Health service delivery beyond COVID-19: A time for reflection, reform

BY: Prof. Fred Binka
Prof. Fred Binka
Prof. Fred Binka

The current COVID-19 pandemic has highlighted the long-standing neglect of health system development.

The health systems in advanced countries such as the US, Europe, including the UK, could not withstand the pandemic. 

There were severe challenges with equipment and staffing. Predictably, many wondered what would happen in the challenged health systems in low and middle income countries.

Most health systems in Africa lack functional and responsive structures in addition to human resource shortages, inadequate diagnostic facilities, poor management and training.

In 2018, a holistic sector assessment using the World Health Organisation (WHO) approved tools showed that the Ghana healthcare system was significantly weak, especially with the distribution of its human resources.

Health frontline staff discharging their duties.

The COVID-19 pandemic has further exposed the gaps in the health sector, not only in Ghana but across the world.

In Ghana, past efforts to control pandemics such as SARS, H1N1 and recently Ebola, were treated as parallel projects nationwide, with no firm links to any of the health sector divisions of the Ministry of Health.

The current pandemic is also being handled the same way, with a committee formed, a plan developed and being implemented.

The lessons from the previous epidemics have, therefore, not been sufficiently taken on board because there are still no institutions to house the structures to ensure continuity.

Effects of loss of institutional memory

The effect was the loss of institutional memory with change in government, undue political “shadow-boxing” and a lack of sectoral ownership. There has been considerable dissipation of resources that could be retained to support the health system post-outbreak.

Secondly, the disruptive effects of the pandemic on non-COVID-19 essential service delivery are not being adequately addressed.

Mothers and their children are not accessing maternal and child healthcare services. Tuberculosis (TB) and HIV treatments have all suffered disruptions. Non-emergency surgeries have been cancelled.

This might be due to the current approach where both patients for COVID-19 and non COVID-19 are being treated in the same health facilities across the country.

The rains have set in and preparations for disease control, for example malaria, have been suspended and no treated nets are being distributed.

Handling a pandemic such as COVID-19 affects all sectors of the economy.

The closure of the borders and the three-week lockdown brought the economy to a standstill, affecting the lives of the people in ways they have never experienced before.

Comparatively, African countries such as Liberia, Guinea and Sierra Leone that had previously experienced Ebola and also Taiwan, Hong Kong and Korea that had suffered from the SARS epidemic, have better responses to COVID-19 on account of their ability to leverage structures created in previous epidemics.

It has been 20 years since we carved the Ghana Health Service and the teaching hospitals out of the then Ministry of Health.

As the adage goes, “an unexamined life is not worth living”.

The current challenges provide an opportunity to reflect on the successes and shortcomings of the undertaking.

There is a suggestion that we need to better define and trim the core functions of the ministry and the health service.

There needs to be a letting go of structures and institutions whose roles have over time been taken by other agencies with better resources to manage.

This will enable resources to be re-directed towards addressing the core expectations of Ghanaians regarding health service delivery.

My proposals

I will dare to propose that it is about time professional training institutions under the Ministry of Health were handed to the public universities under a mutually beneficial arrangement.

I propose three core functions for the Ministry of Health. Administrative and Allied Health Services, (technical coordination, policy regulatory, logistics and development functions); Clinical Health Services and Public Health and Sanitation.

Administrative health services

Administrative and Allied Health Services should be the main domain of the ministry (policy formulation, regulations, National Health Insurance, setting targets and planning, and the overall development of the health sector). 

There are five areas within the health sector that are not sufficiently developed and need urgent attention.

These are private sector hospitals and clinics; religious health services such as CHAG; the quasi-government hospitals (Police, Army, SSNIT, VRA, Ports Authority, Maritime Authority, Bank of Ghana hospitals and clinics); traditional and alternative medicine, and mental health.

The ministry, working closely with these sectors should come to an agreement on how some of them could be integrated into the clinical health services or into the public health and sanitation division or stand on their own directly under the ministry.

The ministry must concentrate on setting targets for the divisions and strengthen its monitoring and evaluation roles.

Clinical health services

The Clinical Health Services should amalgamate the current Ghana Health Service and Teaching hospitals.

It will focus on data sharing to inform policy, harmonisation of clinical services from the community level to the national level.

This will facilitate the creation of appropriate linkages for district, regional and national referral systems that currently do not exist.

It will also help in the development of mechanisms for equitable distribution of equipment, expertise and human resources across all levels of the society.

Public health and sanitation services are fundamental and are the primary functions of the government.

These include the provision of water, basic sanitation facilities, waste disposal, good housing and nutrition.

These functions can be designated as public good, hence our development partners have supported the government to provide these services until we move from low to lower-middle country. These are the key functions of these departments:

1. Environmental and occupational health
2. Health promotion
3. Preventive services, such as maternal, child health and nutrition services
4. Risk factors screening and control
5. Disease surveillance and control
6. Health information
7. Emergency preparedness and control
8. Health security and
9. Public health research.

Some of the above functions can then be grouped together under a new structure known as the Ghana Centre for Disease Control (CDC).

The CDC will build a robust public health system to detect, predict, prepare and control epidemics.

The CDC should establish a national infectious disease hospital and four satellite hospitals in addition to developing links with the African Union CDC and the ECOWAS CDC.

The CDC will also establish a strong laboratory network, create strong linkages with the universities, the veterinary services and the Council for Scientific and Industrial Research and Atomic Energy. It will drive bio-security and advance the non-communicable disease agenda.

The COVID-19 pandemic presents a great opportunity for change in the health sector in the 21st Century and beyond, which must not be missed.

The writer is a Professor of Clinical Epidemiology, School of Public Health, University of Health and Allied Sciences, Ho.