Factors Contributing to and Reducing Delays in the Provision of Adequate Care in Ghana: A Qualitative Study of Trauma Care Providers.

BACKGROUND: Ghana has a large and growing burden of injury morbidity and mortality. There is a substantial unmet need for trauma surgery, highlighting a need to understand gaps in care. METHODS: We conducted 8 in-depth interviews with trauma care providers (surgeons, nurses, and specialists) at a large teaching hospital to understand factors that contribute to and reduce delays in the provision of adequate trauma care for severely injured patients. The study aimed to understand whether providers thought factors differed between patients that were enrolled in the National Health Insurance Scheme (NHIS) and those that were not. Findings were presented for the third delay (provision of appropriate care) in the Three Delays Framework. RESULTS: Key findings included that most factors contributing delays in the provision of adequate care were related to the costs of care, including for diagnostics, medications, and treatment for patients with and without NHIS subscription. Other notable factors included conflicts between providers, resource constraints, and poor coordination of care at the facility. Factors which reduce delays included advocacy by providers and informal processes for prioritizing critical injuries. CONCLUSION: We recommend facility-level changes including increasing equity in access to trauma and elective surgery through targeted system strengthening efforts (e.g., a scheduled back-up call system for surgeons, anesthetists, other specialists, and nurses; designated operating theatres and staff for emergencies; training of staff), policy changes to simplify the insurance renewal and subscription processes, and future research on the costs and benefits of including diagnostics, medications, and common trauma services into the NHIS benefits package.

National health insurance and surgical care for injured people, Ghana.

OBJECTIVE: To determine the association between having government health insurance and the timeliness and outcome of care, and catastrophic health expenditure in injured patients requiring surgery at a tertiary hospital in Ghana. METHODS: We reviewed the medical records of injured patients who required surgery at Komfo Anokye Teaching Hospital in 2015-2016 and extracted data on sociodemographic and injury characteristics, outcomes and out-of-pocket payments. We defined catastrophic health expenditure as ≥ 10% of the ratio of patients' out-of-pocket payments to household annual income. We used multivariable regression analyses to assess the association between having insurance through the national health insurance scheme compared with no insurance and time to surgery, in-hospital mortality and experience of catastrophic health expenditure, adjusted for potentially confounding variables. FINDINGS: Of 1396 patients included in our study, 834 (60%) were insured through the national health insurance scheme. Time to surgery and mortality were not statistically different between insured and uninsured patients. Insured patients made smaller median out-of-pocket payments (309 United States dollars, US$) than uninsured patients (US$ 503; P < 0.001). Overall, 45% (443/993) of patients faced catastrophic health expenditure. A smaller proportion of insured patients (33%, 184/558) experienced catastrophic health expenditure than uninsured patients (60%, 259/435; P < 0.001). Insurance through the national health insurance scheme reduced the likelihood of catastrophic health expenditure (adjusted odds ratio: 0.27; 95% confidence interval: 0.20 to 0.35). CONCLUSION: The national health insurance scheme needs strengthening to provide better financial risk protection and improve quality of care for patients presenting with injuries that require surgery.

In-Country Training by the Ghana College of Physicians and Surgeons: An Initiative that has Aided Surgeon Retention and Distribution in Ghana.

BACKGROUND: Prior to 2003, production of new surgeons in Ghana was limited. In 2003, the Ghana College of Physicians and Surgeons (GCPS) initiated the first wholly in-country training and credentialing of surgeons. The purpose of this study was to assess the impact of in-country training of surgeons in Ghana. METHODS: We interviewed 117 (80%) of the 146 surgeons trained through the GCPS from inception through 2016. We gathered data on type of training, practice location, clinical workload, and administrative and teaching roles. Operations were categorized into those deemed essential (most cost-effective, highest population impact) by the World Bank's Disease Control Priorities project versus other. RESULTS: In-country retention was 87-97%. A little more than half (56%) were working in the two largest cities and 44% were working in higher need areas. Twenty-two (19%) were the first surgeon to have worked at their current hospital. The surgeons performed a mean of 13 operations per week (seven electives, six emergencies). 35% of elective and 77% of emergency operations were in the essential category. Most (79%) surgeons were engaged in training/teaching; 46% were engaged in research; and 33% held an administrative office. CONCLUSIONS: In-country surgical training has led to high retention and wide geographic distribution, including high need areas. The in-country trained surgeons are playing key roles in clinical practice, training, and administration. These data provide support for investments in similar efforts in other low- and middle-income countries.

Assessing the appropriateness of blood transfusion among injured patients at a Ghanaian tertiary hospital: Time for clarity on the use of a scarce resource.

INTRODUCTION: Hemorrhage is an important cause of preventable injury-related death. Many low- and middle-income country (LMIC) patients do not have timely access to safe blood. We sought to determine the degree of appropriateness of blood transfusion among patients with injuries requiring surgical intervention at presentation to a tertiary hospital in Ghana. METHODS: We performed a retrospective review of such patients presenting to Komfo Anokye Teaching Hospital (KATH), from January 2015 to December 2016. Patients' hemoglobin levels at presentation were determined as the first record of hemoglobin after presentation and their receipt of blood transfusion was determined by explicit documentation in the chart. We defined appropriate blood transfusion practice as patients receiving transfusion when hemoglobin was equal or below a threshold, or patients not being transfused when hemoglobin was above the threshold. We considered both restrictive (hemoglobin ≤7 g/dL) and liberal (hemoglobin ≤10 g/dL) transfusion thresholds. RESULTS: There were 1,408 patients who presented to KATH with injuries that met inclusion criteria. Two hundred and ninety two (292) patients were excluded because of missing hemoglobin information. Four hundred and fifty eight (458;41%) patients received blood transfusion. Transfused patients had a higher mean age (38 vs 35 years) and were less likely to be male (62% vs 71%). Transfused patients underwent more external fixation procedures (28% vs 19%), trauma amputations (5% vs 1%) and trauma laparotomies (3% vs 1%). At a restrictive transfusion threshold (hemoglobin ≤7 g/dL), 20% of patients who needed a transfusion did not receive one and 39% of patients who did not need a transfusion received one. At a liberal threshold (hemoglobin ≤10 g/dL), 33% of patients who needed a transfusion did not receive one and 30% of patients who did not need a transfusion received one. Blood transfusion practice was inappropriate in 31%-39% of all patients. CONCLUSION: Our data suggest that clearer guidelines for blood transfusion among emergency surgery patients are needed in Ghana and similar LMICs to avoid inappropriate use of blood as a scarce resource.

Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children.

INTRODUCTION: Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana. METHODS: We performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE. RESULTS: Of the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08-0.55). CONCLUSIONS: NHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children.