Examining inequalities in spatial access to national health insurance fund contracted facilities in Kenya.

BACKGROUND: Kenya aims to achieve universal health coverage (UHC) by 2030 and has selected the National Health Insurance Fund (NHIF) as the 'vehicle' to drive the UHC agenda. While there is some progress in moving the country towards UHC, the availability and accessibility to NHIF-contracted facilities may be a barrier to equitable access to care. We estimated the spatial access to NHIF-contracted facilities in Kenya to provide information to advance the UHC agenda in Kenya. METHODS: We merged NHIF-contracted facility data to the geocoded inventory of health facilities in Kenya to assign facility geospatial locations. We combined this database with covariates data including road network, elevation, land use, and travel barriers. We estimated the proportion of the population living within 60- and 120-minute travel time to an NHIF-contracted facility at a 1-x1-kilometer spatial resolution nationally and at county levels using the WHO AccessMod tool. RESULTS: We included a total of 3,858 NHIF-contracted facilities. Nationally, 81.4% and 89.6% of the population lived within 60- and 120-minute travel time to an NHIF-contracted facility respectively. At the county level, the proportion of the population living within 1-hour of travel time to an NHIF-contracted facility ranged from as low as 28.1% in Wajir county to 100% in Nyamira and Kisii counties. Overall, only four counties (Kiambu, Kisii, Nairobi and Nyamira) had met the target of having 100% of their population living within 1-hour (60 min) travel time to an NHIF-contracted facility. On average, it takes 209, 210 and 216 min to travel to an NHIF-contracted facility, outpatient and inpatient facilities respectively. At the county level, travel time to an NHIF-contracted facility ranged from 10 min in Vihiga County to 333 min in Garissa. CONCLUSION: Our study offers evidence of the spatial access estimates to NHIF-contracted facilities in Kenya that can inform contracting decisions by the social health insurer, especially focussing on marginalised counties where more facilities need to be contracted. Besides, this evidence will be crucial as the country gears towards accelerating progress towards achieving UHC using social health insurance as the strategy to drive the UHC agenda in Kenya.

Effect of social capital on enrolment of informal sector occupational groups in the national health insurance scheme in Ghana: a cross-sectional survey.

BACKGROUND: Enrolment of informal sector workers in Ghana's National Health Insurance Scheme (NHIS) is critical to achieving increased risk-pooling and attainment of Universal Health Coverage. However, the NHIS has struggled over the years to improve enrolment of this subpopulation. This study analysed effect of social capital on enrolment of informal sector workers in the NHIS. METHODS: A cross-sectional survey was conducted among 528 members of hairdressers and beauticians, farmers, and commercial road transport drivers' groups. Descriptive statistics, principal component analysis, and multinomial logit regression model were used to analyse the data. RESULTS: Social capital including membership in occupational group, trust, and collective action were significantly associated with enrolment in the NHIS, overall. Other factors such as household size, education, ethnicity, and usual source of health care were, however, correlated with both enrolment and dropout. Notwithstanding these factors, the chance of enrolling in the NHIS and staying active was 44.6% higher for the hairdressers and beauticians; the probability of dropping out of the scheme was 62.9% higher for the farmers; and the chance of never enrolling in the scheme was 22.3% higher for the commercial road transport drivers. CONCLUSIONS: Social capital particularly collective action and predominantly female occupational groups are key determinants of informal sector workers' participation in the NHIS. Policy interventions to improve enrolment of this subpopulation should consider group enrolment, targeting female dominated informal sector occupational groups. Further studies should consider inclusion of mediating and moderating variables to provide a clearer picture of the relationship between occupational group social capital and enrolment in health insurance schemes.

A health technology assessment of COVID-19 vaccination for Nigerian decision-makers: Identifying stakeholders and pathways to support evidence uptake.

BACKGROUND: Nigeria commenced rollout of vaccination for coronavirus disease 2019 (COVID-19) in March 2021 as part of the national public health response to the pandemic. Findings from appropriately contextualized cost-effectiveness analyses (CEA) as part of a wider process involving health technology assessment (HTA) approaches have been important in informing decision-making in this area. In this paper we outline the processes that were followed to identify COVID-19 vaccine stakeholders involved in the selection, approval, funding, procurement and rollout of vaccines in Nigeria, and describe the process routes we identified to support uptake of HTA-related information for evidence-informed policy in Nigeria. METHODS: Our approach to engaging with policy-makers and other stakeholders as part of an HTA of COVID vaccination in Nigeria consisted of three steps, namely: (i) informal discussions with key stakeholders; (ii) stakeholder mapping, analysis and engagement; and (iii) communication and dissemination strategies for the HTA-relevant evidence produced. The analysis of the stakeholder mapping uses the power/interest grid framework. RESULTS: The informal discussion with key stakeholders generated six initial policy questions. Further discussions with policy-makers yielded three suitable policy questions for analysis: which COVID-19 vaccines should be bought; what is the optimal mode of delivery of these vaccines; and what are the cost and cost-effectiveness of vaccinating people highlighted in Nigeria's phase 2 vaccine rollout prioritized by the government, especially the inclusion of those aged between 18 and 49 years. The stakeholder mapping exercise highlighted the range of organizations and groups within Nigeria that could use the information from this HTA to guide decision-making. These stakeholders included both public/government, private and international organizations The dissemination plan developed included disseminating the full HTA results to key stakeholders; production of policy briefs; and presentation at different national and international conferences and peer-reviewed publications. CONCLUSIONS: HTA processes that involve stakeholder engagement will help ensure important policy questions are taken into account when designing any HTA including any underpinning evidence generation. Further guidance about stakeholder engagement throughout HTA is required, especially for those with low interest in vaccine procurement and use.

Assessing the impacts of COVID-19 vaccination programme's timing and speed on health benefits, cost-effectiveness, and relative affordability in 27 African countries.

BACKGROUND: The COVID-19 vaccine supply shortage in 2021 constrained roll-out efforts in Africa while populations experienced waves of epidemics. As supply improves, a key question is whether vaccination remains an impactful and cost-effective strategy given changes in the timing of implementation. METHODS: We assessed the impact of vaccination programme timing using an epidemiological and economic model. We fitted an age-specific dynamic transmission model to reported COVID-19 deaths in 27 African countries to approximate existing immunity resulting from infection before substantial vaccine roll-out. We then projected health outcomes (from symptomatic cases to overall disability-adjusted life years (DALYs) averted) for different programme start dates (01 January to 01 December 2021, n = 12) and roll-out rates (slow, medium, fast; 275, 826, and 2066 doses/million population-day, respectively) for viral vector and mRNA vaccines by the end of 2022. Roll-out rates used were derived from observed uptake trajectories in this region. Vaccination programmes were assumed to prioritise those above 60 years before other adults. We collected data on vaccine delivery costs, calculated incremental cost-effectiveness ratios (ICERs) compared to no vaccine use, and compared these ICERs to GDP per capita. We additionally calculated a relative affordability measure of vaccination programmes to assess potential nonmarginal budget impacts. RESULTS: Vaccination programmes with early start dates yielded the most health benefits and lowest ICERs compared to those with late starts. While producing the most health benefits, fast vaccine roll-out did not always result in the lowest ICERs. The highest marginal effectiveness within vaccination programmes was found among older adults. High country income groups, high proportions of populations over 60 years or non-susceptible at the start of vaccination programmes are associated with low ICERs relative to GDP per capita. Most vaccination programmes with small ICERs relative to GDP per capita were also relatively affordable. CONCLUSION: Although ICERs increased significantly as vaccination programmes were delayed, programmes starting late in 2021 may still generate low ICERs and manageable affordability measures. Looking forward, lower vaccine purchasing costs and vaccines with improved efficacies can help increase the economic value of COVID-19 vaccination programmes.

Cost of inappropriate prescriptions for uncomplicated malaria in Ghana.

BACKGROUND: Malaria remains a common course of morbidity in many sub-Saharan African countries. While treatment options have improved in recent times, inappropriate prescription seems conventional among providers, increasing the burden on patients and society. This study examined the cost of inappropriate prescriptions for uncomplicated malaria treatment in Ghana. METHODS: This study used retrospective data collected from January to December 2016 in 27 selected facilities, under different ownership in three regions of the country, mainly Volta, Upper East and Brong Ahafo. Stratified random sampling technique was used to extract 1625 outpatient folders of patients diagnosed and treated for malaria. Two physicians independently reviewed patient folders according to the stated diagnoses. Malaria prescriptions were described as inappropriate when they do not adhere to the standard treatment guidelines. The economic cost was mainly treatment cost which was sourced as medication cost. Total and average costs for country were calculated using sample estimates and the total number of uncomplicated malaria cases that received inappropriate prescriptions. RESULTS: The study revealed that patients received an average of two prescriptions per malaria episode. Artemether-lumefantrine (AL) was the major malaria medication (79.5%) prescribed to patients. Other medications usually antibiotics and vitamins and minerals were included in the prescription. More than 50% of prescribers did not follow the guidelines for prescribing medications to clients. By facility type, inappropriate prescription was high in the CHPS compounds (59.1%) and by ownership, government (58.3%), private (57.5%) and mission facilities (50.7%). Thus, about 55% of malaria prescriptions were evaluated as inappropriate during the review period, which translates into economic cost of approximately US$4.52 million for the entire country in 2016. The total cost of inappropriate prescription within the study sample was estimated at US$1,088.42 while the average cost was US$1.20. CONCLUSION: Inappropriate prescription for malaria is a major threat to malaria management in Ghana. It presents a huge economic burden to the health system. Training and strict enforcement of prescribers' adherence to the standard treatment guideline is highly recommended.

Economic evaluations of non-communicable diseases conducted in Sub-Saharan Africa: a critical review of data sources.

BACKGROUND: Policymakers in sub-Saharan Africa (SSA) face challenging decisions regarding the allocation of health resources. Economic evaluations can help decision makers to determine which health interventions should be funded and or included in their benefits package. A major problem is whether the evaluations incorporated data from sources that are reliable and relevant to the country of interest. We aimed to review the quality of the data sources used in all published economic evaluations for cardiovascular disease and diabetes in SSA. METHODS: We systematically searched selected databases for all published economic evaluations for CVD and diabetes in SSA. We modified a hierarchy of data sources and used a reference case to measure the adherence to reporting and methodological characteristics, and descriptively analysed author statements. RESULTS: From 7,297 articles retrieved from the search, we selected 35 for study inclusion. Most were modelled evaluations and almost all focused on pharmacological interventions. The studies adhered to the reporting standards but were less adherent to the methodological standards. The quality of data sources varied. The quality level of evidence in the data domains of resource use and costs were generally considered of high quality, with studies often sourcing information from reliable databases within the same jurisdiction. The authors of most studies referred to data sources in the discussion section of the publications highlighting the challenges of obtaining good quality and locally relevant data. CONCLUSIONS: The data sources in some domains are considered high quality but there remains a need to make substantial improvements in the methodological adherence and overall quality of data sources to provide evidence that is sufficiently robust to support decision making in SSA within the context of UHC and health benefits plans. Many SSA governments will need to strengthen and build their capacity to conduct economic evaluations of interventions and health technology assessment for improved priority setting. This capacity building includes enhancing local infrastructures for routine data production and management. If many of the policy makers are using economic evaluations to guide resource allocation, it is imperative that the evidence used is of the feasibly highest quality.

Assessing the choice of National Health Insurance Fund contracted outpatient facilities in Kenya: A qualitative study.

OBJECTIVE: To assess National Health Insurance Fund (NHIF) members' level of understanding, experiences, and factors influencing their choice of NHIF-contracted outpatient facilities in Kenya. METHODS: We conducted a cross-sectional qualitative study with NHIF members in two purposefully selected counties (Nyeri and Makueni counties) in Kenya. We collected data through 15 focus group discussions with NHIF members. Data were analysed using a framework analysis approach. RESULTS: Urban-based NHIF members had a good understanding of the NHIF-contracted outpatient facility selection process and the approaches for choosing and changing providers, unlike their rural counterparts. While NHIF members were required to choose a provider before accessing care, the number of available alternative facilities was perceived to be inadequate. Finally, NHIF members identified seven factors they considered important when choosing an NHIF-contracted outpatient provider. Of these factors, the availability of drugs, distance from the household to the facility and waiting time at the facility until consultation were considered the most important. CONCLUSION: There is a need for the NHIF to prioritise awareness-raising approaches tailored to rural settings. Further, there is a need for the NHIF to contract more providers to both spur competition among providers and provide alternatives for members to choose from. Besides, NHIF members revealed the important factors they consider when selecting outpatient facilities. Consequently, NHIF should leverage the preferred factors when contracting healthcare providers. Similarly, healthcare providers should enhance the availability of drugs, reduce waiting times whilst improving their staff's attitudes which would improve user satisfaction and the quality of care provided.

Factors influencing health workers' compliance with the WHO intermittent preventive treatment for malaria in pregnancy recommendations in the Northern Region, Ghana.

BACKGROUND: Although IPTp-SP is a lifesaving World Health Organization (WHO) recommended preventive intervention for pregnant women in malaria-endemic regions, IPTp-SP uptake in the Northern region of Ghana is much lower than the sub-optimal national coverage level. Assessing the extent of health workers' compliance and its associated factors will generate valuable pointers to be targeted at the program level. The study examined the factors influencing health workers' compliance with the WHO recommended guidelines for IPTp-SP in the Northern Region. METHODS: A cross-sectional study among 315 health workers in the Northern region was conducted. Semi-structured questionnaires were used to collect data on health workers' sociodemographic characteristics, facility-based factors and knowledge level. Data were collected on health workers' compliance with the recommended practices through covert observations using a checklist. Facility observations were carried out using a checklist. Crude and adjusted logistic regression were used to determine predictors of health workers' compliance, at a 5% significance level adjusting for clustering. RESULTS: Of the 315 health workers studied, the median age was 29 years (26-34 years). Females constituted (80.5%; 252) of the 313 workers. The majority (47.4%;148) of the 312 health workers were midwives. Overall, 56.2% (CI 51.0 - 62.0) were adequately complying with the recommended guidelines. Lower levels of compliance were recorded in health centres 15.6% (5.0 - 33.0) and CHPS compounds 21.2% (11.0 - 35.0). The factors associated with compliance included health workers' knowledge (aOR = 7.64, 95% CI 4.21 - 13.87, p < 0.001), job satisfaction (aOR 10.87, 95% CI 7.04 - 16.79, p < 0.001), in-service training (aOR 10.11, 95% CI 4.53 - 22.56, p < 0.001), supervision (aOR 4.01, 95% CI 2.09 - 7.68, p < 0.001), availability of job aids (aOR 3.61, 95% CI 2.44 - 5.35, p < 0.001), health workers experience (aOR = 10.64, 95% CI 5.99 - 18.91, p < 0.001) and facility type (aOR 0.03, 95% CI 0.01-0.07, p < 0.001). CONCLUSION: Compliance with the recommended IPTp-SP guidelines is suboptimal in the region, with lower-level health facilities recording the least compliance levels. Health centres and CHPS facilities should be prioritized in distributing limited resources to improve health worker quality of care for antenatal care clients.

Impact of insecticide-treated nets and indoor residual spraying on self-reported malaria prevalence among women of reproductive age in Ghana: implication for malaria control and elimination.

BACKGROUND: The Global Fund alone contributed 56% of all international financing for malaria and has invested more than US$13.5 billion in malaria treatment, prevention, and control programmes by June 2021. These investments include interventions such as mosquito nets, indoor residual spraying, and preventive treatment for children and pregnant women. However, there is paucity of studies for assessment of such investments to a reduction in malaria prevalence. This study was aimed at quantifying the impact of household access to insecticide-treated nets (ITNs) and the indoor residual spraying (IRS) on self-reported malaria prevalence among women of reproductive age in Ghana. METHODS: The study analysed the 2016 Ghana Malaria Indicator Survey (MIS) data. The MIS is a nationwide survey that included women aged 15-49 years. Poisson regression model with inverse probability to treatment weighting was used to determine average treatment effect estimate of the two malaria interventions on self-reported malaria prevalence among women of reproductive age in Ghana. RESULTS: A total sample of 4861 women interviewed from the 2016 Ghana MIS was used for analysis. The prevalence of self-reported malaria in 2016 was 34.4% (95% CI [32.4%, 36.4%]). Approximately 80.0% of women lived in households with access to ITNs [Percentage (Pr) = 79.9%, (95% CI [78.0%, 81.7%])], 12.4% (95% CI [7.5%, 19.8%]) of the households had access to IRS and 11.4% (95% CI [7.0%, 18.0%]) of the households had access to both ITNs and IRS. Household access to only ITN contributed to 7.1 percentage point (pt) reduction in the self-reported malaria among women (95% CI [- 12.0%, - 2.1%], p = 0.005) whilst IRS at the households contributed to 6.8pt reduction in malaria prevalence (95% CI [- 12.0%, - 2.1%], p = 0.005). Households with access to both ITNs and IRS contributed to a 27.1pt reduction in self-reported malaria prevalence among women (95% CI [- 12.0%, - 2.1%], p = 0.005). CONCLUSION: Access to both ITNs and application of IRS at the household level contributed to a significant reduction in self-reported malaria prevalence among women of reproductive age in Ghana. This finding confirms the need for integration of malaria control interventions to facilitate attainment of malaria elimination in Ghana.

Achieving global mortality reduction targets and universal health coverage: The impact of COVID-19.

Wenhui Mao and coauthors discuss possible implications of the COVID-19 pandemic for health aspirations in low- and middle-income countries.

Impact of malaria diagnostic refresher training programme on competencies and skills in malaria diagnosis among medical laboratory professionals: evidence from Ghana 2015-2019.

BACKGROUND: The quality of malaria test results is crucial for optimal patient treatment and care. The Ghana Health Service is successfully shifting from presumptive clinical diagnosis and treatment of malaria to the Test, Treat and Track (T3) initiative. In line with the initiative, the National Malaria Control Programme (NMCP) set out to improve the capacity of medical laboratory professionals in Ghana through a five-day Malaria Diagnostic Refresher Training (MDRT) to build competencies and skills in malaria diagnosis, especially in the three components of microscopy: parasite detection, species identification and parasite quantification. This study evaluates the impact of the training on malaria microscopy. METHODS: The training which was based on the World Health Organization basic malaria microscopy training guide employed presentations and practical approaches to malaria diagnosis. A total number of 765 medical laboratory professionals from various health facilities across the country were trained every other year from 2015 to 2019 and were included in this evaluation. Evaluation of this training was done using pre-test and post-test microscopy scores. The Negative Binomial fixed effect model was used in determining the overall effect of the training in improving the competencies of the participants on malaria microscopy. RESULTS: The ability of the medical laboratory professionals to correctly detect malaria parasites increased significantly from a median score of 64% prior to the training to 87% after the training (p < 0.001). The competencies of the medical laboratory scientists to correctly identify malaria parasite species and quantify the number of malaria parasites increased significantly from a median score of 17% and 20% pre-test to 78% and 50% post-test, respectively (p < 0.001). The results showed that participants' competency level and skill to perform malaria microscopy (species identification, parasite quantification and detection of malaria parasites) increased by approximately two folds after the training compared to the no-training scenario (adjusted rate ratio = 2.07, 95% CI 2.01-2.13, p < 0.001). CONCLUSION: The MDRT programme significantly improved participants' performance of malaria microscopy over a short period of time.

Antimicrobial Resistance: Is Health Technology Assessment Part of the Solution or Part of the Problem?

Antimicrobial resistance is a serious challenge to the success and sustainability of our healthcare systems. There has been increasing policy attention given to antimicrobial resistance in the last few years, and increased amounts of funding have been channeled into funding for research and development of antimicrobial agents. Nevertheless, manufacturers doubt whether there will be a market for new antimicrobial technologies sufficient to enable them to recoup their investment. Health technology assessment (HTA) has a critical role in creating confidence that if valuable technologies can be developed they will be reimbursed at a level that captures their true value. We identify 3 deficiencies of current HTA processes for appraising antimicrobial agents: a methods-centric approach rather than problem-centric approach for dealing with new challenges, a lack of tools for thinking about changing patterns of infection, and the absence of an approach to epidemiological risks. We argue that, to play their role more effectively, HTA agencies need to broaden their methodological tool kit, design and communicate their analysis to a wider set of users, and incorporate long-term policy goals, such as containing resistance, as part of their evaluation criteria alongside immediate health gains.

Is value-based payment for healthcare feasible under Ghana's National Health Insurance Scheme?

BACKGROUND: Effective payment mechanisms for healthcare are critical to the quality of care and the efficiency and responsiveness of health systems to meet specific population health needs. Since its inception, Ghana's National Health Insurance Scheme (NHIS) has adopted fee-for-service, diagnostic-related groups and capitation methods, which have contributed to provider reimbursement delays, rising costs and poor quality of care rendered to the scheme's clients. The aim of this study was to explore stakeholder perceptions of the feasibility of value-based payment (VBP) for healthcare in Ghana. Value-based payment refers to a system whereby healthcare providers are paid for the value of services rendered to patients instead of the volume of services. METHODS: This study employed a cross-sectional qualitative design. National-level stakeholders were purposively selected for in-depth interviews. The participants included policy-makers (n = 4), implementers (n = 5), public health insurers (n = 3), public and private healthcare providers (n = 7) and civil society organization officers (n = 1). Interviews were audio-recorded and transcribed. Data analysis was performed using both deductive and inductive thematic analysis. The data were analysed using QSR NVivo 12 software. RESULTS: Generally, participants perceived VBP to be feasible if certain supporting systems were in place and potential implementation constraints were addressed. Although the concept of VBP was widely accepted, study participants reported that efficient resource management, provider motivation incentives and community empowerment were required to align VBP to the Ghanaian context. Weak electronic information systems and underdeveloped healthcare infrastructure were seen as challenges to the integration of VBP into the Ghanaian health system. Therefore, improvement of existing systems beyond healthcare, including public education, politics, data, finance, regulation, planning, infrastructure and stakeholder attitudes towards VBP, will affect the overall feasibility of VBP in Ghana. CONCLUSION: Value-based payment could be a feasible policy option for the NHIS in Ghana if potential implementation challenges such as limited financial and human resources and underdeveloped health system infrastructure are addressed. Governmental support and provider capacity-building are therefore essential for VBP implementation in Ghana. Future feasibility and acceptability studies will need to consider community and patient perspectives.

Cost of illness for childhood diarrhea in low- and middle-income countries: a systematic review of evidence and modelled estimates.

BACKGROUND: Numerous studies have reported the economic burden of childhood diarrhea in low- and middle-income countries (LMICs). Yet, empirical data on the cost of diarrheal illness is sparse, particularly in LMICs. In this study we review the existing literature on the cost of childhood diarrhea in LMICs and generate comparable estimates of cost of diarrhea across 137 LMICs. METHODS: The systematic literature review included all articles reporting cost estimates of diarrhea illness and treatment from LMICs published between January 2006 and July 2018. To generate country-specific costs, we used service delivery unit costs from the World Health Organization's Choosing Interventions that are Cost-Effective (WHO-CHOICE database). Non-medical costs were calculated using the ratio between direct medical and direct non-medical costs, derived from the literature review. Indirect costs (lost wages to caregivers) were calculated by multiplying the average GDP per capita per day by the average number of days lost to illness identified from the literature. All cost estimates are reported in 2015 USD. We also generated estimates using the IHME's service delivery unit costs to explore input sensitivity on modelled cost estimates. RESULTS: We identified 25 articles with 64 data points on either direct or indirect cost of diarrhoeal illness in children aged < 5 years in 20 LMICs. Of the 64 data points, 17 were on the cost of outpatient care, 28 were on the cost of inpatient care, and 19 were unspecified. The average cost of illness was US$36.56 (median $15.73; range $4.30 - $145.47) per outpatient episode and $159.90 (median $85.85; range $41.01 - $538.33) per inpatient episode. Direct medical costs accounted for 79% (83% for inpatient and 74% for outpatient) of the total direct costs. Our modelled estimates, across all 137 countries, averaged (weighted) $52.16 (median $47.56; range $8.81 - $201.91) per outpatient episode and $216.36 (median $177.20; range $23.77 -$1225.36) per inpatient episode. In the 12 countries with primary data, there was reasonable agreement between our modelled estimates and the reported data (Pearson's correlation coefficient = .75). CONCLUSION: Our modelled estimates generally correspond to estimates observed in the literature, with a few exceptions. These estimates can serve as useful inputs for planning and prioritizing appropriate health interventions for childhood diarrheal diseases in LMICs in the absence of empirical data.

Implementing health technology assessment in Ghana to support universal health coverage: building relationships that focus on people, policy, and process.

Ghana is one of the few African countries to enact legislation and earmark significant funding to establish universal health coverage (UHC) through the National Health Insurance Scheme, although donor funds have declined recently. Given a disproportionate level of spending on medicines, health technology assessment (HTA) can support resource allocation decisions in the face of highly constrained budgets, as commonly found in low-resource settings. The Ghanaian Ministry of Health, supported by the International Decision Support Initiative (iDSI), initiated a HTA study in 2016 to examine the cost-effectiveness of antihypertensive medicines. We aimed to summarize key insights from this work that highlights success factors beyond producing purely technical outputs. These include the need for capacity building, academic collaboration, and ongoing partnerships with a broad range of experts and stakeholders. By building on this HTA study, and with ongoing interactions with iDSI, HTAi, WHO, and others, Ghana will be well positioned to institutionalize HTA in resource allocation decisions and support progress toward UHC.

What do we need to know? Data sources to support evidence-based decisions using health technology assessment in Ghana.

BACKGROUND: Evidence-based decision-making for prioritising health is assisted by health technology assessment (HTA) to integrate data on effectiveness, costs and equity to support transparent decisions. Ghana is moving towards universal health coverage, facilitated mainly by the National Health Insurance Scheme (NHIS) established in 2003. The Government of Ghana is committed to institutionalising HTA for priority-setting. We aimed to identify and describe the sources of accessible data to support HTA in Ghana. METHODS: We identified and described data sources encompassing six main domains using an existing framework. The domains were epidemiology, clinical efficacy, costs, health service use and consumption, quality of life, and equity. We used existing knowledge, views of stakeholders, and searches of the literature and internet. RESULTS: The data sources for each of the six domains vary in extent and quality. Ghana has several large data sources to support HTA (e.g. Demographic Health Surveys) that have rigorous quality assurance processes. Few accessible data sources were available for costs and resource utilisation. The NHIS is a potentially rich source of data on resource use and costs but there are some limits on access. There are some data on equity but data on quality of life are limited. CONCLUSIONS: A small number of quality data sources are available in Ghana but there are some gaps with respect to HTA based on greater use of local and contextualised information. Although more data are becoming available for monitoring, challenges remain in terms of their usefulness for HTA, and some information may not be available in disaggregated form to enable specific analyses. We support recent initiatives for the routine collection of comprehensive and reliable data that is easily accessible for HTA users. A commitment to HTA will require concerted efforts to leverage existing data sources, for example, from the NHIS, and develop and maintain new data (e.g. local health utility estimates). It will be critical that an overarching strategic and mandatory approach to the collection and use of health information is developed for Ghana in parallel to, and informed by, the development of HTA approaches to support resource allocation decisions. The key to HTA is to use the best available data while being open about its limitations and the impact on uncertainty.

Capacity building for implementation research: a methodology for advancing health research and practice.

BACKGROUND: Implementation research is increasingly being recognised as an important discipline seeking to maximise the benefits of evidence-based interventions. Although capacity-building efforts are ongoing, there has been limited attention on the contextual and health system peculiarities in low- and middle-income countries. Moreover, given the challenges encountered during the implementation of health interventions, the field of implementation research requires a creative attempt to build expertise for health researchers and practitioners simultaneously. With support from the Special Programme for Research and Training in Tropical Diseases, we have developed an implementation research short course that targets both researchers and practitioners. This paper seeks to explain the course development processes and report on training evaluations, highlighting its relevance for inter-institutional and inter-regional capacity strengthening. METHODS: The development of the implementation research course curriculum was categorised into four phases, namely the formation of a core curriculum development team, course content development, internal reviews and pilot, and external reviews and evaluations. Five modules were developed covering Introduction to implementation research, Methods in implementation research, Ethics and quality management in implementation research, Community and stakeholder engagement, and Dissemination in implementation research. Course evaluations were conducted using developed tools measuring participants' reactions and learning. RESULTS: From 2016 to 2018, the IR curriculum has been used to train a total of 165 researchers and practitioners predominantly from African countries, the majority of whom are males (57%) and researchers/academics (79.4%). Participants generally gave positive ratings (e.g. integration of concepts) for their reactions to the training. Under 'learnings', participants indicated improvement in their knowledge in areas such as identification of implementation research problems and questions. CONCLUSION: The approach for training both researchers and practitioners offers a dynamic opportunity for the acquisition and sharing of knowledge for both categories of learners. This approach was crucial in demonstrating a key characteristic of implementation research (e.g. multidisciplinary) practically evident during the training sessions. Using such a model to effectively train participants from various low- and middle-income countries shows the opportunities this training curriculum offers as a capacity-building tool.

Middle-income countries graduating from health aid: Transforming daunting challenges into smooth transitions.

Gavin Yamey and co-authors discuss approaches to providing support for middle-income countries transitioning away from health aid.

Economic burden of family caregiving for elderly population in southern Ghana: the case of a peri-urban district.

BACKGROUND: Health systems in low and lower-middle income countries, particularly in sub-Sahara Africa, often lack the specialized personnel and infrastructure to provide comprehensive care for elderly/ageing populations. Close-to-client community-based approaches are a low-cost way of providing basic care and social support for elderly populations in such resource-constrained settings and family caregivers play a crucial role in that regard. However, family caregiving duties are often unremunerated and their care-related economic burden is often overlooked though this knowledge is important in designing or scaling up effective interventions. The objective of this study, therefore, was to estimate the economic burden of family caregiving for the elderly in southern Ghana. METHODS: The study was a retrospective cross-sectional cost-of-care study conducted in 2015 among family caregivers for elderly registered for a support group in a peri-urban district in southern Ghana. A simple random sample of 98 respondents representative of the support group members completed an interviewer-administered questionnaire. Costs were assessed over a 1-month period. Direct costs of caregiving (including out-of-pocket costs incurred on health care) as well as productivity losses (i.e. indirect cost) to caregivers were analysed. Intangible costs were assessed using the 12-item Zarit burden interview (ZBI) tool and the financial cost dimension of the cost of care index. RESULTS: The estimated average cost of caregiving per month was US$186.18, 66% of which was direct cost. About 78% of the family caregivers in the study reported a high level of caregiving burden (as measured with the ZBI) with females reporting a relatively higher level than males. Further, about 87% of the family caregivers reported a high level of financial stress as a result of caregiving for their elderly relative. CONCLUSION: The study shows that support/caregiving for elderly populations imposes economic burden on families, potentially influencing the economic position of families with attendant implications for equity and future family support for such vulnerable populations.