A Nunyãdume Reflection on Care and Consequence

In Nunyãdume, the elders say: “When a man runs into the village shouting that a child is dying, you do not ask who will pay before you open the gate.”

And so, they do not argue with a man who has seen death at the doorstep.
They first sit with him in silence, for grief speaks a language louder than policy.

On this, Dr Darius Osei, former Medical Director of the University of Ghana Medical Centre, is right. He speaks to a truth we must never dilute: no life should be lost at the altar of a payment window in a medical emergency.
This is not only a systems failure; it is a moral one.

Indeed, across low- and middle-income countries, delays in emergency care contribute to up to 30–50% of preventable deaths, particularly from trauma, stroke, and obstetric complications. In Ghana, where out-of-pocket payments still account for roughly 30–40% of total health expenditure, the moment of emergency often becomes a moment of financial paralysis.

But the people of Nunyãdume know too well that wisdom is not anger in action.

They say, "A man may wound himself trying to kill the fly that feeds on his sore.”

And they remember a time, centuries ago, when a sanitation plague gripped the land. In response, more toilets were built across Nunyãdume. Yet the people continued to relieve themselves around them.

Those who built the solution had not understood the people.
They had not learned that customs differed across age and lineage.
The problem was not the absence of toilets; it was the absence of understanding.
And so, the answer was not more toilets, but the right toilets, for the right people.

Today, we face a similar design challenge. Evidence from health systems shows that when financial barriers are removed without strengthening triage and referral pathways, tertiary hospitals become overwhelmed, often seeing over 60–70% of cases that could be managed at lower levels of care. The result is not faster care, but longer waiting times, overcrowding, and reduced quality for the critically ill.

The elders did not stop there. They also recall when snakes plagued the land, and a bounty was offered for every cobra killed. At first, the people rejoiced. Then, quietly, the cobras multiplied, not in the wild, but in the homes of men who had learned to breed what they were paid to destroy. And so, a solution became a new danger.

If we declare that all emergencies must be treated without structure, without gatekeeping, without a coordinated referral spine, we risk turning our teaching hospitals into the final refuge of a system that has not been strengthened beneath them.

Already, emergency units in many tertiary centres operate beyond safe capacity, with bed occupancy rates frequently exceeding 100% and clinician-to-patient ratios stretched far beyond recommended standards. In such settings, time-to-triage and time-to-intervention, critical determinants of survival, begin to deteriorate.

The result will not be compassion, but congestion without triage, urgency without prioritisation, and ultimately, the very delays we seek to eliminate.

The question, therefore, is not whether we must treat first. We must.

The question is:
How do we design a system where treating first does not mean collapsing the very centres meant to save the most critical lives?

The answer lies not in abandoning the principle of care first but in structuring it:
1. A national emergency care guarantee, backed by law
2. Triage-linked reimbursement under NHIS, not blanket waivers
3. A ring-fenced emergency fund for rapid facility reimbursement
4. Strengthening district-level stabilisation capacity and ambulance systems
5 . Building true one-stop emergency units, where diagnostics and treatment begin at the point of entry.

Countries that have implemented such structured models have achieved significant reductions in emergency mortality, sometimes by 20–30%, without overwhelming tertiary systems.

“Care first must not mean care without design. A system that tries to treat everyone without structure will soon fail those who need it most.”

In Nunyãdume, wisdom is not choosing between heart and structure.
It is building a system where the heart can act because the structure holds.