Health care delivery management in a Ghanaian penal institution: a case study of Kumasi Central Prisons.

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The Ghana Prisons Service is a public sector organization established by an act of parliament (Prisons Act 128) and is charged with the responsibility of ensuring the safe custody, welfare, reformation and where possible rehabilitation of prisoners. Currently, there are fifty-one (51) penal institutions in the country comprising forty-three (43) prisons and eight (8) settlement camps. Each prison has an infirmary with the exception of the Contagious Diseases Prison (CDP) at Ankaful are manned by nursing orderlies of different categories. Indications are that the general environment in these penal institutions is not conducive to the maintenance of good physical, social and mental health of inmates, and that the existing organization and delivery of health care services is less than satisfactory. This study emanating from the above concern attempts to understand the health care delivery system in penal institutions and explores what health care managers could do to address these pertinent issues. The case study was conducted in one of the largest prisons in the northern section of Ghana. Data were collected from two prisons within the Kumasi Metropolis using a combination of in-depth interviews and structured questionnaires to elicit information from respondents as well as physical observance of clinical signs of disease among inmates. The study population consisted of five medical officers, which included specialists from the Ministry of Health, the Kumasi Metropolitan Health Director and three others who see ill prisoners routinely at their facility. Two public hospital accountants, two pharmacists and a laboratory technician and one hundred convicted inmates were interviewed. Seven prison personnel including the deputy director in charge of the Kumasi Central Prisons, the PRO/Administrative officer, chaplain and the two nursing orderlies in charge of the male and female infirmaries were also included in the study. The following are some of the major findings of the study: I. Health Status of prison inmates Prisoners interviewed attributed the causes of morbidity to poor diet, overcrowding, lack of logistic support and poor sanitary conditions in the prison. Health care providers in the prison and government health facilities agreed that most of the diseases that incapacitate prisoners and deaths are preventable. II. Access to health care The prisoners were of the view that even though physical access to the infirmary was unrestricted the standard of care is poor owing to shortages of essential medical logistics. However, access to seek prompt care at government health institutions, notably at CWC and KATH remains difficult. • Exemptions and access to health care Major problems exist with both the policy on exemptions and the way it is implemented. The inclusion of exemptions, partial or total, in the legislative instrument on hospital fees was supposed to provide access to needed care and income protection for the part of the population that is poor and sick. Prisoners belong to this category of vulnerable groups and the study found that the LI 1313 does not cover them by law. The current mechanism instituted by the ARHA does not function well. The study observed that surgical services were not routinely available to prisoners unless under emergency conditions and is a widespread impediment to adequate health care for male offenders. Alternate levels of care, such as skilled nursing care, chronic and rehabilitative care is generally unavailable in prisons. • Exemptions and health care financing Respondents in all government health facilities studied said clients including prisoner pay user fees for services given except where waivers are applicable. The method used by facilities to assist clients who are unable to pay such as prisoners is to offer credit facilities on agreed terms or they are given prescriptions to purchase drugs from sources outside the health facility. The prison authorities settle these bills as and when FEs are made available on quarterly basis. III. Personnel and Administrative issues The infirmary at the Kumasi Central Prisons (KCP) did not have the required staff strength to facilitate efficient and effective service provision. One nursing orderly to nearly a thousand inmates, officers and dependants under existing conditions in the prison is stressful. As a result the nursing orderly is overburdened with tasks beyond her capabilities. lv. Infrastructure, Drugs and supplies The infirmary is old and ill equipped to cater for the immediate health needs of the teeming inmates. The study found that the maintenance of the building and the scant medical equipment has been neglected. Most of the basic drugs listed are available and prescription drugs are purchased for inmates. The only limitation is the ability of the Service to pay for the drugs. The prison infirmary has no essential drug list and a Health committee. Routine drugs are purchased on ad hoc basis without a Purchasing committee. Inadequate drug supply is a serious issue in the prison. Information obtained through interviews with prisoners indicated that respondents were dissatisfied with drugs given them at the infirmary. V. Management practices • Health policy There was the observation that the Ministry of Interior has no clear-cut policy on Penal Health Care. It appears that the burden of health care provision for prison inmates has been delegated to the MOH without any concrete arrangements. In the absence of a national penal health policy health care delivery in the prisons would remain inadequate for a long time. • Health system The penal system is centralized and generally there is lack of information flow vertically. Opinion sought from the nursing orderlies revealed a lower priority given to inmate health care among other activities. The study found that the health care delivery management system in the prison is weak and inadequately funded. The study, on the basis of these findings recommends the following: I. The establishment of a Medical Directorate with a Public Health Division within the Ghana Prisons Service by the Ministry of Interior to be headed by a competent health professional. II. To formulate policies and implement appropriate strategies in collaboration with other stakeholders to work towards the provision of a national framework for a comprehensive system of penal health care administration. Ill. Heads of Penal Institutions should be encouraged to take active part in budget preparation, allocation and utilization of funds and strengthen the management capacity of their institutional health care providers. IV. Management should recognize the right of prison inmates to dignity and present grievances and should show some visible signs of respecting and addressing their health problems.
A thesis submitted to the Department of Community Health, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, in partial fulfilment of the requirements for the award of Master of Science degree in Health Services Planning and Management, 2001