Organizational capacities of national pharmacovigilance centres in Africa: assessment of resource elements associated with successful and unsuccessful pharmacovigilance experiences.

BACKGROUND: National pharmacovigilance centres (national centres) are gradually gaining visibility as part of the healthcare delivery system in Africa. As does happen in high-income countries, it is assumed that national centres can play a central coordinating role in their national pharmacovigilance (PV) systems. However, there are no studies that have investigated whether national centres in Africa have sufficient organizational capacity to deliver on this mandate and previous studies have reported challenges such as lack of funding, political will and adequate human resources. We conducted interviews with strategic leaders in national centres in 18 African countries, to examine how they link the capacity of their organization to the outcomes of activities coordinated by their centres. Strategic leaders were asked to describe three situations in which activities conducted by their centre were deemed successful and unsuccessful. We analyzed these experiences for common themes and examined whether strategic leaders attributed particular types of resources and relationships with stakeholders to successful or unsuccessful activities. RESULTS: We found that strategic leaders most often attributed successful experiences to the acquisition of political (e.g. legal mandate) or technical (e.g. active surveillance database) resources, while unsuccessful experiences were often attributed to the lack of financial and human resources. Stakeholders that were most often mentioned in association with successful experiences were national government and development partners, whereas national government and public health programmes (PHPs) were often mentioned in unsuccessful experiences. All 18 centres, regardless of maturity of their PV systems had similar challenges. CONCLUSIONS: The study concludes that national centres in Africa are faced with 3 core challenges: (1) over-reliance on development partners, (2) seeming indifference of national governments to provide support after national centres have gained membership of the World Health Organization (WHO) Programme for International Drug Monitoring (PIDM) and (3) engaging public health programmes in a sustainable way.

Equitable access to health insurance for socially excluded children? The case of the National Health Insurance Scheme (NHIS) in Ghana.

To help reduce child mortality and reach universal health coverage, Ghana extended free membership of the National Health Insurance Scheme (NHIS) to children (under-18s) in 2008. However, despite the introduction of premium waivers, a substantial proportion of children remain uninsured. Thus far, few studies have explored why enrolment of children in NHIS may remain low, despite the absence of significant financial barriers to membership. In this paper we therefore look beyond economic explanations of access to health insurance to explore additional wider determinants of enrolment in the NHIS. In particular, we investigate whether social exclusion, as measured through a sociocultural, political and economic lens, can explain poor enrolment rates of children. Data were collected from a cross-sectional survey of 4050 representative households conducted in Ghana in 2012. Household indices were created to measure sociocultural, political and economic exclusion, and logistic regressions were conducted to study determinants of enrolment at the individual and household levels. Our results indicate that socioculturally, economically and politically excluded children are less likely to enrol in the NHIS. Furthermore, households excluded in all dimensions were more likely to be non-enrolled or partially-enrolled (i.e. not all children enrolled within the household) than fully-enrolled. These results suggest that equity in access for socially excluded children has not yet been achieved. Efforts should be taken to improve coverage by removing the remaining small, annually renewable registration fee, implementing and publicising the new clause that de-links premium waivers from parental membership, establishing additional scheme administrative offices in remote areas, holding regular registration sessions in schools and conducting outreach sessions and providing registration support to female guardians of children. Ensuring equitable access to NHIS will contribute substantially to improving child health and reducing child mortality in Ghana.

A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects?

BACKGROUND: The introduction of the national health insurance scheme (NHIS) in Ghana in 2003 significantly contributed to improved health services utilization and health outcomes. However, stagnating active membership, reports of poor quality health care rendered to NHIS-insured clients and cost escalations have raised concerns on the operational and financial sustainability of the scheme. This paper reviewed peer reviewed articles and grey literature on the sustainability challenges and prospects of the NHIS in Ghana. METHODS: Electronic search was done for literature published between 2003-2016 on the NHIS and its sustainability in Ghana. A total of 66 publications relevant to health insurance in Ghana and other developing countries were retrieved from Cochrane, PubMed, ScienceDirect and Googlescholar for initial screening. Out of this number, 31 eligible peer reviewed articles were selected for final review based on specific relevance to the Ghanaian context. RESULTS: Ability of the NHIS to continue its operations in Ghana is threatened financially and operationally by factors such as: cost escalation, possible political interference, inadequate technical capacity, spatial distribution of health facilities and health workers, inadequate monitoring mechanisms, broad benefits package, large exemption groups, inadequate client education, and limited community engagement. Moreover, poor quality care in NHIS-accredited health facilities potentially reduces clients' trust in the scheme and consequently decreases (re)enrolment rates. These sustainability challenges were reviewed and discussed in this paper. CONCLUSIONS: The NHIS continues to play a critical role towards attaining universal health coverage in Ghana albeit confronted by challenges that could potentially collapse the scheme. Averting this possible predicament will largely depend on concerted efforts of key stakeholders such as health insurance managers, service providers, insurance subscribers, policy makers and political actors.

Evaluating a novel neonatal-care assessment tool among trained delivery attendants in a resource-limited setting.

OBJECTIVE: To validate a novel objective structured clinical examination (OSCE) tool for assessing neonatal care skills among delivery attendants trained as part of the Essential Care for Every Baby (ECEB) program and to assess ECEB training effectiveness. METHODS: Between August 1 and September 30, 2015, a cross-sectional study enrolled ECEB-trained healthcare providers who attended deliveries from the Brong Ahafo and Eastern regions of Ghana. Participants completed a previously developed 21-item OSCE tool that assessed neonatal-care competency. Participant performance was scored independently by regional trainers and national master trainers. The inter-rater scoring reliability was assessed using the Cohen kappa coefficient and performance was compared across participant characteristics. RESULTS: The study enrolled 57 trained delivery attendants from 12 district hospitals. Inter-rater agreement was perfect (kappa 1.00) or almost perfect (kappa 0.81-0.99) for nine OSCE items, substantial (kappa 0.61-0.80) or moderate (kappa 0.41-0.60) for 11 items, and fair (kappa 0.21-0.40) for one item. Differences in OSCE-item performance were recorded based on participants' regions, facility type, age, and education level (P<0.05). CONCLUSIONS: In a resource-limited setting, the OSCE tool demonstrated substantial reliability and ECEB-trained healthcare practitioners exhibited satisfactory performance. The OSCE tool could be useful in similar settings and could have potential for up-scaled use in assessing neonatal-management skills.

Assessing the Impact of Community Engagement Interventions on Health Worker Motivation and Experiences with Clients in Primary Health Facilities in Ghana: A Randomized Cluster Trial.

BACKGROUND: Health worker density per 1000 population in Ghana is one of the lowest in the world estimated to be 2.3, below the global average of 9.3. Low health worker motivation induced by poor working conditions partly explain this challenge. Albeit the wage bill for public sector health workers is about 90% of domestic government expenditure on health in countries such as Ghana, staff motivation and performance output remain a challenge, suggesting the need to complement financial incentives with non-financial incentives through a community-based approach. In this study, a systematic community engagement (SCE) intervention was implemented to engage community groups in healthcare quality assessment to promote mutual collaboration between clients and healthcare providers, and enhance health worker motivation levels. SCE involves structured use of existing community groups and associations to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements made and rewards given to best performing facilities for closing quality care gaps. PURPOSE: To evaluate the effect of SCE interventions on health worker motivation and experiences with clients. METHODS: The study is a cluster randomized trial involving health workers in private (n = 38) and public (n = 26) primary healthcare facilities in two administrative regions in Ghana. Out of 324 clinical and non-clinical staff randomly interviewed at baseline, 234 (72%) were successfully followed at end-line and interviewed on workplace motivation factors and personal experiences with clients. Propensity score matching and difference-in-difference estimations were used to estimate treatment effect of the interventions on staff motivation. RESULTS: Intrinsic (non-financial) work incentives including cordiality with clients and perceived career prospects appeared to be prime sources of motivation for health staff interviewed in intervention health facilities while financial incentives were ranked lowest. Intervention health facilities that were assessed by female community groups (Coef. = 0.2720, p = 0.0118) and informal groups with organized leadership structures like Artisans (Coef. = 0.2268, p = 0.0368) associated positively with higher intrinsic motivation levels of staff. CONCLUSION: Community-based approach to health worker motivation is a potential complementary strategy that needs policy deliberation to explore its prospects. Albeit financial incentives remain critical sources of staff motivation, innovative non-financial approaches like SCE should complement the latter.

Perspectives of frontline health workers on Ghana's National Health Insurance Scheme before and after community engagement interventions.

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.

Who uses outpatient healthcare services under Ghana's health protection scheme and why?

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.

Health insurance determines antenatal, delivery and postnatal care utilisation: evidence from the Ghana Demographic and Health Surveillance data.

OBJECTIVE: This study aims to evaluate the effect of maternal health insurance status on the utilisation of antenatal, skilled delivery and postnatal care. DESIGN: A population-based cross-sectional study. SETTING AND PARTICIPANTS: We utilised the 2008 Demographic and Health Survey data of Ghana, which included 2987 women who provided information on maternal health insurance status. PRIMARY OUTCOMES: Utilisation of antenatal, skilled delivery and postnatal care. STATISTICAL ANALYSES: Multivariable logistic regression was applied to determine the independent association between maternal health insurance and utilisation of antenatal, skilled delivery and postnatal care. RESULTS: After adjusting for socioeconomic, demographic and obstetric factors, we observed that among insured women the likelihood of having antenatal care increased by 96% (OR 1.96; 95% CI 1.52 to 2.52; p value<0.001) and of skilled delivery by 129% (OR 2.29; 95% CI 1.92 to 2.74; p value<0.001), while postnatal care among insured women increased by 61% (OR 1.61; 95% CI 1.17 to 2.21; p value<0.01). CONCLUSIONS: This study demonstrated that maternal health insurance status plays a significant role in the uptake of the maternal, neonatal and child health continuum of care service.

Evaluation of alternative school feeding models on nutrition, education, agriculture and other social outcomes in Ghana: rationale, randomised design and baseline data.

BACKGROUND: 'Home-grown' school feeding programmes are complex interventions with the potential to link the increased demand for school feeding goods and services to community-based stakeholders, including smallholder farmers and women's groups. There is limited rigorous evidence, however, that this is the case in practice. This evaluation will examine explicitly, and from a holistic perspective, the simultaneous impact of a national school meals programme on micronutrient status, alongside outcomes in nutrition, education and agriculture domains. The 3-year study involves a cluster-randomised control trial designed around the scale-up of the national school feeding programme, including 116 primary schools in 58 districts in Ghana. The randomly assigned interventions are: 1) a school feeding programme group, including schools and communities where the standard government programme is implemented; 2) 'home-grown' school feeding, including schools and communities where the standard programme is implemented alongside an innovative pilot project aimed at enhancing nutrition and agriculture; and 3) a control group, including schools and households from communities where the intervention will be delayed by at least 3 years, preferably without informing schools and households. Primary outcomes include child health and nutritional status, school participation and learning, and smallholder farmer income. Intermediate outcomes along the agriculture and nutrition pathways will also be measured. The evaluation will follow a mixed-method approach, including child-, household-, school- and community-level surveys as well as focus group discussions with project stakeholders. The baseline survey was completed in August 2013 and the endline survey is planned for November 2015. RESULTS: The tests of balance show significant differences in the means of a number of outcome and control variables across the intervention groups. Important differences across groups include marketed surplus, livestock income, per capita food consumption and intake, school attendance, and anthropometric status in the 2-5 and 5-15 years age groups. In addition, approximately 19 % of children in the target age group received some form of free school meals at baseline. CONCLUSION: Designing and implementing the evaluation of complex interventions is in itself a complex undertaking, involving a multi-disciplinary research team working in close collaboration with programme- and policy-level stakeholders. Managing the complexity from an analytical and operational perspective is an important challenge. The analysis of the baseline data indicates that the random allocation process did not achieve statistically comparable treatment groups. Differences in outcomes and control variables across groups will be controlled for when estimating treatment effects. TRIAL REGISTRATION NUMBER: ISRCTN66918874 (registered on 5 March 2015).

Factors contributing to low uptake and renewal of health insurance: a qualitative study in Ghana.

BACKGROUND: The effort to expand access to healthcare and reduce health inequalities in many low income countries have meant that many have adopted different levels of social health protection mechanisms. Ghana introduced a National Health Insurance Scheme (NHIS) in 2005 with the aim of removing previous barriers created by the user fees financing system. Although the NHIS has made health accessible to some category of people, the majority of Ghanaians (60 %) are not enroled on the scheme. Earlier studies have looked at various factors that account for this low uptake. However, we recognise that this qualitative study will nuance the depth of these barriers to enrolment. METHODS: Minimally structured, qualitative interviews were conducted with key stakeholders at the district, regional and national levels. Focus group discussions were also undertaken at the community level. Using an inductive and content analytic approach, the transcripts were analyzed to identify and define categories that explain low uptake of health insurance. RESULTS: The results are presented under two broad themes: sociocultural and systemic factors. Sociocultural factors identified were 1) vulnerability within certain groups such as the aged and the disabled groups which impeded access to the NHIS 2) cultural and religious norms which discouraged enrolment into the scheme. System-wide factors were 1) inadequate distribution of social infrastructure such as healthcare facilities, 2) weak administrative processes within the NHIS, and 3) poor quality of care. CONCLUSIONS: Mapping the interplay of these dynamic relations between the NHIS, its clients and service providers, the study identifies critical factors at the policy-making level, service provider level, and client level (reflective in household and community level institutional arrangements) that affect enrolment in the scheme. Our findings inform a number of potential reforms in the area of distribution of health resources and cost containment to expand coverage, increase choices and meeting the needs of the end user.

Effect of Community Engagement Interventions on Patient Safety and Risk Reduction Efforts in Primary Health Facilities: Evidence from Ghana.

BACKGROUND: Patient safety and quality care remain major challenges to Ghana's healthcare system. Like many health systems in Africa, this is largely because demand for healthcare is outstripping available human and material resource capacity of healthcare facilities and new investment is insufficient. In the light of these demand and supply constraints, systematic community engagement (SCE) in healthcare quality assessment can be a feasible and cost effective option to augment existing quality improvement interventions. SCE entails structured use of existing community groups to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements identified and rewards provided if the quality gaps are closed. PURPOSE: This paper evaluates whether or not SCE, through the assessment of health service quality, improves patient safety and risk reduction efforts by staff in healthcare facilities. METHODS: A randomized control trail was conducted in 64 primary healthcare facilities in the Greater Accra and Western regions of Ghana. Patient risk assessments were conducted in 32 randomly assigned intervention and control facilities. Multivariate multiple regression test was used to determine effect of the SCE interventions on staff efforts towards reducing patient risk. Spearman correlation test was used to ascertain associations between types of community groups engaged and risk assessment scores of healthcare facilities. FINDINGS: Clinic staff efforts towards increasing patient safety and reducing risk improved significantly in intervention facilities especially in the areas of leadership/accountability (Coef. = 10.4, p<0.05) and staff competencies (Coef. = 7.1, p<0.05). Improvement in service utilization and health resources could not be attributed to the interventions because these were outside the control of the study and might have been influenced by institutional or national level developments between the baseline and follow-up period. Community groups that were gender balanced, religious/faith-based, and had structured leadership appeared to be better options for effective SCE in healthcare quality assessment. CONCLUSION: Community engagement in healthcare quality assessment is a feasible client-centered quality improvement option that should be discussed for possible scale-up in Ghana and other resource poor countries in Africa.

Social capital and active membership in the Ghana National Health Insurance Scheme - a mixed method study.

BACKGROUND: People's decision to enroll in a health insurance scheme is determined by socio-cultural and socio-economic factors. On request of the National health Insurance Authority (NHIA) in Ghana, our study explores the influence of social relationships on people's perceptions, behavior and decision making to enroll in the National Health Insurance Scheme. This social scheme, initiated in 2003, aims to realize accessible quality healthcare services for the entire population of Ghana. We look at relationships of trust and reciprocity between individuals in the communities (so called horizontal social capital) and between individuals and formal health institutions (called vertical social capital) in order to determine whether these two forms of social capital inhibit or facilitate enrolment of clients in the scheme. Results can support the NHIA in exploiting social capital to reach their objective and strengthen their policy and practice. METHOD: We conducted 20 individual- and seven key-informant interviews, 22 focus group discussions, two stakeholder meetings and a household survey, using a random sample of 1903 households from the catchment area of 64 primary healthcare facilities. The study took place in Greater Accra Region and Western Regions in Ghana between June 2011 and March 2012. RESULTS: While social developments and increased heterogeneity seem to reduce community solidarity in Ghana, social networks remain common in Ghana and are valued for their multiple benefits (i.e. reciprocal trust and support, information sharing, motivation, risk sharing). Trusting relations with healthcare and insurance providers are, according healthcare clients, based on providers' clear communication, attitude, devotion, encouragement and reliability of services. Active membership of the NHIS is positive associated with community trust, trust in healthcare providers and trust in the NHIS (p-values are .009, .000 and .000 respectively). CONCLUSION: Social capital can motivate clients to enroll in health insurance. Fostering social capital through improving information provision to communities and engaging community groups in health care and NHIS services can facilitate peoples' trust in these institutions and their active participation in the scheme.

Comparison of Perceived and Technical Healthcare Quality in Primary Health Facilities: Implications for a Sustainable National Health Insurance Scheme in Ghana.

BACKGROUND: Quality care in health facilities is critical for a sustainable health insurance system because of its influence on clients' decisions to participate in health insurance and utilize health services. Exploration of the different dimensions of healthcare quality and their associations will help determine more effective quality improvement interventions and health insurance sustainability strategies, especially in resource constrained countries in Africa where universal access to good quality care remains a challenge. PURPOSE: To examine the differences in perceptions of clients and health staff on quality healthcare and determine if these perceptions are associated with technical quality proxies in health facilities. Implications of the findings for a sustainable National Health Insurance Scheme (NHIS) in Ghana are also discussed. METHODS: This is a cross-sectional study in two southern regions in Ghana involving 64 primary health facilities: 1,903 households and 324 health staff. Data collection lasted from March to June, 2012. A Wilcoxon-Mann-Whitney test was performed to determine differences in client and health staff perceptions of quality healthcare. Spearman's rank correlation test was used to ascertain associations between perceived and technical quality care proxies in health facilities, and ordered logistic regression employed to predict the determinants of client and staff-perceived quality healthcare. RESULTS: Negative association was found between technical quality and client-perceived quality care (coef. = -0.0991, p<0.0001). Significant staff-client perception differences were found in all healthcare quality proxies, suggesting some level of unbalanced commitment to quality improvement and potential information asymmetry between clients and service providers. Overall, the findings suggest that increased efforts towards technical quality care alone will not necessarily translate into better client-perceived quality care and willingness to utilize health services in NHIS-accredited health facilities. CONCLUSION: There is the need to intensify client education and balanced commitment to technical and perceived quality improvement efforts. This will help enhance client confidence in Ghana's healthcare system, stimulate active participation in the national health insurance, increase healthcare utilization and ultimately improve public health outcomes.

'Your health our concern, our health whose concern?': perceptions of injustice in organizational relationships and processes and frontline health worker motivation in Ghana.

Taking a perspective of frontline health workers as internal clients within health systems, this study explored how perceived injustice in policy and organizational matters influence frontline health worker motivation and the consequent effect on workers' attitudes and performance in delivering maternal and neonatal health care in public hospitals. It consisted of an ethnographic study in two public hospitals in Southern Ghana. Participant observation, conversation and in-depth interviews were conducted over a 16-month period. Ethical approval and consent were obtained from relevant persons and authorities. Qualitative analysis software Nvivo 8 was used for coding and analysis of data. Main themes identified in the analysis form the basis for interpreting and reporting study findings. Findings showed that most workers perceived injustice in distributive, procedural and interactional dimensions at various levels in the health system. At the national policy level this included poor conditions of service. At the hospital level, it included perceived inequity in distribution of incentives, lack of protection and respect for workers. These influenced frontline worker motivation negatively and sometimes led to poor response to client needs. However, intrinsically motivated workers overcame these challenges and responded positively to clients' health care needs. It is important to recognize and conceptualize frontline workers in health systems as internal clients of the facilities and organizations within which they work. Their quality needs must be adequately met if they are to be highly motivated and supported to provide quality and responsive care to their clients. Meeting these quality needs of internal clients and creating a sense of fairness in governance arrangements between frontline workers, facilities and health system managers is crucial. Consequently, intervention measures such as creating more open door policies, involving frontline workers in decision making, recognizing their needs and challenges and working together to address them are critical.

Advancing the application of systems thinking in health: provider payment and service supply behaviour and incentives in the Ghana National Health Insurance Scheme--a systems approach.

BACKGROUND: Assuring equitable universal access to essential health services without exposure to undue financial hardship requires adequate resource mobilization, efficient use of resources, and attention to quality and responsiveness of services. The way providers are paid is a critical part of this process because it can create incentives and patterns of behaviour related to supply. The objective of this work was to describe provider behaviour related to supply of health services to insured clients in Ghana and the influence of provider payment methods on incentives and behaviour. METHODS: A mixed methods study involving grey and published literature reviews, as well as health management information system and primary data collection and analysis was used. Primary data collection involved in-depth interviews, observations of time spent obtaining service, prescription analysis, and exit interviews with clients. Qualitative data was analysed manually to draw out themes, commonalities, and contrasts. Quantitative data was analysed in Excel and Stata. Causal loop and cause tree diagrams were used to develop a qualitative explanatory model of provider supply incentives and behaviour related to payment method in context. RESULTS: There are multiple provider payment methods in the Ghanaian health system. National Health Insurance provider payment methods are the most recent additions. At the time of the study, the methods used nationwide were the Ghana Diagnostic Related Groupings payment for services and an itemized and standardized fee schedule for medicines. The influence of provider payment method on supply behaviour was sometimes intuitive and sometimes counter intuitive. It appeared to be related to context and the interaction of the methods with context and each other rather than linearly to any given method. CONCLUSIONS: As countries work towards Universal Health Coverage, there is a need to holistically design, implement, and manage provider payment methods reforms from systems rather than linear perspectives, since the latter fail to recognize the effects of context and the between-methods and context interactions in producing net effects.

Enrolment of older people in social health protection programs in West Africa--does social exclusion play a part?

Although the population of older people in Africa is increasing, and older people are becoming increasingly vulnerable due to urbanisation, breakdown of family structures and rising healthcare costs, most African countries have no social health protection for older people. Two exceptions include Senegal's Plan Sesame, a user fees exemption for older people and Ghana's National Health Insurance Scheme (NHIS) where older people are exempt from paying premiums. Evidence on whether older people are aware of and enrolling in these schemes is however lacking. We aim to fill this gap. Besides exploring economic indicators, we also investigate whether social exclusion determines enrolment of older people. This is the first study that tries to explore the social, political, economic and cultural (SPEC) dimensions of social exclusion in the context of social health protection programs for older people. Data were collected by two cross-sectional household surveys conducted in Ghana and Senegal in 2012. We develop SPEC indices and conduct logistic regressions to study the determinants of enrolment. Our results indicate that older people vulnerable to social exclusion in all SPEC dimensions are less likely to enrol in Plan Sesame and those that are vulnerable in the political dimension are less likely to enrol in NHIS. Efforts should be taken to specifically enrol older people in rural areas, ethnic minorities, women and those isolated due to a lack of social support. Consideration should also be paid to modify scheme features such as eliminating the registration fee for older people in NHIS and creating administration offices for ID cards in remote communities in Senegal.

Do prevailing theories sufficiently explain perceptions and health-seeking behavior of Ghanaians?

The challenges faced by African countries that have pioneered a national health insurance scheme (NHIS) and the lessons learned can be of great value to other countries, contemplating the introduction of such a health financing system. In 2003, Ghana initiated the NHIS to provide access to healthcare for people in both the formal and informal sectors. The paper assesses the applicability of four theoretical models to explain the perceptions and decisions of Ghanaians to participate in the NHIS. To contextualize these models, we used qualitative data from individual and group interviews of Ghanaians. These interviews form part of the study "towards a client-oriented health insurance system in Ghana" to explain the uptake of the Ghanaian social health insurance. The paper argues for a new integrated model to provide a better understanding of clients' perceptions on illness, healthcare and health insurance. Such a model should highlight trust as a fundamental factor influencing the decision of Ghanaians to enroll in the NHIS.

Community concepts of poverty: an application to premium exemptions in Ghana's National Health Insurance Scheme.

BACKGROUND: Poverty is multi dimensional. Beyond the quantitative and tangible issues related to inadequate income it also has equally important social, more intangible and difficult if not impossible to quantify dimensions. In 2009, we explored these social and relativist dimension of poverty in five communities in the South of Ghana with differing socio economic characteristics to inform the development and implementation of policies and programs to identify and target the poor for premium exemptions under Ghana's National Health Insurance Scheme. METHODS: We employed participatory wealth ranking (PWR) a qualitative tool for the exploration of community concepts, identification and ranking of households into socioeconomic groups. Key informants within the community ranked households into wealth categories after discussing in detail concepts and indicators of poverty. RESULTS: Community defined indicators of poverty covered themes related to type of employment, educational attainment of children, food availability, physical appearance, housing conditions, asset ownership, health seeking behavior, social exclusion and marginalization. The poverty indicators discussed shared commonalities but contrasted in the patterns of ranking per community. CONCLUSION: The in-depth nature of the PWR process precludes it from being used for identification of the poor on a large national scale in a program such as the NHIS. However, PWR can provide valuable qualitative input to enrich discussions, development and implementation of policies, programs and tools for large scale interventions and targeting of the poor for social welfare programs such as premium exemption for health care.

Establishing and sustaining research partnerships in Africa: a case study of the UK-Africa Academic Partnership on Chronic Disease.

This paper examines the challenges and opportunities in establishing and sustaining north-south research partnerships in Africa through a case study of the UK-Africa Academic Partnership on Chronic Disease. Established in 2006 with seed funding from the British Academy, the partnership aimed to bring together multidisciplinary chronic disease researchers based in the UK and Africa to collaborate on research, inform policymaking, train and support postgraduates and create a platform for research dissemination. We review the partnership's achievements and challenges, applying established criteria for developing successful partnerships. During the funded period we achieved major success in creating a platform for research dissemination through international meetings and publications. Other goals, such as engaging in collaborative research and training postgraduates, were not as successfully realised. Enabling factors included trust and respect between core working group members, a shared commitment to achieving partnership goals, and the collective ability to develop creative strategies to overcome funding challenges. Barriers included limited funding, administrative support, and framework for monitoring and evaluating some goals. Chronic disease research partnerships in low-income regions operate within health research, practice, funding and policy environments that prioritise infectious diseases and other pressing public health and developmental challenges. Their long-term sustainability will therefore depend on integrated funding systems that provide a crucial capacity building bridge. Beyond the specific challenges of chronic disease research, we identify social capital, measurable goals, administrative support, creativity and innovation and funding as five key ingredients that are essential for sustaining research partnerships.

Confidential inquiries into maternal deaths: modifications and adaptations in Ghana and Indonesia.

OBJECTIVE: Factors contributing to the limited use of confidential inquiries into maternal deaths include the negative focus and demotivating effect of such inquiries, perceptions of unavailability of sufficient documentation of events, and lack of time and resources. To ascertain whether these problems can be overcome, variations to confidential inquiries into maternal deaths were introduced in Ghana and Indonesia. METHODS: Clinical review panels were set up as part of the usual process of confidential inquiries, and modifications to the confidential inquiries were introduced. In Ghana, the traditional confidential inquiry process focusing on health facility care was modified to introduce the assessment of positive factors. In addition to the assessment of positive factors, adaptations in Indonesia consisted of including cases of obstetric complications, as well as deaths, and the use of interview testimonials as data sources. Information about resource and time needs for conducting confidential inquiries was collected. RESULTS: The introduction of positive aspects to the process provided a balanced and more motivating setting for the inquiry. The data obtained from case notes in district hospitals and interview testimonials provided sufficient information to assess why maternal deaths and severe complications occurred. The costs of conducting the inquiries ranged from US $4000 to US $11000 (per study), and the estimated time required for a panel member to review each case was more than 3 hours. CONCLUSION: This study introduced practical ways to encourage the implementation of maternal death reviews, inquiries, and audits that are context specific and, therefore, acceptable to local practitioners.