Someone jokingly said customer care meant that the customer rendered the service. As funny as that sounds, that tends to reflect the quality of customer service with is offered to many clients and customers in various industries in Ghana. The health sector is not immune to this problem.

Whoever coined the phrase “Ghanaians are very hospital people” must have been joking at the time, but it has been widely circulated and believed. Ghanaians are not any more hospital than the people at the North Pole.

Because the health sector has been largely socialized by various governments for political expediency, it has been difficult to inject sound business practices into the sector. The result of this is an entitled patient and a disgruntled service provider.

I have met with patients in both public and private hospitals who are just downright rude to health workers. Those same patients will quietly sit and wait for hours to see some politician in their office. I have also known rude healthcare service providers. There are rude people in every industry.

No one is born with good customer service skills, anymore than anyone is born with the inherent ability to fly a plane. Customer service is a skill. It must be taught.

Major corporations spend significant portions of their revenue on customer care training for their staff. Unfortunately the Health Sector has largely left customer care to the discretion of the staff. Both public and private hospitals are culprits.

People will generally buy goods from people who treat them well, and the same thing extends to the service industry. Banks that have excellent customer service generally do better than those that mistreat their customers. People will keep seeing a doctor they like and trust, and who treats them well. They will keep their distance from one who does not treat them well.

At the bedrock of customer service is quality medical care delivered by highly competent professionals. This is however not enough to make the patient satisfied.

Customers expect attention and communication from their service providers, whether it is at the bank or in a hospital. The hospital patient is however unique. This is primarily because a hospital is not a natural place where anyone would want to visit unless they absolutely had to. The hospital is largely an unfamiliar and scary place for many. This is part of why it is important to make the experience a less painful, if not happy one, for the patient.

One key element which impacts the quality of care is the waiting period. Long waiting periods simply aggravate an already fragile situation. A patient who comes in for an appointment and has to spend 45 minutes in the waiting area before being attended to is more likely to be dissatisfied with the quality of care than one who is promptly seen to. Patient satisfaction has been proven to be inversely related to waiting time. This is not surprising.

In order to reduce waiting times, the first thing a facility needs to do is actually track a patient from the time they entered the facility till the time they left. This can be manually done by the staff, using timing chits which are given to the patients upon arrival at the health facility, with the time the patient gets to each station being documented by the staff at that station. It can also be done using hospital management software, many of which have this feature. It is important to actually measure this index, because it is in measuring the index that you can actually do something about it, and then you can actually see later if you did succeed at it. Generally speaking, even though there is no specific ideal waiting period per se, studies generally agree that thirty minutes is a reasonable maximum. I personally think that for a patient who actually scheduled an appointment and shows up on time, fifteen minutes should be the maximum amount of time they spend waiting to see the doctor. Some other factors which may affect the patient’s satisfaction include the condition of the waiting area, whether or not the staff are friendly, and the availability of entertainment. All these factors can either enhance or diminish the patient’s experience.

It is incumbent upon hospital managements to adopt proper strategies to curb prolonged waiting periods in their facilities. The impact of poor customer service on hospital earnings cannot be overemphasized. Whereas previously patients did not have many options, that situation is fast changing, with the springing up of various health centers particularly in the city. While it may be true that those other facilities may not offer any superior customer service, the patients have not found out yet and will leave your facility first, which will lead to a loss in revenue and possibly reputation for you and your facility. The social media age has brought with it some challenges for health service providers. Various online platforms afford aggrieved patients the opportunity to vent their displeasure publicly. An aggrieved patient could easily post a negative public review.

What factors affect the waiting period in hospitals?

The first factor is inadequate staff strength. Many facilities do not want to invest properly in manpower, and will staff a busy reception with one receptionist to attend to dozens of patients at a time. This of course slows things down significantly, and adds several minutes to the waiting period.

If the number of nurses are disproportionate to the number patients waiting, those patients are going to end up spending longer than expected periods of time waiting.

Other hospital workers such as laboratory technicians, pharmacists and even accounting staff must be adequate. It can be quite irritating for a patient to spend 15 minutes with their doctor and 30 minutes trying to pay to the cashier.

When hospitals fail to hire the right number of staff, the few left doing the work quickly get overwhelmed and become inefficient as a result. The patient bears the brunt of this inefficiency. Names get misspelled, folders get misplaced, minimal attention is paid to the patient, the tendency to be curt with the patient increases by the hour, and the end result is a disgruntled customer right at the beginning of the provision of the service. It is important to adopt best practices from around the world and implement them in our health facilities. There is no need to reinvent the wheel. There are simple algorithms that can tell you how many patients one receptionist can safely attend to, and how many nurses are required to take care of 5, 20, or 50 patients. Some health facility owners are only interested in meeting the bare minimum requirements of staffing, even when their patient load strongly suggests otherwise. For example, the Ministry of Health stipulates that a hospital must have at least 8 full-time nurses, while a clinic must have at least two full-time nurses. The management of the facility must apply the common sense to know whether or not their eight or two nurses are adequate to meet the needs of the patient. If a clinic sees one hundred patients in a day, it would be nonsensical to keep only two full-time nurses on staff. Sometimes too, because of the penny – pinching approach of some business owners, they fail to attract the right caliber of staff. Owning a health facility can be lucrative if done right, and many non-medical persons are opening clinics. This is a good thing for the community because there is increased access. Some of these facilities, however, are primarily profit-driven, which leads the owners to cut costs wherever they can. Unfortunately, they may even cut cost on the essentials, which includes manpower. The outcome of this is facilities that are overcrowded with patients and manned by inadequate staff. 

Service delivery can be greatly enhanced by the right tools. For instance, the use of an electronic sphygmomanometer can greatly streamline the flow of patients in a busy clinic OPD. The use of an infrared thermometer instead of an axillary thermometer can have the same effect. These two equipment alone when properly deployed can cut the patient’s time spent at the nurses’ station in half.

In short, one of the major determinants of customer care is the waiting time in hospitals and clinics. The level of satisfaction by the patient is inversely proportional to the length of the waiting period.

It is important to objectively measure and track the waiting period so as to be able to effect any meaningful change.

The waiting experience needs to be improved for the patient, with proper attention needing to be paid to the air-conditioning, the provision of refreshments and entertainment, and the availability of reading material.

The right caliber and number of staff must be hired, and the right tools must be deployed in order to streamline patient flow.

These will go a long way to affect one of the key determinants of the quality of service.


All things being equal, you should get the exact same experience in the same industry every single time. That is what standardization is about. If I fly Emirates or Delta or American Airlines fifty times, I should have no ordinary way of knowing which specific pilot was in the cockpit. The takeoff experience should be the same, and the landing experience should be the same too, all things being equal. You don’t want to board a flight not knowing what to expect. That is called standardization. The airline industry has almost perfected this art and science. Now I am not talking about whether they serve you potato or beans. As important as that is, that usually has nothing to do with whether you arrive safely at your destination (unless you have some kind of food allergy).

One important outcome of standardization is automatization – the elimination of discretion from the dispensing of a service.

For example, no matter the cook, kitchen hand or chef in a McDonald’s, a hamburger at McDonald’s will taste the exact same way. This is so unlike your local bread baker – one day the bread is soft and tasty, and the next day the bread is half – burnt, depending on the mood of the baker.

Whereas such discrepancies can be acceptable when it comes to bread, in terms of health care it could mean the difference between life and death. If a patient presents to two different facilities with the same complaints at the same time (if that were possible), the clinicians at both places should be able to come to the same diagnosis or diagnoses. Otherwise, one of them is wrong. It’s that simple.

That is called standardization. God is the architect of standardization. A second has the same value in Accra as it does in Beijing, Sydney, and New York City. If it weren’t so, there would be no way to compare various athletic competitions held in different cities at different times.

The Airline Industry understands this very well. A typical preflight checklist consists of well over 30 items for the pilot and crew to check before takeoff. A Boeing B-17 prototype crashed in Dayton, Ohio, in 1935. The pilots, both of whom were killed in the crash, had “forgotten” to disengage the gust locks before takeoff. The result was costly for Boeing and the pilots’ families. The management and engineers of Boeing introduced the checklist into their operations. Checklists have since become the industry norm in aviation. The industry figured that it was simpler to have it written and checked off every time than to rely on the pilots’ good intentions.

In 2014, a Gulfstream IV crashed during takeoff at Bedford-Hanscom field in Massachusetts, killing all four passengers and three crew members. It was found that the crew had failed to disengage the gust lock. Not only that but if they had run a preflight control check, they would have found out that the gust lock was still engaged. In fact, in that case, the National Transportation Safety Board found out from the plane’s records that 98 percent of the plane’s previous 175 flights were conducted with incomplete flight control checks. Further studies also found out that many business jets conducted only partial control checks before takeoff – a significant 15 percent of them. About two percent actually performed no checks whatsoever.

These numbers are much better where commercial airlines are concerned, because of tighter regulatory controls. In fact, it is the introduction of these standards, coupled with innovation, which has made flying the safest mode of transport. If automobile drivers would engage the same level of seriousness to their trade, traveling by road for many people would be much safer.

According to Investopedia, Standardization is a framework of agreements to which all relevant parties in an industry or organization must adhere to ensure that all processes associated with the creation of a good or performance of a service are performed within set guidelines. This ensures that the end product has consistent quality and that any conclusions made are comparable with all other equivalent items in the same class.

In essence, where standardization is applied, the quality of a good or service should not vary widely from point to point.

Many of us have had various experiences with healthcare providers. We have our favorite and least favorite doctors and nurses. Now, where proper standardization is in place, you should not be too worried whether or not your favorite health worker is on duty, because you will get the same quality of service from whoever is on duty.

The Health Sector has embraced some degree of standardization, especially when it comes to the field of surgery. Properly ran operating rooms use checklists. There is very little room for assumption, right from the proper identification of the patient, to the signing of consent forms, to the draping of the patient, to the type of incision, to the manner in which knots are tied.

The field of obstetrics, because of the huge outcry against maternal mortality, has adopted stringent standards as well, and these have led to significant reductions in maternal mortality, even though the situation is still largely unsatisfactory because of the inadequate numbers of suitably qualified health professionals.

Other fields within the health sector need to begin to adopt similar systems in order to enhance the quality of healthcare delivery. For example, instead of leaving the management of the patient to the discretion of the practitioner, some things need to be standardized. These industry standards do exist but are not being practiced universally. Because of this discrepancy, a patient with the same complaints will get two very different management systems from two hospitals a few blocks from each other. Whereas the specific treatments may differ from practitioner to practitioner, the diagnoses should not. A patient who presents with diarrhea and vomiting to a hospital, for example, should always have their electrolytes checked and corrected, in addition to being rehydrated. A diabetic patient who reports for review needs to have their eyes checked as a matter of protocol. Their urine should be checked for microalbuminuria.

Even though various checklists have been developed over the decades by various reputable bodies, many health professionals still rely on their own discretion in the management of patients, with the inevitable results of inconsistency and unreliability in the delivery of health services. One study conducted in Sub-Saharan Africa revealed that eighty percent of anesthetists said they did not know about the WHO surgical safety checklist or did not use it.

There are algorithms that have been developed, tested and found to be effective. It will pay a great dividend to both service providers and patients alike if service providers begin to actively make use of these checklists. There are internationally accepted guidelines for the management of virtually any condition under the sun. This does not mean that a certain outcome is necessarily guaranteed, but it does largely eliminate avoidable errors. In the United States, hospital errors are the third leading cause of death, after heart disease and cancer. That is a whopping 250 000 people dying out of medical errors. In Ghana, the statistics are not available for obvious reasons, but you can take a good guess.

You see a checklist ensures that you don’t miss anything important.

An auto mechanic who uses clearly developed checklists to diagnose his cars and solve problems will outperform a very brilliant mechanic who simply relies on his guts. That is why McDonald’s is a globally successful restaurant business, and your neighborhood eatery is struggling to stay afloat.

An “average” doctor who meticulously sticks to proper industry standards and uses checklists judiciously will deliver greater value to his patients than one who relies on his instincts alone. It is time that we fully embrace the use of timesaving and lifesaving standards in the health sector.



Checklists can save you time, money and lives. Just ask Boeing Airlines. Their B-17 prototype crashed simply because the two pilots “forgot” to disengage the Gust Lock. That was in 1935. Both pilots were killed. The prototype was destroyed. Boeing introduced checklists. Nowadays a typical commercial airline pilot would use about six different checklists prior to takeoff. That is usually about 30 different items to inspect, engage, and check off before takeoff. Pilots and crew who have been cavalier about checklists have paid the price.

In 2014, a business jet registered to SK Travel, LLC, and operated by Arizin Ventures LLC, overrun the runway, and collided with approach lights and a communication antenna, killing the crew of three and four passengers. The National Transportation Safety Board found out the following as a result of their investigations as the probable cause of the crash: “During the engine start process, the flight crew neglected to disengage the airplane’s gust lock system, which locks the elevator, ailerons, and rudder while the airplane is parked to protect them against wind gust loads. Further, before initiating takeoff, the pilots neglected to perform a flight control check that would have alerted them of the locked flight controls. A review of data from the airplane’s quick access recorder revealed that the pilots had neglected to perform complete flight control checks before 98% of their previous 175 takeoffs in the airplane, indicating that this oversight was habitual and not an anomaly. Check the number of times the word “neglected” was used in that paragraph alone. In effect, the particular crew was in the habit of disregarding the standard checklists prior to flying. They did this one hundred and seventy-one times without incident on that particular airplane, but when it finally caused a problem, it led to a loss of lives. The interesting fact is that the pilots were not novices. The Captain had flown more than 11, 250 hours. The First Officer had flown more than 18,200 hours of flight time as pilot-in-command and 2,800 hours in Gulfstream-IV airplanes. But despite their vast experience, they were negligent when it came to observing protocols. A team is only as strong as its checklist.

The airline industry uses checklists to ensure that critical things are actually carried out and recorded.

The field of medicine has greatly evolved over the past 200 years, and many aspects of patient treatment have been standardized and automated. Surgery has greatly benefited from standardization and has used it to effectively improve patient outcomes. A simple thing like an instrument count has gone a long way to ensuring that various instruments are not left inside a patient’s abdomen after a procedure. Those hospitals that have ignored the Instrument count have suffered negative outcomes and negative publicity as a result of catastrophic outcomes. The loss of lives and morbidity that have resulted from such incidents are almost innumerable globally.

The fact is that no matter how skilled a team is if they would not pay attention to standardization, they would eventually get into trouble. A team is just as strong as its checklist. The use of a checklist has many benefits.

Firstly a checklist helps us become better organized. It is simpler to do steps 1 to 10 in that order repetitively than to simply attempt to tackle 10 tasks simultaneously.

A checklist actually enhances creativity too, because it becomes easier to master a set of repetitive steps. As we instinctively begin to perform these tasks with mastery, our imagination is free to take on other tasks. Instead of trying to remember what to do next, a checklist takes care of that, and we can use our minds for more creative tasks.

A checklist enhances productivity because it is easier to accelerate the performance of repetitive tasks individually, leading to more efficient use of the time.

It is easier to delegate specific tasks when we use checklists because there is a way to verify that they are accomplished.

Most importantly, checklists are a lifesaver. Since the introduction of checklists, surgical infections have reduced significantly, leading to a significant reduction (more than 40 percent) in mortality from various procedures.

The use of checklists must be embraced by all health practitioners and hospitals, in order to deliver a predictable level of high-quality care to patients.

Checklists should be used even for the most basic of functions. For example, there are clear recommendations that have been put forward when it comes to the components of a general wellness visit for various age groups and based on gender. Using a checklist ensures that it is possible to conduct a more thorough exam every single time, rather than leaving it to the discretion of the practitioner. Of course, where it is necessary, changes can be made that would suit the specific patient. This simplifies the life of both the doctor and the patient. It is simpler to simply check off a list of things to be done than to laboriously try to list them from memory every single time.

It is not enough to have a checklist in place, however. It must be enforced. There is no team of one, which is why the nurse has a duty to cross-check that the items are actually executed according to plan. There is a nurse who stopped a cardiothoracic surgeon after an open heart surgery from closing up. She insisted that an instrument had been left inside the patient’s chest. The surgeon was adamant. He insisted on closing. He was sure he had accounted for all his instruments. The nurse stood her ground and said: “I will not allow you to close.” The surgeon was angry. They did the instrument count again. That instrument was missing. When the doctor removed his initial clips, there was the instrument in the chest of the patient. These incidents have happened time and again. A good team leader knows the value of his team members, and rather than try to shout them down, will instead empower them to make the team more effective.

Using checklists will greatly enhance the work of the Ghanaian doctor. Not only will the doctor become more efficient, but the patients will also be better satisfied. Time will be saved as well. Instead of writing copious notes, simply checking off items that should be done or that have been done will save a lot of time.

Checklists do not get in the way. They actually make the way clearer and simpler for everyone. Would you like your pilot to say to his First Assistant during taxiing “I wonder if the Gust Lock is off or on?” or you’d rather rest knowing that every single item on the checklist had been meticulously checked and cross-checked. A single “sheet of paper” can save you from a lot of trouble. Literally.



The length of the waiting period is inversely proportional to the patients’ perception of the quality of healthcare delivered, and the patient’s satisfaction. The longer your patients wait to see the doctor, the less satisfied they will be. It is really that simple.


No one likes to wait for long periods for a service, and healthcare is no different in that regard. Healthcare is quite different in other regards though in the sense that the people who come to the hospital are generally not too eager to be there in the first place. Most people would usually not go to the hospital or clinic unless they absolutely had to. Queuing up at Disneyworld is not the same as queuing up in a hospital OPD. The former has the promise of certain fun. The latter generally holds no promise of any kind of fun for the patient. Prolonging their waiting times for longer than necessary just complicates matters.


Patients have been known to get angry and walk off after waiting for great lengths of time. Others have lost their calm and assaulted health personnel. The loss in revenue and reputation to health facilities cannot be overemphasized. This is one area many hospitals have not paid attention to. They used to get by with the nonchalance because patients did not have too many options to choose from. One particular study of the waiting times at a major health facility in Nigeria showed that the patients waited anytime between 60 to 180 minutes just to see the doctor. They spent on average about 5 minutes with the doctor. As scandalous as that sounds, it is quite representative of what pertains in many health facilities, especially public health facilities, which are generally overwhelmed by attendants and understaffed at the same time. In order to change the status quo, there must be a strong political will to overhaul the healthcare system.


The situation in the private sector is quite varied. On one end of the spectrum are some facilities that are battling for survival, with low patronage. Those are not the subject of this post. The other end of the spectrum is made up of facilities which are just like the busy public facilities, with congested waiting areas and short consulting times. For the hospital owner who didn’t use to care about the length of the waiting period, it is time to wake up. This is because patients are becoming aware that they have options. Those that cannot afford the options would simply pray for the day they acquire enough money so they can seek better experiences elsewhere.

There are a few factors that are responsible for the long waiting times in the hospitals.
First is the inadequate staff numbers that are deployed to tackle the disproportionately high numbers of patients. It is not uncommon to see one receptionist attending to dozens of patients at a time. This scenario plays up because for some owners of health facilities, especially people without any medical training, healthcare it is simply a game of numbers, where they are interested in making the barest minimum amount of investment and yet reap high returns.


The healthcare industry can be successful, even lucrative when run properly. The vast majority of investors in the health sector, I am sure, have noble intentions of actually delivering quality service. Some owners, however, are only interested in making a profit. They sacrifice patient satisfaction for a higher return on investment. Some too can simply not help it because they do not have the funds to hire the right number of staff members. They may have jumped into the healthcare industry believing that it was lucrative, only to have the shock of their lives when they realized that it called for much more than they were able or willing to invest.


Another factor that can affect patient satisfaction is the quality of the waiting period. No matter how naturally patient someone is, it is much easier to wait in a beautifully furnished and air-conditioned waiting area than to wait in a crowded, hot and humid “waiting” area with no air – conditioning and no entertainment. The socialist approach to healthcare whereby governments indoctrinate the people to believe that they should expect “free” healthcare has created the situation whereby the government cannot provide decent health facilities for the general population. (Sometimes the government is able to build a beautiful edifice but cannot get it to run efficiently.) Unfortunately, some private health facilities have bought into the dogma of socialist healthcare. They provide the bare minimum at socialist prices. The end result is that they are not able to efficiently run their facilities. A well designed and properly furnished waiting area goes a long way to improve the patient experience. People will appreciate the value you provide, and they will recommend your facility to their family and friends.


Whereas there is no specific “right” waiting period, it is generally accepted that most patients will be happier with a health facility if they waited for no longer than thirty minutes to see their doctor.


Hiring the right number of staff in the beginning, and scaling up to meet increasing demand is the way to go. If your clinic is just starting off and not so busy yet, instead of hiring a receptionist, assign a nurse to your front desk. You can have the nurses rotate. Once your patient load begins to increase, you need to hire a full-time receptionist well trained in customer care. Or you can simply hire an extra nurse to share the workload. It is important that you have a pleasant person at the front desk. It is easier for patients to wait when the front desk person is patient and pleasant. The person at the front desk must be suited to the kind of clients you seek to attract to your facility. If your goal is to compete with the government health posts for patients, then you should hire accordingly. There is nothing inherently wrong with that. Just know that it will be very difficult for you to beat the government in a price war. The government can offer everything for “free’’ because it doesn’t need to work for the money – it can simply extract more taxes from you to pay for the freebies.


If your target is to attract middle and upper-class patients, hire appropriately. You need to respect your patients. Do not put someone at your front desk who is rude, does not communicate well, and always has gum in their mouth. That would just not cut it for your patients. Your business will soon begin to suffer, as your customers discover a facility with a nice receptionist who doesn’t chew gum or frown her face often.
Sometimes the bottleneck is in other parts of the patient flow through the hospital. For instance, you may have very smart receptionists, but your nurses may be inadequate or simply slow. Worse still you may not have the right number of doctors to take care of the patients. A lot of common sense must go into running a health facility. If you have 100 patients in your clinic you cannot have just one or two doctors on duty at the time and be “fine.” You ought to actually sit down and think it through. Does that proposition make sense to you? If you were among the 100 patients waiting would that be acceptable to you to have only one or two doctors?


Sometimes the problem is with the cashier, or the laboratory, or the imaging department if you have one. If your “laboratory” takes 4 hours to run a basic test, it might be a good idea to outsource this to a proper laboratory which would give you timely and accurate results. It is inappropriate for your patient to spend 13 minutes with the doctor and yet spend 20 minutes trying to pay their bill to the cashier. You might need to hire a few more cashiers.


The thing about fixing these issues is that you cannot correct what you don’t measure. You need to actively measure the average waiting time in your facility, and also find out how long patients spend altogether when they come. You can use a timing chit which you give to the patient at the time they enter the facility, and which will be endorsed at each station as the patient progresses through the system in the facility. When you collect about one hundred chits, you will have sufficient information to make a judgment. Some simple arithmetic will give you the average waiting time.


If you are unable to do this, however, you can find a good statistician. If you cannot afford the fees, you can get any high school Math teacher and have him help you. Just make sure you pay a fair price for the help. Paying for the help will help you take it seriously.
Once you have the data, you can begin to look at areas where the patients have been spending the most time. (I can almost bet that is unlikely to be their doctor’s consultation.) You can begin to make changes to your system that will greatly impact on the perception of the quality of care your patients get from your facility.

Investing in the health sector in Ghana

Some tips on setting up a hospital

The Healthcare industry can be lucrative, if you really understand it. It is one of the most rapidly growing industries. Nigerians are said to spend an average of 1 billion US Dollars annually on health tourism. Two hundred and fifty million dollars of that is spent on trips to India alone. Anyone who can properly position themselves to tap into that market stands to make a healthy income and profit. In Ghana the market for medical services is rapidly expanding, with new hospitals springing up regularly.

Even though there is a lot of successes and money to be made, a proper understanding is required. Before you sink your hard earned cash and that of your partners into building a health facility, there are a few things you need to bear in mind …

You are not the government.

The government can do things you as an individual cannot even dream of doing, and even if you were able to conceive of them, it would be illegal for you to attempt them.

The Government can owe people and refuse to pay

As scandalous as that sounds, it is a fact. The government can buy supplies this year and pay next year, and even in that case choose to pay a fraction of the cost. All over the country, you’ll find contractors who have executed contracts and are still yet to be paid years afterward. You will also find many people in jail who defaulted on their debts. Running a hospital requires a lot of supplies, and you have to pay your supplies promptly for obvious reasons. It will pay you a good dividend to keep that in mind.

The government can print money – you can’t.

When the government runs out of money, it can simply print some more. You are not so fortunate to have that right. A government organization was building a hospital. They were setting up several operating rooms. I tried to make contact with them to recommend an anesthesia machine to them. This particular anesthesia machine is from the United Kingdom, and has several features that make it well suited for the peculiar situation in Ghana. For one it is very compact and durable. The parts are easily serviceable. Any technician can be trained to service it. In addition it comes with a standby battery that can power the machine for up to six hours if the main electricity supply goes off. Another advantage is that it comes with a built-in oxygen concentrator. That means that it simply generates its own oxygen from room air. Since we started using this particular machine our oxygen costs went down by about 90 percent, plus we didn’t have to panic anymore whenever the electricity went off in middle of a procedure. We simply continue as if nothing happened. Despite all these features it costs less than a third the cost of the regular anesthesia machines on the market. I wasn’t recommending this machine for personal gain, or for a commission. I wanted to help. The Head of the Committee when he was informed claimed they had already completed the deal for the contractor to supply the high-end anesthesia machines which cost several times more. The sad thing is that these government owned facilities are generally constructed with huge loans which take several years to pay. The particular hospital has been completed and remains unopened for about two years now. Why was the government organization not interested in saving money? Because it’s a government owned organization. They don’t have to save money. You, on the other hand, need to consider several factors before you sink your hard earned cash into frivolous expenditure.

Also on the issue of money, the government hospitals don’t have to worry much about overhead because their workers are paid by the Central Government. Their doctors and nurses are on government payroll. That means that whether theta hospital makes any income or not, their workers will be paid by the Central Government. You don’t have that luxury. You have to run your hospital or clinic as efficiently as possible and generate enough income to continue to attract and retain the right caliber of staff and also generate enough profit to make it work your while.

The government can get away with bad customer service – you can’t.

Just pay a visit to some public hospitals and observe the testy exchanges between some of the staff and the patients. You would be wise not to try that at your private facility. For obvious reasons.

The government can and will survive any number of lawsuits – you might not 

The government can simply post its workers to any of its numerous facilities and does not even have to ensure that they are well suited for the task. The government does not have to enforce the highest standards of care at its facilities. If the government gets sued, life goes on – for the government. You on the other hand, would be playing Russian roulette if you do not ensure that the highest standards of care are implemented at your facility. You must also ensure that you carry adequate professional indemnity, or what is called malpractice insurance. The other day a health worker at a public hospital was found to have killed a few people just by giving them intramuscular injections. They developed florid abscesses and died within days. It was found that the person who administered the injections was not even qualified to administer injections to start with. He was not a doctor or a nurse. It also emerged that he had simply mixed the medication into a bag of diluent and kept drawing from it to administer to the patients. He did this to save himself the trouble of having to mix the drugs as needed. It did not matter that the drugs came as single – dose vials. The case made the news for several days, and then died out as other salacious news items emerged. 

You are not the Red Cross or MSF

You also need to remember that you are not the Red Cross. The Red Cross raises money by begging rich people and countries. They have been in the news recently for not managing the donations well, but the Red Cross keeps going. It hasn’t folded up, nor is it likely to. You on the other hand may not have the elaborate systems instituted for begging for money, and will have to make sure that you are adequately resourced to bear the setting up and operational costs involved. This simply means that while The Red Cross can continue to be a charity, that “business” model will largely not work for you. If your goal is to run a health care charity, it will be simpler for you to focus on raising funds so you can help pay the hospital bills of those in need. Setting up a hospital specifically for that purpose might not be a viable venture. Just for your information, you can be held professionally liable even if you are providing services for free. An aggrieved patient can sue you if they believe your free service caused them harm.

Focus on the 20 percent

You have probably heard of the 80/20 principle. It may actually be 90/10 or 95/5 or 99/1 or 75/25 – it doesn’t make any difference. The point is that most of your income in any business comes from the minority of your range of services, or goods, and from the minority of your clients and customers. Your goal as a business owner or entrepreneur is to identify the niche that will bring you the highest yield, and leave the rest of the services to the government to provide. After all, you’re not going to be up for re-election. Right on the other end, you are up for a different kind of election on a day to day basis. Your customers are always voting on you and your hospital. That is why you have to make sure it counts for something. Why expend so much energy and resources providing low – yield services when you can instead focus on areas that will bring you better returns?

 As simple as this is, this is the point where many enthusiastic businessmen, companies, and professionals meet their death. They acquire a piece of land, put up a building with dozens of patient rooms, and simply wait for the business to flow in. They soon find out that is a dumb business plan. If you were thinking along similar lines, you need to think again. No matter how many patient beds you have available, no well person will come and pay you to simply lie in them. Barring some epidemic, you’d be thankful if you had a thirty percent bed occupancy. And, if there’s an epidemic, chances are your beds are going to be occupied by people for FREE. You cannot eject an EBOLA patient from your hospital because they cannot pay their bills.

Sometime ago the owner of a big health facility was negotiating a partnership agreement with some investors. It increasingly became apparent that the said facility was in dire straits. The owner had sunk a lot of money – borrowed money – into putting up a humongous structure. He ended up utilizing just about a quarter of the structure. Because of all the cash he had sunk into the building itself, he did not have the requisite funds to properly equip the facility, or to attract the requisite skilled labor to serve the patients. The banks were hot on his heels. In addition he couldn’t get his pricing right. He had started off setting his prices, only to quickly backtrack when a few of his initial patients complained. He thought he could attract more patients by reducing his prices. It didn’t work. His lower prices simply made things impossible for him. You need to understand that pricing in the health care industry is not exactly the same as pricing of commodities. You can attract more people to your grocery shop by adjusting your prices. Your market for the groceries is potentially all living and breathing human beings in your catchment area. The healthcare industry is not so. No matter how low your prices are, the only people who will come to your facility are people who need the services you offer. If you don’t position yourself properly in the eyes of the market, you will simply suffer by attracting the wrong kind of customers, and end up not being able to meet your overhead.

When our facility was being set up, I realized from the beginning that we had to pay particular attention to our pricing. More important we had to position ourselves properly. It takes as much work to sell to a “rich man” as it does to sell to a “poor” person. The problem with the latter group is that no matter how hard you work, the person who cannot afford your services simply cannot afford them. In addition, let’s say you are running a Maternal Health facility. You can make your services as cheap as sand, and it won’t make much difference because only a finite number of women are pregnant at a particular point in time. A cheap maternity service cannot attract men to come to your facility, nor will it attract non-pregnant females. Remember also that you cannot beat the government in a price war. The government can offer, or pretend to offer, free health care at will. I recall when Ghana introduced “free” maternity services for pregnant women. It was simply done by an announcement in the media. No change in the number of doctors or nurses, no increase in infrastructure or logistics. Just a cold press release. You see why you can’t compete with government when it comes to pricing? It is far better for you to zero in on the many untapped niches available in the health sector.

From the inception of our hospital, we began to experience the push from various people, some well-meaning, to slash our prices. What they didn’t understand was that a lot of thought went into determining our prices. We knew what it would take to deliver the quality of service we wanted to give our patients. We also knew what would be required to meet our overhead. We stood our ground, and it worked. Which is easier – to sell one pricy item or to sell a hundred cheap item? Unless you are Walmart or Amazon, the former is easier. Within two short years we have had patients come in to see us from across Africa: Mali, Cote D’Ivoire, Togo, Liberia, Nigeria, as well as the United Kingdom, the United States and the Middle East. We serve a growing number of people from the expatriate community. During the same period we have seen other new facilities spring up and do quite well, old ones struggle to the brink of collapse, and some stuck perpetually in the “construction” phase. I recall meeting a certain gentleman who represents a certain global investment group. They had planned to build a multi-specialty facility. They even went as far as recruiting some top-notch doctors from Europe and paid for them to relocate to Ghana. It’s been a few years now, and not a single brick has been laid. The doctors they recruited are drawing salaries while volunteering their services elsewhere. Someone must have taken a special class in how to complicate simple projects. First they were going to put up a new structure in the heart of town. Then they abandoned that plan and went to try to acquire a certain facility. They drafted a plan of redesigning that facility. They must have hired an architect and several engineers. I visited that facility a couple of times and was granted a tour. It had enough rooms to be used for the purposes. There was no need for any redesigning. The project still hasn’t taken off, as at the time of this writing. Hopefully they’ll get it right one day. From all indications they have the money. How else would they have successfully recruited those doctors who are drawing salaries and yet volunteering their services elsewhere? The money isn’t their problem. The lack of relevant common sense is. They could have had a multimillion-dollar business running already if they only knew how to.

Whatever you do, do not copy the government model. When you pass by a hospital that looks busy with lots of patients queued up, don’t be too easily impressed. They could have lots of patients queued up because they operate a poor system which hinders patient flow, or they simply don’t have enough doctors to see the patients. I recall one such facility. They were the first hospital in that community. There was no government hospital nearby. The residents quickly took to the place. They had good patronage. At some point they had about three doctors running the outpatients department in the mornings. One of the doctors died. Then another became too sick to work. They didn’t replace either of them. They were down to one doctor. Then a new hospital opened up nearby. They had excellent customer service. Guess what happened to all the people who used to queue up at the other place. If the first facility were a government hospital however they would not have had much of a problem. After all the National Health Insurance Scheme would have kept them well patronized. People would have continued to go there and queue because they didn’t have to pay out of pocket for many services. Even if the facility wasn’t being patronized the government would still continue to take care of their payroll and other expenditure so they wouldn’t have much to worry about. There would be no investors or venture capitalists breathing down their necks demanding some good returns on their investments.

Keep it simple – sir! (Or Madam)

Don’t set out to set up a big hospital initially. Identify a niche (or a few niches) and focus on that. Focus on services that have a high gross margin. I’ll give just one example in this document. The field of Assisted Reproductive Technology is one rapidly expanding and profitable niche in Ghana. It is recommended that countries maintain a ratio of 1500 IVF cycles per million people. That would mean about 42 000 cycles for a country of 28 million people. Ghana is far from achieving this target. The average IVF center in Ghana conducts about 200 to 400 cycles a year. An IVF suit would cost about 500,000 USD to set up. That is assuming you are setting up ONLY an IVF center without supporting facilities. To maximize that niche, an extra 1million USD should be budgeted for the provision of a properly equipped laboratory and Gynecology units. Most IVF centers in the United States and other countries are well supported by such units, which greatly enhances their success rates. If you don’t include such services, you’ll soon have to outsource those services, thereby missing out on a significant stream of income. Most IVF facilities in Ghana do not spend anything close to this amount for their initial setup. Of course it’s an open market, and you can get a good bargain on your purchases. Right on the other hand, it can simply be a sign of cutting corners, which can be a reason why some centers have lower success rates compared with international standards. If your goal is to set up a lasting business enterprise, you need to be ready to invest properly. Sometimes all it’ll take is for you to shift your business model from a large sprawling edifice to a simpler more compact model. A well designed two – floor structure with a dozen rooms is usually adequate to provide a full range of gynecologic services, and a fully functional IVF center.

IVF services have a very healthy gross margin. A cycle of IVF can cost the patient anywhere up to 10 000 USD. The gross margin can be in the region of 80 percent or even higher. Most centers insist on upfront payment. If you set up and maintain the requisite standards, you are looking at a potential gold mine. If this is potentially so lucrative, why aren’t many more people venturing into it? The answer is that it is simple if you know what you are doing, plus if you have the required funds to invest. Some people know what to do, but they don’t have the funding. Others have the funding but lack understanding of how to do it. This is why the quality of the team is important. I visited a major quasi-government health center. It had just been completed but was yet to be open to the public. It was top notch, with several units and departments. I asked the CEO, “where is your IVF center?” “It’s going to be part of the second phase,” he said. What about your dialysis unit? Phase 2. What about laparoscopic surgery? Phase 2. Cardiac catheterization? Phase 2. It was obvious this facility was soon going to run into problems. They had a large outpatient department, and huge wards for admission. Just to give you an idea, you can keep a patient for 24 hours on a ward and charge them 100 USD. You can carry out a surgical procedure on a patient and charge many times more. Depending on the procedure and other factors they can go home three hours later. Which would you rather be focused on?

Avoid second hand equipment if you can

The issue with second equipment is that they break down. People generally buy these equipment on the flea market, without any form of service agreement. A health facility in Accra went and bought a CT scan machine. The machine was quite old but was still functional. The hospital thought they were getting a good deal. They had it installed. A few months later they needed to carry out minor repairs. The bill they got could have bought another one of those old machines. Both payments could have bought them a brand new CT scan, or at least a certified used one with manufacturer’s warranty. There are payment plans available for new buyers, and it is common sense to properly research into them and get yourself a good deal. The medical equipment market is like the aircraft industry. Airline companies have bought older airplanes at very low prices, only to be forced out of business because they could not pay for the servicing of the aircraft. Another fact to bear in mind is to remember that the older the equipment, the higher the chances that the manufacturer would have stopped making parts to support that particular model.

You need reliable energy

A certain health facility pays about five thousand USD as electricity bill to the Electricity Company of Ghana every month. The sad thing is they hardly make that much in a month? How is that possible? They have a huge structure. Elephants drink a lot of water and consume a lot of food. Big buildings cost a lot to maintain and consume a lot of electricity. It’s that simple. This bill was at a time when there was erratic power supply in the country (the famous “Dumsor”). They had to spend a similar amount powering their generators. The fact is with proper planning that entire building could have been solar powered. Plus they needed a much smaller building than the one they had. 

Central air conditioning is nice and fancy, but you must be cautious. Your operating room suite should have central air conditioning, but everywhere else can do with split units. It’s easier to manage the consumption that way. You can switch off the individual units in offices that are unoccupied and save on your bills. At last check the Electricity Company of Ghana was selling power at $0.2 per kWh. You can easily rack up bills in the tens of thousands if you don’t plan effectively.

Standby generators are a must. In Ghana energy is something you can’t have too much of.

You’ll need to have voltage regulators in place, and you’ll have to have UPS batteries in place for some of your equipment. That goes without saying.

You’ll need water

It will be a good idea to sink a borehole to supplement the water supply from the Ghana Water Company. You’ll need a water purification system as well, for desalination and purification. A well installed reverse osmosis system will go a long way to help you. For the first few years of our operations we relied solely on our borehole system for water. You cannot have a health facility without running water. To maintain the right level of cleanliness you need water. You need water to sterilize your equipment. 

Professional indemnity

By all means you should carry malpractice insurance. Government facilities can survive several lawsuits. You can’t, without adequate insurance cover. There is a private health facility which has faced several lawsuits over the years. They have survived. They have good malpractice insurance. A public hospital was sued for amputating the wrong leg of a young man. They survived it without any insurance cover. They are a public hospital. The government will bail them out if it has to. A good rule of thumb when it comes to estimating how much cover you need is this: multiply whatever you think you’ll be sued for by ten. That should be the minimum total value of the cover you need. I got a call from a friend of mine recently alleging that one of his babies had been stolen at a private facility. He and his wife had undergone antenatal care at the facility for the entire period of the pregnancy. They had done numerous scans, and had been examined by the obstetrician during each antenatal visit. They were told they were carrying twins. He said the sonographer always showed them the two babies. Their obstetrician never took issue with any of the scans. He planned a mode of delivery. An elective cesarean section was planned. The husband was not allowed into the operating room. The twins became a single baby. He is angry and distraught. He’s planning on suing.

Assets all risk insurance 

I assume you will take an assets all risk insurance for your buildings and equipment. That goes without saying. You need to properly insure all your buildings and equipment. Medical equipment can be expensive, and the least you can do is properly insure all your assets.

You’ll need to hire the right staff

Attracting the right caliber of staff is key to the success of your enterprise. Medicine is more than simply prescribing treatment. You must connect with your patients. These are the things that patients and their families remember long after the ailments are cured. If you are deliberate about it, you will attract workers who are not only skilled but compassionate as well. This is the key to the success of your practice. In fact, your caliber of staff will even determine whether or not you’ll get sued, to a large extent. Studies have proven that patients hardly ever sue doctors they like. There is an art to hiring. For certain key positions, I actually go incognito to the candidates’ place of work and observe their interactions with patients and their colleagues. I want to see them in their natural state, not in their “interview state.” 

Part of the hiring decision is the salary you are prepared to pay. You don’t have to break the bank, but you have to be prepared to pay proper wages in order to attract the right caliber of staff. The right workers will pay you back many times over by increasing your patient satisfaction, recommendations and as a result your profitability. The wrong kind of workers will bleed you dry.

There are some things you can compromise on, but others you can’t, or rather shouldn’t. Do not cut corners when it comes to staffing. It is true that you can decide to do the barest minimum required by the regulatory agencies, but you’ll soon find out that that will not help your practice in the long term. Most patients would rather pay and receive quality service than take a chance with their health. Adverse outcomes have occurred in even the best equipped and staffed centers in the world, but there are simple steps you can take to minimize their occurrence.

You’ll need supplies

Medical supplies and consumables are a necessary part of your operations. Public hospitals run out of supplies routinely. There are public hospitals which send out their patients’ relatives to go and buy gloves to be used on the patients. The government can get away with such nonsense. You can’t. Make sure you properly research the medical supplies market, and obtain several sources for each consumable. It is shameful to run out of gloves, gauze and cotton wool. With a little bit of imagination and common sense, you can actually produce some of these supplies on your premises. There are huge rolls of gauze you can buy and cut and sterilize for use at your facility.


If your goal is to become known as a center of excellence, you need to set the tone right from the start. Encourage your practitioners to join international bodies of repute. Membership of such professional bodies helps inculcate a culture of excellence and conformity to certain industry standards. As much as possible, you need to discourage the use of discretion in the management of patients. It is much better and safer to use properly developed and time tested guidelines. For most medical conditions there are management algorithms developed by reputable bodies that have been formulated. The benefits of using such guidelines and checklists include standardization of care within and across facilities. Whereas the finer details of care can vary from doctor to doctor and hospital to hospital, the principles undergirding the proper diagnosis and management of diseases should not vary greatly. It is commonplace to see wildly varying standards and quality of care even within the same facility. Such variability is unacceptable. Take the airline industry for example. The principles of aviation are the same no much which airline you travel with. Aviation is the safest means of travel, and has remained that way for decades. This didn’t just happen fortuitously. It was the result of deliberate effort on the part of the airline industry. When the Boeing B17 prototype crashed shortly after takeoff in 1935, killing the pilots, an extensive investigation was conducted, revealing that the crash was due to the failure of the crew to disengage the gust lock before takeoff. Boeing instituted checklists for pilots, and the entire aviation industry came on board. No commercial pilot is expected to rely on memory, experience or sheer skill to fly a plane. This is why despite a few mishaps here and there, air travel has quickly evolved to become the safest means of travel. If you learn to introduce the use of standard guidelines and checklists into your facility right from the beginning, your practice will quickly acquire a reputation for excellence. Patients can come in expecting to receive the same high standard of care consistently. You can walk into a MacDonalds anywhere in the world and the burger will taste the same. Franchisees make sure they maintain the same standards of cleanliness in the washrooms, else their license would be at risk of being revoked. It is the same standardization that makes every single bottle of Coca Cola taste the same. When you walk into your favorite hairdresser’s salon, you expect the same great service each time. If the service is variable or unpredictable, you will soon begin to look for a new hairdresser. That is the same thing that happens to health facilities. A doctor of average intelligence who uses checklists will have better outcomes than a super intelligent doctor who routinely relies on his discretion and “intuition.” Let me give you one example of how a simple checklist can save lives. In order to prevent the situation where during surgery the wrong operation is carried out, or the wrong site is operated upon, or the wrong patient is operated on, the Joint Commission, an international accreditation body, came out with the Universal Protocol in 2004, which includes the following three steps:

  1. A preoperative verification process
  2. Marking the procedure site
  3. A Time Out performed immediately before starting the procedure. (The Time Out is a simple pause immediately prior to starting the procedure where the surgical team confirm the identity of the patient, the nature of the procedure and where necessary the site, and also mention any important issues that need to be considered by the team. There are a few other details, but essentially the Time Out lasts less than a minute in most cases. 

This simple three – item list has been proven to drastically reduce the incidence of adverse outcomes in hospitals. A public hospital was in the news some time ago for amputating the good leg of a young man. It was not an emergence surgery. Proper implementation of the Universal Protocol would have avoided that situation. If you want to do well and be known as a center for excellence, SOPPs are obligatory. Always be on the lookout for the best available guidelines and protocols and implement them. By doing that you will be able to eliminate discretion to a large extent from your facility, and offer consistently reproducible high quality service which your patients will grow to trust. Treatment will not vary greatly from patient to patient, doctor to doctor or from day to day, even though it will be individualized. Laboratory investigations will not be “forgotten” where they should have been done, and your incidence of misdiagnoses will go down. 

Accounts and Taxes

The Ghana Revenue Authority will pay you a visit at some point during your operations, unless you are running your facility inside the core of the earth without any visible entry or exit. It is better that you initiate the first encounter with the GRA. Simply go over to the nearest office and complete the required forms. Shortly after that process is complete they’ll visit you at your premises, but that visit is much more pleasant than if you stayed in hiding till they came and found you.

Good bookkeeping is important. You can hire a good Accounts Officer, then get a chartered accountant on retainer to supervise the person. Engage the services of an auditor early, so that your books are ready by the due dates for filing your audited accounts.

Good bookkeeping also helps your track your revenue and expenditure, so you can fine tune your finances and attain maximum profitability.

Get these workers on retainer

Plumbers and electricians and biomedical technicians are crucial to the running of any health facility. I suggest you invest in employing an electrician and biomedical technician full time. A good technician will save you lots of money. It can be quite frustrating when you can’t work because some minor fuse needs replacing and you are looking for an electrician to get it done. Plumbing problems can create a mess and drive your patients away. Such issues need to be addressed promptly. Regular maintenance is key. If you have a water purification system installed it needs regular maintenance, and having a plumber on retainer can save your system from collapse. Simple tasks like switching oxygen and gas cylinders and making sure they are filled requires dedicated personnel.

Cleaners, bathrooms, etc

You need to invest in cleaners and cleaning. Your washrooms must be kept spanking clean. That is usually the first place many of your patients head to when they visit your facility. Make sure you have many bathrooms. Having people queuing up to take a leak does not leave a good impression. Have as many bathrooms as possible. There should be bathrooms on each wing and in each office. Bathrooms should be easily accessible to patients and visitors to your facility. The moment someone enters the bathroom and comes out, a member of your staff should quickly go in there and make sure the place is clean and tidy for the next person to use.

Don’t be too eager to offer “24 hour” outpatient or “emergency” services

It sounds nice, but if you’re not careful you’ll simply be increasing your overhead costs unnecessarily. There is no need to open your facility for 24 hours each day. Of course if you have patients on admission you’ll have staff present to attend to them, but don’t simply keep the place open offering outpatient services round the clock. Your electricity consumption will go up. Your water consumption will go up. Wear and tear of your facility will increase. Your wage bill will increase. And you will not be doing enough business at night to cover those expenses. If you are overly concerned about what would happen to “all” the people who might need your services at 1am if you’re not open for business, there is a simple solution. You can site your clinic or hospital close to a government facility that provides 24 hour services. Most poly clinics offer 24 hour services. In addition, make sure that you have your ambulance and ambulance driver ready at all times. It is mandatory for private health facilities to have at least one operational ambulance. This model is not cast is stone, and can be adjusted to meet your peculiar needs. For example, if you run a cardiac catheterization lab, you’ll need to make it more accessible to patients who might require the services. A little nugget here: most imaging centers in Accra do not operate round the clock. You can attract a lot of healthy patronage just by having a CT scan that operates at night, between 6pm and 6am. I do not advise running the same CT scanner round the clock continually. There are ways to go around this, which I will discuss at another time.

Maximize the use of your equipment 

You can run plain CT scans at 100 USD apiece, or you can run CT scans with contrast at five times that amount apiece with minimal increase in direct cost. If you add interventional procedures, you will quickly multiply your revenue. It all depends on your mindset and readiness to invest. You could go on the flea market and procure some run down ultrasound machine, and be charging ten dollars per scan, or you can invest in the right ultrasound machines, get a good radiologist and add other services such as ultrasound guided biopsies that could fetch hundreds of dollars per procedure. 

Regulatory Agencies

Private Health Facilities fall under the jurisdiction of the Health Facilities Regulatory Agency is the body that is in charge of licensing and regulating private health facilities in the country. You cannot operate a health facility in Ghana without the relevant certification. The registration process at HEFRA itself is pretty straightforward, even though it may take some time to complete because of the documents you’ll need to submit. You can visit their website for more information.

The doctors who work at your facility are required to be licensed and be in good standing with the Ghana Medical and Dental Council. This goes for foreign doctors who come in to practice as well. This is one area where some people cut corners. You may get by with it until you get into trouble, and then it could quickly get complicated. 

The Pharmacy Council is in charge of licensing pharmacists, and the Nurses and Midwifery Council is in charge of all nurses and midwives. Make sure all your professional workers are duly licensed. 

This is worth repeating: don’t cut corners, as much as possible. You can consult if you are not sure. A good consultant will save you money.