Economic burden and coping mechanisms by tuberculosis treatment supporters: a mixed method approach from Bono Region, Ghana.

BACKGROUND: The Directly Observed Therapy Short Course (DOTS) strategy recommended by World Health Organization for tuberculosis control requires multiple clinic visits which may place economic burden on treatment supporters especially those with low socio-economic status. The End tuberculosis goal targeted eliminating all tuberculosis associated costs. However, the economic burden and coping mechanisms by treatment supporters is unknown in Ghana. OBJECTIVES: The study determined the economic burden and coping mechanism by treatment supporters in Bono Region of Ghana. METHODS: Cross-sectional study using mixed method approach for data collection. For the quantitative data, a validated questionnaire was administered to 385 treatment supporters. Sixty in-depth interviews with treatment supporters to elicit information about their coping mechanisms using a semi-structured interview guide for the qualitative data. Descriptive statistics, costs estimation, thematic analysis and bivariate techniques were used for the data analysis. RESULTS: Averagely, each treatment supporter spent GHS 112.4 (US$21.1) on treatment support activities per month which is about 19% of their monthly income. Borrowing of money, sale of assets, used up saving were the major coping mechanisms used by treatment supporters. Highest level of education, household size, marital status and income level significantly influence both the direct and indirect costs associated with tuberculosis treatment support. The significant levels were set at 95% confidence interval and p < 0.05. CONCLUSION: We concludes that the estimated cost and coping mechanisms associated with assisting tuberculosis patients with treatment is significant to the tuberculosis treatment supporters. If not mitigated these costs have the tendency to worsen the socio-economic status and future welfare of tuberculosis treatment supporters.

Understanding the policy dynamics of COVID-19 vaccination in Ghana through the lens of a policy analytical framework.

BACKGROUND: Ghana became the first African country to take delivery of the first wave of the AstraZeneca/Oxford vaccine from the COVAX facility. But why has this promising start of the vaccination rollout not translated into an accelerated full vaccination of the population? To answer this question, we drew on the tenets of a policy analytical framework and analysed the diverse interpretations, issue characteristics, actor power dynamics and political context of the COVID-19 vaccination process in Ghana. METHODS: We conducted a rapid online review of media reports, journal articles and other documents on debates and discussions of issues related to framing of the vaccination rollout, social constructions generated around vaccines, stakeholder power dynamics and political contentions linked to the vaccination rollout. These were complemented by desk reviews of parliamentary reports. RESULTS: The COVID-19 vaccination was mainly framed along the lines of public health, gender-centredness and universal health coverage. Vaccine acquisition and procurement were riddled with politics between the ruling government and the largest main opposition party. While the latter persistently blamed the former for engaging in political rhetoric rather than a tactical response to vaccine supply issues, the former attributed vaccine shortages to vaccine nationalism that crowded out fair distribution. The government's efforts to increase vaccination coverage to target levels were stifled when a deal with a private supplier to procure 3.4 million doses of the Sputnik V vaccine collapsed due to procurement breaches. Amidst the vaccine scarcity, the government developed a working proposal to produce vaccines locally which attracted considerable interest among pharmaceutical manufacturers, political constituents and donor partners. Regarding issue characteristics of the vaccination, hesitancy for vaccination linked to misperceptions of vaccine safety provoked politically led vaccination campaigns to induce vaccine acceptance. CONCLUSIONS: Scaling up vaccination requires political unity, cohesive frames, management of stakeholder interests and influence, and tackling contextual factors promoting vaccination hesitancy.

Prevalence, patterns and beliefs about the use of herbal medicinal products in Ghana: a multi-centre community-based cross-sectional study.

OBJECTIVE: Worldwide, herbal medicinal products (HMPs) play key roles in healthcare systems, especially in developing countries, yet there is inconsistent evidence about their prevalence and patterns of use in Ghana. This study therefore sought to determine the prevalence, patterns and beliefs about the use of HMPs in Ghana. METHODS: A descriptive community-based cross-sectional survey was conducted using a researcher-administered questionnaire on 1364 adults, selected from five communities for each of the ecological zones in Ghana using a multi-stage sampling procedure. The study was conducted between December 2019 and March 2020. RESULTS: The prevalence of ever use of HMPs was 76.5% with 73.0% of respondents using these products within the past year. Almost 60% of respondents reported using HMPs that were registered by the Ghana Food and Drugs Authority. About 56.7% used these products to cure diseases. All the sociodemographic characteristics (age, religion, marital status, educational level and employment status) except for sex were significantly associated with the use of HMPs (P < 0.001). For beliefs about HMPs, the proportion of respondents classified to be accepting, ambivalent, indifferent and sceptical was 14.3%, 25.2%, 47.5% and 13.07%, respectively. About 62.2% of study participants had plans to use HMPs in the future, and 69.1% were willing to encourage others to use such products. However, 51.6% of the participants did not perceive HMPs as more effective and safe compared with orthodox products. CONCLUSION: The prevalence of use of HMPs in Ghana is high, thus suggesting an appropriate public health policy to improve the regulation of these products and also provide basis for the integration of HMPs into the healthcare system in Ghana.

Pharmacy premises licensing policy formulation: experience from Ghana.

BACKGROUND: Licences to operate pharmacy premises are issued by statutory regulatory bodies. The Health Institutions and Facilities Act (Act 829) and Health Professions Regulatory Bodies Act (Act 857) regulate pharmacy premises and the business of supplying restricted medicines by retail, respectively, and this could create a potential regulatory overlap for pharmacy practice in Ghana. We theorise that the potential overlap of regulation duties stems from how law-makers framed issues and narratives during the formulation of these Acts. OBJECTIVE: To describe the policy actors involved, framing of narratives and decision-making processes relating to pharmacy premises licensing policy formulation. METHODS: A qualitative study was conducted and data gathered through interviewing eight key informants and reviewing Hansards, reports, bills, memoranda and Acts 829 and 857. Data were analysed to map decision-making venues, processes, actors and narratives. RESULTS: The Ministry of Health drafted the bills in July 2010 with the consensus of internal stakeholders. These were interrogated by the Parliament Select Committee on Health (with legislative power) during separate periods, and decisions made in Parliament to alter propositions of pharmacy premises regulations. Parliamentarians framed pharmacies as health facilities and reassigned their regulation from the Pharmacy Council to a new agency. The Pharmacy Council and the Pharmaceutical Society of Ghana could not participate in the decision-making processes in Parliament to oppose these alterations. The laws' contents rested with parliamentarians as they made decisions in venues restricted to others. Legislative procedure limited participation, although non-legislative actors had some level of influence on the initial content. CONCLUSION: Implementation of these laws would have implications for policy and practice and therefore understanding how the laws were framed and formulated is important for further reforms. We recommend additional research to investigate the impact of the implementation of these Acts on pharmacy practice and business in Ghana and the findings can serve as bargaining information for reforms.

Examining the implementation of the Linda Mama free maternity program in Kenya.

BACKGROUND: In 2013, Kenya introduced a free maternity policy in all public healthcare facilities. In 2016, the Ministry of Health shifted responsibility for the program, now called Linda Mama, to the National Hospital Insurance Fund (NHIF) and expanded access beyond public sector. This study aimed to examine the implementation of the Linda Mama program. METHODS: We conducted a mixed-methods cross-sectional study at the national level and in 20 purposively sampled facilities across five counties in Kenya. We collected data using in-depth interviews (n = 104), administered patient-exit questionnaires (n = 108), and carried out document reviews. Qualitative data were analysed using a framework approach while quantitative data were analysed descriptively. RESULTS: Linda Mama was designed and resulted in improved accountability and expand benefits. In practice however, beneficiaries did not access some services that were part of the revised benefit package. Second, out of pocket payments were still being incurred by beneficiaries. Health facilities in most counties had lost financial autonomy and had no access to reimbursements from NHIF for services provided; but those with financial autonomy were able to boost facility revenue and enhance service delivery. Further, fund disbursements from NHIF were characterised by delays and unpredictability. Implementation experiences reveal that there was inadequate communication, claim processing challenges and reimbursement rates were deemed insufficient. CONCLUSIONS: Our findings show that there are challenges associated with the implementation of the Linda Mama program and highlights the need for process evaluations for programs to track implementation, ensure continuous learning, and provide opportunities for course correcting programs' implementation.

Education of pharmacists in Ghana: evolving curriculum, context and practice in the journey from dispensing certificate to doctor of pharmacy certificate.

BACKGROUND: Understanding the origin and evolution of education of pharmacists is important for practice and health system reforms. In Ghana, education of pharmacists started in the 1880s with the training of dispensers in a government hospital. Over the years, the curriculum and institutional arrangements changed and currently pharmacists are trained in universities. In this study we explored how and why education of pharmacists evolved in Ghana. METHODS: We used a case study design to systematically describe education of pharmacists reforms. Data was collected from October 2018 and December 2019 through document review and in-depth interviews. The data was analysed based on institutional arrangements and contextual factors influencing reforms from the 1880s through 2012, when the Doctor of pharmacy programme was initiated in Ghana. RESULTS: Reforms occurred around four main periods when institutional arrangements including the certificate awarded and expected roles were modified by educators and government. These are: (1) the Certificate of dispensing with dispenser-in-training and nurse-dispenser schemes (1880s to 1942), when dispensers were trained to assist doctors in dispensing or directly diagnosing and treating specific disease conditions. (2) the Diploma and Certificate of competency with the dispenser-in-training and pupil pharmacist schemes (1943 to 1960), where in addition to existing roles, pharmacists operated village dispensers. (3) the Bachelor of pharmacy degree (1961 to 2017), when pharmacists were trained mainly as medicines experts with a strong science base on all aspects of medicines from production, distribution and use; and over time with a gradual move to patient-oriented practice. (4) the Doctor of pharmacy degree (2012 to date), where in addition to existing roles, trainees are exposed to advance professional practice experiences. Important factors influencing the reforms included, health systems demands for village dispensaries and clinically oriented pharmacists, and harmonization with regional and international training and practice. CONCLUSION: Reasons influencing education of pharmacists reforms are context specific and are driven by historical experiences, national and international expectations as well as educators and regulators abilities to influence change. These reforms call for direct corresponding change in professional practice laws and regulation to enable pharmacists contribute fully to health care delivery in Ghana.

Towards an explanatory framework for national level maternal health policy agenda item evolution in Ghana: an embedded case study.

BACKGROUND: Understanding decision-making processes that influence the fate of items on the health policy agenda at national level in low- and middle-income countries is important because of the implications for programmes and outcomes. This paper seeks to advance our understanding of these processes by asking how and why maternal health policy agenda items have fared in Ghana between 1963 and 2014. METHODS: The study design was a single case study of maternal health agenda evolution once on a decision pathway in Ghana, with three different agenda items as sub-units of analysis (fee exemptions for maternal health, free family planning and primary maternal health as part of a per capita provider payment system). Data analysis involved chronologically reconstructing how maternal health policy items evolved over time. RESULTS: The fate of national level maternal health policy items was heavily influenced by how stakeholders (bureaucrats, professional bodies, general public and developmental partners) exercised power to put forward and advocate for specific ideas through processes of issues framing within a changing political and socioeconomic context. The evolution and fate of an agenda item once on a decision pathway involved an iterative process of interacting drivers shaping decisions through cycles of 'active' and 'static' pathways. Items could move from 'active' to 'static' pathways, depending on changing context and actor positions. Items that pursued the 'static' pathway in a particular cycle fell into obscurity by a process that could be described as a form of 'no decision made' in that an explicit decision was not taken to drop the item, but neither was any policy content agreed. Low political interest was exhibited and attempts to bring the item back into active decision-making were made by actors mainly in the bureaucratic arena seeking and struggling (unsuccessfully) to obtain financial and institutional support. Policy items that pursued 'active' pathways showed opposite characteristics and generally moved beyond agenda into formulation and implementation. CONCLUSION: Policy change requires sustaining policy agenda items into formulation and implementation. To do this, change agents need to understand and work within the relevant context, stakeholder interests, power, ideas and framing of issues.

Technical analysis, contestation and politics in policy agenda setting and implementation: the rise and fall of primary care maternal services from Ghana's capitation policy.

BACKGROUND: Why issues get on the policy agenda, move into policy formulation and implementation while others drop off in the process is an important field of enquiry to inform public social policy development and implementation. This paper seeks to advance our understanding of health policy agenda setting, formulation and implementation processes in Ghana, a lower middle income country by exploring how and why less than three months into the implementation of a pilot prior to national scale up; primary care maternal services that were part of the basket of services in a primary care per capita national health insurance scheme provider payment system dropped off the agenda. METHODS: We used a case study design to systematically reconstruct the decisions and actions surrounding the rise and fall of primary care maternal health services from the capitation policy. Data was collected from July 2012 and August 2014 through in-depth interviews, observations and document review. The data was analysed drawing on concepts of policy resistance, power and arenas of conflict. RESULTS: During the agenda setting and policy formulation stages; predominantly technical policy actors within the bureaucratic arena used their expertise and authority for consensus building to get antenatal, normal delivery and postnatal services included in the primary care per capita payment system. Once policy implementation started, policy makers were faced with unanticipated resistance. Service providers, especially the private self-financing used their professional knowledge and skills, access to political and social power and street level bureaucrat power to contest and resist various aspects of the policy and its implementation arrangements - including the inclusion of primary care maternal health services. The context of intense public arena conflicts and controversy in an election year added to the high level political anxiety generated by the contestation. The President and Minister of Health responded and removed antenatal, normal delivery and postnatal care from the per capita package. CONCLUSION: The tensions and complicated relationships between technical considerations and politics and bureaucratic versus public arenas of conflict are important influences that can cause items to rise and fall on policy agendas.

The role of policy actors and contextual factors in policy agenda setting and formulation: maternal fee exemption policies in Ghana over four and a half decades.

BACKGROUND: Development of health policy is a complex process that does not necessarily follow a particular format and a predictable trajectory. Therefore, agenda setting and selecting of alternatives are critical processes of policy development and can give insights into how and why policies are made. Understanding why some policy issues remain and are maintained whiles others drop off the agenda is an important enquiry. This paper aims to advance understanding of health policy agenda setting and formulation in Ghana, a lower middle-income country, by exploring how and why the maternal (antenatal, delivery and postnatal) fee exemption policy agenda in the health sector has been maintained over the four and half decades since a 'free antenatal care in government facilities' policy was first introduced in October 1963. METHODS: A mix of historical and contemporary qualitative case studies of nine policy agenda setting and formulation processes was used. Data collection methods involved reviews of archival materials, contemporary records, media content, in-depth interviews, and participant observation. Data was analysed drawing on a combination of policy analysis theories and frameworks. RESULTS: Contextual factors, acting in an interrelating manner, shaped how policy actors acted in a timely manner and closely linked policy content to the intended agenda. Contextual factors that served as bases for the policymaking process were: political ideology, economic crisis, data about health outcomes, historical events, social unrest, change in government, election year, austerity measures, and international agendas. Nkrumah's socialist ideology first set the agenda for free antenatal service in 1963. This policy trajectory taken in 1963 was not reversed by subsequent policy actors because contextual factors and policy actors created a network of influence to maintain this issue on the agenda. Politicians over the years participated in the process to direct and approve the agenda. Donors increasingly gained agenda access within the Ghanaian health sector as they used financial support as leverage. CONCLUSION: Influencers of policy agenda setting must recognise that the process is complex and intertwined with a mix of political, evidence-based, finance-based, path-dependent, and donor-driven processes. Therefore, influencers need to pay attention to context and policy actors in any strategy.

How and why pharmaceutical reforms contribute to universal health coverage through improving equitable access to medicines: a case of Ghana.

Background: Examining how and why a country prioritizes and implements pharmaceutical reforms tends to show complex processes and myriad efforts made toward improving access to medicines. This study examines factors that enabled the prioritization and implementation of selected pharmaceutical reform items and how these factors contributed to improving equitable access to medicines and universal health coverage in Ghana. Methods: An analytical framework was developed to identify variables to explore in answering the study questions and frame the analysis and presentation of findings. Documents analyzed included the National Medicines Policies, Health Sector Program of Work, and other health policies. Quantitative data were sourced from databases maintained by World Health Organization and the Institute for Health Metrics and Evaluation. Results: The three main factors, evidence, financial and technical support, and alignment to national and global policies, influenced the prioritization and implementation of access to medicines reforms. The reforms targeted rational selection and use of medicines, medicine pricing, sustainable medicine financing, and regulatory and supply chain systems. Although there were limited quantitative data to quantify access to medicine policies" impact on universal health coverage, it can be reasonably assumed that, in Ghana, access to medicine policies has contributed to financial protection and improved access to quality health services. Conclusion: Access to medicine policies targeted at promoting rational medicine selection and use, regulating medicine pricing and improving sustainable financing for medicines as well as the regulatory and supply chain systems arguably contributed to the attainment of UHC and must be sustained. Therefore, data collection and reporting indicators for access to medicines must be prioritized.

Biopsychosocial analysis of antibiotic use for the prevention or management of COVID-19 infections: A scoping review.

BACKGROUND: The novelty and complexity of the COVID-19 pandemic has resulted in various coping mechanisms adopted by individuals as a means of averting the perceived fatalities of the pandemic. The use of antibiotics in the management of COVID-19 is clinically recommended under specific conditions. However, there are increasing trends of non-adherence to the recommended criteria resulting in the unwarranted use of antibiotics as an adaptative approach to the ongoing pandemic. OBJECTIVE: The objective was to identify and classify factors associated with the unwarranted use of antibiotics in the management of COVID-19 from published literature and the perspectives of key stakeholders along a Biopsychosocial model. METHODS: Literature was searched in the following databases: PubMed/MEDLINE, Scopus, Embase and Google Scholar for studies published between 31st December 2019 and 31st January 2022. The Arskey and O'Malley framework modified by Levac in the six-stage methodological process was adopted for this review and included: a) identification of research questions, b) identification of relevant research articles, c) selection of studies, d) data charting and synthesis, e) summary, discussion and analysis, and f) stakeholder consultations. RESULTS: Out of 10,252 records identified from all sources, 12 studies were selected for inclusion in this scoping review. The selected articles reflected both antibiotic use and COVID-19 whilst capturing the biological (medical) and psychosocial perspectives. Most of the studies reported the overuse or abuse of Azithromycin especially in hospital settings. Common themes across the review and stakeholder consultations included fear, anxiety, media influences and deficits in public knowledge. CONCLUSION: The findings of the study highlight the complexity of antibiotic control especially in the context of a pandemic. The identified determinants of antibiotic use provide the necessary framework to simulate health emergencies and be better positioned in the future through the development of targeted and comprehensive policies on antibiotic stewardship.

Determinants of tuberculosis treatment support costs to the treatment supporters in rural Ghana.

Background: The Ghana Health Service has been implementing the Directly Observed Therapy Short Course (DOTS) strategy for decades now, to cure and reduce the transmission of tuberculosis. DOTS strategy requires TB patients and their treatment supporters to make multiple clinic visits in the course of treatment, and this may place financial burden on treatment supporters with low socio-economic status. However, the determinants of tuberculosis treatment support costs to treatment supporters are unknown in Ghana. Objectives: This study determined the costs associated with treatment support to the treatment supporters in Bono Region, Ghana. Methods: In a cross-sectional study using cost-of-illness approach, 385 treatment supporters were selected and interviewed. A validated questionnaire for the direct and indirect costs incurred was used. Descriptive statistics and bivariate techniques were used for data analysis. Results: Averagely, each treatment supporter spent GHS 122.4 (US$ 21.1) on treatment support activities per month, which is about 19% of their monthly income. The findings also revealed that highest level of education, household size, monthly income and district of residence were significant predictors of the direct costs. On the other hand, gender of the respondents, highest level of education, ethnicity, household size, income level and relationship with patient were some of the factors that significantly influenced the indirect costs. The significance levels were set at a 95% confidence interval and p < 0.05. Conclusion: The study concludes that the estimated cost associated with assisting tuberculosis patients with treatment is significant to treatment supporters. If these costs are not mitigated, they have the tendency of affecting the socio-economic status and welfare of individuals assisting tuberculosis patients with treatment.

Advanced pharmacy practice of a doctor of pharmacy student at an allied surgical ward in a hospital in Africa.

Introduction: The pharmacy profession is undergoing transformational change in Ghana. The role of pharmacists has become more patient-focused with increased accountability and responsibility. Aim: This study is aimed at reporting the experiential learning on the clinical interventions made and documented at the Allied Surgical Wards of Korle-Bu Teaching Hospital (KBTH).This involves a review of patient's medical records during the Advanced Pharmacy Practice Experience (APPE) learning. One case each from Eye, Ear, Nose, Throat, (ENT) and Dental units' subspecialty were reviewed from October 7, 2019 to November 15, 2019 b y a Pharm D student. Conclusion: The student was able to make prompt clinical interventions that contributed to patient care in clinical wards assigned during her clinical clerkship.

Implementation of Medicines Pricing Policies in Ghana: The Interplay of Policy Content, Actors' Participation, and Context.

BACKGROUND: Implementing medicines pricing policy effectively is important for ensuring equitable access to essential medicines and ultimately achieving universal health coverage. However, published analyses of policy implementations are scarce from low- and middleincome countries. This paper contributes to bridging this knowledge gap by reporting analysis of implementation of two medicines pricing policies in Ghana: value-added tax (VAT) exemptions and framework contracting (FC) for selected medicines. We analysed implications of actor involvements, contexts, and contents on the implementation of these policies, and the interplay between these. This paper should be of interest, and relevance, to policy designers, implementers, the private sector and policy analysts. METHODS: Data were collected through document reviews (n=18), in-depth interviews (n=30), focus groups (n=2) and consultative meetings (n=6) with purposefully identified policy actors. Data were analysed thematically, guided by the four components of the health policy triangle framework. RESULTS: The nature and complexity of policy contents determined duration and degree of formality of implementation processes. For instance, in the FC policy, negotiating medicines prices and standardizing the tendering processes lengthened implementation. Highly varied stakeholder participation created avenues for decision-making and promoted inclusiveness, but also raised the need to manage different agendas and interests. Key contextual enablers and constraints to implementation included high political support and currency depreciation, respectively. The interrelatedness of policy content, actors, and context influenced the timeliness of policy implementations and achievement of intended outcomes, and suggest five attributes of effective policy implementation: (1) policy nature and complexity, (2) inclusiveness, (3) organizational feasibility, (4) economic feasibility, and (5) political will and leadership. CONCLUSION: Varied contextual factors, active participation of stakeholders, nature, and complexity of policy content, and structures have all influenced the implementation of medicines pricing policies in Ghana.

Institutionalizing Health Technology Assessment in Ghana: Enablers, Constraints, and Lessons.

Health Technology Assessment (HTA) has been institutionalized in Ghana with structures, processes, and methods. This paper identifies and analyzes the policy players involved; the way in which issues were framed; and the manner in which administrative structures were used to set the agenda for, adopt, and implement HTA. It shows that the Ministry of Health, supported by other players, led HTA agenda-setting through training activities and discussions on evidence of selection pharmaceuticals, medical devices, and other health-related technologies. HTA was then captured in a health sector aide memoire that summarized the decisions made at a national health summit. In implementing the HTA policy, technical working groups and a steering committee were constituted to provide recommendations to the minister of health on high-level decisions. The ability of agenda influencers to maneuver existing administrative and bureaucratic structures, align them with national strategic goals, and sustain HTA implementation enabled Ghana to institutionalize HTA. Limited financial support and a dearth of in-country expertise are being addressed through capacity building and funding. To ensure early national buy-in and uptake, policy makers and agenda influencers need to understand each country's health system and align HTA with national policy decision-making processes.

Perspectives of frontline health workers on transition from development assistance for health in Ghana: A qualitative study.

Many Low-income countries depend on development assistance for health (DAH) to finance the health sector. The transition of these countries to middle-income status has led to reduction in effective aid from development partners while these countries are expected to graduate from global funding agencies such as Gavi the vaccine alliance, with implications for service delivery. The aim of this study was to explore the perspectives of frontline health workers regarding the implications of Ghana's transition to middle-income status on service delivery, the likely impact and opportunities it presents to the country. This exploratory qualitative study employed in-depth interviews to collect data from 16 health workers at three hospitals in the Greater Accra Region; one at the regional level and two at the district level. The study was conducted from December 2019 to July 2020. Data from interviews were transcribed, coded and analysed using thematic analysis in NVivo Qualitative Analysis Software version 12. The level of awareness among frontline workers about the transition and decline in DAH was generally low. Nonetheless, frontline health workers perceived that the country seems inadequately prepared for transition as donors continue to be major financiers for the sector and even for emergencies such as the current COVID-19 global pandemic. Potential challenges facilities would face due to transition may include difficulty in funding health programs, human resource challenges and delays in logistics and medicines. The implications for these will be poor health outcomes, defective monitoring and evaluation, and lapses in training programs. In addition, the perceived barriers to transition identified were poor management of resources, political interference and lack of technical expertise. While opportunities such as improvement of the health sector prioritization and efficiency, private sector involvement and autonomy could be gained. Gaps in the health intervention monitoring resulting from DAH transition could pose affect health outcomes, particularly in respect of HIV, tuberculosis and malaria. The country's preparedness to transition from DAH could be better improved with development of a clear transition plan agreed by stakeholders, including government and in-country development partners. For the health sector, the eligibility for DAH transition should not simply be based on economic growth, but importantly on a country's ability to sustain ongoing and upcoming health programs.

Health-related quality of life and its demographic, clinical and psychosocial determinants among male patients with hypertension in a Ghanaian tertiary hospital.

Objectives: This study aimed to evaluate Health-related quality of life (HRQoL) among male patients with hypertension and its associated demographic, clinical and psychosocial factors. Design: This was a facility-based cross-sectional study. Setting: This study was carried out at the outpatient department in Korle-Bu Teaching Hospital. Participants: Three hundred and fifty-eight hypertensive patients were recruited for this study. Data collection: Information on socio-demographic characteristics, clinical features, insomnia, medication adherence, psychological distress, sexual dysfunction and HRQoL were obtained through patient-reported measures using structured questionnaires and standardised instruments. Statistical analysis/Main outcome measure: The study assessed HRQoL among male hypertensive patients. One-way ANOVA was used to compare the average scores of the various domains of HRQL across the independent variables. Multivariate linear regression models with robust standard errors were used to determine factors associated with quality of life. Results: Participants with poor perceived overall HRQoL was 14.0%. Comparatively, HRQoL (mean ± SD) was the least in the physical health domain (56.77±14.33) but the highest in the psychological domain (58.7 ± 16.0). Multivariate linear regression showed that income level, educational level, insomnia, overall satisfaction, sexual desire and medication adherence were significant predictors of HRQoL. Average scores of HRQoL domains reduced with a higher level of sexual desire dysfunction. Conclusion: HRQoL among male hypertensive patients was negatively affected by insomnia, sexual desire dysfunction, educational level and adherence to antihypertensive medications but positively affected by income level. Clinical practice and policy processes should be directed at these factors to improve HRQoL. Funding: No external funding.

Powers, engagements and resultant influences over the design and implementation of medicine pricing policies in Ghana.

INTRODUCTION: Universal availability and affordability of essential medicines are determined by effective design and implementation of relevant policies, typically involving multiple stakeholders. This paper examined stakeholder engagements, powers and resultant influences over design and implementation of four medicines pricing policies in Ghana: Health Commodity Supply Chain Master Plan, framework contracting for high demand medicines, Value Added Tax (VAT) exemptions for selected essential medicines, and ring-fencing medicines for local manufacturing. METHODS: Data were collected using reviews of policy documentation (n=16), consultative meetings with key policy actors (n=5) and in-depth interviews (n=29) with purposefully identified national-level policymakers, public and private health professionals including members of the National Medicine Pricing Committee, pharmaceutical wholesalers and importers. Data were analysed using thematic framework. RESULTS: A total of 46 stakeholders were identified, including representatives from the Ministry of Health, other government agencies, development partners, pharmaceutical industry and professional bodies. The Ministry of Health coordinated policy processes, utilising its bureaucratic mandate and exerted high influences over each policy. Most stakeholders were highly engaged in policy processes. Whereas some led or coproduced the policies in the design stage and participated in policy implementation, others were consulted for their inputs, views and opinions. Stakeholder powers reflected their expertise, bureaucratic mandates and through participation in national level consultation meetings, influences policy contents and implementation. A wider range of stakeholders were involved in the VAT exemption policies, reflecting their multisectoral nature. A minority of stakeholders, such as service providers were not engaged despite their interest in medicines pricing, and consequently did not influence policies. CONCLUSIONS: Stakeholder powers were central to their engagements in, and resultant influences over medicine pricing policy processes. Effective leadership is important for inclusive and participatory policymaking, and one should be cognisant of the nature of policy issues and approaches to policy design and implementation.

The impact of antimicrobial resistance awareness interventions involving schoolchildren, development of an animation and parents engagements: a pilot study.

BACKGROUND: Antimicrobial resistance (AMR) is a global health challenge, particularly in low- and middle-income countries where antibiotics are widely available to consumers, leading to their misuse. However, AMR educational interventions for engaging parents of schoolchildren are mainly lacking in Sub-Saharan Africa. This study aimed to assess the potential of AMR animation and schoolchildren in influencing parents' AMR knowledge, attitudes, and beliefs. METHODS: Parents of schoolchildren aged 11-15 years in Tema, a city in Ghana, watched and discussed an AMR animation designed with ideas from the schoolchildren's top stories and picture drawings. The children from two schools were first engaged with AMR lessons, with one school using storytelling, the other school using picture drawing, and none serving as a control. The children were then asked to discuss the lessons with their parents. Baseline surveys of parents of randomly selected children were conducted to assess AMR knowledge, attitudes and beliefs before engaging the students and parents, and immediately after the parents participated in viewing and discussing the animation. McNemar and t-tests were used to assess changes in AMR knowledge, attitudes and beliefs. RESULTS: Parents who participated in the animation event, and whose schoolchildren were in the storytelling intervention school had significantly improved knowledge regarding the statement "Antibiotics will cure any infection" (p = 0.021, χ2 = 0.711; 88% vs 50%) between baseline and endline. However, these parents also had statistically significant decreased scores regarding the statement "Antibiotics do not kill our good bacteria" (p = 0.021, χ2 = 1.042; 71.4% vs 40%) between baseline and endline. There was no significant effect on any statement among parents whose children were in the picture drawing school. However, t-test results combining the statements as composite scores showed statistically significant difference in only the attitude construct among parents whose children participated in storytelling intervention (p = 0.043) or picture drawing intervention (p = 0.019). There were no statistically significant changes in knowledge and beliefs constructs. CONCLUSIONS: This study shows that interventions involving schoolchildren with parents engagements and AMR animation could influence parents' AMR attitudes. The intervention could also positively or negatively impact parents' AMR knowledge. Modifications of the interventions may be needed for tackling AMR.

Implementation of medicines pricing policies in sub-Saharan Africa: systematic review.

BACKGROUND: High medicine prices contribute to increasing cost of healthcare worldwide. Many patients with limited resources in sub-Saharan Africa (SSA) are confronted with out-of-pocket charges, constraining their access to medicines. Different medicine pricing policies are implemented to improve affordability and availability; however, evidence on the experiences of implementations of these policies in SSA settings appears limited. Therefore, to bridge this knowledge gap, we reviewed published evidence and answered the question: what are the key determinants of implementation of medicines pricing policies in SSA countries? METHODS: We identified policies and examined implementation processes, key actors involved, contextual influences on and impact of these policies. We searched five databases and grey literature; screening was done in two stages following clear inclusion criteria. A structured template guided the data extraction, and data analysis followed thematic narrative synthesis. The review followed best practices and reported using PRISMA guidelines. RESULTS: Of the 5595 studies identified, 31 met the inclusion criteria. The results showed thirteen pricing policies were implemented across SSA between 2003 and 2020. These were in four domains: targeted public subsides, regulatory frameworks and direct price control, generic medicine policies and purchasing policies. Main actors involved were government, wholesalers, manufacturers, retailers, professional bodies, community members and private and public health facilities. Key contextual barriers to implementation were limited awareness about policies, lack of regulatory capacity and lack of price transparency in external reference pricing process. Key facilitators were favourable policy environment on essential medicines, strong political will and international support. Evidence on effectiveness of these policies on reducing prices of, and improving access to, medicines was mixed. Reductions in prices were reported occasionally, and implementation of medicine pricing policy sometimes led to improved availability and affordability to essential medicines. CONCLUSIONS: Implementation of medicine pricing policies in SSA shows some mixed evidence of improved availability and affordability to essential medicines. It is important to understand country-specific experiences, diversity of policy actors and contextual barriers and facilitators to policy implementation. Our study suggests three policy implications, for SSA and potentially other low-resource settings: avoiding a 'one-size-fits-all' approach, engaging both private and public sector policy actors in policy implementation and continuously monitoring implementation and effects of policies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020178166.