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Background: In 2009 Ghana began to design a trachoma pre-validation surveillance plan, based on then-current WHO recommendations. The plan aimed to identify active trachoma resurgence and identify and manage trichiasis cases, through both active and passive surveillance approaches. This paper outlines and reviews the adaptations made by Ghana between 2011 and 2016. The assessment will provide a learning opportunity for a number of countries as they progress towards elimination status., Methods: A mixed methods approach was taken, comprising in-depth interviews and documents review. Between January and April 2016, 20 in-depth interviews were conducted with persons involved in the operationalisation of the trachoma surveillance system from across all levels of the health system. A three-tier thematic coding framework was developed using a primarily inductive approach but also allowed for a more iterative approach, which drew on aspects of grounded theory., Results: During the operationalisation of the Ghana surveillance plan there were a number of adaptations (as compared to the WHO recommendations), these included: (i) Inclusion of surveillance of active trachoma in the passive surveillance approach, as compared to trichiasis alone. Issues with case identification, challenges in implementation coverage and a non-specific reporting structure hampered effectiveness; (ii) Random selection and increase in number of sites selected for the active surveillance component. This likely lacked the spatiotemporal power to be able to identify recrudescence in a timely manner; (iii) Targeted trichiasis door-to-door case searches, led by ophthalmic nurses. An effective methodology to identify trichiasis cases but resource intensive; (iv) A buddy system between ophthalmic nurses to support technical skills in an elimination setting where it is difficult to attain diagnostic and surgical skills, due to a lack of cases. The strategy did not take into account the loss of proficiency within experienced personnel., Conclusions: Ghana developed a comprehensive surveillance system that exceeded the WHO recommendations but issues with sensitivity and specificity likely led to an inefficient use of resources. Improved targeted surveillance strategies for identification of recrudescence and trichiasis case searches, need to be evaluated. Strategies must address the contextual changes that arise because of transmission decline, such as loss of surgical skills.

Background: There is general agreement amongst major international policy makers that sustainability is a key component of health interventions in developing countries. However, there is little evidence on the factors enabling or constraining sustainability. Diffusion of innovation theory can help explain how the continuation of activities is related to the attributes of innovations. Innovations are characterised by five attributes: (i) relative advantage; (ii) compatibility; (iii) complexity; (iv) triability; and (v) observability. An eye care programme was selected as a case study. The programme was implemented in the Brong Ahafo region of Ghana and had been funded over a ten-year period by an international organisation., Methods: Sustainability in the study was defined as the level of continuation of activities after the end of international funding. Measuring the continuation of activities involved checking whether each eye care activity continued (i.e. out-patient consultation, cataract surgery, outreach, school health, and statistics) or was interrupted after the end of Swiss Red Cross funding the 11 district hospitals where the programme was implemented., Results: The results showed a relationship between the level of sustainability and the attributes of every activity. The activities with the lowest score for the attributes were less sustained. School health screening was the least sustained activity after the end of international funding. This activity also held the smallest score in terms of attributes: they were the most incompatible and most complex activities, as well as the least triable and observable activities, amongst the four district activities. In contrast, compared to the three other district activities, facility-based consultations were more likely to be routinised because they were perceived by the hospital managers as very compatible, and not complex., Conclusions: Using diffusion of innovations theories can help predict the sustainability of specific activities within a health programme. The study also highlighted the need for disentangling the various components of a health programme in order to identify which activities are more likely to be continued within a health system. The same methodology could be used in a different setting and could help predict which innovations are more likely to be adopted and maintained over time.