Challenges with adherence to the 'test, treat, and track' malaria case management guideline among prescribers in Ghana.

BACKGROUND: Despite several efforts at addressing the barriers to adherence to the WHO-supported test, treat and track (T3) malaria case management guideline in Ghana, adherence remains a challenge. This study explored the challenges of prescribers regarding adherence to the T3 guideline. METHODS: This was an explorative study using key informant interviews amongst prescribers comprising medical doctors, physician assistants, nurses and a health extension worker from 16 health facilities in six districts in Ghana. The data was analysed using Nvivo 10 and organized into thematic areas. RESULTS: Prescribers lauded the guideline on testing and treatment as it ensures the quality of malaria case management, but irregular supply of malaria rapid diagnostic test kits (RDT), mistrust of laboratory tests, and the reluctance of prescribers to change from presumptive treatment were key barriers to testing. Patients with malaria test negative results if not treated, revisiting the facility with severe malaria, the experience of prescribers, lack of regular training and supervision for old and new staff and the inability of prescribers to investigate non-malaria fever hindered adherence to results-based treatment. CONCLUSION: As malaria remains a significant cause of morbidity and mortality in Ghana, this study provides insights on gaps in adherence to the testing and treatment of malaria. While the diagnostic capacity for malaria case management is a challenge, the lack of training resulting in the inability of some prescribers to investigate non-malaria fever hinders adherence to the malaria case management guideline. Therefore, there is a need to train new prescribers, laboratory personnel, and other staff involved in malaria diagnosis and treatment on the malaria case management guideline before they assume duty. Equipping laboratory personnel and prescribers with the knowledge to investigate non-malaria fevers could improve adherence to the guideline for improved patient care.

The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation.

BACKGROUND: In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations. METHODS: A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES. RESULTS: Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme. CONCLUSIONS: Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.

Improving the first-line treatment of febrile illnesses in Ghana: willingness to pay for malaria rapid diagnostic tests at licensed chemical shops in the Kintampo area.

BACKGROUND: Use of malaria rapid diagnostic test (mRDT) enhances patient management and reduces costs associated with the inappropriate use of antimalarials. Despite its proven clinical effectiveness, mRDT is not readily available at licensed chemical shops in Ghana. Therefore, in order to improve the use of mRDT, there is the need to understand the willingness to pay for and sell mRDT. This study assessed patients' willingness to pay and licensed chemical operators' (LCS) willingness to sell mRDTs. METHODS: The study was a cross-sectional survey conducted in Kintampo North Municipality and Kintampo South District of Ghana. Contingent valuation method using the dichotomous approach was applied to explore patient's willingness to pay. In-depth interviews (IDIs) were used to obtain information from licensed chemical operators' willingness to sell. RESULTS: Majority 161 (97%) of the customers were willing to pay for mRDT while 100% of licensed chemical operators were also willing to sell mRDT. The average lowest amount respondents were willing to pay was Ghana cedis (GH¢) 1.1 (US$ 0.26) and an average highest amount of GH¢ 2.1 (US$ 0.49). LCS operators were willing to sell the test kit at an average lowest price of GH¢1 (US$ 0.23) and average highest price of GH¢2 (US$ 0.47). CONCLUSION: Community members were willing to pay for mRDT and LCS operators are willing to sell mRDTs. However, the high cost of the mRDT is likely to prevent the widespread use of mRDT. There is a clear need to find system-compatible ways to subsidize the use of mRDT via National Health Insurance scheme.

Economic costs of fever to households in the middle belt of Ghana.

BACKGROUND: Malaria is one of the main health problems in the sub-Saharan Africa accounting for approximately 198 million morbidity and close to 600,000 mortality cases. Households incur out-of-pocket expenditure for treatment and lose income as a result of not being able to work or care for family members. The main objective of this survey was to assess the economic cost of treating malaria and/or fever with the new ACT to households in the Kintampo districts of Ghana where a health and demographic surveillance systems (KHDSS) are set up to document population dynamics. METHODS: The study was a cross-sectional survey conducted from October 2009 to July 2011 using community members' accessed using KHDSS population in the Kintampo area. An estimated sample size of 4226 was randomly selected from the active members of the KHDSS. A structured questionnaire was administered to the selected populates who reported of fever within the last 2 weeks prior to the visit. Data was collected on treatment-seeking behaviour, direct and indirect costs of malaria from the patient perspective. RESULTS: Of the 4226 households selected, 947 households with 1222 household members had fever out of which 92 % sought treatment outside home; 55 % of these were females. 31.6 % of these patients sought care from chemical shops. A mean amount of GHS 4.2 (US$2.76) and GHS 18.0 (US$11.84) were incurred by households as direct and indirect cost respectively. On average a household incurred a total cost of GHS 22.2 (US$14.61) per patient per episode. Total economic cost was lowest for those in the highest quintile and highest for those in the middle quintile. CONCLUSION: The total cost of treating fever/malaria episode is relatively high in the study area considering the poverty levels in Ghana. The NHIS has positively influenced health-seeking behaviours and reduced the financial burden of seeking care for those that are insured.

Seeking treatment for uncomplicated malaria: experiences from the Kintampo districts of Ghana.

BACKGROUND: Malaria accounts for many deaths and illnesses, mostly among young children and pregnant women in sub-Saharan Africa. An integrated approach is recommended to ensure effective malaria control. Socio-cultural factors continue to serve as determinants of malaria health-seeking behaviour. An INDEPTH effectiveness and safety study platform was established to unearth issues around the use of licensed and nationally recommended anti-malarials in real life settings. This study reports on treatment-seeking behaviour for uncomplicated malaria among community members. METHODS: A qualitative study was conducted in the dry and rainy seasons in purposively selected communities in Kintampo north and south districts. This was based on distances to a health facility, ethnicity and availability of medicines at the sale outlets. Twenty-four focus group discussions were conducted among adult men, women care-takers of children less than 5 years and pregnant women. Ten INDEPTH interviews were also conducted among operators of medicine sale outlets and managers of health facilities. Fifty-one illnesses narrative interviews were conducted among adult men, women, women caretakers of children less than 5 years and pregnant women. Transcripts were transferred into Nvivo 8 software for data management and analysis. RESULTS: The artemisinin-based combinations that were commonly known and used were artesunate-amodiaquine and artemether-lumefantrine. Use of herbal preparation to treat diseases including uncomplicated malaria is rife in the communities. Drug stores were not the main source of artemisinin-based combination sales at time of the study. Monotherapies, pain killers and other medicines were purchased from these shops for malaria treatment. Dizziness, general body weakness and sleepiness were noted among respondents who used artemisinin-based combination therapy (ACT) in the past. CONCLUSION: There is no clear cut trajectory for management of uncomplicated malaria in the study area. Different approaches are adopted when treating malaria. There is need for community education to influence behaviour on the management of malaria to achieve real gains from ACT use.

Provider compliance to artemisinin-based combination therapy at primary health care facilities in the middle belt of Ghana.

BACKGROUND: In 2004, Ghana implemented the artemisinin-based combination therapy (ACT) policy. Health worker (HW) adherence to the national malaria guidelines on case-management with ACT for children below 5 years of age and older patients presenting at health facilities (HF) for primary illness consultations was evaluated 5 years post-ACT policy change. METHODS: Cross-sectional surveys were conducted from 2010 to 2011 at HFs that provide curative care as part of outpatient activities in two districts located in the middle belt of Ghana to coincide with the periods of low and high malaria transmission seasons. A review of patient medical records, HW interviews, HF inventories and finger-pricked blood obtained for independent malaria microscopy were used to assess HW practices on malaria case-management. RESULTS: Data from 130 HW interviews, 769 patient medical records at 20 HFs over 75 survey days were individually linked and evaluated. The majority of consultations were performed at health centres/clinics (68.3 %) by medical assistants (28.6 %) and nurse aids (23.5 %). About 68.4 % of HWs had received ACT-specific training and 51.9 %, supervisory visits in the preceding 6 months. Despite the availability of malaria diagnostic test at most HFs (94 %), only 39.8 % (241) out of 605 (78.7 %) patients who reported fever were investigated for malaria. Treatment with ACT in line with the guidelines was 66.7 %; higher in <5 children compared to patients ≥5 years old. Judged against reference microscopy, only 44.8 % (107/239) of ACT prescriptions that conformed to the guidelines were "truly malaria". Multivariate logistic regression analysis showed that HW were significantly more likely to comply with the guidelines if treatment were by low cadre of health staff, were for children below 5 years of age, and malaria test was performed. CONCLUSION: Although the majority of patients presenting with malaria received treatment according to the national malaria guidelines, there were widespread inappropriate treatment with ACT. Compliance with the guidelines on ACT use was low, 5 years post-ACT policy change. The Ghana NMCP needs to strengthen HW capacity on malaria case-management through regular training supported by effective laboratory quality control measures.

The Accuracy and Perception of Test-Based Management of Malaria at Private Licensed Chemical Shops in the Middle Belt of Ghana.

The sale of artemisinin-based combination therapy (ACT) by private licensed chemical shops (LCS) without testing is contrary to current policy recommendations. This study assessed the accuracy and perception of test-based management of malaria using malaria rapid diagnostic test (mRDT) kits at private LCS in two predominantly rural areas in the middle part of Ghana. Clients presenting at LCS with fever or other signs and symptoms suspected to be malaria in the absence of signs of severe malaria were tested with mRDT by trained attendants and treated based on the national malaria treatment guidelines. Using structured questionnaires, exit interviews were conducted within 48 hours and a follow-up interview on day 7 (±3 days). Focus group discussions and in-depth interviews were also conducted to assess stakeholders' perception on the use of mRDT at LCS. About 79.0% (N = 1,797) of clients reported with a fever. Sixty-six percent (947/1,426) of febrile clients had a positive mRDT result. Eighty-six percent (815/947) of clients with uncomplicated malaria were treated with the recommended ACT. About 97.8% (790/808) of clients with uncomplicated malaria treated with ACT were reported to be well by day 7. However, referral for those with negative mRDT results was very low (4.1%, 27/662). A high proportion of clients with a positive mRDT result received the recommended malaria treatment. Test-based management of malaria by LCS attendants was found to be feasible and acceptable by the community members and other stakeholders. Successful implementation will however require effective referral, supervision and quality control systems.

Two years post affordable medicines facility for malaria program: availability and prices of anti-malarial drugs in central Ghana.

BACKGROUND: The Affordable Medicines Facility for malaria (AMFm) Program was a subsidy aimed at artemisinin-based combination therapies (ACTs) in order to increase availability, affordability, and market share of ACTs in 8 malaria endemic countries in Africa. The WHO supervised the manufacture of the subsidized products, named them Quality Assured ACTs (QAACT) and printed a Green Leaf Logo on all QAACT packages. Ghana began to receive the subsidized QAACTs in 2010. METHODS: A cross-sectional stock survey was conducted at 63 licensed chemical shops (LCS) and private pharmacies in two districts of the Brong-Ahafo region of Ghana to determine the availability and price of all anti-malarial treatments. Drug outlets were visited over a 3-weeks period in October and November of 2014, about 2 years after the end of AMFm program. RESULTS: At least one QAACT was available in 88.9% (95% CI 80.9% - 96.8%) of all drug outlets with no difference between urban and rural locations. Non-Assured ACTs (NAACT) were significantly more available in urban drug outlets [75.0% availability (95% CI 59.1% - 90.9%)] than in rural drug outlets [16.1% availability (95% CI 2.4% - 29.9%)]. The top selling product was Artemether Lumefantrine with the Green Leaf Logo, a QAACT. There was a significant difference in the mean price of a QAACT [$1.04 USD (95% CI $0.98 - $1.11)], and the mean price of a NAACT in both the urban and rural areas [$2.46 USD (95% CI $2.11 - $2.81)]. There was no significant difference in the price of any product that was available in urban and rural settings. CONCLUSION: About 2 years after the AMFm program, subsidized QAACTs in Ghana were widely available and more affordable than NAACTs in the Kintampo North District and Kintampo South Municipality of Ghana. The AMFm program appeared to have mostly succeeded in making QAACTs available and affordable.

The association between health insurance status and utilization of health services in rural Northern Ghana: evidence from the introduction of the National Health Insurance Scheme.

BACKGROUND: Many households in low- and middle-income countries face financial hardships due to payments for health care, while others are pushed into poverty. Risk pooling and prepayment mechanisms help to lessen the impact of the costs of care as well as assisting to achieve universal health coverage (UHC). Ghana implemented the National Health Insurance Scheme (NHIS) for the promotion of access to health services for all Ghanaians. In this paper, we examined the association between health insurance status and utilization of outpatient and inpatient health services in rural poor communities. METHODS: The study was a cross-sectional household survey conducted in the Kassena-Nankana districts of Northern Ghana. We conducted interviews in 11,175 households and collected data on 55,992 household members. Multiple logistic regression models were used to identify factors associated with the utilization of outpatient and inpatient health services. The dependent variables were the utilization of outpatient and inpatient health services. We adjusted for several potential socio-demographic factors associated with utilization and health insurance status. RESULTS: Significantly, the insured had 2.51 (95% CI 2.3-2.8) and 2.78 (95% CI 2.2-3.6) increased odds of utilizing outpatient and inpatient health services respectively. Respondents with a history of recent illness or injury [32.4 (95% CI 29.4-35.8) and 5.72 (95% CI 4.6-7.1)] and poor or very poor self-reported health status [2.08 (95% CI 1.7-2.5) and 2.52 (95% CI 1.9-3.4)] and those on chronic medication [2.79 (95% CI 2.2-3.5) and 3.48 (95% CI 2.5-4.8)] also had increased odds of utilizing both outpatient and inpatient health services respectively. Among the insured, the poorest use the Community-based Health Planning and Services (CHPS) compounds, while the least poor use private clinics and public hospitals for outpatient health services. The uninsured predominately use pharmacies or licensed chemical shops (LCSs). For inpatient health services, the insured largely use public hospitals, with the uninsured using private clinics or public health centres. CONCLUSION: The findings suggest that being insured with the NHIS is associated with increased utilization of outpatient and inpatient health services in the study area. Overall, the NHIS can be an effective tool for achieving UHC and hence pragmatic efforts should be made to sustain it.

The application of a biometric identification technique for linking community and hospital data in rural Ghana.

BACKGROUND: The reliability of counts for estimating population dynamics and disease burdens in communities depends on the availability of a common unique identifier for matching general population data with health facility data. Biometric data has been explored as a feasible common identifier between the health data and sociocultural data of resident members in rural communities within the Kintampo Health and Demographic Surveillance System located in the central part of Ghana. OBJECTIVE: Our goal was to assess the feasibility of using fingerprint identification to link community data and hospital data in a rural African setting. DESIGN: A combination of biometrics and other personal identification techniques were used to identify individual's resident within a surveillance population seeking care in two district hospitals. Visits from resident individuals were successfully recorded and categorized by the success of the techniques applied during identification. The successes of visits that involved identification by fingerprint were further examined by age. RESULTS: A total of 27,662 hospital visits were linked to resident individuals. Over 85% of those visits were successfully identified using at least one identification method. Over 65% were successfully identified and linked using their fingerprints. Supervisory support from the hospital administration was critical in integrating this identification system into its routine activities. No concerns were expressed by community members about the fingerprint registration and identification processes. CONCLUSIONS: Fingerprint identification should be combined with other methods to be feasible in identifying community members in African rural settings. This can be enhanced in communities with some basic Demographic Surveillance System or census information.

Use of Antimalarial in the Management of Fever during a Community Survey in the Kintampo Districts of Ghana.

BACKGROUND: Epidemiology of malaria and related fevers in most parts of Africa is changing due to scale up of interventions such as appropriate use of ACTs in the effort towards sustained control and eventual elimination of malaria. The use of ACTs in the management of malaria-associated fever was evaluated in the Kintampo districts of Ghana. METHODS: Household survey was conducted between October 2009 and February, 2011. A random selection of 370 households was generated from 25,000 households existing within the Health and Demographic Surveillance Systems in Kintampo, Ghana at the time. All household members present at the time of survey in the eligible households were interviewed based on a two weeks reported fever recall and the use of antimalarial for the management of fever. A finger-prick blood sample was also obtained from each member of the household present and later examined for malaria parasites using microscopy. Descriptive analysis was performed, with univariate and multivariate analysis used to identify predictors of fever and malaria parasitemia. RESULTS: A total of 1436 individuals were interviewed from 370 households. Overall, fever prevalence was 23.8% (341/1436) and was 38.8% (77/198) in children < 5 years, 21.3% (264/1238) in older children plus adults. Participants who sought treatment for fever were 84% (285/341) with 47.7% (136/285) using any anti-malarial. Artemisinin-based Combination Therapy use was in 69.1% (94/136) of cases while 30.9% used mono-therapies. Malaria parasitaemia rate was 28.2% (397/1407). CONCLUSION: The study reports high community fever prevalence, frequent use of antimalarials for fever treatment and relatively high use of mono-therapies especially in children < 5 years in an area with high malaria parasite prevalence in Ghana.

Health providers' perceptions of clinical trials: lessons from Ghana, Kenya and Burkina Faso.

BACKGROUND: Clinical trials conducted in Africa often require substantial investments to support trial centres and public health facilities. Trial resources could potentially generate benefits for routine health service delivery but may have unintended consequences. Strengthening ethical practice requires understanding the potential effects of trial inputs on the perceptions and practices of routine health care providers. This study explores the influence of malaria vaccine trials on health service delivery in Ghana, Kenya and Burkina Faso. METHODS: We conducted: audits of trial inputs in 10 trial facilities and among 144 health workers; individual interviews with frontline providers (n=99) and health managers (n=14); and group discussions with fieldworkers (n=9 discussions). Descriptive summaries were generated from audit data. Qualitative data were analysed using a framework approach. RESULTS: Facilities involved in trials benefited from infrastructure and equipment upgrades, support with essential drugs, access to trial vehicles, and placement of additional qualified trial staff. Qualified trial staff in facilities were often seen as role models by their colleagues; assisting with supportive supervision and reducing facility workload. Some facility staff in place before the trial also received formal training and salary top-ups from the trials. However, differential access to support caused dissatisfaction, and some interviewees expressed concerns about what would happen at the end of the trial once financial and supervisory support was removed. CONCLUSION: Clinical trials function as short-term complex health service delivery interventions in the facilities in which they are based. They have the potential to both benefit facilities, staff and communities through providing the supportive environment required for improvements in routine care, but they can also generate dissatisfaction, relationship challenges and demoralisation among staff. Minimising trial related harm and maximising benefits requires careful planning and engagement of key actors at the outset of trials, throughout the trial and on its' completion.