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.

Barriers to implementing health sector administrative decentralisation in Ghana: a study of the Nkwanta district health management team.

PURPOSE: This paper aims to examine empirically the ways in which workforce knowledge and organisational factors of an implementing agency affected the implementation of health sector administration decentralisation in Ghana with insights from the Nkwanta district health administration. DESIGN/METHODOLOGY/APPROACH: This is a qualitative study using data from individual and group interviews through purposive selection of health officials, who were directly involved in the work of actual implementation of the programme. Specifically, participants included senior management, middle management and junior workers, who had worked at least for the past three months in the district. FINDINGS: The study found that most of the interviewees involved in the implementation process are knowledgeable of the objectives of the decentralisation process. Also, major factors that are militating against effective decentralisation in the district include inadequate funds, lack of qualified personnel, inadequate logistics and equipment, poor interpersonal relationships, lack of transparency and a good operational system, lack of incentives to motivate the staff, political interference, poor infrastructure and high rate of illiteracy. ORIGINALITY/VALUE: The findings of this study will help improve the implementation of decentralisation within the health sector in Ghana. The paper provides recommendations, which, if considered for implementation, will help improve the decentralisation process.

Evaluation of the reporting completeness and timeliness of the integrated disease surveillance and response system in northern Ghana.

OBJECTIVES: The integrated disease surveillance and response (IDSR) and district health information management system II (DHIMS2) strategies were implemented in 2002 and 2012 respectively to improve surveillance data reporting and quality. The objective of this study was to evaluate the reporting completeness and timeliness of the IDSR system at the sub-national level in northern Ghana. METHODS: This was an observational study in Upper East Region (UER). Weekly and monthly disease surveillance reports on completeness and timeliness were downloaded and analysed for 2012 and 2013 from the DHIMS2 in UER, the two Kassena-Nankana districts and their nine health facilities representing public, private and mission providers. Comparison of paper-based and DHIMS2 reporting from the periphery health facilities were assessed. RESULTS: IDSR monthly reporting completeness and timeliness in UER increased by 9% and 37% respectively in 2013 compared to 2012 and weekly completeness and timeliness improved by 79% and 24% respectively in 2013. Similar reporting increases were seen in the districts and health facilities over the same period, except the Kassena-Nankana Municipal which showed decrease of 2% in monthly completeness for 2013. At the health facilities, the paper-based reporting completeness was 96% and timeliness 45% while DHIMS2 completeness was 83% and timeliness 18% in 2012. However, DHIMS2 reporting completeness and timeliness improved in 2013 reaching 100% and 61% respectively. CONCLUSIONS: Disease surveillance reporting through DHIMS2 became more complete over time, but there remain problems with timeliness. Surveillance data need to be timely to enable rapid responses to disease outbreaks.

The Ghana community-based health planning and services initiative for scaling up service delivery innovation.

Research projects demonstrating ways to improve health services often fail to have an impact on what national health programmes actually do. An approach to evidence-based policy development has been launched in Ghana which bridges the gap between research and programme implementation. After nearly two decades of national debate and investigation into appropriate strategies for service delivery at the periphery, the Community-based Health Planning and Services (CHPS) Initiative has employed strategies tested in the successful Navrongo experiment to guide national health reforms that mobilize volunteerism, resources and cultural institutions for supporting community-based primary health care. Over a 2-year period, 104 out of the 110 districts in Ghana started CHPS. This paper reviews the development of the CHPS initiative, describes the processes of implementation and relates the initiative to the principles of scaling up organizational change which it embraces. Evidence from the national monitoring and evaluation programme provides insights into CHPS' success and identifies constraints on future progress.