Reuben K. Esena

Assessment of capacity for Health Policy and Systems Research and Analysis in seven African universities: results from the CHEPSAA project

The importance of health policy and systems research and analysis (HPSR+A) is widely recognized. Universities are central to strengthening and sustaining the HPSR+A capacity as they teach the next generation of decision-makers and health professionals. However, little is known about the capacity of universities, specifically, to develop the field. In this article, we report results of capacity self- assessments by seven universities within five African countries, conducted through the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA). The capacity assessments focused on both capacity ‘assets’ and ‘needs’, and covered the wider context, as well as organizational and individual capacity levels. Six thematic areas of capacity were examined: leadership and governance, organizations’ resources, scope of HPSR+A teaching and research, communication, networking and getting research into policy and practice (GRIPP), demand for HPRS+A and resource environment. The self-assessments by each university used combinations of document reviews, semi-structured interviews and staff surveys, followed by comparative analysis. A framework approach, guided by the six thematic areas, was used to analyse data. We found that HPSR+A is an international priority, and an existing activity in Africa, though still neglected field with challenges including its reliance on unpredictable international funding. All universities have capacity assets, such as ongoing HPSR+A teaching and research. There are, however, varying levels of assets (such as differences in staff numbers, group sizes and amount of HPSR+A teaching and research), which, combined with different capacity needs at all three levels (such as individual training, improvement in systems for quality assurance and fostering demand for HPSR+A work), can shape a future agenda for HPSR+A capacity strengthening. Capacity assets and needs at different levels appear related. Possible integrated strategies for strengthening universities’ capacity include: refining HPSR+A vision, mainstreaming the subject into under- and post-graduate teaching, developing emerging leaders and aligning HPSR+A capacity strengthening within the wider organizational development.

Advancing the application of systems thinking in health: provider payment and service supply behaviour and incentives in the Ghana National Health Insurance Scheme – a systems approach

BackgroundAssuring equitable universal access to essential health services without exposure to undue financial hardship requires adequate resource mobilization, efficient use of resources, and attention to quality and responsiveness of services. The way providers are paid is a critical part of this process because it can create incentives and patterns of behaviour related to supply. The objective of this work was to describe provider behaviour related to supply of health services to insured clients in Ghana and the influence of provider payment methods on incentives and behaviour.MethodsA mixed methods study involving grey and published literature reviews, as well as health management information system and primary data collection and analysis was used. Primary data collection involved in-depth interviews, observations of time spent obtaining service, prescription analysis, and exit interviews with clients. Qualitative data was analysed manually to draw out themes, commonalities, and contrasts. Quantitative data was analysed in Excel and Stata. Causal loop and cause tree diagrams were used to develop a qualitative explanatory model of provider supply incentives and behaviour related to payment method in context.ResultsThere are multiple provider payment methods in the Ghanaian health system. National Health Insurance provider payment methods are the most recent additions. At the time of the study, the methods used nationwide were the Ghana Diagnostic Related Groupings payment for services and an itemized and standardized fee schedule for medicines. The influence of provider payment method on supply behaviour was sometimes intuitive and sometimes counter intuitive. It appeared to be related to context and the interaction of the methods with context and each other rather than linearly to any given method.ConclusionsAs countries work towards Universal Health Coverage, there is a need to holistically design, implement, and manage provider payment methods reforms from systems rather than linear perspectives, since the latter fail to recognize the effects of context and the between-methods and context interactions in producing net effects.

Assessment of mental distress among prison inmates in Ghana’s correctional system: a cross-sectional study using the Kessler Psychological Distress Scale

BackgroundApplying global estimates of the prevalence of mental disorders suggests that about 2.4 million Ghanaians have some form of psychiatric distress. Despite the facts that relatively little community-based treatment is available (only 18 psychiatrists are known to actively practice in Ghana), and that mental disorders are more concentrated among the incarcerated, there is no known research on mental disorders in Ghana prisons, and no forensic mental health services available to those who suffer from them. This study sought to determine the rate of mental distress among prisoners in Ghana.MethodsThis cross-sectional research used the Kessler Psychological Distress Scale to estimate the rates and severity of non-specific psychological distress among a stratified probability sample of 89 male and 11 female prisoners in one of the oldest correctional facilities in the country. Fisher’s exact test was used to determine the rates of psychological distress within the study population.ResultsAccording to the Kessler Scale, more than half of all respondents had moderate to severe mental distress in the four weeks preceding their interviews. Nearly 70% of inmates with only a primary education had moderate to severe mental distress. Though this was higher than the rates among inmates with more education, it exceeded the rates for those with no education.ConclusionsThe high rate of moderate to severe mental distress among the inmates in this exploratory study should serve as baseline for further studies into mental disorders among the incarcerated persons in Ghana. Future research should use larger samples, include more prison facilities, and incorporate tools that can identify specific mental disorders.

Ghana's community-based primary health care: Why women and children are ‘disadvantaged’ by its implementation

Policy analysis on why women and children in low- and middle-income settings are still disadvantaged by access to appropriate care despite Primary Health Care (PHC) programmes implementation is limited. Drawing on the street-level bureaucracy theory, we explored how and why frontline providers (FLP) actions on their own and in interaction with health system factors shape Ghanas community-based PHC implementation to the disadvantage of women and children accessing and using health services. This was a qualitative study conducted in 4 communities drawn from rural and urban districts of the Upper West region. Data were collected from 8 focus group discussions with community informants, 73 in-depth interviews with clients, 13 in-depth interviews with district health managers and FLP, and observations. Data were recorded, transcribed and coded deductively and inductively for themes with the aid of Nvivo 11 software. Findings showed that apart from FLP frequent lateness to, and absenteeism from work, that affected care seeking for children, their exercise of discretionary power in determining children who deserve care over others had ripple effects: families experienced financial hardships in seeking alternative care for children, and avoided that by managing symptoms with care provided in non-traditional spaces. FLP adverse behaviours were driven by weak implementation structures embedded in the district health systems. Basic obstetric facilities such as labour room, infusion stand, and beds for deliveries, detention and palpation were lacking prompting FLP to cope by conducting deliveries using a patchwork of improvised delivery methods which worked out to encourage unassisted home deliveries. Perceived poor conditions of service weakened FLP commitment to quality maternal and child care delivery. Findings suggest the need for strategies to induce behaviour change in FLP, strengthen district administrative structures, and improve on the supply chain and logistics system to address gaps in CHPS maternal and child care delivery.

Willing but unable? Extending theory to investigate community capacity to participate in Ghana’s Community-based Health Planning and service implementation

While primary health care programmes based on community participation are widely implemented in low- and middle- income settings, empirical evidence on whether and to what extent local people have the capacity to participate, support and drive such programmes scale up is scant in these countries. This paper assessed the level of community capacity to participate in one such programme - the Community-Based Health Planning and Service (CHPS) in Ghana. The capacity assessments were drawn from Chaskins (2001) theorised indicators of community capacity with modifications to include: sense of community; community members commitment; community leadership commitment; problem solving mechanisms; and access to resources. These capacity measures guided the design of an interview guide used to collect data from community informants, frontline health providers (FLP) and district health managers. Key qualitative themes were built into a questionnaire administered to households selected through systematic sampling approach. Findings showed that growing individualism, low trust in neighbours and apathetic behaviours undermined the capacity of mutual support for CHPS. The capacity to support CHPS was high for local leadership and community social mobilisation groups who often dedicated time to working with FLP to promote maternal and reproductive health service use, and in advocating broader support for CHPS. Within the wider community, commitment to voluntarism was low as members perceived CHPS to be owned by, and run on government funds and resources. Poor voluntarism was compounded by poverty that crippled the capacity to provide needed resource support for CHPS. Findings have great implications for building strong capable communities for participation in community oriented health programmes.

Pneumonia in Ghana—a need to raise the profile

Despite the high mortality, pneumonia retains a relatively low profile among researchers, funders and policymakers. Here we reflect on the problems and priorities of pneumonia in Ghana, briefly review the evidence base and reflect upon in-person discussions between Southampton-based authors MGH and JB and academic, clinical and policy colleagues in Ghana. The discussions took place in Accra in August 2017.

Erratum to: Pathways to psychiatric care for mental disorders: a retrospective study of patients seeking mental health services at a public psychiatric facility in Ghana.

[This corrects the article DOI: 10.1186/s13033-016-0095-1.].