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Background: Sub-Saharan Africa is unlikely to achieve sustainable development goal (SDG) 3 on maternal and neonatal health due to perceived sub-standard maternal and newborn care in the region. This paper sought to explore the opinions of stakeholders on intricacies dictating sub-standard emergency obstetric and newborn care (EmONC) in health facilities in Northern Ghana. Methods: Drawing from a qualitative study design, data were obtained from six focus group discussions (FGDs) among 42 health care providers and 27 in-depth interviews with management members, clients and care takers duly guided by the principle of data saturation. Participants were purposively selected from basic and comprehensive level facilities. Data analysis followed Braun and Clarke's qualitative thematic analysis procedure. Results: Four themes and 13 sub-themes emerged as root drivers to sub-standard care. Specfically, the findings highlight centralisation of EmONC, inadequate funding, insufficient experiential training, delay in recruitment of newly trained essential staff and provider disinterest in profession. Conclusion: Setbacks in the training and recruitment systems in Ghana, inadequate investment in rural health coupled with extent of health provider inherent disposition to practice may be partly responsible for sub-standard obstetric care in the study area. Interventions targeting the afore-mentioned areas may reduce events of sub-standard care. What is already known on this subject?: Quality of emergency obstetric and newborn care is sub-standard in sub-Saharan Africa. What this study adds?: Sub-standard emergency obstetric and newborn care in rural Ghana may be due to hitches in placement, training and recruitment processes, centralisation of EmONC, inadequate funding, insufficient experiential training, delay in posting of newly trained essential staff and provider disinterest in profession. Adequate and timely resourcing of health facilities and standardisation of admission procedures into schools may reduce events of sub-standard care. [ABSTRACT FROM AUTHOR]

Background: The National Health Insurance Scheme (NHIS) was launched in Ghana in 2003 with the main objective of increasing utilisation to healthcare by making healthcare more affordable. Previous studies on the NHIS have repeatedly highlighted that cost of premiums is one of the major barriers for enrollment. However, despite introducing premium exemptions for pregnant women, older people, children and indigents, many Ghanaians are still not active members of the NHIS. In this paper we investigate why there is limited success of the NHIS in improving access to healthcare in Ghana and whether social exclusion could be one of the limiting barriers. The study explores this by looking at the Social, Political, Economic and Cultural (SPEC) dimensions of social exclusion.Methods: Using logistic regression, the study investigates the determinants of health service utilisation using SPEC variables including other variables. Data was collected from 4050 representative households in five districts in Ghana covering the 3 ecological zones (coastal, forest and savannah) in Ghana.Results: Among 16,200 individuals who responded to the survey, 54 % were insured. Out of the 1349 who sought health care, 64 % were insured and 65 % of them had basic education and 60 % were women. The results from the logistic regressions show health insurance status, education and gender to be the three main determinants of health care utilisation. Overall, a large proportion of the insured who reported ill, sought care from formal health care providers compared to those who had never insured in the scheme.Conclusion: The paper demonstrates that the NHIS presents a workable policy tool for increasing access to healthcare through an emphasis on social health protection. However, affordability is not the only barrier for access to health services. Geographical, social, cultural, informational, political, and other barriers also come into play. [ABSTRACT FROM AUTHOR]

Background: Hypertension, itself a cardiovascular condition, is a significant risk factor for other cardiovascular diseases. Hypertension is recognized as a major public health challenge in Ghana. Beginning in 2014, a collaborative team launched the community-based hypertension improvement program (ComHIP) in one health district in Ghana. The ComHIP project, a public-private partnership, tests a community-based model that engages the private sector and utilizes information and communication technology (ICT) to control hypertension. This paper, focuses on the various challenges associated with managing hypertension in Ghana, as reported by ComHIP stakeholders.Methods: A total of 55 informants - comprising patients, health care professionals, licensed chemical sellers (LCS), national and sub-national policymakers - were purposively selected for interview and focus group discussions (FGDs). Interviews were audio-recorded and transcribed verbatim. Where applicable, transcriptions were translated directly from local language to English. The data were then analysed using two-step thematic analysis. The protocol was approved by the two ethics review committees based in Ghana and the third, based in the United Kingdom. All participants were interviewed after giving informed consent.Results: Our data have implications for the on-going implementation of ComHIP, especially the importance of policy maker buy-in, and the benefits, as well as drawbacks, of the program to different stakeholders. While our data show that the ComHIP initiative is acceptable to patients and healthcare providers - increasing providers' knowledge on hypertension and patients' awareness of same- there were implementation challenges identified by both patients and providers. Policy level challenges relate to task-sharing bottlenecks, which precluded nurses from prescribing or dispensing antihypertensives, and LCS from stocking same. Medication adherence and the phenomenon of medical pluralism in Ghana were identified challenges. The perspectives from the national level stakeholders enable elucidation of whole of health system challenges to ComHIP and similarly designed programmes.Conclusions: This paper sheds important light on the patient/individual, and system level challenges to hypertension and related non-communicable disease prevention and treatment in Ghana. The data show that although the ComHIP initiative is acceptable to patients and healthcare providers, policy level task-sharing bottlenecks preclude optimal implementation of ComHIP. [ABSTRACT FROM AUTHOR]

Background: Computerized decision support systems (CDSS) and performance-based incentives (PBIs) can improve health-worker performance. However, there is minimal evidence on the combined effects of these interventions or perceived effects among maternal and child healthcare providers in low-resource settings. We thus aimed to explore the perceptions of maternal and child healthcare providers of CDSS support in the context of a combined CDSS-PBI intervention on performance in twelve primary care facilities in Ghana's Upper East Region. Methods: We conducted a qualitative study drawing on semi-structured key informant interviews with 24 nurses and midwives, 12 health facility managers, and 6 district-level staff familiar with the intervention. We analysed data thematically using deductive and inductive coding in NVivo 10 software. Results: Interviewees suggested the combined CDSS-PBI intervention improved their performance, through enhancing knowledge of maternal health issues, facilitating diagnoses and prescribing, prompting actions for complications, and improving management. Some interviewees reported improved morbidity and mortality. However, challenges described in patient care included CDSS software inflexibility (e.g. requiring administration of only one intermittent preventive malaria treatment to pregnant women), faulty electronic partograph leading to unnecessary referrals, increased workload for nurses and midwives who still had to complete facility forms, and power fluctuations affecting software. Conclusion: Combining CDSS and PBI interventions has potential to improve maternal and child healthcare provision in low-income settings. However, user perspectives and context must be considered, along with allowance for revisions, when designing and implementing CDSS and PBIs interventions. [ABSTRACT FROM AUTHOR]

Background: Over the past decade, global health policy has increased its focus on measures to halt further increase in tuberculosis (TB) incidence and management of diabetes mellitus (DM). However, the vertical management of these two diseases have not achieved much in addressing the adverse effects of the rising tuberculosis-diabetes co-epidemic. This necessitated the World Health Organisation and the International Union Against Tuberculosis and Lung Disease to develop a framework to manage this dual disease burden. TB-DM co-epidemic is a public health concern in Ghana, adversely threatening the country's fragile health systems. Since frontline healthcare workers are critical in health policy implementation, this study used Lipsky's theoretical framework of street-level bureaucracy to explore their experiences in implementing the collaborative framework at the health facility level in Ghana.Methods: This qualitative study was conducted between July to September 2019 using an exploratory design. Data was generated using a semi-structured interview guide designed to elicit information on knowledge of TB-DM comorbidity as well as systems for co-management. Twenty-three in-depth interviews were conducted among purposively selected frontline healthcare workers (doctors, nurses, TB task- shifting officers, TB institutional coordinators and hospital managers) from three health facilities in the Northern Region of Ghana. The lead author also conducted observations and document reviews, in order to fully address the study objectives. Thematic analysis was guided by the Lipsky's theoretical framework of street level bureaucracy.Results: The findings revealed three main themes and six sub-themes. Main themes were Prioritisation of TB/HIV co-infection while negating TB-DM comorbidity, Poor working conditions, and Coping mechanisms, whereas sub-themes were Low knowledge and awareness of TB-DM comorbidity, Limited awareness of the collaborative framework, High workload in TB & DM Clinics, Multiple roles, Inadequate training, and Space shortage.Conclusions: Frontline healthcare workers had limited knowledge of TB-DM comorbidity and the collaborative framework, which, in turn adversely affected the effectiveness in implementing the framework. The effective implementation of the framework begins with raising awareness about the framework through in service training amongst the frontline healthcare workers. Additionally, an integrated screening tool to detect both TB and DM would help achieve early detection of TB-DM comorbidity. [ABSTRACT FROM AUTHOR]

Background: Inequities in the distribution of and access to maternal and child health care services is pervasive in Ghana. Understanding the drivers of inequity in maternal and child health (MCH) is important to achieving the universal health coverage component of the Sustainable Development Goals (SDGs) and poverty reduction in developing countries. However, there is increasing disparities in MCH services, especially in rural -urban, and income quintiles. The study aimed to examine the disparities in maternal and child health care services in Ghana for policy intervention.Methods: Data for this study was extracted from the nationally representative Ghana Statistical Service (GSS) Multiple Indicator Cluster Survey (MICS) round 4, 2011. Respondents of this survey were women of reproductive age 15-49 years with a sample size of 10,627 households. The models were estimated using multivariate regression analysis together with concentration index (CI) and risk ratio (RR) to assess the distribution of MCH indicator groups across the household wealth index.Results: The results show that women with secondary school level and above were more likely to receive family planning, prenatal care, and delivery by a skilled health professional than those without formal education. Mothers with low level of educational attainment were 87% more likely to have their first pregnancy before the age of 20 years, and 78% were more likely to have children with under-five mortality, and 45% more likely to have children who had diarrhoea. teenage pregnancy (CI = - 0.133, RR =0.679), prenatal care by skilled health worker (CI = - 0.124, RR =0.713) under five mortality, child underweight, reported diarrhoea, and suspected pneumonia, though not statistically significant, were more concentrated in the poorer than in the richer households, The RR between the top and bottom quintiles ranged from 0.77 for child underweight to 0.82 for child wasting.Conclusion: Geographic location, income status and formal education are key drivers of maternal and child health inequities in Ghana. Government can partner the private sector to implement health policies to address inequalities in MCH services through primary health care, and resource allocation skewed towards rural areas and the lower wealth quintile to bridge the inequality gaps and improve MCH outcomes. The government and the private sectors should prioritize female education, as that can improve maternal and child health. [ABSTRACT FROM AUTHOR]

Background: Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions in an urban district, using Ablekuma in Accra, Ghana as a case study.Methods: The study is an analytical cross-sectional study. Nine [1] targeted interviews were carried out for a three-week period in June and July 2019 after informed written consent with two [2] Obstetrics & Gynaecology consultants, two [2] Residents, one family physician, and four [3] Midwives managing emergency obstetric referral across different levels of facilities. Purposeful sampling technique was used to collect data that included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system.Results: Out of the 34 main activities in the referral process within the facilities, the study identified that 24 (70%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), Healthcare providers (HCP) knowledge and compliance to referral policy and guideline, and financing for referral. These findings have implication on delay in accessing care. HCP suggested that strengthening communication and coordination, reviewing referral policy, training of all stakeholders and provision of essential resources would be beneficial.Conclusion: Our findings clearly establish that the emergency obstetric referral system between a typical teaching hospital in an urban district of Accra-Ghana and peripheral referral facilities, is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions, strengthening collaborations, communication and transport along the referral pathway. These suggestions are likely to ensure that women receive timely and quality care. [ABSTRACT FROM AUTHOR]

Background: Globally, hypertension is a leading cause of cardiovascular disease and mortality, with the majority of deaths occurring in low- and middle-income countries. Because the burden of hypertension is increasing in low resource settings with restricted infrastructure, it is imperative that new models for hypertension care are realised. One such model is the Community-based Hypertension Improvement Project (ComHIP) which employs a community-based method of task-shifting for managing hypertension. This study is a qualitative analysis of the barriers and facilitators of the main components of ComHIP.Methods: We purposively selected 55 informants for semi-structured interviews or focus group discussions, which were carried out bythree trained local researchers in Krobo, Twi or English. Informants included patients enrolled in ComHIP, health care providers and Licensed Chemical Sellers trained by ComHIP, and Ghana Health Service employees. Data were analysed using a multi-step thematic analysis.Results: While results of the effectiveness of the intervention are pending, overall, patients and nurses reported positive experiences within ComHIP, and found that it helped enable them to manage their hypertension. Healthcare providers appreciated the additional training, but had some gaps in their knowledge. Ghana Health Service employees were cautiously optimistic about the programme, but expressed some worries about the sustainability of the programme. Many informants expressed concerns over the inability of community nurses and workers to dispense anti-hypertensives, due to legal restrictions.Conclusions: The WHO recommends task-sharing as a technique for managing chronic conditions such as hypertension in resource constrained settings. ComHIP presents an example of a task-sharing programme with a high level of acceptability to all participants. Going forward, we recommend greater levels of communication and dialogue to allow community-based health workers to be allowed to dispense anti-hypertensives. [ABSTRACT FROM AUTHOR]

Background: The burden of hypertension in many low-and middle-income countries is alarming and requires effective evidence-based preventative strategies that is carefully appraised and accepted by key stakeholders to ensure successful implementation and sustainability. We assessed nurses' perceptions of a recently completed Task Shifting Strategy for Hypertension control (TASSH) trial in Ghana, and facilitators and challenges to TASSH implementation.Methods: Focus group sessions and in-depth interviews were conducted with 27 community health nurses from participating health centers and district hospitals involved in the TASSH trial implemented in the Ashanti Region, Ghana, West Africa from 2012 to 2017. TASSH evaluated the comparative effectiveness of the WHO-PEN program versus provision of health insurance for blood pressure reduction in hypertensive adults. Qualitative data were analyzed using open and axial coding techniques with emerging themes mapped onto the Consolidated Framework for Implementation Research (CFIR).Results: Three themes emerged following deductive analysis using CFIR, including: (1) Patient health goal setting- relative priority and positive feedback from nurses, which motivated patients to make healthy behavior changes as a result of their health being a priority; (2) Leadership engagement (i.e., medical directors) which influenced the extent to which nurses were able to successfully implement TASSH in their various facilities, with most directors being very supportive; and (3) Availability of resources making it possible to implement the TASSH protocol, with limited space and personnel time to carry out TASSH duties, limited blood pressure (BP) monitoring equipment, and transportation, listed as barriers to effective implementation.Conclusion: Assessing stakeholders' perception of the TASSH implementation process guided by CFIR is crucial as it provides a platform for the nurses to thoroughly evaluate the task shifting program, while considering the local context in which the program is implemented. The feedback from the nurses informed barriers and facilitators to implementation of TASSH within the current healthcare system, and suggested system level changes needed prior to scale-up of TASSH to other regions in Ghana with potential for long-term sustainment of the task shifting intervention.Trial Registration: Trial registration for parent TASSH study: NCT01802372. Registered February 27, 2013. [ABSTRACT FROM AUTHOR]

Background: Timely access to emergency obstetric care is crucial in preventing mortalities associated with pregnancy and childbirth. The referral of patients from lower levels of care to higher levels has been identified as an integral component of the health care delivery system in Ghana. To this effect, in 2012, the National Referral Policy and Guidelines was developed by the Ministry of Health (MOH) to help improve standard procedures and reduce delays which affect access to emergency care. Nonetheless, ensuring timely access to care during referral of obstetric emergencies has been problematic. The study aimed to identify barriers associated with the referral of emergency obstetric cases to the leading national referral centre. It specifically examines the lived experiences of patients, healthcare providers and relatives of patients on the referral system.Methods: Korle Bu Teaching Hospital, Accra was used as a case study in 2016.The qualitative method was used and in-depth interviews were conducted with 89 respondents: healthcare providers [n = 34];patients [n = 31] and relatives of patients [n = 24] using semi-structured interview guides. Purposive sampling techniques were used in selecting healthcare providers and patients and convenience sampling techniques were used in selecting relatives of patients.Results: The study identified a range of barriers encountered in the referral process and broadly fall under the major themes: referral transportation system, referrer-receiver communication barriers, inadequate infrastructure and supplies and insufficient health personnel. Some highlights of the problem included inadequate use of ambulance services, poor management of patients during transit, lack of professional escort, unannounced emergency referrals, lack of adequate information and feedback and limited supply of beds, drugs and blood. These findings have implications on type II and III of the three delays model.Conclusions: Initiatives to improve the transportation system for the referral of obstetric emergencies are vital in ensuring patients' safety during transfer. Communication between referring and receiving facilities should be enhanced. A strong collaboration is needed between teaching hospitals and other stakeholders in the referral chain to foster good referral practices and healthcare delivery. Concurrently, supply side barriers at referred facilities including ensuring sufficient provision for bed, blood, drugs, and personnel must be addressed. [ABSTRACT FROM AUTHOR]

Background: Antenatal care is one of the three most essential care - antenatal, delivery and post-natal, given to women during pregnancy and has the potential to contribute towards the achievement of the Sustainable Development Goal (SDG) target 3.1- reducing the global maternal mortality ratio to less than 70 per 100,000 and target 3.8 - achieve universal health coverage. The main objective is to examine the contribution of the various providers of antenatal care services in Ghana from 1988 to 2014.Methods: The study uses data from all the six rounds of the Ghana Demographic and Health Survey (GDHS). Binary logistic regression models were applied to examine the association between background characteristics of respondents and providers of antenatal care services.Results: The results show that majority of antenatal care services were provided by nurses over the period under review. The proportion of women who received antenatal care services from nurses improved over the period from 55% in 1988 to 89.5% in 2014. Moreover, there was a decline in antenatal care services provided by traditional birth attendants and women who did not receive antenatal care services from any service provider over the years under review. It was observed that women from rural areas were more likely to utilise antenatal care services provided by traditional birth attendants, whilst those from urban areas were more likely to utilise antenatal care from doctors and nurses.Conclusion: To further improve access to and utilisation of antenatal care services provided by nurses and doctors it is recommended that the Ghana Health Service and the Ministry of Health should put in place systems aimed at improving on the quality of care given such as regular training workshops for health personnel and assessment of patient's satisfaction with services provided. Also, they should encourage women in rural areas especially those from the savannah zone to utilise antenatal care services from skilled providers through social and behaviour change communication campaigns. [ABSTRACT FROM AUTHOR]

Background: Stroke and other non-communicable diseases are important emerging public health concerns in sub-Saharan Africa where stroke-related mortality and morbidity are higher compared to other parts of the world. Despite the availability of evidence-based acute stroke interventions globally, uptake in low-middle income countries (LMIC) such as Ghana is uncertain. This study aimed to identify and evaluate available acute stroke services in Ghana and the extent to which these services align with global best practice.Methods: A multi-site, hospital-based survey was conducted in 11 major referral hospitals (regional and tertiary - teaching hospitals) in Ghana from November 2015 to April 2016. Respondents included neurologists, physician specialists and medical officers (general physicians). A pre-tested, structured questionnaire was used to gather data on available hospital-based acute stroke services in the study sites, using The World Stroke Organisation Global Stroke Services Guideline as a reference for global standards.Results: Availability of evidence-based services for acute stroke care in the study hospitals were varied and limited. The results showed one tertiary-teaching hospital had a stroke unit. However, thrombolytic therapy (thrombolysis) using recombinant tissue plasminogen activator for acute ischemic stroke care was not available in any of the study hospitals. Aspirin therapy was administered in all the 11 study hospitals. Although eight study sites reported having a brain computed tomographic (CT) scan, only 7 (63.6%) were functional at the time of the study. Magnetic resonance imaging (MRI scan) services were also limited to only 4 (36.4%) hospitals (only functional in three). Acute stroke care by specialists, especially neurologists, was found in 36.4% (4) of the study hospitals whilst none of the study hospitals had an occupational or a speech pathologist to support in the provision of acute stroke care.Conclusion: This study confirms previous reports of limited and variable provision of evidence based stroke services and the low priority for stroke care in resource poor settings. Health policy initiatives to enhance uptake of evidence-based acute stroke services is required to reduce stroke-related mortality and morbidity in countries such as Ghana. [ABSTRACT FROM AUTHOR]

Background: Unsafe abortion is an issue of public health concern and contributes significantly to maternal morbidity and mortality globally. Abortion evokes religious, moral, ethical, socio-cultural and medical concerns which mean it is highly stigmatized and this poses a threat to both providers and researchers. This study sought to explore challenges to providing safe abortion services from the perspective of health providers in Ghana.Methods: A descriptive qualitative study using in-depth interviews was conducted. The study was conducted in three (3) hospitals and five (5) health centres in the capital city in Ghana. Participants (n = 36) consisted of obstetrician/gynaecologists, nurse-midwives and pharmacists.Results: Stigma affects provision of safe-abortion services in Ghana in a number of ways. The ambiguities in Ghanaian abortion law and lack of overt institutional support for practitioners increased reluctance to openly provide for fear of stigmatisation and legal threat. Negative provider attitudes that stigmatised women seeking abortion care were frequently driven by socio-cultural and religious norms that highly stigmatise abortion practice. Exposure to higher levels of education, including training overseas, seemed to result in more positive, less stigmatising views towards the need for safe abortion services. Nevertheless, physicians open to practicing abortion were still very concerned about stigma by association.Conclusions: Stigma constitutes an overarching impediment for abortion service provision. It affects health providers providing such services and even researchers who study the subject. Exposure to wider debate and education seem to influence attitudes and values clarification training may prove useful. Proper dissemination of existing guidelines and overt institutional support for provision of safe services also needs to be rolled out. [ABSTRACT FROM AUTHOR]

Background: Barely a decade after introduction of Ghana's National Health Insurance Scheme (NHIS), significant successes have been recorded in universal access to basic healthcare services. However, sustainability of the scheme is increasingly threatened by concerns on quality of health service delivery in NHIS-accredited health facilities coupled with stakeholders' discontentment with the operational and administrative challenges confronting the NHIS. The study sought to ascertain whether or not Systematic Community Engagement (SCE) interventions have a significant effect on frontline health workers' perspectives on the NHIS and its impact on quality health service delivery.Methods: The study is a randomized cluster trial involving clinical and non-clinical frontline health workers (n = 234) interviewed at baseline and follow-up in the Greater Accra and Western regions of Ghana. Individual respondents were chosen from within each intervention and control groupings. Difference-in-difference estimations and propensity score matching were performed to determine impact of SCE on staff perceptions of the NHIS. The main outcome measure of interest was staff perception of the NHIS based on eight (8) factor-analyzed quality service parameters.Results: Staff interviewed in intervention facilities appeared to perceive the NHIS more positively in terms of its impact on "availability and quality of drugs (p < 0.05)" and "workload on health staff/infrastructure" than those interviewed in control facilities (p < 0.1). Delayed reimbursement of service providers remained a key concern to over 70 % of respondents in control and intervention health facilities.Conclusion: Community engagement in quality service assessment is a potential useful strategy towards empowering communities while promoting frontline health workers' interest, goodwill and active participation in Ghana's NHIS. [ABSTRACT FROM AUTHOR]