A qualitative evaluation of stakeholder perspectives on sustainable financing strategies for 'priority' adolescent sexual and reproductive health interventions in Ghana.

BACKGROUND: Adolescent sexual and reproductive health (ASRH) interventions are underfunded in Ghana. We explored stakeholder perspectives on innovative and sustainable financing strategies for priority ASRH interventions in Ghana. METHODS: Using qualitative design, we interviewed 36 key informants to evaluate sustainable financing sources for ASRH interventions in Ghana. Thematic content analysis of primary data was performed. Study reporting followed the consolidated criteria for reporting qualitative research. RESULTS: Proposed conventional financing strategies included tax-based, need-based, policy-based, and implementation-based approaches. Unconventional financing strategies recommended involved getting religious groups to support ASRH interventions as done to mobilize resources for the Ghana COVID-19 Trust Fund during the global pandemic. Other recommendations included leveraging existing opportunities like fundraising through annual adolescent and youth sporting activities to support ASRH interventions. Nonetheless, some participants believed financial, material, and non-material resources must complement each other to sustain funding for priority ASRH interventions. CONCLUSION: There are various sustainable financing strategies to close the funding gap for ASRH interventions in Ghana, but judicious management of financial, material, and non-material resources is needed to sustain priority ASRH interventions in Ghana.

Healthcare provider cost of antimicrobial resistance in two teaching hospitals in Ghana.

Understanding the healthcare provider costs of antimicrobial resistance (AMR) in lower-middle-income countries would motivate healthcare facilities to prioritize reducing the AMR burden. This study evaluates the extra length of stay and the associated healthcare provider costs due to AMR to estimate the potential economic benefits of AMR prevention strategies. We combined data from a parallel cohort study with administrative data from the participating hospitals. The parallel cohort study prospectively matched a cohort of patients with bloodstream infections caused by third-generation cephalosporin-resistant enterobacteria and methicillin-resistant Staphylococcus aureus (AMR cohort) with two control arms: patients infected with similar susceptible bacteria and a cohort of uninfected controls. Data collection took place from June to December 2021. We calculated the cost using aggregated micro-costing and step-down costing approaches and converted costs into purchasing power parity in international US dollars, adjusting for surviving patients, bacterial species and cost centres. We found that the AMR cohort spent a mean of 4.2 extra days (95% CI: 3.7-4.7) at Hospital 1 and 5.5 extra days (95% CI: 5.1-5.9) at Hospital 2 compared with the susceptible cohort. This corresponds to an estimated mean extra cost of $823 (95% CI: 812-863) and $946 (95% CI: US$929-US$964) per admission, respectively. For both hospitals, the estimated mean annual extra cost attributable to AMR was approximately US$650 000. The cost varies by organism and type of resistance expressed. The result calls for prioritization of interventions to mitigate the spread of AMR in Ghana.

Impact of COVID-19 on the management of hypertension: a perspective on disease severity, service use patterns and expenditures from Ghana's health insurance claims data.

Hypertension is a leading cause of morbidity in Ghana and other sub-Saharan African countries, but management has historically suffered from the fragility of health systems in these countries. This has been exacerbated by the COVID-19 pandemic and its associated measures. Our study examines and quantifies the effect of the pandemic on the management of hypertension in Ghana by determining changes in disease severity and presentation, as well as changes in health service use patterns and expenditures. We used cross-sectional data to perform an impact evaluation of COVID-19 on hypertension management before and during the pandemic. We employed statistical tests including t-tests, z-tests, and exact Poisson tests to estimate and compare hypertension episode intensity and related claim expenditures before and during the pandemic using medical claims data from Ghana's National Health Insurance Authority database. The study duration includes a 12-month reference/pre-pandemic period (March 2019-February 2020) relative to the target/pandemic period (March 2020-February 2021). We observed that although there was a 20% reduction in the number of hypertension claimants in the pandemic year, there was an increase in hypertension severity as measured by the number of hypertension episodes per claimant. There was also an 18.64% or $22.88 (95% CI: $21-$25, p = 0.01042) increase in the average cost per hypertension claimant in the pandemic year. The increase in episodes per claimant had the largest financial impact on the average cost per claimant. The findings from our studies are relevant for future policymaking and strategy implementation for hypertension control in Ghana.

Knowledge, attitudes and practices regarding antimicrobial use and resistance among healthcare seekers in two tertiary hospitals in Ghana: a quasi-experimental study.

OBJECTIVE: To evaluate knowledge of antimicrobial resistance (AMR), to study how the judgement of health value (HVJ) and economic value (EVJ) affects antibiotic use, and to understand if access to information on AMR implications may influence perceived AMR mitigation strategies. DESIGN: A quasi-experimental study with interviews performed before and after an intervention where hospital staff collected data and provided one group of participants with information about the health and economic implications of antibiotic use and resistance compared with a control group not receiving the intervention. SETTING: Korle-Bu and Komfo Anokye Teaching Hospitals, Ghana. PARTICIPANTS: Adult patients aged 18 years and older seeking outpatient care. MAIN OUTCOME MEASURES: We measured three outcomes: (1) level of knowledge of the health and economic implications of AMR; (2) HVJ and EVJ behaviours influencing antibiotic use and (3) differences in perceived AMR mitigation strategy between participants exposed and not exposed to the intervention. RESULTS: Most participants had a general knowledge of the health and economic implications of antibiotic use and AMR. Nonetheless, a sizeable proportion disagreed or disagreed to some extent that AMR may lead to reduced productivity/indirect costs (71% (95% CI 66% to 76%)), increased provider costs (87% (95% CI 84% to 91%)) and costs for carers of AMR patients/societal costs (59% (95% CI 53% to 64%)). Both HVJ-driven and EVJ-driven behaviours influenced antibiotic use, but the latter was a better predictor (reliability coefficient >0.87). Compared with the unexposed group, participants exposed to the intervention were more likely to recommend restrictive access to antibiotics (p<0.01) and pay slightly more for a health treatment strategy to reduce their risk of AMR (p<0.01). CONCLUSION: There is a knowledge gap about antibiotic use and the implications of AMR. Access to AMR information at the point of care could be a successful way to mitigate the prevalence and implications of AMR.

Attributable Patient Cost of Antimicrobial Resistance: A Prospective Parallel Cohort Study in Two Public Teaching Hospitals in Ghana.

OBJECTIVE: The aim of this study was to evaluate the attributable patient cost of antimicrobial resistance (AMR) in Ghana to provide empirical evidence to make a case for improved AMR preventive strategies in hospitals and the general population. METHODS: A prospective parallel cohort design in which participants were enrolled at the time of hospital admission and remained until 30 days after the diagnosis of bacteraemia or discharge from the hospital/death. Patients were matched on age group (± 5 years the age of AMR patients), treatment ward, sex, and bacteraemia type. The AMR cohort included all inpatients with a positive blood culture of Escherichia coli or Klebsiella spp., resistant to third-generation cephalosporins (3GC), or methicillin-resistant Staphylococcus aureus (MRSA). We matched the AMR cohort (n = 404) with two control arms, i.e., patients with the same bacterial infections susceptible to 3GC or S. aureus that was methicillin-susceptible (susceptible cohort; n = 152), and uninfected patients (uninfected cohort; n = 404). Settings were Korle-Bu and Komfo Anokye Teaching Hospitals, Ghana. The outcome measures were the length of hospital stay (LOS) and the associated patient costs. Outcomes were evaluated from the patient perspective. RESULTS: From a total of 5752 blood cultures screened, 1836 participants had growth in blood culture, of which, based on our inclusion criteria, 426 were enrolled into the AMR cohort; however, only 404 completed the follow-up and were matched with participants in the two control cohorts. Patients in the AMR cohort stayed approximately 5 more days (95% confidence interval [CI] 4.0-6.0) and 8 more days (95% CI 7.2-8.6) compared with the susceptible and uninfected cohorts, respectively. The mean extra patient cost due to AMR relative to the susceptible cohort was US$1300 (95% CI 1018-1370), of which about 30% resulted from productivity loss due to presenteeism and absenteeism from work. Overall, the estimated annual patient cost due to AMR translates to about US$1 million and US$1.4 million when compared with the susceptible and uninfected cohorts, respectively. CONCLUSION: We have shown that AMR is associated with a significant excess LOS and patient costs in Ghana using prospective data from two public tertiary hospitals. This calls for infection prevention and control strategies aimed at mitigating the prevalence of AMR.

Cost-effectiveness analysis of alcohol handrub for the prevention of neonatal bloodstream infections: Evidence from HAI-Ghana study.

Published evidence of the cost-effectiveness of alcohol-based handrub (ABH) for the prevention of neonatal bloodstream infections (BSI) is limited in sub-Saharan Africa. Therefore, this study evaluates the cost-effectiveness of a multimodal hand hygiene involving alcohol-based hand rub (ABH) for the prevention of neonatal BSI in a neonatal intensive care unit (NICU) setting in Ghana using data from HAI-Ghana study. Design was a before and after intervention study using economic evaluation model to assess the cost-effectiveness of a multimodal hand hygiene strategy involving alcohol-based hand rub plus soap and water compared to existing practice of using only soap and water. We measured effect and cost by subtracting outcomes without the intervention from outcomes with the intervention. The primary outcome measure is the number of neonatal BSI episode averted with the intervention and the consequent cost savings from patient and provider perspectives. The before and after intervention studies lasted four months each, spanning October 2017 to January 2018 and December 2018 to March 2019, respectively. The analysis shows that the ABH program was effective in reducing patient cost of neonatal BSI by 41.7% and BSI-attributable hospital cost by 48.5%. Further, neonatal BSI-attributable deaths and extra length of hospital stay (LOS) decreased by 73% and 50% respectively. Also, the post-intervention assessment revealed the ABH program contributed to 16% decline in the incidence of neonatal BSI at the NICU. The intervention is a simple and adaptable strategy with cost-saving potential when carefully scaled up across the country. Though the cost of the intervention may be more relative to using just soap and water for hand hygiene, the outcome is a good reason for investment into the intervention to reduce the incidence of neonatal BSI and the associated costs from patient and providers' perspectives.

Cost-effectiveness analysis of an active 30-day surgical site infection surveillance at a tertiary hospital in Ghana: evidence from HAI-Ghana study.

OBJECTIVE: To assess the cost-effectiveness of an active 30-day surgical site infection (SSI) surveillance mechanism at a referral teaching hospital in Ghana using data from healthcare-associated infection Ghana (HAI-Ghana) study. DESIGN: Before and during intervention study using economic evaluation model to assess the cost-effectiveness of an active 30-day SSI surveillance at a teaching hospital. The intervention involves daily inspection of surgical wound area for 30-day postsurgery with quarterly feedback provided to surgeons. Discharged patients were followed up by phone call on postoperative days 3, 15 and 30 using a recommended surgical wound healing postdischarge questionnaire. SETTING: Korle-Bu Teaching Hospital (KBTH), Ghana. PARTICIPANTS: All prospective patients who underwent surgical procedures at the general surgical unit of the KBTH. MAIN OUTCOME MEASURES: The primary outcome measures were the avoidable SSI morbidity risk and the associated costs from patient and provider perspectives. We also reported three indicators of SSI severity, that is, length of hospital stay (LOS), number of outpatient visits and laboratory tests. The analysis was performed in STATA V.14 and Microsoft Excel. RESULTS: Before-intervention SSI risk was 13.9% (62/446) as opposed to during-intervention 8.4% (49/582), equivalent to a risk difference of 5.5% (95% CI 5.3 to 5.9). SSI mortality risk decreased by 33.3% during the intervention while SSI-attributable LOS decreased by 32.6%. Furthermore, the mean SSI-attributable patient direct and indirect medical cost declined by 12.1% during intervention while the hospital costs reduced by 19.1%. The intervention led to an estimated incremental cost-effectiveness ratio of US$4196 savings per SSI episode avoided. At a national scale, this could be equivalent to a US$60 162 248 cost advantage annually. CONCLUSION: The intervention is a simple, cost-effective, sustainable and adaptable strategy that may interest policymakers and health institutions interested in reducing SSI.

Costs and Extra Length of Stay because of Neonatal Bloodstream Infection at a Teaching Hospital in Ghana.

BACKGROUND: There are no published studies on the costs of hospital-acquired neonatal bloodstream infection (BSI) in Ghana. Therefore, this study aims to calculate the cost and extra length of stay (LOS) of neonatal BSI. A prospective case-control study was undertaken at the neonatal intensive care unit (NICU) of Korle Bu Teaching Hospital (KBTH) in Ghana. METHODS: The clinical data of 357 neonates were prospectively analysed. Overall, 100 neonates with BSI and 100 control neonates without BSI were matched by weight, sex and type of delivery. The direct and indirect costs to neonates and their caregivers was obtained on a daily basis. The cost of drugs was confirmed with the Pharmacy Department at KBTH. A count data model, specifically negative binomial regression, was employed to estimate the extra LOS in the NICU due to neonatal BSI. The study analyzed the total, average and marginal costs of neonatal BSI for the case and control groups from the perspective of the patients/carers/providers. RESULTS: Fifty-four percent of the total sample were born with a low birth weight. Neonates with BSI recorded higher costs compared with neonates without BSI. The highest difference in direct costs was recorded among neonates with extremely low birth weight (US$732), which is 67% higher than similar neonates without BSI. The regression estimates show a significant correlation between neonatal BSI and LOS in the NICU (p < 0.001). Neonates with BSI stayed an additional 10 days in the NICU compared with their matched cohort. The LOS varies significantly depending on the neonate's weight at birth. The extra days range from 1 day for neonates defined as macrosomia to 15 extra days for extremely low birth weight neonates. CONCLUSIONS: Neonatal BSI was significantly associated with prolonged LOS. The continuous presence of experienced medical staff, as well as parents, to monitor newborns during their stay on the ward has enormous economic burden on both hospitals and caregivers.

The financial impact of puerperal infections on patients, carers and public hospitals in two regions in Ghana.

BACKGROUND: Puerperal infection (PI) is a known maternal health problem globally. However, there is limited information on its economic impact on patients, carers, and public hospitals in lower-middle-income countries, such as Ghana. METHODS: A prospective case-control study was undertaken in two regional hospitals to analyze the cost of PI. A total of 667 and 559 participants were enrolled in the study at the Greater Accra Regional Hospital (GARH) and the Eastern Regional Hospital (ERH), respectively. Total, average and marginal costs were analyzed between patients with and without PI. RESULTS: Within the study period, the prevalence of PI was 9.1% at ERH and 14.9% at GARH. Overall, patients with PI reported excess length of hospital stay (LOS), corresponding to 46.8% and 33.5% increases in average direct cost at ERH and GARH, respectively, compared with their control groups. In almost all cases, the attributable indirect cost was consistent with productivity loss. CONCLUSION: In both hospitals, patients with PI reported excess LOS and increased direct and indirect costs. The total cost of PI to society, which is the sum of the direct cost, productivity loss, and hospital cost, was higher in Greater Accra than in the Eastern region.

Attributable cost and extra length of stay of surgical site infection at a Ghanaian teaching hospital.

BACKGROUND: Limited information is available on the financial impact of healthcare associated infections in Sub-Saharan Africa. A prospective case-control study was undertaken at Korle-Bu Teaching Hospital, Ghana, to calculate the cost of surgical site infections (SSI). METHODS: We studied 446 adults undergoing surgery from the surgical department. In all, 40 patients with SSI and 40 control patients without SSI were matched by type of surgery, wound class, ASA, sex and age. The direct and indirect costs to patients were obtained from patients and their carers, daily. The cost of drugs was confirmed with the pharmacy at the department. RESULTS: The prevalence rate for SSI was 11% of the total 446 cases sampled between June and August 2017. On average patients with SSI who undertook hernia surgery paid approximately US$ 392 more than the matched controls without SSI. The least difference was recorded amongst patients who had thyroid surgery, a difference of US$ 42. The results show that for all surgical procedures, SSI patients report excess length of stay. The additional days range from 1 day for limb amputation, to 16 days for rectal surgery. CONCLUSIONS: In this study, patients with SSI experienced significant prolongation of hospitalisation and increased use of health care costs. In many cases, the indirect costs were much higher than direct costs. These findings support the need to implement preventative interventions for patients hospitalised for various surgical procedures at the Korle Bu Teaching Hospital.

Work history and diagnosed hypertension among older adults in Ghana: Evidence from WHO SAGE Wave2

@#There is limited knowledge in the context of Africa on how work history associates with hypertension at old age. Therefore, this paper analyses such an association using Ghana as a case study. Methods Data from the World Health Organisation Study on Global AGEing and Adult Health Wave 2 was used to explore the relationship between work history and diagnosed hypertension at old age. In the Wave2 study, a multistage cluster sampling was used to select participants at the household level across rural/urban areas in all administrative regions. A multifactor logit regression analysis was performed. The paper also estimated diagnosed hypertension prevalence across subgroups. Results The mean age of the total of 3564 participants examined was 64 years (SD = ±10years). The overall prevalence of hypertension was 10.3% [95% CI = 9.4– 11.1]. The highest predicted rate was 41.1% [95% CI=38.0 – 49.2] among those who stopped working before the statutory retirement age 60 years, whereas it was only 4% [95% CI = 3.7 – 5.2] for those who retired from active work at age 60 years. Those who retired at age <60years recorded the highest risk of hypertension diagnosis [OR = 14.1; 95% CI=10.5-19.5]. There was also a significant association between diagnosed hypertension and a history of working <5 days per week [OR=1.6; 95% CI=1.1-2.3]. It emerged that those with a history of informal sector employment were at significant risk of hypertension at old age, if they worked <5days per week [OR=1.5; 95% CI=1.0-2.3]. Conclusions Overall, retirement age emerged as a significant risk factor for diagnosed hypertension at old age, followed by a history of less than five working days per week. .