In-Depth Qualitative Study of the Health Needs and Perceptions of Healthcare among Ghanaians

GUJHS. 2008 Apr; Vol. 5, No. 1.

Martyna Skowron & Robin Lanzi, PhD, MPH
Georgetown University

Abstract

Ghana has the potential to improve its health system, however, it currently lacks most of the basic necessities that would allow for its development. In order for Ghana to prosper, a stable healthcare foundation must be established. To support this effort, this study sought to assess the health needs and perceptions of healthcare among Ghanaians.
With approval from Georgetown University’s Institutional Review Board, 200 Ghanaians from the Central Ghana region were surveyed about their health needs and perceptions of the healthcare system in Ghana, including specific questions related to whether they have health insurance, diseases that affect their family most, rates of immunizations, aspects of healthcare they would like to see addressed, as well as money spent on healthcare. Further inquiries investigated their water supply and involvement in humanitarian efforts including both Ghanaian government and international government involvement. Participants were recruited by the primary investigator at the Swedru Government Hospital over the course of 2 months. The study sample included about half females (49.5%) and males (50.5%), ranging between 18 and 64 years of age.

The findings indicate that (1) the majority (69.5%) have no health insurance; (2) malaria affects about 4 out of 5 (79%) of Ghanaians; and (3) about 1/3 of all participants (35.6% males, 37.4% females) have no immunizations. It is noteworthy that of those who do participate in the health insurance program, none feel that the program meets their needs. Interestingly, participants overwhelmingly indicated that the international response was very successful when provided.

Given these findings, it is clear that humanitarian efforts must focus on providing systemic support and address the healthcare needs, particularly for the delivery and receipt of effective healthcare, but this must be done along with additional support from the Ghanaian government.

Introduction
Ghana has been continually developing, especially in its health sector. With continuous efforts and improved efficiency, the country could develop much more resourcefully. Currently, 80% of ill health and deaths are caused by infectious diseases, child related problems, pregnancies, and accidents which are all catered by the National Insurance Scheme.

The health sector in Ghana is controlled centrally by the Ministry of Health which then separates further into regional and district levels that are in charge of villages and towns. Although there are some district and community level hospitals, health facilities are primarily located within cities, most of which do not reach rural areas. In terms of numbers, the patient physician ratio seems to be growing. Many physicians have been drained to more developed nations and some have fled to surrounding countries of Nigeria and Burkina Faso for higher pay.

Within the last three years, a new health insurance plan was implemented in the place of the “cash and carry” policy. Previously, patients were required to pay up front before they could receive any medical care. Now, for a subscription of 6,000 Ghanaian cedis or US$0.66 a basic coverage is supplied. The plan is more successful as more people join. However, since its implementation in 2004, it has yet to be evaluated.

As a member of the World Health Organization, Ghana receives support from many developed nations such as the United States and Canada and depends on international aid for its development. The aid received ranges from monetary support, to donations and implementation of various health programs.

Within health conditions, malaria is one of the most rampant diseases. It affects millions of Ghanaians each year and is the number one cause of death of children under five. However, it is not the only disease affecting the population. There are still polio outbreaks due to an incomplete coverage under immunizations and cholera outbreaks occur because of poor sanitary conditions and a lack of access to clean water. Since immunizations have not been reaching the entire population, cases of measles, rubella, yellow fever and mumps are still highly frequent. However, National Immunization Days have been organized to improve these immunization rates.

In the area of child and maternal health, development is new and although it is progressing, currently only about half of all deliveries are performed by skilled personnel. The infant mortality rate decreased rapidly, but the rate differs greatly among the various regions of Ghana.

In Ghana, in order to achieve health sector reforms, access to primary basic care services should be targeted, along with equity and quality of care. This article aims to determine the most critical needs and the best areas of development to achieve the most efficient health progress.

Methods
The Ghanaian medical and health services were analyzed using questionnaires executed by the principal investigator. The survey was conducted in the Central Region of Ghana in the Swedru Government hospital. The subjects were chosen randomly by using the numbers that were assigned to them when they entered the hospital. Roughly five participants were recruited every day for a total of 200. These Ghanaians were questioned in an in- depth descriptive study about their health needs. The survey was conducted over a seven week period between May and July of 2006 and included both qualitative and quantitative parts consisting of open-ended and closed ended responses. The survey involved questions regarding health needs, perceptions of the Ghanaian healthcare system, healthcare insurance, and diseases that affect their family most. Further inquiries revealed rates and types of immunizations, aspects of healthcare they would like to see addressed, money spent on healthcare, water supply, international response, and Ghanaian government aid in healthcare needs. In the last open ended question, Ghanaians also had the opportunity to express their concerns regarding healthcare and anything not covered in the remainder of the survey. The data documents various conditions, attitudes, and characteristics of the Ghanaian needs in order to best address areas of development in the health field. However, all of the results document current Ghanaian conditions, attitudes, and characteristics as no interventions were offered.
Information was collected on individuals 18 years or older who signed a consent form. Individuals were informed of the purpose of the survey and were given contact information of the principle investigator as well as Georgetown University. Each participant was then assigned a number to protect the person’s identity. The number has been since used to associate any data to the participant in order to protect the person’s identity. All precautions were taken to ensure the confidentiality of each participant, the identity of each subject is only known to the principal investigator to eliminate any breaches of confidentiality for the subjects.

The sample consists of 50.5% males and 49.5% females with a median age of about 37 and a median monthly income of about $150 (U.S. dollars). The distribution of ages ranges from 18 to 69 and the income ranges from 0 to 30,000,000 cedis per month (about $3,000 U.S. dollars).

The open ended questions of the study (including aspects of healthcare that need to be addressed, critical health needs, etc) received a variety of responses which were coded into categories that provided some consistency for data analysis.

Agona- Swedru Hospital
This is the setting for the recruitment of the sample for the study. This hospital is responsible for the entire Swedru district which includes the town of Swedru as well as over twenty surrounding towns. The hospital includes an outpatient department, female ward, male ward, pediatric department, maternity ward, pharmacy, and community health. The hospital serves approximately 600 patients a day with two doctors and about 40 nurses.

Experiential Learning International (ELI)
Experiential Learning International (ELI) is a registered nonprofit organization that creates volunteer and intern experiences for students. It allows young individuals to explore areas of interest such as medicine, international development, journalism, and teaching through internships in the various fields. However, it combines this practical knowledge with a desire to help others through volunteering. ELI includes destinations on four continents including Africa, Asia, Europe, and South America in 16 countries of  Ghana, Bolivia, Philippines, Nicaragua, China, India, Argentina, Poland, South Africa, Guatemala, Vietnam, Ecuador, Tanzania, Costa Rica, Nepal, and Kenya. The organization believes in learning life’s most valuable lessons through experiences, particularly international experiences that can advance one’s sense of self and cultivate a global view of life.

Institutional Review Board (IRB)
The study protocol was approved by the Georgetown University Institutional Review Board. Each participant was made aware of his or her rights, explained the purpose of the study, and consented before participation. Participants were also provided with Georgetown University’s and the principal investigator’s contact information if they had questions, wanted further information or were suffering from any unexpected physical or psychological discomforts as a result of the study.

Results
Health Conditions
In order to assess areas that would improve health and development in Ghana, the participants were questioned about various health conditions. Not surprisingly, Ghanaians claimed malaria as their most critical health need confirming its grave impact not only in Ghana, but also worldwide. Malaria affects approximately 650 million people and causes between one and three million deaths mostly in young children.  Apart from malaria, many Ghanaians named various diseases that should be addressed in order to tackle their problematic areas of health. The most commonly named ailments included diabetes (6%), hypertension (5%), arthritis (1%), HIV(3.5%) and asthma (2.5%) which are all significant problems in the U.S. as well.  However, the interviewed sample also named some other diseases that are more common in Ghana such as tuberculosis (1%), typhoid fever (2.5%), cholera (2.5%), and pneumonia (1%). None of these sicknesses are surprising considering that pneumonia, for example, is currently the top killer of children under the age of five worldwide.

28% stated that one of the most basic critical needs is medical equipment, which is seen through lack of basic equipment such as blood pressure cuffs and heart monitors to surgical tools. Along with this, 4.5% believe other essential necessities are medical supplies extending from gloves and hospital bedding to hospital beds. 7% also need medications in order to treat the problems they may be diagnosed of. Not only are the drugs expensive in Ghana, but many of them are not even accessible in their pharmacies. 3% expressed the need for healthcare facilities since the hospitals are small and sparse providing an unreasonable ratio of the number of patients that each hospital or clinic is responsible for. The lack of hospitals also explains the few healthcare personnel that is available to treat patients, which was voiced by 6.5% of the interviewed sample.

Another 12.5% simply need access to healthcare and hospitals. They are limited by funds, a shortage of healthcare providers, and distances to hospitals. 7.5% need better sanitary conditions both in their living environments as well as hospital cleanliness. The houses or huts that many Ghanaians live in provide a habitat for the accretion of a variety of tropical and infectious diseases often multiplying the ailments that affect the Ghanaian population. The unhygienic hospital conditions ease the way for the spread of disease between patients and make recovery even more difficult. The hospitals and housing is not the only sanitary problem, however, when 8.5% desired cleaner water to improve their health conditions.

13.5% need better prevention methods. Condoms are not easily accessible when many Ghanaians do not have enough to feed their families. Many females also have a difficult time convincing their male partners to use condoms, while other birth control methods are socially unacceptable in many areas. Mosquito nets, although cheap according to our financial standards, are still an immense expense in Sub- Saharan Africa which explains why 7.5% believe that more money would allow for the fulfillment of any critical health needs they may have. Knowledge about malaria is enveloped in many misconceptions, bednet usage is low, chloroquine doses are inadequate and various herbs and over the counter drugs are used by traditional healers. The combination of these components prevents the extinguishment or even decreased incidence of the disease. Similar to this, 7% want free healthcare claiming money to be the main constraint of their substandard health.

6% specifically mentioned the area of child and maternal health needing improvement. Before 1920, Ghana did not have any child and maternal health services. However since then, the field is improving dramatically. It has advanced from an infant mortality rate of 360 deaths per 1000 live births to the current average of 121 deaths per live births. This rate varies greatly with region. The north averages about 234 deaths per1000 live births, while the southern areas close to the capital city of Accra average at 85 deaths per 1000 live births.  The difficulties in maternal and child health services are rampant due to the weaknesses and problems relating to the distribution of services, personnel development, and coordination with related agencies. Maternal and child health services perform much better in the urban areas. More than 80% of the population, however, still lives in the rural and disadvantages areas. Therefore, the quality of life and distribution of health services and personnel needs to be improved in order to enable better health performance.

Table: Critical Health Needs

  Health Need Frequency Percent
0 None 22 11%
1 Malaria 42 21%
2 Sanitation 15 7.5%
3 Access to medical care/basic care 25 12.5%
4 Tuberculosis 2 1%
5 Typhoid fever 5 2.5%
6 Medical Equipment 56 28%
7 Drugs 15 7.5%
8 Money 15 7.5%
9 Healthcare workers 13 6.5%
10 Diabetes 12 6%
11 Prevention 27 13.5%
12 HIV/AIDS 7 3.5%
13 Hypertension 10 5%
14 Clean water 17 8.5%
15 Asthma 6 3%
16 Medical supplies 9 4.5%
17 Child and Maternal Health 12 6%
18 Arthritis 2 1%
19 Cholera 3 1.5%
20 Healthcare facilities 6 3%
21 Free healthcare 14 7%
22 Pneumonia 1 0.5%

 

When asked about what kind of help Ghanaians would like to see, 17% asked for medications to ease their financial constraints and inaccessibility of the drugs in their country. 7% admit that a change in the healthcare system might be essential. The healthcare system is weakly controlled and deeply corrupted.  Admitting their poor conditions, 6% want to see sanitary changes particularly when sewage is openly disposed into the streets creating colonies of diseased microbes all around.

7% wanted an improvement in the attitude of Ghanaian healthcare workers, which is often described as very demeaning to the patients. However, the attitude of the hospital staff depends thoroughly on the Ghanaian culture.

Table: Health Aspects you want to see addressed

  Topic to be addressed Frequency Percent
0 None 9 4.5%
1 Drugs 34 17%
2 Volunteers 7 3.5%
3 Better Attitude/treatment by Ghanaian healthcare workers 14 7%
4 Water disposal/ sanitation 12 6%
5 Healthcare professionals 29 14.5%
6 Government change 5 2.5%
7 Reproductive and child health 7 3.5%
8 Bad healthcare system 14 7%
9 Facilities 24 12%
10 Education/prevention 42 21%
11 Supplies 31 15.5%
12 More intervention/ outreach 30 15%
13 Free healthcare 20 10%
14 Money 1 0.5%
15 Diseases- Malaria, typhoid, yellow fever 15 7.5%
16 Non-tropical diseases 6 3%

12% want to see more health facilities which are continually being built by many international sources. 15.5% need supplies without which the hospital facilities can’t function especially since many patients are asked to buy their own supplies when they enter their hospital no matter how grave their health condition is when they enter. 14.5% expressed a need for healthcare professionals which is not only low due to the modest pay of the field in Ghana, but also because of a large amount of nurses and doctors that have left the country to treat internationally for a higher salary. This “brain drain” as it has been called is a leading cause in the growing inequity of health in Ghana.

21% desire more education on prevention knowing that they do know the best ways to prevent illnesses because of misinformation and the lack of education. Prevention, although difficult to install, avoids diseases that are more difficult and costly to treat.

About one-third or 35.6% of males and 37.4% of females have no immunizations. A lack of immunizations offers the body no protection  against some very deadly diseases.  53% of Ghanaians are immunized for the 6 killer diseases including polio myelitis, diptheria, pertussis, hepatits B, haemophilus infleunzae B, and BCG for tuberculosis. 6% only have the polio vaccine. 6.5% have a vaccine for yellow fever and 0.5% have the elephantiasis vaccine.

Malaria affects the families of 78.5% of those interviewed. It is the number cause of premature death in Ghana, particularly in young children. Most Ghanaians are affected by the disease several times in their lifetime and very few take prophylactic measures and even less receive treatment in time. 8.5% said diabetes was the major disease in their family. Currently, in Ghana there are only two major public diabetes clinics which serve only about 10,000 (or less than 5%) of the estimated 300,000 Ghanaians who have the disease. Hypertension affects about 9.5% and is the main non-communicable disease in Ghana. Typhoid involves about 3.5%, asthma affects 3%, Hepatitis A 1.5%, headaches 1%, yellow fever 1.5%, typhoid fever 12.5%, cholera 0.5%, Stomach ailments 0.5%, eye problems 0.5%, measles 0.5%, HIV/AIDS 4%, heart problems 2.5%, Arthritis 1%, polio 1%.

Diseases that affect the family most

  Disease Frequency Percent
0 None 7 3.5%
1 Malaria 157 78.5%
2 Hypertension 19 9.5%
3 Asthma 6 3%
4 Diabetes 17 8.5%
5 Hepatitis A 3 1.5%
6 Headaches 2 1%
7 Yellow fever 3 1.5%
8 Typhoid fever 25 12.5%
9 Cholera 1 0.5%
10 Stomach 1 0.5%
11 Eye problems 1 0.5%
12 Measles 1 0.5%
13 HIV/ AIDS 8 4%
14 Heart problems 5 2.5%
15 Arthritis 2 1%
16 Polio 2 1%

Pipeborne water is a luxury in Ghana and although 70% of participants have pipeborne water, 15% still receive water from a well, and another 15% received their water from a river or stream. The astounding data is that 15.5% classify their water as dirty simply based on their own judgment, which means that number could potentially be higher with further scientific analysis.

Healthcare
92% of Ghanaians in this sample spent $50 or less on healthcare a month with an average of 40% of their income on healthcare. The national expenditure for Ghanaian citizens is approximately US$95 while the United States spends approximately US$ 5,625 per capita and the OECD average is about US$ 2,280.

75% of participants expressed that paying for healthcare is a stress on their life. Further verifying this, there is a correlation found between paying for healthcare being a stress in their life and monthly income (t-test value = 0.00). Those who did not think paying for healthcare is a stress on their life have a mean income of US $418, while those who think paying for healthcare is a stress on their life have a mean monthly income of US $97. There is no correlation, however, between males and females and paying for healthcare being a stress on their life. (males = 0.756, females = 0.107)

When asked if their healthcare was insured by the government, 69.5% said they did not have health insurance. Since 1985, Ghana operated on a “cash and carry” system where Ghanaians would pay up front to be able to receive any care. In 2004, Ghanaian President Kufour launched the National Insurance Scheme which is meant to cater to the poorest nineteen million Ghanaians. Through this plan, Ghanaians would pay a minimum of US$0.66 or 6,000 cedis a month for a subscription. This new system was to aid over 80% of ill- health and early deaths due to infectious diseases, child-related problems, pregnancies, and accidents. However, no assessments of the program have been performed since the implementation of the insurance plan in 2004. There was a correlation found between having health insurance and monthly income. (t-test value = 0.00 <0.05). Those who do not have health insurance have a mean income of $95, while those who have health insurance have a mean monthly income of $364.

A total of 69.5% of Ghanaians did not have health insurance and only 30.5% did. 79.9% of those who did not have health insurance thought paying for healthcare is a stress on their life while only 20.1% did not think paying for healthcare is a stress on their life. Of those who have health insurance, 63.9% still thought paying for health insurance is a stress on their life, while only 36.1% did not think paying for healthcare is a stress on their life. Therefore, it does not seem as though the presence of health insurance made it easier for Ghanaians to pay for their healthcare. In fact, a correlation was found between not having health insurance and paying for healthcare being a stress on their life. (chi-square- 0.017) There was no difference, however, between males or females and whether they had health insurance or not.  (chi – square = 0.742, females = 0.224)

Upon asking the participants to rate their healthcare system, 10.5% had never even received healthcare.  56% rated the healthcare they were receiving as poor or very poor. There was a correlation found for both males and females in how they rank the healthcare they are receiving based on their income. (Chi-square: males – 0.000, females = 0.010). Participants with higher incomes ranked the healthcare system better than did those with lower incomes.

Government and International Response
74% think that the Ghanaian government does not respond to their needs.  Although the other 26% believed that the government did respond, 64% of those believed it was through the new Health Insurance Scheme. The new insurance plan has been implemented recently and is still being revised in order to perform up to its potential.

When questioned about whether the international community helps the Ghanaians, 41%  said the international community does not respond at all. Of those who thought there was an international response, 27.5% said it was in the form of money, 33% said it was in the form of medications, 20.5% said it was in the form of equipment, and 16.5% was in the form of various humanitarian relief programs. There was a bit of a difference between males and females in how much international response they received, 43.6% of males said they have no international response, 38.4% of women receive no international response. However, upon closer data analysis, no correlation was found between males and females and international response (chi-square- 0.456). 63.6% said the healthcare they were receiving was poor or very poor, only 48.5% of males said the healthcare they were receiving was poor or very poor.

Table: International Response to Ghana

  Type of Aid Frequency Percent
1 None 82 41%
2 Money 55 27.5%
3 Drugs 66 33%
4 Equipment 41 20.5%
5 Programs 33 16.5%
6 Vaccines 5 2.5%
7 Outreach 4 2%
8 Donations 1 0.5%
9 Workshops 11 5.5%
10 Volunteers 17 8.5%
11 Vitamin A 9 4.5%

Although it seems as though there are constantly international relief programs, WHO programs, or volunteers in developing countries, only about 50% of those interviewed in Ghana have participated in a humanitarian program, 50% have not. However, of those who participated none believed that the humanitarian program “did not meet their needs.” All claimed it was either successful or at least helpful in some way.  Of those who participated, 47%  participated in a program related to HIV/AIDS, 39% participated in a humanitarian program related malaria, 15% participated ina program related to elephantiasis, 15% of programs were providing immunizations, 10% participated in programs that educated them, 10% were participating in workshops, 10% were being helped in the area of child and maternal health, 6% were taught and helped in nutrition, 2% dealt with tuberculosis, and 2% dealt with diabetes.

Table: Type of Humanitarian Programs implemented by the U.S. to Ghana

  Type of Humanitarian Program Frequency Percent
0 Did not particpate 100 50%
1 HIV/AIDS 47 23.5%
2 Workshops 10 5%
3 Malaria 39 19.5%
4 Elephantiasis 15 7.5%
5 Vaccines 15 7.5%
6 Child and Maternal Health 10 5%
7 Nutrition 6 3%
8 Diabetes 2 1%
9 Education 10 5%
10 Family Planning 1 0.5%
11 Tuberculosis 2 1%

Conclusion
Ghana has made significant improvements in the last 30 years, continued research and support is needed in order to maximize successful development.
There is a significant amount of international aid and government support, however, most of the assistance is geared toward urban and suburban areas. Although those areas need help, rural regions of Ghana are lagging behind in development and they should be targeted for some of the most critical aid in order to advance change and improvement in health. Much of the previous research in Ghana focuses on healthcare equity since the health facilities are mostly located in urban and suburban settings. Because of this, many Ghanaians are not being treated in time and are not provided full medical care. For example, only 11% of children that are suspected of malaria receive appropriate treatment in time due to a lack of hospital access in rural areas. More rural development would enhance health equity. In effect, this would also improve the quality of care.

The inequity problem in Ghana is so significant that it affects the speed with which the country is developing. Forty years ago, Indonesia and Ghana had the same child mortality rate, while now, although the rate is reduced for Ghana it is still more than double that of Indonesia. Although there are some modern hospitals in Ghana they are mostly located in Accra, the capital of Ghana.

Programs in Ghana have also shown to be successful when restructured. For example, the Ghana Leprosy Service, which became more effective after it was decentralized from a one agency to multiple regional and district branches which were accustomed to the practices of each area. Perhaps further institutional change and decentralization separating the health branch from the central government could produce a better functioning health organization to lead Ghana in development. By following models that have worked previously, Ghana may be able to sustain change through capacity building.

Malaria is one of the leading causes of premature death in Ghana. Improvements in prevention and treatment would decrease the incidence and mortality of the disease particularly in very young children. In order to develop the best prevention programs, research must be continued in order to understand why some individuals use preventive methods such as bednets while others do not. Many Ghanaians are still misinformed on the causes of the disease as well as the best treatment methods. However, education about the illness does not always seem to correlate with improved prevention. Integrating health education into more culturally acceptable ideas and providing accurate information between villages would augment the efficiency of public health efforts. However, the problem is also compounded by the other ailments that Ghanaians face, such as malnutrition. Malaria-control programs alone might not be the answer, however, early detection programs would ease the prolonged effect of the disease and decrease mortality.

Although rates of vaccinated Ghanaians are still pretty low, many of the immunization efforts provided have been successful. Factors that influence immunization in Ghana include the mother’s education, presence of prenatal care, and region.  In order to increase rates of those immunized, more rural areas should be targeted. In fact, the Ghanaian government has already increased immunization programs and should continue with its efforts in more secluded areas to increase rates further.

Maternal and child health is even more complex in third world countries where more factors must be addressed in order to provide better care. There is proof of some successful programs such as the Kumasi Health Education Project. This program involves discussions with mothers, baby clinics and trained personnel that provided successful results and satisfaction for its participants. If more projects are based on successful programs even more development can be achieved especially since Ghana has been successful at getting closer to reaching the Millennium Development Goal regarding reducing child mortality.

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