Successful public policies and programs are rare because it is unusual to have progressive and committed politicians and bureaucrats (saints) supported by appropriate policy analysts with available and reliable information (wizards) that manage hostile and apathetic groups (demons) and consequently insulate the policy environment from the vagaries of implementation (systems). Prof J.R.A Ayee (2000)
Long before I heard Dr Fred Wurapa, a Health Policy Analyst describe Ghana’s Health system as one in crises, Dr Saweke, then WHO Country Representative had put a name to the phenomenon at the 50th Anniversary lectures of the Ghana Medical Association.
At the time, Dr Saweke comically portrayed an extra-terrestrial being peeping down on developing countries. Eureka! “Ah! They have only three diseases!” He would then proceed to define an over concentration of donor and health professionals efforts on Malaria, Tuberculosis and HIV. To this he would add a huge wage bill compared to the GDP and an incongruously demotivated work force.
Dr Wurapa would worsen the description of crises at the School of Public Health, Legon: inequities in distributing the health workforce, serious staffing shortages, stagnating or worsening health indices like maternal mortality, infant mortality etc and the resurgence of some so-called neglected diseases like Guinea worm which at the last check was threatening to undergo a name change to Ghana worm.
When Prof Ayee outlined his famous Saints, Wizards, Demons and systems model, I doubt that this is the kind of crises he envisaged. Maybe it was. For reasons that would soon crystallize, it is the demonic component of the model that catches my fancy today. If nothing at all, as a true ‘African’ and Christian, I simply cannot help acknowledging how bad, terrible, evil demons are, especially the variety that occurs in the health sector.
It is neither about the chronic industrial unrests nor the unchanging disease burden that I speak. It is something finer, something far more delicate, a tricky demon that one may miss if sufficiently lacking in attention. It is the demon of blame, accusations and counter accusations that characterizes the relationships among and between different categories of health professionals. It is the subtle and sometimes not so subtle destructive and suspicious ways we view each other, the comparative importance some attach to their work and the extent to which some look down on the contributions of others.
I have been blessed with the opportunity of exposure to various categories of health professionals. A few observations strike me, the first of which is that contrary to what a lot of non-health professionals think and/or say, many health professionals actually do care about their patients and how the health system can be made more responsive to their needs. Ironically, it is this passion for their clients which is the simultaneous driver for the operations of this health demon. Controversial perhaps, but it would appear that an otherwise positive attribute of advocating for improved systems would become corrupted to the extent that frustrations seems to find negative expression in some professionals deriding the efforts of others with an equally great stake in improved healthcare delivery.
As always, Dr. Irene Agyepong, occupant of the Prince Claus Chair and Public Health Expert digs deeper, “I think a large part of the driving agent for the "demon" you describe is our own different professional conceit and the chronic mistrust within the health system of each other as well as of the powers that be. Also the failure to sufficiently appreciate how interdependent we are - the truth is that none of us can do without the other - but we continue to enjoy pretending and imagining that we can. In doing that we sometimes also open ourselves to people using the 'divide and rule' tactic to keep the sector ‘under control'.”
This demon makes different categories of health professionals overvalue their own contributions to the health system and to talk as if, if everything else about others and not themselves were corrected, the health system would at once become perfect.
You would eavesdrop on some nurses’ conversation, “Don’t mind these too-know doctors. They think they know everything! They don’t know anything. Let the doctors show us whether they can do anything in the hospital in our absence. All they know is to give orders left, right and centre. As for administrators, we do all the work while they just sign papers in the office not appreciating that it is our work which brings in the money…”
The technical field officers trained to do disease surveillance etc couldn’t agree more, “One day in my community, the new district doctor came on a visit. Immediately he saw me attending to cases of yaws and treating some of them in a nearby structure, he angrily queried ‘who is that?’ and started advocating for the facility to be shut down. The next time I got a case of yaws, I sent it to him for his opinion. He had never seen a case of yaws before and had no idea what to do immediately. After that time, he was more appreciative of the services I was rendering to sufferers of yaws in my community.”
Then you come to the Administrators, “These doctors and nurses think they are the most important group of professionals in the hospital. They sometimes think they can even do my work when they are not trained administrators. What they don’t realize is that with my pen and a single proposal, I can rake in far more millions into the hospital than they can ever hope to bring in with their work…”
The Pharmacists would not be left out, “We neither understand nor accept the reasons why doctors want to take over the work of pharmacists in this country. Why do doctors want to prescribe and dispense at the same time in some of their facilities? They have to employ qualified pharmacists…”
In come the non-medic management types, “The bane of our health sector is really that of leadership and management. Sometimes, I wonder what all these doctors who call themselves managers are doing. Some of them are so inefficient. How can you sit in a facility, earn so much from health insurance, not have any clues on various investment packages that could turn your money over many times over and just sit there and complain about lack of funds? It is time to allow real managers who are not necessarily health professionals to manage the system!”
And then the health planners enter the fray, “First of all, people sometimes confuse our role with administrators. The work of an administrator is simply procedural. Every system is perfectly designed for the results it gets, so what we see in the health sector doesn’t surprise us. If you want 1000 doctors, you should have thought of it seven years ago. And if you want doctors to go into the rural areas, you must adopt allowances and other policies that will attract them. What is this nonsense about having only four Psychiatrists in Ghana and then you go and develop a single spine salary structure which seeks to reward the doctor who does public health the same as the doctor who is in Psychiatry? Who should go and do the Psychiatry? It is time to begin to implement performance contracts and to begin firing people if they don’t perform…”
As the planner waxes eloquent, the Health Management Information Systems expert practically dismantles both the health planner and the manager, “What is all this talk about planning and management without a sound data base? Sound reliable data is most crucial for every step of the planning/ management cycle. Yes I agree with the planner that it is what gets measured that gets done but in Ghana here, who pays any attention to the reliability of the data gathered in the health sector? For many years we have always said Malaria is 40% of the OPD attendance and yet who knows what the baseline was? How can you be sure that all the malaria is really malaria? If your basic data is not right, then you may introduce all manner of interventions but because what you are measuring is not accurate, you never seem to be making an impact. Let’s just get our HMIS right!”
By this time, it is becoming increasingly obvious that the doctors have had it coming for sometime. But they would not be left out either. In their case, a whole article could even be written on the demons that plague one medical specialty, pitching it against another. You would hear some colleagues say, “What kind of hopeless administrator would sit down and tolerate this chronic cycle of water shortages knowing just how crucial water is to our work? They just sit in their air conditioned offices watching television as if nothing has happened while we sweat it out here in overcrowded emergency rooms and unending patient queues?” To the Pharmacists would be spared a few choice words “What is all this talk about doctors taking over Pharmacists’ work? Shouldn’t they be more concerned with assisting to manufacture the drugs that we need here instead of turning themselves into marketing executives?”
The doctors do not spare each other either! A Specialist Neurosurgeon would say disdainfully to a junior doctor contemplating a research career in Public Health, “You want to do Public Health eh? So you want the easy life? I stand on my feet for over eight hours doing one surgery and you want to ride in big cars?” To this, another clinician would add, “We need people to do the hard work in the clinic only to see young people wasting their time saying they are going to do public health…”
The Public Health doctors shall have recourse to a rejoinder, “The problem with these clinicians is their narrow-minded perception that the solutions to all our health problems can only be found in their consulting rooms. What they don’t realize is that by adopting community-wide preventive approaches, we can even decrease their work load. A lot of them are sitting on important data that could have formed the basis of serious operational research to inform our decisions and actions. They have very poor research habits and yet think the world revolves around them…”
Often, having probably the greatest leverage, the politician would widely be blamed by the technocrats for lacking what it takes to fundamentally transform the system. Talk to the named politician and the blame ball is tossed yet again. “My actions were informed by the advice of the technocrats. You are the technical people! I am only a political head!”
This is my health demon. It is poisonous, it is distasteful and it is destructive. It makes everyone else the problem and none the solution. It prevents us from valuing each other, harnessing each other’s resources and contribution to team effort. What we need in the health sector is the Holy Spirit. We need to be imbued with power from on high to seek now more than ever to work together to find common solutions to common problems. Any efforts to find solutions that start with the automatic assumption of the guilt of other professionals except us will be limited and ultimately fail. It is time to shed the language of blame for one of appreciation, goodwill and good intent. No one man has it all and it is the sum of the parts that make the whole. Indeed systems theorists will have it that the sum of the parts can sometimes be bigger than the whole. The sooner we get this, the better things would be for us all.
Father, send us the Holy Ghost, please!
Dr. Sodzi Sodzi Tettey