Adopting localised health financing models for universal health coverage in Low and middle-income countries: lessons from the National Health lnsurance Scheme in Ghana

The health-related Sustainable Development Goals (SDGs) and the Coronavirus Pandemic (COVID-19) have recently increased awareness of the need for countries to increase fiscal space for health. Prior to these, many Low and Middle-Income Countries (LMICs) had embraced the concept of Universal Health Coverage (UHC) and have either commenced or are in the process of implementing various models of health insurance in order to provide financial access to health care to their populations. While evidence of a relationship between experimentation with UHC and increased access to and utilisation of health care in LMICs is common, there is inadequate research evidence on the specific health financing model that is most appropriate for pursuing the objectives of UHC in these settings. Drawing on a synthesis of empirical and theoretical discourses on the feasibility of UHC in LMICs, this paper argues that the journey towards UHC is not a ‘one size fits all’ process, but a long-term policy engagement that requires adaptation to the specific socio-cultural and political economy contexts of implementing countries. The study draws on the WHO’s framework for tracking progress towards UHC using the implementation of a mildly progressive pluralistic health financing model in Ghana and advocates a comprehensive discourse on the potential for LMICs to build resilient and responsive health systems to facilitate a gradual transition towards UHC.

Epidemiology of Surgical Amputations in Tamale Teaching Hospital, Ghana

The current study aimed to explore the details of surgical amputations in Tamale, Ghana. This was a retrospective descriptive study. We analyzed case files of 112 patients who underwent surgical amputations
between 2011 and 2017. Demographics, site of amputation, indication for amputation, and outcomes were
retrieved from case files. Descriptive statistics were used to report the means and frequencies. Associations
between variables were assessed using Chi-Square, ANOVA, and Student’s t-test. The mean age of the participants was 43.6±23.1 years (range 2 to 86). Most (64.3%) were males. Lower limb amputations accounted for most (78.6%) cases. Diabetic vasculopathy was the most prevalent indication (44.6%), followed by trauma (36.6%). The mean hospital stay was 30.1±22.4 days (range 5 to 120). Surgical site infection (17.9%) was the main complication. In our study setting, there is thus far limited capability for proper management of diabetes mellitus, which needs to be improved. There is also an urgent need for multidisciplinary foot care teams that will help patients receive comprehensive care to reduce complications from diabetes and other vasculopathies

Factors Associated with Serious Injuries among Adolescents in Ghana: Findings from 2012 Global School Health Survey

Introduction. Injuries are of public health concern and the leading cause of residual disability and death among teenagers, especially in low- and middle-income countries (LMICs). In Ghana, the burden of injury among adolescents is under-reported. Hence, the study sought to determine the prevalence of serious injuries (SI) and the potential factors influencing these injuries among school children in Ghana. Methods. This study was conducted in Ghana among Junior High School (JHS) and senior high school students (SHS) using the 2012 Global School-Based Student Health Survey (GSHS) data. The GSHS employed two-stage cluster sampling method. Serious injuries (SI) and independent factors were measured via self-administered questionnaires. Pearson chi-square test between each explanatory variable and serious injuries was conducted and the level of statistical significance was set at 5%. The significant variables from the chi-square test were selected for multiple logistic regression analysis. Multiple logistic regression was performed to estimate the adjusted odds ratio (AOR) at 95% confidence interval (CI). Results. The prevalence of SI in the past 12 months was 66% [CI=61.8–70.2] . The most common cause of SI was fall, 36%. The common types of injuries were cut/stab wounds and broken/dislocated bone. In the multiple logistic regression analysis, after controlling for other variables, educational level (AOR = 0.64, CI = 0.44–0.90,  < 0.015), suicidal ideation (AOR = 1.58, CI = 1.00–2.48,  < 0.002), suicidal attempt (AOR = 1.88, CI = 1.29–2.72,  < 0.001), having at least one close friend (AOR = 1.49, CI = 1.17–1.89,  < 0.002), school truancy (AOR = 1.66, CI = 1.31–2.09,  < 0.000), smoking marijuana (AOR = 2.64, CI = 1.22–5.69), and amphetamine use (AOR = 2.95, CI = 1.46–5.69) were independently associated with SI. Conclusion. The findings of the study established a high prevalence of SI among adolescents in Ghana, with cut/stab wound and broken/dislocated bone being the most reported type of injuries. This study also revealed that factors such as educational level, suicidal ideation, suicidal attempt, at least one close friend, school truancy, smoking marijuana, and amphetamine use are associated with SI among the adolescents. Therefore, pragmatic interventional programs should be targeted at these factors to curb the rate of SI among junior and senior school students.

Neurosurgery in Sub-Saharan Africa – Historical Background and Development of Training Programs in East Africa.

1 INTRODUCTION
Modern Neurosurgery in Sub-Saharan Africa (SSA) has its roots in the 1960s when Neurosurgeons from Europe set up Units in West Africa and East Africa. While it would be unfair to give credit to some individuals, and inadvertently not naming others, Prof Abdeslam El Khamlichi (1) in his book, “Emerging Neurosurgery in Africa,” quoting Professor Adelola Adeloye (2), provided a valuable account: A French Neurosurgeon, Dr. Courson, set up the first neurosurgical unit in West Africa in Senegal in 1967. He was joined by two other French neurosurgeons, Dr. Claude Cournil and Dr. Alliez, in 1972 and 1975. They trained the first Senegalese Neurosurgeon, Dr. Mamadou Gueye, who joined as a trainee in 1977. Dr. Gueye was to become the first Senegalese Professor and Chairman of the Neurosurgery Department.

2 | REGIONS BEGINS

In Ivory Coast, the first unit was set up by Dr. Claude Cournil in Abidjan in 1976, having left Dakar. He joined the first Ivorian Neurosurgeon, Dr. Kanga, who set up practice in 1974 in Abidjan. In Ghana, the first Neurosurgical Unit was set up by Ghanaian Neurosurgeon Dr. Osman Mustaffah in 1969. In Nigeria, the first units were set up by Nigerian Neurosurgeon Dr. Latunde Odeku started the service in Ibadan in 1962. He was joined by two other pioneer neurosurgeons, Dr. Adelola Adeloye in 1967 and Dr. Adebayo Ajayi Olumide in 1974. A second department was set up in Lagos by Dr. de Silva and Dr. Nosiru Ojikutu; in 1968, Dr. Samuel C. Ohaegbulam started the third service in Enugu in 1974 (2). In East Africa, Neurosurgical procedures had been carried out by Dr. Peter Clifford, an ENT surgeon, in 1955 (3).
In Kenya, modern Neurosurgery was introduced by Dr. Renato Ruberti, an Italian Neurosurgeon from Napoli, who set up Private practice in the European hospital in Nairobi in 1967 part-time at the King George V Hospital, which served as the National Hospital. He was joined in 1972 by Dr. Jawahar Dar, from New Delhi. The Indian Dr. Jawahar Dar set up the First Neurosurgery Unit at the King George V hospital, renamed Kenyatta National Hospital while teaching at the University of Nairobi. They were joined by Dr. Gerishom Sande, the first Kenyan Neurosurgeon following his training in Belfast, in 1979 (3).
In Uganda, on advice and recommendation of the renowned British Neurosurgeon, Professor Valentine Logue of the Hospital for Nervous Diseases, Queen Square, London, was invited by the government in 1968 to advise the establishment of neurosurgery at Mulago Hospital, Dr. Ian Bailey moved to Uganda. He was instrumental in establishing the first neurosurgical unit in Uganda at Mulago Hospital in 1969, equipped with 54 beds for the department of neurosurgery and cardiothoracic surgery (4). He was joined by the first Ugandan Neurosurgeon, Dr. Jovan Kiryabirwe, in 1971, who became the first indigenous Ugandan Neurosurgeon and the first African Neurosurgeon in East and Central Africa. He attended medical school at Makerere University School of Medicine in Kampala and subsequently completed postgraduate training at the Royal College of Surgeons in Ireland and Scotland; he also trained at Queens Square with Professor Logue (5).
In Tanzania, the first step towards modern neurosurgery was the establishment of orthopedic and trauma services in 1971 at the
Muhimbili Medical Center (MMC) by Professor Philemon Sarangi (6). At the time, orthopedic surgeons treated most of the cranial and spinal trauma. Over the next few years, several foreign neurosurgeons from Cuba, China, and the Soviet Union spent short stints practicing neurosurgery at MMC. Dr. Reulen, Professor and Chairman of Neurosurgery at University Hospital in Inselspital, Bern, Switzerland, and later in Munich, Germany, provided the impetus for the establishment of a neurosurgery program at MMC teaching in hospital of the University of Dar-es-Salaam and creating a “sandwich” program with training split between national and international centers. He trained Dr. Simpert Kinunda, a plastic surgeon who later became the first Tanzanian with any neurosurgical training.
Peter Kadyanji was the first fully trained Tanzanian neurosurgeon, and he joined MMC in 1985 after completing his training in the Soviet Union. Yadon M. Kohi followed in Kadyanji’s footsteps, graduating from Makerere University and the Faculty of Medicine at the University of Dar-es-Salaam. He obtained his FRCS in Ireland and Glasgow and later was appointed as the General Director of the National Commission for Science and Technology. Dr. Mlay was the third neurosurgeon to join MMC in 1989, with a specialty in pediatric neurosurgery. Professor Sarungi was essential to establish the Muhimbili Orthopedic Institute (MOI), which was opened in 1993 and later combined with MMC to become Muhimbili National Hospital, the national institute of neurosurgery, orthopedics, and traumatology.
Several neurosurgeons have practiced at MOI since its founding, including Dr. Abednego Kinasha and Dr. Joseph Kahamba. They, along with Professor Laurence Museru, the Medical Director of MOI, played a pivotal role in laying the foundation for training the current generation of neurosurgeons in Tanzania (6). Contemporary, locally trained neurosurgeons form the core of the specialized expertise in the country. They provide neurosurgical training and care at MOI at several healthcare institutions around the country. There are currently 20 neurosurgeons in the country, 18 of whom are in public service, one at a Mission hospital in Moshi, one in a private hospital (the Aga Khan University Hospital) Dar-es-salaam, and one at the Mnazi Mmoja/NED Institute in Zanzibar. No dedicated neuroscience nurses or beds are available in the country; however, currently, there are eight neurosurgical intensive care unit beds at MOI. An additional 14 at the new hospital within the Muhimbili hospital complex in Dar-es-Salaam opened in 2018. There are 5 CT scanners and 3 MRI scanners available across the country, mainly in Dar-es-Salaam, the largest city in Tanzania.
In Zimbabwe, Dr. Lawrence Frazer Levy, a British neurosurgeon, started in 1956 (Zimbabwe was called Rhodesia). He set up the Neurosurgery Department at the Central Hospital in Harare (Salisbury), becoming its first Professor and Chairman in 1971. He was joined by a young Scottish neurosurgeon, Dr. Carol Auchtertonie, responsible for starting the second unit at the European Hospital in Harare. The two served patients from Zimbabwe and neighboring Zambia, Malawi, and others for quite a long time (2). From these early beginnings, progress in neurosurgery remained slow, with only a handful of neurosurgeons available in SSA. In 1959, Professor Adelola Adeloye noted that there were only 20 neurosurgeons all across Africa, the majority practicing in South Africa (2). It is against this backdrop that the need to develop neurosurgical care in Sub-Saharan Africa came into focus.

Knowledge of, and complicance to infection prevention and control among nurses in the northern regional hospital

Introduction: Hospital-acquired infections (HAIs) also known as a nosocomial infection is associated with increased morbidity and mortality among hospitalized clients and predisposes health care workers (HCWs) to an increased risk of infections. Therefore, an effective Infection Prevention and Control (IPC) programme is fundamental to quality health care. This study looked at the knowledge of and compliance with infection prevention and control among Nurses at the Northern Regional Hospital Tamale, Ghana. The goal of this study was to assess the knowledge level and compliance with infection prevention and control practices among Nurses in the Northern Regional hospital Tamale, Ghana. Methodology: The study adopted a facility-based descriptive cross-sectional study. Data were collected from 268 staff nurses at Central Hospital, Tamale. A mixed-method was employed and using Self- administered questionnaire and key informant interview guide. Data were collected and entered into IBM SPSS V. 21 for analysis. Results: At the Northern Regional Hospital majority (60.5%) of the respondents had high IPC knowledge, 25.8% had moderate IPC knowledge level and only 13.8% had low IPC knowledge level. The findings on IPC compliance revealed that majority (77.6%) of the respondents had a low IPC compliance level, 19.8% had a moderate IPC compliance level and only 2.6% had a high IPC compliance level. Conclusion: Although the study revealed that most of the respondents had good knowledge of the IPC. However, compliance with IPC guidelines was still very low in the hospital. It was observed from the study that, the hospital has limited access to IPC training manuals couple with inadequate IPC materials such as Hand hygiene materials and Personnel protective equipment (PPEs). The Ghana Health Service in collaboration with the Ministry of Health should intensify monitoring and supervision at all levels of service delivery points to ensure health care providers compiles with IPC standard protocols. The Ghana Health Service, Ministry of Health and Development Partners should ensure IPC materials are in constant supply and made available to all health care service points. The Hospital should regularly conduct refresher training on current IPC standards and ensure compliance through effective monitoring. Health staff should make conscious efforts to protect themselves and clients against infections by ensuring that IPC standards and protocols are strictly followed in the discharge of their duties.

A broken bone no longer a burden to carry: a destination in sight

Worldwide the third leading cause of death among persons under 40 years is attributed to trauma(1). In Ghana road traffic accidents have a case fatality rate of about 17%(3). Over the years with interventions and policies by AO Alliance the burden and morbidity following trauma especially road traffic accidents have reduced; with a destination in sight where a broken bone is no longer a burden to carry.

Silver linings: a qualitative study of desirable changes to cancer care during the COVID-19 pandemic

Introduction: Public health emergencies and crises such as the current COVID-19 pandemic can accelerate innovation and place renewed focus on the value of health interventions. Capturing important lessons learnt, both positive and negative, is vital. We aimed to document the perceived positive changes (silver linings) in cancer care that emerged during the COVID-19 pandemic and identify challenges that may limit their long-term adoption.

Methods: This study employed a qualitative design. Semi-structured interviews (n = 20) were conducted with key opinion leaders from 14 countries. The participants were predominantly members of the International COVID-19 and Cancer Taskforce, who convened in March 2020 to address delivery of cancer care in the context of the pandemic. The Framework Method was employed to analyse the positive changes of the pandemic with corresponding challenges to their maintenance post-pandemic.

Results: Ten themes of positive changes were identified which included: value in cancer care, digital communication, convenience, inclusivity and cooperation, decentralisation of cancer care, acceleration of policy change, human interactions, hygiene practices, health awareness and promotion and systems improvement. Impediments to the scale-up of these positive changes included resource disparities and variation in legal frameworks across regions. Barriers were largely attributed to behaviours and attitudes of stakeholders.

Conclusion: The COVID-19 pandemic has led to important value-based innovations and changes for better cancer care across different health systems. The challenges to maintaining/implementing these changes vary by setting. Efforts are needed to implement improved elements of care that evolved during the pandemic.

“Hanging in a balance”: A qualitative study exploring clinicians’ experiences of providing care at the end of life in the burn unit

Background:
Although the culture in burns/critical care units is gradually evolving to support the delivery of palliative/end of life care, how clinicians experience the end of life phase in the burn unit remains minimally explored with a general lack of guidelines to support them.

Aim:
To explore the end of life care experiences of burn care staff and ascertain how their experiences can facilitate the development of clinical guidelines.

Design:
Interpretive-descriptive qualitative approach with a sequential two phased multiple data collection strategies was employed (face to face semi-structured in-depth interviews and follow-up consultative meeting). Thematic analysis was used to analyze the data.

Setting/participants:
The study was undertaken in a large teaching hospital in Ghana. Twenty burn care staff who had a minimum of 6 months working experience completed the interviews and 22 practitioners participated in the consultative meeting.

Results:
Experiences of burn care staff are complex with four themes emerging: (1) evaluating injury severity and prognostication, (2) nature of existing system of care, (3) perceived patient needs, and (4) considerations for palliative care in burns. Guidelines in this regard should focus on facilitating communication between the patient and family and staff, holistic symptom management at the end of life, and post-bereavement support for family members and burn care practitioners.

Conclusions:
The end of life period in the burn unit is poorly defined coupled with prognostic uncertainty. Collaborative model of practice and further training are required to support the integration of palliative care in the burn unit.

Barriers to inguinal hernia repair in Ghana: prospective, multi-centre cohort study

Inguinal hernia (IH) is the most common general surgical pathology in Ghana with hernia repair rate very low. The objective was to assess patient-perceived barriers to IH repair in Ghana and identify predictors of experiencing delays until surgery. A multicenter prospective study was conducted during the Ghana Hernia Society outreach. Data regarding diagnosis using Kingsnorth’s classification of IH, age of patients, duration of hernia, reason for delay in repair, insurance status, American Society of Anesthesiologists (ASA) class, travel distance, region, hospital, and waiting times were obtained from patients and folders. Multivariable linear regression models were constructed to analyze delay until surgery and Kingsnorth’s classification while controlling for the covariates of age, insurance status, ASA class among others. The most common reasons were queues for surgery (23%), poverty (10%), and seeking traditional medicine (9%). On multivariate linear regression, increasing age and ASA class III were predictors of longer delays. Patients experienced significant increase of 1.1 years delay to surgery for every 10 year increase in of age. ASA Class III patients were significantly more likely to be delayed by 11.5 years compared to ASA Class I patients. Efforts should be made to address and overcome the barriers to IH repair identified.

Feasibility of HPV-based cervical cancer screening in rural areas of developing countries with the example of the North Tongu District, Ghana

Cervical cancer gains increasing recognition as a preventable threat to women’s health, as expressed by WHO Director General Dr. Ghebreyesus in his recent call for its elimination. Developing countries carry the global burden and despite existing recommendations for secondary prevention screening programs their implementation remains a barrier. This doctoral thesis aims to evaluate the feasibility of an HPV-based cervical cancer screening approach in the North Tongu District, Ghana.
Methods This work studied (i) the methodological validity of self-sampling specimens from cervical cancer patients for HPV oncoprotein testing before its use in a screening population, (ii) the HPV prevalence among 2002 women, 18-65 years of age, in the general population of the North Tongu Disctrict, Ghana, through a cross-sectional population-based study with self-sampling collection in rural communities, and (iii) the natural history of HPV infection by longitudinal comparison of HPV type-specific persistence and clearance for 104 women over a four years’ time period. Results Using self-sampling cervicovaginal lavage specimens for HPV oncoprotein detection was methodologically feasible with 95% sensitivity for HPV16/18 positive cervical cancer. However self-sampling cervicovaginal scraping specimens did not reveal reliable HPV oncoprotein test results during the cross-sectional assessment. The high-risk HPV prevalence found among women living in the North Tongu District, Ghana was 32.3% and 27.3% among women in the WHO-recommended screening age range of 30-49 years. Sample collection in the rural communities was successful. Infection associated risk factors were (i) increasing age, (ii) increasing number of sexual partners and (iii) marital status, in particular not being married. Over the four years’ time period 6.7% of the women observed had persistent high-risk HPV infection, while 93.3% cleared their initial infection and 21.2% acquired new infections.
Discussion The high-risk HPV prevalence found among the general population and women 30-49 years is high and therefore requires careful planning and good infrastructure to triage high-risk HPV positive women and reduce the number of women needing treatment. Using HPV oncoprotein triage from the same self-collected specimen is not reliable at this point, stratification by sociodemographic factors risks stigmatization and retesting for HPV persistence necessitates a well-functioning recall system and HPV genotyping.
Conclusion The high HPV prevalence found demands substantial governmental support and investment to build well-functioning screening infrastructure that offers necessary triage and treatment options for women high-risk HPV positive with increased risk for cervical cancer. Integrating local infrastructure and capacity is promising but requires regional assessment rather than one-size-fit-all approaches.