Effect of social capital on enrolment of informal sector occupational groups in the national health insurance scheme in Ghana: a cross-sectional survey.

BACKGROUND: Enrolment of informal sector workers in Ghana's National Health Insurance Scheme (NHIS) is critical to achieving increased risk-pooling and attainment of Universal Health Coverage. However, the NHIS has struggled over the years to improve enrolment of this subpopulation. This study analysed effect of social capital on enrolment of informal sector workers in the NHIS. METHODS: A cross-sectional survey was conducted among 528 members of hairdressers and beauticians, farmers, and commercial road transport drivers' groups. Descriptive statistics, principal component analysis, and multinomial logit regression model were used to analyse the data. RESULTS: Social capital including membership in occupational group, trust, and collective action were significantly associated with enrolment in the NHIS, overall. Other factors such as household size, education, ethnicity, and usual source of health care were, however, correlated with both enrolment and dropout. Notwithstanding these factors, the chance of enrolling in the NHIS and staying active was 44.6% higher for the hairdressers and beauticians; the probability of dropping out of the scheme was 62.9% higher for the farmers; and the chance of never enrolling in the scheme was 22.3% higher for the commercial road transport drivers. CONCLUSIONS: Social capital particularly collective action and predominantly female occupational groups are key determinants of informal sector workers' participation in the NHIS. Policy interventions to improve enrolment of this subpopulation should consider group enrolment, targeting female dominated informal sector occupational groups. Further studies should consider inclusion of mediating and moderating variables to provide a clearer picture of the relationship between occupational group social capital and enrolment in health insurance schemes.

A new scale to assess health-facility level management: the development and validation of the facility management scale in Ghana, Uganda, and Malawi.

BACKGROUND: The increased recognition of governance, leadership, and management as determinants of health system performance has prompted calls for research focusing on the nature, quality, and measurement of this key health system building block. In low- or middle-income contexts (LMIC), where facility-level management and performance remain a challenge, valid tools to measure management have the potential to boost performance and accelerate improvements. We, therefore, sought to develop a Facility-level Management Scale (FMS) and test its reliability in the psychometric properties in three African contexts. METHODS: The FMS was administered to 881 health workers in; Ghana (n = 287; 32.6%), Malawi (n = 66; 7.5%) and Uganda (n = 528; 59.9%). Half of the sample data was randomly subjected to exploratory factor analysis (EFA) and Monte Carlo Parallel Component Analysis to explore the FMS' latent structure. The construct validity of this structure was then tested on the remaining half of the sample using confirmatory factor analysis (CFA). The FMS' convergent and divergent validity, as well as internal consistency, were also tested. RESULTS: Findings from the EFA and Monte Carlo PCA suggested the retention of three factors (labelled 'Supportive Management', 'Resource Management' and 'Time management'). The 3-factor solution explained 51% of the variance in perceived facility management. These results were supported by the results of the CFA (N = 381; χ2 = 256.8, df = 61, p < 0.001; CFI = 0.94; TLI = 0.92; RMSEA [95% CI] = 0.065 [0.057-0.074]; SRMR = 0.047). CONCLUSION: The FMS is an open-access, short, easy-to-administer scale that can be used to assess how health workers perceive facility-level management in LMICs. When used as a regular monitoring tool, the FMS can identify key strengths or challenges pertaining to time, resources, and supportive management functions at the health facility level.

Cost of inappropriate prescriptions for uncomplicated malaria in Ghana.

BACKGROUND: Malaria remains a common course of morbidity in many sub-Saharan African countries. While treatment options have improved in recent times, inappropriate prescription seems conventional among providers, increasing the burden on patients and society. This study examined the cost of inappropriate prescriptions for uncomplicated malaria treatment in Ghana. METHODS: This study used retrospective data collected from January to December 2016 in 27 selected facilities, under different ownership in three regions of the country, mainly Volta, Upper East and Brong Ahafo. Stratified random sampling technique was used to extract 1625 outpatient folders of patients diagnosed and treated for malaria. Two physicians independently reviewed patient folders according to the stated diagnoses. Malaria prescriptions were described as inappropriate when they do not adhere to the standard treatment guidelines. The economic cost was mainly treatment cost which was sourced as medication cost. Total and average costs for country were calculated using sample estimates and the total number of uncomplicated malaria cases that received inappropriate prescriptions. RESULTS: The study revealed that patients received an average of two prescriptions per malaria episode. Artemether-lumefantrine (AL) was the major malaria medication (79.5%) prescribed to patients. Other medications usually antibiotics and vitamins and minerals were included in the prescription. More than 50% of prescribers did not follow the guidelines for prescribing medications to clients. By facility type, inappropriate prescription was high in the CHPS compounds (59.1%) and by ownership, government (58.3%), private (57.5%) and mission facilities (50.7%). Thus, about 55% of malaria prescriptions were evaluated as inappropriate during the review period, which translates into economic cost of approximately US$4.52 million for the entire country in 2016. The total cost of inappropriate prescription within the study sample was estimated at US$1,088.42 while the average cost was US$1.20. CONCLUSION: Inappropriate prescription for malaria is a major threat to malaria management in Ghana. It presents a huge economic burden to the health system. Training and strict enforcement of prescribers' adherence to the standard treatment guideline is highly recommended.

Fragmentation of care during pregnancy in the Volta Region of Ghana: A social network analysis approach.

To determine the extent of care fragmentation during pregnancy and delivery in the Volta Region of Ghana. The National Health Insurance Claims Data for the Volta Region for the period January -December 2013 was used. Pregnant women who delivered at a health facility and made at least 3 visits were included in the study. Social network analysis (SNA) approach was used to determine care fragmentation. Fragmentation of care during delivery was defined to be any delivery at a facility different from the woman's most frequently visited antenatal care (ANC) facility. Network metrics (weighted in-degree and weighted out-degree) were used to determine extent of care fragmentation and also the key facilities contributing to the fragmentation. Overall, 14,474 pregnant women were included in the study with 15% (2,185) having cesarean section (CS). A total of 6,025 (42%) of all the pregnant women visited more than one facility during ANC and delivery, out of which 960 (16%) had CS. About 26% (3,769) of all deliveries and 32% (696) of all CS deliveries were fragmented. Fragmentation among those that had CS was significantly higher compared to those that had vaginal delivery (VD) (32% versus 25%, x²=45.88, p<0.001). Among those who visited multiple facilities, 63% (73% CS and 61% VD, x²=49.22, p<0.001) were fragmented. In addition, 15% of all deliveries (36% among those who visited multiple facilities) and 20% of all CS deliveries (45% among those who visited multiple facilities) were performed at facilities that the pregnant women never received ANC services from. There is high level of care fragmentation during the critical period of delivery among pregnant women who visited more than one facility. This fragmentation is particularly higher among those that had CS compared to vaginal delivery. This calls for policy to ensure coordination and continuity of care during pregnancy.

Insured clients out-of-pocket payments for health care under the national health insurance scheme in Ghana.

BACKGROUND: In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments (OOP) by insured clients is one of such challenges of the scheme. This study sought to examine the types of services OOP charges are made for by insured clients and how much insured clients pay out-of-pocket. METHODS: This was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and the results presented as proportions and means. RESULTS: Of all the survey respondents 49.7% reported paying out-of-pocket for out-patient care while 46.9% of the insured clients paid out-of-pocket. Forty-two percent of the insured poorest quintile also paid out-of-pocket. Insured clients paid for consultation (75%) and drugs (63.2%) while 34.9% purchased drugs outside the health facility they visited. The unavailability of drugs (67.9%) and drugs not covered by the NHIS (20.8%) at the health facility led to out-of-pocket payments. On average, patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Ashanti region, patients living in the Northern region were 74% less at odds to pay out-of-pocket for health care. CONCLUSION AND RECOMMENDATION: Insured clients of Ghana's NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities while the consultation fees are charged to meet the administrative costs of services. These charges occur in disadvantaged regions and in all health facilities. The high reliance on out-of-pocket payments can impede Ghana's progress towards achieving Universal Health Coverage and the Sustainable Development Goal 3, seeking to end poverty and reduce inequalities. In order to build trust and confidence in the NHIS there is the need to eliminate out-of-pocket payments for consultation and medicines by insured clients.

Capacity building for implementation research: a methodology for advancing health research and practice.

BACKGROUND: Implementation research is increasingly being recognised as an important discipline seeking to maximise the benefits of evidence-based interventions. Although capacity-building efforts are ongoing, there has been limited attention on the contextual and health system peculiarities in low- and middle-income countries. Moreover, given the challenges encountered during the implementation of health interventions, the field of implementation research requires a creative attempt to build expertise for health researchers and practitioners simultaneously. With support from the Special Programme for Research and Training in Tropical Diseases, we have developed an implementation research short course that targets both researchers and practitioners. This paper seeks to explain the course development processes and report on training evaluations, highlighting its relevance for inter-institutional and inter-regional capacity strengthening. METHODS: The development of the implementation research course curriculum was categorised into four phases, namely the formation of a core curriculum development team, course content development, internal reviews and pilot, and external reviews and evaluations. Five modules were developed covering Introduction to implementation research, Methods in implementation research, Ethics and quality management in implementation research, Community and stakeholder engagement, and Dissemination in implementation research. Course evaluations were conducted using developed tools measuring participants' reactions and learning. RESULTS: From 2016 to 2018, the IR curriculum has been used to train a total of 165 researchers and practitioners predominantly from African countries, the majority of whom are males (57%) and researchers/academics (79.4%). Participants generally gave positive ratings (e.g. integration of concepts) for their reactions to the training. Under 'learnings', participants indicated improvement in their knowledge in areas such as identification of implementation research problems and questions. CONCLUSION: The approach for training both researchers and practitioners offers a dynamic opportunity for the acquisition and sharing of knowledge for both categories of learners. This approach was crucial in demonstrating a key characteristic of implementation research (e.g. multidisciplinary) practically evident during the training sessions. Using such a model to effectively train participants from various low- and middle-income countries shows the opportunities this training curriculum offers as a capacity-building tool.

Universal health coverage necessitates a system approach: an analysis of Community-based Health Planning and Services (CHPS) initiative in Ghana.

The 9th Global conference on health promotion (Shanghai 2016) reaffirmed the role of primary health care (PHC) in achieving the 2030 Sustainable Development Agenda. Gaining much international recognition, the community-based health planning and services (CHPS) initiative is considered one of the pragmatic strategy in delivering on the promise of universal health coverage (UHC) through the PHC strategy, in Ghana. Yet, certain key factors threaten its successes - renewing the relevance of this study to present the barriers to and facilitators of the initiative. According to our findings, CHPS contribution particularly in bridging geographical access to health cannot be demeaned. Nevertheless, the full functioning of the initiative is limited by factors centered on the following themes: health governance and leadership, provision of services of quality, financial risk protection strategies targeting public health, information and care continuity, and the right mix of trained health professionals of even distribution across communities. Addressing the challenges of CHPS demand a system-approach. Substantial progress is more likely to emerge with improved leadership especially on the part of Governments to take bold political step to provide adequate financial and material resources. However, much will be achieved when stakeholders including the community work in synergies, to manage competing priorities by focusing on the core values and goals of CHPS.

Pneumococcal meningitis outbreak and associated factors in six districts of Brong Ahafo region, Ghana, 2016.

BACKGROUND: Meningitis, a disease of the Central Nervous System is described as inflammation of the covering of the brain and spinal cord (meninges). It is characterised by fever, severe headache, nausea, vomiting, stiff neck, photophobia, altered consciousness, convulsion/seizures and coma. In December, 2015, twelve suspected cases of meningitis were reported in Tain district in Brong Ahafo region (BAR). Subsequently, dozens of suspected cases were hospitalized in five district hospitals in BAR. We investigated to determine the magnitude, causative agent and risk factors for the disease transmission. METHODS: A community-based 1:2 case-control study (with 126 individuals) was conducted form 10/12/15 to 26/4/16 in 27 districts of Brong-Ahafo Region, Ghana. We defined suspected meningitis cases as people presenting with sudden headache and fevers (Temp> 38.0 °C) in combination with one of the following signs: neck stiffness, altered consciousness, convulsions, bulging fontanelle (infants) and other meningeal signs. Controls were selected from the same neighbourhood and defined as individuals with no overt meningitis signs/symptoms. We collected CSF samples and performed serological testing using Pastorex-Meningitis-Kit and culture for bacterial isolation. Moreover, structured questionnaires were used to collect data on socio-demographics, living conditions, health status and other risk factors. We conducted univariate data analysis and logistic regressions to study disease-exposure associations using Stata 15. RESULTS: A total of 969 suspected cases with 85 deaths (CFR = 9.0%) were recorded between December, 2015 and March, 2016. Majority, 55.9% (542/969) were females aged between 10 months-74 years (median 20 years, IQR; 14-34). Of the 969 cases, 141 were confirmed by Laboratory test with Streptococcus pneumoniae identified as the causative agent. Cases were reported in 20 districts but 6 of these districts reported cases above threshold levels. The outbreak peaked in week 6 with 178 cases. Overall attack rate (AR) was 235.0/100,000 population. District specific ARs were; Tain; 143.6/100,000, Wenchi; 110.0/100,000, Techiman; 46.6/100,000, Jaman North; 382.3/100,000 and Nkoranza South; 86.4/100,000. Female and male specific ARs were 251.3/100,000 and 214.5/100,000 respectively. Age group 10-19 years were most affected 33.8% (317/940). We identified sore throat [aOR = 5.2, 95% (CI 1.1-26.1)] and alcohol use [aOR = 9.1, 95%(CI 1.4-55.7)] as factors associated with the disease transmission. CONCLUSION: Meningitis outbreak due to Streptococcus pneumoniae was established in BAR. Upper respiratory tract infection and alcohol use were associated with the outbreak. Mass campaigns on healthy living habits, signs and symptoms of meningitis as well as the need for early reporting were some of the control measures instituted. Moreover, we recommend Pneumococcal vaccination in BAR to prevent future outbreaks.

Burden of malaria in mobile populations in the Greater Accra region, Ghana: a cross- sectional study.

BACKGROUND: The burden of malaria in mobile populations remains poorly documented in sub-Saharan Africa. This study determined the prevalence of malaria among hawkers and long-distance truck drivers in the Greater Accra region of Ghana. METHODS: A cross-sectional design using consecutive sampling method between June and July 2016 in Accra and Tema in Ghana was used in this study. The study population was hawkers who roam and sleep in the Market Streets, and long-distance truck drivers. Participants completed closed ended interview questionnaires on socio-demographic characteristics, primary residence and knowledge about malaria. Rapid diagnostic test and thick blood smears of each participant were stained with Giemsa and read using microscopy. Geographical position system (GPS) was used to collect the station locations of these mobile populations. RESULT: The overall prevalence of malaria was 15.1% and Plasmodium falciparum was responsible for all malaria infection. The malaria prevalence was 18.9 and 10.9% respectively among hawkers and truck drivers (p < 0.05). The hawkers, the single and the no formal educated participants were more likely to get malaria than the long-distance truck drivers (OR = 1.91, 95% CI 1.07-3.42), the married (OR = 1.94 95% CI 1.11-3.40) and the educated participants (OR = 2.56 95% CI 1.10-5.93), respectively. After controlling for other variables, marital status (OR = 2.60 95% CI 1.43- 4.73) and educational level (OR = 2.70 95% CI 1.08-6.77) were statistically significantly associated with malaria. CONCLUSION: This study demonstrated that the prevalence of malaria is high among hawkers and long distance truck drivers. Sociodemographic characteristics, such as marital status, occupation and educational level are significantly associated with malaria. The station locations as determined by GPS technology will make these mobile populations easier to reach for any malaria intervention.

Economic burden of family caregiving for elderly population in southern Ghana: the case of a peri-urban district.

BACKGROUND: Health systems in low and lower-middle income countries, particularly in sub-Sahara Africa, often lack the specialized personnel and infrastructure to provide comprehensive care for elderly/ageing populations. Close-to-client community-based approaches are a low-cost way of providing basic care and social support for elderly populations in such resource-constrained settings and family caregivers play a crucial role in that regard. However, family caregiving duties are often unremunerated and their care-related economic burden is often overlooked though this knowledge is important in designing or scaling up effective interventions. The objective of this study, therefore, was to estimate the economic burden of family caregiving for the elderly in southern Ghana. METHODS: The study was a retrospective cross-sectional cost-of-care study conducted in 2015 among family caregivers for elderly registered for a support group in a peri-urban district in southern Ghana. A simple random sample of 98 respondents representative of the support group members completed an interviewer-administered questionnaire. Costs were assessed over a 1-month period. Direct costs of caregiving (including out-of-pocket costs incurred on health care) as well as productivity losses (i.e. indirect cost) to caregivers were analysed. Intangible costs were assessed using the 12-item Zarit burden interview (ZBI) tool and the financial cost dimension of the cost of care index. RESULTS: The estimated average cost of caregiving per month was US$186.18, 66% of which was direct cost. About 78% of the family caregivers in the study reported a high level of caregiving burden (as measured with the ZBI) with females reporting a relatively higher level than males. Further, about 87% of the family caregivers reported a high level of financial stress as a result of caregiving for their elderly relative. CONCLUSION: The study shows that support/caregiving for elderly populations imposes economic burden on families, potentially influencing the economic position of families with attendant implications for equity and future family support for such vulnerable populations.

Predictors of self-reported health among the elderly in Ghana: a cross sectional study.

BACKGROUND: Self-reported health is a widely used measure of health status across individuals. As the ageing population increases, the health of the elderly also becomes of growing concern. The elderly go through life facing social, economic and financial hardships. These hardships are known to affect the health status of people as they age. The purpose of this study is to assess social and health related factors of self-reported health among the elderly in Ghana. METHODS: A multivariate regression analysis in form of a binary and ordinal logistic regression were used to determine the association between socioeconomic, demographic and health related factors, on self-reported health. The data used for this study was drawn from the World Health Organization (WHO) Study on Global Ageing and Adult Health (SAGE) Wave 1. RESULTS: In total, out of 2613 respondent, 579 (20.1%) rated their health status as poor and 2034 (79.9%) as good. The results showed that the odds of reporting poor health was 2.5 times higher among the old-old compared to the young old. The elderly with one or more than one chronic condition had the odds of 1.6 times and 2 times respectively, of reporting poor health. Engaging in mild to moderate exercise increased the chances of reporting poor health by 1.8 times. The elderly who had never worked in a lifetime were 2 times more likely to report poor health. In the same way, residents of Eastern and Western parts of Ghana were 2 times more likely to report poor health compared to those in the Upper West region. Respondents with functional limitations and disabilities were 3.6 times and 2.4 times respectively, more likely to report poor health. On the other hand, the odds of reporting poor health was 29, 36 and 27% less among respondents in the highest income quintiles, former users of tobacco and those satisfied with certain aspects of life respectively. Also, current alcohol users were 41% less likely to report poor health. CONCLUSION: The health status of the elderly is to an extent determined by the circumstances in which they are born, grow and live. The findings suggest that addressing social issues faced by individuals in youthful age will go a long way to achieving good health in the future. People with physical limitations and disabilities are most vulnerable to unmet healthcare needs and support system from government, policy makers and family.

Situational analysis of antibiotic use and resistance in Ghana: policy and regulation.

BACKGROUND: Antibiotics have played an essential role in decreasing morbidity and mortality from infectious diseases. However, indiscriminate use and unrestricted access is contributing to the emergence of bacterial resistance. This paper reports on a situational analysis of antimicrobial use and resistance in Ghana, with focus on policy and regulation. METHODS: Relevant policy documents, reports, regulations and enactments were reviewed. PubMed and Google search engines were used to extract relevant published papers. Websites of stakeholders such as Ministry of Health (MOH) and its agencies were also reviewed. An interview guide was used to elicit responses from selected officials from these sectors. RESULTS: Laws and guidelines to control the use of antimicrobials in humans were available but not for animals. There was no National Antimicrobial Policy (NAP). A health practice regulatory law mandates Physicians, Physician Assistants, Midwives and trained Nurses to prescribe antimicrobials. However, antibiotics are widely prescribed and dispensed by unauthorised persons, suggesting weak enforcement of the laws. Antibiotics were also supplied to and from unapproved medicine outlets. The Standard Treatment Guidelines (STG), Essential Medicines List (EML) and the National Health Insurance Scheme Medicines List (NHISML) provide restrictions regarding levels of prescribing of antimicrobials. However, existing guidelines on antibiotic use are mostly not adhered to. The use of Automatic Stop Orders to avoid wastage in the hospitals is also not practiced. Data on use of antibiotics for individuals are not readily available in most facilities. Again, there are no standards or guidelines on veterinary use of antibiotics. Surveillance systems for consumption of antibiotics and resistance monitoring were not in place in most health facilities. However, there is an ongoing national action to create awareness on bacteria resistance, strengthening knowledge through research and surveillance and development of NAP in line with global action plan on antimicrobial resistance. CONCLUSION: Absence of national antimicrobial policy, weak regulatory environment and non-adherence to practice standards may have contributed to increased and unregulated access to antimicrobials in Ghana, a catalyst for development and spread of antimicrobial resistance.

Reducing medical claims cost to Ghana's National Health Insurance scheme: a cross-sectional comparative assessment of the paper- and electronic-based claims reviews.

BACKGROUND: A robust medical claims review system is crucial for addressing fraud and abuse and ensuring financial viability of health insurance organisations. This paper assesses claims adjustment rate of the paper- and electronic-based claims reviews of the National Health Insurance Scheme (NHIS) in Ghana. METHODS: The study was a cross-sectional comparative assessment of paper- and electronic-based claims reviews of the NHIS. Medical claims of subscribers for the year, 2014 were requested from the claims directorate and analysed. Proportions of claims adjusted by the paper- and electronic-based claims reviews were determined for each type of healthcare facility. Bivariate analyses were also conducted to test for differences in claims adjustments between healthcare facility types, and between the two claims reviews. RESULTS: The electronic-based review made overall adjustment of 17.0% from GHS10.09 million (USD2.64 m) claims cost whilst the paper-based review adjusted 4.9% from a total of GHS57.50 million (USD15.09 m) claims cost received, and the difference was significant (p < 0.001). However, there were no significant differences in claims cost adjustment rate between healthcare facility types by the electronic-based (p = 0.0656) and by the paper-based reviews (p = 0.6484). CONCLUSIONS: The electronic-based review adjusted significantly higher claims cost than the paper-based claims review. Scaling up the electronic-based review to cover claims from all accredited care providers could reduce spurious claims cost to the scheme and ensure long term financial sustainability.

Economic cost and quality of life of family caregivers of schizophrenic patients attending psychiatric hospitals in Ghana.

BACKGROUND: Low and middle income countries face many challenges in meeting their populations' mental health care needs. Though family caregiving is crucial to the management of severe mental health disabilities, such as schizophrenia, the economic costs borne by family caregivers often go unnoticed. In this study, we estimated the household economic costs of schizophrenia and quality of life of family caregivers in Ghana. METHODS: We used a cost of illness analysis approach. Quality of life (QoL) was assessed using the abridged WHO Quality of Life (WHOQOL-BREF) tool. Cross-sectional data were collected from 442 caregivers of patients diagnosed with schizophrenia at least six months prior to the study and who received consultation in any of the three psychiatric hospitals in Ghana. Economic costs were categorized as direct costs (including medical and non-medical costs of seeking care), indirect costs (productivity losses to caregivers) and intangible costs (non-monetary costs such as stigma and pain). Direct costs included costs of medical supplies, consultations, and travel. Indirect costs were estimated as value of productive time lost (in hours) to primary caregivers. Intangible costs were assessed using the Zarit Burden Interview (ZBI). We employed multiple regression models to assess the covariates of costs, caregiver burden, and QoL. RESULTS: Total monthly cost to caregivers was US$ 273.28, on average. Key drivers of direct costs were medications (50%) and transportation (27%). Direct costs per caregiver represented 31% of the reported monthly earnings. Mean caregiver burden (measured by the ZBI) was 16.95 on a scale of 0-48, with 49% of caregivers reporting high burden. Mean QoL of caregivers was 28.2 (range: 19.6-34.8) out of 100. Better educated caregivers reported lower indirect costs and better QoL. Caregivers with higher severity of depression, anxiety and stress reported higher caregiver burden and lower QoL. Males reported better QoL. CONCLUSIONS: These findings highlight the high household burden of caregiving for people living with schizophrenia in low income settings. Results underscore the need for policies and programs to support caregivers.

Alcohol consumption among pregnant women in James Town Community, Accra, Ghana.

BACKGROUND: Alcohol consumption among pregnant women is a public health concern, considering its adverse outcomes for both mother and the developing foetus. This study examined factors that facilitate prenatal alcohol consumption, knowledge of adverse outcomes of prenatal alcohol exposure and alcohol expenditure among pregnant women in an urban community in Ghana. METHODS: In June 2014, a survey was conducted among 250 pregnant women sampled from James Town, an urban community in the Greater Accra Region of Ghana. Data were collected through face-to-face interviews and descriptive statistics conducted. The prevalence of alcohol consumption among women was determined. Pearson chi-square was used to determine associations between variables where necessary. RESULTS: Fifty-four percent of the pregnant women were aged 20 - 29 years. Seventy-three percent reported that they have ever consumed an alcoholic beverage before pregnancy. Of these, 77% take alcohol "once a while" and 48% reported taking alcohol during pregnancy. Most of the pregnant women (53%) who currently consume alcoholic beverages had it from friends, and their main reason for prenatal alcohol consumption was socialization (39%). Majority of both current alcohol drinkers (78%) and non-current alcohol drinkers (74%) were aware that prenatal alcohol consumption can lead to spontaneous abortion. Additionally, current alcohol drinkers spend averagely GHS 4.54 (SD 4.63) on their favourite alcoholic drink and overall, also spend averagely GHS 4.63 (SD 4.82) on their entire alcoholic beverage weekly. Over two-thirds (63%) of women reported monthly average income of less than GHS200. CONCLUSION: This study shows high prenatal alcohol consumption in James Town, Accra, despite pregnant women's knowledge of its adverse effects on the developing foetus. Alcohol is usually sourced from friends with socialization noted as a major reason for prenatal alcohol consumption. These results could be used to inform future health advocacies and policies on prenatal alcohol exposure and maternal and child health interventions in the country.

Cost-effectiveness of seasonal malaria chemoprevention in upper west region of Ghana.

BACKGROUND: In Ghana, malaria is endemic and perennial (with significant seasonal variations in the three Northern Regions), accounting for 33 % of all deaths among children under 5 years old, with prevalence rates in children under-five ranging from 11 % in Greater Accra to 40 % in Northern Region. Ghana adopted the WHO-recommended Seasonal Malaria Chemoprevention (SMC) strategy with a trial in the Upper West Region in 2015. The objective of this study was to estimate the cost-effectiveness of seasonal malaria chemoprevention. METHODS: Costs were analysed from provider and societal perspectives and are reported in 2015 US$. Data on resource use (direct and indirect costs) of the SMC intervention were collected from intervention records and a survey in all districts and at regional level. Additional numbers of malaria cases and deaths averted by the intervention were estimated based on prevalence data obtained from an SMC effectiveness study in the region. Incremental cost-effectiveness ratios (ICERs) were estimated for the districts and region. Sensitivity analyses were conducted to test the robustness of the ICERs. RESULTS: The total financial cost of the intervention was US$1,142,040.80. The total economic cost was estimated to be US$7.96 million and US$2.66 million from the societal and provider perspectives, respectively. The additional numbers of cases estimated to be averted by the intervention were 24,881 and 808, respectively. The economic cost per child dosed was US$67.35 from societal perspective and US$22.53 from the provider perspective. The economic cost per additional case averted was US$107.06 from the provider perspective and US$319.96 from the societal perspective. The economic cost per additional child death averted by the intervention was US$3298.36 from the provider perspective and US$9858.02 from the societal perspective. The financial cost per the SMC intervention delivered to a child under-five was US$9.66. The ICERs were sensitive to mortality rate used. CONCLUSIONS: The SMC intervention is economically beneficial in reducing morbidity in children under-5 years and presents a viable approach to improving under-five health in Ghana.

Economic burden of malaria on businesses in Ghana: a case for private sector investment in malaria control.

BACKGROUND: Despite the significant gains made globally in reducing the burden of malaria, the disease remains a major public health challenge, especially in sub-Saharan Africa (SSA) including Ghana. There is a significant gap in financing malaria control globally. The private sector could become a significant source of financing malaria control. To get the private sector to appreciate the need to invest in malaria control, it is important to provide evidence of the economic burden of malaria on businesses. The objective of this study, therefore, was to estimate the economic burden on malaria on businesses in Ghana, so as to stimulate the sector's investment in malaria control. METHODS: Data covering 2012-2014 were collected from 62 businesses sampled from Greater Accra, Ashanti and Western Regions of Ghana, which have the highest concentration of businesses in the country. Data on the cost of businesses' spending on treatment and prevention of malaria in staff and their dependants as well as staff absenteeism due to malaria and expenditure on other health-related activities were collected. Views of business leaders on the effect of malaria on their businesses were also compiled. The analysis was extrapolated to cover 5828 businesses across the country. RESULTS: The results show that businesses in Ghana lost about US$6.58 million to malaria in 2014, 90 % of which were direct costs. A total of 3913 workdays were lost due to malaria in firms in the study sample during the period 2012-2014. Businesses in the study sample spent an average of 0.5 % of the annual corporate returns on treatment of malaria in employees and their dependants, 0.3 % on malaria prevention, and 0.5 % on other health-related corporate social responsibilities. Again business leaders affirmed that malaria affects their businesses' efficiency, employee attendance and productivity and expenses. Finally, about 93 % of business leaders expressed the need private sector investment in malaria control. CONCLUSIONS: The economic burden of malaria on businesses in Ghana cannot be underestimated. This, together with business leaders' acknowledgement that it is important for private sector investment in malaria control, provides motivation for engagement of the private sector in financing malaria control activities.

The effect of the National Health Insurance Scheme (NHIS) on health service delivery in mission facilities in Ghana: a retrospective study.

BACKGROUND: In 2004, Ghana began implementation of a National Health Insurance Scheme (NHIS) to minimize out-of-pocket expenditure at the point of use of service. The implementation of the scheme was accompanied by increased access and use of health care services. Evidence suggests most health facilities are faced with management challenges in the delivery of services. The study aimed to assess the effect of the introduction of the NHIS on health service delivery in mission health facilities in Ghana. We conceptualised the effect of NHIS on facilities using service delivery indicators such as outpatient and inpatient turn out, estimation of general service readiness, revenue and expenditure, claims processing and availability of essential medicines. We collected data from 38 mission facilities, grouped into the three ecological zones; southern, middle and northern. Structured questionnaires and exit interviews were used to collect data for the periods 2003 and 2010. The data was analysed in SPSS and MS Excel. RESULTS: The facilities displayed high readiness to deliver services. There were significant increases in outpatient and inpatient attendance, revenue, expenditure and improved access to medicines. Generally, facilities reported increased readiness to deliver services. However, challenging issues around high rates of non-reimbursement of NHIS claims due to errors in claims processing, lack of feedback regarding errors, and lack of clarity on claims reporting procedures were reported. CONCLUSION: The implementation of the NHIS saw improvement and expansion of services resulting in benefits to the facilities as well as constraints. The constraints could be minimized if claims processing is improved at the facility level and delays in reimbursements also reduced.

Factors influencing the work efficiency of district health managers in low-resource settings: a qualitative study in Ghana.

BACKGROUND: There is increasing evidence that good district management practices can improve health system performance and conversely, that poor and inefficient management practices have detrimental effects. The aim of the present study was to identify factors contributing to inefficient management practices of district health managers and ways to improve their overall efficiency. METHODS: Nineteen semi-structured interviews were conducted with district health managers in three districts of the Eastern Region in Ghana. The 19 interviews conducted comprised 90% of the managerial workforce in these districts in 2013. A thematic analysis was carried out using the WHO's leadership and management strengthening framework to structure the results. RESULTS: Key factors for inefficient district health management practices were identified to be: human resource shortages, inadequate planning and communication skills, financial constraints, and a narrow decision space that constrains the authority of district health managers and their ability to influence decision-making. Strategies that may improve managerial efficiency at both an individual and organizational level included improvements to planning, communication, and time management skills, and ensuring the timely release of district funds. CONCLUSIONS: Filling District Health Management Team vacancies, developing leadership and management skills of district health managers, ensuring a better flow of district funds, and delegating more authority to the districts seems to be a promising intervention package, which may result in better and more efficient management practices and stronger health system performance.

Responses to donor proliferation in Ghana's health sector: a qualitative case study.

OBJECTIVE: To investigate how donors and government agencies responded to a proliferation of donors providing aid to Ghana's health sector between 1995 and 2012. METHODS: We interviewed 39 key informants from donor agencies, central government and nongovernmental organizations in Accra. These respondents were purposively selected to provide local and international views from the three types of institutions. Data collected from the respondents were compared with relevant documentary materials - e.g. reports and media articles - collected during interviews and through online research. FINDINGS: Ghana's response to donor proliferation included creation of a sector-wide approach, a shift to sector budget support, the institutionalization of a Health Sector Working Group and anticipation of donor withdrawal following the country's change from low-income to lower-middle income status. Key themes included the importance of leadership and political support, the internalization of norms for harmonization, alignment and ownership, tension between the different methods used to improve aid effectiveness, and a shift to a unidirectional accountability paradigm for health-sector performance. CONCLUSION: In 1995-2012, the country's central government and donors responded to donor proliferation in health-sector aid by promoting harmonization and alignment. This response was motivated by Ghana's need for foreign aid, constraints on the capacity of governmental human resources and inefficiencies created by donor proliferation. Although this decreased the government's transaction costs, it also increased the donors' coordination costs and reduced the government's negotiation options. Harmonization and alignment measures may have prompted donors to return to stand-alone projects to increase accountability and identification with beneficial impacts of projects.