Overview and context
On 14th February 2019, a public engagement workshop on ‘improving stroke rehabilitation in Ghana’ was held at the University of Ghana. This was a collaboration between the Institute of Advanced Studies (UCL) and the Academic Partnership for Chronic Conditions in Africa (APCCA), based at the University of Ghana. The workshop brought together 40 participants which include doctors, nurses, stroke survivors, community members, traditional healers, civil society organisations (Ghana NCD Alliance and Stroke Association Support Network), academic researchers and representatives from the Ministry of Health and Ghana Health Service.
The workshop started with two presentations on the lived experience of stroke in the Ghanaian setting, and nature of acute stroke care services in major referral hospitals in Ghana and the extent to which these conform to international standards. Right after these, the participants were divided into three groups (that were made up of a mix of all the participants) to have detailed discussions on: (a) experiences with stroke care; (b) major issues that Ghana is facing in the presence of the stroke burden, and; (c) the way forward.
Experiences with stroke care
- Financial difficulty was mentioned as one of the major hindrances to proper management of stroke. Particularly, issues regarding the high cost of CT scans and medications were raised during the group discussions. This is compounded by the fact that the National Insurance Scheme (NHIS) does not cover many of the medications prescribed by the doctors, and so many of the stroke patients pay out-of-pocket. This indicates that those who are financially incapable are forced to resort to alternative treatments.
- Stroke care is time-consuming and emotionally draining, compared to caring for people with other conditions such as hypertension or diabetes. Participants raised the fact that stroke is debilitating, and this puts a lot of burden on the family. One of the major consequences is that the long-term care demand has led to increase in school drop-out rates among children who are required to assist in providing care for the stroke survivors.
- Lack of committed caregivers: Health professionals raised an issue that family caregivers bring stroke patients to the hospitals and abandon them because they have to ‘get on with their lives’. These patients, especially those with serious disabilities, then become a burden on the nurses.
- There was a discussion around the fact that health professionals are quick to scold stroke patients and their caregivers for patronizing herbal hospitals for their condition. The context for this was that health professionals do not take their time to listen to the patients or try to understand their rationale for using alternative treatments.
Major issues Ghana is facing in the presence of the stroke burden
- There is a vibrant pluralistic health system in Ghana involving mainstream biomedical health system and ubiquitous herbal and faith healing systems. These health systems most of the times work at cross purposes. All these health systems shape stroke care and rehabilitation in Ghana.
- Medication non-adherence is a common phenomenon when it comes to stroke care in Ghana. Patients mostly do not adhere to medications. Participants mentioned that lack of good transportation (in conveying patients to the hospital), poor health accessibility and lack of faith in the healthcare systems serve as barriers to biomedical treatment adherence.
- Socio-cultural beliefs that orthodox medicine is limited in its ability to cure a stroke. There is still a common belief that stroke is caused by spiritual attack, witchcraft or sorcery and so stroke is not a ‘hospital illness’.
- The mainstream hospitals were seen to be understaffed and under-resourced, and therefore unable to neither meet the increasing number of stroke patients in Ghana nor able to manage the long-term nature of stroke care. The biomedical system can mainly deal with acute care for stroke in the short term while patients are sent home after gaining stability.
- There was a consensus among the participants that stroke care and rehabilitation was a daunting task that requires an all-hands-on-deck approach, involving orthodox practitioners, traditional practitioners, faith healers, caregivers and other family members, civil societies, and the entire community. Since the hospital is limited in its ability to provide long-term care for stroke survivors, it was suggested that while the sudden onset of stroke require attention from the biomedical practitioners as the first point of contact, traditional healers fill important niche in stroke care and management in Ghana in the sense that they have community-based facilities to support long-term stroke rehabilitation. Additionally, biomedical practitioners can focus on the acute care of stroke while they discharge patients to some of the herbal clinics with constant monitoring.
- Participants mentioned that there is a need to promote public awareness of stroke. More importantly, participants believed that the need for intensified advocacy to create awareness on stroke warning signs cannot be overemphasised. This is because the ability to recognise warning signs of stroke may increase early visit to the hospital and which may consequently minimise stroke complications.
- Stroke patients suggested that health professionals should give them listening ears and try to understand the extent of their pains. In this way, they can ‘co-construct’ the treatment plans and this can enhance medication adherence.
- It was mentioned that the Ghanaian government need to be more committed to enhancing stroke rehabilitation through the expansion of the NHIS to cover stroke medications/treatments. This can increase medication adherence among stroke patients.
- There was a suggestion that a mobile stroke unit is needed in Ghana to help diagnose, evaluate and/or treat symptoms of an acute stroke. This will increase the prehospital phase of stroke management and improve patient outcomes.
- Finally, it was identified that the tension between the various health practitioners in Ghana is not only seen in stroke care but in the management of noncommunicable disease (NCD) in general. Nevertheless, this workshop offers an important groundwork and model for reducing this tension, and it provides an important strategy on how to promote collaborations among different health stakeholders in the country.