perhaps also take on additional tasks. For the village level of care there are still many unknown determinants of success or failure. Some of these have been discussed in Chap. 9. As yet we do not have enough information to indicate confidently the type of village health worker most likely to succeed. Only if a number of different approaches are

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IDS HEAL'rHGROUP

tried out and some real evaluation is done will it be possible to determine the most appropriate mix of personnel. A compromise will have to be made between developing tailor-made programmes for each village, depending on the community's wishes and capacities, and planning and coordinating training programmes for village health workers at district level. To help overcome this problem consideration might be given to appointing a number of "health animators" in each district. These people could be community development workers with some additional training in health tor vice versa). (b) First referral level of the health care system or health station It is recommended that two types of basic health worker be trained to provide the services at this level and carry out the functions listed above. Both would be trained in the same basic skills of curative care, maternal and child care, environmental sanitation, data collection and communicable disease surveillance. Some specialisation, however, would take place in the latter part of the training, so that one basic health worker would function more in the area of personal and family care (the community nurse) and the other in the area of community activities (the sanitarianj. The main functions of both health workers would be to give substantial support and supervision to the village health workers and assist the village development committees. To train health workers to function positively in this way will not be easy because the idea of being based at an institution is deeply rooted among many health workers in Ghana. The concept of serving a defined population for whose overall health one is responsible is undeveloped throughout all levels of the health care system. The functions of the community nurses would be to provide a higher level of curative care than that provided in the village, and see referred cases from the village level; to provide maternal and child care (integrated with curative care, i.e. not separately run MCH clinics): and to supervise deliveries referred to them from the village, referring those with higher levels of risk to the district hospital. In addition they should be able to deal with environmental sanitation problems, particularly those connected with homes and families, as an important component of their home visiting activities. They should be able to ensure through the network of village health workers that there is a continuity of care for those with communicable diseases. They should maintain registers, and note those who have been seen and for what purpose: this would also enable them, each month or quarter, to identify who should have been seen but were not. Records should be used to evaluate their own activities in consultation with their supervisors. The sanitarians' tasks would include environmental sanitation, particularly as it relates to the maintenance of public hygiene; the organisation of mass health education campaigns and mass health actions in collaboration with the village development committees; and involvement in community development programmes. They would also be responsible for communicable disease surveillance in common with the community nurses, and should be able to provide some curative care when the need arises. The sanitar-

ians, by the nature of their work, would come into contact with the village programme more regularly and more often than the community nurses. To supervise village health workers they need enough training in areas beyond their immediate priority functions. The numbers of personnel required at each health station should be determined by the size of population in the catchment area. This should be calculated on the basis of expected work loads if each health station is to function optimally. The following components of the workload are given as examples of such a calculation; modification of the targets would, of course, bring about adjustments to the number of personnel required : 1. An average of three general outpatient contacts per person per year in the catchment area: 2. One antenatal contact for all pregnant women (other contacts would be through the village system) and a further three contacts for 2~o who have risk factors associated with their pregnancy; 3. 30% of deliveries to be supervised by the health station personnel; 4. Three child care contacts per annum for underfives (for immunisation and nutritional status check), half of these contacts to take place in the village. Allowing an average of 10 minutes per health worker/ patient contact, and 5 hours daily per health worker for patient contacts at the health unit, plus 10 MCH contacts/field day, two community nurses would be required for each 5000 population in the catchment area of four to five miles radius. In addition, for the other services in the community, one sanitarian would be required for this population. Health stations serving larger populations would require proportionally more basic health workers. On the basis of total population it should therefore be possible to plan nationally the manpower needs for each district. To estimate the number of health stations needed, requires more detailed planning at district level. Training. The training programmes for these workers will require careful planning, as they involve major shifts from the current health worker training programmes and existing staff policy. Adequate training resources probably exist in Ghana but the training institutions would have to be re-organised to meet the educational objectives of training the proposed basic health workers, It is suggested that Appendix IA together with Appendix IB be used as a guideline for defining educational objectives and for designing curricula content. Appropriate training methods will need to be developed and special attention should be given to methods of practical field training. Teaching materials and additional resources will be required. We refer to the discussion on training earlier in the report (Chap. 8:3.) and the problems described there which would need to be resolved. In all this the training of the trainers will be one of the most important determinants of the success of the primary health care programme. Selection procedures and criteria for selection need to be adjusted in order to attract appropriately motivated applicants. The level of educational qualification needs to be determined as well as the length of training. A" two-year training from middle school would perhaps be the minimum level acceptable. It is

Health needs and health services in rural Ghana also suggested that each cadre have the opportunity, after a period of work in the field, to return for a further year's training to improve especially curative skills and managerial ability. This would provide promotional prospects towards jobs with a status equivalent to the existing health centre superintendent. Following this, they would function at the larger units or at district level. Either males or females should be accepted for the community nurse cadre, depending on the acceptability of males, particularly for midwifery tasks.* Attempts should be made as far as possible to integrate basic training with supervision, and there should be coordination between trainers and district supervisors. A mechanism to achieve this should be borne in mind during the planning phase of the training. It is also suggested that, if possible, both types of basic health worker training should be carried out together, or alternatively use shared facilities for the common training at the beginning of the course, branching out to separate training institutions at a later stage. One of the most important problems to be solved is that of retraining existing primary care personnel. Individual tailor-made programmes for in-service training of existing cadres will be necessary to prepare them for their new roles in the primary health care system. This will inevitably pose serious problems, not least because attitudes and role models may be firmly established. The most difficult existing cadres to accommodate into the new system are probably the existing health centre superintendents with their strongly curative orientation. For some, additional training in maternal and child care and public health and some degree of reorientation may be possible to prepare them for the roles of supervisors and leaders of the large health stations. For others, the best option may be to upgrade their curative skills and employ them in the district hospitals to man the outpatient departments. There is likely to be opposition from health care system personnel at all levels and also the public to these proposals for staffing health stations, particularly as they affect existing health centres and health posts. The strategy will be perceived as a reduction in the quality of curative care in particular, by the substitution of lesser trained personnel. The fact that they will be more appropriately trained will not, initially, be recognised and it will probably only be possible to introduce these changes at existing institutions over a period of time. In any ease it will be most important to involve representatives of these--and other-health cadres in the working out of the details. The amalgamation of existing midwives and community health nurses on the one hand, and the health inspectorate and M F U personnel on tlae other, would be a logical and feasible approach towards developing the proposed basic health workers and be unlikely to meet with much opposition from those involved. The planning of the in-service training programmes for existing cadres should be carried out concurrently

* Male traditional birth attendants are common in many parts of Ghana and there appears to be no cultural barrier to the acceptance of male obstetricians.

487

with the planning of a new basic training programme. In-service training programmes will require additional resources for logistic support and personnel, and should probably be planned and implemented at the regional level, starting with existing health personnel who wiil be implementing the primary care programme in the first few districts.

(c) The district level Manpower requirements for the district level are discussed in more detail below, under Organisation and Management, where the functions of the district team are described. The district team should be led by a specially trained district medical officer. Alternatively, where suitable medical officers are not available initially, a specially trained primary health care officer might be appointed, drawn either from the senior health inspector cadre, or from the public health nurses. Back up services would be required from a health administrator (possibly a modification of the existing hospital secretary, given more training in health) who would need to be assisted by a vehicle/ supplies officer, an M F U team (for fire fighting operations in relation to outbreaks of communicable diseases and for immunisation programmes), a public health nurse, a health inspector and nutrition technical officer. The community development activities should also be coordinated with the district health team, if not controlled by them. All members of the district team--and especially the district medical officer, as team leader--will require special training for their role. 4. ORGANISATION A N D MANAC:EMENT:

THE FUNCTION OF THE DISTRICT HEALTH TEAM

There should be a district health organisation able to provide leadership and direction to the PHC st vices of the district. We have described the effects of the rigid, vertical, hierarchical divisions of the health services resulting in uncoordinated programmes at the district level and also at the delivery point of the health care system. Also the absence of a district health organisation makes cooperation with other ministries, and the local administration of the district difficult or impossible. The management of transport and supplies, the collection and interpretation of statistics and supervision of primary health care activities cannot be done without a strong district management team. The district leadership roles need to be clearly specified, most notably those of the District Chief Executive, the District Medical Officer (DMO) and the Senior Medical Officer (SMO) in charge of the district hospital. The question arises as to whether the director of the team, if a district medical officer, should be responsible for the administration of the hospital as well. There are obvious advantages in combining the overall responsibility for the district health services in one organisation and one structure of authority. The function of the hospital must be to support the work of the primary care units, to receive referrals from them and provide feed-back to the units. Some of the technical supervision and in-service training for basic

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health workers should be provided by hospital personnel. Hospital and primary health care services should not be separated organisationally to maintain a functional unity in the system as a whole. There may. however, be considerable problems in creating an organisational structure which places the hospital personnel, some of whom are senior clinicians, under the authority of a junior district medical officer, at least in the short term. Whatever solution is arrived at. the district medical officer should not have clinical responsibilities in the hospital. The selection and training of the district team and the D M O in particular are crucial to the success of the programme. Highly motivated individuals capable of exercising leadership and initiative are required. However, clinical medicine and the urban bias are strongly entrenched in Ghana and it may prove difficult in practice to find doctors with the necessary motivation to undertake the role of DMOs. They will need to spend more than half their time in the field visiting the health stations and villages and will need considerable management skills--neither of which abilities are common amongst the medical profession. The Ministry of Health could facilitate a change of attitude towards the community health approach by giving recognition and higher status to doctors engaged in public health administration.

(a) Liaison and coordination with local go~'ernment The precise nature of the relationship with the district council and other district organisations (community development departments, etc.) must be a matter of experimentation. Ideally the district health team should work under the jurisdiction of the District Chief Executive and the DMO should be responsible to him for all health activities. The district health budget should be managed by the DMO but he should be accountable to the District Council for its use. However. this arrangement may not be feasible in the short term. and a compromise may have to be made whereby the district health team is administered by the Ministry of Health through the Regional Health Office. while working closely with the District Council. To achieve this, decentralised planning should be carried out so that control of health resources and decision-making can be effectively done at the district level. The D M O should, in this case, act as technical advisor to the District Chief Executive and the District Council. and be responsible for the administration of the District Council's health budget which would be matched with the Ministry of Health budget. Through the District Council (and District Planning Committees. as they are formed) the district health team would coordinate activities with other departments such as agriculture, community development, water and sewerage, and education. The district health planning committee should also include representatives from the rural communities. If there are mission institutions in the district, they should be integrated into the district system: mission representatives should also be included in the planning committee so that their resources and programmes can be coordinated with those of other services in the district. The DMO should, in any case, control a n d supervise mission units, ensuring that they conform to

standard reporting procedures and provide an adequate level of health care. The main function of the district team, therefore, is to integrate all health activities in the district.

(b) Control of budget and expenditures The officer in charge of the district health team should have control over the health budget for primary health care and possibly for the hospital as well, if the D M O is to take overall responsibility for the district. National guidelines should be provided, but it is essential that the D M O has authority and resources at his disposal, and procedures should be flexible enough for him to respond to local needs and problems as they arise from below through community participation in planning. Budgeting procedures should allow for this. He should, for example, have at his disposal enough supplies for water and sanitation projects when a community needs such support, or enough T and T allowances to reimburse staff for local costs of travel or other petty cash expenditures.

(c) Establishment of village health care programme The district health team should initiate and develop the village primary care programme by setting up a mechanism for dialogue with village development committees. This could be achieved by the use of specially trained community development workers acting as health "'animators" or health promoters, and also through the basic health workers. Both would require assistance from the district team, which should in any case be responsible for initiating the village health programme and engaging in joint planning with community leaders about the management and selection of health workers and other responsibilities in the village. In the later stages the district team should continue to take overall responsibility for technical supervision and monitoring of the village health programme, although most supervisory tasks would be delegated to the health stations. However, there may be areas where village health programmes can be implemented but which cannot in the short term be adequately covered by health stations for reasons such as a widely dispersed population. Support services would then have to come from the district team. Other aspects of supervision and control of the village health programmes would be dealt with by the village development committees. (d) Traininy and supervision The district team would be responsible for the planning and implementation of the training programmes for village health workers and traditional birth attendants, using nationally developed guidelines and teaching materials. They should also be responsible for the regular in-service training to be given at least every one or two years to basic health workers. In this they would be assisted by the regional and national health administration. They should also provide regular supervision and support to the health stations, the DMO visiting all of them at least once a month and other supporting staff from the district a minimum of twice monthly. Supervisfon should be supportive and used for inservice training and not be used for inspection and

Health needs and health services in rural Ghana fault-finding. Regular meetings should be held once a month or once a quarter at the district headquarters for staff members from each health station, and more frequently at the health station level for all staff at the unit, including the village health workers working in the health area covered by the health station. There should be a system of referral which allows basic health workers to receive information from the hospital on all referred patients. Guidelines for supervision should be established, based on the criteria listed in Appendix 2. A system of on-going evaluation based on information gained from supervisory visits should be established.

re) Recording and reporting--evaluation The district health team would be responsible for the collating and interpreting of statistics collected from the district. These should include: (a) data on utilisation (giving number of people and numbers of attendances for the different services, and numbers of children or pregnant women vaccinated, and comparing these to the numbers at risk or eligible); (b) morbidity data (especially incidence of communicable diseases, the number of tuberculosis and leprosy patients being followed up, and the numbers of defaulters from treatment occurring annually in each health area); (c) vital statistics. If all children have their nutritional status monitored by the use of weight charts, the level of nutrition in the district can be monitored also, and a register can be kept of the numbers of fully immunised children. These data should be used for decision-making and planning for action. They should be discussed both with basic health staff and community leaders, and should also be used for training programmes. Some base-line data will be required before the new primary health care strategy can be implemented in a district. The first task of the DMO and his team will be to carry out an evaluation on broadly similar lines to the study reported here.* A scoring system might be useful to evaluate progress over time if resources exist, but much information would be gained without the scoring, At the central level the Health Planning Unit should set up an operational research team to evaluate the implementation of the primary health care programme and the training programme for all levels of health workers.+

(f) Transport and supplies An injection of new vehicles at district level would be an essential pre-requisite for any improvements to the primary health care services. The maintenance of an efficient transport system is fundamental. More

financial resources going to transport is probably the most effective input that can be made to improve the quality and coverage of primary health care. Some solution will have to be found to the problems discussed earlier in the report (see especially Chap. 3:1 and Chap. 7: 3), particularly the problems relating to the Ministry of Health's access to foreign exchange for the purchase of vehicles and spare parts.

* The observation schedules in 1DS, 1978b: Appendix 2 could be used as a framework for this. + The Community Health Departments of the two medical schools should be asked to participate in this research.

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At the district level there should be a mix of fourwheeled and two-wheeled vehicles, and, depending on the condition of the roads in a district, at least one vehicle might have to be a low ratio, four-wheel drive one. These vehicles should be allocated specifically to the district health team, to be controlled by the officer in charge, although it should be possible to coordinate the use of the district team's transport with that of the district hospital, particularly if overall ",administration of the hospital came under the authority of the DMO. For some aspects of non-technical servicing of peripheral units, such as distributing supplies and general communication, use might be made of district council transport, particularly when there is close coordination between the district health organisation and the district chief executive staff. To manage and coordinate the use of transport, and to be responsible for the regular flow of supplies to peripheral units, there should be a transport/supplies officer in the district health team. There should also be rules about the regularity of maintenance and servicing of vehicles. Each region needs a wellequipped maintenance workshop run by a qualified transport officer, with an adequate supply of spare parts. Smaller subsidiary district workshops should also be considered, run by a trained mechanic, for routine, simple vehicle maintenance and repairs, and possibly even storage of fuel. One permanent driver should be allocated to each four-wheeled vehicle, who could be encouraged to personalise "his" vehicle. He should be expected to take responsibility for keeping it in good condition and repair, and might even be given a bonus annually for keeping the vehicle in good running order during the year. Vehicles should be standardised and contracts for vehicles should include the provision of spare parts, 10-15~o of the cost of each vehicle being invested in spare parts and maintenance costs. If aid agencies are to be approached for assistance with transport, the project should include, as well as the vehicles themselves, the setting up of maintenance workshops and the training of mechanics. The precise numbers and types of vehicles required for the district team need to be estimated on the basis of a closer assessment of need than can be done in this report. It will depend on the number of health stations to be supervised, the condition of roads and size of district, and the composition of the district supervisory team. At least one vehicle would be required for full-time use by the immunisation/communicabledisease control staff, which would also have to be used for the collection and distribution of supplies of vaccines. Vehicles would also be required for the training programmes for village health workers. Two-wheeled vehicles should be used wherever possible to supplement the fourwheeled vehicles. These should be allocated to individual officers who would be responsible for their maintenance. For the health stations some form of transport arrangements will have to be made for the, basic health workers to visit villages in their areas and supervise the village health workers. These requirements will have to be assessed individually, but wherever possible bicycles should be used. These will need to be supplied together with supplies of spare parts to be kept at district workshops, and some active promo-

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tion of the value of bicycles will have to be made. and antiseptics can be stored, specifically for use in Government control of the selling price of bicycles in the environmental sanitation programmes. It should Ghana and better distribution of spare parts, together be possible for the district health team to supply with some publicity as to the value of bicycles, to materials to support projects identified by compromote their status, would help to make bicycles a munities such as those for water supply protection or more acceptable means of transport for health latrine building, for which they have organised workers, although it is difficult to see this being done labour. in present day Ghana. Like transport requirements, the need for environIn other cases public transport may be available, or mental sanitation supplies should not be underestimotor cycles used. Much can be done on foot for • mated. The health system should be more active in villages close to the health stations. Arrangements organising and supporting communities to undertake must be made to budget for and ensure prompt pay- small-scale water improvement projects. For these a ments might be made as routine monthly allowances supply of building materials will be required. These their own vehicles or public transport. T and T pay- programmes should be coordinated with the district ments might be made as routine monthly allowances council and the Water and Sewerage Corporation added to salaries, for those health personnel who are programmes. expected to travel regularly as part of tlaeir normal duties, based on a realistic assessment of their regular (g) Communications and referral To improve communications a radio telephone travel costs. All health workers should be encouraged and helped to buy and use their own two-wheeled should be installed between regional and district headquarters. Alternative communication systems vehicles. should be devised at the lower levels. For emergenBasic equipment and drugs for health stations and cies, where health personnel have motor cycles, village health workers should be standardised, and should include all items necessary to carry out their someone could travel to a nearby town or a main tasks properly. The same equipment and drugs should road junction to send a message, or even go to the be used in training. There should be a district store district hospital, if not too far distant, to ask for an for drugs for peripheral health units. This could be ambulance to be sent. For referral of emergencies, combined with the hospital store, but supplies for the local private vehicle owners might be requested to primary care units should be kept separately to form a standby rota, to be reimbursed by the Ministry ensure that they do not include the sophisticated of Health if their transport is actually used. The Ministry should find ways of financing, or at drugs used by the hospital. A separate store would also make it easier to ensure that adequate supplies of least of subsidising, the referral costs incurred by the few basic drugs are consistently maintained, and patients. The construction or use of self-care hostels make it easier to plan requirements. It is rec- at district hospitals and even health stations should ommended that more use be made of long-acting be considered for referred maternity patients requirpenicillin injections for routine infections, but in gen- ing more skilled care during delivery. Better and more eral oral therapy should be stressed both in health regular supervision should decrease the need for rouworker training and in public educational campaigns. tine referrals. The D M O should visit peripheral units It is strongly recommended that management regimens regularly enough to see non-emergency referrals at for each of the common problems seen in primary care the health stations, thus reducing the need for referunits be standardised nationally and made official ring them to hospital for a second opinion. Clear criMinistry of Health policy. They can then be em- teria for referral and directions for action would imbodied in a manual, and official alterations and ad- prove patient screening. In the case of antenatal care ditions can be made periodically (e.g. by annual these guidelines could be incorporated into personal updatings) and circulated to all health personnel. patient record cards. A referral form, to be sent with There is an urgent need to standardise malaria treat- patients, should be used. This could have a lower ment in particular, and there should be more strict tear-off portion to be returned to the health worker control over the use of chioroquine injections. The referring the patient with information on outcome, standardised management regimens should form the instructions on management on discharge, and genbasis of the drugs list for health stations and village eral advice or guidance about the condition for which health workers. It should also then be possible to the patient was referred. Such feedback to health calculate the approximate amounts of each drug workers provides very valuable inservice training. required annually for each unit, depending on the population served and morbidity patterns from out- (h) Communicable disease control patient returns. This should be used for budgeting All levels of the primary care system should be drug allocations for districts, and provide the guide- involved in the various activities focussing on communicable disease control. The district team responlines to district supervisors of the amount of drugs sible for communicable disease control should not required quarterly by each unit, thus facilitating the operate independently of the primary health care serflow of adequate supplies. It can also be used to convice but should be a supporting service to them. It trol expenditt,re on drugs, as each unit would have a should be responsible for organisation and coordinfinancial allocation. ation of immunisation programmes and special proMaterials and supplies for environmental sanitation grammes for the control of communicable diseases should be budgeted for and made available at the such as tuberculosis. One of the most important probdistrict level in much greater quantities than at lems to be solved will be the organisation of immunispresent. There should be a district store where supplies of cement and building materials, insecticides ation programmes. Once a primary health care pro-

Health needs and health services in rural Ghana

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gramme is operating through a network of village such a mobile team run from the district headworkers and health stations, and the population has quarters, which would also supervise the village been identified and is being contacted regularly, it health workers in the absence of a health station. should be possible to provide reoular immunisation For tuberculosis control, it is suggested that a services at selected delivery sites, villages or health specially trained health worker such as a health instations. The village health workers and health station spector or M F U technical officer be appointed at dispersonnel would be responsible for ensuring that trict level to coordinate and supervise the recording those in need of particular immunisations reach the system for the district, and to ensure that registers of delivery points at the appropriate time, while the re- all cases diagnosed are kept at the district headsponsibility for providin9 the immunisation services quarters and at all health units. He should see that should be divided between the district team and the peripheral health units are informed when a tubercuhealth stations, depending on the nature of the vac- losis patient is diagnosed and when he is discharged cine and its storage requirements. from the hospital. Supervision of treatment should be For example, Triple could be kept at health the responsibility of the health station, using the vilstations and immunisations given monthly or more lage health workers to provide close supervision and frequently, depending on the numbers identified as distribute drugs. requiring immunisations. When Triple is given on a The most essential objective is to ensure that conmass campaign basis, the necessary follow-up care is tinuous and regular treatment is actually taken by the not provided, and this leads to problems because of patients for the specified period of time. To do this the side effects from immunisation. successfully means that regimens should be as acceptMeasles vaccine, because of its particularly unstable able to the patients as possible, even if maximum characteristics and specific storage requirements, effectiveness of a regimen, in medical terms, has to be could be provided at less frequent intervals, say three- slightly reduced. Once weekly injections for the first monthly, at the same delivery points, brought there month are probably the maximum feasible to ensure by the district team shortly beforehand. In this case continuity of treatment. the district team would be responsible for collecting Supervisory visits from the D M O to the health the vaccine from the regional store and storing it in stations could provide an opportunity to review any district refrigerators for the shortest possible period patients causing concern to health workers or when before delivering it to the health stations when the decision to discontinue treatment is necessary. required for use, and when enough children can be There would be no necessity for patients to return to mustered for it to be used quickly. The district team the district hospital unless complications occurred, as should be responsible for maintaining the cold chain the health stations could send sputum specimens at from the Region to the delivery point and should regular intervals. Therapy should be standardised and supervise its use at the delivery centre. the regimen should be based on oral therapy as far as It is essential that the district immunisation pro- possible. gramme be properly coordinated; that all health The health stations should keep a register of all workers and the community are informed in advance tuberculosis patients in their area with details of their when and where immunisations will be available; that follow-up, reporting to the district tuberculosis officer vaccines are collected, stored and delivered to the ser- regularly on how many have been treated each month vice points at the appropriate times. The district team and their progress. The tuberculosis officer should would be responsible for the overall coordination and ensure that health units are supplied with adequate for the supervision of immunisation techniques car- amounts of the appropriate drugs. He should be reried out by health workers. sponsible for collecting sputum slides from patients They should ensure that each immunisation given and suspects sent by the health stations. Village is properly recorded on individuals' record cards and health workers should be taught the signs and sympbe responsible for the collection and collation of data toms of tuberculosis and should refer any suspects to from each area, interpreting these for the whole dis- the health station. They should be especially alerted trict and thereby monitoring geographical coverage. to look for eases among relatives and close associates They should also be responsible for the maintenance of known tuberculosis patients. of refrigerators at health stations, ensure that regular The district health team should also be responsible supplies of an adequate amount of kerosene are avail- for fire-fighting activities when outbreaks of commuable: they should carry spare parts on their regular nicable diseases occur, such as cholera. It should be visits, and ensure that all stations have such things as responsible for collecting and interpreting communicspare glasses, and supervise and train basic health able disease returns from each health station area, workers in refrigerator maintenance. and should closely monitor disease incidence in the The district team may also have t o be responsible district. It should also assist with the planning and for giving immunisations directly at selected delivery mounting of special educational and mass campaigns sites in those areas where health stations cannot be against specific diseases, to be implemented through provided or where health stations have not yet been all extension channels in the district. Other commudeveloped although village health programmes have nicable diseases would be dealt with primarily by the started. Indeed, it should be possible to use a mobile village health programme. Malaria, in particular, immunisation team visiting once a month, or two- could be dealt with by the prompt treatment of monthly, to which one or two other services such as fever, especially in children, and by malaria drug an MCH clinic are added, as the first phase towards prophylaxis. Sanitation and health education underthe implementation of a permanent health station. taken in the village would help to control the spread The village health programme could refer patients to of faecally borne diseases.

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IDS HEALTHGROUP 5. THE FINANCIAL RESOURCES FOR PRIMARY HEALTH CARE

Although there are imbalances in the distribution of resources in the health care system as a whole, between primary care and other types of health care, and also geographically, between regions, there are considerable misallocations within the primary care system at the institution level. Expenditure on drugs, dressings and stores is particularly high, and considerable savings could be made on this item of expenditure if more rational and controlled prescribing was introduced. The second largest item of expenditure is on personal emoluments, and here also there is scope for reallocation by reducing the misuse and underutilisation of manpower by the retraining and redeployment of existing staff. Recommendations in this area have been discussed above under Manpower and Training Requirements. Most striking is the lack of resources going to transport. It is apparent, therefore, that even without new resources, there is room for manoeuvre, and scope for financing the proposed new primary health care strategy by reallocating existing resources more effectively. New resources would be required for capital investment such as vehicles and new buildings (small health stations) and for initial training expenses both for basic training and for inservice training programmes for existing staff.*

(a) Resources required for proposed manpower structure The proposed new manpower structure of the health care system for manning the health stations could probably be financed within the existing personal emoluments allocation. An estimation of the numbers of basic health workers for Jasikan district, on the assumption that three basic health workers would be required for each 5000 population, gives a figure of around 115 health workers. At an average annual salary of ¢1500 (old rates) the total salary bill would be ¢172,500, a sum equivalent to about onefifth of the current district drugs budget. This compares with the sum of ¢128,700 spent on personal emoluments in Jasikan District for medical care alone in 1975/76 (excluding the hospitals). The inclusion of even one-quarter of the sum spent on salaries of environmental sanitation health workers (i.e. excluding labourers) would more than cover the requirements of the proposed manpower structure in that district. For less densely populated districts, however, the costs would be higher. Moreover, this figure does not include the district support team. Some of their salaries could be found within the existing personal emoluments budget, especially if hospitals are included, i.e. from existing district hospital budgets. It should also be remembered that if missions are to be integrated,

* Costs include the design and production of teaching materials, curriculum development and logistical support. The costs of training a health worker are far greater in the initial development phase than in the operational phase. v l-or a turtner aetalled mscuss~on, see the lanai secuon of Barnett et al., 1980. ++This is not necessarily a correct assumption. Revenue raised will automatically go to Treasury coffers and not to the Ministry of Health. Also, the costs of raising the revenue need to be offset against the income generated.

their resources would contribute to some of the required PHC needs, in the short term. But the projection of national resource requirements is not possible from our district-based data, and further preliminary costings are obviously required.

(b) The drugs budget Savings of up to 30% on the national drugs bill could be made if the recommendations are adopted to standardise drug regimens and control the use of drugs. This would mean a reduction in the total list of drugs, using cheaper alternatives and drugs sold under their generic names. The setting up of guidelines as to which drugs should be available at the various levels of health care, supervision of these guidelines, and control of allocations to the various units by the proposed district teams, would reduce opportunities for pilfering, as well as reduce the actual consumption of unnecessary, useless and expensive drugs. Control over drugs expenditure could also be exercised if drugs budgets were planned and administered at regional and district levels, so that careful monitoring of allocations and expenditures by individual units can be implemented. This would require some changes in the current stores system and should be regarded as a priority measure necessary for the successful implementation of the proposed primary health care strategy.'t The additional resources released by better control of drugs expenditures should be spent on transport and the support management system at the district level, and not channelled into hospital expenditure. Within the strategy to provide an adequate level of primary care to the majority of the rural population along the lines proposed in this report, there should be serious reconsideration of policy on the training of medical doctors in Ghana. Currently the medical schools have the capacity to produce 140 doctors per annum. Even allowing for wastage and for employment of substantial numbers of doctors at the proposed strengthened district level, there is a danger that there will be heavy pressures to employ more doctors in the hospital sector with the consequen: impact on recurrent expenditure. This impact couk swamp the savings made from appropriate manpower and drug usage, increasing the national imbalance ol resource allocation in the health sector and seriously inhibiting the successful implementation of the proposed primary health care strategy.

(c) New resources Whilst the most feasible way of financing the proposed primary health care programme will be through the reallocation of existing resources, there have been and continue to be pressures in the health sector for additional resources. Ways of raising revenue are being sought on the grounds that if revenue were raised more resources would be made available to the health sector for its use. + A project team has been set up by the Health Planning Unit tO examine ways of raising new revenue for the health care system in general, and the financing of the primary health care programme is also presumably included in its brief. The most important consideration, however, in finding new resources for the proposed primary care

Health needs and health services in rural Ghana strategy relates to the financing of the village health programme. It is recommended that drugs, training and supervision costs would be met by the Ministry of Health--and these should not be underestimated and should be adequately budgeted for, particularly in the supporting services of the district health team. The financing of village health workers by the community will be one of the most difficult problems to solve. In some instances workers will be part-time volunteers, particularly in small villages, but it is expected that some form of remuneration will be necessary in many larger villages with greater work loads. There are three possible sources of funds for that remuneration: the Ministry of Health, the District Councils, and the communities themselves. The proportional contribution from each will have to be nationally decided; at the very least it should not fall mainly on the communities. In Chapters 8 and 9 we described the difficulties likely to be experienced by communities in providing regular remuneration to village health workers. We would therefore propose that serious consideration be given to paying village health workers from the national or district health budget--a national cost equivalent to approximately 3°~, of the Ministry's current health budget. But, if there is to be a community share, it might come from an internal levy, some form of insurance scheme, or fees for service. Such fees should follow the same pattern as prevails at government health units. However. the introduction of a fee for service may create problems in that it encourages an emphasis on curative activities, while a levy may be difficult to implement. Further experience and experimentation may be necessary before final decisions are taken. If the District Medical Officer works in close collaboration with the District Council and also with the village Development Committees within the district, has control over the use of his Ministry of Health budget and is allowed some flexibility of decision-making within nationally agreed guide-lines, it should be possible to find workable solutions to these problems. Whatever solution is arrived at, it is important that methods of simple accounting and record-keeping at the local level be developed. In summary, it is essential for the overall success of the primary health care programme that budgeting be done at district level and that the district medical officer have resources under his control and be allowed some flexibility to respond to community needs and planning from below.

6. PHASING We do not underestimate the difficulties of implementing the strategy we have outlined. Which involves

493

radical structural changes in the Ministry of Health. Many problems will be encountered in the development of the village programme, but to translate the existing health care system structure, with its stock of manpower and buildings, into the model of health care described here is even more daunting. As far as the village programme is concerned, we discussed the phasing options in Chapter 10:5. We argued for the development of the village programme as a first priority, not to be held back by the inevital~le delays in building and staffing health stations, or in re-training existing health personnel. Also we recommended an initial phase whereby a "'small" package of activities is introduced for a large number of villages, perhaps using initially only part-time volunteers doing a few very simple tasks. Later, further training could be given to a selected number of suitable volunteers to become full-time village health workers. It is proposed that there be experimentation in different districts using alternative approaches, not only of mix of personnel but also using alternative phasing and timing of training programmes for the village health workers or part-time assistants. The re-training of health care system personnel also requires planning of its phasing. The most cost-effective way of improving the quality and range of health care by the health care system is by the re-training and re-deployment of existing personnel. This is therefore another priority. It will not be possible to achieve agreement to so fundamental a change without full involvement of representatives of the groups affected. This point cannot be over-emphasised. Moreover. it is important to synchronise such in-service training with the establishment of an improved support system, otherwise morale would be considerably lowered. The setting up of a team for planning the overall national programme is clearly the first priority, to be followed by the selection of a number of districts in which to initiate the programme, and the development of the district leadership teams. There are many factors which militate against the successful implementation of the kind of primary care system recommended here. Some of these we have. discussed in the body of the report, and also in this chapter. A well-functioning system of primary care depends on the existence of a public health approach. with the associated attitudes and behaviour patterns, among health workers at all levels, and of a management philosophy which rewards initiative and good work performance, and which provides a mechanism for those at the periphery (basic health workers and community) to participate in planning and decisionmaking. But its emergence is clearly contingent upon political commitment at the highest level, and upon changes in the distribution (and location) of power to translate such commitment into action.

APPENDIX

1: PRlMARY

A. TASKS EL RESOURCES

HEALTH

CARE

SERVICE

AND ORGANISATION

A P P E N D I X 1: A. P R I M A R Y H E A L T H CARE SERVICE T A S K S I. M A T E R N A L

CARE

Provide antenatal care for pregnant women involving: - - a minimum of one antenatal contact for all pregnant women - - a n average of three antenatal contacts for 60?/, of pregnancies - - t h e first antenatal contact to be during the first half of pregnancy. {a) Antenatal care ill Take a history to identify risk factors, particularly: - - t h e age of the mother (whether below 18 or above 40 years) --previous obstetric history (number of previous pregnancies: complications associated with, and outcome of, previous pregnanciesl --general health, especially chronic cough, shortness of breath, palpitations. Refer those patients with risk factors. Those with minor risk, e.g. healthy primigravida aged between 20 and 35 years should be encouraged to deliver at health unit. (21 Measure height and weight. Refer or take appropriate action if height below 145 eros in primigravida, or weight less than 40 kg by 20th week a n d o r rate of gain less than 1 kg/month (malnutrition) or more than 1½kg/month (risk of toxaemial. (3~ Check for anaemia, treat, and prevent by: --measurement of haemoglobin concentration by suitable method (to be done at least once during pregnancyl* --clinical examination (conjunctiva. palms of hands, mouth--to be done at every visit) --routine administration of oral iron preparation in appropriate dosage --referring severe cases or cases not responding to iron therapy. (4t Look for toxaemia of pregnancy by: ---examination of ankles and fingers for oedema --examining urine for protein* --checking blood pressure.* (5) Give tetanus vaccine to unimmunised mothers (at least two doses, at least one month apart).* (6) Give tablets for malaria prophylaxis. t71 Give advice on the following topics: --diet in pregnancy, importance of hygiene at delivery, minor complaints and danger signs, care of the newborn (especially cord caret, nutrition of older children, and family planning. 181 Examine abdomen after 7-8 months, to check presentation, position and lie of baby.* (91 Treat infections and minor conditions arising during pregnancy and refer any abnormality or serious disease. (10! Keep register of risk cases or separately identify cards of patients at risk for special care and follow up. Keep register of patients referred and reasons for referral. (bl Delirery care

Supervise all births either directly or through trained TBAs. I 11 Monitor progress in labour and compare with normal progress; use of labour charts.* {21 Look for signs of complications: e.g. foetal distress, bleeding, obstruction. 13~ Ensure cleanliness and aseptic technique during delivery (scrub up, sterilise instruments, keep delivery room cleanl. 14~ Care of newborn: ensure normal respiration, aseptic cutting and care of cord. (5! Extract placenta, control bleeding (by use of ergometrine if necessaryk check perineum.* Train TBAs in appropriate techniques (providing suitable materials, e.g. soap and scissors) and to look for signs of complications requiring referral.*

* Actions which are asterisked are those which normally require a trained worker from the health system (this refers only to Appendix lAI. All other tasks could be performed by a simply trained person from the community. 495

496

IDS HEALTHGROUP

(c) Postnatal care One postnatal contact at home or in clinic. Check condition of mother and child by: ---examining mother for fever, bleeding, tenderness of abdomen, and check size of uterus, breasts and nipples ----examining baby: cord, weight, ask about feeding problems --advising on care of child and family planning, supplying contraceptives when required.

(d) Family planning care (1) Advise community of advantages of family spacing and discuss methods. (2) Supply contraceptives and monitor health of acceptors on pill or with intrauterine devices.

2. CHILD CARE Supervise health of all children under 5 years, involving a minimum of four contacts annually during the first and second years, and two visits annually thereafter. (a) Promotion of nutrition (1) Liaise with extension workers in agriculture and community development to encourage appropriate methods of improving food production, animal rearing, farming, and vegetable growing. (2) Give nutrition education to mothers in homes, villages and clinic, and promote nutrition through community organisations, such as women's clubs and day-care nurseries. Advice on feeding children to include the following: --supplementary feeding to begin at 4-6 months of age --meals not less than 3 times daily --use of appropriate nutritious local foods which are cheap, rather than imported or expensive foods --demonstration of preparation of weaning foods - - h o w to feed sick children --advice on breast feeding. (3) Weigh children regularly and monitor growth by use of weight charts. Identify children at risk and those with inadequate weight gain. Give them special care, e.g. by home visits and extra time on health education of mother: find out reasons for poor growth patterns. Give support and assistance to the families, e.g. food supplements, and/or help with initiating home improvements or food production. If necessary, involve other government sectors in tackling community nutrition problems identified in this way.

(b) Primary prevention of infectious diseases (1) Give immunisations, using an appropriate schedule, against tuberculosis: smallpox: diphtheria, pertussis and tetanus (triple vaccine): poliomyelitis: and measles.* (2) Provide drug prophylaxis of malaria according to an appropriate schedule.

(c) Management of childhood infections (1) Integrate preventive and curative care, by ensuring that children seen at check-up visits are given treatment for intercurrent infections when necessary: that malnourished children seen at home or in the clinic are treated for their almost certain infections: and that curative visits to clinics are used to check nutritional status and to give health and nutrition education. (2) Use standardised regimes for the management of childhood infections, at least for the three common priority symptomatic groups: diarrhoea (frequent watery stools): non-specific fever (presumed to be malaria): cough and fever (respiratory infection). For child with fever: - - t a k e temperature - - i f temperature high. tepid sponge - - l o o k for signs of respiratory distress and cyanosis: examine chest* ---examine ears and throat for infection* - - i f no sign of respiratory infection found, treat with oral chloroquine unless complications (vomiting, fits, very high fever) - - i f respiratory infection found, use antibiotic therapy plus oral chloroquine. For child under 6 months with cough, use antibiotic therapy. For child with diarrhoea: - - l o o k for signs of dehydration --use standardised criteria for therapeutic response, according to degree of dehydration

Health needs and health services in rural Ghana

497

- - o r a l rehydration to be most important part of management, using locally prepared water/sugar/salt solution --antibiotics not to be used unless signs suggesting systemic infection. 3. P O L Y C L I N I C C A R E t

Diagnose and treat those coming to a clinic with complaint of illness. In the absence of defined management regimes laid down in Ghana, it was not considered feasible to list the tasks to be performed for each of the common diseases shown in Table A1. Instead, general principles of consultation practice are specified. ( l ) Take careful history. Room should be quiet and relatively private so that patient is encouraged to talk, and is able to sit down; health worker should be sympathetic; consultation should not take place over a window hatch, through a doorway or even across a table, all of which inhibit communication. Questions asked should follow a line of reasoning according to patients' answers; symptoms of prevalent diseases should be asked about if they are suggested by the initial complaint; usually at least three questions pertinent to the presenting symptom(s) will be needed: the duration of the symptom(s) must always be determined. [2i Examine all patients. Some examination should be carried out on all patients, even if only by looking; usually touching and the use of a clinical instrument are needed as well. In general, with complaints of: --fever, take temperature --diarrhoea in children, examine for dehydration --rashes or other skin complaints, inspect whole body --tiredness or palpitations, examine conjunctiva, mouth and palms for pallor --sick child with fever, examine throat, ears and chest* --cough and fever, examine chest for signs of difficult breathing.* (3t Give proper treatment. This means that: - - t h e cheapest drug effective for the patient's condition is given - - i t is administered by the most appropriate route for the condition and age of patient - - i t is given in the correct dosage for the age of patient and for the correct period of time - - n o unnecessary or useless drugs are prescribed. [4) If injections are given, sterilise needles and syringes properly and re-sterilise needles after a single use.* 151 Give advice on: - - t h e treatment, how often to take it and how much, etc. --when to return to clinic and what to do if complications occur - - h o m e nursing --prevention of the condition. (6} Referral of severe or complex illnesses: --use standardised criteria for referral --send letter or form with patient - - k e e p register of patients referred. (71 Organise clinics* to ensure: --adequate waiting space and seating for patients --toilets and drinking water for patients --minimum waiting time --regular screening of waiting patients to identify early the very sick ----efficient lines of flow between the different stations of the clinic --adequate consultation time per patient - - p r o p e r sterilisation and care of equipment --adequate supplies of essential drugs, ----cleanliness and washing facilities for health workers in all rooms where patients are examined, wounds are dressed, and injections given.

+ This section should be taken in conjunction with the preceding sub-section 2 (c) on Management of childhood infections. .+See IDS. 1978b: p. 18.

498

IDS HEALTH G~OUP

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4. ENVIRONMENTAL SANITATION (HEALTH CARE SERVICE TASKS)

(11 Motivate and support community and individual actions: --give health education (through community meetings and discussions: home visits; clinic visits*) --identify problems and suggest appropriate technical solutions --generate and provide assistance to projects carried out by community - - a c t as liaison for assistance from other agencies. 121 Inspect markets, bars, refuse tips and public latrines regularly, and carry out house to house visits: supervise those responsible for public cleanliness te.g. sanitary workers; communal labour for clearing weeds, drains, sweeping markets, etc.).* (31 Carry out spraying operations or special actions for insect or pest control.* (4) Report special sanitation hazards to appropriate authority responsible for remedial action. (51 Follow up cases of communicable disease in villages; prevent spread of disease by appropriate actions; find and report new cases. 5. SPECIFIC C O M M U N I C A B L E DISEASE C O N T R O L

Tasks will vary according to whether or not there is a special control programme in existence. The following is a check list of possible tasks in relation to priority communicable diseases identified in Ghana (Table A 1).

(a) Recognition and treatment of cases (1) Provide accessible and regular polyclinic services capable of early diagnosis. (2) Apply appropriate treatment regime; use case registers to maintain continuity of care and follow up. (3) Examine contacts of infected persons (visits to villages, schools, etc.) especially for tuberculosis and yaws. (4) Institute findings of new cases by : --regular screening of groups at risk for a particular communicable disease --health education on symptoms and to encourage people to seek treatment early ----clinical examinations/laboratory tests (e.g. blood tests for malaria on fever cases or sputum smears for tuberculosis).* (b) Primary pret'ention in indiciduals (1) Give BCG vaccine to children under 15 years, including newborn babies.* (2) Give regular drug prophylaxis of malaria to children under five years and pregnant women. (c) Enrironmental actions, and promotion of community and personal actions (1) Malaria: --clear mosquito breeding places round houses (fill in swamps, ponds, ditches; clear pots and cans, bush, etc.) - - s p r a y houses and stagnant water - - p r o m o t i o n of drug prophylaxis. (2) Tuberculosis: --improve housing (reduce overcrowding, improve ventilation) --improve nutritional status --give health education relevant to case finding and case volunteering. (3) Yaws: --provide adequate water for washing --give health education on personal hygiene (especially of children) and for case finding and case volunteering.

B. RESOURCES A N D O R G A N I S A T I O N t I. PROVISION O F SERVICES

1.1. Polyclinic care to be provided daily [emergency care at all timesl. 1.2. Antenatal care to be available a minimum of once weekly.* 1.3. Delivery care to be given by trained midwives to mothers with minor degree of risk, and trained and supervised TBAs to perform normal deliveries, 1.4. Child care to be provided daily, both preventive and curative, and special clinics to supervise growth of otherwise healthy children to be held a minimum o f once weekly.* 1.5. Satellite clinics to be held in surrounding villages for MCH care and polyclinic.* 1.6. Home visiting for MCH and environmental sanitation to be carried out in main town and in surrounding villages. 1.7. Immunisation to be provided with BCG, triple, poliomyelitis, smallpox and measles vaccines a minimum of twice monthly.* 1.8. Individual appropriate health education to be given at all consultations. 1.9. Group health education discussions to be held at health unit weekly and/or weekly in surrounding villages. 1.10.Family planning services to be provided a minimum of once monthly.* 1.11.Environmental sanitation services to be provided in the town and surrounding villages. 2. H E A L T H UNITS

2.1. 2.2. 2.3. 2.4. 2.5.

The health unit to be appropriately sited (i.e. close to main population centre}, Buildings to provide adequate space for all activities of the health unit, including adequate waiting areas. To provide private quiet room for consultations, especially for general polyclinic and antenatal care. Design of building to allow efficient lines of flow between clinic stations. The number of beds for maternity to be adequate for the number of deliveries per month {approximately 6 beds per 30 deliveries per monthl. 2.6. An adequate volume of water to be available at an acceptable level of purity. 2.7. Handwashing facilities to be available in rooms used for consultations, injections, dressings and in labour ward. 2.8. Adequate seating, latrines and drinking water for patients. 2.9. Buildings to be clean and in good repair. 2.10.Drug stores to be kept tidy and stock records of drugs properly maintained. 3. SUPPLIES AND EQUIPMENT There should be adequate provision of: 3 1 Essential drugs + 3.2. Vaccines (triple, BCG. tetanus toxoid, measles, poliomyelitis, smallpoxl. 3.3. Refrigerators (maintained in working orderl. 3.4. Syringes and needles (appropriate for the numbers of patients requiring injections daily). 3.5. Sterilisation facilities and fuel to enable instruments to be boiled as often as necessary. 3.6. The following equipment to be present and in working order: thermometers, tongue depressors, torches, sphygmomanometers, scales for adults and children, stethoscopes, equipment for measuring haemoglobin (with more accuracy than Talquist blotting paper methodl. 3.7. Materials for environmental sanitation te,g. building materials, insecticides, soap, etcl. 4. T R A N S P O R T

4.1. 4.2. 4.3. 4.4. 4.5.

Vehicles to be provided as appropriate to the level of unit and its functions. Vehicles to be maintained and serx;iced regularly, and log books kept. Facilities for vehicle servicing to be available within the district and spare parts to be readily obtainable. Adequate allocation of funds for running costs of vehicles. Where staff are expected to use own vehicle or public transport to carry out their work, there should be an efficient system for reimbursing travel claims and provision of loans for the purchase of vehicles.

* Denotes items which ~,ould require modification if applied to a model of health care different from the current Ghanaian system tthis applies throughout Appendix lBI. + This list includes a number of items which may not be applicable in an alternative delivery system.* ~.See IDS, 1978b: p. 18 503

504

IDS HEALTHGROUP

4.6. Transport should be available for supporting environmental sanitation projects and for communicable disease control follow-up. 5. HEALTH PERSONNEL 5.1. They should be skilled in: --general curative care --maternity care ---child care --environmental sanitation ---community development. 5.2. Half of the total personnel time should be spent on preventive activities and half the working time should be spent outside the health unit, one-third of this in surrounding villages. 5.3. Health workers to work a minimum of 6 hours daily.* 5.4. Health workers to perform tasks appropriate to level of skill and training. 5.5. Health workers to be fully employed in useful activities during working time. 5.6. Health workers to receive in-service training at least every five years.* 5.7. Health workers should work as a team, co-operating with each other and co-ordinating activities. 5.8. Staff meetings to be held a minimum of monthly for all health workers in team. 5.9. Health workers should have job satisfaction. 6. SUPERVISION

6.1. Personnel to be supervised in the field by appropriate health workers at a minimum of two-monthly intervals.* 6.2. Supervisors should spend some of the time carrying out normal tasks with health workers, as well as dealing with problems and seeing referrals. 6.3. There should be meetings every 2-3 months involving a health unit's workers, their supervisors and staff from other units.* 6.4. Health workers should receive feedback information on referred patients and have opportunity to discuss the cases with the supervisors. 7. REFERRAL

7.1. Referral consultations for non-emergencies should be available once a week at the unit (as part of a supervisory visit) or within an hour's travel time elsewhere. 7.2. Emergency referral and transport facilities should exist to get patients to hospital in less than 3 hours: transport should be at no more than reasonable cost to patient. 7.3. There should be standard criteria for referral from antenatal, child and general clinics. 7.4. A letter or form should be sent with all referred patients. 7.5. Records of referred patients should be kept at the health unit, registering reasons for referral. 8. ORGANISATION OF CLINICS+ 8.1. Curative and preventive care for children under 5 years to be integrated, and continuity of care to be provided. 8.2. Antenatal and child care to be integrated to at least some degree. 8.3. MCH clinics to be held at a convenient time for community (e.g. on market days). 8.4. There should be enough time for adequate history taking and examination (not less than five minutes for polyclinic care) and for health education. 8.5. Screening of patients to be carried out at busy clinics so that more time can be given by senior qualified staff to the more sick patients. 8.6. Very sick children to be identified by screening mechanism soon after mother arrives at clinic. 8.7. Referral within the health unit between different types of clinic and health workers to be effective and efficient. 8.8. For antenatal care, history taking and examination to be performed by person responsible for giving advice. 8.9. At MCH clinics, health education to be important component of consultation (one-third of consultation time at least), even when it is primarily for curative care.

* Some items apply even when patient contacts are organised outside of a clinic setting.

Health needs and health services in rural Ghana

505

9. R E C O R D KEEPING

9.1. Records should be kept which provide information on the following: --the villages and total population served by the health unit --the numbers of people utilising the different services --the work load of the unit te.g. the number of attendances or contacts, home visits, immunisations performed) --morbidity lattendance by major disease category, incidence of specific communicable diseases) --village of origin of cases of some specific communicable diseases --vital statistics --patients referred and reasons for referral. 9.2. The system of records used for individual patients should facilitate continuity of care for: ----children under 5 years --pregnant women --patients with chronic or communicable diseases. 9.3. Registers should be kept to indicate individuals at risk, needing special care and follow up. 9.4. The system should: --require a minimum of staff time --provide accurate data --not inconvenience patients by long waits at registration stations --minimise loss of individual patient cards. 10. SPECIFIC O R G A N I S A T 1 O N O F C O M M U N I C A B L E DISEASE C O N T R O L P R O G R A M M E S

10.1.There should be a special register of tuberculosis patients showing: --the dates when patients were first diagnosed --when patients first started receiving treatment from health unit -----drugs given and progress of patient at each visit --the frequency and regularity of treatment given over a period of time --patients who have not returned for treatment and therefore require follow up. 10.2.Contacts of tuberculosis cases should be followed up in the community. 10.3.Yaws and measles cases should be recorded by village of origin on diagnosis. 10.4.MFU (or person designated responsible for follow up) should be routinely informed of all yaws and measles cases.* 10.5.Local increase in incidence of specific diseases should be followed up by defined action. I1. C O M M U N I T Y P A R T I C I P A T I O N . AND C O - O R D I N A T I O N WITH O T H E R D E V E L O P M E N T W O R K E R S

l l.l.There should be active involvement of the community in the planning and implementation of health activities in the following ways: --participation in decision making and planning of health programmes by local community leaders; this' will involve consultations and regular meetings with village development committees, etc. --periodic community health projects involving special levies raised by village leadership and/or communal labour --active involvement of health personnel in community activities, e.g. in women's groups, day care nurseries, district and local committees ---co-operation and liaison between health personnel and traditional practitioners, especially TBAs who should be supervised, trained and supported in the community. 11.2.There should be liaison between health personnel and extension workers in other sectors.

APPENDIX

2: CRITERIA

OF EFFECTIVENESS

A P P E N D I X 2: CRITERIA

OF

EFFECTIVENESS

1. RANGE OF SERVICES PROVIDED SCORE

(1) (1) (1) (1) (1)

11) Polyclinic services available more than three times weekly. (2) Antenatal services provided a minimum of once weekly. (3) Maternity delivery care provided. (41 TBAs trained and supervised in area. (5) Child health clinics held a minimum of once weekly. (6) Maternal and child care provided daily: ---daily antenatal clinic = (1) ---daily child clinic = (1). total=

(2)

total =

(6) (1) (1) (1)

(7) Satellite clinics held for: ----child care } --antenatal care --polyclinic care.

score (1) for each clinic held up to maximum of 2 points for each type of clinic

(8) MCH home viming carried out. (9) Home visiting carried out outside main town where health facility situated. (10) One third or more of total MCH care contacts take place in surrounding villages. (11 ) Immunisations: at least two kinds of immunisation have been given by health unit in past year. (12) Health education provided for individuals during: --polyclinic care } ----child care --antenatal care.

(1)

(1)

two out of the three =

113) Health education sessions: - - g r o u p talks/discussion held at health unit minimum of once weekly, and/or \ - - g r o u p talks held in villages minimum of once weekly, J

(1) (1)

(14) Family planning services available a minimum of once monthly. (15) Environmental sanitation services provided: - - i n main town - - i n surrounding villages.

(Not scored*) Maximum score 20

2. INDICATORS OF UTILISATION AND COVERAGE OF MCH SERVICES

(No scores used--data are presented in the text using these indicators as target objectives.t) (a) Maternity serrices

(1) (2) (3) (4)

More than 60% of pregnancies receive a minimum of one antenatal contact. Average number of antenatal visits is 3 or more. Half of births supervised by trained personnel:l: Less than 20% attenders at antenatal clinic first register during last trimester.

* No scores were used for these criteria because of difficulties in assessing how far services were provided in surrounding villages or when services were not provided by the health facility (see text). t- There were not enough differences between units to make scoring a worthwhile exercise. The overall results from all units are presented in the text. + Can include trained TBAs if number of births they attend are recorded. 507

508

IDS HEALTHGROUP

(b) Child serrices (1) More than 60°0 children under 5 years * in area seen at least once in past year. (2) One third or more of total child care contacts are for children over the age of 1 year. (3) Average number of attendances per child registered for more than one year is four or more per year. 14) Less than 20°0 children visit clinic once only. (5) More than 20°o children immunised with BCG and measles vaccines and at least two doses of triple and poliomyelitis vaccines. (6) BCG vaccine given to more than 50°. of new registrations. 3. CHILD CARE

(a) Nutritional screeniny (1) Children weighed accuratelyi': scales checked before clinic. (2) Weight charts: --used } --filled in correctly --referred to by health worker during consultation.

(2)

all three criteria

(3) Unsatisfactory weight gain picked up (whether using chart or plain card) in 80°o of cases seen. (4) Reasons for unsatisfactory weight gain discussed with mother. (5) Mother understands what weight chart means.

(2)

(Not scored) (2) (Not scored)

(b) Nutrition and health education (1) To individuals (in clinic or on home visit): - - m o r e than half consultation time spent on health education ---correct information given all four criteria = --relevant information given --attitude of health worker sympathetic. (2) In groups: ~sessions held at each child clinic or regularly with groups of mothers in village --subjects taught in past 3 months included advice on care and prevention of three major health problems (usually malnutrition, fevers, diarrhoea) --demonstration of preparation of weaning foods given.

(2)

(1) (1) (1)

(3) Nutrition advice given to individuals or in groups includes the following: --weaning foods to be introduced at 4--6 months of age ~ l o c a l cheap foods advised --information on food production given --feed small children a minimum of three times daily. (4) Mothers told how to care for sick child tsponging, fluids, feeding advice, etc.) (c) General (1) Malaria drug prophylaxis given to approximately 80°0 of children under 5 years attending c!,r:ic or by routine distribution in village. (2) Oral rehydration part of management of diarrhoea. (3) Some examination made of sick child. (4) Child with complaint of fever has temperature taken. 15) Child with high fever in clinic given sponging. (6) Oral chloroquine prescribed for uncomplicated cases of non-specific fever.

(2) (2) (2) (2) (2)

~2)

12) (2) ll) (Not scored) (Not scored) Maximum score 28

(d) Clinic organisational efficiency (Not scot,:.! f..r individual units: used as check list.l (11 Mothers spend on average less than 3 hours in health unit. (2) Systematic line of flow avoiding major congestion: orderly queues. * The age group of under 3 years would cater for most of the children specially at risk. but census data were not available to estimate number of such children in catchment area: the latter, was taken to be a 4-mile radius round health units. + All children except those already ~eighed in present mot. h,

Health needs and health services in rural Ghana

509

(3) Registration procedures take up less than a quarter of staff time. (4) No duplication of child's records. (5) Cards of children at risk separately identified and noted for follow up. (6) All children under 3 years attending child clinic to be seen by CHN and have nutritional status assessed by weighing. (7) Sick children seen in a general clinic (on days when no child clinic is available) are to have nutritional status assessed: mothers to be given health education and nutritional advice as indicated. (8) At least one sick child to have been referred to health unit superintendent in past month. 4. MATERNALCARE

(a) Quality of antenatal care First visit (1) In-depth questioning about previous pregnancies: --whether deliveries normal --whether the following specifically asked about: stillbirths, haemorrhage/retained placenta, duration of labour, problems in pregnancy. (2) Height measurement in primipara, or pelvic assessment, or referral to hospital or senior midwife. (3) Haemoglobin estimation (except by Talquist method). (4) Some action taken on mothers identified as at risk.

(2) (1) {1) (Not scored)

Return visits (1) Weighing: --mother weighed on this and previous visit ) --health worker knows what is normal weight ~ both criteria = gain in pregnancy. (2) Conjunctiva examined. (3) Examination of: --ankles for oedema ) - - u r i n e for protein l --blood pressure.

(1) (2)

two out of the three criteria =

(4) Iron therapy given routinely. (5) Tetanus immunisation given to more than 80°0 of mothers. (6) Malaria drug prophylaxis given to more than 80°0 of mothers. (7) Individual health education given to more than half the mothers and not less than a third of consultation time spent on health education. (8) Group health education :* - - m o r e than three women ask questions or comment --includes use of visual aids.

(1) (1) (2) (2)

(Not scored)

(9) Topics covered in group or individual health education are relevant.+ (10) Family planning discussed either individually or in group. (11) At least one sick mother referred for polyclinic care in past month. (12) Low referral rate for labour referrals and high for antenatal referrals.

* Where there are 10 or more mothers at any one time. Topics relevant for antenatal health education: --diet in pregnancy --minor complaints and distinction from danger signs --childhood nutrition for weaned toddler --hygiene at delivery ---care of the cord.

(2)

any three out of the five = (1)

(I) (2) (Not scored) (Not scored)

510

IDS HEALTHGROUP

(13) Less than a third of referrals in labour related to risk situations which could have been identified during antenatal care.*

(Not scored) Maximum score 18

(b) Organisation of maternal care (Not scored for individual units; used as check list.) (1) Antenatal consultation in quiet room. (2) History taking and physical examination performed by same person as giving advice. (3) Risk register kept, or antenatal cards of mothers at risk separately identified. (4) Antenatal records used at the time of admission for delivery. (5) Delivery room: --clean --instruments ready for next delivery. (6) TBAs in area have been contacted/trained/supervised. 5. POLYCLINIC CARE (a) Quality of care History taking (I) Three questions or more about initial complaint put to more than half the patients. (2) Sympathetic attitude by health worker.

(2) (2)

Examinations (1) Some examination carried out on more than half the patients. (2) For complaints of fever, temperature taken. (3) For "diarrhoea", patient examined for dehydration; for "rashes" or skin complaints, whole body inspected; for "tiredness", conjunctiva/mouth exam- two out of the four criteria ined for anaemia; for pyrexial child, throat and ears examined. Treatment (1) Drugs prescribed effective for probable condition. (2) Correct doses for age of patient. (3) Correct duration of treatment. (4) Diarrhoea in children normally treated by oral rehydration. (5) Unnecessary drugs not given. (6) Drugs not given by injection when oral treatment appropriate. (7) Expensive preparations not given when cheaper drug effective. (8) Injection needles resterilized before next patient. (9) Sterilisation of syringes and needles satisfactory. riO) Health education given. (b) E O~ciency of clinic organisation (Not scored for individual units; used as checklist.) (1) Patients spend on average less than two hours in health unit. (2) Orderly queues. (3) Adequate seating. (4) Mechanism whereby sick patient (especially child) can be seen quickly.

* Risk situations which could have been identified at antenatal clinics: --high parity --anaemia --history of stillbirths --history of prematurity --previous Caesarian section --pre-cclampsia --malprescntation --twins. t Not enough children with diarrhoea observed.

(2) (2) (2)

(2) (2) (2) (Not scored)'[" (1) (2) (2) (2) (2) (2) Maximum score 27

Health needs and health services in rural Ghana

511

(5) Average consultation time 5 minutes or more. 16t Referred patients given accompanying letter or form. 17/Less than 2°,, patients" cards lost by patients or clerks per day. (81 One person-day or less spent on registration per 100 patients.

6. ENVIRONMENTALSANITATION (1) Satisfactory group teaching session observed, with active involvement of participants. (2) Satisfactory home visit observed with:

(1)

---explanation of reasons for actions --practical advice --correct information --particularly relevant information --understanding of problems of implementation --knowledge of costs involved.

(1) (1) (1) (1) (1) (1)

13) Health inspector or assistant involved during previous year in a sanitation project using communal labour. (4) Health inspector or assistant involved in water supply improvement in previous year. (5) Observations in village show:

(1) 11)

--village clean and tidy --refuse control satisfactory --latrines kept clean.

(1) (1) (1)

(6) No complaints from health inspector or assistant about village cooperation. (7) Insect control:

(1)

--treatment of stagnant water --health education. (8) Water supply in villages supervised by health inspector or assistant considered be safe. (9) Sanitation hazards reported. (10) Specific communicable disease control:

(1) (1) to

--case finding on home visits --contact tracing.

(1) (Not

scored)

(1) (1) M a x i m u m score 18

7. ASSESSMENT OF RESOURCE INPUTS

(a) Physical facilities

(1) Adequate space for all activities carried out at unit. (2) Quiet room available for polyclinic and ante- t both criteria = natal consultations. (3) Design of building: --allows functional lines of flow ) --adequate waiting area for patients ~ --adequate seating available.

all three criteria =

(1) (1)

(l)

(4) For maternity care: - - a t least about 6 beds/30 deliveries per month } --housing available for midwife at flnit.

both criteria =

(1)

151 Water supply: --adequate volume --satisfactory purity. (61 Hand washing facilities available for all of the following: consulting/examinations, injections, dressings, labour ward. (71 State of repair of buildings satisfactory. 18) Cleanliness satisfactory. 191 Access to telephone.

(1) (1) (1) (1) (1) (1) M a x i m u m score I 0

512

IDS HEALTHGROUP

(b) Supplies and equipment (1) Essential drugs available.* (2) At least two of following vaccines available: triple, BCG, tetanus toxoid, measles, poliomyelitis. (3) Refrigerator in working order. (4) Adequate supply of syringes and needles (minimum of 20 needles). (5) Adequate facilities for sterilisation of instruments (functioning stove, fuel available). (6) Equipment available and in working order:

--thermometers t --spatulas --sphygmomanometers --scales (child) --scales (adult) --stethoscopes.

three out of the six =

(I) (I) (I) (I) (I)

(1)

(7) Adequate supplies for environmental sanitation: --disinfectants } --insecticides --cement/latrine boards --sprayers.

two out of the four =

(I) Maximum score 7

(c) Transport (1) MOH 4-wheeled vehicle supplied.? (2) Vehicle in working order:

(I)

- - a t time of visit ~ --for more than eight months in past year. /

both criteria =

(I)

(3) Maintenance and repairs: --facilities within about 50 miles --spare parts can be obtained within two months.

/

both criteria =

(1) Maximum score 3

(d) Referral facilities (1) Second opinion available for non-emergencies either weekly at health unit or within an hour's travel elsewhere. (2) Emergency referral and transport facilities exist to get patient to hospital in less than 3 hours. (3) Emergency transport to hospital costs patients on average less than a week's usual income.

(I) (I) (Not scored) Maximum score 2

(e) Staffin# quantity (1) Qualified staff include:

- - H C S or trained QRN or dresser --mid wife - - C H N or enrolled nurse trained in child health --health inspector or HIA. (2) Average staff time worked per day is 6 hours or more. (3) More than a third of total staff time spent on preventive activities. (4) Average number of working days per month away from job by qualified staff member is 2 or less in past 6 months.

(1) ( 1) (1) (1) 11) (1) (1) Maximum score 7

* See IDS, 1978b: p. 18. t Alternatives are a car, motorcycle or bicycle(s) owned and used for health work by at least one staff member.

Health needs and health services in rural Ghana

513

( f ) Staffing quality (1) Staff not normally carrying out tasks inappropriate to level of training :* - - H C S , Q R N or SRN --midwives, enrolled nurses, dressers. CHNs --orderlies. ward attendants.

(I) (I) (1)

(2) If staff carrying out tasks without formal training, inservice instruction has been g~ven. (3) At least one qualified staff member has had inservice training during past 5 years. (4} Evidence of team work ; staff co-operate with each other, 151 No gross dissatisfaction amongst particular individuals or types of health worker.

(1) ll) (1) (1) Maximum score 7

(g) Supervision (1) Doctor visited in last two months. (2) Other professional supervisor le.g. Area PHN, health inspector} visited in past two months. (3) Health unit staff informed of outcome of referred patients.

(I) (I) (I) Maximum score 3

8. CRITERIA FOIl ORGANISATIONAL EFFICIENCY+ (a) Physical facilities (1} Unit sited within 15 minutes walking distance of town centre or market (or more than 10,000 people living within an hour's walk if unit not in a town). (2) Health unit clean. (3) Store: - - k e p t tidy ~ --stock record up to date. 1

both criteria

(I) (I)

(1) Maximum score 3

(b) Transport (1) Management of vehicles: --serviced regularly (minimum 3-monthlyt "~ J - - l o g book kept.

both criteria

(2) Efficient system for reimbursing staff for travel expenses (no complaints from health staff). (c) Staffing (1) Staff normally carry out tasks appropriate to training.* (2) If staff perform tasks without formal training, they have had special inservice instruction. (3) Staff do not spend more than a quarter of working time idle. (4) Average working day 6 hours or more. (5) Staff meetings held at least once a month.

(1)

(1) Maximum score 2

(1) (1) (1) (1) (1) Maximum score 5

(dl Supervision (1) Minimum of a 2-monthly meeting held between supervisors and: - - H C S (or equivalent} ] --CHNs l --midwives - - H I A or health inspector.

two out of the four categories

(1}

* Broad tasks appropriate to level of training of different categories of staff: la) HCS, QRN. staff nurse or dresser: consultations, including examination and treatment of general outpatients: overall administration and supervision of health unit. (b) Enrolled Nurse: assisting HCS or QRN. including screening patients and giving prescribed treatment and injections. (ct CHN : child health, antenatal care and treatment of minor complaints in children under supervision of HCS. (d} Midwives: antenatal care, deliveries and treatment of minor complaints in mothers under supervision of HCS. + See text for method of scoring and how these criteria are used.

514

IDS HEALTHGROUP

(2) In-service training provided in past 5 years for one of the following (excluding those who completed training in last 5 years): - - H C S (or equivalent) --~CHN --midwife --health officer.

(1) Maximum score 2

(e) Organisation of clinics

(1) Curative and preventive child care integrated (sick children get preventive care). (2) Antenatal and child care provided on same day. (3) MCH clinics held on market day.

(1) (1) (1) Maximum score 3

( f ) Records

(1) Information available about population served. (2) Information available about villages served. (3) Records provide following information about:

(1) (1)

--number of people using the unit daily --number of people reached by different types of service over a year --geographic origin of patients; staff know which villages are high or low users.

(1) (1) (1)

(4) The system aids continuity of care and identification of risk for: ----children under 5 years --pregnant women --patients with communicable or chronic diseases.

(1) (1) (1)

(5) Some vital statistics are collected in catchment area. (6) Outpatient records system: --requires less than a person-day per 100 outpatients --loses less than 2~ patients' cards, j'

(Not scored)

both criteria =

(1) Maximum score 9

(g) Referral

(1) Standard criteria for referral in: --antenatal care } ---child care --polyclinic care.

two out of the three =

(2) Referred maternity and polyclinic patients take a letter or form with them. (3) Record of maternity and polyclinic referrals kept. (4) Health staff routinely informed of outcome of referred patients.

(1) (1) (1) (1) Maximum score 4

(h) Organisation of specific communicable disease control

(1) Register of tuberculosis patients kept; records show number continuing regular treatment. (2) 80~o of tuberculosis cases diagnosed in past 18 months are still continuing treatment. (3) When case of tuberculosis diagnosed, procedure initiated to follow up contacts. (4) Yaws cases: --recorded by village of origin / - - M F U informed,

(1) (1) (1)

both criteria =

(1)

both criteria =

(I)

1

(5) Measles cases: --recorded by village of origin - - M F U informed,

(6) Malaria control programme in area undertakes: --spraying, and/or ---drug prophylaxis for pregnant women and children under 5 years.

(I) Maximum score 6

Health needs and health services in rural Ghana

515

{i) Community participation and inputs from other sectors

(1) Health staff involved in community activities on a regular basis {women's groups, village development committees, project committees, district or local councilst. (21 Active involvement of community members in health unit activities. 13t Community leaders take part in decision making about health programmes. {4~ Communal labour undertaken. {51 Special levy contributed by people for a health project. [61 Liaison between health unit staff and TBAs and/or traditional practitioners. [7) Liaison between health unit staff and extension workers from other sectors on health-related activities.

"(1) Maximum score 7

BIBLIOGRAPHY Ampofo D. A. Stillbirth and its prevention in Ghana. Ghana Med. d. 10, 23, 1971. Barnett A., Creese A. and Ayivor E. C. K. The economics of pharmaceutical policy in Ghana. Int. d. Hlth Serv. 10, 479, 1980. Brooks R. G. Issues in the Financing of the Ghanaian Health Sector. Mimeo. 1975. Djukanovic V. and Mach E. P. Alternative Approaches to Meeting Basic Health Needs in Developing Countries, A joint UNICEF/WHO study, WHO. Geneva, 1975. Essex B. J. Diagnostic Pathways in Clinical Medicine. Churchill Livingstone, Edinburgh, 1976. Essex B. J. and Everett V. J. Use of an action oriented record card for antenatal screening. Trop. Doctor 7, 134, 1977. Gaisie S. K. Quoted by Kaiser Foundation International in Briefing Book Management Review and Critique, Management of Rural Health Services, Oakland, California, for the Ministry of Health, Government of Ghana Contract Number AID/afr--C--I 116 Ghana, 1977. Ghana Commercial Bank. Econ. Bull., 1977. GIMPA. Paper presented at Health Administration and Management Course held at GIMPA, Accra, October, 1975. Government of Ghana. Census, 1970. Government of Ghana. Annual Estimates 1974/75 and 1976/77. Government of Ghana. Ghana Five Year Development Plan 1973/76--I 979/I¢0 (3 vols). Government of Ghana. Budget Estimates 1976/77, Vol X. Government of Ghana, Central Bureau of Statistics. External Trade Statistics of Ghana, Vol XXV, 167, 1975. Government of Ghana. A Primary Health Care Concept for Ghana. working document. NHPU, Ministry of Health, 1977. Hall B, Mass Campaigns as a Development Strategy The

Tanzanian "'Man is Health" Campaign. Mimeo. IDS, Sussex, 1975. IDS (Health Group). Health Needs and Health Services in Rural Ghana, Vol. 1, IDS, Sussex, 1978a. IDS (Health Group). Health Needs and Health Services in Rural Ghana, Vol. 2, Appendices, IDS, Sussex, 1978b. King M. Medical Care in Developing Countries. Oxford Univ. Press, Nairobi, 1966. King M. Personal health care--the quest for a human right. In CIBA Foundation Symposium 23: Human Rights in Health. Association of Scientific Publishers, Amsterdam, 1974. Lall S. The international pharmaceutical industry and less developed countries, with special reference to India. Oxf Bull. Econ. Star., 1974. Morley D. Paediatric Priorities in the Developing World. Butterworths, U.K., 1973. Ofosu-Amaah S. Reflections on the health budget. Ghana Med. d. 14, 215, 1975. Ofosu-Amaah S., Kratzer J. H. and Nicholas D. D. Is poliomyelitis a serious problem in developing countries'? Lameness in Ghanaian schools. Br. Med. J. 1, 1012, 1977. Twumasi P. A. Medical Systems in Ghana. Ghana Publishing, Tema, 1975. Twumasi P. A., Yangyuoru Y. and Banuaku A. F. A Sociological Study of Rural Water Use. Project Report for the Ghana Water and Sewerage Corporation, 1977. World Bank. Basic Needs A Progress Report. Policy Planning and Program Review Department, mimeo, 1977. World Health Organisation. Provisional Guidelines for Health Programme Evaluation. HPC/DPE/77/2, Geneva, 1977. World Health Organisation. Risk Approach for Maternal and Child Health Care. Offset Publication no. 39, Geneva, 1978.

517