Equitable access to quality trauma systems in Low and Middle Income Countries

Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 (‘Delays to receiving quality care’). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for peoplewho have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality car

Economic evaluation of expanding inguinal hernia repair among adult males in Ghana

An unmet need for inguinal hernia repair is significant in Ghana where the number of specialist general surgeons is extremely limited. While surgical task sharing with medical doctors without formal specialist training in surgery has been adopted for inguinal hernia repair in Ghana, no prior research has been conducted on the long-term costs and health outcomes associated with expanding operations to repair all inguinal hernias among adult males in Ghana. The study aimed to estimate cost-effectiveness of elective open mesh repair performed by medical doctors and surgeons for adult males with primary inguinal hernia compared to no treatment in Ghana and to project costs and health gains associated with expanding operation services through task sharing between medical doctors and surgeons. The study analysis adopted a healthcare system perspective. A Markov model was constructed to assess 10-year differences in costs and outcomes between operations conducted by medical doctors or surgeons and no treatment. A 10-year budget impact analysis on service expansion for groin hernia repair through increasing task sharing between the providers was conducted. Incremental cost-effectiveness ratios for medical doctors and surgeons were USD 120 and USD 129 respectively per disability-adjusted life year (DALY) averted compared to no treatment, which are below the estimated threshold value for cost-effectiveness in Ghana of USD 371–491. Repairing all inguinal hernias (1.4 million) through task sharing between the providers in the same timeframe is estimated to cost USD 194 million. Total health gains of 1.5 million DALYs averted are expected. Inguinal hernia repair is cost-effective regardless of the type of surgical provider. Scaling up of inguinal hernia repair is worthwhile, with the potential to substantially reduce the disease burden in the country.

Inequalities in prevalence of birth by caesarean section in Ghana from 1998-2014

Background
Caesarean section (CS) is an intervention to reduce maternal and perinatal mortality, for complicated pregnancy and labour. We analysed trends in the prevalence of birth by CS in Ghana from 1998 to 2014.

Methods
Using the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the 1998-2014 Ghana Demographic and Health Surveys (GDHS) were analysed with respect of inequality in birth by CS. First, we disaggregated birth by CS by four equity stratifiers: wealth index, education, residence, and region. Second, we measured inequality through simple unweighted measures (Difference (D) and Ratio (R)) and complex weighted measures (Population Attributable Risk (PAR) and Population Attributable Fraction (PAF)). A 95% confidence interval was constructed for point estimates to measure statistical significance.

Results
The proportion of women who underwent CS increased significantly between 1998 (4.0%) and 2014 (12.8%). Throughout the 16-year period, the proportion of women who gave birth by CS was positively skewed towards women in the highest wealth quintile (i.e poorest vs richest: 1.5% vs 13.0% in 1998 and 4.0% vs 27.9% in 2014), those with secondary education (no education vs secondary education: 1.8% vs 6.5% in 1998 and 5.7% vs 17.2% in 2014) and women in urban areas (rural vs urban 2.5% vs 8.5% in 1998 and 7.9% vs 18.8% in 2014). These disparities were evident in both complex weighted measures of inequality (PAF, PAR) and simple unweighted measures (D and R), although some uneven trends were observed. There were also regional disparities in birth by CS to the advantage of women in the Greater Accra Region over the years (PAR 7.72; 95% CI 5.86 to 9.58 in 1998 and PAR 10.07; 95% CI 8.87 to 11.27 in 2014).

Conclusion
Ghana experienced disparities in the prevalence of births by CS, which increased over time between 1998 and 2014. Our findings indicate that more work needs to be done to ensure that all subpopulations that need medically necessary CS are given access to maternity care to reduce maternal and perinatal deaths. Nevertheless, given the potential complications with CS, we advocate that the intervention is only undertaken when medically indicated.

Exploring the experiences of National Health Insurance Scheme subscribers and non-subscribers in accessing healthcare within the Accra Metropolitan Area

Maintaining the health and wellbeing of a nation largely depends on the state of health care policies and programs that guarantees citizens access to health care. Policies and social intervention programs such as the National Health Insurance Scheme (NHIS) should create an enabling operational environment for health institutions. The study examines the experiences of subscribers and non-subscribers of the National Health Insurance Scheme in accessing health care in the Accra Metropolitan Area (AMA) in Ghana. It identifies the challenges in accessing health care, the resources available to individuals and the other strategies individuals employ in accessing health care. A combination of primary and secondary sources was used to collect data for the study. Using a qualitative research design, twelve participants were sampled using a stratified sampling technique. Interviews conducted revealed that many participants had negative experiences in accessing health care with the National Health Insurance Scheme (NHIS). Delays in registration processes, long queuing systems at health centres and delays in reimbursement of health centres by the government were some of the core challenges that led to these negative experiences in accessing health care. As a result, many people resort to alternative means to cater for their health needs. The study further revealed that some people utilized the formal health care facilities only in critical conditions due to past negative experiences and perceptions around accessing health care with the National Health Insurance Scheme (NHIS). However, the NHIS was seen or perceived as an important mechanism for removing financial barrier to achieving equitable access to health care for all citizens in Ghana. The results further showed that the NHIS has improved access and benefits to maternal and child health services. The study concluded by advocating for an improvement and a rebalance of efforts by decision makers to inculcate more health promotion approaches or concepts in making policies concerning public health.

Community engagement and involvement in Ghana: conversations with community stakeholders to inform surgical research

Background: Involving patients and communities with health research in low- and middle-income countries (LMICs) contributes to increasing the likelihood that research is relevant in local context and caters to the needs of the population, including vulnerable and marginalised groups. When done right, it can also support empowerment of wider communities in taking ownership of their own health, lead to increased access and uptake of health services and generally improve the wellbeing of individuals. However, the evidence base of how to undertake successful community engagement and involvement (CEI) activities in LMICs is sparse. This paper aims to add to the available literature and describes how the Global Health Research Unit on Global Surgery’s (GSU) team in Ghana worked collaboratively with the Unit’s team in the UK and a UK-based Public Advisory Group to involve community stakeholders in rural Ghana with surgical research. The aim was to explore ways of reaching out to patients and community leaders in rural Ghana to have conversations that inform the relevance, acceptability, and feasibility of a clinical trial, called TIGER.
Methods: As this kind of larger scale involvement of community stakeholders with research was a novel way of working for the team in Ghana, a reflective approach was taken to outline step-by-step how the GSU team planned and undertook these involvement activities with 31 hernia patients, two Chiefs (community leaders), a community finance officer and a local politician in various locations in Ghana. The barriers that were experienced and the benefits of involving community stakeholders are highlighted with the aim to add to the evidence base of CEI in LMICs.
Results: GSU members from the UK and Ghana planned and organised successful involvement activities that focused on establishing the best way to talk to patients and other community stakeholders about their experiences of living with hernias and undergoing hernia repairs, and their perceptions of the impact of hernias on the wider community. The Ghanaian team suggested 1:1 conversations in easily accessible locations for rural patient contributors, creating a welcoming environment and addressing contributors in their local dialects. A UK-based Public Advisory Group helped in the initial stages of planning these conversations by highlighting potential barriers when approaching rural communities and advising on how to phrase questions around personal experiences. Conversations mainly focused on understanding the needs of hernia patients in rural Ghana to then incorporate these in the design of the TIGER trial to ensure its relevance, acceptability and feasibility. When talking to patient contributors, the GSU teams found that they were more likely to open up when they knew members of the team and the opportunity to speak to local leaders only arose because of the Ghanaian team members being well-respected amongst communities. The experiences of the patient and community contributors led to changes in the study protocol, such as including women in the patient cohort for the trial, and allowed the GSU teams to confirm the relevance and acceptability of this trial. These conversations also taught the team a lot about perceptions of health in rural communities, allowed the Ghanaian team to establish relationships with community leaders that can be utilised when future studies need input from the public, and has changed the minds of the Ghanaian research team about the importance of involving patients with research.
Conclusion: This paper contributes to the evidence base on successful CEI activities in LMICs by providing an example of how CEI can be planned and organised, and the benefits this provides. The conversations the teams had with patient contributors in Ghana are an example of successful patient consultations. Even though there are certain limitations to the extent of these involvement activities, a solid foundation has been built for researchers and community stakeholders to establish relationships for ongoing involvement.

Management of chronic non-communicable diseases in Ghana: a qualitative study using the chronic care model

Background
While the burden and mortality from chronic non-communicable diseases (CNCDs) have reached epidemic proportions in sub-Saharan Africa (SSA), decision-makers and individuals still consider CNCDs to be infrequent and, therefore, do not pay the needed attention to their management. We, therefore, explored the practices and challenges associated with the management of CNCDs by patients and health professionals.

Methods
This was a qualitative study among 82 CNCD patients and 30 health professionals. Face-to-face in-depth interviews were used in collecting data from the participants. Data collected were analysed using thematic analysis.

Results
Experiences of health professionals regarding CNCD management practices involved general assessments such as education of patients, and specific practices based on type and stage of CNCDs presented. Patients’ experiences mainly centred on self-management practices which comprised self-restrictions, exercise, and the use of anthropometric equipment to monitor health status at home. Inadequate logistics, work-related stress due to heavy workload, poor utility supply, and financial incapability of patients to afford the cost of managing their conditions were challenges that militated against the effective management of CNCDs.

Conclusions
A myriad of challenges inhibits the effective management of CNCDs. To accelerate progress towards meeting the Sustainable Development Goal 3 on reducing premature mortality from CNCDs, the Ghana Health Service and management of the respective hospitals should ensure improved utility supply, adequate staff motivation, and regular in-service training. A chronic care management policy should also be implemented in addition to the review of the country’s National Health Insurance Scheme (NHIS) by the Ministry of Health and the National Health Insurance Authority to cover the management of all CNCDs.

Evaluation of postoperative refractive error correction after cataract surgery

Suboptimal cataract surgery outcomes remain a challenge in most developing countries. In Ghana, about 2 million people have been reported to be blind due to cataract with about 20% new cases being recorded yearly. The aim of this study was to evaluate postoperative correction of refractive errors after cataract surgery in a selected eye hospital in Ashanti Region, Ghana. This was a retrospective study where medical records of patients (aged 40–100) who reported to an eye hospital in Ghana from 2013–2018 were reviewed. Included in the study were patients aged ≥40 years and patients with complete records. Data on patient demographics, type of surgery, intra-ocular lens (PCIOL) power, availability of biometry, postoperative refraction outcomes, pre- and postoperative visual acuity were analyzed. Data of two hundred and thirteen eyes of 190 patients who met the inclusion criteria were analyzed. Descriptive analysis and Chi-square test were carried out to determine the mean, median, standard deviation and relevant associations. The mean ± SD age was 67.21±12.2 years (51.2% were females). Small Incision Cataract Surgery (99.5%) with 100% IOL implants was the main cataract surgery procedure in this study. Pre-operative biometry was performed for 38.9% of all patients on their first eye surgery and 41.5% for second eye surgeries. About 71% eyes in this study were blind (presenting VA<3/60) before surgery; 40.4% had post-operative VA <3/60. Pre-existing ocular comorbidities discovered post- surgery, attributed to suboptimal visual outcomes. More than half (55.3%) of patients did not undergo postoperative refraction due to loss to follow-up. Year of surgery (p = .017), follow up visits< 2months (p < .0001) and discovered comorbidity post-surgery (p = .035) were the factors significantly associated with postoperative refraction. Myopia and compound myopic astigmatism were the dominant refractive error outcomes. The timing of post-operative refraction had a significant effect on postoperative refraction done. These findings indicate a clinically meaningful significance between completion of postoperative care and postoperative refraction done. Consequently, with settings in most developing countries, where less biometry is done, it is appropriate that post-operative refractive services are encouraged and done earlier to enhance the patients’ expectations while increasing cataract surgery patronage.

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

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.