Justice Nonvignon’s research while affiliated with University of Ghana and other places

Patient choice of health facilities is increasingly gaining recognition for potentially enhancing the attainment of health system goals globally. In Kenya, National Health Insurance Fund (NHIF) members are required to choose an NHIF-contracted outpatient facility before accessing care. Understanding their preferences could support resource allocation decisions, enhance the provision of patient-centered care, and deepen NHIF’s purchasing decisions. We employed a discrete choice experiment to examine NHIF members’ preferences for attributes of NHIF-contracted outpatient facilities in Kenya. We developed a d-efficient experimental design with six attributes, namely availability of drugs, distance from household to facility, waiting time at the facility until consultation, cleanliness of the facility, attitude of health worker, and cadre of health workers seen during consultation. Data were then collected from 402 NHIF members in six out of 47 counties. Choice data were analysed using panel mixed multinomial logit and latent class models. NHIF members preferred NHIF-contracted outpatient facilities that always had drugs [β=1.572], were closer to their households [β=-0.082], had shorter waiting times [β=-0.195], had respectful staff [β=1.249] and had either clinical officers [β=0.478] or medical doctors [β=1.525] for consultation. NHIF members indicated a willingness to accept travel 17.8km if drugs were always available, 17.7km to see a medical doctor for consultation, and 14.6km to see respectful health workers. Furthermore, NHIF members indicated a willingness to wait at a facility for 8.9 hours to ensure the availability of drugs, 8.8 hours to see a doctor for consultation, and 7.2 hours to see respectful health workers. Understanding NHIF member preferences and trade-offs can inform resource allocation at counties, service provision across providers, and purchasing decisions of purchasers such as the recently formed social health insurance authority in Kenya as a move towards UHC.

Background Acceptability of malaria chemoprevention interventions by caregivers is crucial for overall programme success. This study assessed coverage and acceptability of Seasonal Malaria Chemoprevention (SMC) in selected communities in the Northern part of Ghana. Methods An analytical cross-sectional design was conducted from “July 23rd to August 4th, 2020—a 12-day period that covered 5 days of the first SMC implementation cycle and 7 days post-implementation. Using a stratified multi-stage sampling technique, a total of 495 caregivers providing care for 569 eligible children aged 3–59 months from randomly selected households in the study communities were enrolled into the study. Acceptability of SMC was assessed on a set of 19 questionnaire items-8 of the items measured caregivers’ perceptions and 11 items measured children’s reaction to administered medicines. Univariable and stepwise multivariable logistic regression analyses were performed to assess the predictors of acceptability of SMC at a 95% confidence interval and a p-value of 0.05. Results SMC coverage was 95.1% (541/569). Caregivers had a good level of knowledge of SMC (n = 475; 96.0%; 95% CI 94.2—97.7%) and a good perception of SMC (n = 471; 95.2%; 95% CI 93.3–97.0). Seven out of ten caregivers (70.9%; 95% CI 66.9–74.9%) had good acceptability of SMC. For 7 out of 28 children who did not receive the SMC intervention, their caregivers intentionally refused them the intervention. Of those that received the treatment, 17.2% (n = 85; 95%CI 13.8–20.5%) of caregivers had at least one leftover amodiaquine tablet after the third day of treatment. Caregivers who practice Christianity or Islam had better acceptability than caregivers who practice African traditional religion (p < 0.001). Conclusion Health authorities and stakeholders can work towards bridging the gap between knowledge and SMC treatment practices of caregivers through continuous education, adherence counseling, and effective monitoring of SMC practices in malaria-endemic countries.

Introduction Ghana’s reference case, developed to guide the conduct of economic evaluation as part of health technology assessment (HTA) guidelines, recommends the conduct of cost–utility analysis using outcomes such as quality-adjusted life years (QALYs). There is no national value set available for the Ghanaian population to be used in estimating QALYs. This study aimed to develop a value set for Ghana using the EuroQol 5-dimension 5-level questionnaire (EQ-5D-5L) instrument. Methods Face-to-face preference data were collected from 300 adults across three regions of Ghana using the adapted version of the EuroQol Valuation Technology (EQ-VT) standardized valuation protocol developed specifically for EQ-5D-5L valuation studies using composite time-trade-off (cTTO) and discrete choice experiments (DCEs). Different preference models were generated using both the cTTO and DCE data, individually or together to provide complementary results on respondents’ utility preferences. Models explored include generalized least squares, tobit, heteroskedastic, logit, and hybrid. The best-fitting model was selected for the value set based on its logical consistency, ability to account for left-censored and heteroskedasticity data, and statistical significance of parameters. Results The 300 interviews provided 4,500 cTTO responses and 4,200 DCE responses. The demographic characteristics of respondents were representative of the Ghanaian population for religious background, level of education, and marital status. The preferred model chosen for the Ghana value set was hybrid tobit, random effect heteroskedastic, constrained model. The predicted value for the worst attainable health on the EQ-5D-5L (i.e., health state 55555) was −0.493 and that of the best health state (11112; except full health) was 0.969. The largest decrement was registered for level five mobility (0.369) followed by pain/discomfort (0.312), self-care (0.273), anxiety/depression (0.271), and usual activities (0.268). Conclusions This is the first Ghanaian EQ-5D-5L value set based on social preference derived for a nationally representative sample in Ghana. The value set will play a key role in the institutionalization of HTA in Ghana and the use of economic evaluation studies to inform priority setting where different health technologies can be compared. A planned findings dissemination to stakeholders is underway.

Introduction Many cultures across the world have varying conceptions about death and dying. Perceptions about health states considered “worse than death” also vary based on sociocultural norms as well as health system capacity. We explore worse-than-death health states in Ghana as well as reasons for opting for death in those health states. Methods We interviewed 28 participants from three regions in Ghana to understand the contextual “value of life” in Ghana and factors influencing respondents’ decision to opt to die rather than live in a particular health state. Written consents were sought from all participants to partake in the study. Interviews were conducted in either Twi or English based on each participant’s preference and lasted for an average of 30 to 35 minutes. Interviews were transcribed verbatim and stored in NVivo software. Data were analyzed thematically. Results We identified that health states perceived as worse than death were those associated with impairment in mobility, anxiety/depression, and pain/discomfort. Participants preferred death under these circumstances because they wanted to avoid the financial burden on themselves and family, time spent in caregiving by family, loss of personhood, and loss of social status. Decisions regarding health states worse than death hold considerable importance, particularly in a context where culture and societal norms play a role in shaping how quality of life is assessed. Conclusions An understanding of the value Ghanaians attach to health states perceived as worse than death provides useful information for patient-centered care. Findings from the study can provide evidence on healthcare resource allocation and aid policymakers and clinicians in making informed decisions on which treatments to prioritize, and how to maximize the overall health and well-being of individuals.

Background While patient choice and provider competition are predicted to influence provider behaviour for enhancing access and quality of care, evidence on provider perceptions and response to patient choice and provider competition is largely missing in low-resource settings such as Kenya. We examined provider and purchaser perceptions about whether patient choice and provider competition influenced provider behaviour and enhanced access and quality of outpatient care in Kenya. Methods We conducted a qualitative study to explore this across two purposefully selected counties. We conducted 15 in-depth interviews (IDIs) with health facility managers and National Health Insurance Fund (NHIF) staff across the two counties. We examined these across five areas summarised as either local market conditions or patient feedback following the Vengberg framework. Results NHIF members’ choice of outpatient facilities compelled private and faith-based providers to compete for members while public providers did not view choice as a way of spurring competition. Besides, all providers did not receive any information regarding the exit of NHIF members from their facilities. Providers felt that that information would be crucial for their planning, especially in enhancing service accessibility and quality of care. Most providers ensured the availability of drugs, provided a wider range of services and leveraged on marketing to attract and retain NHIF members. Finally, providers highlighted their redesign of service delivery to meet NHIF members’ needs whilst enhancing the quality-of-care aspects such as waiting time and having qualified health workers. Conclusion There is a need for NHIF to share NHIF members’ exit information with providers to support their service delivery arrangements in response to NHIF members’ needs. Besides, this study contributes evidence on patient choice and provider competition and their influence on access and quality of care from a low-resource setting country which is crucial as NHIF transitioned to the Social Health Authority.

Introduction Worldwide, countries have the challenge of meeting the ever-increasing demand for healthcare amidst limited resources. While priority setting is necessary in all settings, it is especially critical in low-and middle-income countries because of their often-low budgetary allocations for health. Despite the long history of disease programmes supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) in Ghana, there is limited evidence on the approaches used in priority setting for the three disease programmes. This study aimed at exploring the priority-setting approaches adopted by the GFATM-supported programmes in Ghana. Methods In-depth interviews of ten key informants from the three disease programmes, the Ministry of Health and global health partners were conducted. Interviews were transcribed verbatim and analysed both inductively and deductively. Results We identified four main approaches for priority setting: (1) identification of health needs, (2) stakeholder participation, (3) transparency of the process and (4) contextual factors. Priorities were identified through national health strategies and mandates, development/ health partners and global mandates and internally generated data and surveillance. The main actors participating in the decision-making or priority setting were ministries and agencies, development partners, research institutions, committees and working groups. These actors had varying influences and power. The involvement of the general public was limited in the priority-setting process. The approaches were often documented and disseminated through various mediums. Contextual factors reported were mainly barriers that affected priority setting, and these included inadequate funding, aligning priorities with funders and interruptions in the priority-setting process. Conclusion While explicit priority-setting approaches are being expanded globally to support resource allocation decisions in health more generally, evidence from our study suggests that their use in the three GFATM-supported programmes was limited.

Introduction: Sickle cell disease (SCD) is a major cause of morbidity and premature deaths in sub-Saharan Africa (SSA) (GBD 2021 SCD collaborators. Lancet Haematol 2023). However, clinical care of individuals living with SCD, including access-to-medicines, has largely been neglected in the region. In 2019, the Sickle Cell Foundation of Ghana, Ghana Ministry of Health, Ghana Health Services, and Novartis initiated a public-private partnership to address priority aspects of SCD management through a holistic approach involving access to hydroxyurea (HU), newborn screening capabilities, and other health systems strengthening activities. The University of Ghana was subsequently commissioned to conduct monitoring and evaluation (M&E) of selected program components. Aim: To evaluate the effectiveness of the HU program in Ghana (“Ahodwo Program”) with specific focus on biomarkers, clinical outcomes, and health-related quality of life (HRQoL). Methods: The study design was a mixed-methods approach incorporating quantitative and qualitative research (Moore et al. BMJ 2015). Clinical data obtained from a HU management mobile application (designed specifically for the Ahodwo program) and from patient hospital records were used to evaluate biomarkers and clinical outcomes. Data describing HRQoL were obtained from interviews with patients and parents/caregivers in 11 SCD centers. Statistical measures were used to describe quantitative and categorical indicators, and standard regression models quantified the impact of therapy on biomarkers. The study was approved by ethical review boards governing the participating institutions. Results:Data from 1,549 patients enrolled in the program from September 2019 to July 2023 were available through the HU management app. Regression analyses demonstrated that HU therapy led to a significant average increase in hemoglobin levels (Hb) by 0.55g/dL (95% Confidence Interval [CI]: 0.49 to 0.61; P<0.001) compared to pre-treatment levels. The number of patients that achieved Hb of ≥10 g/dL also increased by 9.2 percentage points [95% CI: 7.58 to 10.83; P<0.001]. The impact of HU on Hb was higher among pts aged >16 years (0.61g/dL [95% CI: 0.52 to 0.69; P<0.001]) vs ≤16 years (0.52g/dL [95% CI: 0.44 to 0.60; P<0.001]), and among male (0.62g/dL [95% CI: 0.53 to 0.70; P<0.001]) vs female (0.48g/dL [95% CI: 0.40 to 0.57; P<0.001]). HU therapy led to an increase in the mean corpuscular volume by ([7.07 {95% CI: 6.47 to 7.68}] x109/L; P<0.001]) and reduction in the absolute neutrophil count ([-1.15 {95% CI: -1.28 to -1.01}] x109/L; P<0.001), platelets (-44.92 [95% CI: -52.38 to -37.46; P<0.001]), red blood cells ([-0.14 {95% CI: (-0.18 to -0.10}] x1012/L; P<0.001), and white blood cells ([-1.63 {95% CI: -1.86 to -1.40}] x109/L; P<0.001), vs pre-treatment period. HbF levels and reticulocyte counts were not measured. Persons with SCD taking HU (N=600 total; 186 were enrolled in the Ahodwo program) were interviewed from April to November 2023. The incidences of blood transfusion in adults and pediatric patients reduced by 77% and 66%, sickle cell crises by 37% and 65%, rates of hospitalization by 63% and 64%, and episodes of malaria by 42% and 59%, respectively (all, P<0.001). Data revealed positive impact of HU therapy on overall HRQoL effects among adult and pediatric patients (improvement by 24% and 44%, respectively), observed as improvements in physical, emotional, social, school-related functioning, and pain episodes (all, P<0.01). Conclusion:To our knowledge, this is the largest effectiveness study of HU in Africa outside of a controlled trial. The Ahodwo program demonstrated significant benefits for pediatric and adult patients with SCD as measured by biomarkers, clinical outcomes, and HRQoL. In 2022, the Ghana government announced coverage of HU through its National Health Insurance Scheme. Lessons learned through the Ahodwo program have implications for further efforts in Ghana and may be applicable to other countries in Africa where SCD is highly endemic.

Introduction: Sickle cell disease (SCD) affects millions of people worldwide, with nearly 80% of the global burden incurred in sub-Saharan Africa (SSA) (GBD 2021 SCD collaborators. Lancet Haematol 2023). As part of a public-private partnership to address SCD in Ghana, a multi-faceted health systems strengthening program was implemented that included novel digital applications (‘Apps‘) to support newborn screening (NBS) data management and clinical use of hydroxyurea (HU). The Apps were designed according to inputs received by clinicians (physicians, nurses, and pharmacists) and patients in Ghana to address local needs and were engineered by an mHealth company (Dimagi) that specializes in customizable digital tools for use in low-resource settings. Aim: This analysis evaluated utilization, benefits, and challenges associated with NBS and HU management Apps among healthcare workers in Ghana. Methods: This evaluation is part of a mixed-method monitoring and evaluation (M&E) study involving quantitative and qualitative research designs (Moore et al. BMJ 2015). Healthcare professionals (HCPs) who used the Apps were interviewed. Questionnaires and tools were used to assess satisfaction, challenges, relevance, ease of use, and other relevant parameters for both Apps using a 5-point Likert scale (with “5” corresponding to the most positive assessment). The efficiency and impact of the Apps were determined using indicators such as time spent with patients, patients' length of stay at healthcare centers, time/effort of result distribution and tracking, and more. Data were analyzed using appropriate statistical methods. Results: Overall, 57 in-depth interviews of HCPs (physicians, 13; nurses, 31; pharmacists, 7; lab technicians, 6) were conducted. Their mean (range) age was 36.4 (24-55) years, and on average they worked for 4 years in the SCD units. Nearly half of the HCPs interviewed had heard about the NBS App, 7% were trained to use it, and <5% were actively using it at the time of the survey; 52% had heard about the HU management App, of which 63% were trained to use it and 65% used it. Using the NBS App allowed for data aggregation and direct communication among personnel across birth centers, laboratories, regional program coordinating centers, and SCD counsellors. Users of the NBS App felt strongly (mean score, 4.4) that the App was useful for their healthcare practice and helped HCPs to manage their patient's health effectively. Additional observed benefits of the NBS App included the timely availability of screening results facilitating informed decision-making for both HCPs and parents and easy access, transfer, and retrieval of records. The mean scores for both Apps were nearly 4.0 or higher for ease of learning to use the App, improved ability to deliver healthcare services, and improved communication/interaction with patients. Reported challenges included an extended data entry process (for the HU management App), limited duration of data storage, and difficulties in synchronizing data during poor internet connectivity. Nonetheless, most HCPs expressed acceptance of the Apps and highlighted their ease of use. Conclusion: Digital Apps were reported to be user-friendly and associated with improved efficiencies compared with traditional paper-based chart records. Continued inclusion of these Apps as part of routine clinical care processes in Ghana may help to support optimized patient management. Of note, use of the NBS App is currently being expanded to multiple countries in Africa through a consortium organized through the American Society of Hematology.

Background Decentralisation has increasingly been adopted by countries as an important health sector reform aimed at increasing community participation in decision making while enhancing swift response at decentralised levels, to accelerate the attainment of health system goals. Kenya adopted a devolved system of government where health services delivery became a function of the 47 semi-autonomous county governments with planning and budgeting functions practised at both levels of government. This study sought to explore challenges facing health sector planning and budgeting and how they affect immunisation service delivery at the county level. Methods Data were collected through 77 in-depth interviews of senior county department of health officials across 15 counties in Kenya. We applied an inductive thematic approach in analysing the qualitative data using NVIVO software. Findings The study found a lack of alignment between planning and budgeting processes, with planning being more inclusive compared to budgeting. Inadequate capacity in conducting planning and budgeting and political interference were reported to hinder the processes. Limited budget allocations and delayed and untimely disbursement of funds were reported to affect execution of health and immunisation budgets. Low prioritisation of preventive health interventions like immunisation due to their perceived intangibility influenced resource allocation to the programs. Conclusion The findings highlight the need for effective strategies to align planning and budgeting processes, increased technical support to counties to enhance the requisite capacity, and efforts to improve budget execution to improve budget credibility. Counties should plan to increase their funding commitment toward immunisation to ensure sustainability of the program as Kenya transitions from GAVI support.

We commend the Lancet Commission on Investing in Health for providing a substantive analysis of progress and future prospects for global health.1 Beginning in 1993 with the World Bank's influential report on investing in health, a series of timely analyses2–4 have documented substantial improvements in life expectancy and wellbeing over past decades, as well as evolving opportunities for action to enhance progress into the future. Despite a reversal of progress during the COVID-19 pandemic,5 there are important opportunities for rapid progress. The global health community and governments can build on the progress made in halving child mortality and halve premature death by 2050, as proposed by the Commission in its new Global Health 2050 report.1 The Lancet home. Opens in new tab