“Every day, some children die here.”

Inside the Korle Bu children’s Ward Story by Jamila Akweley Okertchiri

Georgina Afum sits confused and helpless as she wipes saliva from her five-year-old son, Gideon Sam, who lies helpless on one of the few beds in the children’s emergency ward of the Korle Bu children’s hospital. His body trembles uncontrollably every few minutes and stops only after discharging saliva from his mouth. Even though the nurses had given him medication, his condition remains unchanged, as he has the seizure every few minutes. “Three days ago his body temperature rose, so I bath him and gave him Para,” she says. “The following day, at about 12 noon, his temperature rose again, so I bath him and gave him Para. He ate and went out to play. But about seven o’clock in the evening, he had convulsion.” She took him to a clinic, was given medication, and then took him home again. But the convulsions persisted. She took him back to the clinic and was referred to Korle Bu, which is a tertiary facility, part of Ghana’s three-tier hospital structure. “The convulsion is now coming continuously,” she says, “and I don’t know what to do.” She says she has National Health Insurance (NHIS), but has not renewed it and will have to pay the hospital. Sickness And Poverty According to Professor Bamenla Goka, Head of Department of Child Health at Korle Bu, sicknesses are common in people with poor backgrounds because of their living conditions. She says poor people are more vulnerable to infections that can damage the organs in the body, like the heart and kidneys. Complicating the picture is the high cost of health care for people without NHIS. They will often try a number of home remedies before taking their child to hospital. “Many of the illnesses we see are related to poverty in one way or the other,” Prof. Goka says, “and because their parents do not have the financial means, they tend to wait and try alternate forms of care because they are afraid of the hospital bills. And when those alternate forms don’t work, then they try to come to the hospital.”

Theresa Mensah is the mother of eight-year-old Christopher Mensah, who is suffering from an unknown ailment. His face is puffy and swollen. “He came home one day from school and I saw that he had rashes on his skin,” his mother says. “So I gave him a painkiller.” She waited two days, and the swelling continued. She took him to a doctor at Boadua, in Asamankese area, and they were transferred to Kade to see another doctor. According to Theresa, who is a farmer from Asamankese, they stayed for three months at the hospital at Kade before they were referred to Korle Bu. “The doctor said the ailment has reached a critical stage,” she says, “and they needed to conduct a test, which the hospital doesn’t have the machine for.” Prof. Goka expressed worry over the amount of time it takes guardians and parents to bring their children to the hospital. She said a lot of children are brought in almost dead because their guardians do not realize how seriously ill they are. “Every day, some children die here,” she says. “Over 80 per cent of the children who die here die within 24 hours of getting here. This we call, ‘brought-in-dead-people.’”

Dr. Afisah Zakariah is the head of the Policy Planning, Monitoring and Evaluation Directorate of the Ministry of Health. She seems surprised at Prof. Goka’s claim. “This is sad,” she says. “Maybe what we have to do is audit child death so that we actually see what is going on. It is good this has come up if every day we lose a child then we have to sit up.” Dr. Zakariah says there are many policies in place to ensure the health security of children, whether rich or poor. “We give the pregnant women tetanus vaccination because some deliver at home or with a traditional birth assistant,” she says. “So we try to protect them against tetanus, including their babies. And when the children are born, we give the children nine antigens by the time they attain one year.” Those antigens include diphtheria, TB vaccine, polio vaccine, hepatitis B, yellow fever, and measles. She said the ministry plans to introduce vaccines for rotavirus and pneumonia next year. These, she stressed, are free. “The other thing we are struggling with now is malaria,” she adds. “It is endemic here, and we are trying multiple approaches to solve the situation.” She said the ministry promotes insecticide-treated bed nets and combination therapy. They also use an indoor spray that kills mosquito larvae. However, recently studies suggest that treated bed nets are not potent to tame thae mosquitoes. General Challenges In Child Health Although Dr. Zakariah says NHIS covers all of Ghana’s poor people, some residents go without, as did Georgina Afum, who forgot to renew it. Prof. Goka says such situations are common, and parents therefore have to pay for medical treatment. Even for those who have health insurance, services such as MRI scans are not covered. “Now, health care is not free,” says Prof. Goka. “If you don’t pay for the health care yourself, then somebody else is paying for it, either the government or some form of insurance will be paying for it.” Prof. Goka notes that even for those who are paying cash and carry, the fees are highly subsidized. “So the health institutions are not really run on fees that are charged to patients, because they are really far below what is required to provide the direct care that the patient needs and at the same time buy equipment and all that to use for the patients.” According to Prof. Goka, this makes it difficult for individual facilities like Korle-Bu to generate their own revenue through service delivery. She says the hospital endures a shortage of equipment. Sometimes, only one piece of equipment is available throughout the whole hospital, and it will break down a lot because it is overused. She also says patients are occasionally sent outside Korle Bu for tests, which drive costs up further. But Dr. Zakariah says Korle-Bu is just one of many agencies in the Ministry of Health. It has its own chief executive officer, its own financial means, and its own priorities. They manage their resources themselves,” she says. “So they can choose to buy equipment if they want. It depends on the area they want to invest in. We don’t take the money from them. They pay directly. When they take care of the patients, all they do is submit claims to national health insurance authority, which is also an agency under the Ministry of Health, and then they will reimburse them the money.” Dr. Zakariah also says a needs assessment was done with Ghanaian hospitals last year, including Korle-Bu. The assessment has so far produced equipment for hospitals in seven regions, though not yet Greater Accra Region. That, says the Ministry of Health, will come next year. “We definitely cannot do that with cash and carry and NHIS fees that are paid to us,” says Prof. Goka. “So for us to take care of children there has to be additional money for us to take care of the infrastructure and equipment. For example, right now our emergency room is in a very bad state. We know the government is aware of this. But we’ve been waiting for years, and we want a change now.” The Korle Bu Children’s Emergency Unit The emergency unit, which acts as a resuscitation point for every child brought in, is small, dark with very few beds and packed with patients and their parents. “We have lots of problems here,” says a senior nurse who wants to remain anonymous. “When there are emergencies, all hands are on deck. Bring plaster, cotton. You are turning here and there. At the end of the day, when you sit down, you then start feeling pains all over your body. “Sometime when I remove this shoe,” she elaborates, “I cannot even walk home; I just try to take one step at a time like a baby crawling because I have been running too much. When I manage to get home, I can’t sleep. I don’t know why I can’t sleep. I just feel like sleeping but I can’t sleep.” She complains about the way parents treat nurses, saying they don’t understand what goes into health care and they too often complicate the situation by avoiding hospitals. “We are few in this place but we work hard. The parents of the children do not appreciate our work. The public should know that when their child is sick, they should come to the right place.” Despite that aversion, the emergency room is often packed with patients. There can be several to a bed, says the nurse, a reflection of the whole children’s ward, which has 250 beds and runs, according to Prof. Goka, at 120 per cent capacity. “This place is very hectic,” the senior nurse says. “The beds are very few. We need new beds and the place must be expanded. Sometimes, when it comes to epidemic like cholera, we are forced to pile as many as six, sometimes eight, children on two beds because we make sure every child that is brought here gets the first resuscitation treatment before they are sent to the wards.” Whether or not Korle-Bu sets its own priorities, Dr. Zakariah agrees with Prof. Goka on the state of the emergency unit. “The emergency ward is small and crowded,” she says. According to the senior nurse, morale in the emergency unit is ‘zero.’ She goes on at length about the delay of her Single Spine Salary (SSS) transfer, a complaint that Dr. Zakariah says nearly brings tears to her eyes. “We all want higher salaries, but at times we should do a little bit of analysis,” she says, asserting that 95 per cent of the country’s health budget goes to salaries. “Maybe they don’t know the amount that is paid for salaries, but objectively they know that what they take home at the end of the year is much better than what the civil servants take home.” It’s entirely possible, says Dr. Zakariah, that nurses will see their salaries cut when the SSS policy takes effect. Government’s Role The Convention on the Rights of the Child, of which Ghana is a signatory, has a provision guaranteeing health care for children. Children’s health also figures prominently in the United Nations Millennium Development Goals, which Ghana has also signed. Finally, chapter 34 (2) of the Constitution also guarantees the right to good health care. “Children’s health should be given priority,” says Prof. Goka. “It should not all be lumped together with adult problems.” She says if the country has healthy children then actually, “we will have healthy adults and we will spend less on covering adult issues.” She notes that many of the diseases such as, hypertension and diabetes can be traced back to childhood ailments that were not fully treated. “Paying attention to people’s education, housing, food availability, and environmental sanitation will all help to keep people healthy and reduce the need for curative services,” she adds. Dr. Zakariah says the Ministry of Health is very active in Ghana, and that all of its agencies work hard. She takes pride in the country’s battle against guinea worm, which the vice president recently called a categorical success. Even though recent indicates that guinea worms eradication was far from over in the country. She also underscores the country’s success in the fight against HIV/AIDS, saying the prevalence rate is now 1.5 per cent, down from 2.9 in recent years. As for covering MRI scans and similar procedures, she says the NHIS is a creature of tax revenue. “We started by covering almost 95 per cent of the diseases we have,” she says, “and so the load on the insurance is quite heavy, and the majority of the people are in the exempt category: Children below eight years of age, those above 70 years, the very poor in society, pregnant women.” Prof. Goka agrees that NHIS is a powerful tool in the country’s health care system. It should only be improved, she says, never scrapped. “And with that,” she says, “we note that effort has been made to make access for children under the age of 5 easier under the National Health Insurance, and they are the children who are most at risk.” She wants to see children 12 years and under receive the same status. She would also like to see the scope of services covered widened. “We think the that government should subsidize the care of the children in another way, form another source, so that we can actually have the equipment and all that we need to work with,” she says. Dr. Zakariah says the government has a series of programs in place to attract donations and partnerships with third parties, like corporations and NGOs. “That is one of our core mandates,” she says. “Resource mobilization, planning, monitoring and evaluation. And we budget for that. “So we have the government side and the non-government side. We have development partners and other individuals donating things to the health sector of Ghana.”