If Access to Health Care Is a Human Right, Why Isn’t Breast Reconstruction?
Paul Farmer once asked, “If access to health care is considered a human right, who is considered human enough to have that right?” Across Africa and in Ghana in particular, women undergo mastectomies (breast removal surgery) to survive breast cancer, but survival often comes at the cost of dignity. Too many are left without the option of breast reconstruction. Their cure becomes physical, social, and psychological loss.
Photo Credit: Rebekah Vos
That loss is magnified by culture because, in our societies, the breast is never “just” anatomy. It is a vessel of nourishment, a sign of womanhood, a public signifier of private identity. Anthropologists and clinicians alike have documented how breasts carry layered meanings tied to fertility, motherhood, modesty, and social status.
Women’s decisions about treatment and reconstruction are navigated not only in clinics but also in households and congregations, with elders and spouses shaping what is possible, prudent, or permissible. Recent qualitative work with breast cancer patients in Ghana and Ethiopia found that women weighed reconstruction through three lenses: self‑identity versus functionality; life‑stage; and religious ideas of naturalness and divine will. For many, reconstruction promised symmetry and confidence; for others, it risked clashing with deeply held beliefs. The message was clear: any expansion of reconstruction must engage culture, faith, and family. Not only the operating theater. Broader cross‑cultural scholarship echoes this, reminding us that perceptions of the breast have shifted across eras and societies, and that modern oncoplastic care must respect what each woman considers the “most social” part of the breast in her own life.
These cultural meanings begin long before the onset of cancer. Studies in northern Ghana demonstrate how breastfeeding is influenced by norms transmitted through grandmothers and community leaders. Beliefs about colostrum, early prelacteal feeds, and the “right” way to nourish a child persist because elders are often regarded as custodians of tradition. That makes the breast not only a biological organ but also a site of social instruction and moral duty. When illness removes a breast, it disrupts far more than silhouette; it unsettles roles (e.g., mother, wife, worker, congregant) woven tightly into Ghanaian life.
The health‑system reality, however, is stark. Ghana has long had only a handful of plastic and reconstructive surgeons concentrated in a few urban centers. As recently as 2018, Korle Bu’s National Reconstructive Plastic Surgery and Burns Centre estimated that there were roughly 15 plastic surgeons nationwide. That maldistribution makes reconstruction a theoretical choice for most women rather than a real one. More broadly, our surgical system remains under-resourced: national surgical volumes lag behind global targets, district hospitals shoulder essential procedures with inconsistent infrastructure, and patients still pay most surgical costs out of pocket.
Policy compounds the problem. Ghana’s National Health Insurance Scheme (NHIS) lists “cervical and breast cancer treatment” among covered inpatient services, but excludes prostheses and “cosmetic surgeries and aesthetic treatment.” In practice, that exclusion has left external breast prostheses uncovered and post‑mastectomy reconstruction ambiguous and often unpaid because they are misclassified in the public mind (and sometimes on claims) as “cosmetic” rather than restorative care after cancer. Calls in Parliament to integrate breast reconstruction into NHIS have been on the record for years; they must be acted upon. Recent analyses of cancer benefits also show gaps in psychosocial and rehabilitative support.
So what message do we send when mastectomy is covered but reconstruction is not? That survival matters, but dignity does not? That women are human enough to live, but not human enough to heal fully?
We should not pretend that economics is against us. The Lancet Commission on Global Surgery established that surgery is an “indivisible, indispensable” part of universal health coverage and that many essential operations are highly cost‑effective investments in health and productivity. Reconstruction is not an indulgence; it restores function and participation in family and economic life. Recent evidence from low‑ and middle‑income countries shows most surgical interventions compare favorably with common public‑health “best buys,” and that ignoring indirect costs grossly underestimates the true burden of cancer care.
Quality‑of‑life data from Ghana complicate the caricatures, and that is a good thing. In a 2024 study at Korle Bu, overall global health status scores were similar across women who had breast‑conserving surgery, mastectomy alone, and mastectomy with reconstruction. This finding reminds us that reconstruction is not a panacea and that survivorship is a multifaceted process. What it is, for many, is the difference between looking in the mirror without flinching and stepping back into public life without a cloak of shame. The evidence argues for comprehensive survivorship care that includes mental health support and access to prostheses alongside the surgical option of reconstruction.
If we are serious about health as a human right, here is what it will take to make reconstruction real for Ghanaian women and to anchor it in justice rather than charity.
“Reconstruction should be discussed at diagnosis, not as an afterthought”
First, train and deploy more reconstructive surgeons, nurses, anesthetists, and therapists equitably. Ghana’s postgraduate system already trains surgeons; what we lack is scale, subspecialty pathways, and distribution. The West African College of Surgeons currently lists only three accredited plastic surgery training programs in Ghana. Expanding accredited posts in Kumasi, Tamale, Cape Coast, and Ho; investing in microsurgery and oncoplastic fellowships; and creating retention incentives for regional postings would turn possibility into access. Strengthening the district‑to‑tertiary referral chain and equipping regional theaters are equally non‑negotiable.
Second, cover reconstruction and rehabilitation explicitly under NHIS. Update the benefits package to name post‑mastectomy reconstruction (implant‑based and autologous) as medically necessary, not “cosmetic”; fund external prostheses; and reimburse psychosocial services and physiotherapy. That would align coverage with how women actually heal. Policymakers have already been urged to do this; the Authority can move from rhetoric to regulation—and close operational gaps that currently force women into catastrophic out‑of‑pocket spending.
Third, embed oncoplastic thinking throughout cancer pathways. Reconstruction should be discussed at diagnosis, not as an afterthought. Multidisciplinary tumor boards must include reconstructive surgeons; surgical consent should include both ablative and reconstructive options; and outcome measurement should extend beyond survival to body image, return to work, and sexual well‑being using validated tools and local language versions. Ghana’s emerging breast‑cancer guidelines and societies offer a natural convening point for this modernization.
Fourth, honor culture while changing it. Public campaigns should be led by survivors and clinicians together, speaking to the meanings that breasts hold in our homes and pews, and explaining reconstruction in the idioms of faith, modesty, and strength. In Ghanaian families where grandmothers and spouses carry moral authority over women’s bodies, counseling must involve them just as breastfeeding programs have learned to do. That is how stigma loosens and uptake grows.
Finally, organize patient power. Ghana’s breast cancer community is vibrant. For example, consider Breast Cancer International's annual “Walk for the Cure,” which has demystified cancer and rallied a nation. Now we need a sister movement focused on life after mastectomy. Imagine a survivors’ coalition for reconstruction—women who want it, women who chose not to, and women still deciding—meeting monthly, sharing stories, and demanding a seat at the NHIS table as the benefits package is revised. That coalition could partner with the Breast Society of Ghana, BCI, and hospital navigation teams, turning personal courage into policy change.
For policymakers and clinicians who will ask, “Is this feasible now?” Ghana’s surgical leadership has already demonstrated its ability to scale with the right investment and partnerships—the upgraded National Reconstructive Plastic Surgery and Burns Centre is proof that when we invest, patients come and trainees learn. The Lancet Commission has provided the economic case; Ghana’s own SOTA review has identified the bottlenecks; community groups have built the megaphone. The next step is to establish political will: fund training posts, amend NHIS benefits, and measure what matters to women.
This is precisely the work we have set out to do at the Association of Future African Plastic and Reconstructive Surgeons (AfroPRS): to prove, through training, research, and advocacy, that reconstruction is essential surgery and that young Africans can build the workforce our patients deserve. We refuse to accept a world where survival is the finish line. Survival is only the beginning.
Paul Farmer’s question still demands an answer. Who is considered human enough to receive the right to health care? For breast‑cancer survivors across Africa, the answer must be unambiguous: every woman, everywhere, with her dignity restored, her options respected, and her voice heard. If access to care is a right, then access to complete care is the standard. Let’s meet it.
