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.

Perinatal outcomes after hypertensive disorders in pregnancy in a low resource setting.

OBJECTIVE: The objective of this study was to evaluate perinatal outcomes of pregnancies complicated by hypertensive disorders in pregnancy in an urban sub-Saharan African setting. METHODS: A prospective cohort study of 1010 women of less than 17 weeks of gestation was conducted at two antenatal clinics in Accra, Ghana, between July 2012 and March 2014. Information about hypertensive disorders was available for analysis on 789 pregnancies. The main outcomes were pre-term birth, birthweight, Apgar scores, small for gestational age and mortality. Relative risk (RR, 95% confidence interval (CI)) for the association between hypertensive disorders of pregnancy and perinatal outcomes was assessed using logistic regression adjusting for potential confounders. RESULTS: A total of 88.7% of women remained normotensive, 7.5% developed pregnancy-induced hypertension, 2.0% had chronic hypertension, and 1.7% developed (pre-)eclampsia. No adverse effects were observed in women with pregnancy-induced hypertension. Women with chronic hypertension were more likely to have a lower gestational age at delivery (38.0 ± 2.3 weeks vs. 39.0 ± 1.9 weeks, P = 0.04) and higher risk of pre-term delivery (aRR 4.63, 95% CI 1.35-15.91). Women with pre-eclampsia had emergency Caesarean section significantly more often (88.9% vs. 50%, P = 0.04), with a higher risk for low birthweight infants (aRR 7.95, 95% CI 1.41-44.80) and a higher risk of neonatal death (aRR 18.41, 95% CI 1.20-283.22). CONCLUSION: Comparable to high-income countries, in Accra hypertensive disorders during pregnancy were associated with increased risk of adverse perinatal outcomes necessitating maternal and newborn care.

A systems view and lessons from the ongoing Ebola Virus Disease (EVD) outbreak in West Africa.

This article analyses the on-going (2014) Ebola Virus Disease (EVD) outbreak in West Africa from a systems perspective; and draws out lessons for West Africa in general and Ghana in particular.

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.

Pregnancy-associated malaria in a rural community of ghana.

OBJECTIVES: Pregnant women in malaria-endemic communities are susceptible to Plasmodium falciparum infections, with adverse consequences including maternal anaemia, placental malaria parasitaemia and infant low birth weight (LBW). We sought to assess the prevalence, incidence, and clinical markers of pregnancy-associated malaria (PAM) in a rural district of Ghana. METHODS: A total of 294 pregnant women were enrolled and followed passively and actively, monthly and weekly until delivery. Haemoglobin levels, malaria parasitaemia and Hb electrophoresis were done from peripheral blood samples. At delivery, placental smears were examined for malaria parasites. RESULTS: Prevalence of peripheral blood P. falciparum parasitaemia at enrolment was 19.7% and related to parity. Incidence rate of parasitaemia was 0.06 infections/ person/month [95% confidence interval (CI): 0.04 to 0.08]. Symptomatic infections rose sharply from the first trimester to the last. Prevalence of malaria parasites in the placenta was 35.9% (61/170) and highest among primigravidae (P(chi(2))=0.006). Incidence of LBW infants was 17.7% (30/170), most common among those with placental P. falciparum infection (P(chi(2))=0.005) corresponding to a relative risk of 2.8 [1.4 to 5.2]. Median infant birth weight in those with placental infection was significantly lower than in those without infections (P(chi(2))=0.001). Maternal haemoglobin levels were lower (9.7 [9.3-10.1] g/dL) at enrolment, among women who subsequently had placental P. falciparum infection than among those who did not have placental infection at delivery (10.5 [10.2-10.8] g/dL) (P (t)=0.003). CONCLUSION: Primigravidae and secundigravidae are significantly at risk of developing PAM, and low haemoglobin during pregnancy is a clinical indicator of placental P. falciparum infection.

Management of mutual health organizations in Ghana.

OBJECTIVE: Mutual Health Organizations (MHO) emerged in Ghana in the mid-1990s. The organizational structure and financial management of private and public MHO hold important lessons for the development of national health insurance in Ghana, but there is little evidence to date on their features. This paper aims at filling this data gap, and at making recommendations to Ghanaian authorities on how to stimulate the success of MHO. METHODS: Survey among 45 private and public MHO in Ghana in 2004-2005, asking questions on their structure, financial management and financial position. RESULTS: Private MHO had more autonomy in setting premiums and benefit packages, and had higher community participation in meetings than public MHO. MHO in general had few measures in place to control moral hazard and reduce adverse selection, but more measures to control fraud and prevent cost escalation. The vast majority of schemes were managed by formally trained and paid staff. The financial results varied considerably. CONCLUSIONS: Ghanaian authorities regulate the newly established public MHO, but may do good by leaving them a certain level of autonomy in decision-making and secure community participation. The financial management of MHO is suboptimal, which indicates the need for technical assistance.

Improving access to early treatment of malaria: a trial with primary school teachers as care providers.

The feasibility of improving access to early case detection and prompt and adequate management of acute episodes of malaria using school teachers was explored through an intervention trial in Ghana. Of all the 'fevers' diagnosed as presumptive malaria by the trained teachers, 93% met the case definition. However, a lower proportion (75%) of such correctly diagnosed cases were subsequently treated according to the treatment protocol provided. In a scaled up study, pre-packaging of the antimalarial drug improved the rate of adequate treatment to 97% of cases correctly diagnosed as presumptive malaria. Pre-packaging of chloroquine ensured a high level of user compliance (96.6%), even in the face of diminished supervision of the teachers. It is feasible for the health and education sectors to work in partnership to improve access to early case detection and adequate management of acute episodes of malaria.

An evaluation of Health Workers for Change in seven settings: a useful management and health system development tool.

This paper presents the findings of a multi-centre study assessing the impact of Health Workers for Change (HWFC) workshops in seven different primary care sites, based on the common core protocol described in this paper. The paper discusses a common methodology used by the studies, consisting of a triangulation of qualitative and quantitative methods. Such methodologies are inherently complex as they require comparisons across systems, sites and procedures. The studies were conducted in six sites in Africa and one site in Argentina. Generally, the intervention resulted either in positive change or in no change, except in the area of staff relationships where conflicts were more frequent after the intervention than before. This may reflect a willingness to confront problems or contentious issues. Implementing the HWFC workshops improved provider-client relations, facility level functioning and aspects of staff interrelationships, and had some impact at the system level. All studies indicated that overall health system development is essential for improved service provision including quality of care. The findings also indicated that this intervention complemented and could assist health sector reform efforts and can play a role in sensitizing health workers to gender issues. The paper concludes with a discussion of the robustness of the methodology used in the studies.

Continuous quality improvement in public health in Ghana: CQI as a model for primary health care management and delivery.

This article describes the context and examines factors influencing the quality of primary health care delivery and management in Ghana, West Africa. It describes the potential of continuous quality improvement as a management philosophy and tool to improve the quality of primary health care delivery and management in Ghana. It compares the Ghanaian context in which the use of continuous quality improvement in health care is new and untried with the developed country context (mainly the U.S.), where continuous quality improvement has a relatively long history of use in health care and is a requirement for the accreditation of health institutions. Finally, the article discusses the steps that have to be taken to translate continuous quality improvement from a theoretical management concept to improve quality of care to an actual managerial intervention in Ghana. In conclusion, continuous quality improvement is shown to be a potential viable approach to improving quality of care in the Ghanaian context and merits further investigation.

Improving adherence to malaria treatment for children: the use of pre-packed chloroquine tablets vs. chloroquine syrup.

Malaria is a major cause of morbidity and mortality among children under five in sub-Saharan Africa. Prompt diagnosis and adequate treatment of acute clinical episodes are essential to reduce morbidity and prevent complications and mortality. In many countries, chloroquine syrup is the mainstay of malaria treatment for children under five. Not only is syrup more expensive than tablets, adherence to the prescribed dose at home is a problem because mothers use wrongly sized measuring devices or have difficulty with the instructions. We investigated the impact of introducing pre-packed tablets for children on adherence to treatment and compared the total cost of the tablets with that of syrup. Children aged 0--5 years diagnosed with malaria at the clinic over a 6-week period received either pre-packed tablets or syrup by random assignment. The principal caregivers were interviewed at home on day 4 after attending the clinic. Of the 155 caregivers given pre-packed tablets, 91% (n=141) adhered to the recommended dosage, while only 42% (n=61) of 144 who were provided syrup did. Only 20% of caregivers who received syrup used an accurate 5 ml measure. The cost of treatment with tablets was about one-quarter that of syrup and 62% (n=96) of caregivers preferred tablets. Pre-packed chloroquine tablets are a viable alternative to syrup.

Reforming health service delivery at district level in Ghana: the perspective of a district medical officer.

Many countries in sub-Saharan Africa face the problem of organizing health service delivery in a manner that provides adequate quality and coverage of health care to their populations against a background of economic recession and limited resources. In response to these challenges, different governments, including that of Ghana, have been considering or are in the process of implementing varying degrees of reform in the health sector. This paper examines aspects of health services delivery, and trends in utilization and coverage, using routine data over time in the Dangme West district of the Greater Accra region of Ghana, from the perspective of a district health manager. Specific interventions through which health services delivery and utilization at district level could be improved are suggested. Suggestions include raising awareness among care providers and health managers that increased resource availability is only a success in so far as it leads to improvements in coverage, utilization and quality; and developing indicators of performance which assess and reward use of resources at the local level to improve coverage, utilization and quality. Also needed are more flexibility in Central Government regulations for resource allocation and use; integration of service delivery at district level with more decentralized planning to make services better responsive to local needs; changes in basic and inservice training strategies; and exploration of how the public and private sectors can effectively collaborate to achieve maximum coverage and quality of care within available resources.

PIP: Many countries in sub-Saharan Africa are challenged to provide adequate health services to their populations in the context of economic recession and limited resources. In response to such challenges, a number of governments, including Ghana, are either considering or implementing health sector reforms. The authors examine aspects of health services delivery and trends in utilization and coverage, using routine data over time for the Dangme West district of the Greater Accra region of Ghana, from the perspective of a district health manager. Specific interventions through which health services delivery and use at the district level could be improved are suggested. Suggestions include explaining to care providers and health managers that increased resource availability is only successful insofar as it leads to improvements in coverage, use, and quality; and developing indicators of performance which assess and reward use of resources at the local level to improve service coverage, use, and quality. Central government regulations also need to be more flexible with regard to resource allocation and use, the integration of service delivery at the district level with more decentralized planning to make services more responsive to local needs, changes in basic and in-service training strategies, and research into how the public and private sectors can effectively collaborate to achieve maximum coverage and quality of care using available resources.

Mosquito avoidance and bed net use in the Greater Accra Region, Ghana.

Qualitative research and cross-sectional survey methods were used in a study conducted in rural and urban areas of the Greater Accra Region, Ghana, to explore people's understanding of the cause of malaria and patterns of mosquito avoidance, in particular bed net ownership and use. The study indicated far higher bed net ownership and use in rural than urban areas, which was related partly to perceived affordability and partly to the different contexts of and reasons for avoiding mosquitoes. Knowledge of an association between mosquitoes and malaria, the most common cause of illness in both areas, was related to residence but not to literacy or formal education, and this knowledge did not predict bed net use. The paper points to the complexity of social and personal factors implicated in behavioural interventions for malaria control, and questions behavioural models that assume a linear relationship between knowledge and practice.

PIP: In the absence of a vaccine or effective and sustainable means of vector control, public health interventions remain the main means of reducing the incidence of malaria. The most promising current intervention which both limits mosquito bites and kills the vector is the use of insecticide-impregnated bed nets and/or curtains. This paper reports data collected during field trials for the development of the Malaria Manual, conducted in August-September 1992. Qualitative research and cross-sectional survey methods were used in a study conducted in rural and urban areas of the Greater Accra Region, Ghana, to explore people's understanding of the cause of malaria and patterns of mosquito avoidance, especially bed net ownership and use. The level of bed net ownership and use was far higher in rural than urban areas. That difference was partly related to perceptions of affordability and partly to the different contexts of and reasons for avoiding mosquitoes. Knowledge of the existence of an association between mosquitoes and malaria, the most common cause of illness in both areas, was related to residence but not to literacy or formal education. That knowledge, however, did not predict bed net use. Different social and personal factors must be considered when behavioral interventions for malaria control are designed and implemented. Behavioral models which assume a linear relationship between knowledge and practice should be regarded with caution.

A comparative study of clinical and sociocultural aspects of anaemia among adolescent girls in rural Ghana.

This paper presents findings of an exploratory and comparative study of a farming and a fishing community of the Ga-Adangme ethnic group in Ghana, which investigated the prevalence of malaria and anaemia among adolescent girls (10-19 years), illness and community perceptions of blood, anaemia and malaria. In both communities blood is perceived as the source of life, strength and health of an individual. Members of both communities attributed anaemia to poor diet, fevers such as malaria, excessive external heat or hard work, flirting and excessive worry.

The diagnosis and management of fever at household level in the Greater Accra Region, Ghana.

> Qualitative research methods were used in rural and urban areas of the Greater Accra Region to generate data to describe the folk diagnosis, etiology and management of malaria. Respondents defined as fever a set of symptoms loosely concordant with clinical malaria. Primary cause of fever as heat and particularly in rural areas, an understanding of the role of mosquitos in transmitting fever was limited. First- and second-line treatments adopted by caretakers, when either they or their children were sick, involved considerable self-medication with chloroquine and paracetamol. Ethnographic data were supplemented and tested for generalizability through a cross-sectional survey, and the paper discusses this methodological approach.

PIP: In the course of developing a manual for the rapid ethnographic assessment of social and cultural aspects of malaria, community understandings, diagnosis, and treatment of malaria in Ghana were explored through limited focused ethnographic research supplemented by a cross-sectional survey. The research took place during August-September 1992 and November 1992-January 1993 and involved urban and rural residents of two sub-districts of the Greater Accra Region. In both regions, residents use the term "fever" for the set of symptoms that approximate the clinical definition of malaria. The symptoms of "fever" in children are tabulated for rural and urban respondents by order of frequency as are the symptoms in adults (which differ from those in children). Most respondents used two or more symptoms to diagnose "fever." The causes of "fever" are said to include heat exposure, diet, mosquitos, or unhygienic surroundings, and most survey respondents gave more than one cause. The fact that 33% of respondents mentioned mosquitos is in opposition to the qualitative data which indicate that rural Ghanians are unaware of the connection. Knowledge of the cause of malaria was a major point of difference between the urban and rural population, with more of the rural residents attributing it to the sun. The treatment given is very similar for children and adults in both areas. The primary first course of treatment is self-medication, including the use of pharmaceutical products such as paracetamol and chloroquine. When it becomes necessary, medical attention is sought, and adults expect injections for themselves. This delay in treatment is particularly significant for sick infants, because malaria remains a primary cause of death during the first year of life. This research indicates the necessity for health education and control program activities.

Persistent fever in severe malaria in children.

Plasmodium falciparum species with reduced susceptibility to chloroquine have emerged in West Africa since the mid 1980s. Local strains, however, remain sensitive to amodiaquine with peripheral parasite clearance achieved within seven days in the majority. Blood cultures from 33 children (aged two to 12 years), who remained pyrexial after clearance of their parasitaemia, isolated causative organisms in 19 (57.6 pc) samples, with Salmonella species the commonest (68.4 pc) of all isolates. Complicating septicaemia needs consideration and early institution of treatment with antibiotics in children with severe malaria. Persistent pyrexia in malaria is not always due to resistance to antimalarials in areas with recent emergence of chloroquine resistant strains. A combination of amodiaquine and cotrimoxazole is suggested as a useful initial treatment.

PIP: During May 1988 to August 1989, pediatricians enrolled 33 children aged 6 months to 12 years into a study to examine the role of septicemia in cases of severe malaria. The children had persistent fever (5 or more days) despite treatment with chloroquine and were admitted to the Department of Child Health of the University of Ghana Medical School in Accra with severe malaria (Plasmodium falciparum). At admission, all the children had malaria parasites in their blood films, 87.9% of whom had heavy peripheral parasitemia. Chloroquine cleared parasitemia within 3 days of treatment in only 33.3%. Treatment with oral amodiaquine followed when chloroquine failed to resolve the fever in 20 (60.6%) children. Children who still experienced fever then received intravenous (IV) penicillin and IV chloramphenicol over 7-14 days. Two (6.1%) children who died on days 5 and 13 still had a fever at death. 27.3% of all children had neurological complications. Pathogenic bacteria were isolated in 57.6% of all blood samples. Salmonella species were the most frequent species (68.4% of all isolates). These findings have motivated one of the clinical researchers to use a combination of oral amodiaquine (25 mg/kg) and co-trimoxazole to treat children with severe malaria and persistent fever.

Malaria: ethnomedical perceptions and practice in an Adangbe farming community and implications for control.

Malaria is a parasitic disease about which there is much bio-medical knowledge on causation, prevention, treatment and control. Attempts at eradication, as well as control in the past has been mainly a technical and bio-medical endeavour. With the policy shift from world wide eradication of malaria to control as part of primary health care, there is increasing interest in studying all possible determinants of the problem at local as well as regional levels as part of the search for an effective intervention. This paper presents the results of a study into community perceptions and practice relating to causation, treatment and prevention of malaria in a rural Adangbe farming community in Southern Ghana. Malaria is common in this community. Crude parasite rates among adolescent girls (10-19 years old) in the community were 49% towards the end of the major rainy season, and 47% in the early dry season. The symptoms and signs of the disease are readily described by lay people as well as traditional healers. Diagnosis and treatment of uncomplicated episodes of malaria at home, according to ethnomedical perceptions, is the predominant behaviour in this community. Very few cases of uncomplicated malaria are sent to health facilities. Ethnomedical perceptions of malaria causation and treatment on which this self care is based, are different from conventional biomedical ones. Malaria is perceived as an environmentally related disease caused by excessive contact with external heat which upsets the blood equilibrium. Many community members do not connect it with the mosquito in theory or practice. Implications for approaches to control are discussed.

Implementing the Bamako Initiative at community level

The Bamako Initiative was launched in 1987 by UNICEF and in 1989 the Ministry of Health; Ghana in conjunction with UNICEF decided to implement the initiative as the essential drug component of the government's Programme of Action to Mitigate the Social Cost of Adjustment (PAMSCAD)