Medical rehabilitation in Ghana

Disability and Rehabilitation, June 2007; 29(11 – 12): 921 – 927

Medical rehabilitation in Ghana

M. J. TINNEY1, A. CHIODO1, A. HAIG1 & E. WIREDU2 1

University of Michigan Hospital, Department of Physical Medicine and Rehabilitation, Ann Arbor, Michigan, USA, and The University of Ghana, Accra, Ghana

Disabil Rehabil Downloaded from informahealthcare.com by HINARI on 08/09/12 For personal use only.

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Abstract Purpose. To explore the current system of medical rehabilitation services for persons with disabilities in a developing country (Ghana) and to identify future needs, opportunities, and barriers. Methods. Information was obtained through a literature review and through interviews with healthcare providers, disabled people’s organizations, educators, government officials, and consumers. Direct observations were made of Ghana’s capital city, Accra, and of a major tertiary medical center there, Korle Bu Teaching Hospital. Results. Ghana has virtually no medical rehabilitation and few laws to protect the disabled. There are no occupational therapists or physiatrists in the entire country, and only a handful of physical therapists, prosthetists, orthotists, and speech therapists. There are many barriers to the establishment of such services, including lack of funding, limited government support, cultural stigma of the disabled and poor utilization of existing resources. Conclusions. A national model for sustainable medical rehabilitation is needed in Ghana and likely in other similar countries.

Keywords: Rehabilitation, Ghana

Introduction In a world of more than 6 billion people, approximately 600 million have some type of disability. Currently, 80% of the world’s disabled population lives in low-income countries [1]. Unfortunately, the World Health Organization (WHO) reports rehabilitative services in the developing world reach only 1 – 2% of the disabled [2]. This lack of medical rehabilitation is evident in many countries. The reasons for the deficiency in medical rehabilitation services are not intuitive. Unless it is assumed that a person with a disability will die as a result of the disability, the cost-effectiveness of rehabilitation to the disabled individual, to their family, and to their society seem obvious. Even the poorest countries have a sufficient population of middle class or wealthy persons to both require and support medical rehabilitation. Yet it is largely absent. In order to understand the reasons why medical rehabilitation has not become a part of many healthcare systems, it is necessary to look at

historical, cultural, political, and economic factors. Unfortunately very little research has been undertaken in developing countries, where mobility and physical capabilities are so vital [3]. Few papers have been published stating the need for rehabilitation in developing countries, including Ghana [2,4,5]. While not all countries are the same, an in-depth look at this one country may provide some clues that may be useful to others. The current paper examines the situation in Ghana. Its goals are both to propose a model for sustainable medical rehabilitation in that country and to provide a benchmark for evaluation of rehabilitation systems in other countries. Methods A literature search was completed on MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and PubMed to look at medical rehabilitation care in developing countries. Contacts were made and interviews completed with healthcare

Correspondence: Anthony Chiodo, University of Michigan Hospital, Department of Physical Medicine and Rehabilitation, 325E Eisenhower Parkway, Ann Arbor, Michigan, USA. Tel: þ1 734 936 7379. Fax: þ1 734 615 1770. E-mail: [email protected] ISSN 0963-8288 print/ISSN 1464-5165 online ª 2007 Informa UK Ltd. DOI: 10.1080/09638280701240482

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providers, medical school leadership, disabled people’s organizations, the Ghana Health Service, the Ministry of Health, and United States agencies in Ghana. A record was made of direct observations of Accra, Ghana’s capital city, and Korle Bu Hospital, a major tertiary medical center there. A second trip was made to continue contacting care providers and advocates for the disabled. Information was gathered from interviews, formal and informal, and by telephone and in-person.

Results


General background on Ghana Ghana is a country on the west equatorial coast of Africa. The country has a recent stable political history compared to its neighbors. However, with only 13 years of democracy, foreign investment in the country is just beginning. Prior military rule has resulted in a pervasive passive attitude amongst many people, although entrepreneurialship is on the rise. Its population of 20 million has an average income of $300 (U.S.). The top industry is agriculture with cocoa beans as the primary crop [6]. Reports in 2003 showed life expectancy was 58.8 years for women, 56.3 for men. Infant mortality was 66 per 1,000 while maternal mortality was 590 per 100,000. The death rate among children under the age of five was 119 per 1,000. The primary causes of death in children have been infectious, with malaria and diarrheal diseases topping the list. The national HIV rate was 4.1%, although rates in at-risk groups can be quite high. The availability of anti-retroviral therapy has been limited. However, estimates place the HIV rate in 2009 at 7% [6]. While anti-retroviral therapy is available, not all HIV positive patients have access to the drugs. The target is to provide antiretroviral therapy to 66% of infected persons by the year 2010. Health Insurance Scheme has been introduced barely a year ago. As of January 2006, 25% of the Ghanaian population was covered by the community health insurance scheme. For all others outside the scheme, healthcare is a pay-as-you-go commodity. The University of Ghana Medical School is a large, respected campus with capable faculty, most trained in western programs. Korle Bu Teaching Hospital, where the school is based, is the main tertiary hospital in Accra, with approximately 1500 beds. The number of staff is severely limited with 4 orthopedic surgeons and 3 neurosurgeons in a surgical department that provides care for most of the country. Yet, this is the hospital that provides tertiary care to a large share of the Accra city population estimated at 2 million persons and to most parts of the country. The lack of physicians

makes the management of medical and surgical emergencies alone a difficult task to complete. This is worsened by the ‘brain drain’, the loss of Ghanaian physicians to foreign countries, usually at the time of their post-medical school training or fellowship, usually in the United States or Europe. The fact that a medical school faculty member is paid approximately $500 (U.S.) a month to practice in severely understaffed and undersupplied conditions, with limited access to same specialty colleagues, and little chance for continuing medical education, has had a profound effect on the loss of medical talent in Ghana. Among the medical staff interviewed, there was unanimous agreement that medical rehabilitation care is needed. There is no physiatrist on staff at Korle Bu Teaching Hospital, or indeed in the entire country. Disability and rehabilitation in Ghana Ghana has over one million people with disability [7]. Approximately 95% of the disabled population has no access to rehabilitation services [8]. Although there are many causes for disability in Ghana, there is little information published in the medical literature [9]. Trauma, one problem related to rehabilitation, has been studied somewhat and provides some insight into the difficulty in providing rehabilitation care. In 2000, 49% of non-fatal traumatic injuries in Ghana received no formal medical care. Of those who received some type of care, only 20% received care at a hospital [10]. Training for the management of injuries along with rehabilitation of these injuries has received little formal attention, perhaps because of the cost of care [10]. Mock and colleagues state: ‘Labor at the Ghanaian minimum wage equivalent to US $1 per day, the disability time incurred by the injured person alone would be considered higher economic value than the money spent on treatment, especially in rural areas’ [11]. There are no inpatient rehabilitation facilities in the country. There are also no physical medicine and rehabilitation physicians in Ghana. Only one retired occupational therapist and one speech-language pathologist could be identified in the capital city. The approximately 20 – 30 physical therapists in the country were mostly trained in Eastern Europe, around the time of the Cold War. On the average they have less than 10 years of service left before mandatory retirement at age 60. In the field of prosthetics and orthotics there is currently only one prosthetist in Accra. Training is currently through apprenticeship or vocational training for both orthotists and prosthetists, but there is no formal program. There are approximately five fabrication centers throughout the country, all subsidized by the Ghanaian government. Currently


Medical rehabilitation in Ghana the machinery and the facilities are outdated. At these facilities they are able to make lumbar corsets, metal orthotics, custom shoes, cervical collars, simple prosthetics, wooden crutches and back boards. Costs are minimal by Western standards, and 90% is subsidized by the government, but the remainder of the cost is out of reach for most Ghanaians (Table I). The fabrication centers also do wheelchair repair, but many people we saw in Accra had three-wheel bikes with a hand crank system, while some beggars opted for sitting on makeshift skateboards or a mechanics cart. During our investigation, we observed many people on the streets with amputations but not a single prosthetic limb. One of the first steps in developing rehabilitation services in Ghana was the establishment of the School of Allied Health Sciences at the University of Ghana five years ago, which includes a physiotherapy department. Departments in occupational therapy, speech therapy, and prosthetics and orthotics are yet to be established, mainly due to the unavailability of trained personnel to take up faculty positions. The Netherlands has provided much expertise and equipment to the physiotherapy clinical space that serves as the training facility for the students in the School of Allied Health Sciences. Cultural attitudes towards disability in Ghana Traditional beliefs have a large influence on attitudes toward the disabled in Ghana. Illness and disability are often conceptualized as being the result of evil influences or of failure to keep taboos [12]. Traditional religious beliefs in Ghana have played a role in alienating and suppressing people with disabilities, and in the past, to the extreme of even killing them [13]. Earlier studies have indicated disabled persons and their families did not patronize rehabilitation services due to the stigma that comes with disability in Ghana, the majority of which live in rural areas, where the stigma of disability may be more pronounced [14]. In one study, it was observed that disabled persons would instead drift to urban areas to beg for food and money, rather than seek rehabilitation [14].

Table I. Approximate patient costs of orthotics devices in Ghana (2005). The patient pays 10%, subsidized by the Ghanaian government. 1 U.S. $ ¼ 9,411.06 Ghanaian Cedi as of May 2006. Item Custom molded shoe Lumbar corset Crutches Prosthetic leg

Cost (cedis)

Cost (US $)

25,000 50,000 – 65,000 30,000 800,000

2.71 5.42 – 7.05 3.25 86.86

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Support for disability from the Ghanaian and foreign governments The Ministry of Social Welfare, not the Ministry of Health, is the main body responsible for disability. Although there is a register of disabled people under this ministry, the majority of disabled people in Ghana have no contact with government services and there are currently no accurate numbers of disabled people in Ghana. This ministry also manages vocational training at Regional Rehabilitation Centers (RRCs) which provide up to 3 years of training for skills such as shoe mending or leather work. Few who complete the training actually have the resources to start a business. Many disabled people do not even register with the ministry since they feel it is unlikely they will receive benefits [8]. The inadequacy of these social welfare programs led to the development of the Community Based Rehabilitation Program (CBR) [8]. The Department of Social Welfare initiated it in 1992 in 20 districts of the country, eventually becoming one of the few ongoing, national, government-managed CBR programs in the world. The program has been supported by non-governmental organizations (Swedish Organizations of Disabled Persons International Aid Association [SHIA] and the Norwegian Association of the Disabled [NAD]) and by the United Nations. Financial support was provided by United Nations Development Programme (UNDP) and Amici di Raoul Follereau (AIFO). The WHO and others focus on CBR as the preferred system for providing rehabilitation care in the developing world. This is a system that is designed to reach the countryside and provide community resources, increasing access to health, education, and social services, and to provide skills training and work opportunities to the disabled [14,15]. According to the Acting Chief Medical Officer of the Ministry of Health, the CBR Program is not as successful as they hoped it would be. Multiple interviews were conducted and compiled by the WHO to assess the CBR program in Ghana. According to their report coverage remains limited, inter-agency collaboration is weak, there is a lack of reliable data and information, and sustainability is a concern. Although the CBR has not been able to improve physical well-being, it has been successful in improving social acceptance and self-reliance [16]. The U.S. government is more focused on emergencies, not rehabilitation, in Ghana. The United States Agency for International Development (USAID) has a position paper about medical priorities in Ghana [17]. This paper focuses on the prevention of infectious diseases such as HIV, malaria, and tuberculosis. The USAID paper also focuses its attention on improving Ghana’s results in

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national health statistical measures such as infant mortality, child mortality under the age of 5, and maternal mortality. USAID resource utilization in Ghana does not include the disabled or focus attention on functional independence [18]. According to staff members, at this time USAID has no plans to finance or address programs in rehabilitation in Ghana as of September 2005.

children, which currently do not exist. Staff members who were interviewed at VSO reported they were not sure if CBR was still operating because after visiting some of the sites they found they had been dissolved or have not seen funding since 2003. A major accomplishment of VSO is that they were able to get the National Development and Planning Commission of Ghana to list disability under issues to target for poverty reduction.


Non-governmental organizations in Ghana There still remains a pervasive sense that people with disabilities are incapable, which may be influenced by traditional beliefs on attitudes toward the disabled [12]. Nevertheless, consumer groups have taken on a primary role in the education of the population in matters related to persons with disability. Disabled People’s Organizations (DPOs) are working on educational programs to enlighten the population on these and other disability issues. Other DPOs run programs including a school for the blind, a computer training program for the blind, a school for the deaf, and a crafts store for people with disabilities to try and sell their work. A group called Disability OptionsGhana is a non-governmental organization (NGO) dedicated to the physically disabled, with a current emphasis in using athletics to instill self-confidence and pride. Unfortunately, there is little interaction between medical rehabilitation workers and NGOs. We found that the Ghanaian Federation of the Disabled, a national consumer consortium of disability groups, was not aware that a School of Allied Health Sciences had started at the University of Ghana three years previously. One particular NGO called Volunteer Service Overseas (VSO), an international human development agency, has done extensive work in Ghana. VSO receives 75% of funding from the British government and 25% from fundraising. VSO recruits skilled volunteers from the UK, The Netherlands and Canada. Volunteers work for Ghanaian organizations engaged in activities aimed at reducing poverty and where there is a clear shortage of locally available skilled labor. VSO has been working in Ghana for 41 years in partnership with the Ghanaian Government and NGOs. In 1999, VSO-Ghana developed a strategic plan to guide its program for the period 2000 – 2005. A key aim for VSO Ghana is to target support to people with disabilities. They have three goals: Working with DPOs, special education, and civil rights understanding. They provide infrastructure and guidance to people who run DPOs. In 2001 they even put together a list called the Disability Network of Ghana, but it has yet to be published or posted for the general public or healthcare system to access (Table II). A majority of their work is advocating for special education services for disabled

Plans for the future of rehabilitation in Ghana A huge step in the development of medical rehabilitation services was the establishment of the School of Allied Health Sciences at the University of Ghana. The Ministry of Health initially asked the Ministry of Education to develop an allied health professional program. One of the first programs to be started was the physiotherapy training program. They are set to graduate the first class of physiotherapists in 2006. There have been several visiting faculty from other parts of Africa, but a major concern for the future of the physiotherapy program is obtaining and retaining faculty. The School of Allied Health Sciences has yet to include other rehabilitation training programs in occupational therapy, speech therapy and orthotics and prosthetics, although there are continued hopes to establish these programs in the future. In spite of national and international medical imperatives directed towards infectious disease and child and maternal health, the Ministry of Health has also begun exploring policies directed towards managing disabilities. There is a policy on disability in the Ministry of Employment and Social Welfare, but none in the Ministry of Health. No ministry had an advisory group on disability issues, leaving medical providers and consumers with very limited access to decision-making bodies. In discussions with Dr Ahmed Kofi, the Acting Chief Medical Officer of the Ministry of Health, it was agreed that medical leadership and national policy agreement was needed to spearhead any efforts to develop a national system to manage care for people with disabilities. He explained that an important attribute to pursue was to have all citizens reach a point where they were contributing rather than placing a drain on the national economy. To this end, our group was asked to help develop an initial draft of this document. Discussion Although ravaged by curable infectious diseases and great deficiencies in basic public health infrastructure, Ghana has a need and desire to care for its

North American Women’s Association Peace Corps Ghana Accra Psychiatric Hospital

Holy Child Sisters Hope For Life International Needs-Ghana International Trachoma Initiative (ITI) Korle-Bu Teaching Hospital Physiotherapy Department Korle-Bu Teaching Hospital ENT Department Korle-Bu Teaching Hospital Eye Clinic Kristo Asafo Mission of Ghana

British High Commission Castle Road Special School c/o Psychiatric Hospital, Accra Catholic Relief Services, Ghana Programme Centre for the Development of People Disabled Christian Fellowship International

Volta School for the Deaf

Unit for Mentally Retarded

Unit School for the Deaf Kibi Unit school for the Deaf Wassa Rehabilitation Centre

St Theresa’s Centre St Theresa’s Vocational Training Centre for the Handicapped Three Kings Special School

Unit for Mentally Retarded

University College of Education Department of Special Education University of Cape Coast Integration

University of Cape Coast Department of Special Education University of Cape Coast Child Development & Ass. Unit

Volta region Assessment Centre Better Life Organisation Care and Concern Action Group Community Inclusive Special School HO Rehabilitation Centre Hospital Battor Rural Development and advisory Services (RUDAS) Stephanus-Society Ghana

Eastern region National Bureau for Students with Disabilities Okuapeman School Integration School for the Blind School for the Blind Secondary Technical School Integrated Blind Somanya Rehabilitation Centre

Save a Limb Foundation Save the Children (UK) Second Geneses Africa

Rehabilitation International Ghana

Rehabilitation International Centre

Central region Ankaful Leprosarium Ankaful Psychiatric Hospital Christian Rural AID Network Esipon Rehabilitation Centre Franciscan Community Centre Ghana National Association for the Deaf School for the Deaf

Eching Hills Village Inc. Embassy of the Federal Republic of Germany European Union German Development Cooperation

East Legon Hospital

Dzorwulu Special School

Ministry of Health Limb Fitting Centre National Society of Friends of Mentally Handicapped Children Netherlands Development Organisation, SNV New Horizon Special Scholl

Ghana National Association of the Deaf Ghana Society for the Blind Ghana Society of Physically Disabled

Assessment Centre Accra Association for Project-Blind, Ghana Bible Centred Ministries

Eye Care Secretariat Ministry of Health Mental Health Unit

Ghana Federation of the Disabled Ghana Lepers Relief Association Ghana Mental Health Association

Ad Vitam Meliorem ALFO, for CBRP through MOH Aid to Artisans – Ghana

Ministry of Employment & Social Welfare Ministry of Health

Ghana Association of the Blind Ghana Epilepsy Association

Greater Accra AACT for Autistic Children

Table II. Disability network of Ghana (from list of stakeholders compiled by VSO by region).


World Bank World Health Organisation (WHO) World Vision International

Wheel Chair Project Association

VSO Ghana

Department of Social Studies USAID Valco Trust Fund

Sight Savers International Society for the Settlement of the Physically & Mentally Disabled Special Education Division SRF, Dalarna/Support GAB Swedish Organisation of the Visually Impaired State School for the Deaf United Nations Children’s Fund (UNICEF) United Nations Development Programme (UNDP) University of Ghana, Integration University of Ghana

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disabled citizens. Beyond the moral imperative, there are health and economic reasons for policy and program development which is recognized by government officials there. However, with the lack of a national policy and the lack of rehabilitation expertise at the ministry and academic medical center levels, effective strategies are lacking, even in advocacy and consumer groups that are well organized. In our assessment, the CBR program can identify persons with disability but has no resources or direction in which to affect the care needed. There is no consistent interaction with the medical community or academic medical centers. There was little, but now increasing contact with DPOs. In effect, this system is like a pyramid without a point, a failing process due to lack of medical leadership and organization which is needed to make it effective. Clearly medical rehabilitation leadership is necessary. It could be external initially, but it has to be effective and rapidly replaced by someone in the medical system. This is necessary in order to provide the national and medical staff leadership needed to oversee the process of resource allocation for all levels of rehabilitation care and training that will be needed in a comprehensive care system. This individual will need strong medical rehabilitation knowledge. This physician will need to create the context for team management in an acute care oriented system. Equally important, this person needs leadership training. In a small country, the medical rehabilitation expert in the academic medical center will advocate for rehabilitation resources in the Ministry of Health. They can advocate for advisory committees that include medical and education experts as well as consumers. They will need to advocate for vocational programs and accessibility laws. Having the ear of policymakers will make it much easier to be successful, and leadership skill will be needed to effectively swim in those waters. With academic promotion tied to academic productivity, it will be important for a system to exist where this rehabilitation physician has continued peer development with physiatric mentors. Another mechanism to improve the clinical and research environment for these physicians is to make American and European senior physiatry residents available to them for clinical and research rotations in international rehabilitation. This is an area of interest of many residents, which could be coupled with a research requirement that would benefit the resident and the isolated staff physician. The use of the internet and computers to permit rapid education and advice over long distances would be useful as well. Using technology to ‘leapfrog’ over physical barriers is something addressed in the literature for more than ten years [4]. These benefits would go a long way to help prevent the dismantling of the

program by further ‘brain drain’. The availability of boilerplates for all aspects of program development could also follow this model. Assistance with training program development and accreditation could be accomplished which will further ensure program sustainability. Ghana’s disability system is in a crisis. But its strong and forward-looking government, exemplary educational and health systems, and forward-looking economic plans, along with the innovative nature of its citizens, mean that an innovative and effective medical rehabilitation infrastructure can be made. Conclusion Creation of a medical rehabilitation system is a key to successfully improving the quality of life for people with disabilities in developing countries. Ghana serves as an example of a developing country in need of a sustainable rehabilitation program. In evaluating a country, understanding the epidemiology of disability, exploring policymakers and laws, knowing the leadership structure, learning academic acceptance and policy, understanding consumer needs and economic pressures, and understanding current service providers strengths and weaknesses including physiatry, allied health faculty, and psychology is important. Pulling this information together is critical to understanding success paths to develop sustainable rehabilitation medicine. This and societal understanding is why sustainability is obtained by having knowledgeable local physicians who can carry the lead and develop a program that works for the country, its people, and its culture. Acknowledgements This study was funded by a grant from Global Reach, The University of Michigan. The authors would like to acknowledge the insight and assistance of the following persons and organizations: University of Ghana School of Allied Health Sciences – Office of the Dean; Ministry of Health – Dr Kofi Ahmed; Acting Chief Medical Officer; Korle Bu Teaching Hospital – Dr Darko; Chief of Surgery, Korle Bu Teaching Hospital – Dr Osei; Chief of Orthopedics, Korle Bu Teaching Hospital – Dr Ben Annan; Head of Medical Affairs, Dr Laryea; Chief of Orthopedics at 37th Military Hospital; Ghana Federation of the Disabled; Challenged Athlete’s Foundation – Emmanuel Ofosu Yeboah; United States Agency for International Development – Peter Wondergem; Volunteer Service Overseas – McDuff Phiri, Programme Director; American Embassy to Ghana – Christine Rada; Prosthetics and Orthotics Factory in Accra; Disability Options – Ghana – Ann Doe,

Medical rehabilitation in Ghana Director; Ridge Hospital – Gifty Nyante, physiotherapist; University of Ghana – T. Kolapo Hamzat, PhD, physiotherapy instructor.


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