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The Pharmaceutical Journal
Reflections on health care in Ghana
Felicity Smith recently visited the faculty of pharmacy in Kumasi, Ghana. In this article she reflects on differences and similarities in current issues for pharmacy services in two diverse countries, Ghana and Britain
Patterns of morbidity and mortality in Ghana are similar to those in other African countries. Infectious disease, in particular malaria, diarrhoeal disease and specific parasitic diseases, are major health problems. However, many problems commonly associated with industrialised nations are becoming more prominent. The pivotal role of pharmacists in health promotion and health education should be a priority for pharmacists worldwide because despite the differing morbidity patterns, for the vast majority of diseases risk factors and causes are well-established. Researchers in Ghana have found that understanding by the public of causes (and thus appropriate preventive measures) of common but serious diseases is often limited.
In Ghana, as in many developing countries, traditional and "Western" medical practices exist side by side. Colonialism, and its aftermath, has had a major impact on patterns of medicine use, pharmacy education and services. In Ghana, in addition to the Western, or formal government, sector, the traditional health care sector, which includes herbalists and spiritual healers, remains an important source of health care. That people move between the different health care sectors in addressing their health problems is widely documented. Factors such as the type of problem, availability of services, beliefs about the aetiology and appropriate management of disease and the success of treatment determine how and why people resort to care in the different sectors. In Ghana, a Centre for Scientific Research into Herbal Medicine has been established. Tsey1 describes the initiative as "an attempt to modernise and incorporate traditional herbal knowledge and treatment into the formal health sector". In the UK, too, within the public health care sector there is increasing interest in the incorporation of alternative approaches.
In 2001 a new government took office in Ghana. Among its pledges was the abolition of the "cash and carry" system, in which people are required to pay for their drug therapy (and often other services), and its replacement with health insurance. This is a big undertaking, especially in a poor country. The form that the new scheme will take is currently being discussed. The impact of the cash and carry system on access to medicines has been addressed by many researchers. One consequence of the policy was a greater resort to self-medication as an alternative to seeking medical advice, which was more marked in poorer sectors of society. In the UK, too, health problems and health behaviours follow a socioeconomic status gradient. For both the British and Ghanaian governments, addressing inequalities in health status between sectors of the population and, in Ghana in particular, inequities in access to care is a priority. In both countries, health care reforms and policy priorities have implications of pharmacy services. It is in the interests of the profession to identify new opportunities and strategies for their achievement.
Although most of Ghana's population lives in rural areas, the vast majority of pharmacists (as other health professionals) live and work in the cities. Although not dissimilar in kind to the Britain's "post-code prescribing", these discrepancies have a far wider impact in terms of service provision. A sizeable proportion of the population does not have access to pharmacy services. This presents a problem to the profession in terms of providing a nation-wide service with any uniformity. Urban-rural inequalities in health status and service provision are common in developing countries. They are not restricted to health care and their solution is seen in terms of wider socioeconomic development. Shortages of health professionals are further exacerbated by the significant numbers who seek professional opportunities abroad.
In most industrialised countries pharmacies are the principal source of medicines, but in developing countries there are other outlets. These are accepted as a necessity if people in remote areas are to have access to much needed drug therapy. The Pharmacy Council in Ghana (which oversees the registration of pharmacists) licenses and provides some training for chemical sellers. In addition to these licensed chemical sellers, the activities of "drug peddlers", especially among rural communities, have been described by many researchers. They are commonly itinerant, sell medicines alongside other products and generally have no formal training.
In developing countries it is widely acknowledged that medicines elsewhere designated as "prescription-only" are widely available from pharmacies without a prescription. Stricter regulation on the availability of medicines as part of health care reforms in developing countries, could reduce the potential opportunities for pharmacists to contribute to therapeutic management of common diseases, just as the new prescribing roles of pharmacists in Britain enhance their health provider activities.
The faculty of pharmacy in Kumasi has established a new department of clinical and social pharmacy, following similar developments in many pharmacy schools in Britain and elsewhere. Preparing pharmacy students for dynamic, rewarding and valuable professional careers in the context of new health policy priorities, health technologies and population health needs is a challenging task. The development of a social pharmacy research base is also a priority in Ghana. Pharmacy must be evaluated in the light of population health needs and specific health policy objectives. Common issues and problems mean that much research can be shared. However, because of the vast differences in the patterns and experiences of disease, of health care provision between countries and communities, and the social and cultural contexts of health beliefs and actions, all countries need their own body of research to inform appropriate service development.
Pharmacy can contribute more
It is recognised across the globe that pharmacy can contribute more extensively and effectively to health care. Many factors important to the provision and development of pharmacy services span international boundaries, others are country-specific. The goals of promoting appropriate medicine use have to be addressed in terms of the complex interaction between the health care system, patterns of morbidity, and socio-cultural contexts in which care is delivered and consumed which are unique to any country and setting. Although Ghana and Britain possibly differ in these respects as much as any two countries, there are many issues regarding the provision of pharmacy services, education of pharmacy students and aspirations of the profession transcend international boundaries.
Citation: The Pharmaceutical JournalURI: 20006905
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