PAEDIATRIC AND OBSTETRICS EMERGENCIES TOWARDS THE ACHIEVEMENT OF MILLENNIUM DEVELOPMENT GOAL ’ S 4 , 5 , AND 6 : THE ROLE OF THE PHYSICIAN ASSISTANT

The Physician Assistant (PA) plays a very important role in the rural areas manning clinics and health centers where no doctor is available. Millennium development goal (MDG 4) is targeted at reducing under-five mortality rates by half between 1990 and 2015. However, the current rate of 80 deaths per 1000 live births is far greater than the target rate of 40 per 1000 by 2015. MDG5 is aimed at reducing maternal mortality ratio by 2/3 by 2015. However, the current trend shows maternal death of 451 per 10,000 live births as against 185 by 1000 live births. MDG6 aims at combating HIV/AIDS, malaria, and other diseases such as tuberculosis, diabetes mellitus, and hypertension. There is still the need to reduce the prevalence of these diseases. Therefore, there is a need to increase the knowledge and number of PAs in the rural areas to help solve these problems.

I will highlight the current position of Ghana with regards to MDG 4, 5, and 6.

Millennium development goal 4 is targeted at reducing under five mortality rates by half between 1990 and 2015
Although there have been some achievements, it has not been sustained as indicated below: There were: • 122 deaths per 1,000 live births in 1990 • 98 deaths per 1,000 live births in 1998, rose to • 111 deaths per 1,000 live births which remained stagnant between 2003 and 2006, declined by 28% to • 80 deaths per 1,000 in 2008. [2]e current rate is against the expected target of 40 deaths per 1000 live births by 2015.

Millennium development goal 5: To improve maternal health, target at reducing maternal mortality ratio by 2/3 by 2015
The last maternal mortality survey conducted in 2008 showed a reduction in maternal deaths from 503 to 451 per 10,000 live births.The current trend if it continues would suggest maternal mortality will decline only to 340 per 10,000 live births in 2015 as against expected target of 185 per 10,000 live births.

Millennium development goal 6: Combat HIV/AIDS, malaria and other diseases
This aim has three targets to achieve.

INTRODUCTION
The Physician Assistant (PA), previously called the Medical Assistant has been playing a very important role in the health delivery system in our country.Physician Assistant who have been working below B2 health institutions have been working under trying conditions, with lack of some basic amenities, poor environmental conditions and yet care for the very sick and unhealthy people.Improvisation is often the order of the day.
Health is very expensive.The health care in Ghana is regulated by statutory bodies (The Ghana Medical and Dental Council, Nurses and Midwives Council of Ghana) to protect both the patients and the professionals.The Ministry of Health abolished the cash and carry system and has put in place the National Health Insurance Scheme with the view of promoting access to quality health care.However, the current premium is very low and poses a challenge to achieve its objectives.
It is rather unfortunate that the achievement of the millennium development goals (MDG) targets remains a mirage for many developing countries including Ghana.The three development goals chosen concern the most vulnerable in society: Women and children. [1] 3.6% in 2003 declined to 3.2% in 2006 • 2.2% in 2008 rose to 2.9% in 2009.
There is still the need to reduce HIV prevalence rates.

Malaria
Malaria still remains a national challenge to government, health professionals, and the communities.The population most vulnerable to malaria is children under 5 years.About 61% of children under five admitted in our facilities are cases of malaria. [2]e use of insecticide-treated nets was introduced to reduce morbidity and mortalities of children under 5 years by 25% by 2008.However, the usage declined from 55.3% in 2007 to 40% in 2008.
The increasing number of children diagnosed of malaria in our health facilities indicates the situation is only worsening.The key challenge, in my opinion, is lack of collaborative efforts between government, researchers, and the community members in the fight against malaria in the country.
We are hoping that the newly developed anti-malaria vaccine by GlaxoSmithKline research group will be available for use within the shortest possible time.The vaccine with a proven potency of 50% will reduce the rate considerably.
Currently, the vaccine trial is ongoing at the Agogo Presbyterian Hospital.

Other diseases
Prominent among other diseases under this goal include tuberculosis, diabetes mellitus, and hypertension.Recent indicators in the hospitals show that the prevalence of diabetes mellitus and hypertension is on the rise.With regards to tuberculosis, there are many cases of incomplete cure in Agogo Hospital, for example with the current 6 month treatment schedule advised by the WHO, noncompliance, poor nutritional status, and inefficacious drugs are unlikely contributory factors.
Are we therefore having drug resistant strains or that, the 6 month treatment scheduled is insufficient?The impression is that the 6 month treatment schedule is insufficient.These are issues that we should all consider critically with respect to the achievement of the set targets.
As you see, there are many challenges in the medical care in the country.For the PA working in deprived communities with no doctors to consult, there are daunting tasks calling for their ingenuity, dedication, and selfless devotion.

Problems at facilities
A Ghanaian renowned pediatrician from KomfoAnokye Teaching Hospital (KATH) and I with a team visited a hospital last year in Asante Akyem South of the Asante Region and met a PA in a desperate situation involving the fate of a child on admission.We noticed that the child had developed acute abdomen (surgical emergency) and ought to have been in the care of the surgical team at the Agogo Presbyterian Hospital which is the nearest referral center for this hospital.According to the PA, the child had been referred to the Agogo Hospital.
The child and the mother were found hopeless at the hospital on account of what many patients in Ghana face daily: • No ambulance service • The relatives had no money to hire a vehicle • No health insurance card (National Health Insurance Scheme).
The situation in this hospital was just a tip of the ice berg, given the fact that the hospital is close to important reference centers in the region (Agogo and KATH) and therefore has the opportunity of consulting and receiving specialist attention.
Obstetric and gynecological emergencies face similar challenges if not worse due to the involvement of two lives at the same time.There have been instances where maternal cases wait too long at home then, in seeking for obstetric help arrive too late at the hospital either dead on arrival or die soon after admission.This compounds the existing mortality rates.
Although it is highly unlikely to achieve the set targets in 4 years 2015 given the prevailing circumstances in the health sector, it is imperative for stakeholders on maternal and child health including HIV/AIDS and malaria to scale up collaborations and interventions toward improving the current indicators.
I therefore suggest strongly the development of pragmatic policies and interventions to reverse the trends, a strategy in which the PA is a key player.I propose the following measures: • Maternal health interventions including good referral system of which the PA is a key player in deprived areas • There is a need also to break various barriers preventing families and communities to access critical health service • We need to overcome critical issues regarding HIV/ AIDS, which include stigmatization, discrimination, and misconception of the disease by the society especially in the rural areas.
The PAs in spite of the difficult challenges in their facilities are contributing immensely to the health care needs of the Ghanaian population.The number of PAs in the country is relatively too small.
I believe the ratio of PAs to doctors in a District Hospital should be 3:1.The reserve, if not less is prevailing in the country, in spite of the fact that many of our trained doctors have left the country to practice elsewhere.
It is in this direction that the Presbyterian University College of Ghana has taken a new paradigm in developing an upgrade module of the PA curriculum to train students to excel in professional competencies and progress academically.
The BSc. PA course is ongoing at the Faculty of Health and Medical Sciences of the Presbyterian University College at Agogo.In future, masters programs will be embarked upon, after which the PA can perform certain limited but very important operations such as caesarean section and others.
In East Africa for example, about 2000 caesarean sections are performed annually by clinical officers (PAs) and when the results are compared with the operations done by doctors, there is no difference.
In future, migration from the PA program to a full medical course is feasible.Apart from the BSc.Physician Assistantship (Medical), there is also another group in the country; BSc.Herbal Medical Practitioners.We have to study this group and integrate them into our health care delivery system as far as possible.
As much as we appreciate the PAs as an integral part of the medical team, they are expected to work within their limits: • They should consult their supervisors in difficult circumstances regarding their duties • They should refer cases beyond them for specialist attention.It is also important that they get acquainted with doctors and specialists at their reference hospitals, follow-up at the hospitals to ascertain the outcome of their referred patients "Do not take undue money from patients because when people give you money not from their heart, there is no blessing in it." Somehow, the affluent Ghanaian O and G doctor's wife got sick.He sent her to Britain.Breast cancer was diagnosed.
An operation was done there and several times she flew there for reviews and follow-ups.Meanwhile, his son and his friends had crashed his prestigious smashing Mercedes Benz sports car.His wife succumbed to the breast cancer and died.When his mansion was completed and he got ready to move into it from his Korle-Bu bungalow, he also died.He did not get to live in that mansion.Meanwhile, the Indian doctor was still alive and healthy driving his Peugeot 404 car.He advised the young doctors to take this example.
The Indian Obstetrician and Gynecologist's example is worth emulating.
• At the hospital, they should interact with the attending physicians and allow them to explain the disease, diagnosis, investigations, and treatment as a learning experience.The practice of the PA is regulated by the Medical and Dental Council of Ghana and therefore one should uphold the tenets of the Hippocratic Oath.Any contravention to the law and ethics of medical practice in Ghana will result in the withdrawal of one's license, temporary or permanently depending on the degree of the offence.With regards to procedures such as lumbar puncture, either diagnostic or for intervention, tracheotomy and intubation, if you are not trained, refrain from them.One should not be too daring in your profession.One can excel in career by working within one's competencies.PAs should collaborate with other health team members and consult supervisors to minimize untimely deaths.Money, as it is describe as the root of all evils, to a large extent is true.Bu Hospital, one, an Indian and the other a Ghanaian.The Indian drove a Peugeot 404 and the Ghanaian a Mercedes Benz.The Ghanaian visited Makola market and found out that the market women were rich and began charging them exorbitantly.Soon he became rich and bought an expensive Mercedes Benz Sports car.He began building a huge executive mansion.His life style was that of the affluent.The Indian O and G specialist advised the young doctors: