PUBLIC HEALTH RATIONALE FOR INVESTMENTS IN EMERGENCY MEDICINE IN DEVELOPING COUNTRIES – GHANA AS A CASE STUDY

Abstract

Background:

Ghana is a developing country that has strategically invested in expanding emergency care services as a means of improving national health outcomes.

Objectives:

Here we present Ghana as a case study for investing in emergency care to achieve public health benefits that fuel for national development.

Discussion:

Ghana’s health leadership has affirmed emergency care as a necessary adjunct to its preexisting primary health care model. Historically, developing countries prioritize primary care efforts and outpatient clinic-based health care models. Ghana has added emergency medicine infrastructure to its health care system in an effort to address the ongoing shift in disease epidemiology as the population urbanizes, mobilizes, and ages. Ghana’s investments include prehospital care, personnel training, health care resource provision, communication improvements, transportation services, and new health facilities. This is in addition to re-educating frontline health care providers and developing infrastructure for specialist training. Change was fueled by public support, partnerships between international organizations and domestic stakeholders, and several individual champions.

Conclusion:

Emergency medicine as a horizontal component of low- to middle-income countries’ health systems may fuel national health and economic development. Ghana’s experience may serve as a model.

INTRODUCTION

Ghana is a developing country recognizing the value of emergency care services to mitigate the impact of acute illness and injury. As it strives for middle-income status, investments in emergency medicine highlight the necessity of this approach in communities where medical care is most often sought in emergent situations. Clinic-based and disease-specific primary care services have historically been major pillars of health improvement efforts in developing countries (1). Access to emergency care is an underemphasized, yet essential, horizontal component of basic health services in developing nations. Health policy should include the development of emergency medicine as a means of improving health care outcomes. We use Ghana as an example of a developing country prioritizing this approach within its own unique context. This case illustrates that 1) emergency care services are a necessary component of health care for the acutely injured or ill; 2) it is a necessary adjunct to historically prioritized primary care services needed in developing countries; and 3) supporting emergency care services requires re-education of frontline primary care providers in addition to the development of new infrastructure.

BACKGROUND

Prior work comparing the health status of developing and developed countries has demonstrated that communities with more resources have improved individual and population health (1–4). Increased economic status improves living conditions and reduces rates of infectious disease and injury. In more recent decades, however, the role of improved health as fuel for a community’s economic engine has been better studied. As described by health economist David Mirvis, “Poor overall population health. impairs the economic wellbeing of the entire community or nation beyond the cumulative impacts on individuals and specific businesses. The aggregate or macroeconomic effects of improved health. impact everyone in a community–not just those who are ill” (4).

The economic importance of emergency medical services in maintaining health has been long recognized. In a landmark 1993 report on the impact of health investments, The World Bank identified six basic interventions as its minimum package of recommended cost-effective health services. Emergency care for medical and surgical conditions was one of the interventions and has since been recognized as paramount to economic gains (5,6). According to the World Health Organization (WHO), there are three fundamental functions of a health care system: 1) improve the health of the population; 2) respond to the expectations of the people served; and 3) provide protection against financial ruin from health care costs (7). Emergency care is a critical component of each.

Historically, low- and middle-income countries (LMICs) have prioritized primary prevention efforts over emergency delivery systems due to the belief that emergency care was costly and ineffective at mitigating the burden of infectious diseases. Due to shifting health needs, improvements in emergency medicine practice, and the recognized efficacy of modern emergency care systems, many experts have been calling for emergency care investments in developing countries (8). In 2007, the World Health Assembly passed Resolution 60.22, which highlighted the lead role emergency care systems can play to reduce the increasing burden of acute illness and injuries (8,9). The WHO and United Nations Children’s Fund followed by placing an emphasis on emergency-oriented care management to address contemporary population health in developing nations (10,11).

The global burden of disease is shifting, and the types of health needs addressed by emergency medicine compose a substantial share of the current and future burden (2,10–12). In 2013, injuries accounted for over 10% of deaths worldwide. The top categories of injury were road traffic injuries (RTIs), self-harm, falls, and interpersonal violence (12). More than 90% of these deaths occur in LMICs (13). Acute injuries account for more deaths worldwide than human immunodeficiency virus (HIV), cancer, diarrheal diseases, tuberculosis, and malaria (14). For every death from acute injury, an estimated range of 10 to 50 people are permanently disabled (15). With the increasing rates of noncommunicable chronic diseases (such as cardiovascular disease, diabetes, cerebrovascular disease, and respiratory disease), the frequency of acute exacerbations of chronic diseases are on the rise. Urbanization, violence, and regional conflicts have contributed to increasing injury rates (16). Most disturbing is that acute injuries are the leading cause of death among those ages 5–44 years, an age demographic representing a country’s future and those currently working to support families and the economy (17). Yet, annual global estimates for funding per daily adjusted life year is $85.21 for HIV/acquired immune deficiency syndrome and only $0.83 for acute injuries (8).

In November 2013, the African Federation for Emergency Medicine held an international consensus conference where emergency care leaders outlined medical conditions for priority infrastructure development along with associated providers skills and equipment requirements. Given the need to integrate these resources into existing health delivery systems to facilitate access via referrals, they concluded that work to advance emergency care “must occur in the context of a national health system” (18).

DISCUSSION

Ghana’s Health and Development Ghana is an English-speaking parliamentary democracy that claimed its independence in 1957. Its early history involved a series of destabilizing coup d’états, but it has experienced stable governance through the last five democratic presidential elections. Twenty-nine percent of its 27.5 million citizens live below the international poverty line of < $1.25 per day (19). In its heavily agrarian economy, agriculture accounts for 22% of the gross domestic product (GDP) and provides employment for 44.7% of the labor force (20). The country’s dependency ratio, or the ratio of population dependent (ages 0–14 and > 64 years) to those of working age (ages 15– 64 years), is currently 73% (down from 88% in 1990) and reflecting a growing adult population (20).

Ghana’s health development index as calculated by the United National Development Program was 0.579 in 2015, which is comparable with countries like Kenya (0.555) and Nigeria (0.527) (21). This is above the median for Sub-Saharan Africa (0.523), but within reach of medium health development index countries’ median ranking of 0.631 (21,22). Ghana has a fertility rate of four children born per woman, infant mortality rate of 37 per 1000 live births, and average life expectancy of 62.4 years. There are 1.1 physicians and roughly 10 nurses or midwives per 10,000 persons in the population. This amounts to less than half the WHO recommended 23 health workers (physicians, nurses, and midwives only) per 10,000 persons necessary for sufficient coverage of a country’s health care needs. Total health expenditure was 5.4% of GDP in 2013 (19). The main subsystems of health care in Ghana include public, for-profit private, nonprofit private, and local traditional culture health care providers (herbal healers, bone setters, spiritualists, and community birthing assistants). The public system is divided into functional primary, secondary, and tertiary tiers. The Ghana Shared Growth and Development Agenda and the Health Sector Medium-Term Development Plan (2014–2017) were the first national policy documents to include emergency service development as a part of the national health agenda (23,24). Here we explore the factors that began and have sustained this exemplary national commitment.

Emergency Care as a Necessary Adjunct to Primary Care

Ghana’s past health investment strategy has focused on what provided the largest historical impact on population health: early detection of childhood malnutrition, prevention of communicable childhood diseases through immunizations, and reduction of infant and child mortality. This focus placed pre- and postnatal care, childhood health, and infectious disease as the targets for health care funding. The systems built to deliver this kind of care were organized according to an outpatient primary care model, which has historically been distinguished from inpatient hospital-based care. Because emergency care was not originally included as a component of the health care investment strategy, the system was unprepared to handle health issues not addressable through routine primary care, nor the growing shift in disease burden.

In LMIC populations like Ghana, where many lack access to reliable and continuous primary care, emergency care is an essential component of secondary disease prevention and mitigating disease progression. In lowresource settings, medical attention is most often sought after the failure of traditional cultural remedies or home care and with acute injury. Thus, patients are often further along the disease spectrum, causing a larger proportion of presenting cases to be of an emergent nature (25,26).

In most of Ghana, skills for the management of acute illness do not fall clearly within the boundaries of traditional cultural medical or surgical care. In addition, the training of the majority of Ghana’s health care providers is oriented toward either an outpatient clinic or inpatient ward approach; neither of which are adept to adequately triage the emergently ill from those who may have urgent but nonemergency medical needs. To function properly, emergency care systems require providers to understand acute presentations of disease that may fall within one or both of the historically separated medical and surgical arms of health care, and obtain the testing required to differentiate them while simultaneously providing morbidity mitigating care.

Mitigating the Hazards of Development

As Ghana urbanizes and continues to industrialize, more of its citizens are becoming involved in commerce and travel. The result of the increased mobilization has been a rise in RTIs, which has ranked in the top 10 causes of death in Ghana for the last 10 years. Road traffic in West Africa has outpaced the quality of the roads and the abilities of governments to regulate vehicles and drivers. Road traffic collisions cost Ghana 1.6% of its GDP and cause around 2000 deaths annually (27–29). Furthermore, there is an uncounted population of injured and maimed individuals whose lost productivity has immeasurable negative ripple effects within families, communities, and economies.

RTIs became the major stimulus for the promotion of emergency care. It caught the nation’s attention when several of Ghana’s prominent public figures were victims. Former Presidents Rawlings and Kufour experienced motorcade-related RTIs with numerous deaths and injuries to their staff. After these incidents, the government identified a three-point approach to address RTIs as a risk to Ghanaian health: 1) primary prevention via improved road construction, traffic laws, licensing requirements, vehicle registration, and pedestrian walkways; 2) secondary prevention through reducing collision consequences (e.g., improved vehicle inspection, speed control, and limiting vehicle capacity); and 3) tertiary prevention via improved emergency care for injured individuals.

Furthermore, several mass casualty situations in Ghana’s recent history highlighted the need for effective emergency response systems and health care workers trained to manage large-scale disasters. In 2001, an Accra soccer stadium collapsed, creating a large number of injuries. Taxi drivers were the primary means of transportation to hospitals, whose outpatient clinic models were overrun and ill-equipped to triage and stabilize patients in an efficient manner. Among the injured were national and cultural figures. The loss of life, social angst, and occurrence during a primary sporting event brought national attention to the lack of emergency transportation and care.

With Ghana’s annual rate of urbanization of 3.4%, 54% of citizens now live in urban centers, up from 29% in 1970 (20). The social migration and increased urban density contribute to increased injuries and incidence of infectious disease transmission. The urbanization seen in developing countries is contributing to increased vulnerability among the poor. The poor, who comprise the majority of native population growth, are the least socially empowered, most under-resourced, and at highest mortality risk from infectious diseases (30). As a result, acute presentations of both infectious and injurious disease are expected to increase.

The Start of Emergency Medicine in Ghana

After a 2001 publication demonstrating a lack of sufficient emergency care in Ghana for tertiary facility patients in emergency departments (EDs) compared with similarly injured patients in the United States, the Ghanaian government asked Dr. Paul Nyame, then president of the Ghana College of Physicians and Surgeons, to identify which physicians should manage various health care situations (31). Dr. Nyame identified emergency medicine specialists as those trained to receive and stabilize individuals with acute illness or injury while identifying whether the cause and course of continued care is surgical or medical in nature. At the time, emergency medicine was not a specialized training path within the medical educational system for nurses or physicians. Dr. Nyame was tasked with outlining the means of developing a cadre of emergency medicine specialists, increasing emergency responsiveness, and developing the national tentacles of an emergency response system based at a central tertiary care hub. Through this work he became the national champion for emergency care. The University of Michigan had previously made a long-term commitment to the Ghanaian health system’s human capital development. They were approached for assistance (see Figure 1 – Initiating Emergency Medicine in Ghana: Timeline of Key Events and Developments).

Figure 1.

Initiating emergency medicine in Ghana: timeline of key events and developments. WHO = World Health Organization.

A mix of Ghanaian and international stakeholders recognized these training challenges and formed a collaboration that has brought emergency care development to the forefront of Ghana’s priorities. In 2008, six institutions (Kwame Nkrumah University of Science and Technology, Komfo-Anokye Teaching Hospital [KATH], Ghana Ministry of Health, Ghana College of Physicians and Surgeons, Ghana’s National Ambulance Service, and University of Michigan) established the Ghana Emergency Medicine Collaborative, with the goal of establishing high-quality emergency care training to the Ghanaian medical workforce. They have focused their efforts on sustainability and country ownership within the Ghanaian context (27). Their work created the blueprint for the training system and operations of emergency care in Ghana.

In the wake of this work, the Ghana’s Ministry of Health subsequently identified emergency care as one of its seven priority areas in 2009 (28,32). Five landmark developments subsequently occurred. First was the opening of a state-of-the-art tertiary care Accident and Emergency Center at KATH. Kumasi was a strategic location for this tertiary care hub. The major highways leading to Ghana’s southern port cities, which propel international commerce in the region, meet here, and the Ashanti region also experiences the highest incidence of RTIs in Ghana (32).

The second major development was the creation of emergency–medicine-specific training pathways started with the first West African emergency medicine residency (32). The existing model for emergent evaluation at KATH would not be sufficient to meet the future needs of emergency care in the region. In the outdated system, cases were seen in a delayed fashion through outpatient evaluation on a first-come first-served basis, with sick patients being sent to the Casualty Ward, which served as an observation unit, an intensive care unit, and even a trauma bay. The growing need for specialized providers who could identify and stabilize life-threatening illness and initiate care, triage patients for the various medical fields, and eventually provide leadership throughout the country’s health facilities drove the decision to start the residency (33). The program graduated over 50 emergency physicians at the end of 2016. The Kwame Nkrumah University of Science and Technology followed with a 2-year graduate degree (BSc) in Emergency Nursing, with which several hundred nurses have graduated (33,34).

Integrating the new emergency medicine presence and skill set into the existing KATH system was not without difficulties. Departmental development included educating inpatient services about the mechanics of the new emergency medicine system, establishing call schedules and consultation policies, introducing an efficient triage system, and negotiating agreement on hospital admission processes. KATH’s emergency center now sees roughly 35,000 patients annually and has a 40% admission rate. The center occasionally experiences overcrowding, long wait times, equipment failure issues, low drug supplies, and negative consequences from poor hospital communication. Despite these growing pains, the training program is improving. In addition, the KATH emergency center benefits from continuous emergency physician presence, formal handovers at shift changes, clinical guidelines, regular didactic training sessions, and a triage system (33).

The third major development of 2009 began with the creation of the National Ambulance Service (NAS). Each district was supplied with at least one vehicle with drivers who would provide transportation alone. Initially, ambulances were used only for interfacility transfers. An emergency medical technician (EMT) and paramedic training program was piloted via a collaboration of the NAS, regional directorate offices, the national fire service, and Motec Life, a UK-based nonprofit focused on providing health care services in West Africa (34). As of 2013, the NAS had 33 ambulances, and was in the process of acquiring 161 more. There are over 500 Basic EMTs providing Basic Life Support and prehospital care in Ghana, and a 2-year Intermediate EMT training program has recently been established (34). In 2014, the NAS ambulances performed 8000 patient transports, about 70% of which were interfacility transfers. This is thought to be due to slow community adoption, long travel distances between facilities, and limited infrastructure (34–37). However, by 2014 the proportion of the population with access to a NAS station within 60 min rose from 48% to 79% (36). Public private partnership and technologic extension are currently being explored to increase access via private emergency transport adjuncts and drone-based telemedicine in rural areas.

Emergency Systems Development at the District Hospital Level

The fourth development occurred when the Ministry of Health’s implementing arm, the Ghana Health Service (GHS), partnered with the Columbia University sid-HARTe (Strengthening Emergency Systems Program) to 1) increase communities’ access to acute care services and 2) enhance the abilities of health facilities to respond to life-threatening conditions at all levels of Ghana’s health system (37). From 2009–2011 they worked to build emergency medicine human resource capacity of two municipalities, Mampong and Kintampo, in the Ashanti and Brong Ahafo Regions of Ghana, respectively. They then used the training system to develop an Acute Care 5-day In-Service Training Course for physician assistants now delivered in five regions of Ghana, reaching 61 physician assistant students. After the program’s success, GHS Institutional Care Division established the Ghana Acute Care System Strengthening Program Emergency Medicine Technical Working Group—made up of frontline Ghanaian Emergency Medicine providers—to modify and approve components of these programs for the Regional Health Directorate in the North District. The modified tool kit was developed and implemented successfully. It has since been modified and scaled for use in Rwanda.

The fifth achievement was the 2012 development of the Sustainable Emergency Referral Care program (SERC) in the Upper East Region to improve the patient referral network of this more remote and resource-challenged section of the country. Health service statistics show that pregnant women at the time of delivery comprise nearly 90% of all emergency cases. The SERC pilot was developed and launched in consultation with community leaders, women, and workers about practical means of strengthening emergency referral systems for all emergencies with attention to maternal and child health. The pilot ran from March to July 2012 and included implementation sciences studies to determine whether the placement of hubs addressed need, to field test response vehicles in the context of local road conditions, and to monitor the improvement of response delay. Study results were used to scale up the system to an additional 12 sub-districts. National discussions are currently underway to develop a nationally scaled program.

Next Steps

This early work has laid a foundation for emergency medicine in Ghana. There are, however, major challenges ahead. These include surmounting further integration of emergency care units within hospitals; creating systems for blood availability for critically ill emergency patients; ensuring a more equitable distribution of emergency care specialists, skills, and training; strengthening emergency referrals and ambulance transport from accident-prone sites; ensuring consistent funding for NAS; and developing emergency care research. Current activities areas of innovation include public and private partnerships to employ air ambulances, drones, and telemedicine to aid the extension of care networks to rural areas.

Limitations

Ghana’s experience may not be generalizable. Its history includes significant colonial infrastructure development prior to its early independence, no recent violent conflicts, the unique acute events that highlighted the need for emergency care services, and several prominent individuals willing to champion the cause. In addition, the opportunity for emergency medicine development arose from a very public tragedy combined with the availability of a well-poised champion and existing international medical partnerships. This combination of opportunities is difficult to replicate. Ghana has invested in a resource-intensive approach starting with centralized infrastructure that is extending to the community, while initiating the development of multiple facets of infrastructure and personnel in a simultaneous fashion. The political will and funding required for this approach are challenging in many LMICs. Ghana is currently facing sustainable facility and ambulance service financing challenges as donor capital investments and start-up financing come to an end (38). Other countries have developed infrastructure via a more decentralized approach in which 1) ambulances serve as an extension of the hospital system integrated with rural transport, rather than a centralized national service; and 2) Accident and Emergency departments are included in the design of all new hospitals. Multilevel frontline provider training, from community health posts (via programs like SERC) to tertiary care residency training, has introduced emergency medicine. Assuring population impact, however, will require more resources to follow.

CONCLUSION

Investments in emergency care systems in LMIC are early, with little documented in the literature. Ghana is an early adopter in Sub-Saharan African, and it is additionally unique given the intense development approach. Emergency care systems are necessary adjuncts to primary care and a critical horizontal component of LMIC health care systems. Ghana has addressed many core components of high-functioning emergency care systems: prehospital care, personnel training, resource provision, communication, transportation, the state of health facilities, and the financing of emergency care. Integrating a robust acute care system within a preexisting national health system is not an easy task, yet this approach provides a centrally managed system responsive to local needs. By garnering public support and creating partnerships between international organizations and domestic stakeholders, Ghana has made progress toward a health care system that is responsive to Ghana’s shifting epidemiology and supports economic growth.