“Integration” in Ghanaian Ophthalmology

Ghana’s commitment to the “Health for All” movement can be traced back to the 1970s, when the country first adopted the Primary Health Care system. This continued with the establishment of District Health Systems in the 1990s, and, in 2003, saw the development of the National Health Insurance Scheme (NHIS) – an initiative that aimed to provide equitable access and financial coverage for basic health care services to its citizens. While such efforts have supported universal health coverage (UHC), challenges still remain. For example, there is little agreement on the specific steps that must be made to make meaningful progress; national goals and targets for UHC, too, remain unclear.

From an ophthalmic perspective, Ghanaian eye care services are mainly delivered by eye health professionals at district, regional and teaching hospitals, leaving much of the rural populations unserved. Ophthalmic Specialist outreach eye care organized for district hospitals does occur on a regular basis, but the providers are few and inequitably distributed. “Health personnel in rural health facilities are neither trained nor equipped to provide adequate eye health services, and essential eye medicines are either unavailable or insufficient at community health centers,” says Maria Hagan, Ophthalmologist, former Head of the Eye Care Unit Ghana Health Service, and former co-Chair, International Agency for the Prevention of Blindness (Anglophone West Africa). “Many people that are referred to specialist centers also struggle to meet base level costs.”

The NHIS covers most common causes of illness in Ghana and includes in-patient and out-patient care, as well as comprehensive maternal care, diagnostic testing, generic medicines and emergency care. Once an individual is registered with NHIS, they receive health service at PHC facilities. There is, however, a common misconception on the part of some people that payment for the health insurance tariff is one-off, thus, when the tariff expires, such patients often do not renew their insurance. This means many people in rural areas and some, even in the big cities, have expired health insurance cards without even realizing.

Transportation is another major challenge; in some rural communities, public vehicles only operate once or twice a week, typically on market days. Moreover, certain roads are not suitable for motor vehicles, making access to care even more difficult. “While trained eye care personnel are based at District, Regional, and Teaching hospitals, rural residents who need specialized eye care often fail to follow through with referrals, either due to financial constraints or transportation issues,” adds Hagan. She also explains that the District Health Management Team, which oversees frontline and sub-district health activities, does not allocate funds for outreach services from specialist eye care providers.

Community engagement is key to ensuring that people are empowered to take care of their health, including their eye health. Therefore, health education must ensure the involvement of traditional leaders and grassroot activities – at least that’s what Hagan believes. “The incorporation of people-centered eye health into community health services is a sure way of sustainability,” she says. More broadly, Ghana has set itself a 2030 objective to (1) ensure social inclusion, (2) protect the environment, and (3) foster economic growth. The Vision of Ghana’s universal healthcare plan hopes that ‘All people in Ghana have timely access to high quality health irrespective of ability to pay at the point of use’.

As Hagan explains, “eye problems that cannot be managed at CHPS will then be referred to an eye health professional at the District Hospital, which is why it is important to train the frontline health workers and ensure they are equipped and have the logistics and eye health medicines required to treat minor eye ailments. Currently, NHIS covers refraction but not provision of spectacles; patients who need spectacles must pay for their spectacles – an issue that is being addressed through advocacy.” In fact, the entire NHIS tariff is under review.

Eye health, ultimately, must be recognized as a key economic and social development issue, with a focus on "integration," as Hagan emphasizes. This involves incorporating it into the planning, resourcing, and delivery of healthcare, which can help Ghana leverage the UN Resolution on Vision to improve eye care services for the future.