Global Perspectives in Plastic Surgery: View of Plastic Surgeons From Ghana

Abstract

Background:

Ghana is a low- and middle-income country, and providing universal health coverage for its population of more than 30 million is a significant challenge. The predominantly rural population lacks access to essential reconstructive surgery services. In urban areas, where reconstructive services are available, they are not affordable for most patients.

Methods:

This article identified the challenges faced by plastic surgeons in Ghana and proposed potential solutions.

Results:

Ghana’s National Health Insurance Scheme, although a significant step toward universal health coverage, does not cover the cost of most essential reconstructive procedures. This places a significant financial burden on patients and their families, often leading to delayed or foregone treatments. The number of plastic surgeons in Ghana is small and is disproportionately located in Accra and Kumasi, 2 of the biggest cities. The lack of financial compensation models to encourage plastic surgeons to provide reconstructive services in rural settings means that most plastic surgeons will continue to be based in urban areas, where opportunities to engage in financially rewarding cosmetic procedures exist. The infrastructural and logistical challenges also deter plastic surgeons from leaving urban centers, as most regional and district hospitals are not equipped for reconstructive services.

Conclusions:

Challenges affecting essential reconstructive services in Ghana include the uneven distribution of plastic surgeons and the lack of effective financial compensation models. Potential solutions include the need for a more equitable distribution of plastic surgeons, the development of financial compensation models for rural service, and the enhancement of regional hospital infrastructure.

Takeaways

Question: What are the key areas of need for plastic surgeons from Ghana to improve service delivery to patients requiring reconstructive surgery?

Findings: Well-tailored training models, international collaborations, and effective financial compensation models can be the catalyst for ensuring equitable access to reconstructive services in Ghana.

Meaning: Addressing the inadequate and uneven distribution of plastic surgeons in Ghana is essential to improving access to essential reconstructive services.

INTRODUCTION

Ghana is a low- and middle-income (LMIC) country in West Africa that has made significant strides in the health provision space.¹ The Korle-Bu Teaching Hospital is the premier hospital in Ghana, and it is the largest in West Africa and the third largest in Africa. The Korle-Bu Teaching Hospital has been at the forefront of healthcare delivery in West Africa since its establishment in 1923, serving many other West African states, including Gambia, Sierra Leone, and Liberia. The hospital has 4 centers of excellence, including the National Reconstructive Plastic Surgery and Burns Centre, which has grown to provide a wide range of plastic surgery services.

However, before 1993, Ghana had no plastic surgery services for its population. It was the foresight and work of Professor Jack Mustardé, a retired Scottish plastic surgeon, that led to the establishment of plastic surgery services in Ghana. Professor Mustardé was the leader of a team assembled by Rotary International for a surgical mission to Ghana. He later remarked, “There were lots of congenital deformities, cleft palates, twisted limbs, burns, tropical ulcers. There was work to be done.”² He saw a great need for plastic surgery and took the arduous steps that led to the establishment of plastic surgery services at the Korle-Bu Teaching Hospital in Accra and shortly after, at the Komfo Anokye Teaching Hospital in Kumasi. The provision of plastic surgery services is concentrated mainly at these 2 centers in Accra and Kumasi, with the National Reconstructive Plastic Surgery and Burns Centre in Accra offering a wide range of services.

Today, Ghana has 30 plastic surgeons serving a population of more than 30 million, or 1 plastic surgeon per million population.^3,4 In contrast, the United States has 22.7 plastic surgeons per million population.^5,6 These plastic surgeons are distributed in only 4 of the 16 administrative regions of Ghana, with 90% of them located in the metropolitan areas of Accra and Kumasi. This uneven distribution of the skilled workforce significantly hampers equitable access to healthcare services and hinders the attainment of universal health coverage for all, as envisioned in Goal 3 of the Sustainable Development Goals proposed by the United Nations Department of Economic and Social Affairs: Ensure healthy lives and promote well-being for all at all ages.⁷

The commonly managed cases that require reconstructive services include chronic lower limb ulcers, keloids, acute burns and burn contractures, cleft lip and palate, congenital hand anomalies, traumatic injuries, and chronic lymphedema, among others. The demand for cosmetic procedures, including liposuction and abdominoplasty, has increased significantly in recent years. Despite the challenges, the plastic surgeons in Ghana demonstrate remarkable dedication. They primarily focus on performing needs-based surgery during official working hours, with most cosmetic procedures performed after working hours. This commitment to serving the community is truly inspiring.

Plastic surgery is a relatively young specialty in Ghana and has many unmet needs. However, there is significant potential for improvement. The areas to highlight in this miniseries include improving human resources, infrastructure and logistics, healthcare financing, and compensation, offering hope for the future of plastic surgery in Ghana.

WORKFORCE NEEDS

In Ghana, there is a general shortfall in the health workforce, characterized by significant inequities in its distribution, where metropolitan areas are well staffed compared with rural areas.⁸ This is particularly evident in the field of plastic surgery, where there are no plastic surgeons in 12 out of the 16 administrative regions of Ghana, leaving many patients requiring reconstructive services unable to access them. The need for more plastic surgeons in rural areas is crucial to ensure equitable access to healthcare services. Plastic surgeons in Ghana adopt a mixed model where they predominantly provide needs-based reconstructive services during official working hours and provide cosmetic surgical services during after-work hours in the government sector.

Plastic surgeons from LMICs need to provide high-quality data that can provide compelling arguments to help direct government funding in plastic surgery. The scale of work in Ghana, since the days of Jack Mustardé, has significantly increased due to greater awareness of the potential of plastic surgery. However, plastic surgeons need to provide compelling evidence of this unmet need to help direct government funding and investments in plastic and reconstructive services. Plastic surgeons from high-income countries can form effective collaborations with their colleagues from the LMIC in the areas of clinical fellowships and research. Clinical fellowships in high-volume centers are necessary to help build expertise in the ever-growing field of plastic surgery. Burn injury outcomes are often so much better in high-income countries compared with LMICs.⁹ Therefore, making clinical fellowships available for plastic surgeons from LMICs to gain experience in well-resourced treatment centers can help improve outcomes. Research fellowships to help develop the research capabilities of plastic surgeons from LMICs would be a step in the right direction.

Plastic surgery is a specialized area that requires the increasing numbers and expertise of plastic surgeons in Ghana to be mirrored in the other members of the multidisciplinary team, ensuring that the necessary reconstructive services can be offered to the population. The National Reconstructive Plastic Surgery and Burns Centre has taken practical steps to improve the pool of professionals needed in plastic surgery through its Diploma in Plastic Surgery and Burns Nursing program. This program has trained nurses in burn care from all over Ghana and the West African subregion. However, a full complement of professionals is required, including physiotherapists, dietitians, clinical psychologists, occupational therapists, and others. Therefore, there is a need to develop a comprehensive surgical plan that holistically develops other members of the surgical care team.^10,11 Indeed, Ghana has only 68% of its general health workforce employed in service delivery.^8,12

INFRASTRUCTURE AND LOGISTICS

The infrastructure in Ghana has not kept pace with the increasing number of plastic surgeons. In Ghana, only the National Reconstructive Plastic Surgery and Burns Centre has a functional operating microscope. This significantly limits the scope of reconstructive services that can be provided. The National Reconstructive Plastic Surgery and Burns Centre is the largest of the 3 burn centers in Ghana, with an 18-bed burn ward and a burn intensive care unit that operates with a capacity of only 2 patients at a time. This is inadequate for the management of the large volumes of burn injuries, which average 51 cases per 100,000 population.¹³ These 3 burn centers are only available in the southern part of the country, leaving the poorer northern part of the country without access to timely, essential burn care.¹⁴ The infrastructural and logistical deficits are evident in every part of Ghana’s healthcare delivery system, and innovative solutions are needed to address these issues.¹²

To address the infrastructural and logistical gaps, the hub-and-spoke model could be adopted.¹⁵ The hub-and-spoke model describes a central “hub” that is well-resourced and connects to multiple “spoke” locations that are less resourced. The less resourced spoke locations can undertake less complex reconstructive services, whereas the more complex reconstructive services are carried out at the better-resourced hub.

This model enables the established and well-resourced hubs to serve as points of local training and expertise dissemination across the country. The transfer of patients from the spoke locations to the hub is facilitated due to the existence of direct contact between the hub and spoke locations. This model has the most significant potential for enabling meaningful collaboration between surgeons in LMICs and their colleagues from high-income countries, as the hub can provide resources similar to those found in high-income countries. This model also allows high-level training to originate locally and extend to the country’s peripheries.

HEALTHCARE FINANCING

Although Ghana has a National Health Insurance Scheme that has improved access to essential surgical care, this does not cover most plastic surgical procedures, which are often mistakenly considered nonessential. Indeed, patients make more than 90% of out-of-pocket payments for their surgical procedures.¹⁶ Burn care is most significantly affected by the poor healthcare financing model, where most of these injuries result in very high expenditures.^10,17 The current model, where the National Health Insurance Scheme allocates $100–120 for the inpatient care of severe burn injury patients, is highly inadequate and hampers the timely care of such patients. The institution of a separate burn fund, where the government, partners, and individuals can donate toward burn care, could help alleviate the cost burdens on families of burn injury patients.

COMPENSATION

Plastic surgeons in Ghana are victims of the general poor remuneration in public hospitals. This has led most plastic surgeons to adopt a mixed model of providing needs-based surgery as well as cosmetic procedures to augment their incomes. In the government sector, plastic surgeons perform needs-based plastic and reconstructive surgical procedures during official working hours and then privately perform cosmetic procedures during their off-duty hours. This can be a significant strain on the limited number of plastic surgeons, and with an ever-growing need for more needs-based plastic surgical procedures, there needs to be a plan that will encourage plastic surgeons to willingly take up more needs-based surgery. A model offering reasonable compensation to plastic surgeons who perform needs-based surgery outside the major metropolitan areas of Accra and Kumasi is proposed to help improve the inequities in the distribution of the workforce. In Ghana, more than 60% of the population lives in rural areas and is most affected by access to essential surgical care.¹⁸ There must therefore be good financial packages that will encourage plastic surgeons and plastic surgery trainees to take up rural postings.

CONCLUSIONS

This article has highlighted some gaps in the provision of needs-based reconstructive services in Ghana. There is a need to train more plastic surgeons locally who are motivated to offer their services outside of the major urban centers. The hub-and-spoke model will be particularly effective in addressing the shortfall in local training of plastic surgeons, as well as tackling the infrastructural and logistical gaps. This also has the potential to foster more meaningful collaborations, leading to the sustainable transfer of skills and knowledge that enhances local capacity.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.