Assessment of Rehabilitation Capacity in Ghana
Asare B. Christian. MD, MPH.
Clinical Associate, Penn Medicine PM&R, Philadelphia, PA, USA
Outpatient Medical Director, Good Shepherd Rehabilitation Hospital, Allentown, PA, USA
4/27/2018
Disclosures
I have received payment from Ipsen pharmaceuticals for consultative work.
I will not be discussing any Ipsen product.
Learning Objectives
1. Appreciate the need for Global Rehabilitation Medicine
2. Medical Rehabilitation Capacity in Ghana
3. Current State of Rehabilitation-Training of the Ghana doctor in Rehab Medicine
Background
• Rehabilitation Medicine
• Function, quality of life, improve health systems
• 1 billion disable around the world
• 80% live in low resource countries
• Sub-Saharan Africa
• 156 million
• Disease and Disability burden
• 24% disease burden, 3% health workers, 1% healthcare expenditure
Background
• Limited data on Rehab Capacity
• Infrastructure, human, interventions
• Quality of service, education
• A forsaken Global Health issue
• Trauma related disability, cardiovascular, cerebrovascular disease
• Global Rehab capacity
• limited, fragmented, inconsistencies
Background
• 2011 World Report on Disability(WDR)
• Policy Change; CBR to Medical Rehabilitation
• Govt. to expand comprehensive rehabilitation
• Multidisciplinary Rehabilitation care
• For this to be implemented
• A Need assessment to inform policy makers
Background
• Sub-Saharan Rehab workforce
• 6 physiatrist
• 4169 Occupational therapist
• 0.1 per 100, 000 Physical therapist in Ghana, 6.7 per 100,000 in South Africa
• Other Allied health
• 0.04 per 100,000 Social workers
• 0.04-0.06 per 100,000 Rehab psychologist
Objective-Assessment
of Rehab Capacity in
Ghana
• Pilot an assessment tool for capacity of Rehabilitation care in Ghana • Infrastructure, human resources,
interventions provided
• Create a standardize tool for assessing rehabilitation care in resource constraints areas
• Accurate assessment of met and unmet rehabilitation needs
Background
• Ghana: Black star of Africa
• 24.97 million people
• GDP of $39 billion,4.8 of GDP on Healthcare
• Estimated 3.75 million persons with disability
• No medical rehabilitation, PT only, no inpatients
• Rehabilitation Capacity
• Rehabilitation planning
Methods:
•Across the country, easily accessible by transport
•Record keeping
Sampling Selection
•9 Physiotherapist centers in Ghana
•Tema General Hospital (Greater Accra Region)
•Ashanti Mampong Municipal Hospital (Ashanti Region)
•Sunyani Regional Hospital (Brong Ahafo region)
•Koforidua Regional Hospital, Teteh-Quashi Memorial Hospital, and Begoro Rehabilitation Center (Eastern Region)
•Effia Nkwanta Regional Hospital (Western Region)
•Cape Coast Regional Hospital (Central Region)
•Tamale Teaching Hospital (Northern Region).
Settings
Methods
• Interview Process
• A modified Situational Analysis Tool for Assessment of Essential Comprehensive Rehabilitation Care(ECRC) was developed
• 11 Page Questionnaire
• Infrastructure, human resource, interventions
• To be completed by those of in charge of the PT centers
• Lesson from the surgical world
Results
• Infrastructure • 5 out of 9 centers were Regional
Hospital • 1 inpatient rehabilitation
center/Pediatric rehab • Begoro Salvation Army
• Funded by Ghana Ministry of Health
• Centers were built by Enfra Nonius Dutch grant
Results
• Infrastructure •1 center to serve 735,545 person •Pt seen/yr 400-295000 •2 have aquatic therapy •Travel distance to centers 63Km(20-200Km)
•42 physiotherapy centers •22 in Ashanti and Accra
Results
Human Resources
• no PM&R doctors, rehab psychologists, recreational therapist, in country
• 1 OT, no SLP in our sample
• 1 rehab nurse, 1 prosthetics in our sample
• 7 lack a social worker
39 PT’s identified in our study to serve 6.6million people
Results
• Intervention
• Stroke Rehab: 100%
• Spinal cord injury: 90%
• TBI Rehab: 50%
• MSK: 70%
• Pediatric Rehab: 80%
• Medical Rehab: 60%
• Amputations: 90%
Discussion
• Summary
• First study proposing the need to create a standardize tool for comprehensive rehabilitation in Africa
• First study looking at capacity of a nation to provide ECR
• Human resources
• Significant deficiencies in infrastructure, humans resources, and ability to provide comprehensive rehabilitation
• Use of assessment tool feasible in local environment
Study Weakness
• Small sample size (9 out of 42 centers)
• But represent 26% of Ghana Population
• Bigger centers (Accra and Kumasi) not survey
• 5 Regional hospital
• No post-analysis of ease of answering survey
• Some questions might not be appropriate in the environment
• Some questions were not responded to
• The tool proposed has not be validated
• We don’t have one yet
Recommendations
• Essential Comprehensive Rehabilitation is cost-effective and safes lives
• Need most is places where resources are limited
• Implications of its absence are colossal
• Ghana Ministry of Health and external bodies should invest in comprehensive rehabilitation
• WHO should support this initiative to make Rehabilitation needs a Global Health priority
Current Rehabilitation State
•The creation of Physical Medicine and Rehabilitation program in Ghana
•Policy and Proposal
•Rehabilitation Medicine at KATH
Rehabilitation Fellowship in
Ghana
• Name of program?
• Dr. Abena Tanor and Dr. Tesfaye
• A two year curriculum approve by the Ghana Medical board
• Fellowship
• Local leadership and ownership
• Clinical experience
• Blue jeans platform
Fellowship training con’t
Musculoskeletal medicine
Stroke rehabilitation
Traumatic brain Injury rehabilitation
Trauma rehabilitation
Spinal cord injury rehabilitation
Vocational rehabilitation
Pediatric rehabilitation
Amputee care
Pain management
Fellowship
• In and out training
• Ghana, US, Europe, Asia, Ethiopia
• KATH, Nsawam, others……….
• Ghana Rehab Mission visit to KATH
• Clinical management
• Workship
• Policy and advocacy management
• WHO and global presence and advocacy
• Dr. Abena Tannor visit to Good Shepherd Rehab
• Inpatient rehabilitation training
• Outpatient clinic
• w/c clinic and technology ad
Ghana Rehab Mission • Clinic with team
• Inpatient workshop and nurses training
• Policy and advocacy
• Medical rehabilitation proposal
Ghana rehab mission
Fellowship barriers
• Value of Physical medicine and rehabilitation
• Human behavior and culture
Local support and priority
• No funding, volunteer based
• International Rehab Forum
• Ghana Rehab Mission
Outside support
Conclusion
Conclusion
•A comprehensive rehabilitation program is needed in Ghana
•Effort to support such initiatives are needed
Reference: • REFERENCE:
• 1. Christian A., Haig A, Marlis Gonzalez-Fernandez, R. Sam Mayer. Rehabilitation Needs of Persons discharge from an African Trauma Center. Submitted for Publication March 2011. Pan African Medical Journal
• 2. World Health Organization, Disability and Rehabilitation Team (DAR). http://www.who.int/nmh/a5817/en/
• 3. Haig AJ, Im J, Nelson VS, Adewole A, Krabek B. The Practice of Physical Medicine and Rehabilitation in Africa and Antarctica: A White Book or a Black Mark? Journal of Rehabilitation Medicine. 41(6):401-5, 2009 May. PM & R. 1(5):421-6, 2009 May. European Journal of Physical & Rehabilitation Medicine. 45(2):185-91, 2009 Jun. Disability and Rehabilitation 2009 31(13) 1031 – 1037, 2009. Chinese Journal of Rehabilitation Medicine 24(5)385-389, 2009. *Simultaneous publication with consent of all journals
• 4. World Health Organization. (2011). World report on disability. World Health Organization.
• 5. WHO: World Health Report 2006: http://www.who.int/whr/2006/en/
• 6. Mars, M. (2011). Telerehabilitation In South Africa–Is There A Way Forward?.International Journal of Telerehabilitation, 3(1).
• 7. WFOT: World Confederation of Physical Therapists. (2011). from http://www.wcpt.org/africa
• 8. World Federation of Occupational Therapists. (2011). from http://www.wfot.org/
• 9. Assistive Technology Act. United States Congress 2004 (Public Law 108–364) (http://www.ataporg.org/atap/atact_law. pdf, accessed 9/8/11)
• 10. Dunleavy K. Physical therapy education and provision in Cambodia: a framework for choice of systems for development projects. Disability and Rehabilitation, 2007,29:903-920.
• 11. Saxena S et al. Resources for mental health: scarcity, inequity, and inefficiency. Lancet, 2007,370:878-889. doi:10.1016/ S0140-6736(07)61239-2 PMID:17804062
• 12. Tinney, M. J., Chiodo, A., Haig, A. and Wiredu, E., ‘Medical Rehabilitation in Ghana’, Disability & Rehabilitation, 29:11, 921-927
• 13. Haig, AJ. Developing world rehabilitation strategy II: flex the muscles, train the brain, and adapt to the impairment. Disabil Rehabil. 2007 Jun 15-30;29(11-12):977-9.
• 14. Chan DK, Cordato D, O'Rourke F, Chan DL, Pollack M, Middleton S, Levi C. Comprehensive stroke units: a review of comparative evidence and experience, Int J Stroke. 2013 Jun;8(4):260-4
• 15. Mock C, Quansah R, Krishnan R, Arreola-Risa C, Rivara F. Strengthening the prevention and care of injuries worldwide. Lancet. 2004;363:2172–2179
• 16. Mock, C., Arreola-Risa, C., & Quansah, R. (2003). Strengthening care for injured persons in less developed countries: a case study of Ghana and Mexico. Injury Control and Safety Promotion, 10(1-2), 45-51.
• 17. Peden M, Scurfield R, Sleet D, Mohan D, Hyder A, Jarawan E, Mathers C. World Report on Road Traffic Injury Prevention. Geneva, Switzerland: World Health Organization; 2004.
• 18. World Health Organization. Global burden of disease project 2002. Available at:http://www.who.int/healthinfo/bodproject/en/index.html. accessed 5/28/13
• 19. Gupta, N., Castillo-Laborde, C., & Landry, M. (2011). Health-related rehabilitation services: assessing the global supply of and need for human resources. BMC health services research, 11(1), 276.
• 20. Cardenas DD, Haselkorn JK, McElligott JM, Gnatz SM. A bibliography of cost-effectiveness practices in physical medicine and rehabilitation: AAPM&R white paper. Arch Phys Med Rehabil 2001;82:711–719.
• 21. Tom G Briffa, Simon D Eckermann, Alison D Griffiths, Anthony C Keech, Phillip J Harris, M Rose Heath, Saul B Freedman, Lana T Donaldson and N Kathryn Briffa. Cost-effectiveness of rehabilitation after an acute coronary event: a randomised controlled trial Med J Aust 2005; 183 (9): 450-455
• 22. World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical http://www.who.int/surgery/publications/QuickSitAnalysisEESCsurvey.pdf accessed 5/28/13
• 23. British Society of Rehabilitation Medicine. NEUROLOGICAL REHABILITATION ;A Briefing Paper for Commissioners of Clinical Neurosciences www.bsrm.co.uk July 2008
• 24. Anonymous. White Book on Physical and Rehabilitation Medicine in Europe. J Rehabil Med 2007;(45 Suppl): 6–47
• 25. Connor MD, Walker R, Modi G, Warlow CP.Burden of stroke in black populations in sub-Saharan Africa. Lancet Neurol. 2007 Mar;6(3):269-78.
• 26. WHO-AIMS http://www.who.int/mental_health/evidence/AIMS_WHO_2_2.pdf),
• 27. Nguyen, S., Arreola-Risa, C., & Joshipura, M. (2006). Evaluation of trauma care capabilities in four countries using the WHO-IATSIC Guidelines for Essential Trauma Care. World journal of surgery, 30(6), 946-956.
• 28. Joshipura, Manjul, et al. "Essential trauma care: strengthening trauma systems round the world." Injury 35.9 (2004): 841-845.
• 29. Joshipura, M., & Maier, R. (2006). Overview of the essential trauma care project. World journal of surgery, 30(6), 919-929.
• 30. Saxena, S., Lora, A., van Ommeren, M., Barrett, T., Morris, J., & Saraceno, B. (2007). WHO's Assessment Instrument for Mental Health Systems: collecting essential information for policy and service delivery. Psychiatric Services, 58(6), 816-821.
• 31. Saxena, S., Lora, A., Morris, J., Berrino, A., Esparza, P., Barrett, T., ... & Saraceno, B. (2011). Focus on Global Mental Health: Mental Health Services in 42 Low-and Middle-Income Countries: A WHO-AIMS Cross-National Analysis.Psychiatric Services, 62(2), 123-125.
• 32. HRH Profile Countries http://www.hrh-observatory.afro.who.int/en/hrh-country-profiles/profile-by-country.html accessed 5/25/13
• 33. Establishing and Scaling up Physiotherapy education in University of Ghana, Quartey, JNA(PT) MSc (Nig); MSc (Ned) Department of Physiotherapy, School of Allied Health Sciences, College of Health Sciences, University of Ghana. 25 March 2013 16:34
• 34. Langhorne, P., Bernhardt, J., & Kwakkel, G. (2011). Stroke rehabilitation. The Lancet, 377(9778), 1693-1702.
• 35. Frye, B. A. (1993). Review of the World Health Organization's report on disability prevention and rehabilitation. Rehabilitation Nursing, 18(1), 43-44.
• 36. Sagui, E. "[Stroke in sub-Saharan Africa]." Medecine tropicale: revue du Corps de sante colonial 67.6 (2007): 596.
• 37. Kengne, A. P., & Anderson, C. S. (2006). The neglected burden of stroke in Sub‐Saharan Africa. International Journal of Stroke, 1(4), 180-190.
• 38. Lemogoum, D., Degaute, J. P., & Bovet, P. (2005). Stroke prevention, treatment, and rehabilitation in Sub-Saharan Africa. American journal of preventive medicine, 29(5), 95-101.
• 39. Sub-Saharan Africa Populiation http://www.tradingeconomics.com/sub-saharan-africa/population-total-wb-data.html
• 40. Walsh, T., Cotter, S., Boland, M., Greally, T., O'RIORDAN, R., & LYON, D. (2006). Stroke unit care is superior to general rehabilitation unit care. Irish medical journal, 99(10), 300-302.
• 41. Ko, K. F., & Sheppard, L. (2006). The contribution of a comprehensive stroke unit to the outcome of Chinese stroke patients. Singapore medical journal,47(3), 208-212.
• 42. KOTON, S., SCHWAMMENTHAL, Y., MERZELIAK, O., PHILIPS, T., TSABARI, R., BRUK, B., ... & TANNE, D. (2005). Effectiveness of establishing a dedicated acute stroke unit in routine clinical practice in Israel. Israel Medical Association Journal, 7(11), 688-693.
• 43. Cadilhac, D. A., Ibrahim, J., Pearce, D. C., Ogden, K. J., McNeill, J., Davis, S. M., & Donnan, G. A. (2004). Multicenter comparison of processes of care between stroke units and conventional care wards in Australia. Stroke, 35(5), 1035-1040.
• 44. Moodie, M., Cadilhac, D., Pearce, D., Mihalopoulos, C., Carter, R., Davis, S., & Donnan, G. (2006). Economic Evaluation of Australian Stroke Services A Prospective, Multicenter Study Comparing Dedicated Stroke Units With Other Care Modalities. Stroke, 37(11), 2790-2795.
• 45. Anderson, C., Mhurchu, C. N., Rubenach, S., Clark, M., Spencer, C., & Winsor, A. (2000). Home or hospital for stroke rehabilitation? Results of a randomized controlled trial II: cost minimization analysis at 6 months. Stroke,31(5), 1032-1037.
• 46. Rehabilitation for Persons with Traumatic Injuries (2004), created by Drucker brain injury center, at Moss Rehab.( http://www.who.int/disabilities/publications/care/en/) accessed 5/28/13
• 47. Timothy Hardcastle, The 11 P’s of an Afrocentric trauma system for South Africa –time for action!, March 2011, Vol. 101, No. 3 SAMJ
• 48. Benedicte Ingstad, Alister C Munthali, Stine H Braathen and Lisbet Grut,: The evil circle of poverty: a qualitative study of malaria and disability. Malaria Journal 2012 11:15
• 49. Osen, H., Chang, D., Choo, S., Perry, H., Hesse, A., Abantanga, F., & Abdullah, F. (2011). Validation of the World Health Organization tool for situational analysis to assess emergency and essential surgical care at district hospitals in Ghana. World journal of surgery, 35(3), 500-504.
• 50. Choo, S., Perry, H., Hesse, A. A., Abantanga, F., Sory, E., Osen, H., ... & Abdullah, F. (2010). Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool. Tropical Medicine & International Health, 15(9), 1109-1115.
• 51. Abdullah, F., Choo, S., Hesse, A. A., Abantanga, F., Sory, E., Osen, H., ... & Perry, H. (2011). Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews. Journal of Surgical Research,171(2), 461-466.
• 52. Agyepong, I. A., & Adjei, S. (2008). Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme.Health Policy and Planning, 23(2), 150-160.
• 53. World Health Organization: Global Atlas of the Health Workforce. http://www.who.int/globalatlas/autologin/hrh_login.asp accessed 5/28/13
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