Economic burden and coping mechanisms by tuberculosis treatment supporters: a mixed method approach from Bono Region, Ghana.

BACKGROUND: The Directly Observed Therapy Short Course (DOTS) strategy recommended by World Health Organization for tuberculosis control requires multiple clinic visits which may place economic burden on treatment supporters especially those with low socio-economic status. The End tuberculosis goal targeted eliminating all tuberculosis associated costs. However, the economic burden and coping mechanisms by treatment supporters is unknown in Ghana. OBJECTIVES: The study determined the economic burden and coping mechanism by treatment supporters in Bono Region of Ghana. METHODS: Cross-sectional study using mixed method approach for data collection. For the quantitative data, a validated questionnaire was administered to 385 treatment supporters. Sixty in-depth interviews with treatment supporters to elicit information about their coping mechanisms using a semi-structured interview guide for the qualitative data. Descriptive statistics, costs estimation, thematic analysis and bivariate techniques were used for the data analysis. RESULTS: Averagely, each treatment supporter spent GHS 112.4 (US$21.1) on treatment support activities per month which is about 19% of their monthly income. Borrowing of money, sale of assets, used up saving were the major coping mechanisms used by treatment supporters. Highest level of education, household size, marital status and income level significantly influence both the direct and indirect costs associated with tuberculosis treatment support. The significant levels were set at 95% confidence interval and p < 0.05. CONCLUSION: We concludes that the estimated cost and coping mechanisms associated with assisting tuberculosis patients with treatment is significant to the tuberculosis treatment supporters. If not mitigated these costs have the tendency to worsen the socio-economic status and future welfare of tuberculosis treatment supporters.

Determinants of tuberculosis treatment support costs to the treatment supporters in rural Ghana.

Background: The Ghana Health Service has been implementing the Directly Observed Therapy Short Course (DOTS) strategy for decades now, to cure and reduce the transmission of tuberculosis. DOTS strategy requires TB patients and their treatment supporters to make multiple clinic visits in the course of treatment, and this may place financial burden on treatment supporters with low socio-economic status. However, the determinants of tuberculosis treatment support costs to treatment supporters are unknown in Ghana. Objectives: This study determined the costs associated with treatment support to the treatment supporters in Bono Region, Ghana. Methods: In a cross-sectional study using cost-of-illness approach, 385 treatment supporters were selected and interviewed. A validated questionnaire for the direct and indirect costs incurred was used. Descriptive statistics and bivariate techniques were used for data analysis. Results: Averagely, each treatment supporter spent GHS 122.4 (US$ 21.1) on treatment support activities per month, which is about 19% of their monthly income. The findings also revealed that highest level of education, household size, monthly income and district of residence were significant predictors of the direct costs. On the other hand, gender of the respondents, highest level of education, ethnicity, household size, income level and relationship with patient were some of the factors that significantly influenced the indirect costs. The significance levels were set at a 95% confidence interval and p < 0.05. Conclusion: The study concludes that the estimated cost associated with assisting tuberculosis patients with treatment is significant to treatment supporters. If these costs are not mitigated, they have the tendency of affecting the socio-economic status and welfare of individuals assisting tuberculosis patients with treatment.

Power sources among district health managers in Ghana: a qualitative study.

BACKGROUND: In Ghana district directors of health services and district hospital medical superintendents provide leadership and management within district health systems. A healthy relationship among these managers is dependent on the clarity of formal and informal rules governing their routine duties. These rules translate into the power structures within which district health managers operate. However, detailed nuanced studies of power sources among district health managers are scarce. This paper explores how, why and from where district health directors and medical superintendents derive power in their routine functions. METHODS: A multiple case study was conducted in three districts; Bongo, Kintampo North and Juaboso. In each case study site, a cross-sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and 61 participants for interview and focus group discussion. A total of 11 interviews (3 in each district and 2 with deputy regional directors), and 9 focus group discussions (3 in each district) were conducted. Transcriptions of the voice-recordings were done verbatim, cleaned and imported into the Nvivo version 11 software for analysis using the inductive content analysis approach. RESULTS: The findings revealed that legitimacy provides formal power source for district health managers since they are formally appointed by the Director General of the Ghana Health Service after going through the appointment processes. These appointments serve as the primary power source for district health managers based on the existing legal and policy framework of the Ghana Health Service. Additionally, resource control especially finances and medical dominance are major informal sources of power that district health managers often employ for the management and administration of their functional areas in the health districts. CONCLUSIONS: The study concludes that district health managers derive powers primarily from their positions within the hierarchical structure (legitimacy) of the district health system. Secondary sources of power stems from resource control (medical dominance and financial dominance), and these power sources inform the way district health managers relate to each other. This paper recommends that district health managers are oriented to understand the power dynamics in the district health system.

Facilitators and Barriers to Health Seeking among People Who Use Drugs in the Sunyani Municipality of Ghana: An Exploratory Study.

Drug use is one of the global public health issues, and its accompanying disorders have consequences on people's mental, physical, and environmental health. Nevertheless, the majority of people who use drugs have never been treated for drug dependence and other health conditions whilst others discontinue their treatment for drug use disorder. Using the health belief model, the study aimed at exploring facilitators and barriers to health-seeking among people who use drugs in the Sunyani Municipality of Ghana. A descriptive study design was used, employing a qualitative approach. In-depth interviews were conducted with a total of 22 participants, including two key informants (male and female). The first group of participants was recruited from the ghetto (an area in the municipality where people who use drugs are usually located). The other group of participants was recruited using hospital-based records. The interview data were transcribed, coded, and analysed for the generation of themes with the aid of Nvivo version 12 pro. The results showed that people who use drugs face health challenges such as drug dependence, malaria, lungs and breathing complications, cardiovascular complications, and skin complications. People who use drugs experienced poor perceived quality of life and low health status. Health-seeking behaviours of interviewees were influenced by the perceived benefit, perceived severity, cues to action, among others. Multiple sources of healthcare were used by the people who use drugs. Whereas ease of communication, perceived severity, benefit, among others were facilitators to their health-seeking behaviours, cost, dwindling social support, lack of knowledge of the condition, and fear of arrest by law enforcement agencies also served as barriers to seeking healthcare at the orthodox health facilities. This paper suggests a holistic approach to help improve the health and health-seeking behaviours of people who use drugs. The researchers wish to indicate that an earlier version of this manuscript has been presented at the University of Ghana as a thesis.

Rural healthcare providers coping with clinical care delivery challenges: lessons from three health centres in Ghana.

BACKGROUND: Rural settings in low- and middle-income countries are bedeviled with poverty and high disease burden, and lack adequate resources to deliver quality healthcare to the population. Drug shortage and inadequate number and skill-mix of healthcare providers is very common in rural health facilities. Hence, rural healthcare providers have no choice but to be innovative and introduce some strategies to cope with health delivery challenges at the health centre levels. This study explored how and why rural healthcare providers cope with clinical care delivery challenges at the health centre levels in Ghana. METHODS: This study was a multiple case studies involving three districts: Bongo, Kintampo North, and Juaboso districts. In each case study district, a cross-sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and the study participants. The authors conducted 11 interviews, 9 focus group discussions (involving 61 participants), and 9-week participant observation (in 3 health centres). Transcription of the voice-recordings was done verbatim, cleaned and imported into the Nvivo version 11 platform for analysis. Data was analysed using the inductive content analysis approach. Ethical clearance was granted by the Ethics Review Committee of the Ghana Health Service. RESULTS: The study found three main coping strategies (borrowing, knowledge sharing and multi-tasking). First, borrowing arrangements among primary health care institutions help to address the periodic shortage of medical supplies at the health centres. Secondly, knowledge sharing among healthcare providers mitigates skills gap during service delivery; and finally, rural healthcare providers use multi-tasking to avert staff inadequacy challenges during service delivery at the health centre levels. CONCLUSION: Borrowing, knowledge sharing, and multi-tasking are coping strategies that are sustaining and potentially improving health outcomes at the district levels in Ghana. We recommend that health facilities across all levels of care in Ghana and other settings with similar challenges could adopt and modify these strategies in order to ensure quality healthcare delivery amidst delivery challenges.

Maternal birth preparedness and complication readiness in the Greater Accra region of Ghana: a cross-sectional study of two urban health facilities.

BACKGROUND: High maternal mortality ratios remain a critical public health concern in Ghana. Birth preparedness and complication readiness (BP/CR), which is a component of focused antenatal care, is a safe motherhood strategy intended to promote skilled birth attendance by helping women and their families plan for pregnancy and childbirth, thereby reducing maternal mortality. The objective of this study was to determine the level of BP/CR and to assess factors associated with maternal BP/CR in the Greater Accra Region of Ghana. METHOD: A cross sectional descriptive quantitative study was carried out among 300 postnatal women attending the Adabraka Polyclinic and the Greater Accra Regional Hospital both within Accra, the capital city of Ghana. Data were collected with a structured questionnaire which assessed socio-demographic, health facility/provider and social support factors and their associations with BP/CR. Levels of BP/CR were assessed using validated tools. Data from 300 women were analyzed using STATA version 15.0. Logistic regression analysis was conducted to establish associations between BP/CR and socio-demographic, health facility/provider and social support factors. RESULTS: Approximately 234 (78%) of the women were birth prepared. Strong predictors of BP/CR included having ≥4 antenatal clinic visits (aOR 2.63; 95% CI 1.03-6.73), being employed (aOR 4.07; 95% CI 1.49-11.11) and belonging to maternal health promoting clubs or groups during the antenatal period (aOR 3.00; 95% CI 1.07-8.40) . CONCLUSION: BP/CR is generally high among the study population. Predictors of BP/CR are multifactorial and found to cut across all aspects assessed in the study. Therefore, the creation of a BP/CR tool is recommended to routinely monitor trends in maternal birth preparedness in antenatal clinics. This may help to sustain and improve current levels and indicators of BP/CR.

Access to a quality healthcare among prisoners - perspectives of health providers of a prison infirmary, Ghana.

PURPOSE: The purpose of this paper is to explore the influence of health system factors on access to a quality healthcare among prisoners in Ghana. DESIGN/METHODOLOGY/APPROACH: Data were gathered using different qualitative methods (interviews and participant observation) with staff of the James Camp Prison, Accra. Findings were analyzed using a framework method for the thematic analysis of the semi-structured interview data; and interpreted with the theoretical perspective of health systems thinking and innovation. FINDINGS: The study concludes that health system factors such as inadequate funding for health services, lack of skilled personnel and a paucity of essential medical supplies and drugs negatively affected the quality of healthcare provided to inmates. RESEARCH LIMITATIONS/IMPLICATIONS: The limited facilities available and the sample size (healthcare workers and prison administrators) impeded the achievement of varied views on the topic. PRACTICAL IMPLICATIONS: The paper recommends the need for health policy makers and authorities of the Ghana Prison Service to collaborate and coordinate in a unified way to undertake policy analysis in an effort to reform the prisons healthcare system. SOCIAL IMPLICATIONS: The national health insurance scheme was found to be the financing option for prisoners' access to free healthcare with supplementation from the Ghana Prison Service. The study recommends that policy makers and healthcare stakeholders should understand and appreciate the reality that the provision of a quality healthcare for prisoners is part of the entire system of healthcare service delivery in Ghana and as such should be given the needed attention. ORIGINALITY/VALUE: This is one of few studies conducted on male only prisoners/prison in the context of Ghana. It recommends the need for an integrated approach to ensure that the entire healthcare system achieves set objectives in response to the primary healthcare concept.

Modern contraceptive use among reproductive-aged women in Ghana: prevalence, predictors, and policy implications.

BACKGROUND: Modern contraceptive use remains an important public health intervention and a cost-effective strategy to reduce maternal mortality, avert unintended pregnancies and to control population explosion, especially in developing countries. Despite these benefits, there are reports of low usage among reproductive-aged women in most developing countries. This study examined the prevalence and predictors of use of modern contraceptive among reproductive-aged women in an urban center with a high density population in Ghana. METHODS: A cross-sectional, interviewer-administered survey was conducted with 217 randomly selected reproductive-aged women. Data was analyzed with STATA. Logistic regression was performed to identify factors influencing modern contraceptive use. RESULTS: Although we found high levels of knowledge and awareness (98%; n = 213) of modern contraception use, only 21% of participants were using modern contraceptives. Marital status, partner consent and support, and religious beliefs strongly predicted usage. CONCLUSION: Usage of modern contraceptives among reproductive-aged women in the Ledzokuku Krowor Municipality is lower than the national target. A multilevel family planning intervention program that primarily focuses on promoting inclusive participation of husbands, targets the unmarried and non-literates reproductive-aged women, and dispels misconceptions, misinformation and religious myths about modern contraceptives has been discussed.

Relationship marketing strategy.

Purpose The purpose of this paper is to explore how strategies are put in place to formulate policies regarding the introduction and implementation of relationship marketing (RM) in the health sector, and how RM strategies are designed as part of the curricula for the training of prospective health professionals in Ghana. Design/methodology/approach Data were gathered using interviews and documentary review. A purposive sampling technique was used to recruit policy makers and health educationists in Accra for in-depth interviews. Qualitative interviews were analysed using framework analysis. Findings The findings revealed that, currently, there is no policy framework on RM in the health sector nor included in the curricula of health training institutions in the country. Research limitations/implications Due to limited time and funding constraints, the study could not include many policy makers, educationists, health providers, facilities and regions outside the Greater Accra region of Ghana. This means that the authors missed out on useful insights from other relevant policy makers/educationists who would have added to the knowledge that this study contributes. There were still some areas that this study could not cover, including the lack of an exploration of the perceptions of health providers and patients. Practical implications Evidence from the current research provides the basis for scaling up of a similar study to the whole country to address the perennial RM or quality of care/patient satisfaction issues persisting in health facilities in the country. The outcome of this large-scale study would help to confirm the findings of the current study on the adoption and incorporation of RM into both policy framework and curricula of health training institutions in Ghana. The findings would culminate in the preparation and utilisation of guidelines on RM for client-centred service delivery in the health sector of the country. Social implications This paper argues that RM orientation could enable health professionals to improve upon their healthcare service performance and quality of care so as to enhance patient satisfaction. Originality/value The study recommends that RM should be adopted by health policy makers and designers of curricula for health training institutions.

The role of government and community in the scaling up and sustainability of mutual health organisations: An exploratory study in Ghana.

Governments of many developing countries, including those in Sub-Saharan Africa have embraced the community-based health insurance schemes phenomenon under the health sector reforms with optimism. Ghana has introduced a National Health Insurance Scheme, which is amalgamated with social health insurance and community-based health insurance schemes. The aim of this study was to explore the role of the Ghana government and community in the scaling-up and sustainability of mutual health organisations. Four district mutual health insurance schemes were selected using geographical locations, among other criteria, as case studies. Data were gathered through interviews and documentary/literature review. The findings of the empirical study were analysed and interpreted using social policy and community field theories. The findings of the paper suggest that in order to ensure their effective scaling up and maintain overall sustainability, there is the need for some form of government regulation and subsidy. However, since government regulation cannot work without the acceptance of the community, there is the need to integrate these actors in policy formulation.

"When I am with my husband, I do not feel mosquito bite".

Purpose The purpose of this paper is to explore how socio-cultural beliefs and practices could influence the knowledge, attitude and perception of insecticide-treated net (ITN) use in the control of malaria amongst pregnant women attending antenatal clinic. Design/methodology/approach Data were gathered using interviews and documentary review. Framework analysis was applied to classify emerging themes and the findings interpreted using the health belief model. Findings The findings showed that the pregnant women had appreciable knowledge, both the positive and negative attitudes and the perceptions of insecticide treated nets. To most of them, sleeping under an ITN would not affect pregnancy/cause abortion, but rather prevent mosquito bites and associated malaria. Research limitations/implications The limitations include the sample size of participants and health facilities used. Lack of application of a quantitative research method meant that the authors could not quantify the findings to ensure generalisation to the entire population. Practical implications The findings suggest that health policy makers, implementers and health professionals need to appreciate the perception and the attitude of pregnant women when designing policy guidelines for the malaria control programme. Social implications This paper helps to elucidate on how socio-cultural beliefs and practices could influence the knowledge, attitude and perception of ITN usage amongst both pregnant women and people in malaria endemic communities. Originality/value This paper suggests that health policy makers, implementers and health professionals have to devise strategies to address socio-cultural beliefs and practices in the scaling up of malaria control programmes.

Health providers' perception of quality of care for neonates in health facilities in a municipality in Southern Ghana.

Purpose The purpose of this paper is to assess available human resources for neonatal care and their skills, in order to explore health providers' perceptions of quality of neonatal care in health facilities in Ghana. Design/methodology/approach Data were gathered using qualitative interviews with health providers working in the maternity and paediatric wards and midwives; direct observation; and documentary review at a regional hospital, a municipal hospital and four health centres in a municipality in a region in Southern Ghana. Data were analysed using thematic framework through the process of coding in six phases to create and establish meaningful patterns. Findings The study revealed that health providers were concerned about the number of staff available, their competence and also equipment available for them to work more efficiently. Some essential equipment for neonatal care was either not available or was non-functional where it was available, while aseptic procedures were not adhered to. Moreover, personal protective equipment such as facemask, caps, aprons were not used except in the labour wards where staff had to change their footwear before entering. Research limitations/implications Limited number of health providers and facilities used, lack of exploration of parents of neonates' perspective of quality of neonatal care in this study and other settings, including the teaching hospitals. The authors did not examine issues related to the ineffective use of IV cannulation for neonates by nurses as well as referral of neonates. Additionally, the authors did not explore the perspectives of management of the municipal and regional health directorates or policy makers of the Ministry of Health and Ghana Health Service regarding the shortage of staff, inadequate provision of medical equipment and infrastructure. Practical implications This paper suggests the need for policy makers to redirect their attention to the issues that would improve the quality of neonatal health care in health facilities in Ghana and in countries with similar challenges. Social implications The study found that the majority of nursing staff catering for sick newborns were not trained in neonatal nursing. Babies were found sleeping in separate cots but were mixed with older children. The study suggests that babies should be provided with a separate room and not mixed with older babies. Originality/value There seemed to be no defined policy framework for management of neonatal care in the country's health care facilities. The study recommends the adoption of paediatric and neonatal care nursing as a specialty in the curricula of health training institutions. In-service trainings should encompass issues related to management of sick babies, care of preterm babies, neonatal resuscitation and intravenouscannulation, among others.

The contribution of community leadership upon the performance of mutual health organisations in Ghana.

PURPOSE: The purpose of this paper is to investigate the effect of social dynamics on the performance of mutual health organisations (MHOs) exploring the influence of community wealth and community leadership on policy implementation. DESIGN/METHODOLOGY/APPROACH: Four operating district mutual health insurance schemes were selected using geographical locations, among other criteria, as case studies. Data were gathered through interviews and documentary review. The findings were analysed using community field and social capital theories. FINDINGS: Traditional leaders like the Chiefs serve as the pivot around which social and human capital of the communities revolve in the developmental process of the country. RESEARCH LIMITATIONS/IMPLICATIONS: Lack of exhaustive examination of the financial and institutional viability issues of the MHOs. Future studies could assess the interplay between financial, institutional and social viability models when measuring the financial and overall sustainability of MHOs. PRACTICAL IMPLICATIONS: Health policy makers need to involve traditional leaders in the formulation and implementation of national policies since their acceptance or rejection of central government policy could have negative consequences. SOCIAL IMPLICATIONS: Ghana is a dynamic country and there is the need to utilise existing social networks: inter-family and inter-tribal relationships to ensure the viability of MHOs. ORIGINALITY/VALUE: There is and can be a successful interplay between public sector funding and community sector revenue mobilisation for financing the health sector in Ghana. This justifies the complementarity between government funding and community's resource mobilisation efforts in the health sector.

The challenges to performance and sustaining mutual health organisations/health institutions: an exploratory study in Ghana.

PURPOSE: The purpose of this paper is to explore challenges to the performance and sustainability of mutual health organisations (MHOs) and health institutions towards enhancing access to quality health care (HC) in Ghana. DESIGN/METHODOLOGY/APPROACH: Data were gathered through interviews and documentary review. FINDINGS: Problems with late release of reimbursement funds for discharging with claims by the central government has impacted heavily on the financial and strategic management and decision-making processes of the MHOs and health institutions. RESEARCH LIMITATIONS/IMPLICATIONS: The lack of in-depth analysis of the financial viability of the MHOs; and the limited number of schemes selected. PRACTICAL IMPLICATIONS: Recommends the need to ensure prompt release of reimbursement funds by government to enable the MHOs to reimburse claims to health institutions. SOCIAL IMPLICATIONS: There is a perceived tension between the MHOs and HC institutions due to late release of reimbursement funds by the government. ORIGINALITY/VALUE: Contributes to understanding of how the NHI Act influences the operations of MHOs and health institutions towards increasing access to quality HC and financing.