A nationwide quality improvement project to accelerate Ghana's progress toward Millennium Development Goal Four: design and implementation progress.

QUALITY PROBLEM: The gap between evidence-based guidelines and practice of care is reflected, in low- and middle-income countries, by high rates of maternal and child mortality and limited effectiveness of large-scale programing to decrease those rates. CHOICE OF SOLUTION: We designed a phased, rapid, national scale-up quality improvement (QI) intervention to accelerate the achievement of Millennium Development Goal Four in Ghana. Our intervention promoted systems thinking, active participation of managers and frontline providers, generation and testing of local change ideas using iterative learning from transparent district and local data, local ownership and sustainability. IMPLEMENTATION: After 50 months of implementation, we have completed two prototype learning phases and have begun regional spread phases to all health facilities in all 38 districts of the three northernmost regions and all 29 Catholic hospitals in the remaining regions of the country. To accelerate the spread of improvement, we developed 'change packages' of rigorously tested process changes along the continuum of care from pregnancy to age 5 in both inpatient and outpatient settings. LESSONS LEARNED: The primary successes for the project so far include broad and deep adoption of QI by local stakeholders for improving system performance, widespread capacitation of leaders, managers and frontline providers in QI methods, incorporation of local ideas into change packages and successful scale-up to approximately 25% of the country's districts in 3 years. Implementation challenges include variable leadership uptake and commitment at the district level, delays due to recruiting and scheduling barriers, weak data systems and repeated QI training due to high staff turnover.

Occurrence, ecological risk assessment and source apportionment of pharmaceuticals, steroid hormones and xenoestrogens in the Ghanaian aquatic environments.

Elevated levels of pharmaceuticals, steroid hormones and xenoestrogens (PSHXEs) in the aquatic environment pose a serious threat to the ecological balance. The endocrine disrupting PSHXEs in aquatic systems are linked to several adverse effects like reproductive health impairment, feminization, high mortality rate, decreased biodiversity etc. This study, therefore, sought to investigate the occurrence and the ecological risks posed by some selected PSHXEs and also conduct source apportionment of the PSHXEs in the Ghanaian aquatic environments. A total of 48 samples comprising 24 sediments and water each were taken from six waterbodies in Ghana. The samples were extracted using SPE cartridges for water and QuEChERS-dSPE for sediments. The analyses were done using Shimadzu Prominence UFLC 20A series. Ecological risk assessments were also conducted with the aid of USEPA T.E.S.T., whereas source apportionments were conducted using the APCS-MLR receptor model. Elevated mean total levels of PSHXEs ranging between 12,187 and 52,117 ng/L and 2,022-6,047 ng/g for water and sediment samples respectively were found. The risk quotients (RQ > 1) suggested a high risk posed by PSHXEs in water to organisms at the three trophic levels and also to benthic organisms in sediments of the Ghanaian aquatic environments for a short-term period. The APCS-MLR receptor model suggested three statistically significant sources (p < 0.05) designated by signature PSHXEs as domestic (major), mix hospital and industrial and agricultural waste sources. The source apportionment suggested increased use of steroid estrogens and anabolic drugs among the Ghana populace.