The cold war between Ghanaian doctors and physician assistants: Who suffers the consequences

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In September 2000, leaders of 189 countries gathered at the United Nations headquarters and signed the historic Millennium Declaration, in which they committed to achieving a set of eight measurable goals that range from halving extreme poverty and hunger to promoting gender equality and reducing child mortality, improving maternal health, combating HIV/AIDs, malaria and other diseases by the year 2015.

The 8 goals were realistic and easy to communicate, with a clear measurement/monitoring mechanism. Though substantial progress has been made regarding the MDGs in the developed countries with the world already realizing the first MDG of halving the extreme poverty rate as of 2015, the achievements have been uneven with goals number 4, 5, and 6 which has to do with health, yet to be achieved especially in Africa and in particular Ghana, thanks to the managers of our health systems.

It is a fact that Ghana’s maternal mortality ratio declined from 760 per 100,000 live births in 1990 to 319 per 100,000 live births in 2015, however the pace of decline in maternal mortality has been slow, leading to Ghana’s inability to achieve the millennium development goal target of 190 per 100,000 live births in 2015. The maternal mortality ratio remains high and requires strenuous efforts if Ghana has to achieve the sustainable development goal target of 70 per 100,000 live births in 2030.

Most maternal deaths occur in rural areas as compared to urban areas. This has largely been attributed to the high prevalence of skilled birth attendance of 74% in urban areas as compared to 43% in rural areas. Several other factors have been implicated as major contributory factors to maternal deaths in Ghana. Low antenatal coverage, sociocultural factors, lack of logistics, equipment, and blood at healthcare facilities have been largely blamed as reasons for high maternal mortality in Ghana.

It was observed that maternal deaths are usually directly related to causes, such as haemorrhage (bleeding ), unsafe abortion, hypertensive disorders, infections, and obstructed labor while indirect causes, include malaria, HIV/AIDS, and anemia.

Other factors, including poverty, lack of skilled health personnel, and poor transport system have contributed to the high maternal mortality ratio in Ghana. This argument seems to be supported by Thaddeus and Maine’s framework which posit that factors of this nature often result into one of the three delays;

  1. Delay in making a decision to go to hospital,
  2. delay in arriving at the hospital, and
  3. A delay in getting treatment at a health facility

which often lead to maternal mortality

The healthcare system in Ghana is structured in five levels. The tertiary hospitals which are also teaching hospitals are at the apex of the healthcare delivery ladder. This is followed by the regional hospitals which provide specialist care for patients and also serve as referral points for district hospitals. The district hospital provides care at the district level and also serves as referral point for the sub-district facilities (facilities at the community level). The lowest facilities in the healthcare delivery ladder are the community clinics or community-based health planning and services (CHPS)

Doctors and Physician Assistants are the managers of these health facilities. The Doctors are mainly at the District, Regional and Teaching Hospitals. Physician Assistants on the other hand attend to patients at the Sub District health facilities ( they are also the administrative heads at this level) as well as OPDs of most of the District and Regional Hospitals across the country.

The difference between these two cadres of health workers is the number of years spent in school, the level of training and practice. Whiles the Doctor is trained in accredited medical schools for a minimum of 6 years (formerly 8 years) plus a 2year house job at accredited health facilities, the Physician Assistants are currently being trained in universities across the country for a minimum of 4 years plus additional 1year internship at the regional and teaching hospitals with some currently holding Phd. and Masters. Both are currently licensed and regulated by the Medical and Dental Council of Ghana.

Contrary to the notion held by many in Ghana, Physician Assistants do not Assist Doctors in the management of patients, they practice medicine based on their levels of training and competence just as Doctors. However failure on the part of the Medical And Dental Council to take steps to improve curriculum for their training coupled with accreditation of mushroom schools some of which have no laboratories and teaching hospitals. Some of the schools continue to use of part time lectures (some of which uses one or two weekends to complete a semesters syllabus), teaching of subjects without practical coupled with unregulated intake of students (with some schools admitting almost 100 students in a class) for the program. Other schools are currently running the program on weekend bases. These are happening whiles the regulator sits unconcern. These negatively impacted the training and practice of the physician Assistants.

The Medical And Dental Council has taken steps to remove important subjects like Pharmacology (which teaches the students on the use of medicines) and Pathology from the curriculum of schools currently training Physician Assistants. This is an attempt to widen the knowledge gap between the Doctors and the PAs to the Advantage of the Doctors.

The council has refused over the years to mount specialist programs for Physician Assistants though other countries like USA do allow Physician Assistants to specialise in any field of medicine. It is rumoured that the Medical and Dental Council is currently controlled by the Ghana Medical Association having the board dominated by Doctors with only one Physician Assistant on the board. The council recently came out with a scope of practice document for Physician Assistants. The said document among other things is asking a Physician Assistant who spent 5 years in University training, to refer urinary tract infections in pregnancy to a midwife because they are not competent to manage such cases. This directive exposes the council further as it has failed the taxpayer once again.

Entry requirement into the Physician Assistant program in UCC, University of Allied health, Central University and many other universities Across the country is not much different from that for medical schools. So one may wonder how the Physician Assistants were trained that, the council thinks they can’t manage urinary tract infections and malaria in pregnant women.

Readers would wonder why the Medical And Dental Council takes so much interest in the training of doctors in and outside the country but seems to be unconcerned about the training of the Physician Assistants. Was the council set up to champion the interest of Ghana Medical Association or the taxpayer.

Physician Assistants in Kenya are called clinical officers, the Kenyan Government in attempt to reduce maternal mortality in that country decided to introduce the program just as the USA did after the second world war to meet the high demand for doctors. Clinical officers in Kenya are trained for 3 years to do caesarean sections, removal of womb and other forms of surgery aside management of other medical conditions. They work in COLLABORATION with Doctors (not as ASSISTANTS) in that country in order to provide healthcare to the taxpayer just as its done in the USA, Canada, Australia, and many other countries across the world why is the story in Ghana different.

Ghana News Agency on the 25th February 2022 reported an ever widening patient to Doctor ratio in the Northern Region of the country with the ratio being 1:10,901 in 2021 and 1:8,859 in 2020 (from Ghana Health Service Statistics). As usual the data failed to tell how many Physician Assistants are out there working to save lives where the Doctors over the years have refused postings to. However the statistics revealed that the country still doesn’t have adequate number of doctors to see every patient that needs medical care. Nor can the country train enough doctors soonest to fill the gap. So why are the policy makers failing the country, could it be because the Doctors have taken over every leadership position in the health sector hence are manipulating the system to their advantage so they can always hold all of us to ransom anytime they wish.

I wish to use this medium to appeal to our beloved Doctors to;

  1. Not see the Physician Assistants as enemies but rather collaborate with them to give the taxpayer the best of care
  • Stop competing with Physician Assistants on who can manage malaria, Diabetes and Hypertension better and focus on how they can go into the heart and take blood clots out within few minutes of patient arrival at the hospital to save lives of the taxpayer who pays them over GHC8,000 every month.
  • They should focus on how to permanently treat that poor kid born with HIV or sickle cell instead of them having to take drugs for the rest of their lives all in the name of managing the disease
  • They should focus on how to remove that fibroid which is making our ladies infertile without having to cut them open instead of fighting PAs over who can be called a medical practitioner or not
  • Our Doctors should try and focus on how to go into the brain and take out that blood clot if the patient arrived at the hospital within 20 minutes of developing symptoms of stroke so he or she doesn’t become jobless and totally dependent on the family instead of battling with the PA of who can better manage diarrhoea

The District Health Directors should stop collaborating with their accountants to steal monies from accounts of the health centres using flimsy reasons. The situation has made most of the Physician Assistants who man these facilities to incur the rough of these Directors most of whom are Doctors. Monies stolen from the health centres could be used to improve service delivery at these facilities so the patient would not have to be referred to higher facilities where they sometimes don’t even have beds to sleep on

In fact, most health centres where these Physician Assistants work have no well-equipped laboratories or pharmacies with most of the facilities highly indebted to regional medical stores across the country. They work mostly using their clinical judgment yet we turn around to call them incompetent

And to our policy makers, kindly move out of your comfort zones, pay a visit to countries with best practice like our Kenyan Brothers who are making good use of their Physician Assistants and find out how they did it so you can formulate good policies that will improve training and practice of the Ghanaian Physician Assistants all for the benefit of the taxpayer

Government should take the necessary steps to establish a separate regulatory council for the Physician Assistants just like the USA did so they can regulate their training and practice instead of them sharing same council of Doctors who see them as a threat to their continued relevance in Ghana.

Lastly, leadership positions in the healthcare system should not be the preserve of only doctors but any healthcare worker with the requisite qualification and brain power be allowed to compete and lead the health system.

God bless our homeland Ghana and make our nation great and strong, may we continue to be citizens and not spectators.

Disclaimer: The views expressed in this article are the author’s own and do not necessarily reflect AfricansInDispersion’s official position. AfricansInDispersion’s will not be responsible or liable for any inaccurate or incorrect statements contained in this article.