The Ghanaian health sector faces several challenges regarding its financing, which have implications for the health workers and the patients. Health delivery functions as a process of commodification. Admission, diagnosis, treatment and daily care are part of the health market and all the actors involved have to deal with this reality. Patients have to invest money and nurses have to manage financial constraints and develop strategies to successfully do their work and satisfy external and individual expectations. In this section, the patient’s reality is displayed first and then the position and reaction of nurses. How both parties
try to react to the needs they face and how nurses cope with the mechanisms of the modern health sector are discussed.
Patients’ creativity in organizing monies
On admission, every patient is supposed to pay a deposit of ¢ 300,000 (€ 30). This is used for medications required immediately and covers the daily costs of accommodation and food. The patient’s final bill is set off against it. Regular medications and costs for items like dressing materials, syringes, gloves and catheters are not included but calculated separately. On average, patients stay on the ward for 11 days and their final bill varies between ¢ 400,000 and ¢ 800,000 (€ 40-80), in addition to charges for medications and dressing materials (see Appendix E and F). As an autonomous referral and teaching hospital, the government’s policy directive for free treatment to children under five and patients over seventy years of age does not apply. Patients unable to pay their bills may be referred to the Social Welfare Department. Between 2001 and 2005, the hospital paid ¢ 3.1 billion4 in bills for 1,614 poor patients, and 1,977
patients left without paying their bill. In 2005, the Social Welfare Department decided on the cases of 1,120 patients who could not afford to pay what they owed, with the majority of cases being resolved by requesting patients pay in instalments.
While in the traditional setting family members would negotiate treatment and its costs with the healer directly, the delivery of medicines and care in this hospital has standard and non-negotiable prices. On admission, a deposit is paid and prescriptions for medication and examinations start right away. The family is expected to assist in paying these bills but this creates friction and possibly revives past conflicts. One relative visiting a sick relation on the ward said: ‘She [the patient] never contributed to family issues, so now, we cannot support her either.’ This shows the dependency within the larger family system. Unless somebody manages to become finically independent and rich, growing individ- ualization carries the risk of unbearable costs in cases of serious sickness. A nurse commented that: ‘some time ago, the Ghanaian had an extended family. Now, we’re all going back, falling back on our nuclear family in order to help us. The extended family system is not working well because if you don’t con- tribute to the coffers, you don’t benefit.’ As patients have to provide dressing materials for wounds, specific disinfectants and medications themselves, the nurse in charge makes sure that relatives buy these items in the hospital phar- macy and sterilization department. Sometimes fellow patients show solidarity and donate items to their neighbours, and in emergency cases nurses actively
4 In 2005, ¢ 10,000 were equivalent to € 1. The exchange rate changed in 2007 ¢1 = €
ask for an item or just take it. Discharged patients may leave supplies behind and help refill the nurses’ supply. And fearing high costs, many patients delay a hospital consultation or negotiate an early discharge or a termination of their treatment to spare the limited household budget. The new health insurance scheme promises to end such hardship and facilitate medical treatment. How- ever at the time this research was carried out, only a few patients had registered and hospitals had not yet started reimbursements. The idea of national solidarity had not yet reached an acceptable level. Almost all patients had to bear the costs of hospitalization, medical treatment and medication themselves; and only a few civil servants and employees of big companies and institutions were eligible for a refund from their employers.
Most patients come from the immediate neighbourhood and work as traders, farmers or shop keepers, and almost no one is insured or receives a regular income. A short-term admission can often be managed and organized with the help of the extended family. Chronic illness and acute health problems form a more serious threat, and families may then be forced to decide whether to continue treatment or stop it prematurely. The situation of several patients is illustrated here to show the impact of hospitalization.
Akosua is a very friendly young woman who was diagnosed with acute lymphatic leukaemia two years ago. She lives with her mother about an hour’s drive from Accra. She is regularly admitted for medical check-ups and chemo- therapy and reads the Bible and prays for healing. Normally her mother, a nurse herself, stays with her and brings her fresh fruit and juices. Her treatment involves regular lumbar punctures, with her medication being injected straight into the spinal chord. Akosua tries hard to put up with the pain but suffers most from being dependant on others for help. Her condition has not improved over the months of treatment and financing it has become a problem. One chemo- therapy treatment costs more than US$ 100 and she will need 12 to 14. Her aunties and uncles are trying to support her financially, but money is scarce. From talking to her, it appears that some of her costs are covered by the insur- ance of her late father who worked for an international water company, but only as long as she is under 18. Later I learn that it was her maternal uncle’s in- surance and she was declared as his daughter in order to get coverage. At a certain point all efforts prove in vain, her blood count is low and she is dis- charged and sent home to rest and regain strength. She died later at home.
Elisabeth Kwasie is 59 years old, divorced and lives in the eastern region where she works as a cocoa farmer. She is admitted to the ward with pleural effusion on the right side and pneumonia. She has never been hospitalized before. Her brother visits her every week and takes the decisions concerning her treatment and medication. Her youngest (eighteen-year-old) daughter stays in the capital to look after her. She brings her food every day and washes her
clothes and sheets. The nurses accuse the patient of having arrived too late and she is labelled as ignorant for first looking for healing through alternative medi- cine and prayer camps.5 The doctors decide to insert a tube into her right lung
and give her brother a prescription to buy it. Looking at this instrument, the matron explains: ‘It is a single-use system that is meant to be disposable, but we are here in Ghana, we cannot afford that. We will have to empty it and use it again. We cannot just throw it away.’ In the course of the weeks, there is no improvement in Elisabeth’s health. A CT scan is done but reveals no new in- sight into her condition. Her family is angry as the test was expensive and did not provide a new diagnosis. It is decided she should be treated for tuberculosis. The doctor says: ‘The treatment for TB is free. If you as a doctor do not know what the matter is and the patient is short of money, you put her on TB treat- ment. From then on, they do not have to pay. In many cases the real problem is a malignant tumour. We would need a biopsy, but there is no money.’ After four months, she is discharged, weak and coughing. The diagnosis remains un- clear. Her bill totals ¢ 1.5 million (€ 150). Her brother needs several days to organize the money. Elisabeth says when leaving: ‘My family is fighting about the money. My daughter, too, left me today in anger. At home, they have to give me medicine, Blackman medicine, you know? It will help me, so I will take some, together with your medicine. If only God wakes me up.’
Another strategy for manipulating the cost of biomedical treatment is to look for medical treatment elsewhere. One option seems to be healthcare in neigh- bouring countries where costs are supposed to be lower, and also in private clinics where healing is promised. While there are no official statistics and medical histories available, such a strategy is high risk and the long distances involved prohibit patients from attending post-treatment check ups. For ex- ample, a young woman had undergone surgery on her hyperactive thyroid in a neighbouring country. She had been released and sent home but soon afterwards experienced severe complications. On admission to hospital in Ghana, she was diagnosed with severe hypothyroidism, a life-threatening situation. After three weeks of intensive medical treatment she was released with medication for her illness and with a big bill.
Having sufficient money changes the prerequisites for admission. Rich pa- tients can afford first-class treatment in hospital. Several wards have small rooms for better-off patients and there is a so-called VIP ward that promises a hygienic environment, sufficient nurses and fast treatment. It is reported that there is the option to have all kinds of surgery carried out in the well-equipped
5 Prayer camps are healing sessions organized by Pentecostal churches. For further
and sterile heart-surgery unit at excessive prices.6 Such surgery is likely to run
fewer risks of complications, such as wounds not healing. This option is a coping strategy for patients who face serious illness and who are looking for a way to get treatment and improve their health using the biomedical health sys- tem.
Such stories show the reality of hospital admission and the various ap- proaches to organizing treatment from the patient’s point of view. The avail- ability of money is crucial: wealthier patients have more options while poorer ones depend on the solidarity and support of their family, the kindness of reli- gious groups or the functioning of welfare schemes. Cultural, traditional and religious explanations for the disease are given and healing is often sought outside the biomedical health system before admission. The whole family sup- port the sick and share the costs by organizing money ‘from the coffers’. As the hospital is not an isolated space but is embedded in the surrounding society, the hopes of expected results, perceptions about the medical conclusion and threads of the unpredictable outcome are present in the individual patient and the family.
The inventiveness of nurses
Nurses on the ward know about patients’ fears but also have to solve problems concerning their work. In addition to dealing with the given reality, they also develop strategies to improve the situation.
Nurses regularly put their problems in coping with the workload on the ward down to poor working conditions, especially the provision and use of equip- ment. To measure patients’ vital signs, the ward has three digital thermometers, two working blood-pressure gauges with stethoscopes and one machine to check blood-sugar levels. All wards are regularly supplied with general equip- ment like gloves, normal and sterile cotton wool and gauze, syringes and plasters. The laundry service is supposed to deliver clean sheets every morning and collect the dirty ones.7 The main laundry regularly encounters problems
with water and electricity supplies, resulting in less linen or no delivery at all. In the rainy season, the drying process is slower, leading to additional shortages. Once a week, the nurse in charge files a request to the hospital’s pharmacy for disinfectant spirit, parasol and plasters. In addition, there is a basic supply of drips (normal saline and glucose), sterile urinal catheters with urine bags and
6 These stories wee revealed to the researcher in private conversations. Surgeries that
were supposed to be carried out there were caesarean sections and hysterectomies. This could not be verified with hospital officials.
7 The number of sheets collected is recorded in a booklet. Each ward marks its own
stomach probes. The reality however is that stocks of sheets and disposable gloves are limited, which leads to delays. A nurse in charge reported:
Supply is our problem. We make an annual budget and estimate the number of patients, gloves and everything that will be needed. You know, on other wards, they are not so ill, so you do not need so many gloves there. But here, people are sick. Normally they should supply us with equipment twice a week. We write down what we need and it is brought to us from the main supply. I think the shortage has to do with general hospital policy. There are people who say the hospital owes the main supplier money and that is why nothing is given out. Like this, all work is affected. And you know we also had a water shortage last week. There are still not enough sheets for us. On Monday they brought only a few sheets, yesterday none at all, and today five. And these are for the whole ward. And we just have two boxes of gloves for the whole day. What will happen tonight? The night nurse won’t have enough gloves to protect herself if something happens.
Every morning, the nurse in charge provides her team with sheets, a box of gloves and some spirit to disinfect wounds. She keeps the stock locked up in her office: managing the supply carefully and anticipating shortages is part of her responsibility. Depending on the number of sheets, all or just some of the beds are changed. There are sheets of different sizes, and the nurses have to try their best to guarantee no patient is lying on plastic. Nurses refuse to use the patients’ own colourful cloth as they aim to have a ‘clean white ward’. Nurses, doctors and orderlies use disposable gloves for making beds, feeding, dressing wounds, examining a patient, cleaning the ward and so on. An opened box of gloves seems to encourage staff to take several pairs and keep them for later. In the morning, a box (100 pairs) can disappear within half an hour. When later that morning, a doctor needs gloves to set a line, nurses need to insert a urinal catheter or students have to dress wounds or change a soiled sheet, searching for gloves is part of the preparatory procedure. Nurses and doctors alike complain about the shortage, while the students are frustrated and joke about it. One morning, a nursing student feeds a patient suffering from tuberculosis through a tube without wearing gloves. She says: ‘You know they have a strict glove economy here’. The matron justifies her hesitant supply: ‘I give out full boxes. Where do they all go? How can we work without equipment? I am responsible and we need to have enough in store for the doctors’ rounds, then we need to present our ward well.’
Facing shortage and shortcomings, nurses have invented several procedures to manage the situation. Most are combined with market activities, be they selling products or requesting supplies. This way they manage to organize the ward’s finances and arrange for the necessary equipment, thus coming close to realizing their idea of good nursing.
The hospital offers one way of ensuring supplies. The official measure is to fill in cost sheets per patient. This is part of every patient’s file and checked by
the matron on a daily basis. Nurses are expected to note down which items they use in the care of a patient. Standard articles are cotton wool, (disposable and sterile) gloves and plasters, and more specific items include catheters, urine bags and naso-gastral tubes (see Appendix E). When discharged, a patient will be billed for this equipment. The system aims to balance the costs for the hospital: the more equipment needed, the more one has to pay. Some nurses might pity poor patients and charge them for fewer materials but the matron ensures the correct billing. Not charging patients has direct and negative con- sequences for the ward’s status. New colleagues are instructed to understand that sufficient supply is one guarantor of appropriate nursing care.
In addition, nurses sell nursing aids that are necessary but not always pro- vided. The most obvious examples are diapers for incontinent patients and blood-sugar strips for diabetic and newly admitted patients. Nurses buy the diapers and blood-sugar strips at the nearby pharmacy and sell them for ¢ 15,000 (€ 1.50) a time. That is a bit more expensive than the original price and they buy additional cotton wool or soap for the ward with any profits. The same goes for cool drinking water from the fridge. Patients and their relatives ap- preciate this service and willingly pay for it. On admission, patients are asked to pay an additional (voluntary) amount into the ward’s funds to buy equipment that is needed. This money is kept by the nurse in charge and directly reinvested in diapers, blood-sugar strips and water, but also soap, spirit and cotton wool.
Donations are sometimes made. One example is a pledge to provide 200 sheets by the Catholic Archdiocese and four beds from an overseas NGO. If the supply of sheets worsens, the nurses appeal to visitors and patients’ families. The text below appeared on a poster at the entrance to the ward requesting help.
Special appeal: Dear valued visitor, it is our earnest desire to care for our patients in a healthy and conducive environment for their speedy recovery. We are compelled to make a special appeal to your for (1) one or two bed sheets for one bed or (2) more bed sheets for more beds or (3) material for bed sheets or (4) a token amount of money for the purchase of material for bed sheets. Measurement: 180 cm by 270 cm. We would cherish your contribution as a special gift to our ward K and our patients. God loves a cheerful giver. May God richly bless you! The Entire Nursing Staff.