The epidemiological and economic burden of diabetes in Ghana: A scoping review to inform health technology assessment.

Diabetes remains one of the four major causes of morbidity and mortality globally among non-communicable diseases (NCDs. It is predicted to increase in sub-Saharan Africa by over 50% by 2045. The aim of this study is to identify, map and estimate the burden of diabetes in Ghana, which is essential for optimising NCD country policy and understanding existing knowledge gaps to guide future research in this area. We followed the Arksey and O'Malley framework for scoping reviews. We searched electronic databases including Medline, Embase, Web of Science, Scopus, Cochrane and African Index Medicus following a systematic search strategy. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews was followed when reporting the results. A total of 36 studies were found to fulfil the inclusion criteria. The reported prevalence of diabetes at national level in Ghana ranged between 2.80%- 3.95%. At the regional level, the Western region reported the highest prevalence of diabetes: 39.80%, followed by Ashanti region (25.20%) and Central region at 24.60%. The prevalence of diabetes was generally higher in women in comparison to men. Urban areas were found to have a higher prevalence of diabetes than rural areas. The mean annual financial cost of managing one diabetic case at the outpatient clinic was estimated at GHS 540.35 (2021 US $194.09). There was a paucity of evidence on the overall economic burden and the regional prevalence burden. Ghana is faced with a considerable burden of diabetes which varies by region and setting (urban/rural). There is an urgent need for effective and efficient interventions to prevent the anticipated elevation in burden of disease through the utilisation of existing evidence and proven priority-setting tools like Health Technology Assessment (HTA).

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.

Developing a tool to assess the skills to perform a health technology assessment.

BACKGROUND: Health technology assessment (HTA) brings together evidence from various disciplines while using explicit methods to assess the value of health technologies. In resource-constrained settings, there is a growing demand to measure and develop specialist skills, including those for HTA, to aid the implementation of Universal Healthcare Coverage. The purpose of this study was twofold: a) to find validated tools for the assessment of the technical capacity to conduct a HTA, and if none were found, to develop a tool, and b) to describe experiences of its pilot. METHODS: First, a mapping review identified tools to assess the skills to conduct a HTA. A medical librarian conducted a comprehensive search in four databases (MEDLINE, Embase, Web of Science, ERIC). Then, incorporating results from the mapping and following an iterative process involving stakeholders and experts, we developed a HTA skills assessment tool. Finally, using an online platform to gather and analyse responses, in collaboration with our institutional partner, we piloted the tool in Ghana, and sought feedback on their experiences. RESULTS: The database search yielded 3871 records; fifteen those were selected based on a priori criteria. These records were published between 2003 and 2018, but none covered all technical skills to conduct a HTA. In the absence of an instrument meeting our needs, we developed a HTA skill assessment tool containing four sections (general information, core and soft skills, and future needs). The tool was designed to be administered to a broad range of individuals who would potentially contribute to the planning, delivery and evaluation of HTA. The tool was piloted with twenty-three individuals who completed the skills assessment and shared their initial impressions of the tool. CONCLUSIONS: To our knowledge, this is the first comprehensive tool enabling the assessment of technical skills to conduct a HTA. This tool allows teams to understand where their individual strengths and weakness lie. The tool is in the early validation phases and further testing is needed. TRIAL REGISTRATION: Not applicable.

Estimating the cost of COVID-19 vaccine deployment and introduction in Ghana using the CVIC tool.

BACKGROUND: This study estimated cost of COVID-19 vaccine introduction and deployment in Ghana. METHODS: Using the WHO-UNICEF COVID-19 Vaccine Introduction and deployment Costing (CVIC) tool Ghana's Ministry of Health Technical Working Group for Health Technology Assessment (TWG-HTA) in collaboration with School of Public Health, University of Ghana, organized an initial two-day workshop that brought together partners to deliberate and agree on input parameters to populate the CVIC tool. A further 2-3 days validation with the Expanded Program of Immunization (EPI) and other partners to finalize the analysis was done. Three scenarios, with different combinations of vaccine products and delivery modalities, as well as time period were analyzed. The scenarios included AstraZeneca (40%), Johnson & Johnson (J&J) (30%), Moderna, Pfizer, and Sputnik V at 10% each; with primary schedule completed by second half of 2021 (Scenario 1); AstraZeneca (30%), J&J (40%), Moderna, Pfizer, and Sputnik V at 10% each with primary schedule completed by first half of 2022 (Scenario 2); and equal distribution (20%) among AstraZeneca, J&J, Moderna, Pfizer, and Sputnik V with primary schedule completed by second half of 2022 (Scenario 3). RESULTS: The estimated total cost of COVID-19 vaccination ranges between $348.7 and $436.1 million for the target population of 17.5 million. These translate into per person completed primary schedule cost of $20.9-$26.2 and per dose (including vaccine cost) of $10.5-$13.1. Again, per person completed primary schedule excluding vaccine cost was $4.5 and $4.6, thus per dose excluding vaccine also ranged from $2.2 - $2.3. The main cost driver was vaccine doses, including shipping, which accounts for between 78% and 83% of total cost. Further, an estimated 8,437-10,247 vaccinators (non-FTEs) would be required during 2021-2022 to vaccinate using a mix of delivery strategies, accounting for 8-10% of total cost. CONCLUSION: These findings provide the estimates to inform resource mobilization efforts by government and other partners.

Antimicrobial resistance national level dialogue and action in Ghana: setting and sustaining the agenda and outcomes.

BACKGROUND: Antimicrobial resistance (AMR) has gained national and international attention. The design and launch of national policy on antimicrobial use and resistance and action plan marked a milestone in Ghana's commitment to control AMR. These strategies are some outcomes of getting and sustaining AMR issues prominence on government's agenda. Understanding the agenda setting processes, policy actors involved and policy change is important as this provides insights on how and why policy actors defined and framed AMR issues to sustain its prominence despite the changing priorities of government agenda. OBJECTIVE: To examine the processes of setting and sustaining AMR issues on government agenda, the policy actors involved and resulting outcomes. METHODS: A qualitative study was conducted and data collected through interviewing twenty-four respondents and reviewing technical working group meeting reports and health sector documents. Data was analysed drawing on Kingdon's agenda setting framework. RESULT: Members of a multisectoral technical working group (AMR platform) formed in 2011 constantly built consensus on AMR problem definition, solutions and actively engaged decision makers to mobilise support and interest. The AMR platform members sustained AMR attention and prominence on government's agenda through the following multisectoral coordination mechanisms: (1) institutionalising AMR platform activities (2) gathering evidence, sharing findings, and supporting research (3) creating awareness and training (4) gaining and maintaining political support. The activities of the AMR platform contributed to three remarkable outcomes and these are (1) maintained network of AMR Champions, (2) design of a national policy on antimicrobial use and resistance in Ghana (1st edition) and national action plan (2017-2021), and (3) Ghana's hosting of the second Global call to action on AMR. CONCLUSION: The AMR platform members as influencers concentrated their efforts to move and sustain AMR issues on government agenda. The identified multisectoral coordination mechanisms collectively contributed to agenda setting processes and policy change. The AMR platform engagements are ongoing and it is important the momentum is maintained. As multisectoral coordination and activities are vital especially for AMR 'One Health' approach, we hope this paper presents lessons for better understanding of how and why multisectoral groups influence national level agenda setting processes.

Infection prevention and control compliance among exposed healthcare workers in COVID-19 treatment centers in Ghana: A descriptive cross-sectional study.

Compliance with infection prevention and control (IPC) protocols is critical in minimizing the risk of coronavirus disease (COVID-19) infection among healthcare workers. However, data on IPC compliance among healthcare workers in COVID-19 treatment centers are unknown in Ghana. This study aims to assess IPC compliance among healthcare workers in Ghana's COVID-19 treatment centers. The study was a secondary analysis of data, which was initially collected to determine the level of risk of COVID-19 virus infection among healthcare workers in Ghana. Quantitative data were conveniently collected using the WHO COVID-19 risk assessment tool. We analyzed the data using descriptive statistics and logistic regression analyses. We observed that IPC compliance during healthcare interactions was 88.4% for hand hygiene and 90.6% for Personal Protective Equipment (PPE) usage; IPC compliance while performing aerosol-generating procedures (AGPs), was 97.5% for hand hygiene and 97.5% for PPE usage. For hand hygiene during healthcare interactions, lower compliance was seen among nonclinical staff [OR (odds ratio): 0.43; 95% CI (Confidence interval): 0.21-0.89], and healthcare workers with secondary level qualification (OR: 0.24; 95% CI: 0.08-0.71). Midwives (OR: 0.29; 95% CI: 0.09-0.93) and Pharmacists (OR: 0.15; 95% CI: 0.02-0.92) compliance with hand hygiene was significantly lower than registered nurses. For PPE usage during healthcare interactions, lower compliance was seen among healthcare workers who were separated/divorced/widowed (OR: 0.08; 95% CI: 0.01-0.43), those with secondary level qualifications (OR 0.08; 95% CI 0.01-0.43), non-clinical staff (OR 0.16 95% CI 0.07-0.35), cleaners (OR: 0.16; 95% CI: 0.05-0.52), pharmacists (OR: 0.07; 95% CI: 0.01-0.49) and among healthcare workers who reported of insufficiency of PPEs (OR: 0.33; 95% CI: 0.14-0.77). Generally, healthcare workers' infection prevention and control compliance were high, but this compliance differs across the different groups of health professionals in the treatment centers. Ensuring an adequate supply of IPC logistics coupled with behavior change interventions and paying particular attention to nonclinical staff is critical in minimizing the risk of COVID-19 transmission in the treatment centers.

Supporting the Development of Evidence-Informed Policy Options: An Economic Evaluation of Hypertension Management in Ghana.

OBJECTIVES: Universal healthcare coverage in low- and middle-income countries requires challenging resource allocation decisions. Health technology assessment is one important tool to support such decision making. The International Decision Support Initiative worked with the Ghanaian Ministry of Health to strengthen health technology assessment capacity building, identifying hypertension as a priority topic area for a relevant case study. METHODS: Based on guidance from a national technical working group of researchers and policy makers, an economic evaluation and budget impact analysis were undertaken for the main antihypertensive medicines used for uncomplicated, essential hypertension. The analysis aimed to address specific policy questions relevant to the National Health Insurance Scheme. RESULTS: The evaluation found that first-line management of essential hypertension with diuretics has an incremental cost per disability-adjusted life-year avoided of GH¢ 276 ($179 in 2017, 4% of gross national income per capita) compared with no treatment. Calcium channel blockers were more effective than diuretics but at a higher incremental cost: GH¢ 11 061 per disability-adjusted life-year avoided ($7189 in 2017; 160% of gross national income per capita). Diuretics provide better health outcomes at a lower cost than angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or beta-blockers. Budget impact analysis highlighted the potential for cost saving through enhanced price negotiation and increased use of better-value drugs. We also illustrate how savings could be reinvested to improve population health. CONCLUSIONS: Economic evaluation enabled decision makers to assess hypertension medicines in a Ghanaian context and estimate the impact of using such evidence to change policy. This study contributes to addressing challenges associated with the drive for universal healthcare coverage in the context of constrained budgets.

Use of evidence and negotiation in the review of national standard treatment guidelines and essential medicines list: experience from Ghana.

Understanding how countries review their national standard treatment guidelines (STGs) and essential medicines list (EML) is important in the light of ever-changing trends in public health and evidence supporting the selection and use of medicines in disease management. This study examines the 2017 STGs and EML review process, the actors involved and how the list of medicines and disease conditions evolved between the last two editions. We examined expert committee reports, stakeholder engagement reports and the last two editions (2010, 2017) STGs and EML. The review process occurred in both bureaucratic and public arenas where various actors with varied power and interest engaged in ways to consolidate their influence with the use of evidence from research and practice. In the bureaucratic arena, a national medicines selection committee inaugurated by the Minister of Health assessed the 2010 edition through technical sessions considering the country's disease burden, hierarchical healthcare structure and evidence on safety and efficacy and expert opinion. To build consensus and ensure credibility service providers, professional bodies and healthcare managers scrutinized the assessed guidelines and medicines list in public arenas. In such public arenas, technical discussions moved towards negotiations with emphasis on practicability of the policies. Updates in the 2017 guidelines involved the addition of 64 new disease conditions in the STG, with the EML including 153 additional medicines and excluding 56 medicines previously found in the 2010 EML. Furthermore, the level of care categorization for Level 'A' [i.e. community-based health planning and services (CHPS)] and Level 'M' (i.e. midwifery and CHPS with a midwife) evolved to reflect the current primary healthcare and community mobilization activities for healthcare delivery in Ghana. Ghana's experience in using evidence from research and practice and engaging wide stakeholders can serve as lessons for other low and middle-income countries.