Kwahu Government Hospital is located 150km north of Accra, Ghana’s capital city. This hospital serves approximately 230,000 people from over 200 communities and employs three full time doctors. There are 175 beds distributed amongst several main wards, including Paediatric, Maternity and Labour. Akwasiho rural clinic is a small community clinic serving six villages in the surrounding areas. It provides basic health care treatment, child out reach services and maternity care and has a small labour unit. There are no doctors employed at this clinic and the most senior member of staff was the midwife.

Health care in Ghana is free under the insurance scheme that was introduced in March 2004. In order to qualify for treatment the average Ghanaian must pay a minimum of sixty pesewa a month (approximately thirty pence). The current system, although very effective in most cases, means that people who could not afford to pay presented at a late stage of their illness. The emergency treatment that they require would often be delayed because of health care staff refusing to treat unless a deposit was paid. Everyday I saw uninsured patients, in particular children, presenting with severe malaria but treatment being withheld until a deposit was paid.

My aims for this elective were to practice clinical medicine within the context of Ghanaian culture and identify the common diseases that affect this population. Furthermore I wanted to experience how doctors worked in an environment where resources are limited and to develop my own clinical skills. To achieve these aims I spent my first few weeks under the supervision of the doctors working in all departments of the hospital such as out- patient clinics and A and E. Within this period I was able to identify some key illnesses that affected this population, which were mainly malaria, hypertension and type two Diabetes. I also learnt the central importance of a good history and clinical examination in formulating a diagnosis where basic tests were not easily accessible. This sometimes proved to be a challenge due to the translation that was required from Twi to English.

Once I had gained adequate knowledge in diagnosis and treatment of common illnesses I was then sent to the rural community clinic, where my main clinic duties involved seeing patients with a variety of illnesses from every speciality ranging from General Medicine to Psychiatry. I was also involved in antenatal care and child health out reach services specifically the vaccination and weighing programs. The level of responsibility that was given to me at the clinic were at times very overwhelming especially at my junior level, but I did feel that I was able to respect my limitations and refer patients to the hospital out patient clinic where they would be seen by a doctor.

This elective gave me a very real experience of the level of poverty in rural Ghana and how this impacts on health care. Even with the insurance program many basic medications were not available, and although the hospital provided lab services some basic tests were not always accessible. An example of this was the lack urine dipsticks in A and E. I also saw three pre- term babies die because there were no incubators.

Despite all these limitations the doctors that I worked with demonstrated a very high degree of professional behaviour and commitment. They left a deep impression on me about the importance of always performing at a high standard, even if you are working in an environment that is less than adequate.