Operationalization of the Ghanaian Patients’ Charter in a Peri-urban Public Hospital: Voices of Healthcare Workers and Patients

Background: Health is a basic human right necessary for the exercise of other human rights. Every human being is, therefore, entitled to the highest possible standard of health necessary to living a life of dignity. Establishment of patients’ Charter is a step towards protecting the rights and responsibilities of patients, but violation of patients’ rights is common in healthcare institutions, especially in the developing world. This study which was conducted between May 2013 and May 2014, assessed the operationalization of Ghana’s Patients Charter in a peri-urban public hospital. Methods: Qualitative data collection methods were used to collect data from 25 healthcare workers and patients who were purposively selected. The interview data were analyzed manually, using the principles of systematic text condensation. Results: The findings indicate that the healthcare staff of the Polyclinic are aware of the existence of the patients’ Charter and also know some of its contents. Patients have no knowledge of the existence or the contents of the Charter. Availability of the Charter, community sensitization, monitoring and orientation of staff are factors that promote the operationalization of the Charter, while institutional implementation procedures such as lack of complaint procedures and low knowledge among patients militate against operationalization of the Charter. Conclusion: Public health facilities should ensure that their patients are well-informed about their rights and responsibilities to facilitate effective implementation of the Charter. Also, patients’ rights and responsibilities can be dramatized and broadcasted on television and radio in major Ghanaian languages to enhance awareness of Ghanaians on the Charter.

I n a recent contribution to the ongoing debate about the role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics. He identifies three related problems: (1) a lack of agreement among global health scholars about their normative premises, (2) a lack of agreement between global health scholars and policy-makers regarding the normative premises underlying policy, and (3) a lack of willingness among scholars to clearly state their normative premises and assumptions. This confusion is for Ooms one of the explanations "why global health's policy-makers are not implementing the knowledge generated by global health's empirical scholars. " He calls for greater unity between scholars and between scholars and policy-makers, concerning the underlying normative premises and greater openness when it comes to advocacy. 1 We commend the effort to reinstate power and politics in global health and agree that "a purely empirical evidence-based approach is a fiction, " and that such a view risks covering up "the role of politics and power. " But by contrasting this fiction with global health research "driven by crises, hot issues, and the concerns of organized interest groups, " as a "path we are trying to move away from, " Ooms is submitting to a liberal conception of politics he implicitly criticizes the outcomes of. 1 A liberal view of politics evades the constituting role of conflicts and reduces it to either a rationalistic, economic calculation, or an individual question of moral norms. This is echoed in Ooms when he states that "it is not possible to discuss the politics of global health without discussing the normative premises behind the politics. " 1 But what if we take the political as the primary level and the normative as secondary, or derived from the political? That is what we will try to do here, by introducing an alternative conceptualization of the political and hence free us from the "false dilemma" Ooms also wants to escape. "Although constructivists have emphasized how underlying normative structures constitute actors' identities and interests, they have rarely treated these normative structures themselves as defined and infused by power, or emphasized how constitutive effects also are expressions of power. " 2 This is the starting point for the political theorist Chantal Mouffe, and her response is to develop an ontological conception of the political, where "the political belongs to our ontological condition. " 3 According to Mouffe, society is instituted through conflict. " [B]y 'the political' I mean the dimension of antagonism which I take to be constitutive of human societies, while by 'politics' I mean the set of practices and institutions through which an order is created, organizing human coexistence in the context of conflictuality provided by the political. " 3 An issue or a topic needs to be contested to become political, and such a contestation concerns public action and creates a 'we' and 'they' form of collective identification. But the fixation of social relations is partial and precarious, since antagonism is an ever present possibility. To politicize an issue and be able to mobilize support, one needs to represent the world in a conflictual manner "with opposed camps with which people can identify. " 3 Ooms uses the case of "increasing international aid spending on AIDS treatment" to illustrate his point. 1 He frames the I n a recent contribution to the ongoing debate about the role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics. He identifies three related problems: (1) a lack of agreement among global health scholars about their normative premises, (2) a lack of agreement between global health scholars and policy-makers regarding the normative premises underlying policy, and (3) a lack of willingness among scholars to clearly state their normative premises and assumptions. This confusion is for Ooms one of the explanations "why global health's policy-makers are not implementing the knowledge generated by global health's empirical scholars. " He calls for greater unity between scholars and between scholars and policy-makers, concerning the underlying normative premises and greater openness when it comes to advocacy. 1 We commend the effort to reinstate power and politics in global health and agree that "a purely empirical evidence-based approach is a fiction, " and that such a view risks covering up "the role of politics and power. " But by contrasting this fiction with global health research "driven by crises, hot issues, and the concerns of organized interest groups, " as a "path we are trying to move away from, " Ooms is submitting to a liberal conception of politics he implicitly criticizes the outcomes of. 1 A liberal view of politics evades the constituting role of conflicts and reduces it to either a rationalistic, economic calculation, or an individual question of moral norms. This is echoed in Ooms when he states that "it is not possible to discuss the politics of global health without discussing the normative premises behind the politics. " 1 But what if we take the political as the primary level and the normative as secondary, or derived from the political? That is what we will try to do here, by introducing an alternative conceptualization of the political and hence free us from the "false dilemma" Ooms also wants to escape. "Although constructivists have emphasized how underlying normative structures constitute actors' identities and interests, they have rarely treated these normative structures themselves as defined and infused by power, or emphasized how constitutive effects also are expressions of power. " 2 This is the starting point for the political theorist Chantal Mouffe, and her response is to develop an ontological conception of the political, where "the political belongs to our ontological condition. " 3 According to Mouffe, society is instituted through conflict. "[B]y 'the political' I mean the dimension of antagonism which I take to be constitutive of human societies, while by 'politics' I mean the set of practices and institutions through which an order is created, organizing human coexistence in the context of conflictuality provided by the political. " 3 An issue or a topic needs to be contested to become political, and such a contestation concerns public action and creates a 'we' and 'they' form of collective identification. But the fixation of social relations is partial and precarious, since antagonism is an ever present possibility. To politicize an issue and be able to mobilize support, one needs to represent the world in a conflictual manner "with opposed camps with which people can identify. " 3 Ooms uses the case of "increasing international aid spending on AIDS treatment" to illustrate his point. 1 He frames the

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to individual citizens and the nation at large cannot be over-emphasized. Studies have established that provision of effective healthcare has a direct correlation to the economic worth of a nation. 2,3 Recognizing this, the World Health Organization (WHO) has established that healthcare is a fundamental human right. 4 Thus, the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, and political belief, economic or social condition. It is evident in Article 25 of the Universal Declaration on Human Rights that everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, etc. 5 Patient Charters are guidelines that target the relationship between health professionals and users of health services, providing information on standards of care that patients can expect to receive and demand as a basic human right. 6 Discussions in the literature reviewed are developed within a human rights context. Developed countries such as New Zealand, the United Kingdom, Australia, the United States, and Norway have seen the introduction of patient bills of rights and responsibilities or patient Charters. These documents recognized patients' rights, defined healthcare objectives, and emphasized the complementary nature of rights and responsibilities between patients and healthcare providers. In some of these nations, patients' rights have the force of law; in others, they are statements of health policy. Regardless of the form they take, these initiatives have two goals: to empower patients by providing them with certain rights and entitlements as they interact with healthcare providers and institutions; and to place the patient-healthcare provider relationship on a more equal footing. By outlining what is expected of healthcare providers, institutions and patients, they serve as important guidelines for the delivery of healthcare services. 7 In the United States for instance, a report revealed that the effectiveness of the patient Charter was largely due to state legislation that oversees the process. 8 This indicates a limitation of patient Charter operationalization in countries whose patient Charters are not legislated, including Ghana. An overview of different patient bills of rights has affirmed that the potential of patient Charters to strengthen the position of the patient in the patient-healthcare provider relationship. 7 However, therein lies a significant limitation of patient Charters. Patient rights and Charters only deal with the aspect of health in relation to healthcare services and do not necessarily address the broader, complex underlying determinants of health. In Africa and the developing world, legislative instruments that are meant to promote patients' rights exist. Some of these are South African Patients' Rights Charter, 9 launched in 1997, and the Ministry of Health's Service Charter in Nigeria. 10 In a comparative analysis of patients' rights across five countries, it has been explained that irrespective of the comprehensiveness of a country's statement of rights, patients' awareness and familiarity with the rights are crucial to quality in and effectiveness of the healthcare system. 11 Patients need to know their rights and responsibilities to ensure that they take actions and ask questions relevant to their care and delivery. However, it has been found in another study that half of the patients who participated had never heard of patients' rights. 12 This finding indicates how the healthcare system has neglected such an important justice issue. It was discovered in the same study that no single poster on patients' rights was available on the walls of the unit and no lessons were given to patients concerning their rights. Also, a study that interviewed 128 patients in a large hospital in Turkey using questionnaires that included items on patients' rights, reported that 23% of the patients were aware of patients' rights. In addition, 38% of the patients did not know their own diagnosis, and 63% of those undergoing surgery did not know the reason for their operation. The researchers concluded that the two factors which contributed to these findings were the patients' low socio-economic status and the low educational level of the women participants (about half of those taking part in this study). The authors noted that, although the nurses in the hospital where this research took place were aware of the Turkish Patients' Rights Regulations, they believed they could not influence the system to achieve implementation of those rights. 13 Establishing patients' rights is a step towards protecting patients' rights, but violation of patients' rights is common in healthcare institutions, and this is attributed to systemic and institutional obstacles, such as insufficient healthcare staff and inadequate acquisition and maintenance of technological equipment. 14 Meeting patients' needs must be the core concept for the meaning of patients' rights, however, lack of knowledge about rights, lack of standard of practice among hospitals and the impact of service pressure and subsequent lack of holistic care, are some of the factors known to inhibit the implementation of patients' rights. 15 Article 30 of the 1992 Republican Constitution of Ghana stipulates that no individual who by reason of illness or any other cause is unable to give consent shall be deprived by any other person of medical treatment, education or any other social or economic benefit. Thus, the increasing awareness of the government on the need to ensure quality healthcare by becoming more committed to the provision of effective and reliable healthcare for its citizens resulted in the enactment of the patient's Charter. 16 This Charter highlights the patients' rights and responsibilities in the care process irrespective of age, gender, ethnic background and religion. Health facilities must provide for and respect the rights and responsibilities of patients or clients, families, health workers and other healthcare providers. The patients' Charter is expected to ensure that the dignity of patients, irrespective of their sociocultural and religious affiliation, among other differences must be held paramount and has been in existence since 2002. Ten years after the Ghana Health Service (GHS) established the patients' Charter as a tool to ensure that patients' rights and dignity are protected and upheld, the GHS in its report on clinical care quality assurance conference in 2012 highlighted some key challenges confronting the service in the implementation of the tenets of the Charter. These include patient safety, poor staff attitude and long client waiting time. The meeting, thus, agreed to sustain dissemination of the patients' Charter and the GHS Code of Conduct and Disciplinary Procedures to ensure quality of service. The

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report recommended that conscious efforts be made to arrest the root cause of conduct that can compromise the provisions in the Ghanaian Patients' Charter. 17 By these assertions, one may suggest that behaviors that compromise the provisions of the Charter still existed ten years after its inception. Further, a study on the patients' Charter conducted in four health facilities in Accra, the capital city of the country, on the implementation of the patients' Charter, indicated that a significant number of patients complained of impolite treatment from a cross-section of hospital staff. The majority of patients studied reported that their consent were not sought before drugs were given to them, males were less likely to be consulted than females, the majority of patients and a significant number of providers were ignorant of the existence and contents of the Charter, and providers had generally not been able to carry out their obligations under the Charter as expected. 18 Additionally, a baseline study undertaken by the Royal Health Organization (ROHEO) in partnership with other non-profit organizations established that the patients' Charter, remains largely unheeded to in the discharge of health services. According to this report, an overall assessment showed that 338 of 376 respondents constituting 90% of respondents had low knowledge about the patients' Charter. The limited studies on the patient Charter have focused on the knowledge and implementation of the patients' Charter in the Greater Accra and Volta regions of the country using quantitative methods. 18,19 While the GHS is focusing on improving access to healthcare, there is the need to ensure that patients who use the services and facilities are treated in a humane manner. The Ghanaian patients' Charter like all similar documents around the world as published by the GHS is meant to protect the rights of the patient. It addresses the right of the Ghanaian to an easily accessible, equitable and comprehensive healthcare of the highest quality within the available resources of the country, respect for the patient as an individual who has a right of choice in his or her healthcare plan decisions, the right to be protected from discrimination stemming from culture, ethnicity, language, religion, gender, age and type of disability or illness, the role and responsibility of the client or patient for personal and communal health via promotive, preventive, and basic curative strategies. The GHS has also indicated in its introductory statement to the patients' Charter that the service institutions require collaboration between health workers, patients and clients, as well as society to implement the tenets of the Charter. Hence, optimal healthcare depends on team work among all relevant stakeholders. Again the GHS calls on healthcare institutions to adopt the patients' Charter to ensure that service personnel as well as patients, clients and their families understand their rights and responsibilities. Although the operationalization of the patients' Charter seems to be very difficult as depicted by relevant literature, information and opportunities to learn about issues such as the definition and reinforcement of patients' rights should be available to everyone, not just healthcare professionals or patients. We employed qualitative methods to study the experiences of patients and health workers on the Ghanaian patients' Charter by specifically assessing their awareness, knowledge and experiences on the patients' Charter, as well as the factors that influence the operationalization of the Charter in a peri-urban public hospital in Ghana.

Study Design
A case study design was employed to study the experiences of patients and health workers on the Ghanaian Patients' Charter by specifically assessing their awareness, knowledge, and experiences on the Charter as well as the factors that influence the operationalization of the Charter in a periurban public facility. The case study design was used because it offers a holistic form of inquiry 20,21 and has wide application especially in nursing research. Thus, it is seen as appropriate since the researchers are interested in a particular setting and how the rights and responsibilities of patients are being operationalized. This design offered the opportunity to do an in-depth assessment and analysis of each of the objectives for the study with a view not to generalize the findings of the study, but to portray what specifically pertains to Kasoa Polyclinic, Central Region, Ghana (a peri-urban public health hospital) in regard to the implementation of the Ghanaian Patients' Charter. The structure of Ghana's health system follows a top down approach with the Ministry of Health (MoH) as the top body responsible for setting the health sector's broad policy objectives, and coordinating and regulating activities of the numerous healthcare agencies in the country, including the GHS, which is a public service body established under Act 525 of 1996 as required by the 1992 constitution of Ghana as the public sector implementation body of health activities and programs. The GHS has organized health administration into three levels: national, regional, and district, which are further divided into five functional levels: national, regional, district, sub-district, and community levels. Healthcare delivery is structured in three parts: primary, secondary, and tertiary. The study was conducted at the Kasoa Polyclinic (a subdistrict public facility) in the Awutu Senya East Municipal Assembly of the central region and provides both primary and limited secondary health services to its catchment populace. The Polyclinic is one of the three Government health facilities in the Municipality. It was established in 1983 as a health centre until December 2012 when it was elevated to the status of a Polyclinic. There are six main units in the polyclinic. They are the Reproductive and Child Health Unit, Disease Control Unit, Laboratory Unit, Maternity Unit, Children's Unit as well as the general Outpatients' Department. As a GHS institution, the Kasoa Polyclinic is expected to adopt the patient's Charter to ensure that service personnel as well as patients or clients and their families understand their rights and responsibilities. Nurse to patient ratio, and doctor to patient ratio at the Kasoa Polyclinic as at 2012 were 1:464, and 1:25039, respectively. The Kasoa Polyclinic was selected purposively for the study because it is a peri-urban public health facility, and no research on the patients' Charter has been conducted in the facility.

Study Population, Sampling and Sample Size
The population for the study comprised all staff and patients of the Kasoa Polyclinic in the Awutu-Senya Municipal Assembly of the central region of Ghana. Purposive sampling was used to select 25 persons who were willing to participate in the study. They consisted of 5 frontline health workers

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who had worked for more than 2 years in the Polyclinic and are knowledgeable on the operations of the facility. Those volunteers were four staff nurses and the Administrator of the Polyclinic (who was included because he is supposed to make the necessary arrangement for policy implementation), and 20 patients, 10 from the maternity ward and 10 from the outpatients unit. The out patients and the maternity units of the Polyclinic were purposively selected with the support of the Administrator of the facility. The selected units were better placed to have respondents who are adult patients 18 years and older, have visited the facility at least once before their current visit, and would be able to engage in interviews.

Data Collection Method, Instrument, and Process
The study employed a qualitative research approach. This approach guides the researcher in the planning and implementation in such a way that it is most likely to achieve the intended goals. 22 This research approach allowed for a deeper understanding about the operationalization of the patients' Charter in the Kasoa Polyclinic, and of the experiences of patients and health management regarding the operationalization of the patients' Charter. In-depth interviews using in-depth interview guide were used in gathering data from the participants. Each interview was recorded with an MP3 Recorder. Informal observation on information for patients in the form of posters and writing of field notes as well as other secondary data from print media, journal articles and annual reports were used to obtain additional information for the study. During the data collection process, the selected units in the clinic were visited on regular basis. On each occasion, the Administrator supported identifying appropriate in-patient respondents who met the selection criteria for the study. Interviews were conducted in either English language or the local Guan or Twi language as per the choice of participants.

Data Analysis
The audio recordings were transcribed, and together with field notes, analyzed manually. Themes and subthemes were generated from the data with the objectives of the study as a guide. Qualitative research requires a methodological soundness and adequacy, therefore, Guba's Model of Trustworthiness as described by Lincoln and Guba 23 was used to ensure this. The strategies that were used to ensure trustworthiness were credibility and confirmability. Credibility requires sufficient submersion of the researcher in the research setting to enable the recurrent patterns to be identified and verified. This was addressed by listening to the audio recordings repeatedly after which a verbatim transcription of the recordings were made. The transcripts were typed in English and read many times during analysis. The strategy of confirmability guarantees that the findings, conclusions and recommendations are supported by the data and that there is congruence in the interpretation and the actual evidence. 24,25 This was achieved by maintaining objectivity throughout the research process. The actual evidence includes the transcribed interviews, field notes, and participation with the respondents. Verbatim quotes were then selected and coded to ensure anonymity and also separate health workers from patients. Hence HW was used to represent health worker and PAT for patient. While most of the participant responses were reported verbatim, few of them were edited to improve readability.

Results and Discussion
The findings and discussions are presented under two main themes and five subthemes (Table) that were generated manually from the interviews to represent the findings of the study. These are knowledge and supposition (with subthemes: awareness and general knowledge, training, and availability and sensitization) and factors influencing operationalization (with subthemes: promoting factors, and inhibiting factors) The majority of respondents were females (13 of 20 patients; and 3 of 5 healthcare workers). They were all adults aged between 21 and 55 years.

Knowledge and Supposition Awareness and Knowledge
Health workers of Kasoa Polyclinic are aware that every patient has rights which must be respected. All the HWs interviewed indicated promptly that patients, like all human beings have rights which need to be respected. Additionally, all HWs indicated their awareness of a document containing a list of rights and responsibilities of patients -the Charter. This buttresses previous quantitative finding in Ghana that healthcare providers exhibit awareness and content knowledge on the patients' Charter, however, when it comes to knowledge on the content of the Charter, the findings of the present study quite differ from those of the previous study. 26 The following are some the responses gathered HWs were asked to explain what the patients' Charter is about:

"The patients' Charter is a document that contains the patients' rights and responsibilities. It is a very important document as most often patients' rights are trampled upon by health workers" (HW-O4).
"It is a document that spells out things like the right to healthcare, right to privacy, not to be discriminated against" (HW-02).

"In a nutshell it is a document that tells health workers about the dos and don'ts when it comes to handling of patients in this facility" (HW-05). "Personally I have not seen the document but I know that the Charter is to guide health workers in their daily interactions with patients" (HW-01).
When HWs were asked to mention at least three rights and three responsibilities of patients contained in the Charter, only two of the five (40%) were able to provide some answers. Thus, the content of the patients' Charter include: "The right to be treated well, respected and have some privacy" (HW-04).

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"Patients also have the responsibility to be respectful, corporative in the care process and they must be treated fairly and equally" (HW-04). "Patients need to do their part in the care process by following all the instructions we give them" (HW-02). The health workers also expressed the usefulness of the patients' Charter in the care process. "If patients know their rights and responsibilities, health workers will treat them with care and will uphold the rights of patients" (HW-04). Patients' knowledge and awareness on their rights and responsibilities revealed a stark reality. This is consistent with other studies that have indicated low knowledge of patients' Charter among patients, in fact, some patients have never heard of patients' rights before. 27 Not only were PATs of this study unaware of their rights, they seemed not to care about them. Their sole aim as indicated by the majority (16 of 20) of them was to get well as soon as possible and go back to their economic activities. While 7 of 20 patients were not able to express any knowledge on their rights and responsibilities, the remaining 13 indicated they knew something. However, their knowledge were mixed with regards to the content of the Charter.
"I know that everyone should be accepted in this facility and every patient should be treated equally.  -20). "To respect the nurses who take care of me" (PAT-09). Awareness and knowledge of the content of both patients and health staff on the patients' Charter are two crucial elements in operationalizing the patients' Charter. In fact, a comprehensive analysis of patients' rights across five countries concluded that irrespective of the comprehensiveness of a country's statement of rights, patients' awareness and familiarity with the rights are crucial to quality and effectiveness of the healthcare system. The patients' Charter is set to empower patients by providing them with certain rights and entitlements as they interact with healthcare providers and institutions, and to provide for a more balanced patient-healthcare provider relationship on a more equal pedestal. Outlining what is expected serves as important guidelines for the delivery of healthcare services by healthcare providers, institutions, and patients. Thus, patients need to know their rights and responsibilities to ensure that they take actions and ask questions relevant to their care and delivery. 28 Therefore, an effective and efficient operationalization of patients' Charters can be realized when aggressive measures are put in place to ensure that both patients and health workers are adequately informed about their rights and responsibilities.

Availability and Sensitization on the Charter
The availability of the Charter is necessary to ensure knowledge and adherence to respecting patients' rights as well as patients' responsibilities. According to the health workers interviewed, a copy of the patients' Charter was posted in all the units of the facility, but because of the ongoing refurbishments in the facility, all posters had been removed and will be posted after the painting of the walls of the facility. They indicated that they are quite often reminded to adhere to the Charter during monthly and annual review meetings. Management also does spot-checks occasionally to ensure that the patients are being treated well as per the relevant portions of the tenets of the patients' Charter. The Charter was not visible on the wards of the facility, and this might have contributed to the poor knowledge on the Charter among patients of the facility. The availability of the Charter serves as a constant reminder to both health workers and patients about the need to respect the provisions in the Charter. Meeting patients' needs must be the pivot of healthcare for patients' rights to be realized. Thus, the nonavailability of the Charter to both patients and health workers, leads to low knowledge about the rights and responsibilities of patients, lack of appreciable standard of practice among the hospitals, and the impact of service pressure and subsequent lack of holistic care, are some of the barriers to rights-based practice among healthcare providers. 15 Operationalization of the patients' Charter requires affirmative steps to educating the general public especially patients. Thus, information and opportunities to learn about issues such as the definition and reinforcement of patients' rights should be available to everyone, not just to healthcare professionals or patients. Mass communication media, educational institutions, medical companies, political parties, and religious groups should all have an important role to play in the making the Charter available to all as well as its reinforcement.

Training and Monitoring on the Charter
A proper managerial policy on training, monitoring, and responsive managerial systems are necessary ingredients in ensuring knowledge and operationalization of the patients' Charter according to HW respondents. They believe these

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can be achieved through training and monitoring on the Charter. Information gathered from the health worker respondents indicated that although there are standards for health professionals' conduct that are taught in their training, most of the tenets are flouted without the enforcement of sanctions against perpetrators. Thus, monitoring with regards to the tenets of the Charter is very weak in the facility and has contributed to the low knowledge among health workers and patients on the Charter. With regards to training on the Charter, it was evident from the interview with respondents in the health worker category that there has not been any official training specifically on the patients' Charter. They explained that training is done in an integrated manner and is mostly incorporated into customer care trainings which are organized infrequently.
"Some customer care trainings do not even make mention of the patients' Charter at all" (HW-04).

Factors Influencing Operationalization of The Patients' Charter
Promoting Factors Almost all the health workers interviewed mentioned availability of the Charter, sensitization, training and monitoring on the Charter and enforcement of sanctions against perpetrators as factors that would promote the implementation of the tenets of the patients' Charter in public health institutions in the country. According to them lack of these has contributed to the low knowledge and operationalization of the Charter in the facility. "If the Charter is made available everywhere, especially in schools and the hospitals, a lot of people will know about it and people will insist on their rights when they seek healthcare" (HW-04). "Sanctions against health workers who trample upon the rights of patients or disrespect patients will deter others from doing same, and would make the Charter effective" (HW-01). "Although as health workers, we are told to respect the rights of patients, I believe that we will see the Charter at work if we're periodically called for training specifically on the Charter" (HW-03). The patient interviewees, 40% (8 of 20) felt that if more health workers are trained and employed, the problems they face with health workers with regards to interpersonal relationship and ethical issues would be minimized. In addition, they mentioned availability and creation of awareness as factors that would facilitate its operationalization. "Health workers are usually stressed out because of heavy workload, and that makes them impatient most of the time. If they are many, the work load will be less and would have time to better interact with us, and make sure that our rights as patients are upheld" (PAT-05). "I haven't set eyes on the patients' Charter before, so I believe that if the Charter is available and the public is made aware of its contents, when we go to the hospital, we'll be expecting something that when we find absent, we will demand. This will aid the implementation of the patients' Charter" (PAT-16).

Inhibiting Factors
Several factors were found to inhibit the effective operationalization of the patients' Charter. These were grouped into institutional implementation structures and complaint procedure.
Institutional Implementation Structures Although all respondents (HW) agreed that the patients' Charter is an important tool to improve the care process, they were quick to add that operationalizing the Charter requires resources which when not available make operationalization unrealistic. To these health workers, certain institutional inadequacies such as lack of supervision, heavy work load because of staff shortage, and lack of space and equipment as well as basic logistics to ensure that the tenets of the Charter are adhered to, make the operationalization of the Charter very difficult. All respondents (HW and PAT) complained that the facility is too small and respect for one's privacy is a challenge. The limited space in the facility gives patients no grounds to complain when their rights are violated especially with regards to issues of privacy.
"We're committed to observing patients' rights, but in order to ensure for instance, confidentiality and privacy, there are certain basic prerequisites such as expanded space, enough tools and equipment. As you can see, this room is ideally to take two patients but there are currently six patients occupying it. How do we ensure privacy for example in this situation?" (HW-02) While HWs explained that patients again do not complain because: "They know the conditions in this facility and cannot complain about something like privacy" (HW-05), patient respondents also explained that they rarely complained because of fear of being tagged as difficult. Although an in-patient who has been on the ward for some time indicated that her last complaint was well-addressed, she was afraid to complain again because of what she witnessed when a patient tagged as difficult was neglected most of the time. . This finding is in line with the empirical assertion that the success of a policy depends critically on two broad factors -local capacity and will, and the will to implement a task is influenced by factors largely beyond the reach of policy formulators. 29 Thus, competing centres of authority, contending priorities or pressures and other aspects of socio-political environment can profoundly influence an implementer's willingness. This emphasis on individual motivation and internal institutional conditions implies that external policy features have limited influence on outcomes, particularly at lower levels in the institution. 29 Human and capital resources are very essential in executing the tenets of the Charter. Similar studies attest to this fact. In a qualitative research conducted in Israel concerning physicians' opinions about the Patient's Rights Law, the researchers concluded that, although the law was very important, the work conditions of physicians in Israel (time and place limitations) made it difficult to implement it. They were concerned that the law could be abused by patients, and may lead to medical care being practiced defensively. 30 Establishing patients' rights is a step towards protecting the rights of patients, yet the violation of these rights is common in healthcare institutions, and this is due to the presence of systemic and institutional obstacles, such as insufficient healthcare staff, and inadequate purchase and maintenance of technological equipment. 14 Complaint Procedure Findings of the study indicate that there is neither systematic nor structured complaint procedure at the Kasoa healthcare facility. All the health workers interviewed could not readily explain how complaints are handled. Although a complaint box sits in an obscure place close to the office of the Administrator, it is rusted and has not been used for years. One health Staff observed that patients rarely complain to her: "Last January during the Municipal's end of year performance review, one of our media partners from PINK FM lamented that the nurses of this facility are impolite to patients. But I explained that the patient's Charter and other codes enshrine on us to be polite. Patients have every right to report any misconduct to the senior nurse in-charge or the Administrator, but most of the time we do not receive these complaints, and this may be due to the absence of formal complaint procedure in the facility" (HW-03). The majority of patient respondents could not tell who to complain to when their rights were violated by a health worker in the facility. Patients who have had issues with the care process at one point in time or another did not know the process to follow for redress. A respondent who narrated his experience with regards to how he was handled during his last visit to the facility indicated that he did not even know the identity of the staff handling him, thus, should there be the need to lodge complaints, he would have to describe her using her physical features.
"None of the nurses handling me introduced herself to me, I only know them as aunty nurse and the doctor as chief, so if they mishandle me all I can do is to use their physical features to describe them if I want to seek redress" (PAT-10). The adage 'knowledge is power' and 'the doctor knows best' are perhaps most appropriate in trying to describe what is inhibiting the operationalization of the Charter at the Kasoa Polyclinic. Because the majority of patients have no knowledge on their rights and do not know of any steps to follow to get their complaints addressed, they do not complain when their rights are violated. Due to low level of knowledge on their rights as patients, they do not insist on anything, but comply with whatever the health worker instructs them to do, for 'the doctor knows best. ' This confirms the assertion in 2007, by the Special Rapporteur on Health reporting to the Human Rights Council which recognized the pivotal role that health professionals can potentially play in promoting health within a human rights framework. 31 The realization of rights to the highest attainable standard of health depends upon health professionals enhancing public health, delivering medical care, developing equitable health policies and programs and making key decisions about priorities and resources within governmental and non-governmental health sectors. 31 However, health professionals of developing countries may be unaware of human rights frameworks or may feel uncomfortable about them, 32 believing that it would put them at risk or place unreasonable demands on them. These reasons may have contributed to making the operationalization of the Ghanaian Patients' Charter almost impossible at the Kasoa Polyclinic. When patients are empowered with the knowledge on the tenets of the Charter, they will insist on them and health workers will be alerted and work in conformity to the tenets of the Charter.

Limitation of the Study
Because this study was carried out in a peri-urban public hospital facility with a small number of study participants, findings may be limited to the studied facility, however, findings may not be very different from similar facilities where infrastructure, human and material resources are similar or the same. We recommend that future research should focus on the role of various levels -national, regional, and other district facilities in the implementation of the tenets of the patients' Charter, so as to ascertain the status of the operationalization of Ghana's Patients' Charter.

Conclusion
Health workers at the Kasoa Polyclinic are aware and knowledgeable of the patients' Charter, however, the majority of patients have no knowledge about their rights and responsibilities, and hence, do not insist on them. This affects a successful implementation of the patients' Charter. Making the patients' Charter operational in the facility is marred by institutional inadequacies as well as lack of knowledge among patients. However, there exist opportunities for Management of the facility to ensure that the operationalization of the Charter is realized. These include making the patients' Charter available, sensitizing community members, training as well as monitoring activities of frontline health workers to

A r c h i v e o f S I D
www.SID.ir ensure a successful operationalization of the Charter at the facility. Management of Kasoa Polyclinic and similar healthcare facilities are encouraged to increase awareness of patients' rights and responsibilities by posting and making copies of the Charter available to patients, and through awareness campaigns on local radio stations. Besides, constant monitoring and surveys will reveal a lot about the effectiveness of the campaigns conducted to raise awareness on patients' rights and responsibilities. The Municipal Health Directorates should urgently provide enough human and capital resources in order to ensure that patients' rights are respected in all health facilities in their respective catchment areas. This may be done by appointing a patient rights officer for the Municipal Health directorate whose role among other things, would be to ensure the implementation of the tenets of the Charter in public health institutions in the Municipality. Mass communication media, educational institutions, medical and nursing organizations and councils, political parties and religious groups should all have an important role to play in the enforcement of the patients' Charter.