Formalising 'informal' mHealth in Ghana: Opportunities and challenges for Universal Health Coverage (UHC).

While mobile phones promise to be an important tool for bridging the healthcare gaps in resource-poor areas in developing countries, scalability and sustainability of mobile phones for health (mhealth) interventions still remain a major challenge. Meanwhile, health workers are already using their own mobile phones (referred to as 'informal mhealth') to facilitate healthcare delivery in diverse ways. Therefore, this paper explores some strategies for integrating 'informal mHealth' in the healthcare delivery of Ghana, by highlighting some opportunities and challenges. The study mainly employed a combination of literature review, focus group discussions and key informant interviews with community health nurses (CHNs) and other stakeholders, who were purposively selected from the three ecological zones in Ghana. The study found that, while scale-up of 'formal mhealth' remains challenging in Ghana, almost all CHNs in our study are using their personal mobile phones 'informally' to bridge healthcare gaps, thereby promoting universal health coverage. This provides opportunities for promoting (or formalising) 'informal' mhealth in Ghana, in spite of some practical challenges in the use of personal mobile phones that need to be addressed to ensure sustainable healthcare delivery in the country.

Mobile phone use and the welfare of community health nurses in Ghana: An analysis of unintended costs.

The use of mobile phones is fast transforming the healthcare delivery landscape in Ghana. A substantial number of health facilities are now dependent on mobile phones to facilitate their work. Evidence of the use of mobile phones in Ghana's healthcare is however limited. In order to contribute to the evidence of the value of using mobile phones to promote healthcare, we interrogated and highlighted unexpected costs imposed on community health nurses who use their personal mobile phones for healthcare delivery in the country. Data for the study were derived from 598 completed questionnaires and extracts from focus group discussions with community health nurses who were sampled from three regions across the three main ecological zones of Ghana. The results show that over 90% of nurses bear the cost of paying for airtime, bundles and chargers used for work-related activities, yet less than 10% of them receive direct compensation. This costly burden has the potential to demotivate the nurses and threaten the country's progress towards the achievement of universal health coverage. More significantly, the data strongly suggest that physical distance, regional location and gender are the main factors triggering extra costs incurred by the nurses. We conclude that the use of personal mobile phones for healthcare delivery imposed huge financial burden on community health workers in Ghana. A suggested intervention to forestall negative consequences on performance is to offer incentive packages to nurses as a compensation for the financial and non-physical costs of using personal mobile phones for work-related activities.

Informal mhealth at scale in Africa: Opportunities and challenges.

The extraordinary global growth of digital connectivity has generated optimism that mobile technologies can help overcome infrastructural barriers to development, with 'mobile health' (mhealth) being a key component of this. However, while 'formal' (top-down) mhealth programmes continue to face challenges of scalability and sustainability, we know relatively little about how health-workers are using their own mobile phones informally in their work. Using data from Ghana, Ethiopia and Malawi, we document the reach, nature and perceived impacts of community health-workers' (CHWs') 'informal mhealth' practices, and ask how equitably these are distributed. We implemented a mixed-methods study, combining surveys of CHWs across the three countries, using multi-stage proportional-to-size sampling (N = 2197 total), with qualitative research (interviews and focus groups with CHWs, clients and higher-level stake-holders). Survey data were weighted to produce nationally- or regionally-representative samples for multivariate analysis; comparative thematic analysis was used for qualitative data. Our findings confirm the limited reach of 'formal' compared with 'informal' mhealth: while only 15% of CHWs surveyed were using formal mhealth applications, over 97% reported regularly using a personal mobile phone for work-related purposes in a range of innovative ways. CHWs and clients expressed unequivocally enthusiastic views about the perceived impacts of this 'informal health' usage. However, they also identified very real practical challenges, financial burdens and other threats to personal wellbeing; these appear to be borne disproportionately by the lowest-paid cadre of health-workers, especially those serving rural areas. Unlike previous small-scale, qualitative studies, our work has shown that informal mhealth is already happening at scale, far outstripping its formal equivalent. Policy-makers need to engage seriously with this emergent health system, and to work closely with those on the ground to address sources of inequity, without undermining existing good practice.

Managing uncertainty in medicine quality in Ghana: The cognitive and affective basis of trust in a high-risk, low-regulation context.

Where regulation is weak, medicine transactions can be characterised by uncertainty over the drug quality and efficacy, with buyers shouldering the greater burden of risk in exchanges that are typically asymmetric. Drawing on in-depth interviews (N = 220) and observations of medicine transactions, plus interviews with regulators (N = 20), we explore how people in Ghana negotiate this uncertainty and come to trust a medicine enough to purchase or ingest it. We identify two mechanisms - attempts to mitigate uncertainty through seeking observable signs of quality and attempts to reduce informational asymmetry - that underpin cognitive assessments of a medicine's trustworthiness. However, these 'cognitive' forms of trust assessment have limited traction where uncertainty is high and trustworthiness remains unknowable, so a third mechanism comes into play: one based on affective relationships within which transactions are socially embedded. Even these, however, cannot eliminate uncertainty, because of the dispersed and under-regulated nature of wider supply chains. In conclusion, we reflect on the need for careful research on actors' practices and decision-making across supply chains to inform more effective policy and regulation.

Who bears the cost of 'informal mhealth'? Health-workers' mobile phone practices and associated political-moral economies of care in Ghana and Malawi.

Africa's recent communications 'revolution' has generated optimism that using mobile phones for health (mhealth) can help bridge healthcare gaps, particularly for rural, hard-to-reach populations. However, while scale-up of mhealth pilots remains limited, health-workers across the continent possess mobile phones. This article draws on interviews from Ghana and Malawi to ask whether/how health-workers are using their phones informally and with what consequences. Health-workers were found to use personal mobile phones for a wide range of purposes: obtaining help in emergencies; communicating with patients/colleagues; facilitating community-based care, patient monitoring and medication adherence; obtaining clinical advice/information and managing logistics. However, the costs were being borne by the health-workers themselves, particularly by those at the lower echelons, in rural communities, often on minimal stipends/salaries, who are required to 'care' even at substantial personal cost. Although there is significant potential for 'informal mhealth' to improve (rural) healthcare, there is a risk that the associated moral and political economies of care will reinforce existing socioeconomic and geographic inequalities.

The impact of gender and physical environment on the handwashing behaviour of university students in Ghana.

OBJECTIVES: To establish levels of handwashing after defecation among students at the University of Cape Coast in Ghana, and to test hypotheses that gender and washroom environment affect handwashing behaviour. METHODS: Data on students' handwashing behaviour after defecation were collected by structured observations in washrooms. Eight hundred and six observations were made (360 female students and 446 males) in 56 washrooms over 496 observation periods. Observers recorded gender, duration of handwashing, use of soap, and physical characteristics of the washroom (cleanliness, availability of soap, tap flow and presence of handwashing posters). RESULTS: Fewer than half the students observed washed their hands or bathed after defecation. Of these, only two-thirds washed both hands and a minority (20%) used soap; only 16 students (all men) washed their hands for the recommended 15 s or longer. Female students were more likely to wash their hands at all, and were more likely to wash both hands, than males. Cleanliness of the washroom was strongly associated with improved handwashing behaviour for both women and men, as was tap flow quality for female students. CONCLUSIONS: Handwashing behaviour is generally poor among UCC students, mirroring results from North American Universities. The findings underline the plasticity of handwashing behaviour among this population, and highlight the need for ensuring that the physical environment in washrooms on university campuses is conducive to handwashing.

Community perceptions of human excreta as fertilizer in peri-urban agriculture in Ghana.

Although human excreta contain the necessary nutrients for plant growth, local authorities in Ghana spend huge sums of money to dispose them as waste. Reusing excreta for agricultural purposes saves expenditure for chemical fertilizers, improves soil fertility, reduces poverty and ensures food security. People's attitudes and perceptions about excreta vary between cultures and even within specific cultures. This study aimed to explore attitudes and perceptions among a peri-urban agricultural community towards sanitized human excreta and its use. The study adopted an exploratory design and collected data from 154 randomly selected households using questionnaires and focus group discussions. It was found that there is a general negative attitude to fresh excreta and the handling of it. However, the residents accept that excreta can be used as fertilizer, but they are not willing to use it on their own crops or consume crops fertilized with excreta. The study recommends open discussions in the community for a successful implementation of ecological sanitation.