Summary of Ghana Out Of Program Experience
OOPE
6 August 2009 to 30 October 2009
By Dr Clive Stanton
I spent the last 3 months of an extended out
of program experience in Ghana through a joint Challenges World
Wide (CWW) and Royal College of Psychiatrists Board of
International Affairs initiative. The program was developed
by Professor Sheila Hollins and Dr Deji Oyebode in conjunction with
South West London & St Georges Mental Health NHS Trust.
Our Training Program Director Dr Peter Hughes,
himself extensively travelled, with a distinct interest in
international psychiatry helped with the program at the Trust.
I have been an observer and traveller in
Sub-Saharan Africa. This time I wanted to contribute to a community
by sharing my skills and embracing culture through participation.
This would not only be a rewarding professional experience but an
enriching personal one.
Background
Ghana has a population estimated to be over 24
million people with about 50% living rurally. There are three large
psychiatric hospitals that serve the entire country. Accra
Psychiatric Hospital (700beds), located in Central Accra. Pantang
Hospital (500beds), located on the Northerly outskirts of
Accra. Ankaful Hospital (500beds) located along the Coast to
the West of Accra at Cape Coast. These hospitals provide in
conjunction with some community psychiatric nurses the statutory
psychiatric services. There are some private services
available (mainly in Accra) and other NGO funded initiatives
particularly in more rural areas of the country.
At the time of writing there were only 5
consultant grade psychiatrists practicing in the statutory services
and 15 medical assistants (MAs). The bulk of the service is
provided by MAs. They are qualified nurses that spend 6 months on a
specialised training course to diagnose and manage (including
prescribing) a range of medical conditions, including mental
disorder.
A friend and colleague of mine Dr Jim Crab had
embarked on a similar Ghana experience just prior to the inception
of this initiative under his own steam and I was keen to
follow. Dr Norman Poole the pioneer of this particular
initiative actually worked alongside Jim in Pantang Hospital!
Drs Abdi Sanati and Olimpia Pop had developed
the program mainly at the Accra site in a more central location
with Dr Akwasi Osei (Acting Chief Psychiatrist, Ghana Health
Service).
I was tasked with developing the service back
at Pantang again, located in a suburb on the outskirts of Accra
about 2hrs from Accra Psychiatric Hospital, though probably only
10miles as the crow flies! The site is over 365 acres in size. It
was opened in 1975 before it was completed, hence, the many disused
and unfinished buildings. Dr Anna Dzadey provided in country
mentoring, Dr Peter Hughes UK mentoring and Dr Norman Poole
research supervision. I also met with Dr Akwasi Osei to discuss the
overall program as the Chief Psychiatrist of the Ghana Health
Service.
My work was split between service provision,
teaching & training, research and service development. This
report outlines the structure, the challenges and the rewards of
the experience and makes recommendations for the future of the
program.
I must state at the outset that this was for
me the best professional training experience of my life and one I
thoroughly enjoyed, even more so on reflection!
Service Provision
When I was at Pantang there were only two
qualified psychiatrists. Dr Dzadey the medical director who was
exhausted with hospital administrative work and understandably
unable to see many patients. The other consultant psychiatrist was
Dr Mfodwo who was in the process of transfer across to Accra
Psychiatric Hospital. That left just three MAs to provide almost
the entire service.
It was necessary for me to participate in out
patient clinics to gain trust amongst colleagues and first hand
experience of the difficulties facing the clinicians. This in turn
informed my teaching and service development focus.
I encountered significant challenges. The
clinics are drop in, first come, first served. The queues were long
and patients would come from distant parts of the country with
little resources themselves. Often the patients could not
speak English. Sometimes I had to translate through two people who
understood an intermediary language.
A common care pathway would be illness
emergence at home. Containment within the family, followed by
containment within the community. Then usually a Prayer Camp
intervention would be sought privately. This would involve several
days or even weeks of continuous prayers at the very least. If this
intervention was unsuccessful, as it often was, then the family
would seek help at the hospital as a last resort. This was
the pathway for a range of illnesses.
Commonly I saw Epilepsy, Learning Disability,
Drug induced psychosis, functional mental disorder and often acute
medical conditions, especially in relation to infectious disease
and neuropathology. Somatisation and conversion were not as
common as I had anticipated.
The Main Entrance at
Pantang Hospital
Ward rounds were conducted on an ad
hoc basis by the MAs. I decided to focus on just two acute
wards in a basic service development project outlined below. I had
to address the MAs lack of knowledge of their own inpatients. I
approached the medical director for folders and devised a simple
system for them to record each admitted patient with review dates
in a book that they would keep with them at all times. At first
there was a reluctance to use the folders but they could gradually
see the benefits to both the patients and themselves.
Teaching and training @
Pantang
The Medical Assistants
completing a test in one of the clinic rooms at Pantang
Hospital
This was where I focused most of my energy.
Instead of conducting clinics alone I spent most of my time in
clinics with the MAs. I would see the patients with them, initially
showing them how to conduct proper assessments to arrive at solid
differentials to inform appropriate management. After a few times
observing, they would then conduct the clinics with my supervision
and I would teach them in real time. I found this to be the most
effective way to change their practice. I would spend one morning a
week with each MA and then take a different MA on a ward round in
the afternoon on 3 days of the week.
For the Pantang MAs I prepared daily teaching
for three days of the week and insisted that each one present a
case for discussion each week. We used to meet early to minimise
the disruption to the clinic, after all there was no one else to
cover for them!
I had a busy time-table.
I focused on a service development project on
the wards and tried to tap into the huge resource of the nursing
staff (over 150).
The Nurses and Nursing
Students gather on ward 8 for ward round at Pantang Hospital
Service Development @
Pantang
With advice from Peter Hughes in the UK I
tried to help implement a new named nurse system so that each nurse
would take responsibility for certain patients. They would need to
spend 1:1 time with each patient each week and write a clear entry
in the notes for the ward round. Dr Pop had successfully
implemented such a system at Accra. Unfortunately I think I started
this too late in the day and it was met with some inertia, so it
has probably not been sustainable. I combined the project with a
weekly teaching for the nursing staff.
The Nurses and Nursing
Students gather for weekly teaching in the conference suite at
Pantang Hospital
Teaching @ Accra Psychiatric
hospital
The program rightly focused on the teaching of
the MAs but I was placed at Pantang with only 3 MAs, whilst there
were 7 MAs at Accra. My predecessors had variable luck with
attendance due to the logistical difficulties of travelling between
the two sites. I decided that it would be easier and more exciting
for me to make the trip once a week to Accra rather than have 7 MAs
leave clinic to come and be taught at Pantang. The journey
was about 2 hours by local Tro Tro (minibus) through dense traffic.
I had to prepare a completely different teaching program for the
Accra MAs. They would only see me once a week so I set a timetable
for thorough presentation and discussion, homework and interactive
teaching with lots of tests. The MAs responded well and their
attendance was excellent. They were engaged and lively and I think
learnt an enormous amount.
Some of the Medical
Assistants gather for teaching at Accra Psychiatric Hospital
Research @ Pantang
Following Dr Poole’s initial research into
Insight in a population in Ghana we met to discuss developing the
research further on his return, so that I might continue in a
similar vein with similar interests in insight. Dr Poole devised
the research protocol and I set about testing the relationship
between insight, affect and self-deception in a sample of Ghanaian
patients that spoke good English. I completed 4 different scales on
50 different patients in the one day of the week I assigned in my
timetable.
Challenges
Ghanaian culture is extremely laid back. It
was difficult to organise and motivate the Pantang MAs to come to
my teaching. I found that although they did subjectively prefer a
more didactic approach to teaching they did not engage particularly
well. I tried a range of different teaching styles to motivate the
MAs and in the end found a combination of real time interactive
case based discussion whilst seeing a patient or just after seeing
a patient provided the greatest change in cases of poor practice.
In more didactic settings I found that asking a series of prepared
MCQs for different topics generated enthusiasm.
Some of the patients were plum lucid and had
been for years but families had never come to pick them up. People
with physical disorders were routinely admitted to the wards. Often
they were misdiagnosed as having functional conditions or otherwise
because they had epilepsy for instance which falls into the
psychiatric remit in Ghana.
To address the difficulties of the wards I
tried (albeit too late) to implement a named nurse system. The
nurses I worked with were excellent.
They were very responsive to teaching. There
was a real sense that they wanted to improve their knowledge and
skills and I encouraged many of them to apply for the MA
course. They are a large staff body and although
hierarchically less powerful their size gives them real power for
supporting change.
There needs to be more investment in resources
throughout the hospital. I note that since Dr Poole has been, a new
laboratory had been built with help from the AIDS Commission, a new
farm had been built for rehabilitation with help from Basic Needs.
A new Drug & Alcohol Unit had been opened in collaboration with
Voluntary Service Overseas (VSO) and the Rotary Club had drilled a
new borehole.
Medication availability was a real problem.
Most medication would have to be paid for. An Olanzapine tablet
(the commonest prescription) was about 1 Cedis for 10mg, which is
roughly 50p in English money. This is probably half of the average
working Ghanaians daily wage. Prescription choice was decided by
availability rather than clinical effectiveness or tolerability. I
noticed the strong presence of drug sales representatives on the
wards with nursing staff and in clinics with the MAs.
There was a very strong medical model approach
in psychiatric practice. Every patient left with a
prescription. Pharmacy resources were very limited. There was one
trainee psychologist available for psychological interventions and
she was finding it difficult to get supervision. The hospital did
have 2 welfare officers who performed a similar function to a
social worker in the UK and the hospital was hoping to recruit an
occupational therapist as I left.
My wife re-organised the staff library so that
it could be used as a learning resource and we tried to acquire
books through the BMA/BMJ Information Fund. Future placements
should focus early on encouraging local staff to develop particular
special interests to teach on the program, which could be weekly
and multidisciplinary.
Mentoring and supervision
Dr Anna Dzadey provided my direct supervision
whilst at Pantang. I developed a respect for the changes she was
trying to make to Pantang despite the heavy financial difficulties
she inherited. She was supportive of all the initiatives I wanted
to try and implement. She helped both my wife and I feel settled
and welcomed and helped us understand some of the intricacies of
the culture and people of Ghana.
Dr Peter Hughes provided my UK mentoring. He
was in Somaliland and Chad for much of my trip and was able to
provide excellent support and help on an almost daily basis over
email. His ideas and understanding of working in low and
middle-income countries were invaluable and he helped me through
the frustrating times and the seemingly impervious barriers to
change.
I also met with Dr Akwasi Osei the Acting
Chief Psychiatrist to discuss the future of the program. He was
very supportive of the program and had some good ideas for its
future direction.
The MAs particularly Ambrose Amenuvor provided
excellent support with adjusting to a new and very different
culture and helped me understand much of the cultural mythology
around mental illness.
There were two VSO volunteers at Pantang
during my placement from Sweden and The Philippines who were great
to bounce ideas off. They had been in country for over two
years.
Personal Anecdotes
This was, however brief, one of the most
rewarding and challenging experiences of my life. The Ghanaian
people were very welcoming. There is a cultural focus upon real
interaction and interest in the welfare of others. My cycle ride to
work would take me as long as a walk there stopping to chat with
all the ‘petty sales’ people on the way with their beaming smiles
and their particular use of the English language. I learnt to speak
some Twi and they really warmed to this and embraced my efforts. I
enjoyed the food and ate a varied diet from the various different
ladies stores near my house - Kenke, Banku, Red Red, Killi Willi
and my favourite, Fu Fu. My wife and I enjoyed travelling around
the country at the weekends by Tro Tro and hustling at the local
markets during the weekends when we were at home.
Recommendations for the Future of the
Placement
1. The program should
continue at one site as it is difficult to build robust systems
without them collapsing if we spread ourselves too thinly. Pantang
has the greater need of the 2 services and has a brighter future,
as Accra Psychiatric is likely to reduce in size over the coming
years.
2. The core of the work
should continue to focus around MA training as they provide most of
the front line service and make most of the life enhancing
decisions.
3. Regular ward rounds
should be implemented. My impression is that morning ward
rounds are likely to be better attended.
4. There should be a weekly
academic meeting that could be multidisciplinary and make use of
local staff special interests and skills as well as the local
doctors.
5. The nurses are a powerful
and large group that could be helped to develop better ward systems
in conjunction with a weekly academic program. If the culture is to
change then this is the group of staff that are most likely to make
it happen.
6. Conduct research that
supports the hospital to develop services that generate income for
service development plans in the future. For example research could
focus on the links between HIV infection and mental disorder. The
Aids commission have helped develop some of the service already at
Pantang.
7. In the longer term we
could help establish a continuing professional development
structure for the Medical Assistants.
Acknowledgements
I would like to thank all the people who made
this experience so special. Dr Peter Hughes and the Royal College
of Psychiatrists. Eoghan Mackie & Challenges World Wide. Dr
Anna Dzadey and Dr Akwasi Osei. All of the Medical Assistants of
both Accra and Pantang. The VSO volunteers. The rest of the staff
at Pantang and last but not least all the lovely people I met on my
journeys to work, lunch, the markets and all the other parts of
Ghana I visited. You all made me feel so welcome.