Emerging issues in public health: a perspective on Ghana's healthcare expenditure, policies and outcomes

Infant mortality in Ghana: investing in health care infrastructure and systems

Child and infant mortality is a global problem. Almost half of deaths of children under age 5 years occur in the neonatal period, the first 28 days of life, with 2.4 million neonatal deaths globally in 2020. Sub-Saharan Africa has disproportionately high numbers of neonatal deaths. Ghana's neonatal mortality rate is 22.8 per 1000 live births and remains behind targets set by the United Nations Sustainable Development Goals. Quality antenatal care, postnatal monitoring, breastfeeding support, and postnatal family planning are important in preventing neonatal deaths. While Ghana has made progress in making care more financially accessible, it has not been matched with the improvements in the critical infrastructure required to ensure quality health care. The improvements have also not eliminated out-of-pocket costs for care, which have hindered progress in decreasing infant mortality. Policymakers should consider investments in health care infrastructure, including expanding public-private partnerships. Policies that improve workforce development programs, transportation infrastructure, and health insurance systems improvements are needed.

Pre-eclampsia training needs of midwives in a Ghanaian tertiary hospital: A cross-sectional study

AIM

This study aimed to assess the specific clinical and non-clinical training needs of midwives and determine their preferred approach to enhancing performance.

BACKGROUND

Pre-eclampsia remains one of the leading causes of maternal deaths in low and middle-income countries. Pre-eclampsia-related deaths may be due to reduced midwifery knowledge and inadequate management. Therefore, a training needs assessment is vital in identifying gaps in practice, especially, in poorly resourced settings for maximal use of training resources.

DESIGN

A hospital-based cross-sectional study.

SETTING

The largest tertiary hospital in Ghana.

METHODS

An online version of the validated WHO Hennessy-Hicks Training Needs Analysis questionnaire was used to assess midwives' training needs on the management of pre-eclampsia. The tool has good psychometric properties and was used to assess 1) midwives' confidence in performing tasks, 2) the importance of the task to their role and 3) their preferred performance improvement approach. Data analysis adhered to the guidelines specified in the Hennessy-Hicks Training Needs Analysis Questionnaire and the priority training requirements of the midwives were assessed through descriptive statistics and a series of independent t-tests.

RESULTS

Among the 250 midwives who responded, most possessed 1-5 years of experience (74.7 %). All 28 tasks were viewed by midwives as essential responsibilities in pre-eclampsia management. Midwives had the greatest need for training in research/audit and clinical skills domains respectively (p < 0.001, 95 % confidence interval: 1.08-1.47, Cohen's-D = 1.27; and p < 0.001, 95 % confidence interval: 0.69-1.06, Cohen's-D = 0.87). The foremost primary training necessity, as recognised by midwives, was undertaking health promotion activities, including antenatal health education (MD= 0.43, 95 % confidence interval: 0.29-0.57). Training courses were identified as the preferred approach to address training needs and improve overall proficiency.

CONCLUSION

Midwives in Ghana require comprehensive training covering research and clinical-based competencies to improve pre-eclampsia management. Considering the pivotal role of Ghanaian midwives in safeguarding maternal well-being, there is a compelling need to enhance the calibre of midwifery services. These findings can guide stakeholders in countries with comparable healthcare contexts in creating effective, resource-efficient training programs that avoid counterproductivity, ultimately supporting national initiatives to enhance pre-eclampsia management and the quality of care.

A socioecological description of the influencing factors to midwives' management of preeclampsia in a Ghanaian tertiary hospital

INTRODUCTION

In low-resource settings, midwives are the first contact for women with preeclampsia and lead the coordination of care. Unfavourable preeclampsia outcomes create a burden for women, families, and the health system. It is therefore important to understand the unique context of midwives' practice and the complex factors that influence the delivery of maternal healthcare.

AIM

This qualitative study explored the perspectives of key stakeholders in a tertiary hospital in Ghana regarding the facilitators and barriers influencing midwives' provision of preeclampsia care using a socioecological model.

METHODS

Semi-structured interviews were conducted with 42 participants comprising senior managers (n = 7) and hospital midwives (n = 35) in 2021. Thematic analysis used Braun and Clarke's six-step method, and the findings were organised within four levels of the socioecological model: individual, interpersonal, organisational, and public policy.

RESULTS

Two main themes were identified: 1) Facilitators of preeclampsia management, and 2) Barriers to preeclampsia management. Facilitators were identified at three levels (individual, interpersonal, and organisational) and included midwives' knowledge of preeclampsia; midwives' self-efficacy; midwives' skillset to enhance preeclampsia care; collaborative practice; and strategies for preeclampsia care quality improvement. At the individual level, the barriers were inadequate pre-service preparation, lack of evidence-based midwifery care, and colleagues' work attitudes. Hierarchical decision-making and staff views of women's risk perceptions were identified as barriers at the interpersonal level. At the organisational level, the barriers were: scarce resources and staff shortages, and a lack of midwifery-specific guidelines. Two barriers were identified within the public policy level: the high cost of preeclampsia care and issues with the referral system.

CONCLUSION

Multi-faceted factors play a significant role in midwives' management of preeclampsia. Hence context-specific multi-level interventions have the potential to improve the quality-of-care women in Ghana receive.

An Assessment of Personal Hygiene Practices Among Young Adults: A Cross-Sectional, Descriptive Study

Background Personal Hygiene behavior and practices play a major role in health promotion and disease prevention. Socio-demographic, behavioral, and psychological factors sway a person's overall adaptation of good practices. Disease burden leading to loss of productivity and its influence on the economy cannot be overstated. As medical professionals come in contact with a large number of people, they carry the potential to be super-spreaders in disease outbreaks. Thus, it is of utmost importance that medics and paramedics maintain hygiene to the highest standards. Method This cross-sectional study comprised 323 young adult participants from Muslim Town, Faisalabad. A structured questionnaire containing close-ended questions was used for data collection regarding personal hygiene behavior and practices. Dependency between various qualitative categorical variables and hygiene practices was analyzed using Chi-squared tests. Results It was found that although the majority of the participants followed good hygiene for most of the practices; laziness, lack of relevant education, improper time management, and unreliable water supply posed a significant barrier to good practices. Females had demonstrably better practices compared to males. Urbanity did not have a significant correlation with the results.  Conclusion We conclude that a rigorous program of awareness and education regarding this subject is the need of the hour to facilitate an improvement in predictive and preventive health care and reduce morbidity and mortality. Steps should be taken to ease the barriers that are obstructing optimal hygienic practices.

Willingness to enroll and pay for community-based health insurance, decision motives, and associated factors among rural households in Enugu State, Southeast Nigeria

Background

Over 70% of Nigeria's population is poor and rural, and most lack financial risk protection against ill health. Community-based health insurance (CBHI) may be an essential intervention strategy for ensuring that quality healthcare reaches the informal and rural populations.

Aim

This article explores the willingness to enroll (WTE) and willingness to pay (WTP) for CBHI by community members, their decision considerations, and associated factors in Enugu State, Nigeria.

Materials and Methods

We adopted a cross-sectional survey design with a multi-stage sampling approach. A validated and pre-tested questionnaire was used to elicit information from the respondents. WTE and WTP for CBHI was determined using the bid contingent valuation method. A test of correlation/association (Chi-square and ordinary least square regression) was conducted to ascertain the relationship between WTP for CBHI and other variables at a 95% confidence interval. The socioeconomic status index was generated using principal component analysis. A test of association was conducted between the demographic characteristics and WTE and WTP variables.

Key Findings

A total of 501 household heads or their representatives were included in the study which yielded a return rate of 98.2%. The finding showed that most (92.4%) of the respondents indicated a WTE in CBHI. 86.6% indicated a willingness to pay cash for CBHI, while 84.4% indicated a willingness to pay other household members for CBHI. There was a significant association between gender, marital status, education, location, and willingness to pay. The study shows that 81.6% of the respondent stated that qualified staff availability motivates their WTE/WTP for CBHI, while 78.1% would be willing to enroll and pay for CBHI if services were provided free, and 324 (74.6%) stated that proximity to a health facility would encourage them to enroll and pay for the CBHI.

Conclusion

This community demand analysis shows that rural and peri-urban community members are open to using a contributory mechanism for their health care, raising the prospect of establishing CBHI. To achieve universal health coverage, policy measures need to be taken to promote participation, provide financial and non-financial incentives and ensure that the service delivery mechanism is affordable and accessible. Further studies are needed to explore ways to encourage participation and enrollment in CBHI and other contributory schemes among under-served populations and improve access to and utilization of healthcare services.

Whose public, whose goods? Generations of patients and visions of fairness in Ghanaian health

Since Ghana's independence in 1957, the country has seen an ebb and flow of reforms intended to expand and fund state healthcare, informed by diverse notions of affordability and adequate provision. Cycles of attempted health reforms have emerged from disparate political and economic ideologies, themselves a product of broader global histories and specific national experiences. Based on group interviews with people across most administrative regions of Ghana, this paper examines how the formative historical experiences of different generations gives rise to a multiplicity of understandings of what constitutes a 'fair' distribution of national health resources. It discusses the forms and contents of arguments that people of different ages raised in both rural and urban settings in the course of the study - with particular reference to the operation of Ghana's current National Health Insurance Scheme, and in light of their perceptions of the justice or injustice of present day healthcare in relation to earlier periods.

The relationship between facilities management service quality and patients’ health-care experience: the mediating effect of adequacy of health-care resource

Purpose

With challenges in health-care facilities management (FM) and adequacy of health-care resources constraints in most developing countries, improving patient’s health-care experience has become of strategic importance in public health-care delivery. This paper aims to investigate the mediating effect of adequacy of health-care resources on the relationship between the quality of health-care FM services and patient’s health-care experience.

Design/methodology/approach

This cross-sectional study adopts a quantitative approach based on a questionnaire survey conducted on 660 patients of three teaching hospitals in Ghana. In total, 622 valid questionnaires were used for data analysis using partial least squares structural equation modelling.

Findings

The mediating effect of adequacy of health-care resources on the relationship between responsiveness and tangibility and patients’ health-care experience were supported, while that of empathy, reliability and assurance were not supported. The relationship between and adequacy of health-care resources and patients’ health-care experience was also supported.

Research limitations/implications

The study limitation is that it was only the teaching hospitals that were surveyed. In future studies, a comparative analysis can be conducted between both public and private hospitals. Other constructs and relationships such as the mediating effect of the quality of health-care administrative process on the relationship between FM service quality and patients’ health-care experience as well as the moderation effect of adequacy of health-care resource on the relationship between FM service quality and patients’ health-care experience can also be tested. Future studies on the same subject can use health-care workers as the respondents of the study.

Practical implications

The result should inspire health-care managers to prioritize attention on health-care FM to create and sustain a decent health-care environment. Facilities managers should ensure standards are not compromised by keeping health-care resources in good condition through the organisation and management of resources.

Originality/value

To the best of the authors’ knowledge, this paper is one of the pioneer studies to test the mediating effect of adequacy of health-care resources on the relationship between patient’s health-care experience and health-care FM service quality. The proposed framework can be adapted to various sectors and countries as this empirical validation extends knowledge.

Using health policy and systems research to influence national health policies: lessons from Mexico, Cambodia and Ghana

Health system reforms across Africa, Asia and Latin America in recent decades demonstrate the value of health policy and systems research (HPSR) in moving towards the goals of universal health coverage in different circumstances and by various means. The role of evidence in policy making is widely accepted; less well understood is the influence of the concrete conditions under which HPSR is carried out within the national context and which often determine policy outcomes. We investigated the varied experiences of HPSR in Mexico, Cambodia and Ghana (each selected purposively as a strong example reflecting important lessons under varying conditions) to illustrate the ways in which HPSR is used to influence health policy. We reviewed the academic and grey literature and policy documents, constructed three country case studies and interviewed two leading experts from each of Mexico and Cambodia and three from Ghana (using semi-structured interviews, anonymized to ensure objectivity). For the design of the study, design of the semi-structured topic guide and the analysis of results, we used a modified version of the context-based analytical framework developed by Dobrow et al. (Evidence-based health policy: context and utilisation. Social Science & Medicine 2004;58:207-17). The results demonstrate that HPSR plays a varied but essential role in effective health policy making and that the use, implementation and outcomes of research and research-based evidence occurs inevitably within a national context that is characterized by political circumstances, the infrastructure and capacity for research and the longer-term experience with HPSR processes. This analysis of national experiences demonstrates that embedding HPSR in the policy process is both possible and productive under varying economic and political circumstances. Supporting research structures with social development legislation, establishing relationships based on trust between researchers and policy makers and building a strong domestic capacity for health systems research all demonstrate means by which the value of HPSR can be materialized in strengthening health systems.

Patients satisfaction of core health-care business: the mediating effect of the quality of health-care infrastructure and equipment

Purpose

Although the quality of health-care infrastructure and equipment influences patient’s overall health-care experience, health-care infrastructure and equipment are not always managed and maintained with the attention required. This is due mainly to the complexity of health-care infrastructure and equipment and shortage of maintenance budget. This study aims to determine if patient’s satisfaction of core health-care business is mediated by the quality of health-care infrastructure and equipment.

Design/methodology/approach

This cross-sectional study comprises 622 adult patients at the Physician OPD and Polyclinic of Komfo Anokye Teaching hospital, Tamale Teaching hospital and Cape Coast Teaching hospital in Ghana. Structural equation model Smart PLS was used to analyse the data.

Findings

The study results showed that the quality of health-care infrastructure and equipment has a positive significant influence (mediation) on the relationship between health-care delivery and patient’s satisfaction as well as the relationship between adequacy of health-care resources and patient’s satisfaction. However, it was shown not to have a positive significant influence (mediation) on the relationship between quality of health-care personnel and patients’ satisfaction as well as health-care administrative process and patient’s satisfaction.

Research limitations/implications

First, the study findings are centred on cross-sectional data, which capture the opinion of the patients at a specific time period instead of over a period of time. Consequently, in future, though difficult to achieve, a longitudinal study can be piloted to provide more insight. Second, the data was collected from only one country (Ghana); thus, the ability to generalise the results may be a challenge.

Practical implications

The implication of this study is that there is the need to prudently maintain hospital infrastructure and equipment in good working condition as it has a positive effect on patients’ satisfaction of their overall health-care experience.

Originality/value

Most studies have concentrated on patient’s health-care experience. This study extends the knowledge of patient’s health-care experience by determining the mediating role of quality of health-care infrastructure and equipment on the relationship between patient’s satisfaction and core health-care business. There are limited studies of such nature in Ghana. Therefore, this study will provide invaluable empirical data for the health-care sector of a developing African country.

Contribution of child health interventions to under-five mortality decline in Ghana: A modeling study using lives saved and missed opportunity tools

Background

Increased coverage of interventions have been advocated to reduce under-five mortality. However, Ghana failed to achieve the Millennium Development Goal on child survival in 2015 despite improved coverage levels of some child health interventions. Therefore, there is the need to determine which interventions contributed the most to mortality reduction and those that can further rapidly reduce mortality to inform the prioritization of the scale-up of interventions.

Materials and methods

Deterministic mathematical modeling was done using Lives Saved and Missed Opportunity Tools. Secondary data was used, and the period of the evaluation was between 2008 and 2014. Some of the interventions assessed were complementary feeding, skilled delivery, and rotavirus vaccine.

Results

A total of 48,084 lives were saved from changes in coverage of interventions and a reduction in the prevalence of stunting and wasting. Reduction in wasting prevalence saved 10,372(21.6%) lives, insecticide-treated net/indoor residual spraying 6,437(13.4%) lives saved, reduction in stunting 4,315(9%) lives saved and artemisinin-based combination therapy (ACTs) 4,325(9.0%) lives saved. If coverage levels of interventions in 2014 were scaled up to 90% in 2015, among neonates, full supportive care for prematurity (5,435 lives saved), full supportive care for neonatal sepsis/pneumonia (3,002 lives saved), and assisted vaginal delivery (2,163 lives saved), would have saved the most lives among neonates, while ACTs (4,925 lives saved), oral rehydration salts (ORS) (2,056 lives saved), and antibiotics for the treatment of pneumonia (1,805 lives saved) would have made the most impact on lives saved among children 1–59 months. Lastly, if all the interventions were at 100% coverage in 2014, the under-five mortality rate would have been 40.1 deaths per 1,000 live births in 2014.

Discussion

The state of the package of interventions will likely not lead to rapid mortality reduction. Coverage and quality of childbirth-related interventions should be increased. Additionally, avenues to further reduce stunting and wasting, including increased breastfeeding and complementary feeding, will be beneficial.

Understanding the information culture for self-management support of people living with diabetes in Ghana

Purpose

The purpose of this study is to explore the information culture of people living with Diabetes Mellitus (DM) and how that impacts their self-management practices in Ghana. The study focuses on the information experiences and information cultural patterns and creates awareness of the need for people to be aware of effective information management for sustainable self-management support.

Design/methodology/approach

An interpretive qualitative approach was used. A total of 12 interviewees involving 10 diabetes patients and 2 health professionals provided data for the study. Allowing the participants to freely talk about their attitude and behaviour, defining their experiences around information for their self-management was the best approach to achieve an in-depth understanding this study seeks.

Findings

The specific elements defining the information of people living with DM in Ghana can be identified. People living with the condition are willing to share information about their condition not only with those within their diabetic community but also with anyone interested. They prefer to use information from sources they find reliable and trust, and they have good information-related competencies that are consistent with diabetic patients in other countries’ contexts to help them identify, access, use and share relevant information. Only a few of the interviewees have difficulty in evaluating the accuracy and currency of some of the information. But they receive a lot of support from experienced people from their community. People also prefer to have information about the condition in their ethnic language. It is important for people living with the condition in Ghana to get involved in the diabetic groups, clubs and community, as members appear to receive the most benefit and support from the community to self-manage the condition alone.

Research limitations/implications

The study is limited by the number of participants and the distances between the researchers and the research context. Also, even though two groups of participants were interviewed (diabetic patients and health professionals), the analysis did not separate the responses of the different groups of study participants. This paper provides a useful insight and understanding of the culture of people living with diabetes in Ghana in terms of how they access, use and share the information they need to support their self-management. It will create awareness of the importance of being mindful of information culture patterns in people in other groups in Ghana and beyond. The research processes and procedures described in the paper can be replicated by other researchers in other contexts.

Originality/value

Although there have been a lot of studies about diabetes and people living with the condition in Ghana, to the best of the authors’ knowledge, this is the first study looking at how people define their need for information, how they identify the source of the information and how they access and use the information, including their general behavioural patterns that influence these information experiences.

Patients satisfaction with healthcare delivery in Ghana

Background

The service industry has been an evolving sector and a great concern to providers ensuring continuously that clients’ satisfaction is met. Hence, the importance of patient satisfaction in the healthcare sector. This study focused on the satisfaction of women with the delivery of health services in Ghana and aims to be different from other studies which has focused on patient satisfaction with urban and rural health services, regional health services and health insurance. Our study examines the percentages of satisfaction with the multiple outcomes defined and identifies the key health system and demographic related factors associated with women satisfaction.

Methods

This study used data from the 2014 Ghana Demographic and Health Survey and a total of 12,831 households were systematically selected with reproductive women aged 15–49 years eligible for interview. Data for this study was analysed quantitatively using descriptive statistics, chi square and regression analysis. A total of 3648 women were included in this study and the final analysis thus involved a weighted sample of 3507 women. Satisfaction indicators were put together into SERVQUAL dimensions in the study and reliability test run using Cronbach Alpha (α). All data analyses were carried out in STATA 13.0. The adjusted odds ratios (AOR) with their corresponding 95% confidence intervals (CI) were calculated.

Results

Analysis showed that independently, education and religion were significantly associated with service reliability, overall satisfaction and responsiveness. Payment option was also associated with responsiveness and tangibility dimensions. Furthermore, place of residence was independently associated with responsiveness, tangibility and overall satisfaction. Finally, maternal age, region, provider friendly, ease of getting care and opening hours were all independently associated with reliability, responsiveness, tangibility and overall service satisfaction at the multivariable level.

Conclusions

Dimensions of service quality which focus on patient-centered atmosphere and efficient service delivery system should be integrated and strengthened by hospital management in order to increase patient satisfaction. Key maternal characteristics and health system related factors were revealed to have positive association with patient satisfaction with health services delivery and this cannot be ignored by health care managers in ensuring that systems are improved for better health care.

Construct validity of the Suboptimal Health Status Questionnaire-25 in a Ghanaian population

Background

The Suboptimal Health Status Questionnaire-25 (SHS-Q-25) developed to measure Suboptimal Health Status has been used worldwide, but its construct validity has only been tested in the Chinese population. Applying Structural Equation Modelling, we investigate aspects of the construct validity of the SHS-Q-25 to determine the interactions between SHS subscales in a Ghanaian population.

Methods

The study involved healthy Ghanaian participants (n = 263; aged 20–80 years; 63% female), who responded to the SHSQ-25. In an exploratory factor and parallel analysis, the study extracted a new domain structure and compared to the established five-domain structure of SHSQ-25. A confirmatory factor analysis (CFA) was conducted and the fit of the model further discussed. Invariance analysis was carried out to establish the consistency of the instrument across multi-groups.

Results

The extracted domains were reliable with Cronbach’s \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\alpha$$\end{document}α of 0.846, 0.820 and 0.864 respectively, for fatigue, immune-cardiovascular and cognitive. The CFA revealed that the model fit indices were excellent \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\left( {{\text{RMSEA}} = 0.049~ < ~0.08,\,{\text{CFI}} = 0.903 > 0.9,\,{\text{GFI}} = 0.880 < 0.9,\,{\text{TLI}} = 0.907 > 0.9} \right)$$\end{document}RMSEA=0.049<0.08,CFI=0.903>0.9,GFI=0.880<0.9,TLI=0.907>0.9. The fit indices for the three-domain model were statistically superior to the five-domain model. There were, however, issues of insufficient discriminant validity as some average variance extracts were smaller than the corresponding maximum shared variance. The three-domain model was invariant for all constrained aspects of the structural model across age, which is an important risk factor for most chronic diseases.

Conclusion

The validity tests suggest that the SHS-Q25 can measure SHS in a Ghanaian population. It can be recommended as a screening tool to early detect chronic diseases especially in developing countries where access to facilities is diminished.

Prioritizing the National Aging Policy in Ghana: Critical Next Steps

Most developing nations are facing rapid population aging with limited economic and social resources. In Ghana, a National Aging Policy (NAP) was promulgated by the government in 2010 to ensure the well-being of older adults. Since its passage, the NAP has yet to be funded and implemented. In this paper we synthesize key information on policies and programs targeted at older adults in Ghana and identify the challenges that are adversely impacting their welfare, including the non-implementation of the National Aging Policy. To give the NAP needed attention and promote its implementation, a national coordinating body exclusively devoted to older adults is an essential first step. Critical next steps are offered to promote the effective implementation of the NAP and ensure the well-being of older adults in Ghana. With its current foundation of support programs for older adults, Ghana has the opportunity to be the lead nation in Sub-Saharan Africa to establish a national level office dedicated to promoting older adults' well-being and including them in the nation's development efforts.

Availability of low vision services and barriers to their provision and uptake in Ghana: practitioners' perspectives

Background

Provision and uptake of low vision services are essential.

Objective

To assess the availability of low vision services and barriers to their provision and uptake in the Ashanti and Brong Ahafo regions of Ghana from the perspective of eye care practitioners.

Methods

A descriptive, quantitative, cross-sectional study design using semi-structured questionnaires was used to collect information from eye care practitioners selected from 58 eye care facilities in the Ashanti and Brong Ahafo regions of Ghana.

Results

Forty-four eye care practitioners from Ashanti region and 10 from Brong Ahafo region responded to the questionnaire. Seventeen (34%) of the 50 eye care facilities who reported having patients seeking low vision services in their facilities provided such services. Lack of low vision devices (94.4%) and equipment (87%) were reported to be the main barriers to the provision of low vision services. Major barriers to low vision services uptake were lack of awareness (88.7%), high cost (70.4%) and social unacceptability of low vision assistive devices (59.3%).

Conclusion

Lack of adequate low vision services and barriers to their provision and uptake impact negatively on efforts to prevent visual impairment and blindness in Ghana.

Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol

BACKGROUND

Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam.

METHODS

We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors' expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions' actual performance.

DISCUSSION

The study's key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.

Correlates of child functional difficulties status in Ghana: A further analysis of the 2017/18 multiple indicator cluster survey

BACKGROUND

Functional difficulties have long-term implications for children's physical, cognitive, emotional, social, and academic growth and development. Although the subject of functional difficulties has received enough scholarly attention in the developed world, few studies have addressed the issue in Ghana. Therefore, the study aimed to regress child, maternal and household and geographical level factors associated with the functional difficulty of children in Ghana.

METHOD

We analysed the 2017/18 multiple indicator cluster survey dataset. The study sample consists of weighted cases of 21,871 children within the ages of 5-17 years. Summary statistics were produced for the study variables. Bivariate analyses were performed to select significant correlates for the multivariate analysis. We accounted for sample design and weight before using Poisson regression techniques to do the bivariate and multivariate analysis.

RESULTS

These factors were significantly associated with functional difficulties among 5-17 years old children in Ghana: not covered with health insurance, mothers who have a functional difficulty and those without information on their functional difficulty status, and children who dwelt in richer households compared to the richest households. Compared to the northern region, children from the remaining nine regions in Ghana were more likely to have had a child functional difficulty.

CONCLUSION

Given the results, the government of Ghana and other development partners should promote policies and programs to reduce the consequences of disability or functional difficulties in children by taking into consideration factors like mothers' functional difficulty, access to health insurance, and regional and economic disparities in Ghana.

How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana

Introduction: District health managers (DHMs) play a pivotal role in the operation of district health systems in low-and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system in which they are embedded. The objective of this paper is to explore how district health management emerges from contextual, organizational, and individual factors in order to demonstrate that capacity strengthening efforts at district level need to transcend individual competencies to take on more systemic approaches. Methods: Semi-structured interviews (n = 21) were conducted to gain insight into aspects that affect district health management in the Eastern Region of Ghana. Interviews were conducted with DHMs (n = 15) from six different districts, as well as with their superiors at the regional level (n = 4) and peers from non-governmental organizations (n = 2). A thematic analysis was conducted by using an analytical approach based on systems theory. Results: Contextual aspects, such as priorities among elected officials, poor infrastructure and working conditions, centralized decision-making, delayed disbursement of funds and staff shortages, affect organizational processes and the way DHMs carry out their role. Enabling organizational aspects that provide DHMs with direction and a clear perception of their role, include positive team dynamics, good relations with supervisors, job descriptions, appraisals, information systems, policies and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by vertical programs and limited opportunities for professional development provide DHMs with limited authority to make decisions and dampens their motivation. The DHMs ability to carry out their role effectively depends on their perception of their role and the effort they expend, in addition to their competencies. In regards to competencies, a need for more general management and leadership skills were called for by DHMs as well as by their superiors and peers. Conclusion: Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management.

Towards Population Salt Reduction to Control High Blood Pressure in Ghana: A Policy Direction

Although population salt reduction is considered a "best buy" in addressing hypertension and cardiovascular disease, Ghana shares a high hypertension burden with a seemingly high salt consumption. This article discusses best practices in reducing population salt intake and provides preliminary data on salt and potassium intake, as well as the process to develop a road map and identification of actions needed to support the development of a strategic national document towards salt reduction in Ghana. In February 2019, a 2-d stakeholder meeting was held with government agencies, researchers, nongovernmental organizations, civil society organizations, and international partners to deliberate on salt reduction strategies and interventions needed in the face of rising hypertension and other noncommunicable diseases (NCDs) in Ghana. Recommendations were developed from the stakeholder meeting and are being considered for inclusion in the revision of Ghana's national NCD policy.

An audit of MRI machines and services in Ghana

INTRODUCTION

Magnetic resonance imaging (MRI) is a useful medical imaging modality for the diagnosis and management of patients. However, the huge costs associated with establishing and operating MRI means it may not be readily accessible and affordable for hospitals in developing countries. Little is currently known about the availability of MRI machines in Ghana. Such information may assist in informing future health service development within the country. This study reports on the findings and implications of an audit of MRI machines in Ghana.

METHODS

A quantitative descriptive cross-sectional survey was conducted involving all MRI machines in Ghana. Data obtained was analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Independent-samples t-test was conducted to compare the mean cost of MRI examinations between privately-owned and state-owned MRI machines in Ghana.

RESULTS

18 MRI machines, spread across five regions, are available in Ghana. 15 (83.3%) of the MRI machines are located in the Greater-Accra and Ashanti regions. MRI examinations are more expensive in privately-owned machines compared to state-owned machines (p < 0.05). Four state-owned machines have been non-operational for between three-six years resulting in a revenue loss of GHC 36 million (US$7.2 million).

CONCLUSION

There are few MRI machines in Ghana and the majority are concentrated in the two largest regions. The increase in MRI machines over the past decade can be attributed to private investment in the sector.

IMPLICATIONS FOR PRACTICE

This study will inform the Ghana Health Service and other healthcare policy makers in Ghana to increase investment in MRI machines to ensure equitable regional distribution of MRI machines so that patients across Ghana would have access to the diagnostic benefits associated with MRI machines.

Suboptimal health pregnant women are associated with increased oxidative stress and unbalanced pro- and antiangiogenic growth mediators: a cross-sectional study in a Ghanaian population

Optimal oxidative stress (OS) is important throughout pregnancy; however, an increased OS may alter placental angiogenesis culminating in an imbalanced of angiogenic growth mediators (AGMs). Suboptimal Health Status (SHS), a physical state between health and disease, may be associated with increased OS and unbalanced AGMs. In this study, we explored the association between SHS, biomarkers of OS (BOS) and AGMs among normotensive pregnant women (NTN-PW) in a Ghanaian Suboptimal Health Cohort Study (GHOACS). This comparative GHOACS recruited 593 NTN-PW from the Komfo Anokye Teaching Hospital, Ghana. SHS was measured using a Suboptimal Health Status Questionnaire-25 (SHSQ-25). Along with the subjective SHS measure, objective BOS: 8-hydroxy-2-deoxyguanosine (8-OHdG), 8-epiprostaglandinF2 alpha (8-epi-PGF2α), total antioxidant capacity (TAC), and AGMs: vascular endothelial growth factor-A (VEGF-A), soluble fms-like tyrosine kinase receptor 1 (sFlt-1), placental growth factor (PIGF) and soluble endoglin (sEng) were evaluated. Compared to optimal health NTN-PW, levels of PlGF, VEGF-A and TAC were significantly (p < 0.05) reduced and negatively associated with SHS whilst sEng, sFlt-1, 8-epiPGF2α, 8-OHdG, and combined ratios of sFlt-1/PlGF, 8-epiPGF2α/PlGF, 8-OHdG/PlGF, and sEng/PlGF were significantly increased and positively associated with SHS. The first quartile for PIGF (2.79-fold) and VEGF-A (5.35-fold), and the fourth quartile for sEng (4.31-fold), sFlt-1 (1.84-fold), 8-epiPGF2α (2.23-fold), 8-OHdG (1.90-fold) and urinary 8-OHdG (1.95-fold) were independently associated with SHS (p < 0.05). SHS is associated with increased OS and unbalanced AGMs. Early identification of SHS-related OS and unbalanced AGMs may inform clinicians of the need for therapeutic options.

Identifying Key Challenges Facing Healthcare Systems In Africa And Potential Solutions

INTRODUCTION

Healthcare systems in Africa suffer from neglect and underfunding, leading to severe challenges across the six World Health Organization (WHO) pillars of healthcare delivery. We conducted this study to identify the principal challenges in the health sector in Africa and their solutions for evidence-based decisions, policy development and program prioritization.

METHODS

The study was conducted as part of a recent African Epidemiological Association Meeting in Maputo, Mozambique with participants drawn from 11 African countries, Cuba, Portugal and the United Kingdom. Participants were divided into 10 groups, consisting of 7 to 10 persons each. Brainstorming approaches were used in a structured, modified nominal group process exercise to identify key challenges and strategies to mitigate healthcare service challenges in Africa. Identified challenges and solutions were prioritised by ranking 1-5, with 1 most important and 5 being least important.

RESULTS

The first three challenges identified were inadequate human resources (34.29%), inadequate budgetary allocation to health (30%) and poor leadership and management (8.45%). The leading solutions suggested included training and capacity building for health workers (29.69%), increase budgetary allocation to health (20.31%) and advocacy for political support and commitment (12.31%).

CONCLUSION

The underdeveloped healthcare systems in Africa need radical solutions with innovative thought to break the current impasse in service delivery. For example, public-private initiatives should be sought, where multinational companies extracting resources from Africa might be encouraged to plough some of the profits back into healthcare for the communities providing the workforce for their commercial activities. Most problems and their solutions lie within human resources, budget allocation and management. These should be accorded the highest priority for better health outcomes.

Barriers to formal healthcare utilisation among poor older people under the livelihood empowerment against poverty programme in the Atwima Nwabiagya District of Ghana

BACKGROUND

Even though there is a growing literature on barriers to formal healthcare use among older people, little is known from the perspective of vulnerable older people in Ghana. Involving poor older people under the Livelihood Empowerment Against Poverty (LEAP) programme, this study explores barriers to formal healthcare use in the Atwima Nwabiagya District of Ghana.

METHODS

Interviews and focus group discussions were conducted with 30 poor older people, 15 caregivers and 15 formal healthcare providers in the Atwima Nwabiagya District of Ghana. Data were analysed using the thematic analytical framework, and presented based on an a posteriori inductive reduction approach.

RESULTS

Four main barriers to formal healthcare use were identified: physical accessibility barriers (poor transport system and poor architecture of facilities), economic barriers (low income coupled with high charges, and non-comprehensive nature of the National Health Insurance Scheme [NHIS]), social barriers (communication/language difficulties and poor family support) and unfriendly nature of healthcare environment barriers (poor attitude of healthcare providers).

CONCLUSIONS

Considering these barriers, removing them would require concerted efforts and substantial financial investment by stakeholders. We argue that improvement in rural transport services, implementation of free healthcare for poor older people, strengthening of family support systems, recruitment of language translators at the health facilities and establishment of attitudinal change programmes would lessen barriers to formal healthcare use among poor older people. This study has implications for health equity and health policy framework in Ghana.

Integration of suboptimal health status evaluation as a criterion for prediction of preeclampsia is strongly recommended for healthcare management in pregnancy: a prospective cohort study in a Ghanaian population

Background

Normotensive pregnancy may develop into preeclampsia (PE) and other adverse pregnancy complications (APCs), for which the causes are still unknown. Suboptimal health status (SHS), a physical state between health and disease, might contribute to the development and progression of PE. By integration of a routine health measure in this Ghanaian Suboptimal Health Cohort Study, we explored the usefulness of a 25-question item SHS questionnaire (SHSQ-25) for early screening and prediction of normotensive pregnant women (NTN-PW) likely to develop PE.

Methods

We assessed the overall health status among a cohort of 593 NTN-PW at baseline (10-20 weeks gestation) and followed them at 21-31 weeks until 32-42 weeks. After an average of 20 weeks follow-up, 498 participants returned and were included in the final analysis. Hematobiochemical, clinical and sociodemographic data were obtained.

Results

Of the 498 participants, 49.8% (248/498) had 'high SHS' at baseline (61.7% (153/248) later developed PE) and 38.3% (95/248) were NTN-PW, whereas 50.2% (250/498) had 'optimal health' (17.6% (44/250) later developed PE) and 82.4% (206/250) were NTN-PW. At baseline, high SHS score yielded a significantly (p < 0.05) increased adjusted odds ratio, a wider area under the curve (AUC) and a higher sensitivity and specificity for the prediction of PE (3.67; 0.898; 91.9% and 87.8%), PE coexisting with intrauterine growth restriction (2.86, 0.838; 91.5% and 75.9%), stillbirth (2.52; 0.783; 96.6% and 60.0%), hemolysis elevated liver enzymes and low platelet count (HELLP) syndrome (2.08; 0.800; 97.2% and 63.8%), acute kidney injury (2.20; 0.825; 95.3% and 70.0%) and dyslipidaemia (2.80; 0.8205; 95.7% and 68.4%) at 32-42 weeks gestation.

Conclusions

High SHS score is associated with increased incidence of PE; hence, SHSQ-25 can be used independently as a risk stratification tool for adverse pregnancy outcomes thereby creating an opportunity for predictive, preventive and personalized medicine.

Self-Assessment of Hygiene Practices towards Predictive and Preventive Medicine Intervention: A Case Study of University Students in Ghana

INTRODUCTION

Personal hygiene is essential to the current paradigm shift towards predictive, preventive, and personalized medicine, which enables the prediction and prevention of infectious disease outbreaks.

OBJECTIVE

The aim of this paper was to evaluate the personal hygiene practices among university students aiming at providing a basis for preventive and predictive medical interventions and to make future efforts improve target interventions for young people.

METHODS

The study was conducted using a cross-sectional study. Validated instruments that related personal hygiene practices were used to obtain quantitative data from 412 tertiary students from seven universities in Accra, Ghana. The resulting data were analyzed with IBM-SPSS, version 23.

RESULTS

There were more female respondents (54.4%) in the study than male respondents (45.6%). Respondents between the age group of 19-24 years constituted majority (59.7%) of the respondents in the study. Respondents from urban areas exhibited good hygiene practice compared to those from urban residences. There was a significant association between residence and hygiene practice (χ 2=17.8, P≤0.001). We also observed that those respondents within the upper class in society had a poor hygiene practice, compared to the Lower Class and Middle Class respondents. Lack of education (63.1%) was observed as the main barrier to personal hygiene among the respondents. Future of the society depends on the health of its youth.

CONCLUSION

A significant number of students are not actively practicing good hygiene. There is a need for deployment of preventive medicine interventions targeted at young people. It calls for improvement in methods of hygiene education for young people in tertiary institutions and the inclusion of hygiene in school curricula.

Modelling the influence of healthcare facilities management service quality on patients satisfaction

Purpose

Facilities management (FM) professionals state that adopting FM will positively support core service delivery and ensure customer satisfaction. Evidences of such claim are important as it will enhance the rationale for institutionalising prudent FM service quality in hospitals in Ghana. This paper aims to assess the mediating effect of healthcare FM service quality on patients’ satisfaction and overall healthcare delivery.

Design/methodology/approach

This is a cross-sectional study involving adult patients at the Physician outpatient departments and Polyclinics of Komfo Anokye, Tamale and Cape Coast Teaching hospitals in Ghana. A questionnaire survey using a well-structured five-point likert scale based on the SERVQUAL dimensions and Healthcare core service dimensions rooted in the FM framework was used to collect data from 660 patients. Smart PLS was used to analyse the data of 622 valid questionnaires.

Findings

The study results revealed that FM service quality mediates the relationship between patients’ satisfaction and three of the constructs under core healthcare delivery. That is, (the quality of healthcare delivery, the quality of healthcare personnel and the adequacy of healthcare resources) – surprisingly, the fourth construct (the quality of administration process) was not supported.

Originality/value

There is no or at best very limited studies on the contribution of healthcare FM on patients satisfaction of core healthcare delivery in Ghana. Therefore, this study will enrich and contribute to knowledge in healthcare FM in general and that of a developing African country in particular.

The potential of N-glycosylation profiles as biomarkers for monitoring the progression of Type II diabetes mellitus towards diabetic kidney disease

Background

On a global scale, type II diabetes mellitus (T2DM) remain a major health problem and it is the driver for chronic kidney disease (CKD). Despite this association, we still do not have sufficient biomarkers to anticipate better outcomes. N-glycosylation profiles are robust biomarkers and can be used for early monitoring of the progression of T2DM towards CKD.

Methods

In this cross-sectional study, we recruited 241 T2DM patients from January to May 2016. Demographic and anthropometric data were collected, following which fasting blood samples were collected for clinical analyses. Renal function decline was determined by estimation of glomerular filtration rate (eGFR) and N-glycosylation profiles were analysed by Ultra-performance liquid chromatography (UPLC).

Results

The prevalence of undiagnosed CKD was 31.53%. Compared to men, women had a statistically significantly higher HbA1c (p = 0.031), TG (p = 0.015), HDL-c (p < 0.0001), creatinine (<0.0001), urea (p < 0.028) and uric acid (p < 0.0001). T2DM patients with undiagnosed CKD had higher serum creatinine (145.75 ± 50.83 vs 88.59 ± 19.46, p < 0.0001), higher uric acid (361.10 ± 115.37 vs 294.54 ± 97.75; p < 0.0001) and higher urea (5.17 ± 2.35 vs 3.58 ± 1.19; p < 0.0001). After performing logistic regression and adjusting for age, sex and BMI, three N-glycan peaks [OR (95%CI): (GP12 (0.05(0.01-0.54), p = 0.013)); GP16 (0.61(0.43-0.87), p = 0.006)); GP22 (0.60(0.39-0.92), p = 0.018)) were associated with renal function.

Conclusion

There was an increased prevalence of undiagnosed CKD among T2DM patients. This prevalence is the consequence of uncontrolled modifiable risk factors, which collectively may lead to end stage renal disease (ESRD). Although, the identified N-glycans could not adequately predict incident CKD, our investigation indicates the potential role of N-glycosylation in renal function and that their inclusion may improve risk stratification for CKD.

Using GIS to detect cluster and spatial disparity in maternal health indicators: a need for social health interventions

Maternal mortality remains a serious global health concern. Although global efforts have produced some encouraging results in some World Health Organization's health regions, disparities persist within many countries. Additionally, in many developing countries, inadequate documentation of various health events including maternal mortality and morbidity, make it difficult to determine the true extent of the problem. Maternal health indicators are therefore proxies used in estimating health status in developing countries. Using geospatial and geovisualization techniques, this study examines district level disparities in two maternal health indicators in Ghana antenatal care (ANC) visits and skilled birth attendance (SBA). The results reveal districts with complete lack of access to higher health care professionals and others with underutilization of antenatal services. The findings provide important input for targeting location-specific public health and maternal health interventions.

Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries

OBJECTIVE

To provide an update on economic related inequalities in caesarean section rates within countries.

DESIGN

Secondary analysis of demographic and health surveys and multiple indicator cluster surveys.

SETTING

72 low and middle income countries with a survey conducted between 2010 and 2014 for analysis of the latest situation of inequality, and 28 countries with a survey also conducted between 2000 and 2004 for analysis of the change in inequality over time.

PARTICIPANTS

Women aged 15-49 years with a live birth during the two or three years preceding the survey.

MAIN OUTCOME MEASURES

Data on caesarean section were disaggregated by asset based household wealth status and presented separately for five subgroups, ranging from the poorest to the richest fifth. Absolute and relative inequalities were measured using difference and ratio measures. The pace of change in the poorest and richest fifths was compared using a measure of excess change.

RESULTS

National caesarean section rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic. Within countries, caesarean section rates were lowest in the poorest fifth (median 3.7%) and highest in the richest fifth (median 18.4%). 18 out of 72 study countries reported a difference of 20 percentage points or higher between the richest and poorest fifth. The highest caesarean section rates and greatest levels of absolute inequality were observed in countries from the region of the Americas, whereas countries from the African region had low levels of caesarean use and comparatively lower levels of absolute inequality, although relative inequality was quite high in some countries. 26 out of 28 countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth (median 0.9 percentage points per year) compared with the poorest fifth (median 0.2 percentage points per year), indicating an increase in inequality over time in most of these countries.

CONCLUSIONS

Substantial within country economic inequalities in caesarean deliveries remain. These inequalities might be due to a combination of inadequate access to emergency obstetric care among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries. Country specific strategies should address these inequalities to improve maternal and newborn health.

Profiling of cardio-metabolic risk factors and medication utilisation among Type II diabetes patients in Ghana: a prospective cohort study

BACKGROUND

Type II diabetes mellitus (T2DM) is complicated by multiple cardio-metabolic risk factors. Controlling these factors requires lifestyle modifications alongside utilisation of anti-diabetic medications. Different glucose lowering [(biguanides (BIGs), sulfonylureas (SUAs), thiazolidinediones (TNZ)], lipid lowering (statins), and anti-hypertensive medicines [angiotensin converting enzyme inhibitors (ACEIs), calcium channel blockers (CCBs), angiotensin II receptor blockers (ARBs) and central acting drugs (CADs)] have been approved for controlling hyperglycaemia, dyslipidaemia and hypertension respectively. Here, we examined factors that characterise T2DM and explored the response to medication therapy among T2DM patients.

METHODS

This prospective cohort study recruited 241 T2DM patients reporting at a clinic in Ghana, from January through to August, 2016. Each patient's demographic, medications and anthropometric data was obtained while information on medication adherence was captured using Morisky adherence scale-8 (MMAS-8). Fasting blood samples were collected for biochemical analysis.

RESULTS

The mean age of participants was 57.82 years for baseline and six-month follow-up. Physical activity differed at baseline and follow up (p < 0.05) but not body mass index (BMI). BIG alone, or in combination with SUA and TNZ did not improve glycaemic status at follow up (p > 0.05). Many participants using either ACEI or ARB were able to control their blood pressures. Among dyslipidaemia patients under statin treatment, there was an improved lipid profile at follow-up.

CONCLUSIONS

Statin medications are effective for reducing dyslipidaemia in T2DM patients. However, control of modifiable risk factors, particularly blood glucose and to a lesser degree blood pressure is suboptimal. Addressing these will require concomitant interventions including education on medication adherence and correct dietary plans, lifestyle modifications and physical activity.