Public health management can be challenging. There are many causes of illness and disease and increasingly, social, cultural, economic and political factors are being examined. Researchers and practitioners now pay more attention to non-medical causes and effects of illness.
Ghana is considered a middle-income but ‘developing’ country (World Bank, 2017). The Ghana AIDS Commission (2014) estimates that there are over 220,000 Persons Living with HIV and AIDS (PLHIV) in Ghana. But this figure may be more because of difficulties accessing testing and the stigma associated with HIV. HIV continues to be considered an epidemic. Globally, 37 million people live with HIV, with 70% in Sub-Saharan Africa. The current state of HIV and AIDS is being influenced and impacted by non-medical factors, and this in turn affects how government, non-government and private entities are able to respond to the crisis.
Public health management refers to the management of institutions and resources in an effort to increase knowledge and skills that build effective health systems. In Ghana, health efforts are officially coordinated by the Ministry of Health through Ghana AIDS Commission and the National AIDS Control Programme (NACP). Non-government organisations (NGOs) also implement many interventions. Donors to both the government and non-government sectors include USAID, John Snow Inc., and The Global Fund. While government and other organisations coordinate efforts, there exist challenges incorporating non-medical factors into healthcare systems. This is not unique to Ghana; many countries experience such difficulties. According to WHO (2002, p. 5), this can be due to not receiving “firm enough support at political level”, and “under-resourcing of the public health infrastructure and capacity”.
HIV and AIDS continues to be a significant public health issue. It requires not only a medical approach to prevention and treatment, but also psychosocial intervention. Voluntary Counselling and Testing (VCT; also HIV Testing and Counselling or HTC) has been a key intervention in HIV surveillance, prevention and treatment. However, its uptake in Ghana has been low because of non-medical, socio-cultural issues (Koku, 2011; Yawson et al., 2014). Linkages and referrals between primary, secondary and tertiary care facilities can be weak in developing countries, and workloads at facilities can be high (Nambiar et al., 2007). While in 2009, Ghana Health Service and NACP expended 7 million USD, with half this amount spent training staff (Yawson et al. 2014), challenges at district level facilities can still be seen with under-staffing and service delivery.
According to Anafi, Mprah and Asiamah (2014), there is a need for intensive education in rural areas to increase knowledge for family members of PLHIV and reduce fear and stigma. Stigmatisation is considered by many researchers to be the number one challenge “to the prevention of HIV transmission, treatment, care, and the provision of support … in Ghana” (Abrefa-Gyan, Cornelius & Okundaye, 2016, p. 207; see also Kwansa, 2010; Poku et al., 2017). HTC is considered “the primary gateway to all systems of AIDS-related care” (Yawson et al., 2014, p. 1181). Despite this, the HTC service is under-utilised because of stigma (Koku, 2011; Yawson et al., 2014). In this regard, non-medical factors influence the public health management of HIV in a limited manner, while undermining effectiveness. The HTC service demands a more dedicated approach to national education on HIV and AIDS. Higher levels of education in the general population could be a step towards minimising actual stigma as well as the fear of being stigmatised.
Knowledge of HIV and AIDS is critical for behaviours that minimise transmission of the disease; in 2014 in Ghana, 72.3% of newly diagnosed PLHIV occurred amongst the general low-risk population (Fenny, Crentsil & Asuman, 2017, pp. 32-33). This suggests that health education programs need to be promoted within the general population regularly and consistently. In practice within Ghana, there is a long way to go until public knowledge of HIV and acceptance of PLHIV are high enough to significantly limit stigma. While stigma is often discussed, it is rarely incorporated into public health in an ongoing, effective manner. Voluntary testing has long been a government initiative, however for testing to be voluntary, fear and stigma avoidance must be minimised.
Ghana utilises what is known as ‘volunteer healthcare co-providers’ within their HIV facilities to offer education, counselling and support services from volunteer staff who are also PLHIV. They are known as Models of Hope. While this is a step towards understanding, recognition and inclusion of non-medical factors in HIV services, these volunteer staff are not often officially supported (Koku, 2011). Prevention efforts require community knowledge and practice to be high, while treatment efforts require counselling and education efforts on matters of medication adherence, nutrition, and the psychological effects of living with HIV.
Alternative remedies such as herbal or spiritual treatments present a problem to public health management in Ghana. Alternative treatments are often not monitored or supported by public health programs. People outside of conventional medicine are therefore at risk of missing out on key medications, diagnoses and support. These people may also be likely to miss out on education at facilities, as are people living in rural areas where healthcare initiatives are not regular or are minimally supported. At worst, people seeking alternative treatments instead of medical treatments for HIV can fall victim to fake medications or become very unwell without access to approved HIV medications.
Non-medical factors affect healthcare-seeking behaviour, prevention and treatment strategies. Lack of health education and different cultural beliefs can adversely impact HIV prevention strategies. Broader political and economic factors can undermine public health management of HIV. A multi-faceted and national approach requires improved coordination by multiple stakeholders. Management of such an approach would require dedicated funding mechanisms, but most of all, require transparent communication between government, non-government and others, including traditional or alternative providers.
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