From PERFORM to PERFORM2Scale: Lessons from scaling-up a health management strengthening intervention to support Universal Health Coverage in three African countries.

Strengthening management and leadership competencies among district and local health managers has emerged as a common approach for health systems strengthening and to achieve Universal Health Coverage (UHC). While the literature is rich with localised examples of initiatives that aim to strengthen the capacity of district or local health managers, particularly in sub-Saharan Africa, considerably less attention is paid to the science of how to scale-up these initiatives. The aim of this paper is thus to examine the process of scaling-up a management strengthening intervention (MSI) and identify new knowledge and key lessons learned that can be used to inform the scale-up process of other complex health interventions, in support of UHC. Qualitative methods were used to identify lessons learned from scaling-up the MSI in Ghana, Malawi and Uganda. We conducted 14 interviews with district health management team members, three scale-up assessments with 20 scale-up stakeholders, and three reflection discussions with 11 research team members. We also kept records of activities throughout MSI and scale-up implementation. Data was recorded, transcribed, and analysed against the Theory of Change to identify both scale-up outcomes and the factors affecting these outcomes. The MSI was ultimately scaled-up across 27 districts. Repeated MSI cycles over time were found to foster greater feelings of autonomy among district health management teams (DHMTs) to address longstanding local problems, a more innovative use of existing resources without relying on additional funding, and improved teamwork. The use of 'resource teams' and the emergence of MSI 'champions', were both instrumental in supporting scale-up efforts. Challenges to the sustainability of the MSI include limited government buy-in and lack of sustained financial investment.

Associations of socioeconomic disparities with buccal DNA-methylation measures of biological aging.

BACKGROUND: Individuals who are socioeconomically disadvantaged are at increased risk for aging-related diseases and perform less well on tests of cognitive function. The weathering hypothesis proposes that these disparities in physical and cognitive health arise from an acceleration of biological processes of aging. Theories of how life adversity is biologically embedded identify epigenetic alterations, including DNA methylation (DNAm), as a mechanistic interface between the environment and health. Consistent with the weathering hypothesis and theories of biological embedding, recently developed DNAm algorithms have revealed profiles reflective of more advanced aging and lower cognitive function among socioeconomically-at-risk groups. These DNAm algorithms were developed using blood-DNA, but social and behavioral science research commonly collect saliva or cheek-swab DNA. This discrepancy is a potential barrier to research to elucidate mechanisms through which socioeconomic disadvantage affects aging and cognition. We therefore tested if social gradients observed in blood DNAm measures could be reproduced using buccal-cell DNA obtained from cheek swabs. RESULTS: We analyzed three DNAm measures of biological aging and one DNAm measure of cognitive performance, all of which showed socioeconomic gradients in previous studies: the PhenoAge and GrimAge DNAm clocks, DunedinPACE, and Epigenetic-g. We first computed blood-buccal cross-tissue correlations in n = 21 adults (GEO111165). Cross-tissue correlations were low-to-moderate (r = .25 to r = .48). We next conducted analyses of socioeconomic gradients using buccal DNAm data from SOEP-G (n = 1128, 57% female; age mean = 42 yrs, SD = 21.56, range 0-72). Associations of socioeconomic status with DNAm measures of aging were in the expected direction, but were smaller as compared to reports from blood DNAm datasets (r = - .08 to r = - .13). CONCLUSIONS: Our findings are consistent with the hypothesis that socioeconomic disadvantage is associated with DNAm indicators of worse physical health. However, relatively low cross-tissue correlations and attenuated effect sizes for socioeconomic gradients in buccal DNAm compared with reports from analysis of blood DNAm suggest that in order to take full advantage of buccal DNA samples, DNAm algorithms customized to buccal DNAm are needed.

Comparison of Methyl Bromide and Phosphine for Fumigation of Necrobia rufipes (Coleoptera: Cleridae) and Tyrophagus putrescentiae (Sarcoptiformes: Acaridae), Pests of High-Value Stored Products.

Fumigation with methyl bromide has been a long established and effective method for controlling many pests of stored products, including the key major pests that infest dry-cured hams, aged cheese, and other value-added durable stored products. Methyl bromide had been widely used for the disinfestation of dry-cured ham facilities in the United States, but is now phased out of use since it is an ozone-depleting substance. This paper reports laboratory studies to evaluate the efficacies of methyl bromide and phosphine for controlling two of the key arthropod pests of dry-cured hams and aged cheeses. Larvae of the red-legged ham beetle, Necrobia rufipes (Fabricius), were the most tolerant life stages when treated with either phosphine or methyl bromide for 48 h exposure at 23°C, whereas eggs of the mold mite, Tyrophagus putrescentiae (Schrank), were slightly more tolerant than mobile stages for both compounds. Under laboratory conditions, complete control was achieved for the both species with concentrations of 0.85 and 4.0 g/m3 of phosphine and methyl bromide, respectively, at 48 h exposure. The results give new information for judicious use of the existing stocks of methyl bromide, whether for pest mitigation or to help in developing a quarantine treatment schedule with that gas. Phosphine shows good potential as an effective alternative to methyl bromide, but if it was to be adopted as a fumigant in the dry-cured ham industry, methods to prevent metal corrosion would need to be designed and effectively implemented.

Health worker transfer processes within the public health sector in Ghana: a study of three districts in the Eastern Region.

INTRODUCTION: The lack of appropriate policies and procedures to ensure transparent transfer practices is an important source of dissatisfaction among health workers in low- and middle-income countries. In order to alter and improve current practices, a more in-depth and context-specific understanding is needed. This study aims to (1) identify rationales behind transfer decisions in Ghana and (2) examine how transfers are managed in practice versus in policies. METHODS: The study took place in 2014 in three districts in Eastern Ghana. The study population included (1) national, regional, and district health administrators with decision-making authority in terms of transfer decisions and (2) health workers who had transferred between 2011 and 2014. Data was collected through semi-structured and structured face-to-face interviews focusing on rationales behind transfer decisions, health administrators' role in managing transfers, and health workers' experience of transfers. A data triangulation approach was applied to compare identified practices with national policies and procedures. RESULTS: A total of 44 health workers and 21 administrators participated in the study. Transfers initiated by health workers were mostly based on family conditions and preferences to move away from rural areas, while transfers initiated by administrators were based on service requirements, productivity, and performance. The management of transfers was not guided by clear and explicit procedures and thus often depended on the discretion of decision-makers. Moreover, health workers frequently reported not being involved in transfer decision-making processes. We found existing staff perceptions of a non-transparent system. CONCLUSION: Our findings suggest a need to foster incentives to attract and retain health workers in rural areas. Moreover, health worker-centered procedures and systems that effectively guide and monitor transfer practices must be developed to ensure that transfers are carried out in a timely, fair, and transparent way.

Health Policy, Health Systems Research and Analysis Capacity Assessment of the School of Public Health, University of Ghana.

INTRODUCTION: Health Policy and Systems Research and Analysis (HPSR&A) is an applied science that deals with complexity as it tries to provide lessons, tools and methods to understand and improve health systems and health policy. It is defined by the kinds of questions asked rather than a particular methodology. OBJECTIVE: Our objective was to assess capacity and capacity strengthening needs for HPSR&A conduct and teaching in the University of Ghana School of Public Health (UG-SPH). We conceptualized dynamically inter-related levels of capacity as contextual, institutional and individual. METHODS: The study had a cross sectional, mixed methods design. Data collection involved desk review, ,an in-depth interview, focus group discussions (FGD) and an interviewer administered questionnaire with closed and open ended items. Netmap was used as a tool in the FGD. FINDINGS: At all levels, HPSR&A capacity exists in Ghana but is somewhat fragile. The fragility reflects in part contextual challenges related to national income and priorities as well as the fact that globally HPSR&A remains an emerging field. At the contextual level, Institutions involved in some way or other in HPSR&A were part of larger organizations with broader mandates. Only a handful of SPH staff indicated that they specifically do teaching and /or research related to HPSR&A. CONCLUSION & RECOMMENDATIONS: There is a need to raise awareness of the field of HPSR&A and its potential contributions to health sector development; build upon already existing contextual, institutional and individual capacity; and also attract and develop the next generation of researchers and teachers.

Efficacy of Methyl Bromide for Control of Different Life Stages of Stored-Product Psocids.

The psocid species Liposcelis paeta Pearman, Liposcelis entomophila (Enderlein), Liposcelis decolor (Pearman), Liposcelis bostrychophila Badonnel (Psocoptera: Liposcelididae), and Lepinotus reticulatus Enderlein (Psocoptera: Trogiidae) were evaluated in laboratory bioassays to determine their susceptibility to six concentrations of methyl bromide (0.027, 0.113, 0.280, 0.393, 0.452, and 0.616 g/m3) after 48 h of exposure at 27.5°C. The life stages that were evaluated were adults (for all species), nymphs (for all species except Lep. reticulatus), and eggs (for L. entomophila, L. decolor, and L. bostrychophila). Adults and nymphs were very susceptible, and complete mortality was recorded at concentrations between 0.027 and 0.280 g/m3. In contrast, eggs were by far more tolerant than adults and nymphs for all species tested. At 0.027 g/m3, mortality did not exceed 53%, while survival was high even at 0.113 g/m3. Complete (100%) egg mortality was recorded at 0.393 g/m3 for L. decolor and at 0.452 g/m3 for L. entomophila and L. bostrychophila; concentrations estimated to give 99% mortality for eggs of these three species were 0.710, 1.044, and 0.891 g/m3, respectively. These results show that stored-product psocids are susceptible to methyl bromide, but concentrations of ≥0.452 g/m3 should be used to control all life stages.

Mental Health-Related Stigma and Discrimination in Ghana: Experience of Patients and Their Caregivers.

BACKGROUND: Mental health is now attracting increased public health attention from health professionals, policy makers and the general population. However, stigma and discrimination usually have enormous negative impact on the patients and their families. This study reports on stigma and discrimination faced by mental health patients and their caregivers in a suburban area of Ghana and the coping strategies used. METHOD: This is a cross-sectional exploratory study which used both quantitative and qualitative approaches. Two hundred and seventy seven mental health patients were purposively interviewed. Focus group discussions were held with caregivers and in-depth interviews were held with mental health professionals. The quantitative data were analyzed using SPSS and Microsoft Excel(®) whilst the qualitative data were coded and manually analyzed thematically. RESULTS: Mental disorder cuts across all age, sex, education, ethnicity, employment, and marital status. More females were stigmatized than males at the work/employment and educational levels. Various forms of stigma were observed at the economic, psychological and social levels, whilst for discrimination it was only observed at the economic and social levels. Caregivers were also stigmatized and discriminated. The coping strategies adopted by the mental patients and their caregivers were also economic, psychological and social in nature. CONCLUSION: Mental health patients and their families suffer from stigma and discrimination from the individual, family, work, employment, education to the health level. Thus, community level policy on mental health care needs to be developed and implemented. Furthermore mental health education needs to be intensified at the community level.

Pathways Utilized for Antenatal Health Seeking Among Women in the Ga East District, Ghana.

BACKGROUND: Ghana's maternal mortality ratio has been declining over the last two decades but at a rather slow pace. Poor access to effective maternity care is identified as one of the key challenges of maternity care. The current study mapped out the pathways to pregnancy care seeking among urban-dwelling adult women in a peri-urban district located in the Greater Accra region of Ghana. METHODS: A total of 300 women who had a live birth in the last 12 months participated in a community-based survey. They answered questions on care seeking behavior related to their last pregnancy. A multivariate Logistic regression model was used to identify factors associated with multiple care seeking behavior. RESULTS: Almost all women in the survey (98%) reported accessing skilled antenatal care (ANC) from a biomedical provider, although 35% begun ANC later than the first trimester. About 45% of women simultaneously utilized both ANC and alternative care providers (ACP) including traditional birth attendants, herbalists, and spiritualists. A complex pathway to antenatal care seeking behavior involving shuttling between providers was observed. Controlling for household wealth, household size, and age, seeking care from multiple providers concurrently was associated with residence in Kwabenya sub-district OR=2.13 (95% CI: 1.28, 3.55) and previous abortion OR=2.08 (95% CI: 1.11, 3.91). CONCLUSIONS: Urban-dwelling women in Ga East District seek antenatal care concurrently from multiple sources. Health system interventions must seek ways to integrate alternative care providers into the existing biomedical health care system.

Socio-economic differences in cost of pregnancy-related health services in the peri-urban Accra, Ghana.

BACKGROUND: Financial and physical barriers are known to limit access to maternal health services in developing countries. These limitations are often compounded by the low socio-economic status of women. This study examined socio-economic differences in health services cost incurred by pregnant women. METHODS: A cross-sectional cost survey of 300 women who had delivered a live birth in the last 12 months was undertaken. RESULTS: Majority of the women were aged between 20 and 39 years. About 63% of the women claimed they were registrants of the National Health Insurance Scheme (NHIS). However, only 64% of them provided valid NHIS identification cards. There were relatively more insured women in the rich quintiles (44%) compared with insured women in the poor quintiles (33%). Generally, women who were in the rich quintile incurred the highest average medical and non-medical costs, spent the highest time prior to service provision and lost the highest average incomes. CONCLUSIONS: Women socio-economic differences play a critical role in access to health services. We recommend that awareness campaigns on the NHIS must be intensified. The Ghana Health Services through its Community-based Health Planning Service should carefully structure its home visits to cover education on pregnancy-related health services.

Can action research strengthen district health management and improve health workforce performance? A research protocol.

INTRODUCTION: The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome. METHODS: The overall aim of the PERFORM project is to identify ways of strengthening district management in order to address health workforce inadequacies by improving health workforce performance in SSA. The study will take place in three districts each in Ghana, Tanzania and Uganda using an action research approach. With the support of the country research teams, the district health management teams (DHMTs) will lead on planning, implementation, observation, reflection and redefinition of the activities in the study. Taking into account the national and local human resource (HR) and health systems (HS) policies and practices already in place, 'bundles' of HR/HS strategies that are feasible within the context and affordable within the districts' budget will be developed by the DHMTs to strengthen priority areas of health workforce performance. A comparative analysis of the findings from the three districts in each country will add new knowledge on the effects of these HR/HS bundles on DHMT management and workforce performance and the impact of an action research approach on improving the effectiveness of the DHMTs in implementing these interventions. DISCUSSION: Different challenges were faced during the development of the methodology. These include the changing context in the study districts, competing with other projects and duties for the time of district managers, complexity of the study design, maintaining the anonymity and confidentiality of study participants as well as how to record the processes during the study. We also discuss how these challenges are being addressed. The dissemination of this research protocol is intended to generate interest in the PERFORM project and also stimulate discussion on the use of action research in complex studies such as this on strengthening district health management to improve health workforce performance.

An exploratory study of physical activity and over-weight in two senior high schools in the Accra Metropolis.

BACKGROUND: Overweight and physical inactivity are major risk factors for non-communicable diseases. However, little evidence on physical activity, and overweight exists to support intervention in specific sub-populations including adolescents in low-income settings like Ghana. This study aimed at estimating overweight and determining the pattern and level of physical activity among senior high school students in the Accra Metropolis. METHODS: A cross-sectional study was conducted in the Accra Metropolis, among senior high school students, ages 15 to 19 years. Participants were selected using a two-stage cluster sampling technique. Structured questionnaire and anthropometric measurement were employed to gather information for the study. Students were considered as overweight if their Body Mass Index (BMI) ≥ +1SD, and obese if BMI ≥ +2SD. RESULTS: Out of 444 students, 17% were classified as engaging in low level physical activity, 49% in moderate activity, and 34% in high level of physical activity. Much of the activity in boys was recreational while among girls, was due to domestic chores. The prevalence of overweight was 11.7%. Overweight prevalence was higher among female students (15.6%) compared to 4.5% in males. Furthermore the risk of overweight was lower among students who engaged in high physical activity than those engaged in low activity. Overweight was independently associated with physical activity (p=0.01), sex (p=0.001) and age (p=0.01), after controlling for age sex and physical activity and diet. CONCLUSION: Majority of students in the study engaged in moderate to high physical activity. The prevalence of overweight was 11.7%. Physical activity was significantly related to overweight among students in the study.

Sexual harassment in public medical schools in Ghana.

OBJECTIVE: This study investigated the prevalence and incidence of Traditional (where a person in a position of power harasses a subordinate) and contra power sexual harassment, (where a subordinate is the harasser of authority figure) in medical schools in Ghana. among. DESIGN: Cross-sectional study. METHOD: Four hundred and nine medical students from four medical schools in Ghana were interviewed. We also considered if academic and financial dependence would predict either traditional or contra power sexual harassment. We further investigated, whether women were more bothered by sexual harassment than men and the correlation between sexual harassment and health. RESULTS: Women were 61% more likely to be sexually harassed than men 39%. Sexual harassment negatively affects the victims' health outcome. We found that the traditional form of sexual harassment was prevalent in medical schools in Ghana and that academic dependence predicted attacks. In the first and second years, women at these institutions are more likely to be sexually harassed than men. CONCLUSION: Sexual harassment policies of medical school need to be widely circulated. The various medical schools should provide reporting procedures and counseling for victims. This paper would inform policy and research.

Phosphine resistance in Tribolium castaneum and Rhyzopertha dominica from stored wheat in Oklahoma.

Phosphine gas, or hydrogen phosphide (PH3), is the most common insecticide applied to durable stored products worldwide and is routinely used in the United States for treatment of bulk-stored cereal grains and other durable stored products. Research from the late 1980s revealed low frequencies of resistance to various residual grain protectant insecticides and to phosphine in grain insect species collected in Oklahoma. The present work, which used the same previously established discriminating dose bioassays for phosphine toxicity as in the earlier study, evaluated adults of nine different populations of red flour beetle, Tribolium castaneum (Herbst), and five populations of lesser grain borer, Rhyzopertha dominica (F.) collected from different geographic locations in Oklahoma. One additional population for each species was a laboratory susceptible strain. Discriminating dose assays determined eight out of the nine T. castaneum populations, and all five populations of R. dominica, contained phosphine-resistant individuals, and highest resistance frequencies were 94 and 98%, respectively. Dose-response bioassays and logit analyses determined that LC99 values were approximately 3 ppm for susceptible and 377 ppm for resistant T. castaneum, and approximately 2 ppm for susceptible and 3,430 ppm for resistant R. dominica. The most resistant T. castaneum population was 119-fold more resistant than the susceptible strain and the most resistant R. dominica population was over 1,500-fold more resistant. Results suggest a substantial increase in phosphine resistance in these major stored-wheat pests in the past 21 yr, and these levels of resistance to phosphine approach those reported for other stored-grain pest species in other countries.

Hospital all-risk emergency preparedness in Ghana.

OBJECTIVE: This paper assessed the emergency preparedness programs of health facilities for all-risks but focused on Road Traffic Accidents, (RTA) resulting in surge demand. It adopted W. H. O checklist covering hospital preparedness, equipment, manpower and surge capacity planning as best practices for the mitigation of public health emergencies. METHOD: This is a cross-sectional study of purposively selected health facilities. The method used consisted of site visit, questionnaire survey, literature and internet review. The W. H. O. standard for emergency preparedness of health facilities was used to evaluate and assess the nation's hospitals surge capacity programs. The study was conducted between March-June, 2010. A total of 22 district and regional health facilities including teaching hospitals participated in the study. All 10 regions of the country were covered. RESULT: These were: (1) many of the nation's hospitals were not prepared for large RTA's resulting in surge demands, and did not possess general emergency preparedness programs. (2) The hospitals' respective abilities to handle large scale RTA's were compromised by the lack of competent medical and allied health personnel and adequate supplies. DISCUSSION: The inadequacies of the hospital system in responding to emergencies raise serious public health concerns. The biggest challenge facing the hospitals in their emergency intervention is the lack of pre-emergency and emergency preparedness plans as well as the coordination of the hospitals response mechanisms. CONCLUSION: The paper ended with recommendations on how the nation's hospitals and their supervisory agencies could improve emergency preparedness.

Effectiveness of sulfuryl fluoride for control of different life stages of stored-product psocids (Psocoptera).

With the phase-out and impending ban of methyl bromide, sulfuryl fluoride is among the most promising alternative fumigant insecticides for control of stored-product insect pests. It has been evaluated for control of several stored-product insect pests, but there are few data available on its efficacy for control of stored-product psocids (Psocoptera). We evaluated sulfuryl fluoride for control of different life stages of the psocids Liposcelis paeta Pearman, L. entomophila (Enderlein), L. bostrychophila Badonnel, L. decolor Pearman, and Lepinotus reticulatus Enderlein (Trogiidae) in 48-hr trials at 27.5 degrees C. Adults and nymphs were susceptible to sulfuryl fluoride. Complete (100%) adult and nymphal mortality was recorded at concentrations between 4 and 8 g/m3, except for L. decolor for which all adults were only killed at 24 g/m3. Eggs were tolerant to sulfuryl fluoride. Complete egg mortality was achieved at 24 and 72 g/m3 for L. reticulatus and L. decolor, respectively. Survival of L. paeta eggs was recorded even after exposure to 96 g/m3. Given that the highest United States label concentration for sulfuryl fluoride for a 48-h exposure interval is 31.25 g/m3, our study indicates that high doses and/or longer exposures are needed for complete mortality of eggs of L. decolor and L. paeta. Moreover, the present work suggests that there is considerable variation in efficacy of sulfuryl fluoride for control of different psocid species.

Improving medical records filing in a municipal hospital in Ghana.

BACKGROUND: Medical records are kept in the interest of both the patient and clinician. Proper filing of patient's medical records ensures easy retrieval and contributes to decreased patient waiting time at the hospital and continuity of care. This paper reports on an intervention study to address the issue of misfiling and multiple patient folders in a health facility. DESIGN: Intervention study. SETTING: Municipal Hospital, Goaso, Asunafo North District, Brong Ahafo Region, Ghana. METHODS: Methods employed for data collection were records review, direct observation and tracking of folders. Interventions instituted were staff durbars, advocacy and communication, consultations, in-service trainings, procurement and monitoring. Factors contributing to issuance of multiple folders and misfiling were determined. Proportion of multiple folders was estimated. RESULTS: Results revealed direct and indirect factors contributing to issuance of multiple patient folders and misfiling. Interventions and monitoring reduce acquisition of numerous medical folders per patient and misfiling. After the intervention, there was significant reduction in the use of multiple folders (i.e., overall 97% reduction) and a high usage of single patient medical folders (i.e., 99%). CONCLUSION: In conclusion, a defined medical records filing system with adequate training, logistics and regular monitoring and supervision minimises issuance of multiple folders and misfiling.

Challenges in provider payment under the Ghana National Health Insurance Scheme: a case study of claims management in two districts.

UNLABELLED: In 2004, Ghana started implementing a National Health Insurance Scheme (NHIS) to remove cost as a barrier to quality healthcare. Providers were initially paid by fee - for - service. In May 2008, this changed to paying providers by a combination of Ghana - Diagnostic Related Groupings (G-DRGs) for services and fee - for - service for medicines through the claims process. OBJECTIVE: The study evaluated the claims management processes for two District MHIS in the Upper East Region of Ghana. METHODS: Retrospective review of secondary claims data (2008) and a prospective observation of claims management (2009) were undertaken. Qualitative and quantitative approaches were used for primary data collection using interview guides and checklists. The reimbursements rates and value of rejected claims were calculated and compared for both districts using the z test. The null hypothesis was that no differences existed in parameters measured. FINDINGS: Claims processes in both districts were similar and predominantly manual. There were administrative capacity, technical, human resource and working environment challenges contributing to delays in claims submission by providers and vetting and payment by schemes. Both Schemes rejected less than 1% of all claims submitted. Significant differences were observed between the Total Reimbursement Rates (TRR) and the Total Timely Reimbursement Rates (TTRR) for both schemes. For TRR, 89% and 86% were recorded for Kassena Nankana and Builsa Schemes respectively while for TTRR, 45% and 28% were recorded respectively. CONCLUSION: Ghana's NHIS needs to reform its provider payment and claims submission and processing systems to ensure simpler and faster processes. Computerization and investment to improve the capacity to administer for both purchasers and providers will be key in any reform.

Ethics and electronic health information technology: challenges for evidence-based medicine and the physician-patient relationship.

OBJECTIVES: The National Health Insurance Scheme (NHIS), and the National Identification Authority (NIA), pose ethical challenges to the physician-patient relationship due to interoperability. This paper explores (1) the national legislation on Electronic Health Information Technology (EHIT), (2) the ethics of information technology and public health and (3) the effect on the Physician-patient relationship. METHOD: This study consisted of systematic literature and internet review of the legislation, information technology, the national health insurance program, and the physician-patient relationship. RESULT: The result shows that (1) EHIT have eroded a big part of the confidentiality between the physician and patient; (2) The encroachment on privacy is an inevitable outcome of EHIT; (3) Legislation on privacy, the collection, storage and uses of electronic health information is needed and; (4) the nexus between EHIT, NHIS, NHA, Ethics, the physician-patient relationship and privacy. CONCLUSION: The study highlights the lack of protection for physician-patient relationship as medical practice transitions from the conventional to the modern, information technology driven domain.

Economic burden of motorcycle accidents in Northern Ghana.

BACKGROUND: Motorcycles are the most popular means of transportation in northern Ghana, and their accidents are major causes of out-patient attendance and admissions in the Bolgatanga Municipality. OBJECTIVE: This paper estimates the economic burden of motorcycle accidents in the Bolgatanga Municipality in Northern Ghana. DESIGN: Retrospective cross-sectional cost study. METHODS: Data were collected from Drivers and Vehicle Licensing Authority, the Police, health facilities and motorcycle accident victims. Both quantitative and qualitative approaches were used for data collection. Cost analysis was based on the standard road accident cost conceptual framework. RESULTS: Ninety-eight percent of vehicles registered in the municipality in 2004 - 2008 were motorcycles. The motorcycles were significantly more than the cars registered. The economic burden of motorcycle accidents was estimated to be about US$1.2 million, of which, 52% were accident-related costs (i.e. property damage and administration) and 48% casualty-related costs (i.e. medical costs, out-of-pocket expenses, lost labour outputs, intangible costs and funeral expenses). Most motorcycle accident victims were in their productive ages and were males. Only a third of the motorcycles were insured. Majority of the riders (71%) did not possess valid driving license and would want to avoid the police. Main motorcycle injuries were head injuries, fractures, lacerations and contusions. Majority of the accidents were caused by lack of formal motorcycle riding training, abuse of alcohol, unrestrained animals and donkey carts. CONCLUSION: Motorcycle accidents could be reduced through law enforcement, continuous mass education and helmet use.