«Page 1 of 21 Introduction Ghana, located in West Africa, was the first of the colonized countries in Africa to declare its independence. Accra is ...»
Health Care and Infrastructure in Accra, Ghana
Jennifer L. Pehr
Advanced Issues in Urban Planning
27 April 2010
Page 1 of 21
Ghana, located in West Africa, was the first of the colonized countries in Africa to declare its
independence. Accra is Ghana‟s capital city, and serves as the geographic and economic
gateway to this region. The city‟s diverse economy is home to both local and regional traders as
well as many international companies.
Since its independence, Accra‟s population has increased rapidly. In 1957, the city had a population of approximately 190,000 (Grant &Yankson, 2003); today, the city‟s population is estimated to be over three million (Millennium Cities Initiative website). Accra experienced a period of rapid spatial expansion in the 1980s, and has been urbanizing rapidly ever since. Much of the city‟s growth has not been planned, and as a result, Accra‟s spatial expansion in recent years has occurred in some of the poorest areas of the city. This unfettered and unplanned growth has had severe implications for the population of Accra, and is most pronounced in the lack of basic urban infrastructure, including water and sanitation, transportation, education and health care in many parts of the city.
In January 2010, Accra partnered with the Millennium Cities Initiative (MCI) to become a “Millennium City.” MCI works with underserved urban areas in sub-Saharan Africa to help them eradicate extreme poverty and to attain the Millennium Development Goals (MDGs) (MCI website). To fully realize a city‟s social and economic potential, needs assessments are conducted in many areas, including education, gender, water and sanitation, health and opportunities for economic development and foreign direct investment. All of the components of the above-mentioned needs assessments combine to provide a holistic understanding of the challenges a Millennium City faces and the investment opportunities that are required in order to achieve the MDGs.
This paper explores the health care system infrastructure in Accra by examining public health needs and addressing the challenges and goals identified by the Accra Metropolitan Assembly (AMA) Metro Health Services and Public Health Directorates. This paper also proposes recommendations for future research.
Page 2 of 21 Framework for Health Assessment In this paper, Accra‟s health systems and needs are analyzed in terms of the three health-related MDGs and the challenges identified by the AMA Metro Health Services and the AMA Metro Public Health Department. The following chart lists the health-related MDGs and the
corresponding indicators used to measure the progress against each goal:
In a recent presentation, AMA Metro Health Services identified essential health-related
challenges and needs for Accra. The directorate named challenges in two primary areas:
physical health structures and issues related to adequate staffing and data reporting. According to AMA Metro Health Services, Accra faces the challenges of inadequate emergency care, infrastructure and equipment, and a lack of office and residential accommodations for health professionals. There are critical physical challenges at the hospitals themselves, and many units lack an adequate number of beds and specialty services. In addition, AMA Metro Health Services highlighted the severely low number of experienced health professionals in the city: the doctor to patient ratio is 1:12,000 and the nurse to patient ratio is 1:1,837. Finally, data collection and surveillance are weak.
In another presentation, AMA Metro Public Health Department emphasized Accra‟s health challenges from a population perspective. First, the department identified health issues related to environmental protection, which included noise nuisance, malaria control and pollution. The second critical health issue to be addressed was human waste disposal. The AMA Metro Public Page 3 of 21 Health Directorate reported that 70% of Accra‟s residents do not have access to toilets or sanitary latrines, leading to defecation in many public areas including beaches and drains. This is a particular challenge in areas where there has not been adequate urban planning. Finally, issues related to food and water safety are also of concern to the AMA Metro Public Health Department.
The gaps in achieving the MDGs and challenges listed by the AMA Metro Health Services and Metro Public Health Department underscore the public health challenges that residents of Accra face, and each area of focus emphasizes challenges that compromise the health and well-being of the population. However, there appear to be frameworks for approaching public health problems. While the MDGs focus directly on reducing morbidity and mortality rates within a population, the AMA Metro Health Services approaches Accra‟s health challenges by addressing issues related to the health system‟s physical and resource infrastructure. The AMA Metro Public Health Department looks at broader, urban-related factors and how such challenges influence the health of the entire city‟s population. All three perspectives articulate important ways to improve the health conditions of Accra, but each evaluates and addresses the city‟s health challenges using a different methodology.
Structure of Health Care in Ghana Two governmental bodies oversee health care infrastructure and delivery in Ghana – the Ministry of Health (MOH) and Ghana Health Services (GHS). Until 1996, the MOH oversaw the direct provision of health service delivery in Ghana. Today, health service delivery is provided by GHS. The goal of MOH is, “to improve the health status of all people living in Ghana through effective and efficient policy formulation, resource mobilization, monitoring and regulation of delivery of health care by different health agencies” (www.moh-ghana.org).
MOH works on policy formation, the monitoring and evaluation of health service delivery throughout the country, resource allocation for health services and the regulation of health services delivery. MOH also develops the framework for the regulations of food, drugs and health service delivery.
The following organizations are under the oversight of MOH:
MOH includes the following directorates:
Policy, Planning, Monitoring and Evaluation (PPME) Research, Statistics and Information Management (RSIM) Human Resource Development and Management (HRDM) Administration (Admin) Procurement and Supplies (P&S) Traditional and Alternative Medicine (TAM) Finance (FIN) With the passing of Act 525, the responsibilities of health service delivery were consolidated within GHS. According to MOH, there was not a great deal of actual separation of service provision, and in order to fully carry out the Ministry‟s duty of policy formation and regulation oversight, there was a need to rethink the role of MOH in Ghana‟s health care delivery system (www.moh-ghana.org).
The second governmental body that works with health care in Ghana is GHS, an “autonomous Executive Agency responsible for implementation of national policies under the control of the Minister for Health through its governing Council - the Ghana Health Service Council. The GHS “continues to receive public funds and thus remains within the public sector” (Ghana Health Services website). This organization is the service provision arm of the health care system in the country, and works to implement national health care policies, provide health care services and
manage resources for health care delivery. The functions of GHS include:
Developing strategies and technical guidelines to achieve national policy goals and objectives Undertaking management and administration of health resources within GHS Promoting healthy living and habits among residents Establishing effective disease surveillance, prevention and control Determining charges for health services (contingent on approval from MOH)
There are three administrative levels of GHS and five functional (service distribution) levels of health care in Ghana.
Administrative Levels of GHS
Accra is divided into 10 administrative health sub-districts, which include: Accra Metro, Ledokuku-Krowor Municipality, Tema Municipality, Ashiaman Municipality, Adenta Municipality, Ga West District, Ga South District, Ga East District, Dangme West District and Page 6 of 21 Dangme East District (Greater Accra Region Annual Report, 2008). The urban makeup of these ten different districts varies greatly. Putting this in perspective, Tema Municipality has approximately 500,000 people and a government hospital, three health centers and many private hospitals and clinics. Ga West District, which used to include Ga South, used to be a primarily rural area, but rapid urbanization has led to an area population of more than 400,000. The Amasaman District Hospital is located in Ga West (Greater Accra Region Annual Report, 2008), and has six Community Health Based Planning and Services (CHPS) zones, two health centers and a clinic. Similar to Ga West, Ga East used to be a rural area, but due to rapid urbanization in Accra, the district‟s population is greater than 250,000 people. GHS lists one functional CHPS compound, three health centers and a mother-child health clinic in the district, and the Greater Accra Region Annual Report lists a mission clinic and a quasi-governmental clinic in the district (Greater Accra Region Annual Report, 2008). Dangme West and Dangme East Districts, which used to be one district, are now two rural areas where poverty is prevalent.
Health Infrastructure in Accra
The city of Accra has approximately 20 government-run health facilities, which include:
Three Hospitals (Achimota Hospital; Princess Marie Louise Children‟s Hospital; La General Hospital);
Three Quasi-Governmental Facilities;
Ten Smaller Clinics;
Two CHPS Compounds;
More than 800 private health facilities.
There is supposed to be one polyclinic in each sub-metro area, but currently this is not the case.
This shortage of polyclinics may be due to the recent sub-division of four districts into ten new sub-metro areas.
GHS runs three national programs: The Tuberculosis (TB) Control Programme, the National Buruli Ulcer Control Programme and the Expanded Programme on Immunization (EPI).TB is a major health challenge in Ghana (Ghana DHS, 2008), and the TB Control program began in 1994 to address this infectious disease in the country. In 1994, the country also adopted the Direct Observation Treatment Short Course (DOTS) strategy for controlling TB in Ghana. The
Pursuing high-quality DOTS expansion and enhancement Addressing TB/HIV, MDR-TB and other challenges Contributing to health system strengthening Engaging all care providers Empowering people with TB, and communities Enabling and promoting research A Buruli ulcer is a skin disease that causes large ulcers, mainly on the skin and arms. They can damage soft tissue and lead to limited functions of joints. It is a treatable disease, and early intervention can prevent the more severe skin and joint damage (Ghana Health Services website).
The National Buruli Ulcer Control Programme provides over 30 sites for treatment in six
different regions in Ghana. WHO standards guide this program, including:
Finally, EPI is the program used to immunize pregnant women and children against preventable diseases, including tuberculosis, polio, diphtheria, neonatal tetanus, whooping cough, hepatitis B, haemophilus influenza type B, measles and yellow fever (Ghana Health Services website). EPI coverage is addressed in the following section.
Health Concerns for Accra Residents MDG 4: Reduce Child Mortality Rapid urban growth can greatly affect a population‟s health. Children in particular are susceptible to the ancillary effects that unplanned urban growth can have on a community‟s health. This section addresses issues related to child health, including antenatal care, infant mortality rate, child (under five) mortality rate, immunization coverage and nutrition.
Page 8 of 21 Antenatal care is an important variable in child health. The WHO recommends four antenatal visits for pregnant women. The Greater Accra Annual Report addresses the percentage of women per sub-metro who are accessing antenatal care, and the results vary greatly across the ten sub-metro districts. For example, Adenta has a 3% antenatal coverage, while Tema has 124% coverage. The report attributes this high degree of variability in part to pregnant women who live in one district and register in another or register at more than one clinic for care (Greater Accra Region Annual Report, 2008).
Another report cited in this paper, Ghana Facts and Figures (2008), notes the infant and child (under five years of age) mortality rates for Accra.
Source: Data from Ghana Facts and Figures, 2008 The Ghana Demographic and Health Survey (2008) also demonstrates that the rate of child mortality has decreased in the country over the past 20 years. The rate of child mortality is 80/1,000. Similarly, the infant mortality rate in Ghana is 50/1,000.
There are varying levels of immunization coverage among children in Accra. There have been upward trends in child immunizations overall since 1999, with 80% of children in Accra receiving the Penta 3 vaccinations.
Source: Reproduced from Greater Accra Region Annual Report, 2008 Figure 2.Penta 3 Routine Coverage by District, January – December 2008 Source: Reproduced from Greater Accra Region Annual Report, 2008 A portion of the discrepancies in Figure 2 might be attributed to the sub-division of some of the sub-metro districts. However, adequate coverage and better surveillance of immunizations will help protect children against these treatable diseases and identify where any problem areas are located.