2024 Survey Report Service Delivery Indicators Health Survey for Ghana © 2025 The World Bank Group 1818 H Street NW, Washington DC 20433; Telephone: 202–473-1000; Internet: www.worldbank.org and www.ifc.org SOME RIGHTS RESERVED. This work is a product of the staff of The World Bank and the International Finance Corporation (the World Bank Group) with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank’s Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the information included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. RIGHTS AND PERMISSIONS. The material in this work is subject to copyright. 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Survey Report: Service Delivery Indicators Health Survey for Ghana (c) World Bank Group.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. 1 Table of Contents Abbreviations....................................................................................................................... 12 Acknowledgements............................................................................................................. 14 Executive Summary............................................................................................................. 16 Chapter 1. Background........................................................................................................ 21 1.1. Health care system in Ghana.............................................................................................................23 1.2. History of primary health care in Ghana.......................................................................................26 1.3. Motivation for the Ghana SDI survey.............................................................................................28 1.4. How the Ghana SDI measures primary health care..................................................................29 Chapter 2. Methods............................................................................................................. 32 2.1. Survey Development.............................................................................................................................32 2.2. Sample Design........................................................................................................................................32 2.3. Data Collection and Analysis.............................................................................................................34 Chapter 3. Foundations....................................................................................................... 38 3.1 Care organization....................................................................................................................................42 3.1.1 Facility connective networks......................................................................................................42 3.1.2 Service and case mix.....................................................................................................................44 3.1.3 Service delivery organization.....................................................................................................52 3.2 Systems.......................................................................................................................................................56 3.2.1 Financing...........................................................................................................................................56 3.2.2 Institutions for accountability for quality..............................................................................60 3.2.3 Management and supervision...................................................................................................70 3.2.4 Physical infrastructure..................................................................................................................74 3.2.5 Policies and protocols...................................................................................................................87 3.3 Tools.............................................................................................................................................................89 3.3.1 Information systems......................................................................................................................89 3.3.2 Medical equipment and supplies.............................................................................................93 3.3.3 Medicines and Vaccines...............................................................................................................95 3.4 Workforce...................................................................................................................................................97 3.4.1 Availability.........................................................................................................................................97 3.4.2 Education and training.............................................................................................................. 100 3.4.3 Satisfaction and retention........................................................................................................ 110 3.4.4 Workload........................................................................................................................................ 111 2 Chapter 4: Processes of Care............................................................................................. 114 4.1 Competent care systems................................................................................................................... 116 4.1.1 Diagnosis, treatment, counseling.......................................................................................... 116 4.1.2 Referral, continuity, integration............................................................................................. 138 4.1.3 Safety, prevention, detection.................................................................................................. 147 4.2 Positive user experience.................................................................................................................... 149 4.2.1 Respect and autonomy............................................................................................................. 149 4.2.2 User focus....................................................................................................................................... 151 Chapter 5: Person-centered outcomes............................................................................ 153 5.1 Confidence in system......................................................................................................................... 155 5.1.1 Care uptake and retention....................................................................................................... 155 5.1.2 Satisfaction and recommendation....................................................................................... 159 5.2 Financial protection............................................................................................................................. 163 5.2.1 Opportunity costs....................................................................................................................... 164 5.2.2 out-of-pocket costs.................................................................................................................... 165 Chapter 6. Conclusion........................................................................................................ 171 Appendix............................................................................................................................. 174 Annex A. Additional Statistics................................................................................................................. 174 Annex B. Description of SDI Subdomains.......................................................................................... 185 Annex C. Sampling Methodology and Representativeness........................................................ 192 Annex D. Description of Indicators....................................................................................................... 198 3 List of Figures Figure 1. Top 10 causes of death in Ghana (2021)..................................................................................22 Figure 2. Structure of Primary Health Care Delivery System in Ghana............................................24 Figure 3. Overview of Service Delivery Indicators domains of assessment...................................30 Figure 4. Proportion of facilities with emergency transport capacity, by tier (%) (N = 500).. 43 Figure 5. Median number of outpatient visits per day over a 3-month period (October - December 2023), by tier (N = 497)...............................................................................................................44 Figure 6. Median number of outpatient visits over a three-month period (October - December 2023), by service type and facility tier (N = 500)...............................................................45 Figure 7. Proportion of facilities connected to a motorable road, by tier (%) (N = 500).........55 Figure 8. Proportion of facilities with public transport station/stop within a 10-minute walk, by tier (%) (N = 499)...........................................................................................................................................56 Figure 9. Proportion of facilities receiving revenue from patient fees during January 2023 - December 2023, by tier (%) (N = 499).........................................................................................................60 Figure 10. Proportion of facilities with community advisory boards, by tier (%) (N = 499)...61 Figure 11. Frequency of community advisory board meetings (%) (N = 356).............................62 Figure 12. Proportion of facilities that conducted quality improvement activities during January - December 2023, by tier (%) (N = 498).....................................................................................63 Figure 13. Proportion of health facilities with quality improvement targets, by tier (%) (N = 280)............................................................................................................................................................................64 Figure 14. Proportion of health facilities with quality improvement data shared with external leadership during January - December 2023, by tier (%) (N = 281)...............................64 Figure 15. Proportion of health facilities with at least one supervisory visit during January - December 2023, by tier (%) (N = 500).........................................................................................................65 Figure 16. Proportion of health facilities with supportive supervision components (%) (N = 455)............................................................................................................................................................................66 Figure 17. Proportion of health facilities that sought feedback from their catchment community during January - December 2023, by tier (%) (N = 500)..............................................67 Figure 18. Proportion of health facilities utilizing community feedback data (%) (N = 490).................................................................................................................................................................68 Figure 19. Proportion of facilities using staff performance assessment tools (multi-select) during January - December 2023 (%) (N = 485)......................................................................................72 Figure 20. Distribution of selection criteria for selecting staff for in-service training (%) (N = 482).................................................................................................................................................................73 4 Figure 21. Proportion of providers who report being satisfied with direct supervisor support, by tier (%) (N = 1191).......................................................................................................................73 Figure 22. Proportion of health facilities with accessibility features for persons with disabilities (%).......................................................................................................................................................75 Figure 23. Consultation room with visual and auditory privacy, by tier (%) (N = 500)............76 Figure 24. Proportion of health facilities with electricity (%) (N = 500).........................................77 Figure 25. Proportion of health facilities with at least one functional refrigerator for storing vaccines (%) (N = 500).......................................................................................................................................79 Figure 26. Proportion of health facilities with at least one functional refrigerator for storing blood (%) (N = 500)............................................................................................................................................80 Figure 27. Proportion of health facilities with water availability (%) (N = 500)...........................80 Figure 28. Proportion of health facilities with toilets with various characteristics (%) (N = 500).................................................................................................................................................................82 Figure 29. Proportion of health facilities with WaSH infrastructure (%) (N = 500)....................83 Figure 30. Proportion of health facilities with five selected infection prevention and control measures (%) (N = 500).....................................................................................................................................84 Figure 31. Proportion of health facilities with ventilation (%) (N = 500).......................................85 Figure 32. Proportion of health facilities with fire safety (%) (N = 500).........................................85 Figure 33. Proportion of health facilities with internet, by tier (%) (N = 500)..............................87 Figure 34. Proportion of health facilities with up-to-date IPC guidelines, by tier (%) (N = 500).................................................................................................................................................................88 Figure 35. Median proportion of observed up-to-date clinical guidelines (N = 500)..............89 Figure 36. Proportion of facilities with LMIS system, by tier (%) (N = 500)..................................90 Figure 37. Distribution of LMIS formats used by facilities (%) (N = 260).......................................90 Figure 38. Proportion of health facilities with quality assurance of inventory protocols, by tier (%) (N = 500).................................................................................................................................................91 Figure 39. Proportion of health facilities with protocols for indentation for inventory management (%) (N = 500).............................................................................................................................92 Figure 40. Average duration between when facility indented medicine or medical supply inventory and when it received it during January - December 2023 (N = 455)..........................92 Figure 41. Average duration between emergency indenting and the inventory being received at the facility during January - December 2023 (N = 204)................................................93 Figure 42. Median proportion of available and functional equipment, by tier and equipment category (%) (N = 500)...............................................................................................................94 Figure 43. Proportion of patients who received all tests recommended by provider on day of survey (%) (N = 980)......................................................................................................................................95 5 Figure 44. Proportion of patients who received medicine on the day of the survey among those prescribed (%) (N = 2113)....................................................................................................................97 Figure 45. Provider absence rates (%) (N = 1732)..................................................................................99 Figure 46. Provider educational attainment (%) (N = 1227)............................................................ 110 Figure 47. Proportion of providers reporting being satisfied across different aspects of work (%) (N = 1227).................................................................................................................................................... 111 Figure 48. Average proportion of time spent by providers across different activities in the most recent work week, by provider cadre (%) (N = 1227)............................................................. 112 Figure 49. Median proportion of time spent by providers across different activities in the most recent work week, by tier (%) (N = 1227).................................................................................... 112 Figure 50. Correct vignette primary diagnosis and treatment, by provider cadre and tier (%) (N = 1227) .......................................................................................................................................................... 125 Figure 51. Proportions of ANC patients, > 20 weeks gestation, who received each (and all together) of the specified services at this or a previous visit (N = 154)...................................... 135 Figure 52. Median number of referrals providers report making from October - December 2023, by tier (N = 1174)................................................................................................................................. 140 Figure 53. Percentage of patients referred for care within the same health facility on the day of the survey, as reported by the patients (%), by tier (N = 2758)....................................... 141 Figure 54. Frequency of outpatient referral information sharing, as reported by the providers (%), by tier (N = 850)................................................................................................................... 143 Figure 55. Percentage of patients rating different aspects of their experience (auditory privacy, visual privacy, communication, greetings and introduction, patient involvement in care) as “good” or “very good”, by tier (N = 2758)............................................................................. 150 Figure 56. Percentage of patients that reported all their questions were answered during their consultation, among patients who received services/care, by tier (N = 2758).............. 150 Figure 57. Percentage of patients rating different aspects of their experience as “good” or “very good” (N = 2758).................................................................................................................................. 152 Figure 58. Percentage of ANC patients who have visited other health facilities for ANC (N = 216)......................................................................................................................................................................... 156 Figure 59. Percentage of NCD care patients who have visited other health facilities for NCD care (%) (N = 225)............................................................................................................................................. 157 Figure 60. Percentage of patients who state there is a health facility closer to them where they could receive the same services sought for the visit the day of the survey (N = 2758)............................................................................................................................................................ 158 Figure 61. Percentage of patients who would recommend facility to a friend or family member who needed the same service they received that day, by tier (N = 2758) ............. 159 6 Figure 62. Percentage of patients satisfied with different aspects (overall quality of care, health care provider skills, choice of health care provider) of the quality of care received during their visit, by tier (N = 2758).......................................................................................................... 160 Figure 63. Median time (minutes) to reach facility as reported by the patients, by tier (N = 2758) .......................................................................................................................................................... 164 Figure 64. Percentage of patients who report losing income due to the time it took to visit the health facility, by tier (N = 2758) ....................................................................................................... 165 Figure 65. Percentage of patients who incurred expenses on travel, consultation, medications, laboratory tests, or childcare/elder care costs (%) (N = 2758)............................. 166 Figure 66. Category of highest cost among patients who incurred costs on their visit, by tier (%) (N = 2098).................................................................................................................................................... 166 Figure 67. Percentage of patients who reported having different active insurances, by tier (N = 2752)............................................................................................................................................................ 167 Figure 68. Proportion of facilities with at least one patient consultation room with a functional light source (N = 500) .............................................................................................................. 174 Figure 69. Proportion of facilities with at least one patient consultation room with a functional air conditioning (AC) unit or ventilating fan (N = 500)................................................ 175 List of Tables Table 1. Number of health facilities in sampling frame........................................................................32 Table 2. Number of health care providers in sampling frame............................................................33 Table 3. Timeline of fieldwork activities.......................................................................................................34 Table 4. Number of health facilities surveyed in facility survey.........................................................35 Table 5. Number of health care providers surveyed during first visit in provider survey........35 Table 6. Number of providers surveyed for absence.............................................................................36 Table 7. Number of patients surveyed in patient exit survey..............................................................37 Table 8. Proportion of health facilities able to provide the required PHC services, by service category (N = 500)..............................................................................................................................................46 Table 9. Proportion of health facilities able to provide the required laboratory services, by laboratory category (N = 500)........................................................................................................................51 Table 10. Facility catchment population distribution, by tier (N = 459).........................................52 Table 11. Proportion of facilities operating on each day of the week, by tier (N = 500).........53 Table 12. Median duration (hours) of operation of facilities per day, by tier (N = 500)..........54 7 Table 13. Proportion of facilities receiving revenue from various sources during January - December 2023(%), by tier (N = 500)..........................................................................................................57 Table 14. Median revenue (’000 GH¢) received from various sources during January 2023 - December 2023 among facilities that received revenue (N = 399).................................................58 Table 15. Average In-kind revenue during January - December 2023, by tier (N = 499)........59 Table 16. Five most common areas for facility improvement according to community feedback during January - December 2023, by tier (N = 483)..........................................................69 Table 17. Five most common positive areas according to community feedback during January - December 2023, by tier (N = 483).............................................................................................70 Table 18. Components of facility management capacity (%), by tier...............................................71 Table 19. Frequency of electricity interruption at health facilities between October - December 2023, by tier (N = 414).................................................................................................................77 Table 20. Median longest duration (hours) of electricity interruption at health facilities over a 3-month period (October - December 2023), among those facilities with varying numbers of interruptions, by tier (N = 414).................................................................................................................78 Table 21. Frequency of water interruption at health facilities between October - December 2023, by tier (N = 431).......................................................................................................................................81 Table 22. Median longest duration (days) of water interruption at health facilities over a 3-month period (October - December 2023), among those facilities with varying numbers of interruptions, by tier (N = 431).................................................................................................................81 Table 23. Proportion of facilities with functioning information technology infrastructure items on the day of the survey (N = 500)..................................................................................................86 Table 24. Median proportion of available and unexpired medicine, by tier and medicine category (%) (N = 500)......................................................................................................................................96 Table 25. Median staff availability..................................................................................................................98 Table 26. Median number of PHC providers, by cadre and tier (%) (N = 490)............................98 Table 27. Top five reasons for absence from the facility on day of survey (N = 354)............ 100 Table 28. Median years of experience of providers, by cadre and tier (N = 1227)................ 101 Table 29. Proportion of health facilities with at least one provider that received in-service training during 2022-2023 in each service category (%) (N = 500).............................................. 102 Table 30. Proportion of health facilities with at least one provider that received in-service training in laboratory services during 2022 - 2023 in each service category (%) (N = 500)....106 Table 31. Health facilities with at least one provider trained in specialized services and topics (%) (N = 500)......................................................................................................................................... 107 Table 32. Proportion of providers reporting receipt and modality of training in specialized services (%) (N = 1227)................................................................................................................................... 109 8 Table 33. Provider workload in the most recent typical work week (self-reported) (N = 1227)............................................................................................................................................................ 113 Table 34. Correct diagnosis and treatment by clinical vignette case for each of the one child and two adult cases ........................................................................................................................................ 118 Table 35. Clinical knowledge: Diagnostic accuracy in clinical vignettes (%), by provider cadre and tier, (N = 1227).......................................................................................................................................... 119 Table 36. Clinical knowledge: Diagnoses selected by providers, by vignette (%), (N = 1227)............................................................................................................................................................ 120 Table 37. Clinical knowledge: Treatment accuracy in clinical vignettes (%), by provider cadre and tier, (N = 1227).......................................................................................................................................... 122 Table 38. Clinical knowledge: Treatments selected by providers, by vignette (%), (N = 1227)............................................................................................................................................................ 124 Table 39. Clinical knowledge: Diagnostic accuracy for emergency response vignette simulations by tier and provider cadre (%), (N = 530)....................................................................... 126 Table 40. Clinical knowledge: Treatment accuracy for the postpartum hemorrhage (PPH) clinical vignette, by tier and provider cadre (%), (N = 397).............................................................. 127 Table 41. Clinical knowledge: Treatment accuracy for the neonatal asphyxia clinical vignette simulation, by tier and provider cadre (%) (N = 398).......................................................................................................................................... 130 Table 42. Proportions of ANC patients who received each (and all together) of the specified services across all visits (N = 216).............................................................................................................. 133 Table 43. Percentage of patients reporting NCD services performed at current or previous visit (%) (N = 225)............................................................................................................................................. 136 Table 44. Percentage of patients reporting sick child services performed at current visit (%), by tier (N = 331)................................................................................................................................................ 138 Table 45. Distribution of frequency (always, often, sometimes, rarely, never) with which patients visit the health facility at which they were interviewed, for care (%), by tier (N = 2758)............................................................................................................................................................ 139 Table 46. Distribution of frequency (always, often, sometimes, rarely, never) with which patients see the same provider when they seek care at this health facility (%), by tier (N = 2758) .......................................................................................................................................................... 140 Table 47. Percentage of patients who report being referred to outside facility during the day of their visit, by tier (%), by tier (N = 2758).................................................................................... 142 Table 48. Distribution of most common reasons for referral outside facility as reported by the facility manager (N = 350)..................................................................................................................... 142 Table 49. Mode of patient information transfer for outpatient referrals as reported by providers, by tier (%) (N = 850)................................................................................................................... 144 9 Table 50. Mode of patient information transfer for outpatient referrals as reported by the facility managers (%), by tier (N = 106).................................................................................................... 145 Table 51. Mode of patient information transfer for outpatient referrals to other facilities as reported by the patients (among those having a referral in a three-month period from October - December 2023) by tier (%) (N = 71)................................................................................... 145 Table 52. Health record availability among patients (multiple-select), by tier (%) (N = 2758)............................................................................................................................................................ 146 Table 53. Surveillance and IPC systems and practices, by tier (%) (N = 500)............................ 147 Table 54. Emergency preparedness protocols, by tier (%) (N = 500)........................................... 148 Table 55. Percentage of visits based on appointments and without an appointment, by tier (N = 2758)............................................................................................................................................. 151 Table 56. Median wait time and consultation time as reported by patients (in minutes), by tier (N = 2758)................................................................................................................... 152 Table 57. Proportion of patients reporting receipt of intended care, intention to seek a second opinion, and indicating they would return to same facility for a similar service, by tier (%) (N = 2758) ........................................................................................................................................... 155 Table 58. Distribution of reasons for visiting more than one facility for ANC (N = 39) ....... 156 Table 60. Top five areas for facility improvement according to patient feedback, by tier (%) (N = 2758)............................................................................................................................................................ 161 Table 61. Top five reasons for choosing this facility, as reported by patients, by tier (%) (N = 2758).................................................................................................................................................... 162 Table 62. Top five reasons for choosing this facility, as reported by patients who indicated that there is a health facility closer to them where they could receive the same services, by tier (%) (N = 935).............................................................................................................................................. 163 Table 63. Percentage of patients incurring costs by tier and insurance status (self-reported) (N = 2758)............................................................................................................................................................ 168 Table 64. Median costs (in Cedis) incurred and reported by patients who incurred costs on their visit, by cost category and tier (N = 2098) .................................................................................. 169 Table 65. Distribution of the sources of funds to pay for current health care visit as reported by the patients, by tier (%) (N = 2098) .................................................................................................... 169 Table 66. Median outpatient volume, by service type and tier (%)............................................... 174 Table 67. Availability of all 23 required guidelines, by tier (%)........................................................ 175 Table 68. Proportion of facilities with listed equipment, by tier (%) (N = 500) ....................... 177 Table 69. Proportion of facilities with listed medicines, by tier (%) (N = 500).......................... 180 Table 70. Proportion of providers reporting being satisfied across different aspects of work, by tier (%) (N = 1227)...................................................................................................................................... 184 10 Table 71. Reasons for visit for pediatric patients (%) (N = 906) .................................................... 184 Table 72. Facility-reported median waiting times (minutes) (N = 500) ...................................... 185 Table 73. Target number of health care providers to be surveyed in each selected health facility, by provider and facility Type......................................................................................................... 193 Table 74. Criteria for assigning clinical vignettes to selected health providers........................ 194 List of Boxes Box 1. Key observations on primary health care foundations in Ghana.........................................38 Box 2. Key observations on primary health care processes of care in Ghana........................... 114 Box 3. Key observations on primary health care person-centered outcomes in Ghana....... 153 11 Abbreviations ACE Angiotensin-converting-enzyme AMR Antimicrobial resistance ANC Antenatal Care BP Blood Pressure CHO Community Health Officer CHPS Community-Based Health Planning and Services CHV Community Health Volunteer DHMT District Health Management Team DHS Demographic and Health Survey DSC Developmentally Supportive Care ECG Electrocardiogram EENC Early Essential Newborn Care GDP Gross Domestic Product GH¢ Ghanaian Cedi GHS Ghana Health Service ICT Information and Communication Technology IUCD Intrauterine contraceptive device IMNCI Integrated Management of Neonatal and Childhood Illnesses IPC Infection Prevention and Control ISSER Institute of Social and Economic Research LMIC Lower Middle-Income Country LMIS Logistics management information system mhGAP Mental Health Gap Action Programme MoH Ministry of Health NCD Non-communicable disease NHIA National Health Insurance Authority NHIF National Health Insurance Fund NHIL National Health Insurance Levy NHIS National Health Insurance Scheme NHQS National Health care Quality Strategy NoP Network of Practice MCH Maternal and Child Health OPD Outpatient department ORS Oral rehydration solution PALS Pediatric Advanced Life Support PCPN Primary Care Provider Network PHC Primary Health Care 12 PHCPI Primary Health Care Performance Initiative PPH Postpartum hemorrhage SDG Sustainable Development Goal SDI Service Delivery Indicator SSA Sub-Saharan Africa SSNIT Social Security and National Insurance Trust TB Tuberculosis UHC Universal Health Care USAID United States Agency for International Development VAT Value Added Tax WaSH Water, sanitation, and hygiene WB World Bank WHO World Health Organization 13 Acknowledgements The Ghana Service Delivery Indicator Survey (SDI) was prepared in collaboration with the Ministry of Health (MoH) acting through the Ghana Health Service (GHS). The team acknowledges the oversight provided by the Honorable Minister of Health, Hon. Kwabena Mintah Akandoh as well as Prof. Dr. Grace Ayensu-Danquah (Deputy Minister of Health, MOH), Mr. Desmond Boateng (Chief Director, MOH) and Dr. Belinda Afriyie Nimako (Director, PPME, MOH). The team also extends appreciation to the Director General of the GHS, Prof. Samuel Kaba Akoriyea, Dr. Caroline Reindorf Amissah (Deputy Director General, GHS), Dr. Patrick Kuma Aboagye (Former Director General, GHS), Prof. Anthony Adofo Ofosu (Former Deputy Director General, GHS), Dr. Samuel Kwabena Boakye-Boateng (Director, PPMED, GHS), Dr. Alberta Biritwum-Nyarko (Former Director, PPMED, GHS), Dr. Lawrence Ofori-Boadu (Director, ICD), Dr. Dr Salamatu Attah-Nantogma (Deputy Director, PPMED, GHS), Dr. Andrews Ayim (Former Deputy Director, PPMED, GHS) and all Regional and District Directors at GHS, for their contributions throughout the survey process. The team would also like to thank survey managers, Professor Alfred Edwin Yawson and Dr. Nana Ayegua Hagan Seneadza for their invaluable guidance during the adaptation of the survey instrument and sampling design, as well as for their leadership in managing on-the- ground survey operations. The team also acknowledges the valuable contributions of faith-based organizations, private medical practitioners’ associations and other health sector agencies, regional/district health information officers and individuals at various stages of the survey. The cooperation of facility heads, health professionals at sampled primary health care facilities, and patients who participated in the survey is also sincerely appreciated. The team is also grateful for the guidance and inputs of workshop participants at each stage of this work. Through their contextual insights and in-depth discussions, they helped ensure that the results were well grounded and accurately reflected the realities of Ghana’s health system. The World Bank SDI technical team was led by Kathryn Andrews (Senior Health Economist), Jigyasa Sharma (Health Economist) and Ruchika Bhatia (Consultant), with contributions from Juan Muñoz (Consultant), Christian Augusto Maino Vieytes (Consultant), Khushboo Gupta (Consultant), Natalie Ezem (Consultant), Nilmini Wijemunige (Consultant), and Frederic Cochinard (Consultant). The team is grateful to Dorothee Chen (Senior Economist), Enoch Oti Agyekum (Health Economist), Elisha Kipkemoi Ngetich (Health Economist), Kojo Twum Nimako (Consultant), Pearl Adwoa Opoku Youngmann (Consultant), Dr. Awudu Tinorgah (Consultant), Stephen Tettevi (Program Assistant), and Global Financing Facility (GFF) team led by Anju Malhotra (Gender Equity Monitoring Lead), Alison Morgan (Senior Health Specialist), Karin Lane Gichuhi (Senior Health Specialist), Indira Prihartono (Research Associate II, International Health), Jessica Brown (Research Associate II, International Health), Elizabeth Hazel (Associate 14 Research Professor, International Health), and Shatha Elnakib (Assistant Research Professor, International Health) for their advice, comments and suggestions during the preparation of the survey and report. The team also appreciates the work of Sanigest International and the Institute of Statistical Social and Economic Research (ISSER), who managed data collection and field implementation for this study. This work was supported by funding from MDTF funded by Canada, FCDO and GAVI. 15 Executive Summary The Service Delivery Indicators (SDI) Health Survey in Ghana serves as a vital tool for assessing and benchmarking the performance of primary health care service delivery. This comprehensive evaluation provides policy-relevant evidence to enable governments, citizens, and other stakeholders to pinpoint successes and bottlenecks in health service delivery, monitor progress over time, and make cross-country comparisons. The results of the assessment are designed to inform action to improve population health outcomes. The Ghana SDI Health Survey is the first in the Sub-Saharan Africa (SSA) region to be implemented following the survey’s comprehensive content and methodological revamp. This revamp both strengthened methodological rigor — reducing potential sources of bias— and expanded the scope and depth of the content, aligning it with current literature and best practices for measuring health service delivery. The Ghana SDI Health Survey was conducted through a partnership comprising of the World Bank, the MoH of Ghana, and Ghana Health Service (GHS). With data collection spanning March - September 2024 (seven-months), the Ghana SDI Health Survey included surveys at 500 health care facilities, and interviews with 1,227 health care providers and with 2,409 patients at these facilities. The results presented in this report are not only nationally representative but also representative of facility tiers that provide primary health care in Ghana. The SDI Health Survey stands apart from other similar assessments in its focus on the perspective of the service beneficiary and its comprehensive, three-pronged assessment of primary health care service delivery: 1. Health service delivery foundations: This domain encompasses essential aspects such as the overall health system, organization, and availability of care. It evaluates the presence of a qualified workforce, their training, workload, and job satisfaction. Additionally, it assesses the availability of essential medicines, medical and non- medical equipment, and supplies. The presence and functionality of information systems supporting health care is also analyzed. 2. Processes of care: In this domain, the SDI examines the competency of health care providers, ensuring that they possess the necessary skills and knowledge to accurately diagnose, treat, and counsel patients. It also evaluates the frequency, flow, continuity, and integration of referral systems designed to coordinate patient care effectively. Furthermore, it assesses the readiness and capacity of health facilities and workers to respond to emergencies and practice infection, prevention and control (IPC). The accessibility of health services to patients and the level of respect and autonomy they experience when seeking care is also evaluated within this domain. 3. Person-centered outcomes: This domain focuses on the experiences and outcomes of individuals seeking health care. It gauges patient satisfaction with the services they receive and examines factors influencing the uptake of care and patient retention. Additionally, it measures both direct and indirect costs that patients may incur while seeking health care. 16 By assessing these three fundamental domains comprehensively, the SDI survey delivers a holistic view of the status of primary health care service delivery. While many data sources offer insights into the average availability of health care components across the sector, the SDI survey offers a distinct perspective by examining how each of these vital service delivery elements comes together within a single health care facility. This perspective equips policymakers and stakeholders with the necessary evidence for making informed decisions and driving policy improvements in the health care sector. The survey serves as a crucial tool in enhancing the quality and effectiveness of health care services, ultimately benefiting both health care providers and the individuals who rely on these services. Each chapter of the report is organized according to the analytical domains defined above, along with their respective subdomains and components of service delivery that have been assessed. Key findings from the survey are presented below. Health facility infrastructure While 79.1 percent (95% CI: 73.4 - 83.8) of facilities in Ghana had a primary source of power available, only 18.7 percent (95% CI: 12.6 - 24.8) had uninterrupted electricity during October- December 2023 (three-months). The availability of an improved and functioning water source was high (79 percent; 95% CI: 73.4 - 83.7). However, only 34.7 percent (95% CI: 29.3 - 40.4) of facilities in Ghana had improved, functioning, on-premises and uninterrupted (October - December 2023) water source. An improved, functioning, accessible, and private toilet was available on-premises in 64.1 percent (95% CI: 58.1 - 69.8) of facilities, and 53.2 percent (95% CI: 47.2 - 59.0) of facilities had an improved toilet dedicated for staff only. However, the availability of a separate improved toilet for females only was relatively lower (37.2 percent; 95% CI: 31.9 - 42.9), and an improved toilet for females that had menstrual hygiene facilities was available in only 19.1 percent (95% CI: 15.2 - 23.7) of the facilities. The most prevalent IPC features included appropriate infectious waste disposal facilities (43.9 percent; 95% CI: 38.2 - 49.8) and functional hand hygiene facilities at least one point of care (47.7 percent; 95% CI: 41.9 - 53.5). The least common measures included a physical barrier at one or more points of initial patient contact (15.9 percent; 95% CI: 12.7 - 19.6), at least one designated site for patient isolation (10.5 percent; 95% CI: 7.7 - 13.2), and at least one separate waiting area for patients (9.1 percent; 95% CI: 6.6 - 12.5). Key fire safety infrastructure and processes, such as a functional fire alarm (13.5 percent; 95% CI: 10.7 - 16.9) and functional fire extinguishers (23.0 percent; 95% CI: 19.3 - 27.2) were low. The availability of infrastructure to facilitate access by persons with disabilities was low, with just 30.9 percent (95% CI: 25.7 - 36.6) of facilities having tactile flooring, 14.1 percent 17 (95% CI: 10.7 - 18.3) having improved functional toilet for persons with disabilities, and 3.6 percent (95% CI: 2.1 - 6.3) having assistive technology for the people with visual impairment. Among the facilities with more than one floor, only 7.6 percent (95% CI: 4.9 - 11.7) had a functional lift. Health facility inputs and systems During October - December 2023, on average, 35.4 percent (95% CI: 29.8 - 41.4) of facilities were able to provide all measured child health and nutrition services, 15.7 percent (95% CI: 12.4 - 19.8) were able to provide all measured family planning services, 10.6 percent (95% CI: 7.3 - 15.0) were able to provide all measured maternal and newborn health services, and 6.3 percent (95% CI: 4.5 - 8.9) were able to provide all measured risk factor assessment services. Nationally, a typical facility had 64.4 percent of the equipment and supplies required for primary care services, including 62.5 percent of reproductive and child health equipment and supplies and general/acute care equipment and supplies, and 60.0 percent of infection prevention and control (IPC) equipment and supplies, all available and functioning. Further, a typical facility had 50 percent of controlled drugs, injections and oral medicines, 66.7 percent of Intravenous (IV) fluids and 80 percent of vaccines. Most (90.3 percent; 95% CI: 85.0 - 93.4) facilities had at least one supervisory visit from central or external leadership between January - December 2023. However, among the facilities that received supportive supervisory visits, only 34.8 percent (95% CI: 29.0 - 41.1) included all components required to consider the visit “supportive” by World Health Organization (WHO) standards.1 Two-thirds (66.4 percent, 95% CI: 60.3 - 72.0) of the facility managers had a degree in management or had attended at least a month-long management training. Among facilities with more than one health care provider or support staff, 78.4 percent (95% CI: 72.7 - 83.1) held performance review meetings with health care providers and 68.3 percent (95% CI: 60.0 - 75.5) with support staff between January - December 2023. About two-thirds (64.8 percent; 95% CI: 58.8-70.4) of facility managers received a performance review between January - December 2023. More than half of patients (65.0 percent; 95% CI: 62.8 - 67.2) reported typically using the same health facility for care and nearly half (48.8 percent: 95% CI: 46.1 - 51.4) reported typically seeing the same health care provider when they visited the same facility. When outpatient (non-emergency) referrals took place, patients bore the burden of physically transferring their own health information, as reported by patients (98.7 percent; 95% CI: 89.6 - 99.8) and providers (86.0 percent; 95% CI: 83.1 - 88.5); electronic, telephonic, or other means of direct information transfer between health care providers were rare. 1   World Health Organization (WHO). 2008. Training for Mid-level Managers (MLM). Module 4: Supportive Supervision (republished 2020). Geneva: WHO. https://apps.who.int/iris/bitstream/handle/10665/337056/9789240015692-eng. pdf 18 Availability and characteristics of health care staff A median of 1.4 providers and 1.6 total staff were available for every 1,000 individuals in the catchment population. The median tenure in clinical service of doctors, physician assistants, nurses and midwives (the four cadres assessed in the survey) were four, nine, five, and eight years, respectively. Overall, 25.8 percent (95% CI: 18.7 - 34.4) midwives, 15.1 percent (95% CI: 9.6 - 23.0) nurses, 13.7 percent (95% CI: 8.4 - 21.3) physician assistants, and 18.1 percent (95% CI: 12.6 - 25.3) doctors were not present at the health facility on the day of the survey. Absence due to unauthorized reasons was negligible. The most common reasons for absence differed by provider cadre, and included annual leave, training, seminar or meeting, study leave, and parental leave. Most providers were able to provide the correct primary diagnosis and treatment for simulation cases of diarrhea (79.5 percent; 95% CI: 72.1 - 85.3), type-2 diabetes (92.5 percent; 95% CI: 87.1 - 95.7) and hypertension (83.4 percent; 95% CI: 75.0 - 89.4). For intrapartum emergency response simulations, while most providers were able to provide the correct diagnosis for postpartum hemorrhage (96.3 percent; 95% CI: 88.5 - 98.9), only 77.5 percent (95% CI: 65.6 - 86.1) of providers provided the correct diagnosis for neonatal asphyxia. For the treatment, 94.8 percent (95% CI: 83.8 - 98.5) of providers performed the correct primary treatment for postpartum hemorrhage while 70.2 percent (95% CI: 40.9 - 88.0) of providers achieved the key treatment step for birth asphyxia (chest rise in one minute). Over ninety percent of providers reported being satisfied with job meaningfulness (99.1 percent; 95% CI: 97.5 - 99.7), relationship with coworkers (98.5 percent; 95% CI: 97.2 - 99.2), clarity in work responsibilities (95.7 percent; 95% CI: 92.3 - 97.6), and work likeability (95.0 percent; 95% CI: 90.2 - 97.5). On average, providers reported spending the majority of their time on patient care (72 percent), followed by administrative work (15 percent), management activities (5 percent) and educational activities (4 percent). Nationally, 21.7 percent (95% CI: 17.0 - 27.3) of providers were dissatisfied with the balance of work between clinical and administrative work. Patient experience of and satisfaction with care Among patients receiving antenatal care (ANC), 12.1 percent (95% CI: 6.1 - 22.5) reported having received all of a set of 21 services during current or a previous visit. Among ANC patients who were over 20 weeks pregnant, only 41.7 percent (95% CI: 24.3 - 61.4) reported having received all of a set of five key ANC services during their pregnancy. Among patients receiving noncommunicable disease (NCD) care, receipt of various services was highly variable: over 90 percent of patients reported being asked about their diet (99.1 percent; 95% CI: 95.3 - 99.8), physical activity (96.9 percent; 95% CI: 89.4 - 99.1), having received their blood glucose result (99.8 percent; 95% CI: 98.3 - 100.0), having had their blood pressure taken (100.0 percent; 95% CI: 100.0 - 100.0), but only 48.0 percent (95 % CI: 18.5 - 79.0) 19 had their cholesterol/lipids tested across all their visits. For those seeking sick childcare, 30.8 percent (95% CI: 21.4 - 42.2) reported being asked about the child’s immunization history, 12.3 percent (95% CI: 6.9 - 21.1) had their growth plotted, and 52.1 percent (95% CI: 43.0 - 61.0) were informed of the diagnosis. More than 85 percent of the patients interviewed rated various aspects of their experience, such as visual privacy (88.7 percent; 95% CI: 85.3 - 91.4), auditory privacy (88.8 percent; 84.3 - 92.1), communication/explanation by the health care provider (92.9 percent; 95% CI: 91.0 - 94.5), patient involvement in care (87.2 percent; 95% CI: 84.6 - 89.4), greetings and introduction by the provider (93.4 percent; 95% CI: 91.2 - 95.1), convenience of hours of operation (91.1 percent; 95% CI: 88.4 - 93.3), duration of consultation (91.9 percent; 95% CI: 89.9 - 93.6), cleanliness of rooms (80.3 percent; 95% CI: 74.9 - 84.7) as good or very good. However, travel time to facility (74.8 percent; 95% CI: 71.1 - 78.2), waiting time before consultation (78.8 percent; 95% CI: 74.8 - 82.3), physical conditions of rooms (78.1 percent; 95% CI: 73.2 - 82.4) and availability/functioning of equipment/supplies/ medicine (65.6 percent; 95% CI: 60.2 - 70.7) were rated good or very good by the least percentage of patients. The median travel time reported by patients to reach the facility was 15.0 minutes, and the median waiting time between arrival at the facility and being seen by a health care provider was 10.0 minutes. Overall, 83.1 percent (95% CI: 80.6 - 85.3) of patients incurred expenses in seeking care on transportation, consultation, medication, laboratory tests, or child/elder care costs on the day of the survey. On average, patients reported incurring the highest expense on medicine costs (47.5 percent; 95% CI: 43.8 - 51.2) and travel costs (24.2 percent; 95% CI: 21.1 - 27.6), followed by costs for laboratory tests (16.9 percent; 95% CI: 14.3 - 19.8) and consultation fees (11.4 percent; 95% CI: 9.1 - 14.2). This report is organized as follows. Chapter 1 presents an overview of Ghana and the context within which the primary health care system is situated. Chapter 2 summarizes the methodology used for all phases of research, from design to data analysis. Chapter 3 provides an in-depth view into the foundations domain. Chapter 4 presents the processes of care domain. Chapter 5 presents the person-centered outcome domain, focusing on the patient experience to evaluate the health care system from the end-user perspective. Chapter 6 presents the concluding remarks. 20 Chapter 1. Background Over the years, Ghana has made significant investments in its health care system. This has included significant investment in primary health care (PHC) through the Community-based Health Planning and Services (CHPS) initiative beginning in the 1990s2, and the National Health Insurance Scheme (NHIS), which was established in 2003 (Act 650) to provide affordable and equitable health care services to individuals in Ghana.3 More recently, Ghana has invested in reforming the health care sector to enhance service delivery, efficiency, and health outcomes, all aligning with the nation’s broader development goals.4 However, the country still faces significant challenges in ensuring equitable access to high- quality health care, particularly in rural areas.5 This is due to a range of factors, including inadequate health facility infrastructure, suboptimal staff mix, and high out-of-pocket costs, which collectively hinder the ability of Ghanaians to access quality health care.6 According to annual reports from the GHS, there is an unequal distribution of health care services, with service availability and quality of care falling below expectations in the country.7 At the primary level, there is an insufficient and disproportionate staff mix affecting several districts. 50 percent of primary-level facilities lack basic infrastructure and equipment. There are also challenges with the procurement and coordination of medicine supplies at primary health facilities.8 The NHIS covers a variety of essential medical treatments, which reduces the financial barriers to health care, but Ghana’s 2021 census reported that only 68.6 percent of the population is covered by either the NHIS or private health insurance schemes.9 At the macro level, there is also a significant reduction in government non-wage budgetary allocation to health (excluding NHIS) and total budget as a percentage of the Gross Domestic Product (GDP).10 Financing for public health interventions in Ghana was stable until the country became a Lower Middle-Income Country (LMIC), which led to the withdrawal of funds from several 2 Elsey, H., Abboah-Offei, M., Vidyasagaran, A. L., Anaseba, D., Wallace, L., Nwameme, A., Gyasi, A., Ayim, A., Ansah-Ofei, A., Amedzro, N., Dovlo, D., Agongo, E., Awoonor-Williams, K., & Agyepong, I. (2023). Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: A history and systematic review of what works, for whom and why. Frontiers in Public Health, 11, 1105495. https://doi.org/10.3389/fpubh.2023.1105495 3   NHIA. (n.d.). Retrieved February 26, 2025, from https://www.nhis.gov.gh/nhia 4   Ministry of Health, Republic of Ghana. (2024, April). National Health care Quality Strategy-Revised Edition (2024-2030). 5   Peprah, P., Budu, H. I., Agyemang-Duah, W., Abalo, E. M., & Gyimah, A. A. (2020). Why does inaccessibility widely exist in health care in Ghana? Understanding the reasons from past to present. Journal of Public Health, 28(1), 1–10. https://doi. org/10.1007/s10389-019-01019-x 6   ibid 7   GHS. (2014). Ghana Health Service 2013 Annual Report.; GHS. (2016). Ghana Health Service 2015 Annual Report.; GHS. (2017). Ghana Health Service 2016 Annual Report. 8   ibid 9   International Trade Administration. (2022, July 22). Ghana—Health care. Ghana - Country Commercial Guide. https://www.trade.gov/country-commercial-guides/ghana-healthcare 10   GHS. (2014). Ghana Health Service 2013 Annual Report.; GHS. (2016). Ghana Health Service 2015 Annual Report.; GHS. (2017). Ghana Health Service 2016 Annual Report. JLN DRM Collaborative. (2022). Public Expenditure on Health in Ghana: A Narrative Summary. Domestic Resource Mobilization Collaborative. https://jointlearningnetwork.org/wp-content/ uploads/2022/12/GHANA-Narrative-Summary.pdf 21 development partners.11 As a result, gradual dwindling of financing has further compounded the challenges faced by the health system in Ghana. An estimated annual US$350 million of co-payments will be needed to fund Ghana’s vaccine and other commodity commitments.12 Furthermore, there is diminished availability of essential commodities such as family planning supplies, vitamin A, and folic acid.13 Additionally, Ghana is experiencing a triple burden of disease with communicable diseases, non-communicable diseases (NCDs), and injuries. NCDs have become the most significant cause of mortality and morbidity, representing 47 percent of deaths in 2021.14 In 2021, stroke, ischemic heart disease, and kidney diseases were among the top 10 causes of mortality in the country (figure 1). The prevalence of the main NCD risks remains high: 4.8 percent of adults aged 18-69 years currently smoke tobacco, 22.6 percent consume alcohol, 19.6 percent have elevated blood pressure (defined as systolic blood pressure ≥ 140 mmHg and/ or diastolic blood pressure ≥ 90 mmHg), 20.9 percent are overweight (defined as BMI 25 - 29.9 kg/m²), and 13.4 percent are classified as obese (defined as BMI ≥30 kg/m²).15 Figure 1. Top 10 causes of death in Ghana (2021) Source: The World Health Organization, 2025 Although NCDs remain the leading cause of mortality in Ghana, particularly among the adult population, as of 2021, tuberculosis, lower respiratory infections, malaria, HIV/AIDS, and COVID-19 were still among the most common causes of death across all age groups.16 Significant progress has been made over the last few decades, including implementing cost- effective interventions to reduce communicable diseases, but tremendous work still needs to 11   Mao, W., McDade, K. K., Huffstetler, H. E., Dodoo, J., Abankwah, D. N. Y., Coleman, N., Riviere, J., Zhang, J., Nonvignon, J., Bharali, I., Bandara, S., Ogbuoji, O., & Yamey, G. (2021). Transitioning from donor aid for health: Perspectives of national stakeholders in Ghana. BMJ Global Health, 6(1), e003896. https://doi.org/10.1136/bmjgh-2020-003896   Ministry of Health. (2020, January). Ghana’s Roadmap for Attaining Universal Health Coverage 2020-2030. https://www. 12 moh.gov.gh/wp-content/uploads/2021/08/UHC-Roadmap-2020-2030.pdf 13   GHS. (2014). Ghana Health Service 2013 Annual Report.; GHS. (2016). Ghana Health Service 2015 Annual Report.; GHS. (2017). Ghana Health Service 2016 Annual Report. 14   World Health Organization 2025 data.who.int, Ghana [Country overview]. (Accessed on 25 July 2025) 15   https://www.afro.who.int/countries/ghana/publication/ghana-steps-report-2023 16   World Health Organization 2025 data.who.int, Ghana [Country overview]. (Accessed on 25 July 2025) 22 be done to improve access and quality of health care in the country. 17 18 19 20 Lastly, injuries remain a significant health concern in Ghana, affecting both urban and rural populations.21 According to a longitudinal World Health Organization (WHO) survey report for Ghana, urban residents were found to have a higher prevalence (36.3%) of injury resulting in disability from road traffic accidents compared to their rural counterparts.22 However, when looking at types of injuries more broadly and excluding road traffic accidents, rural residents of Ghana reported a larger prevalence (24.8%) of injuries resulting in disability.23 With the current health coverage in Ghana and the burden of disease as described, the need for a robust primary health care system cannot be overemphasized. 1.1. Health care system in Ghana Ghana’s MoH plays a key role in shaping primary health care delivery by promoting access to quality services through motivated personnel. Established in 1996, the GHS operates under the MoH and is responsible for implementing national health policies and managing government health services. GHS focuses on delivering comprehensive and accessible care, with an emphasis on primary health care across the country. Building on this foundation, Ghana continues to prioritize primary health care as the central strategy for advancing toward Universal Health Coverage by 2030. Currently, Ghana has approximately 10,000 health care delivery facilities providing health care.24 The PHC delivery system is structured in three tiers (district, sub-district, and community) as shown in figure 2 below.25   Adjei, B., Hormenu, T., & Mintah, J. K. (2025). Community-based surveillance system structures and knowledge level 17 of community-based surveillance volunteers on priority diseases in Ghana. PLOS Global Public Health, 5(4), e0003779. https://doi.org/10.1371/journal.pgph.0003779   Adokiya, M. N., Awoonor-Williams, J. K., Barau, I. Y., Beiersmann, C., & Mueller, O. (2015). Evaluation of the integrated 18 disease surveillance and response system for infectious diseases control in northern Ghana. BMC Public Health, 15(1), 75. https://doi.org/10.1186/s12889-015-1397-y 19   Nsubuga, P., Eseko, N., Tadesse, W., Ndayimirije, N., Stella, C., & McNabb, S. (2002). Structure and performance of infec- tious disease surveillance and response, United Republic of Tanzania, 1998. Bulletin of the World Health Organization, 80(3), 196–203.   WHO Regional Office for Africa. (2015). Integrated Diseases Surveillance and Response in the African Region: Com- 20 munity-based Surveillance (CBS) Training Manual. https://www.afro.who.int/sites/default/files/2017-06/communi- ty-based-surveillance_idsr_training-manual.pdf 21   World Health Organization 2025 data.who.int, Ghana [Country overview]. (Accessed on 25 July 2025)   Biritwum, R., Mensah, G., Yawson, A., & Minicuci, N. (2013). Study on global AGEing and adult health (SAGE), Wave 1: The 22 Ghana National Report. University of Ghana Medical School, Department of Community Health. 23   ibid   Sasu, D. D. (2024, September 30). Number of health facilities in Ghana as of August 2022, by type of ownership. Statista. 24 https://www.statista.com/statistics/1238760/number-of-health-facilities-in-ghana-by-ownership/   Ministry of Health. (2020, January). Ghana’s Roadmap for Attaining Universal Health Coverage 2020-2030. https://www. 25 moh.gov.gh/wp-content/uploads/2021/08/UHC-Roadmap-2020-2030.pdf 23 Figure 2. Structure of Primary Health Care Delivery System in Ghana Source: Ghana’s roadmap for attaining Universal Health Coverage 2022-2030 Figure 2 Acronyms: PHC = Primary Health Care; DHMT = District Health Management Team; SDHMT = Sub-District Health Management Team; CHPS = Community-Based Health Planning and Services; CHO = Community Health Officer; CHV = Community Health Volunteer; CHT = Community Health Technician; NIDs = National Immunization Days The Apex (Level C) is at the District Hospital and the District Health Administration.26 Management at the Apex collaborates with local government and decentralized agencies to plan, supervise, monitor, and coordinate health service delivery. The District Hospital delivers the most advanced comprehensive care in the district and serves as the primary referral facility, with a typical bed capacity of 50 - 60 and a catchment population ranging from 100,000 - 200,000. It integrates curative, preventive, promotive, diagnostic, surgical, and specialized services, and often shares this role with other hospitals, including faith-based institutions operating at the same level.27 The Sub-district (Level B) is responsible for planning, developing, monitoring, and evaluating the implementation of community-based service delivery.28 The health center is traditionally the initial point of contact between clients and the formal health system.29 It is led by a physician assistant and staffed with program heads who specialize in midwifery, laboratory services, public health, environmental health, and nutrition. Each health center typically serves a population of approximately 20,000. These centers provide basic curative and preventive services for both adults and children, along with reproductive health services.   Service, G. S., & Macro, O. R. C. (2004). Ghana Service Provision Assessment Survey 2002. https://dhsprogram.com/ 26 publications/publication-spa6-spa-final-reports.cfm 27   ibid 28   ibid 29   ibid 24 They perform minor surgical procedures such as incision and drainage, conduct outreach services, and refer serious or complex cases to more appropriate tiers of care.30 The Polyclinic serves as the urban counterpart to the rural health center and are commonly found in metropolitan areas.31 Polyclinics are generally larger facilities that provide a broader and more comprehensive range of services. They are staffed by physicians and are capable of performing complicated surgical procedures.32 The Community level (Level A) provides health services closer to community members.33 In order to strengthen PHC, the MoH and the GHS introduced the CHPS initiative in 1999.34 This was later formalized through the National CHPS Policy, which defines CHPS as a national strategy to provide essential health services based on community involvement in planning and delivery.35 The primary aim is to improve access to health services in underserved sub-districts and to promote proximity of care. However, inconsistent service delivery has contributed to hesitancy among patients in seeking care at local CHPS centers.36 A CHPS Zone is a specific geographic area that includes up to 5,000 individuals or 750 households in densely populated locations.37 Each zone may consist of a single town, part of a town, or a cluster of villages or settlements that are mapped for better planning and efficient delivery of mobile services. Community Health Officers (CHOs) and Community Health Volunteers (CHVs) are assigned to each zone. A CHPS Zone often includes a CHPS Compound, particularly in areas where there is no health center or hospital.38 A CHPS Compound is defined as a recognized structure that includes both a service delivery point and residential accommodation, both of which are required for its official status.39 Private Maternity Homes are under the authority of the Ghana Registered Midwives Association. These homes represent approximately 17 percent of all health facilities that offer reproductive health services in Ghana and are present in every region. These homes operate in partnership with the Reproductive and Child Health Unit of the GHS, offering family planning and reproductive services as well as child welfare services.40 30   ibid 31   ibid 32   ibid 33   ibid; Ministry of Health. (2014, November). National Community Health Planning and Services (CHPS) policy: Work- ing draft for validation. Accra, Ghana: Ministry of Health, Republic of Ghana, https://www.moh.gov.gh/wp-content/ uploads/2016/02/CHPS-policy-final-working-draft-for-validation.pdf 34   ibid 35   ibid   Awudu, T.,& Enimanyew,N.(2019) Strengthening Primary Health Care Delivery Through Provider Networking in Ghana/ 36 Results for Development. (n.d.). https://r4d.org/projects/strengthening-primary-health-care-delivery-provider-net- working-ghana/ 37   Ministry of Health. (2014, November). National Community Health Planning and Services (CHPS) policy: Working draft for validation. Accra, Ghana: Ministry of Health, Republic of Ghana, https://www.moh.gov.gh/wp-content/up- loads/2016/02/CHPS-policy-final-working-draft-for-validation.pdf 38   ibid 39   ibid   Service, G. S., & Macro, O. R. C. (2004). Ghana Service Provision Assessment Survey 2002. https://dhsprogram.com/ 40 publications/publication-spa6-spa-final-reports.cfm 25 1.2. History of primary health care in Ghana Since gaining independence in 1957, Ghana has prioritized health care as part of its national strategy to improve the quality of life for its residents. The country’s commitment to improving equitable access to health care services has led to the adoption of numerous initiatives aimed at strengthening the health care infrastructure. Timeline of primary health care evolution in Ghana Alma-Ata Declaration on Primary Health Care41 Since signing the Alma-Ata Declaration on Primary Health Care in 1978, Ghana has seen a number of changes to its health care system. With a primary emphasis on the public health approach, these changes have 1978 concentrated on strengthening institutional development and funding, investment in health development, and governance and delivery of health services. The growth of the health system has also been positively impacted by the creation of regulations, a health policy, and regulatory agencies. In their areas of competence, civil society is also starting to play a bigger role in developing health care. Vision 202042 The Ghanaian government introduced Vision 2020 as a long-term national development framework to transform the country into a middle-income 1996 country by 2020 through human, economic, and regional development. Improvements in the health care sector were critical to this vision. For example, this framework focused on expanding access to quality health care, reducing disease burden, increasing life expectancy, and increasing maternal and child health outcomes. Community-based Health Planning and Services Initiative43 Ghana launched the CHPS initiative as a strategy to improve Primary Health care services in rural and underserved communities. This initiative 1999 primarily focused on training more community health officers in order to deliver essential health care services at the community tier. This initiative increased health care utilization and helped bridge the health care access gap between urban and rural populations.   World Health Organization. (1978, September). Declaration of Alma-Ata. https://www.who.int/publications/i/item/ 41 WHO-EURO-1978-3938-43697-61471   Ministry of Finance - Government of Ghana. (2000, March 1). DEVELOPMENT STRATEGY FOR POVERTY REDUCTION. 42 https://documents1.worldbank.org/curated/en/124221468029685239/pdf/multi-page.pdf   Adusei, A. B., Bour, H., Amu, H., & Afriyie, A. (2024). Community-based Health Planning and Services programme in Gha- 43 na: A systematic review. Frontiers in Public Health, 12, 1337803. https://doi.org/10.3389/fpubh.2024.1337803 26 National Health Insurance Scheme44 Ghana established the NHIS to address financial barriers to health care access. This program essentially operates as a universal health insurance program within the country. The program is funded by 4 sources: (1) The 2003 National Health Insurance Levy (NHIL), which is a 2.5 percent levy on goods and services collected under the Value Added Tax (VAT), (2) 2.5 percentage points of Social Security and National Insurance Trust (SSNIT) contributions per month, (3) return on National Health Insurance Fund (NHIF) investments, (4) premium paid by informal sector subscribers. 2030 Agenda for Sustainable Development45 Sustainable Development Goal 3 (SDG3) is titled “Ensure healthy lives and promote well-being for all at all ages.” SDG3 aligns with the global commitment to fostering a healthy society and safeguarding everyone’s 2016 right to the highest attainable standard of physical and mental health. The 13 targets and 28 embedded indicators of SDG3 address major health priorities, such as reproductive, maternal, child, and adolescent health; communicable and non-communicable diseases; universal health coverage; and access to safe, effective, and quality medicines and vaccines. Declaration of Astana46 In October 2018, the Global Conference on Primary Health Care in Astana, Kazakhstan endorsed a new declaration emphasizing the critical role of 2018 primary health care around the world. The declaration aims to refocus efforts on primary health care to ensure that everyone everywhere can enjoy the highest possible attainable standard of health. As a signatory of the Astana Declaration, Ghana has reaffirmed and renewed its political commitment to primary health care. Global Action Plan for Healthy Lives and Well-being for All47 This initiative enhanced Ghana’s ability to coordinate resource allocation 2019 and evidence-based health interventions through the engagement of 13 multilateral health, development, and humanitarian agencies. It continues to strengthen PHC delivery in Ghana by promoting community engagement, strengthening health care finance, and improving workforce capacity. 44   National Health Insurance Scheme. (n.d.). About Us. Retrieved July 28, 2025, from https://www.nhis.gov.gh/about   UNITED NATIONS. (n.d.). Goal 3: Ensure healthy lives and promote well-being for all at all ages. United Nations Sustain- 45 able Development. Retrieved July 28, 2025, from https://www.un.org/sustainabledevelopment/health/   World Health Organization. (2018, October 26). Declaration of Astana. https://www.who.int/publications/i/item/ 46 WHO-HIS-SDS-2018.61   Ministry of Health. (2020, January). Ghana’s Roadmap for Attaining Universal Health Coverage 2020-2030. https://www. 47 moh.gov.gh/wp-content/uploads/2021/08/UHC-Roadmap-2020-2030.pdf 27 Networks of Practice Established48 The MoH, in collaboration with the United States Agency for International Development (USAID), piloted the Primary Care Provider Networks (PCPN) initiative in two districts from 2017 to 2019 to enhance PHC services. The pilot demonstrated that networking among facilities led to improved collaboration, strengthened technical and operational support, expanded 2020 service delivery, enhanced referral and feedback systems, and better NHIS claims management, making it a key strategy for achieving Universal Health Care (UHC) by 2030. Based on these positive outcomes, the MoH endorsed a nationwide scale-up under the leadership of the GHS. The initiative was subsequently expanded to 10 districts and rebranded as Networks of Practice (NoPs), with a focus on strengthening health centers as effective hubs within the network to improve service delivery and accessibility across multiple districts. Revised National Health Care Quality Strategy (2024-2030)49 The National Health Care Quality Strategy (NHQS) Revised Edition (2024- 2030) aims to enhance health care quality in Ghana by prioritizing safe, effective, and patient-centered care. The initial NHQS (2017-2021) faced systemic challenges that hindered full implementation, preventing the 2024 country from achieving key health goals, including reducing child mortality, improving maternal health, and combating HIV/AIDS. To address these gaps, the revised NHQS aligns with the National Health Policy and UHC roadmap, emphasizing safety, efficiency, and equity. It hopes to strengthen health care delivery by enhancing system capacity, reinforcing regulatory mechanisms, and fostering greater community involvement. 1.3. Motivation for the Ghana SDI survey The MoH and GHS have been working diligently to enhance PHC delivery in Ghana. However, there is still a lack of comprehensive understanding regarding the availability of equipment and medicines, the knowledge and skills of health care workers, and the overall patient experience in relation to PHC service delivery. To continue strengthening primary care in Ghana, it is crucial to gather additional data that can accurately assess the current situation and identify areas of success and for improvement. This will serve as another step in Ghana’s trajectory of building a robust PHC system that provides quality services to all citizens. Furthermore, evaluating service delivery in the context of the NHIS can help ensure that the proposed benefits align with the capacity to deliver the necessary services at the PHC level.   World Bank Group. (2024). Health system technical support to Government of Ghana: Patient pathway analysis and 48 summative network analysis – Consolidated findings report. Washington, DC: World Bank Group. https://documents. worldbank.org/curated/en/099121924100512855   Ministry of Health. (2023). National Health care Quality Strategy 2024–2030. Accra, Ghana: Ministry of Health, Republic 49 of Ghana. 28 Several recent health assessments, including the 2022 Demographic and Health Survey (DHS)50 and the 2023 Ghana Health Service’s Holistic Assessment report51, have contributed important data on health outcomes and system performance. However, these surveys did not fully capture key dimensions of service delivery at the facility tier, such as provider competence, availability of essential inputs, and the quality of patient-provider interactions. To address these critical gaps, the Government of Ghana requested technical assistance from the World Bank to implement a SDI Health Survey. The SDI Health Survey in Ghana provides a comprehensive overview of the PHC service delivery system in the country. By identifying the system’s strengths and weaknesses, the survey results offer a better understanding of health care providers’ knowledge and job satisfaction, patient experience, and the availability of essential inputs in PHC facilities. Ultimately, this will inform health system improvements, such as the ongoing scaling of the NoPs initiative. 1.4. How the Ghana SDI measures primary health care The first step in measuring the quality of service delivery in health is to define the concept. As many decades of scholarship have indicated, quality of care is a multi-dimensional concept. Perhaps the most canonical definition was proposed by Avedis Donebedian who defined quality-of-care along three domains: structure, process, and outcomes of care.52 Building on this definition and other work, the Lancet Global Health Commission on High Quality Health System proposed an updated definition which articulates high-quality health system as “one that optimizes health care in a given context by consistently delivering care that improves or maintains health outcomes, by being valued and trusted by all people, and by responding to changing population needs.”53 The new generation of SDI health survey is informed by the recent literature and guidance on measuring quality of health systems, primarily that from the Lancet Global Health Commission on high quality health systems. The Commission emphasizes the lack of and need for measuring quality of care along three domains, namely foundations, processes of care, and quality impacts. The guiding framework of the SDI health survey (figure 3) is built on these axes, with measures being organized into these three domains. The SDI framework also draws from other relevant frameworks such as the Primary Health Care Performance Initiative (PHCPI), which describes the critical components of strong primary health care system along five key areas: systems, inputs, service delivery, outputs, and outcomes.   Ghana Statistical Service (GSS) and ICF. 2024. Ghana Demographic and Health Survey 2022. Accra, Ghana, and Rockville, 50 Maryland, USA: GSS and ICF. https://dhsprogram.com/publications/publication-FR387-DHS-Final-Reports.cfm   Ministry of Health (Republic of Ghana). (2024, May). 2023 Holistic Assessment Report. Accra, Ghana: Ministry of Health. 51 https://www.moh.gov.gh/wp-content/uploads/2025/01/2023-HOLISTIC-ASSESSMENT-REPORT.pdf 52   Daniel R. Gerard, “Quality Improvement Using the Donabedian Model,” HMP Global Learning Network, April 17, 2022, https://www.hmpgloballearningnetwork.com/site/emsworld/original-contribution/quality-improvement-us- ing-donabedian-model   Margaret E Kruk et al., “High-Quality Health Systems in the Sustainable Development Goals Era: Time for a Revolution - 53 PMC,” Lancet Global Health 6 (September 5, 2018): e1196–1252. 29 Figure 3. Overview of Service Delivery Indicators domains of assessment Foundations of, or inputs to, high-quality primary care, include subdomains related to systems, care organization, workforce, and tools—critical enablers for ensuring delivery of primary care services that meet the needs and expectations of the population. The performance of the system is measured along the components that serve as the backbone of primary care systems: policies and protocols, institutions for accountability for quality, management and supervision, financing, and physical infrastructure. Care organization is systematically investigated along three subdomains: service delivery organization, facility connective networks, and service and case mix. Appropriate care organization, which means a balanced mix of facility and provider types, connectivity across facilities, and case mix, is critical for optimizing resource allocation and outcomes. Availability, education and training, workload, and satisfaction and retention are four components which inform the measurement of workforce in the SDI framework. Taking a step forward in addressing human resource challenges in service delivery, the SDI health survey views health care providers as both agents and subjects of the health system and attempts to measure not just the workforce’s availability and credentials, but also factors that might be affecting their performance, such as workload and satisfaction with work. Finally, the survey also measures tools required for care delivery categorized along three groups, namely medical equipment and supplies, medicine, and information systems. These foundations are necessary pillars of a strong primary health care system yet are not sufficient alone to ensure high-quality primary health care. For this reason, the SDI health survey provides additional measurement of processes of care and person-centered outcomes. 30 Processes of care refer to the actual delivery (or receipt) of care in a facility setting and can be assessed along two unique but interrelated subdomains: competent care systems and positive user experience. The SDI health survey measures the competency of health care systems in delivering high-quality care along three dimensions: 1. Diagnosis, treatment, and counseling are used to understand the knowledge and clinical competency of health care providers through clinical case simulations. 2. Referral, continuity, and integration are examined to understand how referral systems function and to assess patients’ willingness to continue seeking care from the same health facility or health care provider. 3. Safety, prevention, and detection are evaluated to determine whether practices are in place to prevent health care acquired infections and to detect and prevent the spread of contagious diseases in a timely manner. The survey employs three categories of indicators to assess patients’ experience in receiving care: 1. Respect and autonomy are measured to assess health care practices that foster the feeling of respect and autonomy in patients. 2. User focus is evaluated to understand the systems in place that prioritize patients’ needs in every step of service delivery. 3. Responsiveness to feedback is assessed to determine how health facilities respond to feedback provided by patients. Person-centered outcomes ensure that a patient is at the “center of care,” and that patients are empowered to make decisions regarding their own health. This involves sharing all relevant information and resources with patients so that they can consider all their choices and make an informed decision. In understanding how well the health system allows for patient-driven health care, the SDI health survey assesses two subdomains, covering confidence in the health system and financial protection. 1. Satisfaction and recommendations are assessed to understand patient satisfaction with various aspects of care received and the likelihood of recommending a health facility or health care provider to others based on their experience. 2. Care uptake and retention are examined to determine the likelihood that patients will continue to receive care at a single health facility or multiple health facilities, as well as the reasons for their choice. The survey also employs two other components for assessing the various financial costs that patients bear in receiving care, namely, out-of-pocket costs and opportunity costs, for example, income lost or time taken away from work in receiving care. The survey does not capture outcomes such as quality of life or functional status due to the complexity of measuring these types of outcomes and the inappropriateness of linking them to a given facility or experience of care as measured by the SDI health survey. 31 Chapter 2. Methods 2.1. Survey Development As per the SDI methodology, the survey in Ghana consisted of three primary interview tools: one questionnaire for health facility managers, one for health care providers, and a third for patients. All components of the questionnaires were reviewed by clinical experts, in partnership with the GHS, to best reflect and assess the primary health care system in the country. The data collection was led by a partnership between two entities: Sanigest International and University of Ghana’s ISSER. Survey experts from University of Ghana also contributed to adapting the survey tool and methodology to the country context. Further details on the components measured under each domain and sub-domain of the SDI analytical framework (as shown previously in figure 3) can be found in Annex B. 2.2. Sample Design To be eligible for the SDI survey, a facility must have been providing PHC services, have at least one eligible PHC provider present and be able to provide health care on day of the survey, and be operating from a permanent structure (i.e., not a mobile CHPS) at the time of the survey. The sample frame of relevant primary health care facilities was obtained from GHS and included Level A facilities (CHPS and maternity homes), Level B facilities (health centers, polyclinics and clinics) and Level C facilities (district and other hospitals), as well as 26 health facilities that were earmarked for NoP model health centers (for monitoring and evaluating the NoP model) in the two regions of Bono and Volta at the time of the survey. Facilities were sampled as shown in table 1, with facilities from each level selected with equal probability, with the exception of the 26 health facilities earmarked for NoP model health centers, which were selected with 100 percent probability. The sample size for each level was calculated such that the results are nationally representative and representative of the different facility tiers in the country. Out of 9,324 health facilities, a sample of 500 facilities was selected from all 16 regions of the country. Table 1. Number of health facilities in sampling frame Total Sample Tier/ Level of PHC (percentage) (percentage) 6844 160 Level A - Community (CHPS/Maternity homes) (73.4) (32.0) 1889 178 Level B - Sub-District (Health centers/Polyclinics/Clinics) (20.3) (35.6) 565 136 Level C - District (District hospitals/ other hospitals) (6.1) (27.2) 32 Total Sample Tier/ Level of PHC (percentage) (percentage) 26 26 Earmarked for NoP intervention in Bono or Volta (0.3) (5.2) 9324 500 Total (100.0) (100.0) Note: Values in brackets are the percentages For the provider survey, health care workers who were deemed “eligible” (i.e., the ones who provide outpatient primary care) were randomly chosen to participate in the survey in each selected health facility. The different health care positions were pooled into four cadres for sampling purposes: doctors, physician assistants, nurses and midwives. Different cadres of health workers were proportionately sampled based on the sizes of the cadres of staff in the selected health facilities. The provider survey results are nationally representative and representative of the three facility tiers and four cadres. Table 73 in Annex C provides more details on provider selection across different facility strata. Table 2 below outlines the provider sampling frame based on the facilities included in the facility survey. While the four strata (three facility tiers and earmarked facilities) were used for sampling and weight creation, for analysis and presentation purposes, the 26 earmarked facilities were reassigned to existing tiers – one to the community tier and 25 to the sub- district tier. All subsequent tables and graphs will therefore present data using the three facility tiers: community, sub-district, and district, with earmarked facilities included within them. Table 2. Number of health care providers in sampling frame Number of Number of Physician Number of Number of Tier Doctors Assistants Nurses Midwives Community1 0 2 369 88 Sub-District2 25 177 1,039 732 District 415 269 1,531 1,213 Total 440 448 2,939 2,033 1 This includes 1 earmarked NoPs model health center; 2 This includes 25 earmarked NoPs model health centers. Patients were randomly selected upon arrival at the facility and were interviewed after receiving care. Eligibility for participation in the survey was limited to patients aged 18 years or older, or adult support person accompanying children under 18 years who were seeking screening, preventive, diagnostic, or therapeutic services, and who had consulted with a physician (i.e., general practitioner, family doctor, or pediatrician). Further details on sample design and the survey weights developed to account for the Ghana SDI survey sample design are available in Annex C. 33 2.3. Data Collection and Analysis Table 3 shows the timeline for training, testing of the survey instruments and protocols, data collection, and data quality assurance back-checks. A pre-test of the facility, patient and provider questionnaires was conducted in four facilities in February 2024. This was followed by training the team leads and enumerators in February - March 2024. A pilot was conducted by 48 of these trained enumerators in March 2024 at seven facilities, followed by an additional debriefing and training for further clarifications prior to fieldwork and to provide further training on questionnaires that were revised following the pilot. The main data collection took place over a 5-month period from March 25 - August 25 2024. Back- checks were conducted in person and via telephone interviews from May - September 2024 to check the quality of the data. Table 3. Timeline of fieldwork activities Activity Round 1 Instrument and protocol testing Pilot in 4 facilities: February 12 to February 16, 2024 Fieldwork staff training February 22 to March 1, 2024 Pilot Pilot in 7 facilities: March 5 to March 7, 2024 Main data collection March 25 to August 25, 2024 Back-checks 10 May to 27 September, 2024 Table 4 presents details on the number of health facilities surveyed in Ghana, along with the effective completion rate, calculated as the proportion of facilities successfully interviewed out of those selected. Overall, 92.6 percent of facilities approached agreed to and completed the facility survey. Completion rates were highest in the sub-district and district tiers, while the community tier showed relatively lower rates. This was largely due to 19 CHPS facilities in the community tier being deemed ineligible during data collection, as they were mobile units without a fixed location. These facilities were subsequently replaced. However, due to a coding error, four community-tier facilities were incorrectly replaced by four sub-district-tier facilities. As a result, the final sample included a slightly higher number of sub-district facilities and a lower number of community-tier facilities than targeted. By the end of fieldwork, interviews had been successfully completed at 500 facilities in Ghana as targeted. 34 Table 4. Number of health facilities surveyed in facility survey Number of Number of Number of Completion Tier facilities facilities facilities sur- Remarks rate targeted selected veyed Community¹ 161 185 157 84.9 % 19 facilities were found to (32.2) (34.3) (31.4) be ineligible during data collection, 9 could not be interviewed for safety rea- sons (active conflict or road conditions), 24 of these were replaced successfully*. Sub-District² 203 212 207 97.6 % 2 facilities were found to be (40.6) (39.3) (41.4) ineligible and 3 could not be interviewed for safety rea- sons. These were replaced by 9 facilities*. District 136 143 136 95.1 % 1 facility was found to be (27.2) (26.5) (27.2) ineligible during data collec- tion, 2 could not be inter- viewed for safety reasons, 4 refused. All 7 were success- fully replaced. 500 540 500 Total 92.6 % (100.0) (100.0) (100.0) Note: Values in brackets are the percentages *4 facilities in community tier were incorrectly replaced by 4 facilities in sub-district tier due to a coding error. 1 This includes 1 earmarked NoP model health center; 2 This includes 25 earmarked NoP model health centers. Table 5 provides details on the number of primary health care providers surveyed in Ghana. Overall, the response rate was highest among midwives (95.9 percent) and nurses (96.4 percent), and lowest among doctors (63.4 percent), with some variation across facility tiers. A total of 1,227 health care providers were surveyed during the first visit. Most respondents were nurses (36.8 percent), followed by midwives (30.2 percent), physician assistants (18.2 percent), and doctors (14.8 percent). Table 5. Number of health care providers surveyed during first visit in provider survey Commu- Sub-Dis- Provider Type District Total nity trict Eligible doctors 0 24 391 415 Doctors selected 0 19 268 287 Doctors interviewed 0 13 169 182 Doctor response rate NA 68.4 % 63.1 % 63.4 % Eligible physician assistants 3 175 262 440 Physician assistants selected 2 148 113 263 Physician assistants interviewed 0 127 96 223 35 Commu- Sub-Dis- Provider Type District Total nity trict Physician assistant response rate 0.0 % 85.8 % 85.0 % 84.8 % Eligible nurses 344 875 1458 2677 Nurses selected 150 194 132 469 Nurses interviewed 150 176 126 452 Nurse response rate 100.0 % 90.7 % 95.5 % 96.4 % Eligible midwives 88 730 1215 2033 Midwives selected 61 194 131 386 Midwives interviewed 54 193 123 370 Midwife response rate 88.5 % 99.5 % 93.9 % 95.9 % Table 6 provides details on the number of primary health care providers surveyed for absence in Ghana. A total of 2,409 providers were assessed for absence from the facility in the second visit. Of these, 39.5 percent of those assessed were nurses, 34.7 percent were midwives, 13.2 percent were doctors, and 12.7 percent were physician assistants. Table 6. Number of providers surveyed for absence Physician As- Tier Doctor Nurse Midwife Total sistant Community NA NA 221 66 287 (23.2%) (7.9%) (11.9%) Sub-District 18 150 333 347 848 (5.7%) (49.2%) (35.0%) (41.5%) (35.2%) District 299 155 397 423 1274 (94.3%) (50.8%) (41.7%) (50.6%) (52.9%) 317 305 951 836 2409 Total (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) Note: Values in brackets are the percentages; NA indicates that the provider cadre is not available at that facility tier. Table 7 provides details on the number of patients surveyed in Ghana. Patient interview sampling was based on facility-reported outpatient volumes from the three days prior to the survey. As a result, the actual number of interviews conducted could vary slightly depending on the outpatient volume observed on the day of the survey. Overall, 2758 patients were interviewed with a response rate of 81.5 percent. 36 Table 7. Number of patients surveyed in patient exit survey Number of Number of Number of eli- Number of Patient re- Tier patients se- patients inter- gible patients refusals sponse rate lected viewed Community 1,395 718 483 235 67.3 % Sub-District 4,731 1,429 1,201 228 84.0 % District 6,946 1,235 1,074 161 87.0 % Total 13,072 3,382 2,758 624 81.5 % All results presented in the following chapters were obtained using cleaned data sets, applying the relevant survey weights. Survey weights are applied to ensure the representativeness of measurements. This ensures that indicators accurately reflect PHC facilities in Ghana, providers offering primary health care, and patients seeking such care in the country. Further details on survey weights, sample size determination, and potential sources of bias are available in Annex C. Data were cleaned using Stata 16 software and analyzed using R software in RStudio.54 A summary of the domains and corresponding indicator definitions is included in Annex B and D. The results for categorical variables are presented using proportions with accompanying confidence intervals when relevant. Continuous variables underwent a normality test (Shapiro-Wilk test), with summaries of normally-distributed data presented as means (and applicable confidence intervals), and non-normally distributed data presented using the median and interquartile range.55 It is important to note that tests of statistical significance were not conducted, unless explicitly stated. This applies only to select indicators related to provider vignettes where selected tests of statistical significance were conducted. In these selected cases, two-sample Z-tests for proportions, accounting for the survey design, were implemented for two-way comparisons of group proportions. The alpha value of 0.05 was used for all tests of significance. Therefore, caution should be exercised when interpreting differences between group means or proportions in cases where significance is not reported. As a general approximation, non-overlapping confidence intervals between two statistics suggest a statistically significant difference. However, overlapping confidence intervals do not necessarily indicate the absence of a significant difference. 54   Hadley Wickham et al., “Ggplot2: Elegant Graphics for Data Analysis,” ggplot2, 2016, https://ggplot2.tidyverse.org/.   S.S. Shapiro and M.B. Wilk, “An Analysis of Variance Test for Normality (Complete Samples),” Biometrika 52, no. 3–4 (De- 55 cember 1965): 591–611, https://doi.org/10.1093/biomet/52.3-4.591. 37 Chapter 3. Foundations This chapter presents findings that assess the foundational strength of high-quality primary health care. Most data have been sourced from interviews with facility managers, although some have been analyzed using data collected from patients and health care providers. As defined earlier, foundations of high-quality primary health care include four key sub- domains: systems, care organization, workforce, and tools. Through these sub-domains, the strength of key pillars for high-quality primary care in Ghana are explored, ranging from inter- facility and facility-patient connectivity to provision of required and specialized care, human resources for health, adherence to clinical guidelines, and facility physical infrastructure. Box 1 highlights some of the key findings related to foundations of PHC in Ghana. Definitions of sub-domains and in-depth analysis of their associated indicators are presented in due order within this chapter. Box 1. Key observations on primary health care foundations in Ghana Care Organization • Emergency transport capacity was available in 30.1 percent (95% CI: 22.9 - 38.5) of district facilities,10.4 percent (95% CI: 5.4 - 19.1) at the sub-district tier and 1.9 percent (95% CI: 0.6 - 5.9) of community tier facilities. • Between October – December 2023, the median number of daily outpatient visits across Ghanaian PHC facilities was seven. Disaggregated by facility tier, community facilities had a median of six visits/day, sub-district facilities had 12 visits/day, and district facilities reported 48 visits/day. • While many facilities offered at least some of the services required at their tier, few were able to deliver the full set mandated as per the guidelines – particularly in areas such as adolescent health, family planning, and NCDs. In terms of laboratory capacity, fewer than 10 percent of facilities could provide the required tests for communicable and non-communicable diseases, and only 3.1 percent (95% CI: 1.9 - 5.2) met the full laboratory service package expected at their level. • Opening hours were generally consistent on weekdays across all facility tiers, with nearly all district facilities and most sub-district and community facilities reporting being open. Weekend availability was lower, however; district and sub-district facilities were more likely to remain open on weekends compared to community facilities. • Most health facilities were physically accessible, with 93.0 percent (95% CI: 89.2 - 95.6) connected to a motorable road and almost two-thirds (64.6 percent; 38 95% CI: 58.6 - 70.3) located within a 10-minute walk of a public transport stop. Accessibility was slightly lower at the community tier, particularly for public transport stop, where only 60.0 percent (95% CI: 52.0 - 67.5) of facilities reported proximity to a stop. Systems • In 2023, 77.7 percent (95% CI: 72.1 - 82.4) of health facilities reported receiving revenue, primarily from drug sales, general consultations, and NHIA reimbursements. Facilities at the district level generated significantly higher revenue, particularly from laboratories and diagnostics. In-kind revenue were reported by 12.0 percent (95% CI: 8.5 -16.6), mainly in equipment and furniture. 83.5 percent (95% CI: 78.6 - 87.5) of facilities reported revenue from patient fees between January and December 2023. • Approximately half of facility managers (50.6 percent; 95% CI: 44.6 - 56.6) reported having a management degree. Performance reviews were regularly conducted in most facilities, with 78.4 percent (95% CI: 72.7 - 83.1) holding reviews for health care providers and 68.3 percent (95% CI: 60.0 - 75.5) for support staff. Supervisor assessments were the most frequently used evaluation method, applied in 72.4 percent (95% CI: 66.4 - 77.7) of facilities. • Selection of staff for in-service training predominantly considered provider specialty (45.2 percent; 95% CI: 39.1 - 51.4) and availability (36.9 percent; 95% CI: 31.1 - 43.1), though 18.2 percent (95% CI: 13.7 - 23.8) of facilities reported no formal selection process. • Overall, 85.5 percent (95% CI: 81.0 - 89.0) of health care providers reported satisfaction with the support received from supervisors. • Accessibility features in health facilities were limited. Among facilities with steps or inclines, 35.6 percent (95% CI: 30.1 - 41.4) had ramps to assist persons with disabilities. Fewer facilities had tactile flooring (30.9 percent; 95% CI: 25.7 - 36.6), accessible toilets (14.1 percent; 95% CI: 10.7 - 18.3), lifts (7.6 percent; 95% CI: 4.9 - 11.7), or assistive technology for people with visual impairment (3.6 percent; 95% CI: 2.1 - 6.3). At least one consultation room providing both auditory and visual privacy were present in 65.8 percent (95% CI: 59.8 - 71.2) of facilities. • A functioning electricity source was available in 73.4 percent (95% CI: 67.6 - 78.6) of health facilities, though only 16.4 percent (95% CI: 11.9 - 22.2) also reported uninterrupted power supply between October - December 2023. Half of facilities (50.2 percent; 95% CI: 44.3 - 56.1) had vaccine refrigerators operating at appropriate temperatures, while 56.6 percent (95% CI: 48.1 - 64.8) of district- level facilities maintained functional blood refrigerators at the appropriate level. 39 • Access to water, sanitation, and hygiene (WaSH) infrastructure was uneven. While 79.0 percent (95% CI: 73.4 - 83.7) of facilities had a functioning improved water source, only 34.6 percent (95% CI: 29.3 - 40.4) also had uninterrupted and on-premises water supply. The majority (75.5 percent; 95% CI: 65.8 - 85.1) reported no water supply interruptions during the reference period. Improved toilets with menstrual hygiene facilities were present in 19.1 percent (95% CI: 15.2 - 23.7) of facilities, and 47.7 percent (95% CI: 41.9 - 53.5) had functional hand hygiene facilities at points of care. • Key IPC infrastructure was limited, with only 2.8 percent (95% CI: 1.0 - 3.1) of facilities having all essential components in place. The most commonly available elements were functional hand hygiene facilities (47.7 percent; 95% CI: 41.9 - 53.5) and infectious waste disposal systems (43.9 percent; 95% CI: 38.2 - 49.8). Physical barriers at patient contact points (15.9 percent; 95% CI: 12.7 - 19.6), designated isolation areas (10.5 percent; 95% CI: 7.7 - 13.2), and separate waiting areas (9.1 percent; 95% CI: 6.6 - 12.5) were less common. • While 75.1 percent (95% CI: 69.3 - 80.1) of facilities reported some form of ventilation, only 8.4 percent (95% CI: 5.8 - 12.0) had conducted ventilation performance assessments within two years prior to the survey. Fire safety infrastructure was limited, with 13.5 percent (95% CI: 10.7 - 16.9) having fire alarms and 23.0 percent (95% CI: 19.3 - 27.2) having fire extinguishers. • Regarding communication technology, 61.9 percent (95% CI: 55.9 - 67.6) of facilities had a functional telephone on the day of the survey, while fewer had functioning computers (45.5 percent; 95% CI: 40.0 - 51.1) or printers (23.0 percent; 95% CI: 19.5 - 27.0). Internet connectivity was limited, with only 25.2 percent (95% CI: 20.8 - 30.3) of facilities reporting access and 10.6 percent (95% CI: 7.6 - 14.5) maintaining uninterrupted service between October - December 2023. Functionality of ICT infrastructure was lowest at the community tier and highest at the district level. Tools • Across Ghana, a median of 64.4 percent of the assessed essential medical equipment and supplies were available and functional in health facilities, with variation by facility tier. District facilities had the highest availability across equipment and supply categories, including a median of 94.9 percent of general/acute care equipment, 90.2 percent of reproductive and child health equipment, and 85.7 percent of laboratory equipment. • For medicines and vaccines, a typical facility had 50.3 percent of all assessed medicines available and unexpired at the national level, with availability 40 increasing by facility tier. Vaccines were consistently available at a median of 80 percent across tiers. • From the patient perspective, 98.0 percent (95% CI: 96.8 - 98.8) of patients received all provider-recommended tests on the survey day. Among those prescribed medicines, 77.1 percent (95% CI: 73.5 - 80.4) reported receiving medicines during their visit. Workforce • On average, there were a median of 1.4 health care providers and 1.6 total staff available per 1,000 individuals in the catchment population. • Overall, 25.8 percent (95% CI: 18.7 - 34.4) midwives, 15.1 percent (95% CI: 9.6 - 23.0) nurses, 13.7 percent (95% CI: 8.4 - 21.3) physician assistants, and 18.1 percent (95% CI: 12.6 - 25.3) doctors were not present at the health facility on the day of the survey. The most common reasons for absence were annual leave for doctors, physician assistants and midwives and study leave for nurses. Absence due to unauthorized reasons was very low, at 0.9 percent (95% CI: 0.2 - 1.6) overall. • Self-reported median weekly working hours were 40 nationally, with doctors working a median of 48 hours and physician assistants working a median of 42 hours. Median outpatient contacts per day ranged from 8 for midwives to 27 for physician assistants. • The median tenure in clinical service among health care providers was three years for doctors, five years for physician assistants, seven years for midwives, and four years for nurses. • The proportion of facilities that both could provide a given service in the three months before the survey and had at least one provider who had received in-service training on that service in the past two years varied widely across service areas. Providers were most likely to have received recent in-service training on services related to maternal and newborn care. In contrast, services like HPV immunization (29.1 percent; 95% CI: 14.3 - 50.3), condom distribution (32.4 percent; 95% CI: 26.1 - 39.4), and child protection (38.2 percent; 95% CI: 23.1 - 56.0) had much lower coverage. • At least 95 percent of providers reported being satisfied with the meaningfulness of their work, relationships with co-workers, clarity in work responsibilities and work likeability. The lowest satisfaction was reported with regard to benefits (22.5 percent; 95% CI: 17.4 - 28.6) and pay (20.4 percent; 95% CI: 15.7 - 26.1). Additionally, 21.7 percent (95% CI: 17.0 - 27.3) of providers were dissatisfied with the balance between clinical and administrative work. 41 • Providers reported spending the largest share of their time on patient care (72.0 percent) in the most recent work week, followed by administrative work (15.0 percent), management activities (five percent), and educational activities (four percent). Time spent on home visits, outreach, or commuting was minimal across cadres and tiers. Doctors allocated 78.0 percent of their time to patient care, while nurses and midwives spent 71.0 percent and 72.0 percent of their time on patient care, respectively. Community-level providers spent a smaller share of time on patient care (57.0 percent) and higher share on outreach (11.0 percent), home visits (13.0 percent), and administrative work (11.0 percent). 3.1 Care organization This sub-domain provides an overview of facility connective network strength (emergency transport capacity, lab service availability, and pharmacy availability), service and case mix (outpatient volume by service type and provision of required and specialized services), and service delivery organization (facility connectivity to patients, facility operating hours, and catchment population). 3.1.1 Facility connective networks In many cases, service delivery can be strengthened by connective networks between health facilities that allow for interfacility communication and enable patient linkages for continued care across facilities. This includes links between facilities and pharmacy and laboratory services. In some cases, health facilities may be part of formal, designated networks that share staff and infrastructure or part of formal referral systems. Health facilities may also be connected, in that they have systems for communicating with one another during emergencies or have an ambulance or other form of transportation on-site that can link patients to other facilities. This is in cases where required services are not available at the patient’s initial point of care. These connections often include links between facilities and key services such as on-site laboratory and pharmacy services, as well as emergency transport capacity. Connectivity with laboratory and pharmacy services Connectivity between clinical services such as laboratory and pharmacy services can promote patient-centered care by promoting information exchange and creating a “one-stop shop” for receiving care. Across Ghana, 74.6 percent (95% CI: 68.6 - 80.6) of the facilities were able to provide at least one laboratory test. The depth and breadth of available laboratory and pharmacy capacity are explored in more detail in the next subdomain, service and case mix. 42 Emergency transport capacity Emergency transport capacity refers to facility ownership of at least one ambulance or other four-wheeled motor vehicle that is functional, has fuel, and has authorized staff available to drive it at the time of the survey. As shown in figure 4, 5.6 percent (95% CI: 3.7 - 8.3) of health facilities nationwide reported having emergency transport capacity. The national estimate is primarily driven by the proportion observed among community tier facilities, where 1.9 percent (95% CI: 0.6 - 5.9) of facilities reported having emergency transport available. The proportion increases to 10.4 percent (95% CI: 5.4 - 19.1) at the sub-district tier and 30.1 percent (95% CI: 22.9 - 8.5) at the district tier. However, this reflects that Ghana has exceeded the expectations set by its own regulations. Under the ‘One Constituency, One Ambulance’ initiative56, each of the 275 constituencies is to be equipped with a dedicated ambulance to strengthen emergency response systems - thereby reducing the need for individual health facilities to permanently station ambulances. Further analysis indicates that 14.7 percent (95% CI: 8.7 - 22.4) of sub-district facilities had an ambulance on-site, regardless of the state of functionality. The gap between this value and the emergency transport capacity indicator may be explained by the presence of non- functioning vehicles among on-site ambulances; however, the associated estimate (11.6 percent; 95% CI: 4.2 - 28.2) is imprecise and should be interpreted with caution. At the district tier, 41.2 percent of facilities (95% CI: 33.1 - 49.7) reported ambulance availability, regardless of state of functionality. The presence of non-functioning vehicles in district tier facilities is higher (23.2 percent; 95% CI: 13.7 - 36.4). At the community tier, when ambulances were available, they were also functional, fueled, and staffed by authorized personnel. Figure 4. Proportion of facilities with emergency transport capacity, by tier (%) (N = 500)   Zakariah, A. N., Boateng, E., Achena, C., Ansong-Bridjan, F., & Mock, C. (2024). The National Ambulance Service of Ghana: 56 Changes in capacity and utilization over 20 years. African journal of emergency medicine : Revue africaine de la medecine d’urgence, 14(3), 172–178. https://doi.org/10.1016/j.afjem.2024.06.008 43 3.1.2 Service and case mix This section captures the number and types of primary care services that were available at the facility, including availability of required laboratory services. Key indicators in this subdomain include outpatient volume overall and by service type, availability of required and specialized services, and availability of specific laboratory services. Outpatient volume Figure 5 illustrates the median number of outpatient visits per day that the facility was open over a three-month period from October - December 2023, by facility tier. The primary purpose for presenting this information is to understand the relative health care utilization patterns across different facility tiers. Overall, the median daily outpatient visits per facility over the three-month reference period was seven outpatient visits. The median daily visits varied across facility tiers, with community facilities observing a median of six outpatient visits, sub-district facilities observing 12 outpatient visits, and district facilities observing 48 outpatient visits. Figure 5. Median number of outpatient visits per day over a 3-month period (October - December 2023), by tier (N = 497) Figure 6 provides insights into the outpatient volume per facility for a few selected service types over the three-month period from October - December 2023. Outpatient volume here represents median aggregate outpatient visits over the three months from October -December 2023 at facilities and is not representative of service-specific outpatient volume for each health care worker. While only a few selected high-priority service types are presented, figure 6 indicates varying levels of demand and utilization of health care services 44 across facility tiers. Overall, high median volumes were observed for child growth monitoring (median of 215 visits), malaria visits (median of 106 visits) and antenatal care (ANC) visits (median of 58 visits) over the three-month period. Meanwhile, mental health (median of zero visits), dental services (median of zero visits) and adult Tuberculosis (TB) (median of zero visits) had low volumes per facility over this period. There was wide variation in outpatient visits by facility tier. Community tier facilities had the highest median outpatient visits for child growth monitoring (206 visits), followed by malaria (81 visits). Sub-district facilities recorded a median of 296 visits for child growth monitoring, 217 visits for malaria, and 122 visits for ANC. In addition, they had a median of 20 visits for adult hypertension. District facilities reported the highest median visits for malaria (423 visits), child growth monitoring (419 visits), ANC (388 visits), and adult hypertension (146 visits). Table 66 in Annex A presents more details. Figure 6. Median number of outpatient visits over a three-month period (October - December 2023), by service type and facility tier (N = 500) Primary care service provision: Availability of required services Table 8 shows the proportion of required primary health care services offered across facility tiers during October - December 2023, as reported by facility managers. The analysis for each facility tier includes only those services that are mandated by national regulations for that specific tier. At the national level, coverage varied widely by service category. For child health and nutrition, community facilities had a high availability of routine immunization (93.6 percent; 95% CI: 88.4 - 96.5) and growth monitoring (94.2 percent; 95% CI: 89.2 - 97.0). Services such as the management of acute malnutrition or care for children with disabilities which were only required at district tier, were available in 56.3 percent (95% CI: 47.7 - 64.5) and 19.3 percent (95% CI: 13.4 - 26.9) of district facilities, respectively. The availability of all 45 assessed child health and nutrition services was highest at sub-district (39.1 percent; 95% CI: 30.0 - 49.0) and community tier (36.5 percent; 95% CI: 29.3 - 44.5) but dropped at the district tier (6.6 percent; 95% CI: 3.5 - 12.3). In the maternal and newborn health category, 91.9 percent (95% CI: 85.9 - 95.5) of district facilities offered antenatal care and 91.2 percent (95% CI: 85.0 - 95.0) offered normal delivery services. In contrast, 36.5 percent (95% CI: 29.3 - 44.5) of community facilities offered normal delivery services. Critical emergency obstetric services were offered at district facilities only, and availability ranged from 80.0 percent (95% CI: 72.3 - 86.0) for caesarean section and 80.7 percent (95% CI: 73.1 - 86.6) for blood transfusion. Neonatal resuscitation and essential newborn care were widely available at the district tier (87.5 percent; 95% CI: 80.7 - 92.1), but less so in community facilities (21.8 percent; 95% CI: 16.0 - 29.1). Prenatal care services offered prior to pregnancy, required only at district facilities, were available at 82.2 percent (95% CI: 74.7 - 87.9) of district facilities. Availability of all risk factor assessment and management services, including services for NCDs and mental health, was highest at district tier (33.1 percent; 95% CI: 25.6 - 41.5) and lowest at community tier (2.6 percent; 95% CI: 1.0 - 6.7). Diabetes diagnosis was available in 89.0 percent (95% CI: 82.4 - 93.3) and hypertension diagnosis in 92.6 percent (95% CI: 86.8 - 96.0) of district facilities. Mental health services, such as psychotherapy were only available in 37.5 percent (95% CI: 29.7 - 46.0) of district facilities. Table 8. Proportion of health facilities able to provide the required PHC services, by service category (N = 500) Category Service Community Sub-District District Ghana Adolescent friendly health 60.9 54.7 47.1 58.7 services [53.0 - 68.3] [44.1 - 64.9] [38.7 - 55.6] [52.5 - 64.5] 2.6 9.4 19.9 5.2 HPV Immunization [1.0 - 6.7] [5.0 - 16.9] [13.9 - 27.5] [3.3 - 7.9] 23.7 44.5 63.2 30.9 Adoles- Screening for breast cancer [17.6 - 31.1] [34.7 - 54.7] [54.7 - 71.0] [25.9 - 36.4] cent Health Services And 1.9 8.8 34.6 5.4 Cervical cancer screening Interventions [0.6 - 5.9] [4.6 - 16.4] [27.0 - 43.0] [3.7 - 7.9] 0.6 7.8 50.7 5.2 Screening for pelvic tumors [0.1 - 4.5] [3.7 - 15.5] [42.3 - 59.1] [3.8 - 7.2] All above Adolescent 0.0 0.3 9.6 0.6 Health Services and Inter- [0.0 - 0.0] [0.0 - 2.3] [5.6 - 15.9] [0.4 - 1.1] ventions Routine childhood immuni- 93.6 71.4 66.9 86.8 zation services [88.4 - 96.5] [59.2 - 81.1] [58.5 - 74.4] [82.3 - 90.4] Child Health Child growth monitoring and 94.2 71.7 69.1 87.5 And Nutrition promotion [89.2 - 97.0] [59.5 - 81.4] [60.8 - 76.4] [83.0 - 90.9] Services Diagnosis of maternal and NA NA 63.0 63.0 newborn health (MAM) [54.4 - 70.8] [54.4 - 70.8] 46 Category Service Community Sub-District District Ghana NA NA 56.3 56.3 Management of MAM [47.7 - 64.5] [47.7 - 64.5] NA NA 57.8 57.8 IMNCI [49.2 - 65.9] [49.2 - 65.9] Management of neuro-de- NA NA 23.0 23.0 velopmental conditions in [16.6 - 30.9] [16.6 - 30.9] children Child Health Support and Care for the NA NA 19.3 19.3 And Nutrition child with disability [13.4 - 26.9] [13.4 - 26.9] Services Micronutrient supplementa- 39.1 43.3 52.2 40.9 tion [31.7 - 47.1] [33.7 - 53.4] [43.7 - 60.6] [35.1 - 46.9] Identification of suspected NA NA 37.8 37.8 childhood/adolescent cancer [29.9 - 46.3] [29.9 - 46.3] Services related to child NA NA 25.9 25.9 protection [19.2 - 34.1] [19.2 - 34.1] All above Child Health and 36.5 39.1 6.6 35.4 Nutrition services [29.3 - 44.5] [30.0 - 49.0] [3.5 - 12.3] [29.8 - 41.4] 67.3 95.5 94.9 75.5 Malaria diagnosis [59.5 - 74.3] [86.1 - 98.6] [89.5 - 97.5] [69.7 - 80.5] 67.3 95.1 94.1 75.4 Malaria treatment [59.5 - 74.3] [86.1 - 98.4] [88.6 - 97.1] [69.6 - 80.4] NA NA 54.1 54.1 TB screening/ diagnosis [45.5 - 62.4] [45.5 - 62.4] TB treatment (prescription 11.5 25.9 47.8 17.0 and/or treatment follow-up) [7.4 - 17.6] [18.9 - 34.5] [39.4 - 56.3] [13.4 - 21.4] 59.0 86.5 89.0 67.2 HIV testing and counselling Communica- [51.0 - 66.5] [75.5 - 93.0] [82.4 - 93.3] [61.1 - 72.7] ble Diseases HIV/AIDS antiretroviral pre- NA NA 57.0 57.0 scription and/or treatment [48.5 - 65.2] [48.5 - 65.2] NA 62.0 79.4 65.5 Enteric fever diagnosis [51.5 - 71.5] [71.7 - 85.5] [56.9 - 73.2] NA 55.3 76.5 59.5 Enteric fever treatment [44.9 - 65.2] [68.5 - 82.9] [50.8 - 67.5] Measles diagnosis and man- NA 35.8 56.6 39.9 agement [27.1 - 45.6] [48.1 - 64.8] [32.4 - 47.9] All above communicable 0.0 0.0 0.0 0.0 diseases [0.0 - 0.0] [0.0 - 0.0] [0.0 - 0.0] [0.0 - 0.0] 92.9 87.1 83.1 91.0 Family planning counselling [87.6 - 96.1] [76.0 - 93.5] [75.7 - 88.6] [86.8 - 94.0] Family 70.5 66.2 50.7 68.4 Planning Distribution of condoms [62.8 - 77.2] [54.9 - 75.9] [42.3 - 59.1] [62.4 - 73.8] Services Provision of oral contracep- 83.3 74.9 72.1 80.7 tives [76.6 - 88.4] [63.5 - 83.7] [63.8 - 79.0] [75.4 - 85.1] 47 Category Service Community Sub-District District Ghana 71.2 76.2 71.3 72.4 Insertion of Implants [63.5 - 77.8] [64.7 - 84.9] [63.1 - 78.4] [66.4 - 77.6] Family 14.8 39.8 55.9 23.0 Planning Insertion of IUCD [10.0 - 21.3] [30.6 - 49.8] [47.3 - 64.1] [18.8 - 27.9] Services All above Family Planning 8.3 32.4 38.2 15.7 services [4.9 - 13.9] [24.1 - 41.9] [30.4 - 46.8] [12.4 - 19.8] 55.8 84.3 91.9 64.6 Antenatal care services [47.8 - 63.4] [72.3 - 91.6] [85.9 - 95.5] [58.4 - 70.3] PMTCT (Testing / and coun- NA 73.0 86.8 75.7 selling and ART) [61.2 - 82.3] [79.9 - 91.5] [66.0 - 83.4] Management of pregnancy NA 49.0 85.3 56.2 complications [38.9 - 59.2] [78.2 - 90.4] [47.5 - 64.4] 36.5 81.0 91.2 50.2 Services for normal delivery [29.3 - 44.5] [69.2 - 89.1] [85.0 - 95.0] [44.4 - 56.0] Management of labour com- NA 53.1 85.3 59.5 plications [42.7 - 63.2] [78.2 - 90.4] [50.6 - 67.7] Abortion care and post-abor- NA 41.9 68.4 47.2 tion care [32.4 - 52.0] [60.0 - 75.7] [39.0 - 55.4] NA 62.3 84.6 66.7 PPH management [51.2 - 72.2] [77.4 - 89.8] [57.4 - 74.9] NA 34.0 61.0 39.4 Assisted vaginal delivery [24.9 - 44.5] [52.5 - 68.9] [31.6 - 47.7] NA 23.5 77.9 34.3 Obstetric ultrasonography [16.1 - 32.9] [70.1 - 84.2] [27.6 - 41.7] Maternal NA 29.8 77.2 39.2 and Newborn Evacuation of the uterus [21.3 - 39.8] [69.3 - 83.6] [31.8 - 47.1] Health Services Management of breech NA NA 73.3 73.3 delivery [65.1 - 80.2] [65.1 - 80.2] Repair of 3rd degree perineal NA NA 76.3 76.3 tears [68.3 - 82.8] [68.3 - 82.8] NA NA 80.7 80.7 Blood transfusion [73.1 - 86.6] [73.1 - 86.6] NA NA 80.0 80.0 Caesarean section [72.3 - 86.0] [72.3 - 86.0] Neonatal resuscitation with 21.8 65.9 87.5 36.0 bag and mask [16.0 - 29.1] [54.6 - 75.6] [80.7 - 92.1] [31.0 - 41.3] 32.7 74.6 88.2 45.8 Essential newborn care [25.7 - 40.5] [62.9 - 83.6] [81.6 - 92.7] [40.1 - 51.5] Vitamin K injection for new- 30.1 74.0 89.7 43.9 born [23.4 - 37.9] [62.3 - 83.0] [83.3 - 93.8] [38.4 - 49.6] Kangaroo Mother Care 17.3 44.6 65.4 26.5 (KMC) [12.1 - 24.2] [34.9 - 54.7] [57.0 - 73.0] [22.0 - 31.6] Developmentally Supportive NA NA 41.5 41.5 Care (DSC) for LBW/preterm [33.4 - 50.1] [33.4 - 50.1] babies 48 Category Service Community Sub-District District Ghana Prevention/management of NA NA 77.0 77.0 birth asphyxia [69.1 - 83.4] [69.1 - 83.4] Maternal Prevention/management of NA NA 59.3 59.3 and Newborn neonatal seizures [50.7 - 67.3] [50.7 - 67.3] Health NA NA 82.2 82.2 Services Prenatal care services [74.7 - 87.9] [74.7 - 87.9] All above Maternal and 10.9 7.7 17.6 10.6 Newborn Health services [6.9 - 16.9] [3.3 - 17.1] [12.1 - 25.1] [7.3 - 15.0] Medical emergency and criti- NA NA 65.2 65.2 cal care services [56.7 - 72.8] [56.7 - 72.8] Rehabilitative and disability NA NA 10.4 10.4 care services [6.2 - 16.8] [6.2 - 16.8] Home visitation by nurses NA NA 54.8 54.8 and/or physicians to provide [46.3 - 63.1] [46.3 - 63.1] home-based services Other Screening for gender-based NA NA 20.7 20.7 Primary Care violence [14.7 - 28.5] [14.7 - 28.5] Services Services for gender-based NA NA 14.8 14.8 violence survivors [9.7 - 22.0] [9.7 - 22.0] Services for aged (e.g. mental NA NA 48.9 48.9 health, visual, hearing) [40.5 - 57.4] [40.5 - 57.4] NA NA 17.8 17.8 Palliative/terminal care [12.1 - 25.3] [12.1 - 25.3] All above Other primary NA NA 3.7 94.4 care services [1.5 - 8.6] [94.1 - 94.7] NA 62.5 89.0 67.8 Diabetes diagnosis [52.4 - 71.7] [82.4 - 93.3] [59.5 - 75.1] NA 78.1 92.6 81.0 Hypertension diagnosis [68.1 - 85.6] [86.8 - 96.0] [72.9 - 87.1] NA 58.9 89.7 65.0 Diabetes treatment [48.7 - 68.3] [83.3 - 93.8] [56.7 - 72.4] NA 72.5 91.2 76.2 Risk Factor Hypertension treatment [62.3 - 80.7] [85.0 - 95.0] [67.9 - 82.8] Assessment Services Diagnosis of mental health NA 32.9 50.7 36.4 conditions [25.0 - 41.9] [42.3 - 59.1] [29.5 - 43.9] Pharmacotherapy for mental NA 23.4 40.4 26.8 health conditions [17.0 - 31.3] [32.4 - 49.0] [21.1 - 33.3] Psychotherapy for mental 2.6 22.0 37.5 9.2 health conditions [1.0 - 6.7] [15.8 - 29.8] [29.7 - 46.0] [7.0 - 11.8] All above risk factor ser- 2.6 11.1 33.1 6.3 vices [1.0 - 6.7] [7.0 - 17.2] [25.6 - 41.5] [4.5 - 8.9] 0.0 0.0 0.0 0.0 All Services All above services [0.0 - 0.0] [0.0 - 0.0] [0.0 - 0.0] [0.0 - 0.0] Note: Values in brackets are the 95% confidence interval. Values are marked as NA when a service is not provided at a particular tier. In such cases, the calculation for ‘all services’ excludes that service for the respective tier. 49 Table 9 shows the proportion of health facilities that were equipped to offer required laboratory services over the three months (October - December 2023). At the national level, 3.1 percent (95% CI: 1.9 - 5.2) of facilities were able to provide all the assessed laboratory services that they were required to provide as per the regulations. This ranged from 21.3 percent (95% CI: 15.2 - 29.1) at the district tier to zero percent of the facilities at the community tier. For communicable disease laboratory services, the availability at national level varied across different tests. For instance, the blood film for malaria parasites was available at 53.8 percent (95% CI: 45.4 - 61.9) of all facilities, with 94.1 percent (95% CI: 88.6 - 97.1) of district facilities able to offer it compared to 43.8 percent (95% CI: 34.0 - 54.2) at the sub-district tier. Other tests, such as stool routine examinations and hepatitis BsAg, exhibited similarly high availability at the district tier but were less accessible at the sub-district tier. At the district tier, 29.4 percent (95% CI: 22.3 - 37.7) of facilities reported the availability of all communicable disease laboratory services, while at the sub-district tier, availability was 21.0 percent (95% CI: 13.6 - 31.0). These laboratory services were not required at the community tier at the time of the survey. Among non-communicable disease laboratory tests, fasting blood sugar testing was available at 80.2 percent (95% CI: 72.6 - 86.2) of all facilities, with 94.9 percent (95% CI: 89.5 - 97.5) of district facilities and 76.6 percent (95% CI: 67.2 - 84.0) of the sub-district facilities able to offer to it. Other tests, such as blood group and rhesus factor, were available at 52.8 percent (95% CI: 44.5 - 60.9) of all facilities, with 91.2 percent (95% CI: 85.0 - 95.0) of district facilities and 43.3 percent (95% CI: 33.3 - 53.8) of sub-district facilities equipped to offer it. At the district tier, 51.5 percent (95% CI: 43.0 - 59.9) of facilities reported the availability of all non- communicable disease laboratory services, while 27.3 percent (95% CI: 18.6 - 38.1) of sub- district facilities reported the same. The availability of routine outpatient department (OPD) laboratories at the national level also varied across different tests. For instance, urine pregnancy tests were available at 76.7 percent (95% CI: 71.0 - 81.6) of all facilities, with sub-district facilities at 98.1 percent (95% CI: 95.7 - 99.2), and community facilities at 68.0 percent (95% CI: 60.1 - 74.9). Other tests, such as malaria rapid diagnostic test were available at 77.8 percent (95% CI: 72.2 - 82.6) of all facilities, with sub-district facilities at 93.9 percent (95% CI: 85.6 - 97.5), district facilities at 86.0 percent (95% CI: 79.0 - 91.0) and community facilities at 71.8 percent (95% CI: 64.2 - 78.4). At the district tier, 75.7 percent (95% CI: 67.7 - 82.3) of facilities reported the availability of all routine OPD laboratory services, while community and sub-district facilities reported availability at 30.8 percent (95% CI: 24.0 - 38.5) and 25.4 percent (95% CI: 16.8 - 36.4), respectively. 50 Table 9. Proportion of health facilities able to provide the required laboratory services, by laboratory category (N = 500) Category Service Community Sub-District District Ghana NA 43.8 94.1 53.8 Blood film for malaria parasites [34.0 - 54.2] [88.6 - 97.1] [45.4 - 61.9] NA 84.8 95.6 87.0 HIV test [74.2 - 91.6] [90.4 - 98.0] [78.3 - 92.5] NA 58.2 93.4 65.2 Urine routine examination [47.9 - 67.8] [87.7 - 96.5] [56.8 - 72.7] Commu- NA 34.9 75.7 43.0 nicable Stool routine examination [25.4 - 45.7] [67.7 - 82.3] [35.0 - 51.3] disease laborato- NA 58.8 94.1 65.8 Hepatitis B sAg ries [48.6 - 68.4] [88.6 - 97.1] [57.4 - 73.3] NA 68.7 77.9 70.5 HIV/Syphilis combo test [57.9 - 77.8] [70.1 - 84.2] [61.7 - 78.1] NA NA 43.0 43.0 Blood & urine cultures [34.8 - 51.5] [34.8 - 51.5] All above communicable dis- NA 21.0 29.4 6.7 ease laboratories [13.6 - 31.0] [22.3 - 37.7] [4.8 - 9.2] Glucose 6 phosphate dehydro- NA 29.0 74.3 37.9 genase [20.2 - 39.7] [66.2 - 81.0] [30.4 - 46.1] NA 43.3 91.2 52.8 Blood group and rhesus factor [33.3 - 53.8] [85.0 - 95.0] [44.5 - 60.9] NA 76.6 94.9 80.2 Fasting blood sugar Non-com- [67.2 - 84.0] [89.5 - 97.5] [72.6 - 86.2] municable Blood urea, electrolytes & cre- NA NA 71.1 71.1 disease atinine [62.8 - 78.2] [62.8 - 78.2] laborato- ries NA NA 66.7 66.7 Liver function tests [58.2 - 74.2] [58.2 - 74.2] NA NA 69.6 69.6 Hemoglobin electrophoresis [61.3 - 76.9] [61.3 - 76.9] All above non-communicable NA 27.3 51.5 9.4 disease laboratories [18.6 - 38.1] [43.0 - 59.9] [7.2 - 12.3] 68.0 98.1 96.3 76.7 Urine pregnancy test [60.1 - 74.9] [95.7 - 99.2] [91.4 - 98.5] [71.0 - 81.6] 32.1 82.6 94.1 47.6 Urine dipstick for proteins [25.1 - 39.9] [72.3 - 89.7] [88.6 - 97.1] [41.9 - 53.2] 71.8 93.9 86.0 77.8 Routine Malaria rapid diagnostic test [64.2 - 78.4] [85.6 - 97.5] [79.0 - 91.0] [72.2 - 82.6] OPD labo- ratories NA 42.2 89.7 51.6 Sickling status test [32.4 - 52.8] [83.3 - 93.8] [43.4 - 59.8] NA 39.2 94.1 50.1 Full blood count [29.3 - 50.2] [88.6 - 97.1] [42.0 - 58.2] NA 69.2 94.9 74.3 Hemoglobin [59.2 - 77.7] [89.5 - 97.5] [66.1 - 81.1] 51 Category Service Community Sub-District District Ghana NA 79.9 94.9 82.9 Routine Random blood sugar [71.0 - 86.6] [89.5 - 97.5] [75.7 - 88.3] OPD labo- ratories All above routine OPD 30.8 25.4 75.7 32.1 laboratories [24.0 - 38.5] [16.8 - 36.4] [67.7 - 82.3] [26.8 - 38.0] All labora- 0.0 8.0 21.3 3.1 All above laboratories tories [0.0 - 0.0] [3.5 - 17.3] [15.2 - 29.1] [1.9 - 5.2] Note: Values in brackets are the 95% confidence interval. Values are marked as NA when a laboratory service is not provided at a particular tier. In such cases, the calculation for ‘all laboratory services’ excludes that service for the respective tier. 3.1.3 Service delivery organization This section aims to assess how PHC services are delivered and how health facilities are situated to serve their catchment populations. This section describes the types of health facilities that deliver primary health care; the size of the population they serve; their hour(s) of operation; their accessibility to this population - average time taken for catchment population to reach facility; their outreach practices; and their connectivity to the population through local public transportation and motorable roads. Table 10 shows the median catchment population, as reported by the health facility managers. The community tier reported a median of 2,712 individuals compared to 6,856 at the sub- district tier and 38,358 at the district tier. At the community tier, the upper quartile is nearly double the median, suggesting that while many facilities serve relatively small populations, over 25 percent were responsible for larger catchments. Similar patterns were observed at the sub-district and district tiers, indicating substantial variability in service volumes and catchment sizes across facilities. Although the majority of facilities had records of their catchment population or were able to provide estimates, data on catchment population were unavailable for 41 facilities (6 community tier facilities, 13 sub-district tier facilities, and 22 district tier facilities). Table 10. Facility catchment population distribution, by tier (N = 459) Lower Upper Tier Minimum Median Maximum Quartile Quartile Community 60 1,474 2,712 5,200 22,447 Sub-District 131 3,321 6,856 15,379 253,140 District 250 10,630 38,358 118,973 500,000 Ghana 60 1,690 3,407 7,034 500,000 Note: Catchment population data is not available for 41 facilities. 52 Health facility operating hours Table 11 shows the proportion of facilities in operation each day of the week, excluding standard holidays. Operational days were more consistent at the district tier, where almost all facilities were open throughout the week. Sub-district and community tiers also reported high weekday availability, though with slightly more variation. In contrast, service availability decreases over the weekend, particularly at the community tier, where less than half of facilities reported operating on Saturdays (48.1 percent; 95% CI: 40.3 - 56.0) and Sundays (39.8 percent; 95% CI: 32.3 - 47.7). A much larger share of sub-district and district tier facilities reported being operational over the weekend, with district-level facilities reporting the highest levels of weekend operation. Table 11. Proportion of facilities operating on each day of the week, by tier (N = 500) Wednes- Tier Monday Tuesday Thursday Friday Saturday Sunday day Commu- 94.9 94.9 95.5 94.9 96.2 48.1 39.8 nity [90.0 - 97.4] [90.0 - 97.4] [90.8 - 97.9] [90.0 - 97.4] [91.6 - 98.3] [40.3 - 56.0] [32.3 - 47.7] Sub-Dis- 98.1 95.8 99.7 98.1 98.1 90.6 83.4 trict [87.5 - 99.7] [86.0 - 98.8] [97.7 - 100.0] [87.5 - 99.7] [87.5 - 99.7] [80.4 - 95.7] [73.0 - 90.3] 100.0 100.0 99.3 100.0 100.0 99.3 96.3 District [100.0 - 100.0] [100.0 - 100.0] [94.8 - 99.9] [100.0 - 100.0] [100.0 - 100.0] [94.8 - 99.9] [91.4 - 98.5] 95.9 95.4 96.7 95.9 96.8 61.0 53.3 Ghana [92.3 - 97.9] [91.7 - 97.5] [93.4 - 98.4] [92.3 - 97.9] [93.5 - 98.5] [55.0 - 66.7] [47.4 - 59.1] Note: Values in brackets are the 95% confidence interval. Table 12 shows the median number of hours that facilities were operating on different days of the week, and for emergency care as well as non-emergency OPD care. During weekdays (Monday - Friday), district tier facilities reported the longest operating hours, with a median of 23.5 hours per day. District facilities were operational for a median of 23.5 hours each weekday for emergency care and a median of 17.1 hours for non-emergency OPD hours. Sub-district facilities operated for a median of 15.5 hours, while community facilities were operational for a median of 8.5 hours each weekday. The pattern displayed during the weekdays persisted during weekends. District facilities that were operational on Saturdays and Sundays reported operating a median of 23.5 hours each day. Sub-district facilities reported a median of 15.5 hours each day while community facilities reported a median of 10 hours on Saturdays and 11.5 hours on Sundays. Across all tiers, emergency services were generally available for longer hours than non-emergency outpatient care, especially during weekends. For instance, on Sunday, community facilities reported a median of 11.5 hours for emergency care, compared to nine hours for non-emergency outpatient services. This trend is consistent across sub-district and district tiers facilities. While weekend coverage was reported across all tiers, community-level facilities typically provided fewer hours and reported greater variability, as reflected in larger interquartile ranges. 53 Table 12. Median duration (hours) of operation of facilities per day, by tier (N = 500) Commu- Day Sub-District District Ghana nity 8.5 15.5 23.5 9.5 Median daily hours (Monday-Friday) (7.0 - 11.5) (11.6 - 23.5) (15.5 - 23.5) (7.5 - 15.5) Median daily non-emergency OPD hours 8.0 13.9 17.1 9.0 (Monday-Friday) (7.0 - 10.0) (11.1 - 23.2) (12.0 - 23.5) (7.0 - 15.5) Median daily emergency care hours 9.0 15.5 23.5 11.0 (Monday-Friday) (7.0 - 12.0) (12.0 - 23.5) (15.5 - 23.5) (8.0 - 16.0) 10.0 15.5 23.5 12.6 Median hours (Saturday) (7.1 - 16.0) (12.0 - 23.5) (15.5 - 23.5) (9.0 - 23.0) Median non-emergency OPD hours 9.0 15.5 17.0 12.0 (Saturday) (7.0 - 15.5) (11.5 - 23.5) (12.5 - 23.5) (8.0 - 23.0) 12.0 16.0 23.5 15.5 Median emergency care hours (Saturday) (8.0 - 23.0) (13.0 - 23.5) (15.5 - 23.5) (10.0 - 23.5) 11.5 15.5 23.5 15.5 Median hours (Sunday) (7.0 - 23.0) (12.5 - 23.5) (15.5 - 23.5) (9.2 - 23.5) 9.0 15.5 20.2 13.0 Median non-emergency OPD hours (Sunday) (7.0 - 16.0) (12.0 - 23.5) (14.6 - 23.5) (8.5 - 23.0) 11.5 16.0 23.5 15.5 Median emergency care hours (Sunday) (7.0 - 23.0) (12.5 - 23.5) (15.5 - 23.5) (9.5 - 23.5) Note 1: Values in parenthesis are the 25th and 75th percentile values. Note 2: OPD = Outpatient Department Access to facilities Another critical component of service delivery organization is the presence of physical infrastructure through which health facilities can be accessed by the population. Accordingly, to understand the state of facility access, the survey asked questions regarding connectivity and distance to health facilities in Ghana. Figure 7 highlights the proportion of facilities connected to a motorable road, with a breakdown by facility tier. Nearly all facilities in the country (93.0 percent; 95% CI: 89.2 - 95.6) were connected to a motorable road. The lowest proportion was found at community tier, with 92.3 percent (95% CI: 86.9 - 95.6) connected to a motorable road. In comparison, 96.3 percent (95% CI: 91.4 - 98.5) of district tier facilities were connected to a motorable road. 54 Figure 7. Proportion of facilities connected to a motorable road, by tier (%) (N = 500) While road availability is an important and basic measure of access, connectivity through public transport is also beneficial to improve equitable access for different socioeconomic groups. Figure 8 highlights the proportion of facilities within a 10-minute walk of a public transport stop by facility tier. At the national level, 64.6 percent (95% CI: 58.6 - 70.3) of health facilities were situated within a 10-minute walk of a public transport stop or station. This estimate of the national average was influenced by lower accessibility at the community tier, where 60.0 percent (95% CI: 52.0 - 67.5) of facilities were within a 10-minute walk of a public transport stop. In contrast, a higher proportion of facilities at the sub-district tier (73.6 percent; 95% CI: 63.8 - 81.5) and district tier (84.6 percent; 95% CI: 77.4 - 89.8) were located within a 10–minute walk of a public transport stop. 55 Figure 8. Proportion of facilities with public transport station/stop within a 10-minute walk, by tier (%) (N = 499) 3.2 Systems System performance was measured across several components, including facility financing, policies and protocols, institutions tasked with accountability for quality, management and supervision, financing, and physical infrastructure. Some examples of key data presented in this section include facility funding sources, presence of up-to-date clinical and operational guidelines, information on facility accountability mechanisms such as frequency and sources of feedback on facility performance, feedback dissemination frequency and audience; staff performance assessment; and the presence of key physical infrastructure (e.g., accessibility for individuals with disabilities, auditory and visual privacy, and Information and Communication Technology (ICT)). 3.2.1 Financing Financing systems in health facilities have implications for facility-level and provider-level incentives, efficiency, and accountability. Information on financing at the facility tier includes the sources and amount of revenue generated from the facility. Table 13 shows the proportion of facilities that reported receiving revenue from various sources between January - December 2023 by facility tier. At the national level, 77.7 percent (95% CI: 72.1 - 82.4) of health facilities reported receiving revenue from at least one source. Disaggregated by facility tier, 76.9 percent (95% CI: 69.6 - 82.9) of community tier facilities reported receiving revenue from at least one source during the reference period. This proportion increased to 81.5 percent (95% CI: 70.7 - 88.9) for sub-district tier and 71.1 percent 56 (95% CI: 62.8 - 78.2) for district tier. The most common source of revenue reported at the national level was from drug sales (50.5 percent; 95% CI: 44.5 - 56.5), general/non-specialist consultation revenue (38.9 percent; 95% CI: 33.2 - 44.9) and NHIA revenue (37.8 percent; 95% CI: 32.3 - 43.7). This trend was consistent across facility tiers. However, a much higher share of district tier facilities reported revenue from laboratory tests (57.0 percent; 95% CI: 48.5 - 65.2), diagnostic tests (35.6 percent; 95% CI: 27.9 - 44.1) and specialist consultants (28.1 percent; 95% CI: 21.1 - 36.4) compared to community and sub-district tiers. Table 13. Proportion of facilities receiving revenue from various sources during Janu- ary - December 2023(%), by tier (N = 500) Source Community Sub-District District Ghana Funds 23.1 11.2 8.9 19.5 Government of Ghana Funds [17.1 - 30.4] [6.5 - 18.6] [5.1 - 15.1] [15.0 - 24.9] 32.1 51.2 54.1 37.8 National Health Insurance Authority [25.1 - 39.9] [40.9 - 61.4] [45.5 - 62.4] [32.3 - 43.7] District funds (e.g. District Assembly common 12.8 4.8 2.2 10.3 fund) [8.4 - 19.1] [2.0 - 11.2] [0.7 - 6.8] [7.1 - 14.9] Private funding sources (e.g., direct donations 4.5 1.7 7.4 4.0 from private sector) [2.1 - 9.2] [0.7 - 3.9] [4.0 - 13.3] [2.2 - 7.1] 4.5 3.9 1.5 4.2 Donor pooled funds [2.1 - 9.2] [1.0 - 14.1] [0.4 - 5.8] [2.2 - 7.7] 6.4 2.7 6.7 5.6 Other Funds [3.5 - 11.6] [1.4 - 5.3] [3.5 - 12.4] [3.3 - 9.1] Services 34.6 50.9 42.2 38.9 General / non-specialist consultations [27.5 - 42.5] [40.7 - 61.1] [34.1 - 50.8] [33.2 - 44.9] 0.0 5.1 28.1 2.8 Specialist consultations [0.0 - 0.0] [1.8 - 14.0] [21.1 - 36.4] [1.8 - 4.5] 1.3 8.7 35.6 5.0 Diagnostic tests (e.g. X-rays) [0.3 - 5.1] [4.0 - 17.7] [27.9 - 44.1] [3.3 - 7.5] 1.3 35.6 57.0 12.6 Laboratory tests [0.3 - 5.1] [26.2 - 46.2] [48.5 - 65.2] [9.9 - 15.8] 43.6 68.5 61.5 50.5 Drugs [36.0 - 51.6] [57.7 - 77.6] [52.9 - 69.4] [44.5 - 56.5] 0.0 0.6 5.2 0.5 Intra-mural [0.0 - 0.0] [0.2 - 2.6] [2.5 - 10.6] [0.2 - 0.9] 16.0 21.7 31.1 18.2 Others (e.g. other services / tests) [11.0 - 22.7] [14.2 - 31.6] [23.8 - 39.5] [14.1 - 23.3] 76.9 81.5 71.1 77.7 Any Source [69.6 - 82.9] [70.7 - 88.9] [62.8 - 78.2] [72.1 - 82.4] Note: Values in brackets are the 95% confidence interval. 57 Among the facilities that reported receiving revenue in the 12 months between January 2023 - December 2023, table 14 shows the median revenue received by source and facility tier. There was substantial disparity in median revenue across facility tiers, with district- tier facilities reporting a total median revenue more than 20 times that of sub-district-tier facilities, and over 500 times that of community-tier facilities. The largest source of revenue reported at the community tier was from laboratory tests, with a median revenue of Ghanaian Cedi (GH¢) 78,100. In contrast, revenue from different funding sources were relatively low, ranging from a median of GH¢ 1,100 from “other funds” to GH¢ 13,700 from the NHIA. In comparison, at the sub-district tier, “other funds” represented the largest revenue source, with a median of GH¢ 3,768,900. For the district tier, the primary source of revenue was Government of Ghana funds, with a median of GH¢ 19,840,500. Table 14. Median revenue (’000 GH¢) received from various sources during January 2023 - December 2023 among facilities that received revenue (N = 399) Source Community Sub-District District Ghana Funds Government of Ghana 1.7 14.7 19,840.5 2.0 Funds (1.0 - 2.2) (3.6 - 2,156.0) (14,199.7 - 55,656.3) (1.1 - 2.9) National Health Insur- 13.7 135.8 1,533.0 38.2 ance Authority (4.3 - 38.2) (63.7 - 329.0) (561.8 - 2,939.0) (8.7 - 137.9) 1.6 1.5 85.0 1.5 District funds (1.2 - 4.4) (0.5 - 6.9) (85.0 - 85.0) (1.2 - 4.3) 4.9 12.1 251.0 4.9 Private funding sources (3.1 - 6.6) (11.1 - 13.2) (150.5 - 351.4) (3.5 - 11.3) 2.8 121.0 3,936.2 3.0 Donor pooled funds (2.2 - 3.6) (16.4 - 148.1) (3936.2 - 3936.2) (2.8 - 15.7) 1.1 3,768.9 713.1 1.6 Other Funds (0.5 - 2.9) (19.0 - 24012.6) (442.0 - 984.3) (0.6 - 4.3) Services General / non-specialist 2.1 24.6 306.6 4.1 consultations (0.9 - 4.3) (5.9 - 98.0) (115.3 - 990.5) (1.3 - 28.3) 55.4 121.7 78.5 Specialist consultations NA (30.3 - 78.5) (65.7 - 339.5) (30.3 - 132.5) Diagnostic tests (e.g. 6.5 146.3 65.6 56.4 X-rays) (2.3 - 7.8) (57.9 - 242.2) (30.0 - 241.4) (9.6 - 180.3) 78.1 45.4 304.0 77.0 Laboratory tests (2.2 - 101.3) (14.0 - 207.5) (89.6 - 726.6) (15.4 - 286.9) 2.2 36.8 687.6 4.9 Drugs (1.0 - 5.0) (11.6 - 144.8) (216.3 - 1662.3) (1.6 - 36.8) 5.4 1,096.1 208.7 Intra-mural NA (5.4 - 5.4) (695.5 - 1,496.7) (108.4 - 309.0) Others (e.g. other ser- 1.2 52.1 326.7 5.1 vices / tests) (0.3 - 5.1) (10.5 - 90.5) (169.4 - 765.7) (0.8 - 52.1) 58 Source Community Sub-District District Ghana 3.6 70.5 1,472.2 8.3 Total Paid Services (1.2 - 11.5) (16.8 - 342.7) (575.9 - 4,761.3) (2.1 - 74.2) 7.5 190.5 4115.7 19.2 Total (3.2 - 27.1) (72.5 - 1,012.4) (1,570.1 - 12,422.6) (4.9 - 108.2) Note: Values in parentheses are the 25th and 75th percentile values. Unlike the previous tables that presented monetary revenue, Table 15 presents the proportion of facilities that reported receiving in-kind revenue between January - December 2023 from various sources as well as the median revenue reported from each source, disaggregated by facility tier. At the national level, 12.0 percent (95% CI: 8.5 - 16.6) of facilities reported receiving in-kind revenue. These revenue were most frequently reported at the community tier, where 12.8 percent (95% CI: 8.4 - 19.1) of facilities reported receipt of in-kind revenue. At the district tier, 8.1 percent (95% CI: 4.5 - 14.2) of the facilities reported receiving in-kind revenue. At the sub-district tier 10.4 percent (95% CI: 5.8 - 17.8) of facilities reported such revenue. Nationally, the median value of in-kind revenue received from non-government sources during the period from January - December 2023 was GH¢ 7,092. The median value of in-kind revenue from government sources was GH¢ 6,499. Among facilities that reported receiving any in-kind revenue during the reference period, the most common types57 - both in terms of the proportion of facilities reporting and the median value received - were medical and general furniture (median value GH¢ 11,000) from government sources and medical equipment (median value GH¢ 11,000) from non-government sources.. Table 15. Average In-kind revenue during January - December 2023, by tier (N = 499) Source Community Sub-District District Ghana Proportion of facilities re- 12.8 10.4 8.1 12.0 ceiving in-kind revenue (%) [8.4 - 19.1] [5.8 - 17.8] [4.5 - 14.2] [8.5 - 16.6] Median in-kind revenue value (GH¢) 6,020.7 78,909.9 266,450.0 6,499.0 Government sources (1,600.0 - 16,414.0) (42,955.0 - 114,864.9) (266,450.0 - 266,450.0) (2,557.9 - 16,561.7) 6,000.0 15,154.8 630,443.7 7,092.8 Non-government sources (1,110.0 - 14,097.3) (7,642.5 - 16,774.2) (377,721.8 - 883,165.5) (1,110.0 - 15,165.6) 6,000.0 15,200.0 355,248.8 9,004.3 All Sources (1,500.0 - 15,047.6) (4,572.7 - 22,770.2) (197,624.4 - 519,610.6) (1,600.0 - 16,222.6) Note: Values in parentheses are the 25th and 75th percentile values, and values in [] brackets are the 95% confidence intervals. Figure 9 presents the proportion of facilities that received revenue from patient fees between January - December 2023. Nationally, 83.5 percent (95% CI: 78.6 - 87.5) of facilities reported receiving revenue from patient fees. This trend was relatively consistent across facility tiers: 84.0 percent (95% CI: 77.3 - 89.0) of community tier, 83.7 percent (95% CI: 75.5 - 89.6) of sub- district tier, and 77.0 percent (95% CI: 69.1 - 83.4) of district tier facilities reported receiving 57  Not presented in the figure. 59 revenue from patient fees over the reference period. The median patient fees received by facilities across Ghana during the reference period was GH¢ 3,788. Figure 9. Proportion of facilities receiving revenue from patient fees during January 2023 - December 2023, by tier (%) (N = 499) 3.2.2 Institutions for accountability for quality This section captures the frequency of collection, review, and sharing of data on facility-level performance indicators, and the methods and frequency of feedback solicitation from the population served by the facility. Additionally, it describes the institutions and practices in place for external supervision, such as supportive supervision visits from central authorities. Finally, it evaluates the extent to which any supervisory activities adhere to the WHO definition of “supportive”: open, two-way communication; team approaches facilitating problem-solving; monitoring performance towards goals; using data for decision-making; and regular follow-up to ensure correct implementation.58 To measure the presence of external supervisory institutions, the survey asked health facilities about their engagement with community advisory boards and community management committees. These types of groups typically meet to address primary health care issues and identify areas for improvement. Figure 10 highlights the proportion of facilities with a community advisory board or community management committee. At the national level, 77.8 percent (95% CI: 72.6 - 82.2) of facilities had established these boards or committees. While community facilities reported a high establishment rate of 86.5 percent (95% CI: 80.2 - 91.1), 60.6 percent (95% CI: 49.3 - 70.9) of sub-district and 40.0 percent (95% CI: 32.0 - 48.6) of   WHO. 2020. “Training for Mid-Level Managers (MLM). Module 4: Supportive Supervision.” Geneva: World Health Organi- 58 zation. https://iris.who.int/handle/10665/337056. 60 district facilities reported having a community administrative board or committee. However, it is important to note that in Ghana, community advisory boards are typically established only at the community tier. At the district level, oversight and coordination are generally provided by the District Health Management Team (DHMT), which comprises the District Director of Health Services, the District Public Health Nurse, the District Disease Control Officer, the District Nutrition Officer, the Medical Superintendent in charge of the district hospital, and other co-opted members such as the accountant and pharmacist. Despite this structure, 40.0 percent (95% CI: 32.0 - 48.6) of district facilities reported having a community board; a higher proportion would be expected given the typical governance structure. Figure 10. Proportion of facilities with community advisory boards, by tier (%) (N = 499) To better understand existing mechanisms of accountability for quality, the survey asked facility managers about the frequency of advisory board and committee meetings between January - December 2023. Figure 11 shows the meeting frequency of community advisory boards among the 357 facilities with such boards between January – December 2023. At the national level, 59.3 percent (95% CI: 50.4 - 68.1) of facilities reported meeting less frequently than every month but at least every three months, 19.6 percent (95% CI: 13.9 - 25.4) of facilities reported conducting these meetings less frequently than every three months but at least every six months while 3.2 percent (95% CI: 0.6 - 5.7) of facilities reported never conducting these meetings over the reference period. 61 Figure 11. Frequency of community advisory board meetings (%) (N = 356) Beyond community advisory boards, internal tools and processes utilized by health facility management also play an important role in facility performance and quality. Figure 12 shows the proportion of facilities that conducted quality improvement activities between January - December 2023. Quality improvement activities refer to efforts to implement iterative, measurable changes to make health services more effective, safe, and people-centered. Quality improvement activities may include setting and tracking achievements toward targets; implementing decision support tools, safety protocols, and checklists; benchmarking performance; promoting patient engagement, and so on. At the national level, 44.8 percent (95% CI: 39.0 - 50.8) of facility managers reported conducting quality improvement activities. At the district tier, 76.5 percent (95% CI: 68.5 - 82.9) of facilities reported conducting quality improvement activities, compared to 64.1 percent (95% CI: 54.0 - 73.1) of the sub-district facilities and 35.9 percent (95% CI: 28.7 - 43.8) of the community tier facilities. 62 Figure 12. Proportion of facilities that conducted quality improvement activities dur- ing January - December 2023, by tier (%) (N = 498) Health facilities may have targets to improve the health of the catchment population or to improve service delivery at the health facility. Examples of numeric, time-bound targets include increasing coverage of childhood immunization from 90% to 95% within 12 months, or decreasing patient wait time at the health facility from 30 minutes to 20 minutes by the end of the year. Among the facilities that reported conducting quality-improvement activities between January - December 2023, figure 13 shows the proportion of facilities that had set numeric, time-bound targets for improving health or health care outcomes during the 12 months. At the national level, 78.3 percent (95% CI: 70.2 - 84.7) of facility managers reported setting quality-improvement targets during the reference period. This proportion was consistent across facility tiers: 78.5 percent (95% CI: 65.5 - 87.6) of the community facilities, 77.9 percent (95% CI: 64.5 - 87.2) of the sub-district facilities, and 78.6 percent (95% CI: 69.5 - 85.6) of the district facilities reported setting numeric, time-bound quality improvement targets during the 12 months. 63 Figure 13. Proportion of health facilities with quality improvement targets, by tier (%) (N = 280) Among the facilities that reported conducting any quality improvement activities between January - December 2023, the proportion that shared quality improvement data with external leadership (DHO, MoH, community advisory board or community management committee) is presented in figure 14. Overall, 62.7 percent (95% CI: 53.9 - 70.7) of the facilities that conducted any quality improvement activities during the reference period reported sharing the data with the external leadership. When disaggregated by facility tier, 46.2 percent (95% CI: 36.7 - 55.9) of district facilities, 61.9 percent (95% CI: 47.7 - 74.2) of sub-district facilities, and 66.1 percent (95% CI: 52.4 - 77.5) of community facilities reported sharing such data. Figure 14. Proportion of health facilities with quality improvement data shared with external leadership during January - December 2023, by tier (%) (N = 281) 64 Complementary to data sharing from health facilities to external leadership is supportive supervision from central or external leadership. Supportive supervision encourages open, two-way communication, and building team approaches that facilitate problem-solving. It focuses on monitoring performance towards goals, and using data for decision-making, and depends upon regular follow-up with staff to ensure that new tasks are being implemented correctly. Supportive supervision visits may occur when, for example, external supervisors from district or regional level visit the health facility to improve/support clinical care, adherence to protocols, data collection, quality improvement efforts, and so on. Figure 15 depicts the proportion of facilities that reported at least one supervisory visit conducted between January 2023 and December 2023. At the national level, 90.3 percent (95% CI: 85.8 - 93.4) of facility managers reported having at least one supervisory visit, with 96.5 percent (95% CI: 89.4 - 98.9) of sub-district facilities, 94.9 percent (95% CI: 89.5 - 97.5) of district facilities and 87.8 percent (95% CI: 81.6 - 92.1) of community facilities reporting a supportive supervision visit during this period. Figure 15. Proportion of health facilities with at least one supervisory visit during Jan- uary - December 2023, by tier (%) (N = 500) Among the facilities that received supportive supervisory visits between January - December 2023, 34.8 percent (95% CI: 29.0 - 41.1) of facilities reported that the most recent supervision visit included all components required to consider the visit supportive by WHO standards59. Figure 16 presents the components that are included under the definition of supportive supervisory visit. Most facility managers reported that during the most recent supervisory visit they received, providers shared challenges and problems with their work (93.1 percent;   World Health Organization (WHO). 2008. Training for Mid-level Managers (MLM). Module 4: Supportive Supervision (re- 59 published 2020). Geneva: WHO. https://apps.who.int/iris/bitstream/handle/10665/337056/9789240015692-eng.pdf 65 95% CI: 88.9 - 95.8); external supervisors shared findings or discussed issues (87.5 percent; 95% CI: 82.4 - 91.3); and/or engaged in collective problem solving about these issues (81.9 percent; 95% CI: 76.2 - 86.5). The component most often lacking from supervisory visits was receipt of written feedback with 37.6 percent (95% CI: 31.6 - 44.0) of health facility managers reporting that they did not receive written feedback. It is worth noting that 52.8 percent (95% CI: 43.9 - 61.6) of district facilities reported that the most recent supervisory visit included all components required to consider the visit supportive compared to a little over 30 percent of community and sub-district facilities. Figure 16. Proportion of health facilities with supportive supervision components (%) (N = 455) In addition to supervision and feedback from central or external leadership, systems and practices of community feedback collection, review, and dissemination are crucial to promote accountability and strengthen facility responsiveness to community needs. Figure 17 shows the proportion of health facilities that collected feedback data from their communities (catchment population or patients). At the national level, almost all facilities (96.7 percent; 95% CI: 93.4 - 98.4) reported collecting feedback data from their community between January - December 2023. This pattern did not appear to vary substantially across facility tiers. 66 Figure 17. Proportion of health facilities that sought feedback from their catchment community during January - December 2023, by tier (%) (N = 500) Figure 18 reports the proportion of health facilities utilizing community feedback data by sharing the data with patients/catchment population, external leadership, facility management/staff and reviewing the data at least every six months. Nationally, 65.5 percent (95% CI: 59.5 - 71.0) of the facilities reported reviewing community feedback data at least every six months. While 66.4 percent (95% CI: 58.4 - 73.6) of community facilities reported reviewing the data at least every six months, only 51.5 percent (95% CI: 43.0 - 59.9) of district facilities reported the same. At the national level, 77.8 percent (95% CI: 72.0 - 82.6) of facilities reported sharing the data with facility management or staff; 60.4 percent (95% CI: 54.4 - 66.3) reported sharing data with external leadership (DHO/MoH/ community advisory board); and only 19.9 percent (95% CI: 15.4 - 25.4) reporting sharing the data with patients or catchment population. 67 Figure 18. Proportion of health facilities utilizing community feedback data (%) (N = 490) Table 16 presents the five most commonly reported areas for facility improvement based on community feedback collected between January - December 2023 as reported by the facility managers. The availability and functioning of essential equipment, supplies, or medicines emerged as the most frequently cited area for improvement, reported by 30.1 percent (95% CI: 22.7 - 37.6) of community facilities and 24.7 percent (95% CI: 16.5 - 33.0) of sub- district facilities. At the district tier, the most commonly reported area for improvement was the waiting time before consultation, noted by 22.9 percent (95% CI: 15.7 - 30.1) of facility managers. Good infrastructure, including cleanliness and amenities, was the second most reported area for improvement at the community tier (23.3 percent; 95% CI: 16.4 - 30.2) and sub-district tier (12.4 percent; 95% CI: 5.4 - 19.4); and fourth most reported area for improvement at the district tier (11.5 percent; 95% CI: 6.0 - 16.9). Specialized services or care availability appeared consistently among the top five across all tiers, while concerns related to facility operational hours were also noted at community and sub-district tiers. A notable share of respondents at the community (13.0 percent; 95% CI: 7.5 - 18.5) and district (9.9 percent; 95% CI: 4.8 - 15.1) tiers reported no perceived areas for improvement. 68 Table 16. Five most common areas for facility improvement according to community feedback during January - December 2023, by tier (N = 483) Rank Community Sub-District District Availability and functioning of Availability and functioning Waiting time in the health facility required equipment, supplies, of required equipment, before being seen for consultation 1 or medicine (30.1 percent supplies, or medicine (24.7 by health care provider(s) (22.9 [22.7 - 37.6]) percent [16.5 - 33.0]) percent [15.7 - 30.1]) Good infrastructure, amenities, Good infrastructure, ame- Specialized services or care avail- and/or cleanliness (including nities, and/or cleanliness ability (15.3 percent [9.1 - 21.4]) disability-friendly infrastruc- (including disability-friend- 2 ture, comfort of waiting area) ly infrastructure, comfort of (23.3 percent [16.4 - 30.2]) waiting area) (12.4 percent [5.4 - 19.4]) Nothing (13.0 percent Days facility is open/hours Level of respect/courtesy from 3 [7.5 - 18.5]) of operation (11.0 percent health facility staff (13.7 percent [2.5 - 19.5]) [7.8 - 19.7]) Specialized services or care Specialized services or care Good infrastructure, amenities, availability (6.2 percent availability (10.8 percent and/or cleanliness (including 4 [2.2 - 10.1]) [4.9 - 16.8]) disability-friendly infrastructure, comfort of waiting area) (11.5 percent [6.0 - 16.9]) Days facility is open/hours of Cost of services/drugs Nothing (9.9 percent [4.8 - 15.1]) 5 operation (5.5 percent (8.1 percent [0.5 - 15.6]) [1.8 - 9.2]) Note: Values in [] brackets are the 95% confidence interval. Table 17 summarizes the five most commonly reported positive aspects of health service delivery based on community feedback from January - December 2023, as reported by the facility managers. The level of respect and courtesy from health facility staff was the most frequently mentioned positive aspect at both the community (36.3 percent; 95%CI: 28.5 - 44.1) and sub-district (23.7 percent; 95% CI: 14.2 - 33.3) tiers, while specialized services or care availability ranked highest at the district tier (21.4 percent; 95% CI: 14.3 - 28.4). At the district tier, clinical competence of health care providers (16.0 percent; 95% CI: 9.7 - 22.3) and staff courtesy (15.3 percent; 95% CI: 9.1 - 21.4) were reported as second and third most frequent positive aspects. At the sub-district level, availability and functioning of required equipment (11.2 percent; 95% CI: 3.5 - 19.0) and specialized services availability (10.5 percent; 95% CI: 3.6 - 17.3) ranked among the top positive aspects. “Nothing” was reported as a response by a notable share of respondents at the community tier (15.1 percent; 95% CI: 9.2 - 20.9). Other recurring themes included good infrastructure and cleanliness, facility operating hours and waiting time, and clear communication with providers. 69 Table 17. Five most common positive areas according to community feedback during January - December 2023, by tier (N = 483) Rank Community Sub-District District Level of respect/courtesy Level of respect/courtesy from Specialized services or care 1 from health facility staff (36.3 health facility staff (23.7 per- availability (21.4 percent [14.3 - percent [28.5 - 44.1]) cent [14.2 - 33.3]) 28.4]) Nothing (15.1 percent [9.2 - Availability and functioning of Clinical competence of health 20.9]) required equipment, supplies, care provider(s) (16.0 percent 2 or medicine (11.2 percent [3.5 [9.7 - 22.3]) - 19.0]) Days facility is open/hours of Specialized services or care Level of respect/courtesy from 3 operation (11.0 percent [5.9 availability (10.5 percent [3.6 health facility staff (15.3 percent - 16.0]) - 17.3]) [9.1 - 21.4]) Clear communication (listen- Good infrastructure, amenities, Good infrastructure, amenities, ing or explaining) with health and/or cleanliness (including and/or cleanliness (including 4 care provider(s) ( 9.6% [4.8 disability-friendly infrastruc- disability-friendly infrastructure, - 14.4]) ture, comfort of waiting area) ( comfort of waiting area) ( 13.7% 9.4% [2.6 - 16.2]) [7.8 - 19.7]) Clinical competence of health Waiting time in the health Availability and functioning of care provider(s) ( 6.2% [2.2 - facility before being seen for required equipment, supplies, or 5 10.1]) consultation by health care medicine ( 9.2% [4.2 - 14.1]) provider(s) ( 8.8% [3.0 - 14.6]) Note: Values in [] brackets are the 95% confidence interval. 3.2.3 Management and supervision It is not just the broader accountability architecture that influences the quality of primary care service delivery, but also the direct management and supervision of staff members. The management and supervision domain focuses on the internal procedures and practices within a health facility that aim to review staff performance and provide feedback and support for improvement. Key indicators in this section include how often staff are provided with feedback on their performance, and the protocols and metrics used to measure performance and conduct internal staff evaluations. Given the impact of management capacity on provider and facility performance, additional information was collected on facility manager credentials. Table 18 presents key components of facility management, including whether the manager had any management degree or training, the frequency of individual meetings to conduct provider and support staff performance reviews, and the use of management tools for staff performance support. Overall, 50.6 percent (95% CI: 44.6 - 56.6) of the facility managers reported having a degree (defined as a certificate, diploma, bachelors, masters’ or above) in management, while 32.0 percent (95% CI: 24.4 - 40.8) of managers without a degree in management reported attending a management training for at least one month. Conducting periodic performance reviews of health facility staff is crucial for maintaining and improving service quality. Among the eligible health facility60 managers, 78.4 percent (95% 60  Facilities with more than one health care provider or support staff 70 CI: 72.7 - 83.1) reported holding performance review meetings with health care providers and 68.3 percent (95% CI: 60.0 - 75.5) with support staff between January -December 2023. Lastly, about two-thirds (64.8 percent; 95% CI: 58.8 - 70.4) of facility managers reported receiving a performance review between January - December 2023. Table 18. Components of facility management capacity (%), by tier Facility Managers Manager manager re- without a has at least Facility Facility ceived per- In-charge management a manage- conducts conducts formance holds a degree who ment degree provider support staff review Tier degree in have attended or attended performance performance between management management management reviews reviews January-De- (N = 500) training training (N = 500) (N = 368) cember, (N = 179) (N = 500) 2023 (N = 500) Commu- 44.2 28.7 60.2 72.4 52.0 64.1 nity [36.6 - 52.2] [20.1 - 39.3] [52.3 - 67.7] [64.8 - 78.9] [38.0 - 65.7] [56.2 - 71.3] Sub-Dis- 60.7 43.8 77.9 92.2 79.2 64.3 trict [50.2 - 70.4] [28.1 - 60.9] [67.5 - 85.7] [84.5 - 96.3] [68.3 - 87.1] [53.7 - 73.6] 86.8 61.1 94.9 94.1 94.1 75.7 District [79.9 - 91.5] [36.1 - 81.4] [89.5 - 97.5] [88.6 - 97.1] [88.6 - 97.1] [67.7 - 82.3] 50.6 32.0 66.4 78.4 68.3 64.8 Ghana [44.6 - 56.6] [24.4 - 40.8] [60.3 - 72.0] [72.7 - 83.1] [60.0 - 75.5] [58.8 - 70.4] Note 1 : Values in brackets are the 95 percent confidence intervals. Note 2: In-charge has attended management training is evaluated only for facilities where the manager does not hold a degree in manage- ment. Only facilities with more than one health care provider or support staff are eligible for staff performance review indicators. Figure 19 illustrates the prevalence of various performance assessment tools among facility managers that conduct staff assessments and have more than one staff member. Nationally, the most commonly used performance assessment tool was an assessment by the supervisor or manager, reported by 72.4 percent (95% CI: 66.4 - 77.7) of the health facilities. This was followed by self-assessments employed by 50.2 percent (95% CI: 44.0 - 56.5) of facility managers, peer assessments (33.4 percent; 95% CI: 27.9 - 39.5), knowledge assessments (31.1 percent; 95% CI: 25.7 - 37.0), clinic record review (29.7 percent; 95% CI: 24.5 - 35.6), and catchment population/patient assessments (23.2 percent; 95% CI: 18.3 - 28.9). Overall, 9.1 percent (95% CI: 6.0 - 13.6) of facility managers reported not utilizing any performance assessment tool. 71 Figure 19. Proportion of facilities using staff performance assessment tools (multi-se- lect) during January - December 2023 (%) (N = 485) In addition to the facility managers’ use of tools for staff performance assessment, the processes that facilities put in place to select staff for training can impact staff performance and opportunities for growth. In-service training61 and continuing medical education play a crucial role in keeping health care workers well-informed and updated on the latest advancements in medical care and treatment. Ideally, a careful review of each provider’s specific training needs, supported by information on performance and areas of growth, would guide training decisions. Figure 20 highlights the criteria that facility managers reported their facilities use to select which providers receive training. This was only applicable for facilities with more than one staff member and managers had the option of selecting multiple criteria. The most common criterion used for selecting health care providers for in-service training was the health care provider’s specialty or topic of training (45.2 percent; 95% CI: 39.1 - 51.4) and health care provider availability (36.9 percent; 95% CI: 31.1 - 43.1). Following this, 30.6 percent (95% CI: 25.3 - 36.5) relied on a formal review of in-service training needs for each provider, 24.3 percent (95% CI: 19.3 - 30.1) considered health care provider interests or requests, 24.8 percent (95% CI: 20.0 - 30.4) relied on a health care provider performance assessment, 13.4 percent (95% CI: 9.8 - 18.1) was based on health care provider licensing requirements and regulations. Ensuring that health care providers received an equal amount of training (11.2 percent; 95% CI: 7.9 - 15.6) and relying on the health care providers’ rank or years in the profession (8.9 percent; 95% CI: 6.0 - 12.9) were the least used criteria for selecting staff for in-service training in health facilities. Overall, 18.2 percent (95% CI: 13.7 - 23.8) of the eligible health facilities had no specific process for selecting staff for in-service training. 61   Any training received by health care providers during their employment after completing their preservice education and training. 72 Figure 20. Distribution of selection criteria for selecting staff for in-service training (%) (N = 482) While subsequent sections of this report shed light on health care provider job satisfaction and work environment, figure 21 presents the proportion of providers who agreed or strongly agreed with being satisfied with the support they received from their direct supervisors. Across Ghana, from the perspective of health care providers themselves, 85.5 percent (95% CI: 81.0 - 89.0) reported being satisfied with the level of support and guidance received from their supervisors. There was minimal variation between the facility tiers. Figure 21. Proportion of providers who report being satisfied with direct supervisor support, by tier (%) (N = 1191) 73 3.2.4 Physical infrastructure The physical infrastructure component measures the availability and functioning of key physical infrastructure required for the daily operation of the health facility and for its successful operation in case of an emergency. This type of infrastructure-specific emergency, such as damage to buildings or extended power outages, is distinct from a public health emergency like a disease outbreak. Furthermore, the physical infrastructure component also includes the availability and functioning of infrastructure to facilitate the utilization of services by individuals with disabilities, such as ramps, lifts, tactile flooring, toilets for clients with limited mobility, and assistive technologies (for example, signage with braille) for people with visual impairment. Infrastructure items required for safe and respectful care include provisions for auditory and visual privacy for patients consulting with providers; improved, functioning, accessible, and private toilet facilities; and handwashing facilities. Other key components include uninterrupted electricity; equipment for ambient temperature control such as heaters, air conditioners, and fans; refrigerators for storing vaccines and blood; a functional fire safety system including alarms and extinguishers; and ICT tools such as telephones, radios, computers, and internet access. It should be noted that this component captures the characteristics of the infrastructure of the facility itself, not infrastructure in the surrounding area or infrastructure such as public transport required to reach the facility. It also omits medical equipment, which is covered in a subsequent section. Accessibility for individuals with a disability Figure 22 presents the availability of various accessibility features for persons with disabilities by facility tier. Overall, across Ghana, 30.9 percent (95% CI: 25.7 - 36.6) of facilities had tactile flooring, 14.1 percent (95% CI: 10.7 - 18.3) of facilities had an improved functional toilet for individuals with disabilities62, 35.6 percent (95% CI: 30.1 - 41.4) of facilities with steps or inclines to enter any parts of the health facility had a ramp, and 3.6 percent (95% CI: 2.1 - 6.3) had assistive technology for the people with visual impairment63. Among the facilities with more than one floor, only 7.6 percent (95% CI: 4.9 - 11.7) had a functional lift. When examining facility tiers, district level health facilities typically reported higher proportion of accessibility features for people with disabilities compared to sub-district and community level facilities. 62   A toilet is accessible for people with limited mobility if it can be accessed without stairs or steps, has hand rails for support that are attached either to the floor or sidewalls, has a door that is at least 80 cm wide, and has a door handle and seat that are within reach of people who are using wheelchairs or crutches/sticks.   For example, signage with braille to help those who are blind or have visual impairment to read information about the 63 health facility, such as opening hours and contact information, department locations within the health facility, or to facilitate use of amenities. 74 Figure 22. Proportion of health facilities with accessibility features for persons with disabilities (%) Infrastructure for patient comfort and privacy Beyond accessibility of health facilities, additional key infrastructure needs to include provisions for auditory and visual privacy for patients consulting with providers; improved, functioning, accessible, and private toilet facilities; and handwashing facilities. In Ghana, 65.8 percent (95% CI: 59.8 - 71.2) of the facilities had at least one consultation room with both auditory and visual privacy (figure 23). There was variation among facility tiers, with over 85 percent of sub-district (87.9 percent; 95% CI: 79.5 - 93.2) and district facilities (98.5 percent; 95% CI: 94.2 - 99.6) reporting the presence of a consultation room with both visual and auditory privacy, whereas only 55.8 percent (95% CI: 47.8 - 63.4) of community facilities had a consultation room with both visual and auditory privacy. Figures 68 and 69 in Annex A provide further details on the availability of consultation room features including infrastructure elements related to patient comfort, such as ambient air temperature management and light source availability. 75 Figure 23. Consultation room with visual and auditory privacy, by tier (%) (N = 500) Availability of electrification and electricity-dependent infrastructure Figure 24 presents the proportion of facilities that had a functioning primary source of electricity on the day of the survey, as well as the proportion of facilities that reported having no interruptions to facility electrification over a three-month period (October - December 2023). Almost all health facilities at the sub-district (96.1 percent; 95% CI: 89.4 - 98.7) and the district (100 percent; 95% CI: 100.0 - 100.0) tiers had a primary source of electricity available compared to only 71.6 percent (95% CI: 63.9 - 78.2) of community tier. Similarly, more than 90 percent of facilities at the sub-district (92.1 percent; 95% CI: 84.5 - 96.2) and district (95.6 percent; 95% CI: 90.4 - 98.0) tier had a functioning primary power source on the day of the survey compared to 65.4 percent (95% CI: 57.5 - 72.5) of community tier. Additionally, power disruptions were reported to be relatively common as only 16.4 percent (95% CI: 11.9 - 22.2) of all facilities in Ghana reported experiencing uninterrupted electricity during October - December 2023. Across tiers, the proportion of facilities with functional electricity and that reported experiencing no power interruptions during October - December 2023 ranged from 11.0 percent (95% CI: 6.7 - 17.6) at district tier to 16.8 percent (95% CI: 10.9 - 25.0) at community and 16.8 percent (95% CI: 9.6 - 27.6) at sub-district tiers. 76 Figure 24. Proportion of health facilities with electricity (%) (N = 500) Table 19 details the frequency of power interruptions between October – December 2023. While 18.7 percent (95% CI: 12.6 - 24.8) of facilities (irrespective of functionality on the day of the survey) did not experience any interruptions in electricity during the period, 39.6 percent (95% CI: 31.4 - 47.7) reported experiencing one to ten separate power interruptions. Less than 6 percent of health facilities experienced between 51 - 100 interruptions (5.4 percent; 95% CI: 2.4 - 8.5) and over 100 interruptions (5.4 percent; 95% CI: 2.6 - 8.3) over the three- month period from October - December 2023. Table 19. Frequency of electricity interruption at health facilities between October - December 2023, by tier (N = 414) Between Between Between Between Over 100 No inter- Tier 1-10 inter- 11-20 inter- 21-50 inter- 51-100 in- interrup- ruptions ruptions ruptions ruptions terruptions tions 19.6 46.1 16.7 10.8 3.9 2.9 Community [11.9 - 27.4] [36.3 - 55.8] [9.4 - 23.9] [4.8 - 16.9] [0.1 - 7.7] [-0.4 - 6.2] 18.5 28.5 22.4 12.7 8.6 9.3 Sub-District [7.8 - 29.2] [18.4 - 38.6] [12.4 - 32.4] [7.2 - 18.2] [2.1 - 15.1] [2.7 - 15.8] 12.0 25.6 27.2 16.8 6.4 12.0 District [6.3 - 17.7] [17.9 - 33.3] [19.4 - 35.0] [10.2 - 23.4] [2.1 - 10.7] [6.3 - 17.7] 18.7 39.6 19.1 11.8 5.4 5.4 Ghana [12.6 - 24.8] [31.4 - 47.7] [13.4 - 24.7] [7.5 - 16.1] [2.4 - 8.5] [2.6 - 8.3] Note: Values in brackets are the 95% confidence intervals. Table 20 presents the median longest duration of electricity interruptions among facilities experiencing different numbers of interruptions over the three-month period from October - 77 December 2023. Notably, those experiencing between one to 10 interruptions during the reference period endured a median interruption duration of 15.9 hours. However, facilities experiencing between 11 and 100 interruptions had substantially longer interruptions, with a median of 24.0 to 31.0 hours. Furthermore, community facilities that experience between 21 - 100 interruptions encountered the lengthiest interruptions with a median of 72 hours (i.e., 3 days). Table 20. Median longest duration (hours) of electricity interruption at health facili- ties over a 3-month period (October - December 2023), among those facilities with varying numbers of interruptions, by tier (N = 414) Between 11- Between 21- Between 51- Between 1-10 Over 100 in- Tier 20 interrup- 50 interrup- 100 interrup- interruptions terruptions tions tions tions 16.8 24.0 72.0 72.0 12.0 Community (4.0 - 24.0) (5.0 - 31.3) (12.0 - 72.0) (48.0 - 96.0) (12.0 - 20.0) 24.0 36.2 24.0 22.9 48.0 Sub-District (2.0 - 48.0) (6.0 - 48.0) (12.0 - 24.2) (11.5 - 44.6) (14.4 - 48.0) 21.0 25.8 41.8 32.5 28.9 District (5.8 - 29.2) (18.8 - 45.0) (22.5 - 62.7) (28.2 - 36.7) (18.6 - 55.3) 15.9 24.0 24.0 31.0 20.0 Ghana (4.0 - 48.0) (5.0 - 45.3) (12.0 - 72.0) (24.0 - 70.5) (12.0 - 48.0) Note: Values in brackets are the 24th and 75th percentiles. Electricity interruptions can have a direct impact on service delivery and service availability. One of the key elements of health facility infrastructure includes refrigerators that can store blood and vaccines at controlled temperatures at 2 – 8 degrees Celsius. Figure 25 presents the percentage of facilities that had refrigerators for storing vaccines, as well the functional status and temperature of the observed refrigerator(s) on the day of the survey. Nationally, half (50.2 percent; 95% CI: 44.3 - 56.1) of all facilities surveyed had a functioning refrigerator at appropriate temperature for vaccine storage. Across facility tiers, community facilities had the lowest proportion of refrigerators observed for vaccines (41.7 percent; 95% CI: 34.1 - 49.6), as well as the lowest rates of having a functional refrigerator on the day of the survey (40.4 percent; 95% CI: 32.9 - 48.4) and a functional vaccine refrigerator maintained at the appropriate temperature (39.8 percent; 95% CI: 32.3 - 47.7). Sub-district facilities had the highest percentage of refrigerators that were functional and had the correct temperature (76.3 percent; 95% CI: 64.8 - 85.0), followed by district facilities (72.1 percent; 95% CI: 63.8 - 79.0). It should be noted that in Ghana, while some community-level facilities do store vaccines and therefore require refrigerators, they typically obtain vaccines from the sub-district level and use vaccine carriers or cold boxes for transport. As such, it is not surprising to observe the lowest refrigerator availability rates at the community tier. 78 Figure 25. Proportion of health facilities with at least one functional refrigerator for storing vaccines (%) (N = 500) The availability of functional refrigerators for blood storage was far less prevalent, as expected per Ghanaian guidelines. As shown in figure 26, 2.6 percent (95% CI: 1.0 - 6.7) of community and 7.1 percent (95% CI: 2.8 - 16.8) of sub-district tiers had refrigerators for blood storage. Community-level facilities do not typically carry out blood transfusions in Ghana, so they are not required to have refrigerators for storing blood. As such, it is not surprising to observe the lowest refrigerator availability rates at the community tier. Further, 1.3 percent (95% CI: 0.3 - 5.1) of community and 4.8 percent (95% CI: 1.6 - 13.9) of sub-district facilities had a functioning refrigerator for blood at the appropriate temperature of two - eight degrees Celsius. At the district level, 65.4 percent (95% CI: 57.0 - 73.0) of facilities were observed to have a refrigerator for blood and 56.6 percent (95% CI: 48.1 - 64.8) had a functioning refrigerator at the appropriate temperature on the day of the survey. 79 Figure 26. Proportion of health facilities with at least one functional refrigerator for storing blood (%) (N = 500) WaSH infrastructure Another important component of facility infrastructure is the availability of WaSH infrastructure within facilities. Figure 27 presents a cascade of water availability metrics to highlight the predominant drivers behind any suboptimal rates of consistent water availability. The survey findings revealed that while the availability of an improved and functioning water source was high (79.0 percent; 95% CI: 73.4 - 83.7), only 53.9 percent (95% CI: 47.8 - 60.0) of health facilities also had uninterrupted water supply during October - December 2023. Overall, only 34.7 percent (95% CI: 29.3 - 40.4) of facilities in Ghana had an improved, functioning, uninterrupted (October - December 2023) water source that was available on-premises. Figure 27. Proportion of health facilities with water availability (%) (N = 500) 80 Tables 21 and 22 add further detail to the picture of the availability and state of WaSH infrastructure by showing the reported frequency of interruption in water supply, as well as the median longest duration of water interruption at health facilities between October - December 2023. Across Ghana, the majority of health facilities (75.5 percent; 95% CI: 65.8 - 85.1) did not report any water interruptions in the three-month period (table 21), 10.5 percent {95% CI: 6.2 - 14.8) reported one - five interruptions while 7.4 percent (95% CI: 3.5 - 11.3) reported 6-10 interruptions. Less than seven percent of facilities reported over 10 interruptions. Table 21. Frequency of water interruption at health facilities between October - De- cember 2023, by tier (N = 431) No interrup- Between 1-5 Between 6-10 Between 11-20 Over 20 inter- Tier tions interruptions interruptions interruptions ruptions Commu- 80.4 8.4 8.4 0.9 1.9 nity [72.7 - 88.1] [3.1 - 13.7] [3.1 - 13.7] [0.0 - 2.8] [0.0 - 4.4] Sub-Dis- 64.2 16.7 5.5 6.0 7.7 trict [50.3 - 78.1] [7.8 - 25.6] [0.0 - 11.6] [3.2 - 8.7] [1.3 - 14.0] 75.0 5.5 6.2 8.6 4.7 District [67.5 - 82.5] [1.5 - 9.4] [2.0 - 10.5] [3.7 - 13.5] [1.0 - 8.4] 75.5 10.5 7.4 2.9 3.7 Ghana [65.8 - 85.1] [6.2 - 14.8] [3.5 - 11.3] [1.4 - 4.3] [1.2 - 6.1] Note: Values in brackets are the 95% confidence intervals. Furthermore, table 22 presents the median longest duration of water interruptions among facilities experiencing different numbers of interruptions over the three-month period from October - December 2023. Health facilities experiencing over 20 interruptions and community facilities with 11-20 interruptions between October -December 2023 reported the highest median duration of longest interruption at seven days. There was minimal variability in the median longest duration of water interruption by tier. Table 22. Median longest duration (days) of water interruption at health facilities over a 3-month period (October - December 2023), among those facilities with varying numbers of interruptions, by tier (N = 431) Between 1-5 Between 6-10 Between 11-20 Over 20 Tier interruptions interruptions interruptions interruptions 3.0 1.3 7.0 5.6 Community (0.1 - 5.6) (0.2 - 4.6) (7.0 - 7.0) (1.0 - 7.0) 1.0 1.0 1.6 7.0 Sub-District (1.0 - 4.1) (0.2 - 1.5) (1.0 - 6.4) (2.5 - 60.0) 1.5 0.5 2.3 8.5 District (1.2 - 1.7) (0.3 - 0.6) (1.7 - 3.2) (6.8 - 10.3) 3.0 1.0 2.0 7.0 Ghana (1.0 - 3.9) (0.1 - 3.0) (1.0 - 7.0) (1.0 - 20.0) Note: Values in brackets are the 24th and 75th percentiles. 81 The availability of multiple types of sanitation and hygiene infrastructure in health facilities was also assessed (figure 28). Overall, 64.1 percent (95% CI: 58.1 - 69.8) of facilities had at least one improved, functioning, accessible, and private toilet64 available within the premises, and 53.2 percent (95% CI: 47.2 - 59.0) of facilities had an improved toilet dedicated for staff only. However, the availability of a separate improved toilet for females only was relatively lower (37.2 percent; 95% CI: 31.9 - 42.9), and an improved toilet for females that had menstrual hygiene facilities was the least common, available in only 19.1 percent (95% CI: 15.2 - 23.7) of the facilities. At district tier, where more than 90 percent (95% CI: 85.9 - 95.5) had a separate improved toilet for females, only two-thirds (68.4 percent; 95% CI: 60.0 - 75.7) had an improved toilet for females with menstrual hygiene facilities. Figure 28. Proportion of health facilities with toilets with various characteristics (%) (N = 500) Figure 29 presents WaSH indicators by tier. Overall, 47.7 percent (95% CI: 41.9 - 53.5) of health facilities reported having a functional hand hygiene facility at at least one point of care. This metric varied by tier, with district tier (91.2 percent; 95% CI: 85.0 - 95.0) having a greater proportion of functional hand hygiene facilities compared to sub-district (74.2 percent; 95% CI: 65.2 - 81.5) and community (35.3 percent; 95% CI: 28.1 - 43.2) tiers. At least one improved, functioning, uninterrupted on-premises water source was available in 34.7 percent (95% CI: 29.3 - 40.4) of facilities. There is little variation across facility tiers. 64   A toilet is considered improved if it is a flush/pour-flush toilet to sewer connection, tank or pit; pit latrine with slab; or composting toilet. A toilet is in functioning condition when the hole or pit is unblocked, water is available for flush/pour- flush toilets, and there are no cracks or leaks in the toilet structure. A toilet is accessible when it is unlocked or can be unlocked by an available key. A toilet is considered private if it has doors that can be locked from the inside and there are no large gaps or holes in the structure. 82 At least one improved, functional, and accessible, and on-premises toilet was available in 64.1 percent (95% CI: 58.1 - 69.8) of the facilities. There was notable variability for this metric across tiers, with 97.8 percent (95% CI: 93.3 - 99.3) of district level facilities having an improved, functional, accessible toilet on-premises, followed by 84.7 percent (95% CI: 75.6 - 90.9) of sub-district and 54.5 percent (95% CI: 46.5 - 62.2) of community facilities. Lastly, 52.1 percent (95% CI: 46.2 - 57.9) of health facilities had access to running water and soap within five meters of at least one toilet, ranging from 40.4 percent (95% CI: 32.9 - 48.4) of community facilities to 96.3 percent (95% CI: 91.4 - 98.5) of district facilities. It is important to note, however, that the metrics for toilet, handwashing and hand hygiene facilities were only reported on the availability of at least one of each item per facility. Therefore, the information does not indicate whether all toilets were improved, and all points of care had hand hygiene facilities. Figure 29. Proportion of health facilities with WaSH infrastructure (%) (N = 500) Safety and infection prevention and control infrastructure This subsection of the report focuses on infrastructure, while subsequent sections contain additional details regarding IPC practices. Figure 30 highlights the availability of key IPC infrastructure, including the presence of physical barriers at one or more points of initial patient contact, presence of designated sites for patient isolation, a separate entrance for patients with suspected contagious disease, at least one functional handwashing facility, and adequate65 waste disposal system for infectious waste. Fewer than half of the facilities had appropriate infectious waste disposal facilities (43.9 percent; 95% CI: 38.2 - 49.8) and functional hand hygiene facilities at least at one point of 65   Infectious waste is considered to be adequately disposed if it is not visible at all or is visible in a protected area. 83 care (47.7 percent; 95% CI: 41.9 - 53.5). Additionally, 15.9 percent (95% CI: 12.7 - 19.6) had a physical barrier at one or more points of initial patient contact, 10.5 percent (95% CI: 7.7 - 13.2) of facilities had at least one designated site for patient isolation, and 9.1 percent (95% CI: 6.6 - 12.5) had at least one separate waiting area for patients. Among the five assessed IPC infrastructure metrics, the availability of functional hand hygiene facilities, designated isolation sites, separate waiting areas, and physical barriers varied by tier. Overall, less than three percent (2.8 percent; 95% CI: 1.0 - 3.1) of health facilities had implemented all the assessed infection prevention measures. Figure 30. Proportion of health facilities with five selected infection prevention and control measures (%) (N = 500) Adequate ventilation infrastructure is important in preventing infection transmission for airborne microbes. Figure 31 records the proportion of facilities with environmental ventilation (natural ventilation through windows/doors, mechanical ventilation such as window fans or air ducts, or a combination of both), which was commonly available in at least one outpatient consultation room (75.1 percent; 95% CI: 69.3 - 80.1). Less common was the completion of a ventilation performance assessment (quantification of airflow and/or air exchange rate) between January - December 2023, conducted in only 8.4 percent (95% CI: 5.8 - 12.0) of the facilities across Ghana. 84 Figure 31. Proportion of health facilities with ventilation (%) (N = 500) Figure 32 highlights the availability of key fire safety infrastructure by tier. Specifically, this concerned the availability of functional smoke detectors and fire extinguishers, whether the facility conducted an assessment of fire vulnerability, and any drills or simulations on fire safety between January - December 2023. Only 13.5 percent (95% CI: 10.7 - 16.9) of health facilities in Ghana had a functional fire alarm, ranging from 1.9 percent (95% CI: 0.6 - 5.9) of community facilities to 79.4 percent (95% CI: 71.7 - 85.5) of district facilities. On average, facilities were more likely to have fire extinguishers (23.0 percent; 95% CI: 19.3 - 27.2). Safety infrastructure and processes such as having conducted a fire drill (13.1 percent; 95% CI: 10.4 - 16.4) and having conducted a fire safety assessment (20.2 percent; 95% CI: 16.4 - 24.6) in the reference period were also low overall. It is worth noting that district level facilities had higher proportions of fire safety measures than the other health facility tiers. Figure 32. Proportion of health facilities with fire safety (%) (N = 500) 85 Information and communications technology (ICT) infrastructure Table 23 presents the availability and functioning of various ICT infrastructure across facility tiers. Functionality is defined as the presence of at least one functioning unit of the ICT item at the facility that is owned or paid for by the facility. Overall, community tier facilities had a notably lower proportion of functioning ICT infrastructure across all ICT items. More than half of surveyed facilities (61.9 percent; 95% CI: 55.9 - 67.6) had a functioning landline telephone, mobile phone, or smartphone that was paid for by the facility. Nearly half (45.5 percent; 95% CI: 40.0 - 51.1) had at least one functioning computer on the day of the survey. Internet connectivity was relatively low, with only 25.2 percent (95% CI: 20.8 - 30.3) of facilities reporting access on the day of the survey. The least prevalent was access to at least one functioning printer, reported by 23.0 percent of facilities (95% CI: 19.5 - 27.0). It should be noted that community tier facilities were not required to have printers at the time of the survey, and presence of a functioning printer was higher at sub-district (60.5 percent; 95% CI: 50.5 - 69.7) and district (97.1 percent; 95% CI: 92.3 - 98.9) tiers. Table 23. Proportion of facilities with functioning information technology infrastruc- ture items on the day of the survey (N = 500) Landline telephone, mo- Tier Computer Internet Printer bile phone, or smartphone 29.5 14.1 53.9 4.5 Community [22.8 - 37.2] [9.4 - 20.6] [45.9 - 61.6] [2.1 - 9.2] 80.8 44.2 79.6 60.5 Sub-District [70.7 - 88.1] [34.1 - 54.8] [71.3 - 86.0] [50.5 - 69.7] 97.1 83.8 88.2 97.1 District [92.3 - 98.9] [76.5 - 89.2] [81.6 - 92.7] [92.3 - 98.9] 45.5 25.2 61.9 23.0 Ghana [40.0 - 51.1] [20.8 - 30.3] [55.9 - 67.6] [19.5 - 27.0] Note: Values in brackets are the 95% confidence intervals. Figure 33 further details internet connectivity status in Ghana’s health facilities by presenting a cascade of metrics of internet availability. It shows that 26.6 percent (95% CI: 22.1 - 31.7) of facilities reported having internet available, while a similar percentage also had functional internet connectivity on the day of the survey. However, only 10.6 percent (95% CI: 7.6 - 14.5) had available and functional internet that remained uninterrupted between October - December 2023. This pattern was consistent across all tiers, with district facilities showing a higher proportion of availability, functionality, and uninterrupted service. These results highlight the fact that the availability of infrastructure does not always go hand-in-hand with consistent functionality. 86 Figure 33. Proportion of health facilities with internet, by tier (%) (N = 500) 3.2.5 Policies and protocols This section presents information on the physical verification of the presence of the most up- to-date written guidelines on IPC processes and clinical practice. The successful operation of a facility relies on adherence to operational and process guidelines, including IPC protocols, and high-quality clinical care aligned with international and local clinical guidelines for patient examination/consultation, diagnosis, and treatment. While appropriate implementation of and adherence to guidelines can be difficult to measure, ensuring that the guidelines are easily available for staff to reference facilitates adherence. Figure 34 shows the proportion of facilities with up-to-date IPC guidelines physically present at the facility. Overall, 66.2 percent (95% CI: 60.2 - 71.8) of facilities had up-to-date IPC guidelines. Sub-district (85.2 percent; 95% CI: 76.0 - 91.2) and district facilities (93.4 percent; 95% CI: 87.7 - 96.5) had a notably higher proportion of up-to-date guidelines compared to community facilities (57.7 percent; 95% CI: 49.7 - 65.3). 87 Figure 34. Proportion of health facilities with up-to-date IPC guidelines, by tier (%) (N = 500) Figure 35 shows the median proportion of the most recent clinical guidelines observed at the facility. The survey included direct observation of the presence or absence of 23 clinical guideline documents such as National guidelines for Comprehensive Abortion Care, 2021; National Kangaroo Mother Care Training Manual, 2021; Ghana Standards for Improving the Quality of Care for Children and Adolescents. The median proportion of available guideline documents was 21.7 percent (95% CI: 4.3 - 43.5), meaning the typical facility had less than a quarter of the required guidelines. The least commonly available up-to-date clinical guidelines were WHO Guidelines on Mental Health Gap Action Programme (mhGAP) (2020) and Ghana MIP Guidelines (2020), available in less than 10 percent of the facilities. While the most commonly available guidelines were User Guide for Maternal and Child Health Record Book (2021) and Standard Treatment Guidelines (2017), available in over half of the facilities. Table 67 in Annex A presents the tier wise availability of individual guidelines. 88 Figure 35. Median proportion of observed up-to-date clinical guidelines (N = 500) 3.3 Tools 3.3.1 Information systems The use of information systems to record and manage relevant data is essential for health facilities to make data-driven decisions, whether for tracking patient history or managing supply of medical items. Such facility-level data, when aggregated at a macro level, provide important insights about the health system in the country, including ongoing challenges and the country’s current disease burden. Having this information therefore helps in the design of targeted interventions to improve the quality of health care. Figure 36 presents the proportion of facilities using LMIS, a system of records and reports used to aggregate, analyze, validate, and display data that can be used to make logistics decisions and manage the supply chain. Only 39.0 percent (95% CI: 33.4 - 44.9) of health facilities in Ghana reported using the LMIS ranging from 32.7 percent (95% CI: 25.7 - 40.5) of community facilities to 71.3 percent (95% CI: 63.1 - 78.4) of district facilities. 89 Figure 36. Proportion of facilities with LMIS system, by tier (%) (N = 500) Figure 37 shows the LMIS formats used in health care facilities across Ghana by tier. Overall, 32.3 percent (95% CI: 23.3 - 41.3) of health facilities reported using electronic LMIS formats, 31.6 percent (95% CI: 21.1 - 42.0) reported using paper-based versions, and 36.1 percent (95% CI: 26.1 - 46.2) reported using both. Similar patterns were observed at the community and sub-district tiers. However, district facilities showed a lower proportion of facilities relying exclusively on paper-based LMIS formats (8.2 percent; 95% CI: 2.7 - 13.8) and over half (53.6 percent; 95% CI: 43.6 - 63.6) reported using only electronic LMIS formats. Figure 37. Distribution of LMIS formats used by facilities (%) (N = 260) 90 Managing the supply of medical items is a critical component of effective primary health care delivery. Figure 38 highlights the proportion of health facilities with quality assurance protocols for inventory management, broken down by tier. Overall, 73.8 percent (95% CI: 68.0 - 79.0) of health facilities across Ghana reported all three assessed quality assurance measures, including availability of quality inspection protocols; following first-expired, first- out procedures; and following protocols for physically separating and disposing of damaged or expired inventory. There was little variation across tiers; however, on average, community tier facilities reported lower implementation of each quality assurance of inventory protocol compared to sub-district and district tiers. Figure 38. Proportion of health facilities with quality assurance of inventory proto- cols, by tier (%) (N = 500) Furthermore, figure 39 shows the proportion of health facilities with protocols for indentation for inventory management. Indenting refers to placing a formal order or requisition for medicine and medical supply inventory. Overall, 83.8 percent (95% CI: 78.4 - 88.0) of health facilities reported indenting medicine and medical supply inventory. Nationally, 40.6 percent (95% CI: 35.0 - 46.4) of health facilities had protocols for emergency indenting in cases of stock-outs or near stock-outs, but this metric varied widely by tier: ranging from 31.4 percent (95% CI: 24.6 - 39.2) of community facilities to 57.9 percent (95% CI: 47.4 - 67.7) of sub-district and 82.4 percent (95% CI: 74.9 - 87.9) of district facilities. 91 Figure 39. Proportion of health facilities with protocols for indentation for inventory management (%) (N = 500) Figures 40 and 41 provide further details on the indenting process for medicine and medical supply inventory. Specifically, figure 40 shows the average duration between when facilities placed an indent and when the inventory was received during the 12-month period between January - December 2023. Overall, 23.7 percent (95% CI: 17.5 - 29.9) of facilities reported receiving the medical supply inventory within a week of indenting, 19.3 percent (95% CI: 13.9 - 24.8) reported receiving it between one - two weeks of indentation, and a further 21.4 percent (95% CI: 15.7 - 27.2) reported receiving it between two - three weeks of indentation. Figure 40. Average duration between when facility indented medicine or medical sup- ply inventory and when it received it during January - December 2023 (N = 455) 92 Figure 41 shows the average duration between emergency indenting and the receipt of inventory between January - December 2023. Overall, 56.9 percent (95% CI: 43.2 - 70.6) of facilities across Ghana reported that the process took less than one week. This ranged from 45.2 percent (95% CI: 27.2 - 63.2) at community and 65.4 percent (95% CI: 41.1 - 89.6) at sub- district tiers to 80.5 percent (95% CI: 72.1 - 88.8) at district tier. Figure 41. Average duration between emergency indenting and the inventory being received at the facility during January - December 2023 (N = 204) 3.3.2 Medical equipment and supplies This section covers the availability of functional essential medical equipment and supplies required for primary care services. Shortages of equipment or supplies can negatively impact patient trust and continuity of care. It is worth noting that in this section, the indicators reflect the presence of at least one item; the results presented are not meant to capture the entire volume of medical equipment and supplies. The survey evaluated the availability and functionality, wherever applicable, of at least one of each of the 67 key equipment and supplies across five broad categories. These were: surgical (N = 1), laboratory (N = 7), general/acute care (N = 39), reproductive and child health (N = 10), and IPC (N = 10). Only equipment that was required at each facility tier at the time of the survey, as per the Ghanaian guidelines, was included in the analysis for that tier. Figure 42 presents the median proportion of functional equipment available in facilities, by equipment category and facility tier. Nationally, a typical facility had 64.4 percent of all assessed equipment and supplies. A typical community facility had 55.6 percent of all equipment and supplies compared to 82.4 percent at the sub-district tier and 88.1 percent 93 at the district tier. Disaggregated data by service category reveal notable variation across tiers. District facilities consistently report the highest median availability of functional equipment across all service categories, including a median of 94.9 percent for general/ acute care equipment and supplies, 90.2 percent of reproductive and child health equipment and supplies, and 85.7 percent of laboratory equipment and supplies. A typical district facility also had at least one functional surgical theatre (surgical equipment category). In contrast, equipment availability and functionality at the community facilities showed gaps, with a typical community facility reporting 56.2 percent of general/acute care equipment and supplies, 50.0 percent of reproductive and child health equipment and supplies, and 40.0 percent of IPC equipment and supplies. Sub-district facilities demonstrate intermediate levels of availability and functionality of the assessed equipment and supplies, with a typical sub-district facility having 81.6 percent of general/acute care equipment and supplies, 87.5 percent of reproductive and child health equipment and supplies, and 80.0 percent of IPC equipment and supplies. Table 68 in Annex A presents the availability of each assessed equipment by facility tier. Figure 42. Median proportion of available and functional equipment, by tier and equipment category (%) (N = 500) The results presented above reflect facility-level availability of equipment and supplies. To complement this, patient interviews provide a perspective on availability from the patient’s point of view, proxied by the percentage of patients who received all provider-recommended tests on the day of the survey (figure 43). Overall, 98.0 percent (95% CI: 96.8 - 98.8) of patients received all the tests recommended by their provider on the day of the survey. This pattern remains consistent across facility tiers, with 98.2 percent (95% CI: 96.3 - 99.1) of patients at district tier, 97.9 percent (95% CI: 95.6 - 99.0) of patients at sub-district tier, and 91.5 percent (95% CI: 73.3 - 97.7) of patients at community tier reported receiving all 94 recommended tests on the day of the survey. It should be noted that some patients whose providers recommended tests may have been referred to other facilities for testing. Figure 43. Proportion of patients who received all tests recommended by provider on day of survey (%) (N = 980) 3.3.3 Medicines and Vaccines This section covers the availability of essential medicines and vaccines required for primary care service delivery. Data were collected based on direct observation of at least one available and unexpired medicine unit. As in the previous section, the data in this section are not meant to capture the exact volume of supply, but rather the presence of at least one item. Table 24 presents the median proportion of unexpired medicines available in facilities across different tiers in Ghana, categorized by medicine category. A typical facility in Ghana had 50.3 percent of all assessed medicines. There was some variation across tiers: a typical community facility had 45.1 percent, a typical sub-district facility had 58.2 percent, and a typical district facility had 70.7 percent of all assessed medicines. The availability across different medicine categories also varied considerably. For controlled drugs, a median of 25.0 percent of the assessed medicines were available at the sub-district facilities compared to 50.0 percent at district facilities. A similar trend was observed for intravenous (IV) fluids, where availability increased from a median of 66.7 percent in sub-district facilities to 71.7 percent in district facilities. Availability of injectable medicines ranged from a median of 33.3 percent at the community tier to a median of 61.0 percent at the sub-district level and 81.8 percent at the district level. Oral medicines also showed notable variation, with a median of 45.5 percent at the community tier, 59.1 percent at the sub-district level, and 69.7 percent at the district level. Suppository, consisting of one medicine (paracetamol suppository), was available in 95 all facilities across all tiers. In contrast, wound care medicine, also consisting of a single item (Gentian violet, 5%), was unavailable across all facilities tiers. Vaccines exhibited the most consistent availability, with a median of 80 percent at each tier. Table 69 in Annex A presents the availability of each assessed medicine by facility tier. Table 24. Median proportion of available and unexpired medicine, by tier and medi- cine category (%) (N = 500) Category Community Sub-District District Ghana 25.0 50.0 50.0 Controlled Drugs (N = 6) NA (25.0 - 50.0) (33.3 - 71.8) (25.0 - 50.0) 33.3 61.0 81.8 50.0 Injection (N = 11) (16.7 - 66.7) (42.9 - 71.4) (63.7 - 90.9) (16.7 - 71.4) 66.7 71.7 66.7 Intravenous (IV) fluids (N = 7) NA (50.0 - 83.3) (71.4 - 100.0) (50.0 - 83.3) 45.5 59.1 69.7 50.8 Oral (56) (15.2 - 60.6) (43.2 - 68.2) (58.9 - 78.6) (21.2 - 65.9) 100.0 100.0 100.0 100.0 Suppository (N = 1) (0.0 - 100.0) (100.0 - 100.0) (100.0 - 100.0) (0.0 - 100.0) 80.0 80.0 80.0 80.0 Vaccines (N = 10) (0.0 - 90.0) (10.0 - 90.0) (0.2 - 90.0) (0.0 - 90.0) 0.0 0.0 0.0 0.0 Wound care (N = 1) (0.0 - 0.0) (0.0 - 100.0) (0.0 - 100.0) (0.0 - 0.0) 45.1 58.2 70.7 50.3 All Medicines (92) (27.5 - 60.8) (49.3 - 66.1) (57.6 - 78.3) (33.2 - 64.7) Note: Values in parentheses are the 25th and 75th percentiles. Values are marked as NA when medicines in a category are not needed at a particular tier. In such cases, the calculation for ‘all medicines’ excludes that medicine for the respective tier. The results presented above reflect facility-level availability of medicines. To complement this, patient interviews provide a perspective on availability from the patient’s point of view, proxied by the percentage of patients who received all provider prescribed medicines on the day of the survey. Figure 44 shows the proportion of patients who received the prescribed medicines during their visit to the health facility. At the national level, 77.1 percent (95% CI: 73.5 - 80.4) of patients reported receiving the medicines they were prescribed on the day of the survey. 84.4 percent (95% CI: 62.8 - 94.5) of patients at community tier reported receiving their prescribed medicines, followed by 79.1 percent (95% CI: 73.9 - 83.5) at the district and 74.7 percent (95% CI: 69.1 - 79.6) at the sub-district tiers. 96 Figure 44. Proportion of patients who received medicine on the day of the survey among those prescribed (%) (N = 2113) 3.4 Workforce 3.4.1 Availability This component captures the available human resources at surveyed health facilities. Key indicators in this subsection include the number of staff of different provider cadres; the number of staff providing only outpatient care or both outpatient and inpatient care; and the number of administrative/support staff. This section outlines information on provider absence from the facility for authorized or unauthorized reasons as well as information on the number of facilities with at least one provider offering specific services. Health care providers are health professional staff who are licensed to provide diagnostic or therapeutic services to patients. These include doctors, health assistants, nurses, dental services providers, and so on, but excludes pharmacists and technicians. Clinical support staff include pharmacists and technicians (including laboratory technicians, dental technicians, pharmacy technicians, X-ray technicians, and so on). Administrative support staff are administrative and clerical staff who coordinate and facilitate patient care; this includes receptionists, record keepers, drivers, janitorial and maintenance staff, and so on. This includes both regular and contract staff but excludes volunteers. Table 25 presents the median number of staff across facility tiers. Across facilities in Ghana, the median number of total staff was five individuals. The median number of health care providers, clinical support staff, and administrative support staff were four, zero and zero, respectively. District facilities were the most densely staffed facilities with a median staff size of 74, compared to 6 at sub-district and 3 at community tiers. Across Ghana, there were a 97 median of 1.4 health care providers per 1,000 catchment population and a median of 1.6 total staff per 1,000 catchment population. The health care provider density ranged between a median of 1.3 per 1,000 catchment population in community tier to 2.1 at district tier. Table 25. Median staff availability Total Staff Total Provid- Administra- per 1000 Health Care Clinical Sup- ers per 1000 tive Support Total Staff catchment Tier Providers* port Staff catchment Staff (N = 496) popula- (N = 496) (N = 466) population (N = 496) tion (N = 458) (N = 458) Commu- 3.0 0.0 0.0 3.0 1.3 1.4 nity (2.0 - 5.0) (0.0 - 0.0) (0.0 - 1.0) (2.0 - 6.0) (0.7 - 2.2) (0.8 - 2.3) Sub-Dis- 13.0 1.0 3.0 19.5 2.0 2.5 trict (7.0 - 30.2) (0.0 - 3.0) (1.1 - 8.0) (10.0 - 43.0) (0.9 - 4.0) (1.3 - 5.2) 43.0 7.4 19.6 74.0 2.1 3.4 District (20.4 - 124.8) (3.7 - 12.1) (8.8 - 40.6) (36.2 - 173.1) (0.8 - 5.2) (1.5 - 8.4) 4.0 0.0 0.0 5.0 1.4 1.6 Ghana (2.0 - 10.0) (0.0 - 1.0) (0.0 - 2.0) (3.0 - 11.0) (0.7 - 2.5) (0.9 - 3.0) Note: Values in parentheses are the 25th and 75th percentile values. *Health care providers here refer to all licensed health professionals authorized to deliver diagnostic or therapeutic services to patients, including those offering specialized non-PHC services Table 26 highlights the median number of providers, by cadre and facility tier. At the community tier, there were a median of two nurses and zero midwives. As per Ghanaian health sector staffing policy at the time of the survey, community tier facilities, which include CHPS compounds and maternity homes, were not staffed with doctors or physician assistants. Accordingly, there were no doctors or physician assistants reported at the community tier. Sub-district facilities had a median of one physician assistant, three nurses, and two midwives. A median of zero doctors reported at the sub-district tier, which was also consistent with the staffing guidelines. Health centers and clinics – comprising over 90 percent of sub-district facilities – were not typically staffed with doctors. District facilities had a median of two doctors, two physician assistants, seven nurses, and six midwives. Table 26. Median number of PHC providers, by cadre and tier (%) (N = 490) Physician Assis- Tier Doctors Nurses Midwives tants 0.0 0.0 2.0 0.0 Community (0.0 - 0.0) (0.0 - 0.0) (1.0 - 3.0) (0.0 - 1.0) 0.0 1.0 3.0 2.0 Sub-District (0.0 - 0.0) (0.0 - 1.0) (1.0 - 5.0) (1.0 - 4.0) 2.0 2.0 7.0 6.0 District (1.0 - 4.0) (1.0 - 3.0) (3.0 - 15.1) (2.0 - 11.0) 0.0 0.0 2.0 1.0 Ghana (0.0 - 0.0) (0.0 - 0.0) (1.0 - 4.0) (0.0 - 2.0) Note: Values in parentheses are the 25th and 75th percentile values. 98 Figure 45 presents the provider absence rates by cadre and facility tier. Absence from facility was assessed based on an unannounced follow-up visit to facilities at a random interval of two to seven days from the initial interview date. Providers could be absent from the facility due to authorized reasons – for example, off duty or at training – or unauthorized reasons. Overall, 25.8 percent (95% CI: 18.7 - 34.4) midwives, 15.1 percent (95% CI: 9.6 - 23.0) nurses, 13.7 percent (95% CI: 8.4 - 21.3) physician assistants, and 18.1 percent (95% CI: 12.6 - 25.3) doctors were not present at the health facility on the day of the survey. Disaggregated by facility tier, 31.3 percent (95% CI: 20.8 - 44.2) of midwives in sub-district tier and 21.8 percent (95% CI: 13.0 - 34.4) in district tier, and 17.9 percent (95% CI: 7.0 - 38.6) in community tier were absent on the day of the survey. For nurses, the highest absence rates, on average, were observed at community tier (23.5 percent; 95% CI: 16.0 - 33.2), followed by the district tier (14.5 percent; 95% CI: 6.8 - 28.2), and sub-district tier (15.5 percent; 95% CI: 8.9 - 25.6). Among physician assistants, 18.8 percent (95% CI: 9.4 - 33.9) in sub-district tier and 9.9 percent (95% CI: 5.2 - 18.0) in district tier were absent on the day of the survey. For doctors, the highest absence rate, on average, was observed at the sub- district tier (23.1 percent; 95% CI 4.7 - 64.7), followed by district tier (18.0 percent; 95% CI: 12.4 - 25.4). Community tier facilities did not have any doctors or physician assistants on staff, as per the country policy. Figure 45. Provider absence rates (%) (N = 1732) It is important to understand the rate at which providers are absent from facilities, and equally important to know the reason why providers were marked as absent on the day of the follow-up interview, regardless of whether their absence was expected or not. Table 27 summarizes the top five reasons for provider absence on the day of the survey, disaggregated by provider cadre. Absence due to unauthorized reasons was extremely low, with only 0.9 percent (95% CI: 0.2 - 1.6) of providers being absent without authorization. By provider 99 type, it was 0.2 percent (95% CI: 0.0 - 0.6) for doctors and 0.2 percent (95% CI: 0.0 - 0.5) for midwives and 1.1 percent (95% CI: 0.0 - 2.3) for nurses; however, 5.9 percent (95% CI: 0.0 - 12.5) of physician assistants were absent without authorization. Among doctors, the most commonly cited reason for absence was annual leave (23.8 percent; 95% CI: 3.4 - 44.1), followed by casual leave (15.7 percent; 95% CI: 2.9 - 28.6), being on call (15.3 percent; 95% CI: 3.9 - 26.6), attending training/seminars or meetings (10.6 percent; 95% CI: 0.3 - 20.9), and study leave (8.7 percent; 95% CI: 0.0 - 17.4). For physician assistants, the top reason was also annual leave (37.3 percent; 95% CI: 0.8 - 64.9), closely followed by training/seminars or meetings (32.9 percent; 95% CI: 0.0 - 0.7 - 66.5). Among nurses, the most frequent reason for absence was study leave (36.2 percent; 95% CI: 0.0 -0.6 - 73.0), followed by annual leave (33.7 percent; 95% CI: 13.2 - 54.1). For midwives, the leading reasons were annual leave (26.8 percent; 95% CI: 11.8 - 41.0), being on call (24.8 percent; 95% CI: 3.6 - 46.1), casual leave (16.7 percent; 95% CI: 0.0 - 1.5 - 34.9). Although the distribution of absence reasons varies across cadres, these findings should be interpreted with caution. The data are descriptive and based on relatively small sample sizes, particularly for doctors and physician assistants, and do not permit statistical comparisons between groups. Table 27. Top five reasons for absence from the facility on day of survey (N = 354) Doctor Physician Assistant Nurse Midwife Rank (N = 39) (N = 35) (N = 147) (N = 127) Annual leave Annual leave Study leave Annual leave 1 (23.8 percent [3.4 - 44.1]) (37.3 percent [9.8 - 64.9]) (36.2 percent [0.0 - 73.0]) (26.8 percent [11.8 - 41.9]) Casual leave Training/seminar/ meeting Annual leave On call 2 (15.7 percent [2.9 - 28.6]) (32.9 percent [0.0 - 66.5]) (33.7 percent [13.2 - 54.1]) (24.8 percent [3.6 - 46.1]) On call On call Casual leave Casual leave 3 (15.3 percent [3.9 - 26.6]) (11.5 percent [0.0 - 25.6]) (7.3 percent [0.9 - 13.8]) (16.7 percent [0.0 - 34.9]) Training/seminar/ meeting Unauthorized absence On call Maternity/paternity leave 4 (10.6 percent [0.3 - 20.9]) (5.9 percent [0.0 - 12.5]) (5.1 percent [0.0 - 11.4]) (9.5 percent [1.9 - 17.0]) Study leave Study leave Maternity/paternity leave Study leave 5 (8.7 percent [0.0 - 17.4]) (4.6 percent [0.0 - 10.7]) (4.9 percent [1.8 - 8.0]) (9.1 percent [0.9 - 17.3]) Note: Values in parentheses are proportion of respondents and [] brackets are the 95% confidence interval. 3.4.2 Education and training This component measures not only the pre-service education level of providers at each facility, but also the proportion of facilities with at least one provider trained in required and specialized services, median in-service tenure of providers. Table 28 presents the median years of experience of health care providers in Ghana, disaggregated by cadre and facility tier. Overall, providers had worked a median of five years in their current position, three years at their current facility, and six years in clinical service. Tenure patterns were generally consistent across facility tiers. In the community tier, 100 the health care providers had worked a median of 4.1 years in their current position, three years at their current facility and 5.2 years in clinical service. Providers at sub-district facilities reported a median of four years in their current position, three years at their current facility, and six years in clinical service. District-level providers had slightly longer median tenures, with a median of five years in their current position, four years at their current facility, and six years in clinical service. By cadre, these findings suggest that doctors (providing primary health care) in Ghana had, on average, less work experience than other provider types, while midwives and physician assistants had relatively longer service histories. Midwives had the longest tenure in their current positions with a median of seven years, and clinical service with a median of eight years. Physician assistants had a median of five years in their current position, three years at their current facility, and nine years in clinical service. Nurses reported a median of four years in their current position, three years at their current facility, and five years in clinical service. Doctors had the shortest tenure with a median of three years in their current position, two years at their current facility, and four years in clinical service. Table 28. Median years of experience of providers, by cadre and tier (N = 1227) Years in current posi- Type Years in current facility Years in clinical service tion Tier 4.1 3.0 5.2 Community (3.0 - 8.4) (2.6 - 4.7) (3.0 - 9.7) 4.0 3.0 6.0 Sub-District (3.0 - 8.0) (2.0 - 4.0) (3.0 - 12.0) 5.0 4.0 6.0 District (3.0 - 9.0) (2.0 - 7.0) (3.0 - 10.0) Cadre 3.0 2.0 4.0 Doctor (1.0 - 6.0) (0.0 - 4.0) (3.0 - 7.0) 5.0 3.0 9.0 Physician Assistant (3.0 - 8.8) (1.0 - 5.8) (4.0 - 14.0) 4.0 3.0 5.0 Nurse (3.0 - 7.0) (2.0 - 5.0) (3.0 - 8.0) 7.0 3.0 8.0 Midwife (3.0 - 10.0) (2.0 - 7.0) (4.0 - 13.0) 5.0 3.0 6.0 Ghana (3.0 - 8.0) (2.0 - 5.0) (3.0 - 11.0) Note: Values in parentheses are the 25th and 75th percentile values. Table 29 shows the proportion of facilities that were able to provide each service during the three months prior to the survey (October - December 2023) and that had at least one provider who had received in-service training on the topic in the two years prior to the survey (January 2022 - December 2023). Facility tiers that were not required to offer a 101 particular service under Ghanaian guidelines at the time of the survey were excluded from the analysis for that service. The most common service types where providers had received in-service training were: Developmentally Supportive Care (DSC) for LBW/preterm babies (82.1 percent; 95% CI: 69.5 - 90.3), management of labor complication (73.6 percent; 95% CI: 65.6 - 80.3), postpartum hemorrhage (PPH) management (73.1 percent; 95% CI: 65.6 - 79.5), HIV/AIDS antiretroviral prescription and/or treatment (71.1 percent; 95% CI: 59.7 - 80.3), management of pregnancy complications (70.1 percent; 95% CI: 60.1 - 78.5). Among those measured, the least common topics for in-service trainings were HPV Immunization (29.1 percent; 95% CI: 14.3 - 50.3), distribution of condoms (32.4 percent; 95% CI: 26.1 - 39.4), services related to child protection (38.2 percent; 95% CI: 23.1 - 56.0), enteric fever diagnosis (39.4 percent; 95% CI: 30.2 - 49.4), and provision of oral contraceptives (39.8 percent; 95% CI: 33.5 - 46.4). Table 29. Proportion of health facilities with at least one provider that received in-ser- vice training during 2022-2023 in each service category (%) (N = 500) Category Service Community Sub-District District Ghana Adolescent friendly 39.0 59.4 64.1 44.6 health services [29.6 - 49.3] [47.6 - 70.2] [51.4 - 75.0] [37.0 - 52.5] HPV Immunization 25.0 20.6 51.9 29.1 [0.8 - 93.0] [7.3 - 46.0] [32.7 - 70.5] [14.3 - 50.3] Adolescent Health Services Screening for breast 37.9 72.2 65.1 52.7 And Interven- cancer [23.5 - 54.8] [59.7 - 82.0] [54.3 - 74.6] [42.6 - 62.5] tions Cervical cancer screening 66.7 73.9 57.4 66.0 [1.0 - 99.7] [45.9 - 90.5] [42.7 - 71.0] [47.0 - 81.0] Screening for pelvic 0.0 77.7 62.3 62.1 tumors [** - **] [45.7 - 93.5] [50.1 - 73.1] [44.7 - 76.8] Routine childhood immu- 49.3 57.4 53.8 51.1 nization services [41.2 - 57.5] [46.8 - 67.3] [43.4 - 64.0] [44.6 - 57.6] Child growth monitoring 51.4 55.9 59.6 52.6 and promotion [43.2 - 59.5] [45.4 - 65.9] [49.2 - 69.1] [46.1 - 59.1] Diagnosis of maternal 60.2 60.2 and newborn health NA NA [49.2 - 70.3] [49.2 - 70.3] (MAM) Management of MAM 65.8 65.8 NA NA Child Health And [54.2 - 75.7] [54.2 - 75.7] Nutrition Services IMNCI 61.5 61.5 NA NA [50.1 - 71.8] [50.1 - 71.8] Management of neu- 61.3 61.3 ro-developmental condi- NA NA [42.6 - 77.1] [42.6 - 77.1] tions in children Support and Care for the 65.4 65.4 NA NA child with disability [44.6 - 81.6] [44.6 - 81.6] Micronutrient supple- 42.6 54.0 52.2 46.1 mentation [30.7 - 55.5] [39.6 - 67.7] [40.2 - 63.9] [37.1 - 55.4] 102 Category Service Community Sub-District District Ghana Identification of suspect- 46.9 46.9 ed childhood/adolescent NA NA [33.2 - 61.2] [33.2 - 61.2] Child Health And cancer Nutrition Services Services related to child 38.2 38.2 NA NA protection [23.1 - 56.0] [23.1 - 56.0] Malaria diagnosis 55.8 57.0 62.5 56.6 [46.0 - 65.1] [46.3 - 67.0] [53.7 - 70.5] [49.7 - 63.3] Malaria treatment 44.8 57.6 61.4 49.8 [35.4 - 54.5] [46.9 - 67.6] [52.6 - 69.6] [43.0 - 56.6] TB screening/ diagnosis 63.0 63.0 NA NA [51.2 - 73.5] [51.2 - 73.5] TB treatment (prescrip- 38.9 71.9 72.3 56.1 tion and/or treatment [18.6 - 63.9] [54.9 - 84.4] [60.0 - 82.0] [43.1 - 68.3] follow-up) Communicable HIV testing and counsel- 44.6 58.9 61.0 50.2 Diseases ling [34.6 - 55.0] [48.3 - 68.8] [51.8 - 69.5] [43.0 - 57.3] HIV/AIDS antiretrovi- 71.1 71.1 ral prescription and/or NA NA [59.7 - 80.3] [59.7 - 80.3] treatment Enteric fever diagnosis 38.3 43.0 39.4 NA [26.8 - 51.2] [33.8 - 52.7] [30.2 - 49.4] Enteric fever treatment 43.4 48.5 44.7 NA [30.5 - 57.2] [38.9 - 58.3] [34.6 - 55.2] Measles diagnosis and 55.9 54.5 55.5 NA management [40.8 - 69.9] [43.2 - 65.5] [44.3 - 66.2] Family planning counsel- 41.4 65.4 67.6 48.2 ling [33.6 - 49.7] [55.2 - 74.4] [58.2 - 75.7] [41.9 - 54.5] Distribution of condoms 27.3 43.2 61.8 32.4 [19.7 - 36.5] [32.5 - 54.6] [49.5 - 72.7] [26.1 - 39.4] Family Planning Provision of oral contra- 33.3 55.6 62.9 39.8 Services ceptives [25.7 - 42.0] [44.7 - 66.0] [52.7 - 72.0] [33.5 - 46.4] Insertion of Implants 43.3 65.0 68.7 50.1 [34.3 - 52.7] [54.1 - 74.6] [58.7 - 77.3] [43.1 - 57.0] Insertion of IUCD 39.2 58.5 69.3 51.2 [21.0 - 61.0] [43.7 - 72.0] [57.8 - 78.9] [40.2 - 62.2] Antenatal care services 44.2 71.0 74.2 54.9 [33.9 - 55.0] [61.1 - 79.2] [65.7 - 81.2] [47.7 - 62.0] PMTCT (Testing / and 60.7 65.8 61.8 NA counselling and ART) [49.8 - 70.6] [56.6 - 73.9] [53.2 - 69.8] Maternal And Management of preg- 67.7 75.7 70.1 Newborn Health NA nancy complications [53.8 - 79.1] [66.9 - 82.7] [60.1 - 78.5] Services Services for normal de- 35.1 65.2 67.5 49.9 livery [23.7 - 48.6] [55.0 - 74.1] [58.6 - 75.3] [42.2 - 57.6] Management of labour 72.9 75.4 73.6 NA complications [62.0 - 81.6] [66.6 - 82.6] [65.6 - 80.3] 103 Category Service Community Sub-District District Ghana Abortion care and 67.2 70.3 68.1 NA post-abortion care [50.9 - 80.1] [60.0 - 78.9] [56.2 - 78.0] PPH management 71.4 78.1 73.1 NA [61.6 - 79.6] [69.4 - 84.8] [65.6 - 79.5] Assisted vaginal delivery 70.1 69.5 69.9 NA [52.2 - 83.4] [58.5 - 78.6] [57.5 - 80.0] Obstetric ultrasonogra- 62.6 64.4 63.4 NA phy [43.1 - 78.7] [54.6 - 73.1] [52.0 - 73.5] Evacuation of the uterus 47.6 61.5 53.0 NA [30.1 - 65.8] [51.7 - 70.5] [41.1 - 64.6] Management of breech NA 65.3 65.3 NA delivery [55.2 - 74.2] [55.2 - 74.2] Repair of 3rd degree 9.1 66.0 60.8 46.2 perineal tears [0.9 - 51.0] [47.5 - 80.7] [50.9 - 69.9] [34.5 - 58.5] Blood transfusion 69.4 56.5 61.3 NA [29.6 - 92.5] [46.9 - 65.6] [46.9 - 73.9] Maternal And Caesarean section 60.9 54.7 56.4 NA Newborn Health [14.8 - 93.3] [45.0 - 64.1] [42.1 - 69.7] Services Neonatal resuscitation 41.2 58.4 75.4 53.4 with bag and mask [25.6 - 58.8] [46.6 - 69.2] [66.7 - 82.4] [44.5 - 62.1] Essential newborn care 39.2 60.2 76.5 51.4 [26.6 - 53.5] [49.5 - 69.9] [67.9 - 83.3] [43.3 - 59.4] Vitamin K injection for 34.1 47.9 61.7 42.8 newborn [21.7 - 49.0] [37.2 - 58.9] [52.6 - 70.0] [34.9 - 51.0] Kangaroo Mother Care 37.0 54.3 70.8 48.7 (KMC) [20.6 - 57.1] [40.7 - 67.3] [60.3 - 79.4] [38.5 - 59.0] Developmentally Sup- 82.1 82.1 portive Care (DSC) for NA NA [69.5 - 90.3] [69.5 - 90.3] LBW/preterm babies Prevention/management 65.0 65.0 NA NA of birth asphyxia [55.2 - 73.7] [55.2 - 73.7] Prevention/management 59.5 59.5 NA NA of neonatal seizures [48.2 - 69.9] [48.2 - 69.9] Prenatal care services 61.5 61.5 NA NA [51.9 - 70.2] [51.9 - 70.2] Medical emergency and 62.1 62.1 NA NA critical care services [51.3 - 71.8] [51.3 - 71.8] Rehabilitative and dis- 64.3 64.3 NA NA ability care services [34.9 - 85.8] [34.9 - 85.8] Other Primary Home visitation by 44.4 44.4 Care Services nurses and/or physicians [33.2 - 56.3] [33.2 - 56.3] NA NA to provide home-based services Screening for gen- 63.0 63.0 NA NA der-based violence [42.8 - 79.5] [42.8 - 79.5] 104 Category Service Community Sub-District District Ghana Services for gen- 50.0 50.0 der-based violence NA NA [28.1 - 71.9] [28.1 - 71.9] survivors Other Primary Services for aged (e.g. 41.5 41.5 Care Services mental health, visual, NA NA [30.0 - 54.1] [30.0 - 54.1] hearing) Palliative/terminal care 65.2 65.2 NA NA [43.0 - 82.3] [43.0 - 82.3] Diabetes diagnosis 57.3 58.3 57.5 NA [43.8 - 69.8] [49.2 - 66.9] [47.3 - 67.2] Hypertension diagnosis 51.8 61.9 54.1 NA [40.4 - 63.0] [53.0 - 70.1] [45.1 - 62.9] Diabetes treatment 54.1 62.3 56.3 NA [39.9 - 67.6] [53.3 - 70.5] [45.6 - 66.4] Risk Factor Hypertension treatment 53.4 60.5 55.1 NA Services [41.4 - 65.1] [51.5 - 68.8] [45.7 - 64.2] Diagnosis of mental 48.8 60.3 52.0 NA health conditions [35.9 - 61.9] [48.0 - 71.4] [41.8 - 62.0] Pharmacotherapy for 50.1 58.2 52.5 NA mental health conditions [34.9 - 65.3] [44.5 - 70.7] [40.8 - 64.0] Psychotherapy for mental 75.0 48.5 53.1 54.8 health conditions [7.0 - 99.2] [33.0 - 64.3] [38.8 - 66.8] [40.8 - 68.1] Note: Values in brackets are the 95% confidence interval. NA indicates where the indicator is not applicable at the tier. Table 30 shows the proportion of facilities that were able to provide each laboratory service during the three months prior to the survey (October - December 2023) and that had at least one provider who had received any in-service training on this topic in the two years prior to the survey (January 2022 - December 2023). Facility tiers that were not required to offer a particular laboratory service under Ghanaian guidelines at the time of the survey were excluded from the analysis for that service. Among communicable diseases-related laboratory services, in-service training was most commonly reported for HIV testing (54.2 percent; 95% CI: 45.5 - 62.6) and blood film for malaria parasites (56.0 percent; 95% CI: 45.3 - 66.2). In-service training for NCD diagnostics also showed relatively broad coverage, including liver function tests (58.4 percent; 95% CI: 47.8 - 68.3), hemoglobin electrophoresis (58.5 percent; 95% CI: 48.2 - 68.2), and blood urea, electrolytes, and creatinine testing (59.4 percent; 95% CI: 49.1 - 68.9). Routine outpatient diagnostic services demonstrated moderate national training rates, with in-service training for hemoglobin testing at 51.3 percent (95% CI: 41.6 - 60.8) and random blood sugar at 45.5 percent (95% CI: 36.4 - 54.9). 105 Table 30. Proportion of health facilities with at least one provider that received in-service training in laboratory services during 2022 - 2023 in each service category (%) (N = 500) Commu- Sub-Dis- Category Service District Ghana nity trict 53.9 60.0 56.0 Blood film for malaria parasites NA [38.4 - 68.7] [51.1 - 68.3] [45.3 - 66.2] 51.9 62.5 54.2 HIV test NA [41.2 - 62.5] [53.7 - 70.5] [45.5 - 62.6] 43.4 53.2 46.2 Urine routine examination NA Commu- [30.0 - 57.9] [44.3 - 61.9] [36.0 - 56.7] nicable 46.7 51.0 48.2 disease Stool routine examination NA [28.6 - 65.7] [41.1 - 60.8] [35.5 - 61.0] laborato- ries 48.6 56.3 50.8 Hepatitis B sAg NA [34.9 - 62.5] [47.5 - 64.8] [40.6 - 60.9] 52.8 54.3 53.1 HIV/Syphilis combo test NA [41.0 - 64.4] [44.6 - 63.7] [43.6 - 62.4] 51.7 51.7 Blood & urine cultures NA NA [38.7 - 64.5] [38.7 - 64.5] Glucose 6 phosphate dehydro- 42.6 53.0 46.7 NA genase [23.4 - 64.4] [43.1 - 62.7] [33.7 - 60.1] 49.5 53.7 50.9 Blood group and rhesus factor NA [33.0 - 66.1] [44.7 - 62.5] [39.5 - 62.3] Non-com- 39.9 59.1 44.3 municable Fasting blood sugar NA [28.7 - 52.3] [50.2 - 67.4] [35.3 - 53.8] disease laborato- Blood urea, electrolytes & creat- 59.4 59.4 NA NA ries inine [49.1 - 68.9] [49.1 - 68.9] 58.4 58.4 Liver function tests NA NA [47.8 - 68.3] [47.8 - 68.3] 58.5 58.5 Hemoglobin electrophoresis NA NA [48.2 - 68.2] [48.2 - 68.2] 18.9 51.0 55.5 31.1 Urine pregnancy test [12.4 - 27.6] [40.6 - 61.3] [46.7 - 63.9] [25.6 - 37.3] 22.0 53.5 53.1 38.2 Urine dipstick for proteins [12.4 - 36.0] [42.5 - 64.2] [44.4 - 61.7] [31.0 - 46.1] 37.0 57.2 58.8 44.0 Malaria rapid diagnostic test [28.4 - 46.4] [46.6 - 67.2] [49.4 - 67.5] [37.5 - 50.8] Routine 50.0 53.8 51.3 OPD labo- Sickling status test NA [33.6 - 66.4] [44.7 - 62.6] [39.9 - 62.5] ratories 52.9 56.5 54.2 Full blood count NA [34.2 - 70.8] [47.5 - 65.0] [41.8 - 66.1] 49.7 55.9 51.3 Hemoglobin NA [37.3 - 62.2] [47.1 - 64.4] [41.6 - 60.8] 43.2 53.5 45.5 Random blood sugar NA [31.9 - 55.2] [44.7 - 62.1] [36.4 - 54.9] Note: Values in brackets are the 95% confidence interval. NA indicates where the indicator is not applicable at the tier. 106 Table 31 reports the percentage of health facilities with at least one provider trained in specialized services and topics in the two years between January 2022 - December 2023. Overall, the most common specialized service types where providers had received in-service training were: proper client documentation and history taking (55.2 percent; 95% CI: 49.1 - 61.2), IPC (54.3 percent; 95% CI: 48.3 - 60.2), how to check blood pressure (BP) (47.6 percent; 95% CI: 41.6 - 53.6), proper wound dressing (41.1 percent; 95% CI: 35.4 - 47.0). In contrast, in-service training in Pediatric Advanced Life Support (PALS) (9.1 percent; 95% CI: 6.6 - 12.4) and disaster preparedness and/or climate change and health (9.5 percent; 95% CI: 6.8 - 13) had relatively lower coverage. Facility-level variations were notable, with district facilities generally reporting higher training proportions compared to community tier facilities. Table 31. Health facilities with at least one provider trained in specialized services and topics (%) (N = 500) Sub- Service Community District Ghana District 3.8 16.0 46.2 9.1 Pediatric Advanced Life Support (PALS) [1.7 - 8.4] [9.8 - 25.1] [37.8 - 54.9] [6.6 - 12.4] 12.9 41.2 70.0 22.8 Management of neonatal asphyxia [8.5 - 19.2] [31.8 - 51.3] [61.5 - 77.3] [18.7 - 27.5] 44.2 77.1 86.3 54.3 Infection Prevention and control [36.6 - 52.2] [67.2 - 84.7] [79.1 - 91.2] [48.3 - 60.2] 19.2 45.1 66.4 27.9 First Aid; proper positioning during fractures [13.7 - 26.3] [35.1 - 55.5] [57.8 - 74.1] [23.1 - 33.3] 14.1 37.3 72.0 22.8 Cardiopulmonary Resuscitation [9.4 - 20.6] [27.8 - 47.8] [63.6 - 79.0] [18.5 - 27.8] 20.5 54.5 72.7 31.4 How to set a line for IV fluids [14.9 - 27.7] [44.1 - 64.5] [64.4 - 79.7] [26.5 - 36.9] 21.2 53.9 75.8 32.0 How to arrest bleeding [15.4 - 28.4] [43.6 - 63.9] [67.6 - 82.4] [26.9 - 37.4] How to identify onset of shock and its early 12.8 48.4 68.9 24.4 management [8.4 - 19.1] [38.3 - 58.8] [60.4 - 76.3] [20.0 - 29.3] 12.8 41.6 62.9 22.4 Bandaging with splint [8.4 - 19.1] [31.6 - 52.2] [54.2 - 70.8] [18.1 - 27.3] Management of poisonous bites or ingestion of 15.5 40.6 59.1 23.9 poisonous substances [10.6 - 22.1] [30.8 - 51.3] [50.4 - 67.2] [19.4 - 29.0] 41.0 61.3 73.3 47.6 How to check BP [33.5 - 49.0] [50.6 - 70.9] [65.0 - 80.2] [41.6 - 53.6] 50.6 63.4 78.8 55.2 Proper client documentation and history taking [42.8 - 58.5] [52.6 - 73.0] [70.9 - 85.0] [49.1 - 61.2] 32.7 58.4 74.2 41.1 Proper wound dressing [25.7 - 40.5] [47.9 - 68.2] [66.0 - 81.1] [35.4 - 47.0] 5.8 38.4 62.9 16.6 Training on MgSO4 Protocol [3.0 - 10.8] [28.9 - 48.8] [54.2 - 70.8] [13.3 - 20.5] 107 Sub- Service Community District Ghana District 6.4 43.6 71.0 18.8 Management of prolonged labour [3.5 - 11.6] [33.8 - 54.0] [62.5 - 78.2] [15.3 - 22.8] 21.2 45.7 70.2 29.7 Protocol on waste segregation [15.4 - 28.4] [35.7 - 56.1] [61.7 - 77.5] [24.7 - 35.2] 10.9 38.0 70.2 20.6 Management of shock [6.9 - 16.9] [28.5 - 48.5] [61.7 - 77.5] [16.6 - 25.2] 3.9 29.3 59.5 12.9 Repair of cervical tear [1.7 - 8.4] [20.4 - 40.0] [50.8 - 67.7] [10.0 - 16.6] 3.2 22.5 49.2 10.3 Manual vacuum aspiration [1.3 - 7.5] [14.9 - 32.5] [40.6 - 57.9] [7.7 - 13.6] Disaster preparedness and/or climate change 4.5 18.0 36.4 9.5 and health [2.1 - 9.2] [11.2 - 27.7] [28.5 - 45.0] [6.8 - 13.0] Note: Values in brackets are the 95% confidence interval. Table 32 presents the proportion of health care providers who reported receiving in-training in various specialized services between January 2022 - December 2023. Overall, the most common specialized services that providers reported receiving training on were: resuscitation drills (39.1 percent; 95% CI: 32.7 - 46.0), adult infectious diseases (38.9 percent; 95% CI: 32.7 - 45.4), PPH drills (38.1 percent; 95% CI: 33.4 - 43.2), Early Essential Newborn Care (EENC) (37.3 percent; 95% CI: 31.0 - 44.1) and Integrated Management of Neonatal and Childhood Illnesses (IMNCI) (26.5 percent; 95% CI: 20.2 - 33.9). Training on gender-based violence (8.6 percent; 95% CI: 6.1 - 12.2), disaster and/or climate change (13.3 percent; 95% CI: 9.9 - 17.6), and the PEN protocol (14.8 percent; 95% CI: 11.0 - 19.7) were the least commonly reported. The training coverage varied across tiers and provider cadres. For most services, providers at district facilities had the highest reported rates of training in the two years prior to the survey. For example, 46.0 percent (95% CI: 36.7 - 55.6) of providers in district tier participated in resuscitation drills compared to 26.6 percent (95% CI: 10.1 - 53.7) of the community tier and 28.2 percent (95% CI: 22.1 - 35.2) of sub-district tier. By provider cadre, doctors typically reported the highest rates of training in specialized services across various categories, including resuscitation drills (64.0 percent; 95% CI: 54.9 - 72.2), PPH (58.6 percent; 95% CI: 49.6 - 67.0), and ischemic heart disease (57.8 percent; 95% CI: 48.8 - 66.3). Midwives, on the other hand, had the highest proportion trained in EENC (65.2 percent; 95% CI: 56.2 - 73.3) and PPH drills (60.4 percent; 95% CI: 50.5 - 69.4). Physician assistants had the highest proportion trained in adult infectious diseases (57.7 percent; 95% CI: 48.4 - 66.4) and ischemic heart disease (50.8 percent; 95% CI: 41.7 - 59.9), while nurses reported the highest proportion trained in adult infectious diseases (46.5 percent; 95% CI: 36.5 - 56.7). 108 Table 32. Proportion of providers reporting receipt and modality of training in specialized services (%) (N = 1227) Phy- Commu- Sub- Service District Doctor sician Nurse Midwife Ghana nity District Assistant Participated 26.6 28.2 46.0 64.0 42.5 21.3 58.5 39.1 resuscitation [10.1 - 53.7] [22.1 - 35.2] [36.7 - 55.6] [54.9 - 72.2] [33.7 - 51.8] [13.5 - 31.9] [48.5 - 67.9] [32.7 - 46.0] drills Received PEN 8.7 12.7 16.2 22.3 23.7 14.2 12.5 14.8 Protocol [4.6 - 15.6] [7.0 - 21.9] [11.4 - 22.5] [15.9 - 30.4] [16.6 - 32.6] [8.3 - 23.3] [8.2 - 18.4] [11.0 - 19.7] Trained COPD 4.8 12.6 20.4 46.6 39.5 17.7 6.6 17.3 [2.2 - 9.9] [6.5 - 23.1] [15.5 - 26.3] [37.8 - 55.5] [30.9 - 48.8] [11.3 - 26.6] [3.9 - 11.1] [13.4 - 22.1] Trained EENC 27.8 23.4 45.9 54.6 32.4 15.5 65.2 37.3 [11.2 - 54.1] [18.0 - 29.9] [37.2 - 54.8] [45.6 - 63.3] [24.4 - 41.5] [9.1 - 25.1] [56.2 - 73.3] [31.0 - 44.1] Trained IMNCI 23.8 19.6 30.6 46.4 27.4 22.3 28.1 26.5 [15.1 - 35.5] [14.3 - 26.1] [21.5 - 41.6] [37.7 - 55.4] [20.0 - 36.3] [14.9 - 32.0] [19.2 - 39.3] [20.2 - 33.9] Trained PPH 23.2 27.4 44.7 58.6 42.1 18.3 60.4 38.1 drills [7.4 - 53.2] [20.5 - 35.5] [38.6 - 51.0] [49.6 - 67.0] [33.5 - 51.3] [11.8 - 27.2] [50.5 - 69.4] [33.4 - 43.2] Trained adult 25.1 32.8 42.8 53.3 57.7 46.5 21.6 38.9 infectious dis- [16.4 - 36.3] [23.7 - 43.4] [34.4 - 51.5] [44.4 - 62.0] [48.4 - 66.4] [36.5 - 56.7] [14.6 - 30.8] [32.7 - 45.4] eases Trained disaster 3.1 7.8 16.8 20.1 19.3 14.8 8.8 13.3 and/or climate [1.3 - 7.3] [4.3 - 13.7] [11.9 - 23.2] [14.4 - 27.4] [13.1 - 27.4] [9.5 - 22.2] [5.2 - 14.4] [9.9 - 17.6] change Trained gen- 4.2 5.0 10.9 21.9 10.8 8.2 6.3 8.6 der-based [2.1 - 8.3] [2.8 - 8.9] [7.2 - 16.2] [14.8 - 31.0] [6.4 - 17.5] [4.6 - 14.2] [2.8 - 13.6] [6.1 - 12.2] violence Trained ischemic 0.8 11.6 25.3 57.8 50.8 19.0 7.7 19.9 heart disease [0.2 - 2.7] [6.7 - 19.4] [19.2 - 32.5] [48.8 - 66.3] [41.7 - 59.9] [12.3 - 28.3] [4.4 - 13.0] [15.7 - 25.0] Trained mental 14.1 15.1 26.7 37.1 31.9 23.7 15.3 22.2 health [5.8 - 30.3] [9.0 - 24.2] [19.5 - 35.3] [29.1 - 46.0] [23.9 - 41.2] [16.3 - 33.1] [9.2 - 24.4] [17.1 - 28.3] Note: Values in brackets are the 95% confidence interval. Figure 46 illustrates the educational attainment of health care providers. Overall, 50.9 percent (95% CI: 42.0 - 59.7) of providers reported holding a diploma or higher national diploma, while 37.2 percent (95% CI: 30.1 - 44.3) reported holding a bachelor’s degree. A smaller portion, 9.5 percent (95% CI: 5.1 - 13.9) reported holding a certificate, 1.8 percent (95% CI: 1.2 - 2.4) reported holding a master’s degree, and 0.7 percent (95% CI: 0.4 - 1.0) reported holding a doctorate or higher degree. The majority of midwives (68.4 percent; 95% CI: 52.5 - 84.3) and nurses (52.0 percent; 95% CI: 39.7 - 64.3) reported holding a diploma or higher national diploma. In contrast, the majority of doctors (72.2 percent; 95% CI: 56.2 - 88.4) and physician assistants (87.2 percent; 95% CI: 75.7 - 98.8) reported holding a bachelor’s degree. 109 Figure 46. Provider educational attainment (%) (N = 1227) 3.4.3 Satisfaction and retention To capture the self-reported job satisfaction of the interviewed providers, respondents were asked whether they strongly agreed, agreed, disagreed, or strongly disagreed with a series of prompts. This method was used to capture job satisfaction across 18 domains including work content; autonomy (balance between independence in decision-making and clear structure at work); growth/development (opportunities to develop professional skills); financial rewards; promotion; supervision; communication (systems in place to solicit and address staff feedback); relationships with co-workers; meaningfulness/personal accomplishment; workload; and work demands. Figure 47 presents the proportion of providers who agreed or strongly agreed with the statements about different aspects of their work. Among all providers, satisfaction was highest for meaningfulness of job (99.1 percent; 95% CI: 97.5 - 99.7), relationship with coworkers (98.5 percent; 95% CI: 97.2 - 99.2), clarity in work responsibilities (95.7 percent; 95% CI: 92.3 - 97.6), and work likeability (95.0 percent; 95% CI: 90.2 - 97.5). In contrast, lower satisfaction was reported for functioning of equipment, supplies, and medicine (35.7 percent; 95% CI: 29.7 - 42.2), and for infrastructure amenities (39.9 percent; 95% CI: 33.2 - 46.9). The lowest rates of satisfaction were reported for benefits (22.5 percent; 95% CI: 17.4 - 28.6) and pay (20.4 percent; 95% CI: 15.7 - 26.1). Disaggregated by provider cadre, satisfaction with the meaningfulness of the job was nearly universal among doctors (99.6 percent, 95% CI: 98.2 - 99.9), nurses (98.7 percent, 95% CI: 94.8 - 99.7), midwives (99.7 percent, 95% CI: 99.2 - 99.9), and physician assistants (97.9 percent, 95% CI: 93.6 - 99.3). Clarity in work responsibilities, relationships with coworkers, 110 and work likeability were also consistently rated highly across all groups. In contrast, satisfaction with pay and benefits was substantially lower, particularly among midwives (pay: 20.6 percent, 95% CI: 13.7 - 29.7; benefits: 16.5 percent, 95% CI: 11.1 - 23.9) and nurses (pay: 17.5 percent, 95% CI: 11.4 - 25.8; benefits: 24.4 percent, 95% CI: 16.9 - 33.8). Satisfaction with infrastructure and functioning of equipment, supplies, and medicine was moderate to low across all professions. Table 70 in Annex A presents further details on provider satisfaction by facility tier. Figure 47. Proportion of providers reporting being satisfied across different aspects of work (%) (N = 1227) 3.4.4 Workload Figure 48 presents the average proportion of time spent by providers across different activities in their most recent work week, as reported by the providers. On average, providers reported spending the majority of their time on patient care (72 percent), followed by administrative work (15 percent), management activities (5 percent) and educational activities (4 percent). There was not much variation across provider cadres. On average, doctors reported spending 78 percent of their time on patient care, followed by administrative work (13 percent). Physician assistants reported spending, on average, 75 percent of their time on patient care and 14 percent on administrative work. Nurses reported spending, on average, 71 percent of their time on patient care, 15 percent on administrative work, and 6 percent on management activities. Midwives reported spending, on average, 72 percent of their time on patient care and 14 percent on administrative work. 111 Figure 48. Average proportion of time spent by providers across different activities in the most recent work week, by provider cadre (%) (N = 1227) Figure 49 presents the average proportion of time spent by providers across different activities in the most recent work week by facility tier. On average, providers in district facilities reported spending 73 percent of their time on patient care, followed by administrative work (14 percent), educational activities (five percent) and management activities (five percent). Providers in sub-district facilities reported similar time division between the activities. In contrast, providers in the community tier reported spending 57 percent of their time on patient care, followed by home visits (including commute to and from) (11 percent), administrative work (11 percent), and community health outreach (11 percent). Figure 49. Median proportion of time spent by providers across different activities in the most recent work week, by tier (%) (N = 1227) 112 Table 33 presents the median workload of providers during a typical work week. Providers reported working a median of 40.0 hours during a typical week. This ranged from a median of 48.0 hours for doctors to a median of 40.0 hours for midwives and nurses. Providers reported a median of 14 outpatient contacts per day. Providers at community tier reported a median of 10 outpatient contacts per day, providers at the district facilities reported a median of 12 patient contacts per day, and providers at sub-district facilities reported a median of 17 contacts per day. By provider cadre, this ranged from 27 patient contacts per day reported by doctors to 8 patient contacts reported by midwives. Dissatisfaction with the balance between clinical and administrative work was reported by an average of 19.0 percent (95% CI: 12.8 - 27.4) doctors, 22.8 percent (95% CI: 16.5 - 30.6) physician assistants, 24.1 percent (95% CI: 16.5 - 33.9) nurses, and 18.8 percent (95% CI: 12.4 - 27.4) midwives. Table 33. Provider workload in the most recent typical work week (self-reported) (N = 1227) Percentage of providers dissatisfied Total hours Median outpatient Type with the balance of work between worked contacts per day clinical and administrative work Tier 40.6 10.1 24.4 Community (40.0 - 55.4) (7.0 - 15.4) [13.5 - 40.0] 40.0 17.0 29.2 Sub-District (35.0 - 45.0) (7.9 - 27.0) [21.2 - 38.9] 40.0 12.0 16.8 District (36.0 - 45.0) (5.0 - 29.0) [11.4 - 23.9] Cadre 48.0 22.0 19.8 Doctor (40.0 - 60.0) (17.0 - 33.0) [13.6 - 28.0] 42.0 27.0 23.4 Physician Assistant (39.7 - 50.0) (17.0 - 38.8) [17.0 - 31.4] 40.0 17.0 23.8 Nurse (35.0 - 45.0) (7.0 - 32.0) [16.2 - 33.4] 40.0 8.0 18.3 Midwife (36.0 - 45.0) (4.0 - 16.3) [12.0 - 27.0] 40.0 14.0 21.5 Ghana (35.0 - 45.0) (7.0 - 27.0) [16.8 - 27.1] Note: Values in parentheses are the first and third quartiles. Values in [] brackets are the 95% confidence intervals. 113 Chapter 4: Processes of Care This chapter describes the caregiving services provided in primary health care facilities. While most of the data have been collected from provider and patient interviews during the SDI health survey, some of the observations were derived from the facility manager interviews. As described previously, processes of care refer to the delivery or receipt of care in a facility setting. From the broadest perspective, this domain aims to understand a country’s primary health care service delivery system and gauge the competence and accessibility of services to patients. Within this domain, indicators are further assessed along two unique but interrelated categories: competent care systems and positive user experience. Box 2 highlights some of the key findings related to processes of care in primary health care facilities in Ghana. Definitions of sub-domains and in-depth analysis of their associated indicators are presented in due order within this chapter. Box 2. Key observations on primary health care processes of care in Ghana Competent care systems Diagnosis, treatment and counselling • Most providers were able to provide the correct primary diagnosis and treatment for simulated cases of diarrhea (90.9 percent; 95% CI: 84.5 - 94.9), type-2 diabetes (92.5 percent; 95% CI: 87.1 - 95.7) and hypertension (83.4 percent; 95% CI: 75.0 - 89.4). • For intrapartum emergency response simulations, while most providers were able to provide the correct diagnosis for postpartum hemorrhage (96.3 percent; 95% CI: 88.5 - 98.9), 77.5 percent (95% CI: 65.6 - 86.1) of providers provided the correct diagnosis for neonatal asphyxia. For the treatment of postpartum hemorrhage, 94.8 percent (95% CI: 83.8 - 98.5) of providers performed the correct primary treatment. Of the 34 steps outlined in the Ghanaian National Guidelines, providers completed a median of 12 steps. The key treatment step in birth asphyxia (chest rise in 1 minute) was achieved by 70.2 percent (95% CI: 40.9 - 88.0) of providers. • From the patient experience perspective, 12.1 percent (95 CI: 6.1 - 22.5) of patients reported that they received all of a list of 21 ANC services across all their visits for their current pregnancy. This increased to 41.7 percent (95% CI: 24.3 - 61.4) for patients more than 20 weeks pregnant for receiving five key ANC services. For NCD care, 0.5 percent (95% CI: 0.1 - 2.0) of patients reported 114 receiving all of a list of 24 services across all their visits. None of the caregivers of sick children reported that they received all of the 15 sick-child services when seeking care for their sick child. Referral, continuity, integration • Overall, more than half of patients (65.0 percent; 95% CI: 62.8 - 67.2) reported typically (always or often) using the same health facility for care and nearly half of the patients (48.8 percent; 95% CI: 46.1 - 51.4) reported typically seeing the same provider when they seek care at this health facility. • The burden of transferring health information for referrals most often relies on the patient themselves as reported by the patients (98.7 percent; 95% CI: 89.6 - 99.8) as well as providers (86.0 percent; 95% CI: 83.0 - 88.5), rather than on electronic or other means of information transfer between health care providers. Safety, prevention, and detection • Half the providers (50.7 percent; 95% CI: 44.7 - 56.6) received in-service IPC training. Less than a quarter (23.5 percent; 95% CI: 19.1 - 28.7) of facilities tested for notifiable diseases, but 93.5 percent (95% CI: 83.4 - 97.7) of those that did reported national notifiable diseases to a higher-level authority. • Records to monitor dispensed antibiotics were maintained in 36.3 percent (95% CI: 31.0 - 41.9) of facilities, and 11.6 percent (95% CI: 8.9 - 15.1) of facilities had at least one provider that received training on antimicrobial resistance (AMR). • While 61.9 percent (95% CI: 55.8 - 67.5) of facilities had protocols to access backup human resources in emergencies, 16.8 percent (95% CI: 12.9 - 21.5) had protocols to access essential medicines, consumables and equipment from medical buffer stores during emergencies. Drills on managing surge capacity had been conducted in 13.1 percent (95% CI: 10.4 - 16.4) of facilities, while 4.0 percent (95% CI: 2.8 - 5.7) had conducted a drill on safety procedures in the event of a natural disaster in the preceding 2 years (January 2022 - December 2023). Positive user experience • More than 85 percent of patients rated various aspects of their experience, including auditory and visual privacy, communication and their involvement in their care, as “good” or “very good”. Most patients (97.9 percent; 95% CI 96.5 - 98.7) reported that all of their questions were answered. • Patients rated aspects of the facilities such as duration of the consultation (91.9 percent; 95% CI: 89.9 - 93.6) and convenience of the hours of operation 115 (91.1 percent; 95% CI: 88.4 - 93.3) as “good” or “very good”. Less patients rated the availability and functioning equipment, supplies and medicines as “good” or “very good” (65.6 percent; 95% CI: 60.2 - 70.7). • The median waiting time before the consultation, as reported by patients, was 10.0 minutes, while the median consultation time was 15.0 minutes. 4.1 Competent care systems This domain provides greater insight into the clinical and interpersonal competencies of primary health care providers in the country. To comprehensively understand quality and competence, this section provides an overview of diagnosis, treatment, counseling quality, referrals, continuity procedures, and processes for safety, detection, and prevention. 4.1.1 Diagnosis, treatment, counseling This subsection reviews the knowledge and clinical competencies of health care providers, specifically their ability to competently deliver diagnostic services and provide adequate treatment and counseling to patients. This is based on provider performance on clinical case simulations, and on experiences of patients receiving care as reported through outpatient exit interviews. While the former highlights health care provider performance on clinical assessments, the latter corroborates the information from the patient’s perspective of receiving care. Diagnosis, treatment, counseling as measured through clinical vignettes Health care provider capacity to correctly diagnose and treat common health conditions is integral to high-quality primary care service delivery. There are many ways to assess clinical competency, including direct observation, chart review, standardized patient, written assessments — all of which have strengths and weaknesses. The SDI uses clinical vignettes, which are clinical simulation cases given to a health care provider through two enumerators. One enumerator acts as a patient, and the other as an observer. The patient-enumerator begins by giving a presenting complaint, followed by a prompt to ask all important specific (close-ended) initial questions. The patient-enumerator provides standardized responses. Similarly, the patient-enumerator sequentially asks the provider what physical examinations they would perform, investigations they would order assuming that the case is being managed in the facility, their diagnosis or diagnoses, the treatments and referrals they would make and health education and counselling they would give. The patient-enumerator provides standardized responses to each question asked by the provider and the observer- enumerator records the responses using a structured questionnaire. The provider is aware that they are undergoing a clinical competency assessment, and no feedback is provided to 116 the validity of the questions or responses given by the provider. One vignette, on neonatal asphyxia, followed a different format, where the provider had to physically complete actions on a doll, and was then asked for a diagnosis, about risk factors and other questions to assess competency. Analysis of the vignettes are done secondarily, and captures the level of completeness and specificity of the diagnoses and treatments proposed. For example, in the type-2 diabetes vignette, it captures whether a health care provider specified a “type-2” diagnosis, and not “type-1” or simply “diabetes”. It also captures the completeness of the diagnosis, such as a co-morbid dyslipidemia in the hypertension vignette. Information on incorrect or incomplete diagnoses and treatment can help guide policymakers in interventions and policy design to improve quality of care. In SDI surveys, clinical vignette topics are selected for international comparability and country-specific burden of disease and priorities. They are adapted based on each country’s clinical context and guidelines. Participating doctors, physician/medical assistants, nurses and midwives were randomly assigned two out of five vignettes, with the selection limited to vignettes relevant to their expertise and the types of cases that they would commonly see and are expected to be able to diagnose and treat according to local guidelines. There were two adult cases, type-2 diabetes and hypertension, and one child case: diarrhea. There were two intrapartum cases: postpartum hemorrhage and neonatal asphyxia. Table 74 in Annex C provides a detailed explanation of provider eligibility criteria for each of the clinical vignettes.66 Table 34 shows the correct primary and complete diagnoses and treatment for the one child and two adult vignettes. The splitting into primary and complete categories gives an assessment of the comprehensiveness of the provider’s diagnoses and treatment, where a provider should identify the primary diagnoses and treatment, but an ideally-performing provider identifies all diagnoses and treatments in the complete category. This is particularly so in the hypertension vignette where the complete diagnoses and treatments addresses key co-morbid conditions. 66   Footnote: The eligibility for a clinical vignette depends on the provider type, their specialty and the facility tier. For exam- ple, only doctors and physician assistants in sub-district and district facilities were eligible for the diabetes and hyperten- sion vignettes, and a pediatric doctor in a district facility was only eligible for the neonatal asphyxia vignette. 117 Table 34. Correct diagnosis and treatment by clinical vignette case for each of the one child and two adult cases Primary diag- Complete specific Complete specific treat- Case Primary treatment nosis diagnosis ment 1 Diarrhea, acute Diarrhea or acute Start intravenous (IV) Start intravenous (IV) fluid diarrhea, gas- diarrhea or gas- fluid (plan C), or refer (plan C) or refer to another troenteritis, or troenteritis, and to another health care health care provider in this severe dehydra- severe dehydration provider in this health health facility or refer ur- tion facility, or refer urgently gently to higher-level facility to higher-level facility for IV treatment, and ORS for IV treatment, or oral by mouth and zinc tablet rehydration solution (ORS) by mouth along with referring to another health care provider or facility for IV treatment 2 Diabetes, or Diabetes or diabe- Metformin and at least Metformin and at least one diabetes mellitus tes mellitus type II one behavioral change behavioral change interven- type II and not diabetes intervention tion and statin mellitus type I, and obesity 3 Hypertension Hypertension and Antihypertensive drug, Of the following antihyper- hyperlipidemia/​ or oral calcium channel tensives, any two of: other dyslipidemia/​hy- blockers, or oral ACE oral ACE inhibitors, oral cal- percholesterolemia inhibitors, or losartan cium channel blockers, other and obesity, or and other angiotensin oral diuretics (furosemide, metabolic syn- receptor blockers, or oral spironolactone); or any two drome diuretics (furosemide, of: losartan and other an- spironolactone) giotensin receptor blockers, oral calcium channel block- ers, other oral diuretics (fu- rosemide, spironolactone); and atorvastatin and at least one behavioral change intervention The percentage of providers that gave the correct primary and complete diagnoses by the provider type and facility tier is shown in table 35. For the diarrhea vignette, 91.5 percent (95% CI: 84.9 - 95.3) of providers in Ghana provided the correct primary diagnosis with little variation between facility tiers. While 98 percent or more of doctors (98.9 percent; 95% CI: 95.4 - 99.7), physician assistants (99.5 percent; 95% CI: 96.2 - 99.9) and midwives (98.2 percent; 95% CI: 95.4 - 99.3) gave the correct primary diagnosis, a somewhat lower percentage of nurses (89.0 percent; 95% CI: 80.3 - 94.1) made the correct primary diagnosis. In Ghana, only 16.9 percent (95% CI: 11.4 - 24.3) of providers made the correct complete diagnosis, with little variation between facility tiers. More physician assistants (43.3 percent; 95% CI: 31.0 - 56.5) and doctors (35.5 percent; 95% CI: 23.3 - 50.0) correctly made the complete diagnosis compared to nurses (14.7 percent; 95% CI: 8.3 - 24.7) and midwives (8.3 percent; 95% CI: 3.6 - 17.8). 118 For the diabetes vignette, 99.2 percent (95% CI: 97.2 - 99.8) of providers in Ghana gave the correct primary diagnosis with little variation between facility tiers and provider types. The correct complete diagnosis was only given by 17.4 percent (95% CI: 11.0 - 26.5) of providers in Ghana, with little variation between facility tiers. On average, more doctors (26.6 percent; 95% CI: 16.1 - 40.8) than physician assistants (8.8 percent; 95% CI: 3.4 - 21.0) correctly made the complete diagnosis. A high proportion of providers (90.3 percent; 95% CI: 84.0 - 94.4) gave the correct primary diagnosis for the hypertension vignette, with little variation by facility tier, and with more physician assistants making the correct primary diagnosis (96.3 percent; 95% CI: 92.5 - 98.2) than doctors (83.1 percent; 95% CI: 70.5 - 91.0). However, this result was not statistically significant, as it did not cross the threshold for significance (p = 0.08). As with the other vignettes only a small fraction of providers (14.8 percent; 95% CI: 9.4 - 22.6) gave the complete diagnosis for the hypertension vignette, with little variation by facility tier and provider type. Table 35. Clinical knowledge: Diagnostic accuracy in clinical vignettes (%), by provider cadre and tier, (N = 1227) Diarrhea Diabetes Mellitus Hypertension (N = 796) (N = 216) (N = 204) Primary Complete Primary Complete Primary Complete Provider Cadre 98.9 35.5 98.6 26.6 83.1 11.2 Doctor [95.4 - 99.7] [23.3 - 50.0] [94.3 - 99.7] [16.1 - 40.8] [70.5 - 91.0] [5.8 - 20.5] Physician 99.5 43.3 99.8 8.8 96.3 17.8 Assistant [96.2 - 99.9] [31.0 - 56.5] [98.2 - 100.0] [3.4 - 21.0] [92.5 - 98.2] [9.7 - 30.4] 89.0 14.7 NA NA NA NA Nurse [80.3 - 94.1] [8.3 - 24.7] 98.2 8.3 NA NA NA NA Midwife [95.4 - 99.3] [3.6 - 17.8] Tier 92.4 17.7 NA NA NA NA Community [84.7 - 96.4] [11.6 - 26.0] 91.4 9.5 99.0 10.0 92.4 15.0 Sub-District [80.0 - 96.6] [5.8 - 15.2] [92.1 - 99.9] [2.4 - 33.9] [84.8 - 96.4] [5.4 - 35.4] 91.5 23.8 99.2 18.5 89.9 14.8 District [81.8 - 96.3] [14.4 - 36.6] [96.8 - 99.8] [11.4 - 28.5] [82.0 - 94.5] [8.8 - 23.7] 91.5 16.9 99.2 17.4 90.3 14.8 Ghana [84.9 - 95.3] [11.4 - 24.3] [97.2 - 99.8] [11.0 - 26.5] [84.0 - 94.4] [9.4 - 22.6] Note: Values in brackets are the 95% confidence intervals. NA indicates no providers in that stratum were administered that given vignette. Table 36 further breaks down the diagnoses given by providers, showing the percentage of providers who mentioned each diagnosis. As providers were able to select multiple diagnoses, the values under each vignette do not sum to 100 percent. Across all vignettes, 119 the primary diagnosis was most often cited by providers who participated in that respective vignette. For the diarrhea vignette, providers gave diagnoses such as gastroenteritis (52.4 percent; 95% CI: 44.7 - 60.0), diarrhea (41.5 percent; 95% CI: 33.6 - 50.0), acute diarrhea (31.0 percent; 95% CI: 24.2 - 38.6) or severe dehydration (20.1 percent; 95% CI: 14.0 - 28.1)—all of which were correct primary diagnoses. A sizable proportion incorrectly identified moderate dehydration (18.6 percent; 95% CI: 12.8 - 26.4) or mild dehydration (6.8 percent; 95% CI: 4.3 - 10.8) instead of severe dehydration. The severity of dehydration guides treatment decisions, with severe dehydration necessitating intravenous fluid replacement. Furthermore, some providers incorrectly diagnosed cholera (6.8 percent; 95% CI: 4.0 - 11.2) and dysentery (6.6 percent; 95% CI: 3.6 - 11.8) where case management would often include antibiotics, unlike case management of acute diarrhea. The consideration of these conditions may reflect awareness of more serious etiologies of diarrhea. For the diabetes vignette, most providers correctly identified type-2 diabetes (87.2 percent; 95% CI: 80.8 - 91.6), however 8.5 percent (95% CI: 5.1 - 13.9) incorrectly gave a diagnosis of type-1 diabetes, and 3.5 percent (95% CI: 1.0 - 12.2) gave a diagnosis of hyperthyroidism. Only 18.1 percent (95% CI: 11.6 - 27.1) of providers correctly identified co-morbid obesity in this vignette. For the hypertension vignette, while 90.3 percent (95% CI: 84.0 - 94.4) of providers correctly diagnosed hypertension, only 46.2 percent (95% CI: 38.0 - 54.6) and 25.8 percent (95% CI: 18.5 - 34.8) correctly identified co-morbid hyperlipidemia and obesity respectively, with 1.9 percent (95% CI: 0.7 - 5.1) correctly identifying metabolic syndrome. Some providers incorrectly diagnosed pre-hypertension (4.3 percent; 95% CI: 1.8 - 9.9) and diabetes (4.3 percent; 95% CI: 1.8 - 9.9), while 5.4 percent (95% CI: 2.7 - 10.8) said that the patient was healthy and did not have any disease. Table 36. Clinical knowledge: Diagnoses selected by providers, by vignette (%), (N = 1227) Primary Complete Diagnosis Option % of Providers Diagnosis Diagnosis Clinical Vignette: Diarrhea Gastroenteritis 52.4 [44.7 - 60.0] + + Diarrhea 41.5 [33.6 - 50.0] + + Acute diarrhea 31.0 [24.2 - 38.6] + + Severe dehydration 20.1 [14.0 - 28.1] + ✔ Dehydration 19.2 [14.1 - 25.6] Moderate dehydration 18.6 [12.8 - 26.4] Mild dehydration 6.8 [4.3 - 10.8] Cholera 6.8 [4.0 - 11.2] 120 Primary Complete Diagnosis Option % of Providers Diagnosis Diagnosis Dysentery 6.6 [3.6 - 11.8] Chronic/persistent diarrhea 1.7 [0.9 - 3.1] Patient does not have any disease/patient is healthy 0.2 [0.1 - 0.4] Clinical Vignette: Diabetes Mellitus Diabetes Mellitus Type II 87.2 [80.8 - 91.6] + + Diabetes 75.6 [66.7 - 82.7] + + Obesity 18.1 [11.6 - 27.1] ✔ Diabetes Mellitus Type I 8.5 [5.1 - 13.9] Hyperthyroidism 3.5 [1.0 - 12.2] Stroke 0.7 [0.2 - 2.8] Patient does not have any disease/patient is healthy 0.4 [0.1 - 3.2] Clinical Vignette: Hypertension Hypertension 90.3 [84.0 - 94.4] ✔ □ Hyperlipidemia/Dyslipidemia/Hypercholesterolemia 46.2 [38.0 - 54.6] □ Obesity 25.8 [18.5 - 34.8] □ Pre-hypertension 7.9 [4.0 - 15.1] Patient does not have any disease/patient is healthy 5.4 [2.7 - 10.8] Diabetes 4.3 [1.8 - 9.9] Metabolic syndrome 1.9 [0.7 - 5.1] ✔ Aortic coarctation 1.1 [0.2 - 7.6] Renal artery stenosis 0.3 [0.0 - 1.9] Note: Values in brackets are the 95% confidence intervals. Additional Notes: 1. At least one of the options marked (+) must have been selected by the provider to count for the primary/complete diagnosis. 2. All checked (✔) options and at least one of the options marked (+) must have been selected by the provider to count for the primary/ complete diagnosis. 3. All options marked (□) or the option marked (✔) must have been selected by the provider to count for the primary/complete diagnosis. 4. For the Diabetes Mellitus vignette, if a provider made a diagnosis of Diabetes Mellitus Type I, the diagnosis does not count as complete, even if all other criteria were met. Table 37 shows the percentage of providers who provided the correct primary treatment and complete treatment by provider type and facility tier for the three vignettes. In the diarrhea vignette, 84.8 percent (95% CI: 78.4 - 89.6) of providers recommended the correct primary treatment, while 45.7 percent (95% CI: 37.4 - 54.3) provided the correct complete treatment. More providers in district (92.2 percent; 95% CI: 85.0 - 96.1) and sub-district (77.8 percent; 95% CI: 66.4 - 86.2) facilities provided the correct primary treatment than in community facilities (40.5 percent; 95% CI: 32.0 - 49.7). Similarly, more providers in both district (43.4 percent; 95% CI: 32.6 - 54.9) and sub-district (48.6 percent; 95% CI: 35.9 - 61.5) facilities provided the correct complete treatment compared to community facilities (27.0 percent; 95% CI: 19.7 - 35.8). Most providers gave the correct primary treatment for the diabetes vignette (92.9 percent; 121 95% CI: 87.9 - 95.9), with only 28.3 percent (95% CI: 20.3 - 37.8) of providers providing the correct complete treatment as well. There was little variation between facility tiers for the primary treatment, however, on average more providers in district facilities (31.1 percent; 95% CI: 22.3 - 41.6) provided the correct complete treatment than in sub-district facilities (7.2 percent; 95% CI: 2.7 - 17.9). For the hypertension vignette, 88.3 percent (95% CI: 80.7 - 93.2) of providers recommended the correct primary treatment, although only 21.5 percent (95% CI: 15.5 - 29.0) of providers recommended the correct complete treatment. More providers in district facilities (24.6 percent; 95% CI: 17.6 - 33.4) recommended the correct complete treatment than in sub- district facilities (7.5 percent; 95% CI: 3.5 - 15.1). There was little variation by provider type for the correct primary and complete treatment for the three vignettes. Table 37. Clinical knowledge: Treatment accuracy in clinical vignettes (%), by provider cadre and tier, (N = 1227) Diarrhea Diabetes Mellitus Hypertension (N = 796) (N = 216) (N = 204) Primary Complete Primary Complete Primary Complete Provider Cadre 89.5 46.9 92.6 34.1 88.4 22.3 Doctor [79.8 - 94.8] [36.2 - 58.0] [85.3 - 96.4] [22.7 - 47.6] [76.5 - 94.7] [13.6 - 34.2] Physician 92.4 58.5 93.2 22.7 88.2 20.9 Assistant [84.2 - 96.6] [45.7 - 70.2] [85.5 - 97.0] [14.1 - 34.6] [75.0 - 94.9] [11.9 - 34.1] 85.0 45.1 NA NA NA NA Nurse [77.5 - 90.3] [35.2 - 55.4] 78.2 42.8 NA NA NA NA Midwife [64.5 - 87.7] [28.4 - 58.5] Tier 40.5 27.0 NA NA NA NA Community [32.0 - 49.7] [19.7 - 35.8] 77.8 48.6 98.4 7.2 85.3 7.5 Sub-District [66.4 - 86.2] [35.9 - 61.5] [93.1 - 99.7] [2.7 - 17.9] [55.6 - 96.4] [3.5 - 15.1] 92.2 43.4 92.1 31.1 89.0 24.6 District [85.0 - 96.1] [32.6 - 54.9] [86.4 - 95.6] [22.3 - 41.6] [81.1 - 93.8] [17.6 - 33.4] 84.8 45.7 92.9 28.3 88.3 21.5 Ghana [78.4 - 89.6] [37.4 - 54.3] [87.9 - 95.9] [20.3 - 37.8] [80.7 - 93.2] [15.5 - 29.0] Note: Values in brackets are the 95% confidence intervals. NA indicates no providers in that stratum were administered that given vignette. 122 Table 38 further breaks down the treatment given by providers, showing the percentage of providers who recommended each treatment. For the diarrhea vignette, most providers (84.3 percent; 95% CI: 77.9 - 89.1) recommended starting intravenous fluid (plan C) with 8.6 percent (95% CI: 4.5 - 15.8) of providers recommending referral to another provider in the same facility and 5.1 percent (95% CI: 3.4 - 7.6) recommending referral to a higher- level facility for intravenous treatment—all acceptable primary treatments. Approximately three-quarters of providers recommended ORS by mouth (75.3 percent; 95% CI: 66.6 - 82.4). National guidelines at the time of the survey recommended that ORS be trialed for patients before and during transfer: 87.8 percent (95% CI: 75.8 - 94.3) of providers who recommended referral to another provider in the same facility or to a higher-level facility for intravenous treatment, also correctly prescribed ORS. However, 13.3 percent (95% CI: 8.8 - 19.5) of providers incorrectly recommended only ORS, without recommending other correct treatment options such as IV fluids or transfer. Oral zinc was correctly recommended by the majority of providers (69.4 percent; 95% CI: 61.2 - 76.6). Over half the providers prescribed antibiotics, which were not indicated (53.3 percent; 95% CI: 44.9 - 61.5). Small percentages of providers incorrectly recommended zinc syrup (5.2 percent; 95% CI: 3.3 - 8.2) and rehydration by nasogastric tube started by them (2.7 percent; 95% CI: 1.7 - 4.1) or in another facility (1.2 percent; 95% CI: 0.6 - 2.6). For the diabetes vignette, the primary treatments of metformin and at least one behavioral change intervention was correctly identified by 94.6 percent (95% CI: 89.8 - 97.2) and 97.9 percent (95% CI: 94.7 - 99.2) of providers, respectively. Atorvastatin or another statin, which was required for the complete treatment, was correctly recommended by 27.8 percent (95% CI: 19.6 - 37.8) and 7.5 percent (95% CI: 3.6 - 14.9) of providers. However, some providers recommended treatments that were not in keeping with the guidelines, such as a sulfonylurea (42.2 percent; 95% CI: 33.9 - 51.0), insulin (35.6 percent; 95% CI: 27.8 - 44.2), phenformin (3.4 percent; 95% CI: 1.2 - 9.1), and aspirin (8.0 percent; 95% CI: 3.8 - 16.1). For example, the guidelines at the time of the survey recommended that sulfonylurea should only be prescribed after three months if blood sugar control is inadequate with metformin. For the hypertension vignette, the primary treatment included one of a range of anti- hypertensives, among which oral calcium channel blockers were the most commonly recommended by 74.7 percent (95% CI: 66.4 - 81.5) of providers in Ghana. The complete treatment included a combination of two anti-hypertensives, excluding oral β-blockers or the specific combination of an oral angiotensin-converting-enzyme (ACE) inhibitor and losartan/ other angiotensin receptor blockers. Only 46.9 percent (95% CI: 39.3 - 54.7) of providers correctly prescribed atorvastatin, which was a part of the complete treatment. Despite not being indicated for this vignette, oral β-blockers (19.7 percent; 95% CI: 13.7 - 27.4), aspirin (12.6 percent; 95% CI: 8.1 - 19.2), metformin (10.1 percent; 95% CI: 5.9 - 16.8) and oral vasodilators (6.6 percent; 95% CI: 3.2 - 13.1) were recommended by providers. 123 Table 38. Clinical knowledge: Treatments selected by providers, by vignette (%), (N = 1227) Primary Complete Treatment Option % of Providers Treatment Treatment Clinical Vignette: Diarrhea Start intravenous (IV) fluid (plan C) 84.3 [77.9 - 89.1] ⨁ + ORS by mouth 75.3 [66.6 - 82.4] ▽ ✔ Zinc tablet 69.4 [61.2 - 76.6] ✔ Antibiotics 53.3 [44.9 - 61.5] Refer to another health care provider within this health facility 8.6 [4.5 - 15.8] ⨁ □ + Vitamin A 5.7 [3.5 - 9.2] Zinc syrup 5.2 [3.3 - 8.2] Refer urgently to higher-level facility for IV treatment 5.1 [3.4 - 7.6] ⨁ □ + Start rehydration by naso-gastric (NG) tube 2.7 [1.7 - 4.1] Refer to another health facility 1.3 [0.8 - 2.1] Refer urgently to higher-level facility for NG treatment 1.2 [0.6 - 2.6] No treatment or referral is needed, so send patient home 0.5 [0.2 - 1.5] Clinical Vignette: Diabetes Mellitus At least one behavioral change intervention 97.9 [94.7 - 99.2] ✔ ✔ Metformin 94.6 [89.8 - 97.2] ✔ ✔ Sulfonylurea 42.2 [33.9 - 51.0] Insulin 35.6 [27.8 - 44.2] Atorvastatin, Lipitor, Colestop 27.8 [19.6 - 37.8] + Aspirin 8.0 [3.8 - 16.1] Any other statin, Crestor 7.5 [3.6 - 14.9] + Phenformin 3.4 [1.2 - 9.1] Clinical Vignette: Hypertension At least one behavioral change intervention 99.0 [96.3 - 99.7] ✔ Oral calcium channel blockers 74.7 [66.4 - 81.5] + ▲ □ Antihypertensive drug 62.7 [53.1 - 71.4] + Atorvastatin 46.9 [39.3 - 54.7] ✔ Oral ACE inhibitors 34.4 [24.9 - 45.2] + ▲ Losartan and other angiotensin receptor blockers 23.9 [17.3 - 32.0] + □ Oral β-blockers (bisoprolol, carvedilol, metoprolol, ateno- 19.7 [13.7 - 27.4] lol, propranolol) Oral diuretics (furosemide, spironolactone) 17.9 [12.1 - 25.8] + ▲ □ Aspirin 12.6 [8.1 - 19.2] 124 Primary Complete Treatment Option % of Providers Treatment Treatment Metformin 10.1 [5.9 - 16.8] Oral vasodilators (nitroglycerine, glyceryl trinitrate, isosor- 6.6 [3.2 - 13.1] bide dinitrate, sodium nitroprusside) Note: Values in brackets are the 95% confidence intervals. Additional Notes: 1. All checked (✔) options and at least one of the options marked (+) must have been selected by the provider to count for the primary/ complete treatment. 2. At least one of the options marked (⨁), or the option marked (▽) and at least one of the options marked (□) must have been selected by the provider to count for the primary treatment in the diarrhea vignette. 3. Two options marked (▲) or two options marked (□), and all options marked (✔) must have been selected by the provider to count for the complete treatment in the hypertension vignette. Figure 50 shows the proportion of providers who gave both the correct primary diagnosis and primary treatment for each vignette, by facility tier and provider type, respectively. In Ghana, most providers gave both the correct primary diagnosis and primary treatment for type-2 diabetes (92.5 percent; 95% CI: 87.1 - 95.7), followed by hypertension (83.4 percent; 95% CI: 75.0 - 89.4) and diarrhea (79.5 percent; 95% CI: 72.1 - 85.3). With relation to provider type, there was some variation in the diarrhea vignette with 88.9 percent (95% CI: 79.2 - 94.3) of doctors and 91.9 percent (95% CI: 83.7 - 96.2) physician assistants giving the correct primary diagnosis and treatment compared to 78.0 percent (95% CI: 69.1 - 84.9) of nurses and 77.7 percent (95% CI: 63.9 - 87.2) of midwives. Figure 50. Correct vignette primary diagnosis and treatment, by provider cadre and tier (%) (N = 1227) 125 Intrapartum Emergency Response Of the five vignettes, two assessed the capacity of providers to respond to emergency intrapartum cases. Table 39 displays the proportion of providers able to correctly diagnose the PPH and neonatal asphyxia cases, by provider type and facility tier. On average, 96.3 percent (95% CI: 88.5 - 98.9) and 77.5 percent (95% CI: 65.6 - 86.1) of providers correctly diagnosed PPH and neonatal asphyxia respectively. Table 39. Clinical knowledge: Diagnostic accuracy for emergency response vignette simulations by tier and provider cadre (%), (N = 530) PPH Neonatal Asphyxia (N = 397) (N = 398) Provider Cadre Doctor 100.0 [100.0 - 100.0] 95.6 [79.1 - 99.2] Physician Assistant 96.6 [89.4 - 99.0] 91.1 [83.0 - 95.6] Nurse 100.0 [100.0 - 100.0] 68.7 [24.9 - 93.5] Midwife 96.2 [87.7 - 98.9] 77.4 [62.5 - 87.5] Tier Community 100.0 [100.0 - 100.0] 89.9 [71.9 - 96.9] Sub-District 98.9 [96.8 - 99.6] 85.1 [74.2 - 91.9] District 95.1 [83.1 - 98.7] 74.7 [59.5 - 85.5] Ghana 96.3 [88.5 - 98.9] 77.5 [65.6 - 86.1] Note: Values in brackets are the 95% confidence intervals. Table 40 shows the percentage of providers who performed each action as part of the management recommended for PPH. The correct critical management included administering oxytocin by either intramuscular or intravenous routes (via an infusion), along with gentle fundal massage or bimanual abdominal compression, in line with recommendations by the International Federation of Gynecology and Obstetrics.67 More doctors (94.8 percent; 95% CI: 83.8 - 98.5) recommended the complete treatment than midwives (71.5 percent; 95% CI: 61.9 - 79.5), nurses (47.4 percent; 95% CI: 10.4 - 87.5) and physician assistants (45.5 percent). Oxytocin was recommended by 66.9 percent (95% CI: 56.8 - 75.6) of providers by the intramuscular route, and 71.2 percent (95% CI: 62.5 - 78.6) of providers by the intravenous route (infusion). A gentle fundal massage was recommended by 73.2 percent (95% CI: 64.4 - 80.5) of providers while 13.5 percent (95% CI: 9.4 - 19.0) opted for bimanual abdominal compression. There was some variation by facility tier and provider cadre for these key indicators. For example, more doctors than midwives recommended gentle fundal massage (94.8 percent (95% CI: 83.8 - 98.5) compared to 73.1 percent (95% CI: 63.7 - 80.8)) and bimanual abdominal compression (45.8 percent (95% CI: 23.7 - 69.6) compared to 12.3 percent (95% CI: 8.2 - 18.0)).   Escobar, M. F., Anwar, H. N., Theron, G., et al. (2022). FIGO Recommendations on the Management of Postpartum Hem- 67 orrhage 2022. International Journal of Gynecology & Obstetrics, 157(Suppl. 1), 3-50. https://doi.org/10.1002/ijgo.14116. 126 Table 40. Clinical knowledge: Treatment accuracy for the postpartum hemorrhage (PPH) clinical vignette, by tier and provider cadre (%), (N = 397) Provider Cadre Tier Complete Physician Step Doctor Nurse Midwife Community Sub-District District Ghana Treatment Assistant Call for help 62.6 48.8 75.0 47.9 51.6 38.5 53.0 48.5 [35.3 - 83.7] [30.3 - 67.7] [39.2 - 93.3] [37.1 - 58.8] [40.6 - 62.4] [26.6 - 52.0] [38.8 - 66.8] [38.3 - 58.7] Reassure the woman 29.8 47.9 70.7 46.7 47.4 45.3 46.8 46.3 [12.6 - 55.6] [29.5 - 66.9] [32.6 - 92.3] [35.8 - 57.8] [37.3 - 57.7] [32.7 - 58.4] [32.8 - 61.2] [36.0 - 57.0] Determine the cause 67.0 41.9 21.2 64.3 25.0 58.8 66.3 63.6 [39.7 - 86.2] [24.6 - 61.4] [5.0 - 57.6] [54.3 - 73.2] [8.5 - 54.3] [46.0 - 70.6] [53.4 - 77.2] [54.0 - 72.2] Insert urine catheter/Fo- 68.4 19.0 56.1 64.7 61.4 53.5 68.2 63.5 ley catheter to empty the [45.2 - 85.0] [9.4 - 34.8] [17.4 - 88.6] [54.3 - 73.8] [27.2 - 87.1] [40.0 - 66.5] [55.2 - 78.9] [53.7 - 72.3] bladder Gentle fundal massage + 94.8 57.3 49.0 73.1 66.4 74.7 72.6 73.2 [83.8 - [38.5 - 74.2] [11.5 - 87.7] [63.7 - 80.8] [33.6 - 88.5] [62.0 - 84.2] [60.5 - 82.1] [64.4 - 80.5] 127 98.5] Set up intravenous (IV) 89.0 86.2 79.4 70.8 80.0 78.8 68.4 71.8 access/IV line size 16 or [71.3 - 96.3] [74.6 - 93.0] [43.8 - 95.0] [57.8 - 81.1] [53.9 - 93.2] [65.9 - 87.8] [51.6 - 81.5] [59.5 - 81.5] 18G Give normal saline 88.3 87.3 65.3 73.7 72.2 83.1 70.5 74.5 through IV bolus [71.6 - 95.7] [76.0 - 93.7] [25.9 - 91.0] [60.8 - 83.5] [41.4 - 90.5] [70.7 - 91.0] [53.7 - 83.1] [62.3 - 83.7] Administer intramuscu- □ 89.2 54.4 71.2 66.5 52.9 69.4 65.9 66.9 lar (IM) oxytocin 10 IU [74.3 - [35.4 - 72.3] [33.2 - 92.5] [55.8 - 75.7] [42.2 - 63.3] [57.0 - 79.5] [51.9 - 77.6] [56.8 - 75.6] 95.9] Administer IV tranexamic 74.7 16.4 5.4 31.7 8.9 26.0 35.8 32.5 acid 1 g STAT [49.6 - 89.8] [7.9 - 30.9] [0.7 - 31.0] [22.6 - 42.6] [2.9 - 24.3] [15.8 - 39.6] [23.8 - 49.9] [23.6 - 42.8] Administer misoprostol 54.2 17.9 2.2 40.8 30.0 46.6 37.6 40.3 per rectal 4 tablets (800 [29.5 - 76.9] [8.7 - 33.2] [0.4 - 12.1] [30.9 - 51.4] [15.2 - 50.8] [33.9 - 59.7] [25.8 - 51.1] [31.1 - 50.3] mcg) STAT Administer misoprostol 20.5 19.6 42.5 27.9 27.9 35.3 23.9 27.5 sublingual 4 tablets (800 [8.9 - 40.6] [8.0 - 40.8] [7.3 - 87.5] [19.5 - 38.3] [12.7 - 50.8] [23.2 - 49.7] [14.4 - 37.1] [19.5 - 37.3] mcg) STAT Provider Cadre Tier Complete Physician Step Doctor Nurse Midwife Community Sub-District District Ghana Treatment Assistant 20 units oxytocin in □ 49.2 41.5 17.4 73.1 47.9 74.9 69.8 71.2 normal saline at 20 [31.1 - [24.3 - 61.1] [4.2 - 49.9] [63.9 - 80.6] [37.1 - 58.9] [62.7 - 84.2] [57.8 - 79.6] [62.5 - 78.6] drop per minute 67.5] 1 ampoule IM injection 26.4 3.4 9.8 5.3 6.8 4.0 6.7 5.9 of methergine (ergo- [10.6 - 51.9] [0.7 - 14.1] [1.2 - 49.6] [3.1 - 8.9] [1.4 - 27.4] [1.6 - 9.7] [3.8 - 11.7] [3.7 - 9.3] metrine) Do bimanual abdomi- + 45.8 20.5 11.9 12.3 11.0 21.5 9.9 13.5 nal compression [23.7 - 69.6] [9.0 - 40.2] [1.9 - 49.1] [8.2 - 18.0] [3.2 - 31.7] [13.3 - 32.8] [5.9 - 16.1] [9.4 - 19.0] Do aortic compression 13.9 3.4 8.7 3.7 5.3 8.3 2.0 4.0 [3.5 - 41.9] [0.7 - 14.1] [0.9 - 51.2] [1.4 - 9.7] [0.8 - 27.1] [2.4 - 25.2] [0.7 - 5.5] [1.6 - 9.5] Give condom tampon- 60.3 5.6 11.4 19.3 9.2 29.3 16.1 20.2 ade (vaginal packing) [37.9 - 79.1] [1.6 - 17.5] [1.7 - 48.7] [12.5 - 28.7] [2.4 - 29.8] [18.6 - 42.8] [8.6 - 28.2] [13.6 - 28.9] Check vitals every 15 60.0 32.8 6.5 38.3 10.5 44.6 36.3 38.6 128 minutes [32.8 - 82.2] [16.9 - 53.8] [1.3 - 27.7] [28.4 - 49.2] [3.6 - 26.8] [31.6 - 58.3] [24.3 - 50.2] [29.2 - 48.9] Blood grouping and 52.2 33.3 6.5 22.1 6.8 18.8 25.5 23.2 cross-matching with 2 [31.3 - 72.3] [18.1 - 52.9] [1.3 - 27.7] [15.0 - 31.2] [2.1 - 20.4] [11.4 - 29.4] [16.1 - 37.8] [16.3 - 31.9] donors Blood transfusion 62.8 22.9 8.7 24.9 6.8 20.1 28.9 25.9 [43.8 - 78.5] [10.8 - 42.2] [1.6 - 35.1] [17.0 - 35.1] [2.0 - 20.6] [11.2 - 33.3] [18.5 - 42.1] [18.2 - 35.5] Complete Treatment1 94.8 45.5 47.4 71.5 64.5 73.9 70.3 71.3 [83.8 - 98.5] [27.4 - 64.9] [10.4 - 87.5] [61.9 - 79.5] [31.3 - 87.9] [61.3 - 83.5] [57.9 - 80.2] [62.3 - 78.9] Median no. of steps 11.9 7.0 12.6 8.0 7.2 9.0 8.0 8.0 taken Note: Values in brackets are the 95% confidence intervals. The bolded treatment options are key steps in the Ghana national guidelines. 1 One option marked (+) and one option marked (□) must be selected to count for the complete treatment. Table 41 shows the percentage of providers who performed each action as part of the management recommended for neonatal asphyxia. The critical treatment step is achieving a chest rise within one minute, which was only achieved by 65.3 percent (95% CI: 53.7 - 75.3) of providers in Ghana. A higher percentage of providers in district facilities (70.8 percent; 95% CI: 56.8 - 81.8) achieved a chest rise in one minute, compared to providers in sub-district facilities (50.3 percent; 95% CI: 36.0 - 64.6) and community facilities (29.4 percent; 95% CI: 10.3 - 60.1). A higher percentage of nurses (80.5 percent; 95% CI: 47.4 - 95.0), doctors (70.2 percent; 95% CI: 40.9 - 88.9) and midwives (64.3 percent; 95% CI: 53.4 - 73.9) achieved a chest rise in one minute, than physician assistants (41.1 percent; 95% CI: 26.1 - 58.0). Along with the low percentage of providers achieving a chest rise in one minute, only 58.4 percent (95% CI: 45.1 - 70.6) of providers in community facilities positioned the head correctly, which is needed to get an adequate chest rise, compared to 83.6 percent (95% CI: 75.3 - 89.5) overall. There was variation in the completion of each action. In particular, the use of monitoring equipment after the baby started breathing was low, with only 41.1 percent (95% CI: 32.9 - 49.9) of providers applying a pulse oximeter and 16.3 percent (95% CI: 10.3 - 25.0) applying an electrocardiogram (ECG). Counselling across all facility tiers was generally low: 49.0 percent (95% CI: 40.2 - 57.8) of clinicians counselled the mother that the baby would require continued monitoring, with 47.6 percent (95% CI: 39.0 - 56.3) advising that the baby could be fed and 33.7 percent (95% CI: 25.9 - 42.6) explaining at least three hunger signs or cues. 129 Table 41. Clinical knowledge: Treatment accuracy for the neonatal asphyxia clinical vignette simulation, by tier and provider cadre (%) (N = 398) Provider Cadre Tier Step Physician Doctor Nurse Midwife Community Sub-District District Ghana Assistant Called out the time of birth 55.8 53.9 74.3 62.7 31.7 51.4 67.9 63.4 [36.3 - 73.6] [35.8 - 71.0] [33.3 - 94.3] [52.1 - 72.3] [11.0 - 63.6] [37.0 - 65.6] [55.0 - 78.5] [52.6 - 72.9] Initiated drying the baby within 5 91.5 81.5 99.2 91.6 86.3 93.7 91.4 92.0 seconds after birth [71.3 - 97.9] [62.7 - 92.0] [96.7 - 99.8] [85.0 - 95.4] [64.5 - 95.6] [83.7 - 97.7] [83.4 - 95.8] [86.1 - 95.5] Dried the baby thoroughly 97.7 64.9 81.3 92.7 89.7 86.1 92.7 91.0 [86.4 - 99.6] [44.1 - 81.3] [38.3 - 96.8] [87.3 - 95.9] [70.3 - 97.0] [73.3 - 93.3] [86.1 - 96.3] [85.5 - 94.6] Stimulation by rubbing the back 73.3 80.8 81.1 85.5 86.8 75.3 87.8 84.6 [51.3 - 87.8] [61.3 - 91.7] [38.3 - 96.8] [76.9 - 91.2] [65.9 - 95.8] [57.2 - 87.4] [79.6 - 92.9] [76.9 - 90.1] Removed the wet cloth that was used 66.1 57.2 78.3 73.4 41.8 70.6 74.5 73.2 for drying [45.3 - 82.1] [38.7 - 73.9] [36.7 - 95.8] [63.0 - 81.8] [13.9 - 76.2] [54.6 - 82.8] [62.2 - 83.8] [63.4 - 81.2] 130 Put baby in direct skin-to-skin contact 62.8 52.1 74.9 64.7 81.9 68.6 63.9 65.3 with mother [42.4 - 79.5] [34.1 - 69.6] [32.9 - 94.8] [51.3 - 76.2] [55.9 - 94.2] [52.4 - 81.2] [50.4 - 75.6] [54.4 - 74.7] Covered baby's body and head with 69.7 55.2 75.0 70.6 40.8 70.2 71.1 70.6 dry cloth and hat/bonnet [48.0 - 85.2] [36.7 - 72.4] [33.9 - 94.6] [57.2 - 81.2] [13.6 - 75.0] [54.4 - 82.2] [58.7 - 81.0] [60.9 - 78.7] Checked if baby is breathing or not 100.0 81.5 98.9 95.7 88.1 92.4 97.0 95.7 [100.0 - 100.0] [62.4 - 92.1] [95.8 - 99.7] [91.9 - 97.8] [66.2 - 96.6] [85.1 - 96.2] [92.5 - 98.8] [92.3 - 97.7] Called for help 55.4 40.0 76.5 58.3 49.6 45.6 64.2 59.3 [35.6 - 73.7] [23.9 - 58.6] [35.1 - 95.1] [46.2 - 69.4] [39.2 - 60.1] [32.1 - 59.9] [53.1 - 73.9] [50.7 - 67.4] Removed outer pair of gloves 67.0 24.2 58.4 47.6 43.9 35.0 53.1 48.4 [39.8 - 86.2] [14.0 - 38.6] [17.3 - 90.4] [36.1 - 59.3] [32.4 - 56.2] [22.6 - 49.7] [36.5 - 69.0] [35.3 - 61.7] Clamped and cut cord 86.5 75.0 93.9 84.4 89.7 89.7 83.3 85.0 [57.7 - 96.8] [53.9 - 88.5] [65.8 - 99.2] [68.6 - 93.0] [71.3 - 96.8] [74.0 - 96.4] [67.2 - 92.4] [72.6 - 92.4] Moved baby to resuscitation area 98.0 90.7 95.3 95.4 88.1 96.8 94.9 95.3 [85.1 - 99.8] [79.0 - 96.2] [75.4 - 99.3] [90.9 - 97.7] [64.6 - 96.8] [93.4 - 98.5] [89.1 - 97.7] [91.3 - 97.5] Provider Cadre Tier Step Physician Doctor Nurse Midwife Community Sub-District District Ghana Assistant Covered baby during and after trans- 89.7 62.2 86.1 80.5 83.7 81.2 80.5 80.7 fer [62.4 - 97.9] [43.4 - 77.9] [40.3 - 98.3] [70.1 - 87.9] [59.8 - 94.7] [65.9 - 90.6] [68.0 - 88.9] [71.1 - 87.7] Positioned the head correctly to open 96.9 71.9 72.2 84.8 58.4 84.3 83.7 83.6 airway [86.1 - 99.4] [53.9 - 84.9] [30.7 - 93.9] [75.9 - 90.8] [45.1 - 70.6] [69.8 - 92.6] [72.9 - 90.8] [75.3 - 89.5] Cleared the airway 100.0 81.5 83.3 96.2 88.6 89.7 96.5 94.7 [100.0 - 100.0] [61.8 - 92.3] [40.1 - 97.4] [91.2 - 98.4] [66.1 - 96.9] [75.8 - 96.1] [90.8 - 98.7] [89.8 - 97.3] Applied face mask firmly over baby's 100.0 85.4 81.9 87.8 80.7 93.8 85.4 87.5 chin, mouth, and nose [100.0 - [66.4 - 94.6] [39.6 - 96.9] [69.4 - 95.8] [53.3 - 93.8] [80.5 - 98.2] [68.6 - 94.0] [74.4 - 94.4] 100.0] Started bag ventilation with air 98.9 92.0 82.8 91.4 88.6 93.3 90.0 90.8 [91.2 - 99.9] [83.8 - 96.3] [39.8 - 97.2] [81.3 - 96.3] [68.5 - 96.6] [80.4 - 97.9] [73.4 - 96.7] [79.0 - 96.3] Took ventilation corrective steps 100.0 61.6 79.8 85.2 73.9 77.6 86.9 84.4 131 [100.0 - 100.0] [42.2 - 78.0] [37.7 - 96.3] [77.1 - 90.8] [44.1 - 91.1] [62.0 - 88.1] [77.8 - 92.6] [76.7 - 89.9] Achieved chest rise within 1 minute 70.2 41.1 80.5 64.3 29.4 50.3 70.8 65.3 [40.9 - 88.9] [26.1 - 58.0] [47.4 - 95.0] [53.4 - 73.9] [10.3 - 60.1] [36.0 - 64.6] [56.8 - 81.8] [53.7 - 75.3] Squeezed bag to give 30 to 50 93.5 53.5 81.8 77.8 75.2 66.7 81.7 77.9 breaths per minute [75.0 - 98.6] [35.3 - 70.9] [46.1 - 95.9] [67.7 - 85.4] [45.8 - 91.6] [50.5 - 79.7] [69.7 - 89.7] [67.9 - 85.4] Maintained good chest rise, squeez- 96.9 67.8 89.3 76.4 56.8 57.8 85.1 77.9 ing bag min 5 times [86.1 - 99.4] [49.7 - 81.8] [61.2 - 97.8] [66.7 - 84.0] [44.1 - 68.7] [42.2 - 72.0] [74.5 - 91.8] [68.4 - 85.2] Checked breathing and pulse at least 82.7 72.1 65.8 73.3 56.3 70.2 73.9 72.8 every 1–2 minutes [54.3 - 95.0] [53.9 - 85.1] [24.6 - 91.9] [59.6 - 83.6] [43.9 - 68.0] [54.2 - 82.3] [61.8 - 83.3] [63.4 - 80.5] Applied pulse oximeter if available 69.7 40.9 66.5 37.5 20.6 22.8 47.7 41.1 [42.9 - 87.6] [24.8 - 59.2] [25.3 - 92.1] [27.5 - 48.7] [7.0 - 47.5] [14.8 - 33.6] [37.0 - 58.5] [32.9 - 49.9] Applied electrocardiogram (ECG) if 14.5 17.3 7.3 17.3 13.9 8.7 19.0 16.3 available [5.1 - 35.0] [7.4 - 35.5] [1.4 - 30.0] [10.9 - 26.4] [4.2 - 37.1] [5.2 - 14.1] [10.8 - 31.2] [10.3 - 25.0] Stopped mechanical ventilation when 95.0 61.0 74.3 64.0 72.9 63.7 66.3 65.7 baby started crying [82.5 - 98.7] [42.3 - 77.0] [32.4 - 94.6] [50.9 - 75.3] [42.5 - 90.7] [48.1 - 76.9] [52.9 - 77.5] [55.3 - 74.8] Provider Cadre Tier Step Physician Doctor Nurse Midwife Community Sub-District District Ghana Assistant Returned baby to mother's chest 74.1 75.2 63.1 74.8 78.1 78.8 72.0 73.7 [52.6 - 88.0] [57.3 - 87.3] [22.1 - 91.2] [60.2 - 85.4] [50.3 - 92.6] [63.1 - 89.0] [57.1 - 83.2] [62.0 - 82.8] Checked for another baby 22.9 16.6 48.1 15.4 12.4 18.6 18.7 18.6 [8.7 - 48.0] [8.6 - 29.6] [10.1 - 88.4] [9.5 - 23.9] [3.9 - 33.2] [10.6 - 30.6] [10.6 - 30.9] [12.0 - 27.7] Gave oxytocin to the mother 80.0 65.2 71.0 74.5 55.5 76.9 73.4 74.1 [57.2 - 92.3] [45.6 - 80.6] [29.5 - 93.5] [60.9 - 84.6] [44.1 - 66.5] [61.5 - 87.3] [60.9 - 83.0] [64.3 - 81.9] Delivered placenta 82.7 82.4 71.7 78.0 84.8 85.1 75.0 77.7 [58.4 - 94.2] [67.0 - 91.5] [30.1 - 93.7] [63.6 - 87.8] [62.4 - 94.9] [69.8 - 93.3] [61.9 - 84.7] [67.1 - 85.6] Reassured mother 61.0 46.1 54.6 66.4 69.8 65.7 64.1 64.5 [39.9 - 78.7] [29.0 - 64.1] [14.5 - 89.5] [53.7 - 77.0] [38.2 - 89.6] [51.1 - 77.9] [53.5 - 73.5] [56.0 - 72.3] Counseled mother that baby will 49.2 46.9 56.4 48.3 28.9 50.9 48.6 49.0 require continued monitoring [30.8 - 67.8] [29.8 - 64.9] [15.8 - 89.9] [37.0 - 59.7] [10.1 - 59.4] [36.6 - 65.1] [37.8 - 59.5] [40.2 - 57.8] 132 Counseled mother that baby can be 38.4 37.0 51.0 47.8 45.2 62.2 42.6 47.6 fed [21.8 - 58.2] [22.2 - 54.8] [12.0 - 88.8] [36.7 - 59.2] [34.2 - 56.7] [48.5 - 74.2] [32.5 - 53.3] [39.0 - 56.3] Counseled mother on at least 3 hun- 29.0 26.7 48.3 32.6 16.5 38.2 32.4 33.7 ger cues/signs [13.7 - 51.2] [14.2 - 44.5] [10.3 - 88.4] [23.2 - 43.5] [5.4 - 40.5] [24.9 - 53.6] [23.1 - 43.4] [25.9 - 42.6] Provided routine care 88.7 58.4 81.8 68.5 75.2 79.4 66.7 70.0 [73.0 - 95.8] [39.2 - 75.3] [39.5 - 96.9] [55.3 - 79.4] [46.5 - 91.4] [64.9 - 89.0] [55.2 - 76.5] [60.6 - 78.0] Note: Values in brackets are the 95% confidence intervals. The step in bold is the primary treatment for this vignette. Processes of care as experienced by patients While the previous section measured the quality of processes of care through clinical simulation cases, this subsection explores care received as reported by patients. Survey participants who sought antenatal, hypertension or diabetes care, or who were accompanying pediatric patients for sick child care, were asked questions about the receipt of crucial components of care in the services they received that day, or in a previous visit for the same condition. Table 42 presents the results from women seeking antenatal care who reported having received some or all of 21 relevant services. This information is split into two frames: the patient’s current visit and all visits-including current visit-during their pregnancy. This split follows WHO guidance on specific services that should be offered during each visit, compared to those that may be offered at specific times during the pregnancy.68 Overall, 12.1 percent (95% CI: 6.1 - 22.5) of the interview respondents who were seeking ANC reported that they had received all 21 ANC services either during their current or a previous visit for this pregnancy. Certain services were provided for almost all patients in the current visit, with most patients reporting that providers asked for their Maternal and Child Health (MCH) handbook (98.4 percent; 95% CI: 95.0 - 99.5), measured their weight (91.9 percent; 95% CI: 85.4 - 95.6) and blood pressure (86.6 percent; 95% CI: 77.0 - 92.6). However, only 50.8 percent (95% CI: 33.4 - 68.0) and 56.3 percent (95% CI: 38.3 - 72.8) of patients, respectively, received feedback on whether their weight and blood pressure were normal or not. Most aspects of counselling were provided for close to 70 percent or more patients in the current or a previous visit, such as counseling on alcohol (72.7 percent; 95% CI: 57.1 - 84.2), tobacco (72.8 percent; 95% CI: 64.1 - 80.1), harms of marijuana and illicit drugs (71.5 percent; 95% CI: 58.1 - 81.9), physical activity (79.0 percent; 95% CI: 64.4 - 88.7), diet (92.2 percent; 95% CI: 85.7 - 95.9), pregnancy danger signs (87.2 percent; 95% CI: 79.6 - 92.3) and advice on exclusive breastfeeding (68.4 percent; 95% CI: 53.7 - 80.2). Table 42. Proportions of ANC patients who received each (and all together) of the specified services across all visits (N = 216) This or a previ- ANC Service This visit ous visit Provider asked for maternal and child health handbook 98.4 [95.0 - 99.5] 98.4 [95.0 - 99.5] Provider estimated delivery date 26.0 [16.4 - 38.6] 81.0 [71.0 - 88.1] Measured weight 91.9 [85.4 - 95.6] 99.6 [97.7 - 99.9] Informed whether weight was normal/higher/lower than normal 50.8 [33.4 - 68.0] 61.4 [40.3 - 79.0] Measured height 46.3 [35.8 - 57.1] 89.4 [81.5 - 94.1]   WHO. 2016. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Luxembourg, Geneva: 68 World Health Organization. https://iris.who.int/handle/10665/250796. 133 This or a previ- ANC Service This visit ous visit Blood pressure (BP) measured 86.6 [77.0 - 92.6] 94.0 [78.5 - 98.5] Informed BP was normal/higher/lower than expected1 56.3 [38.3 - 72.8] 72.8 [57.2 - 84.3] Urine sample 61.0 [47.1 - 73.3] 95.6 [90.2 - 98.1] Screened for HIV 16.6 [9.2 - 28.0] 87.9 [78.2 - 93.6] Screened for syphilis 12.5 [6.2 - 23.5] 84.9 [74.4 - 91.6] Blood group test 14.2 [8.2 - 23.3] 89.7 [82.3 - 94.2] Recommended to take iron or folic acid 69.9 [55.7 - 81.1] 94.5 [88.6 - 97.4] Discussed the side effects of iron pills2 26.7 [18.3 - 37.1] 41.2 [30.7 - 52.6] Counseled on alcohol 33.0 [21.3 - 47.3] 72.7 [57.1 - 84.2] Counseled on tobacco 30.0 [18.5 - 44.7] 72.8 [64.1 - 80.1] Counseled on harms of marijuana and illicit drugs 27.2 [16.8 - 41.1] 71.5 [58.1 - 81.9] Counseled on physical activity 44.0 [28.7 - 60.5] 79.0 [64.4 - 88.7] Counseled on diet 67.2 [59.4 - 74.3] 92.2 [85.7 - 95.9] Counseled on pain relief and management of common pregnan- 33.8 [21.6 - 48.7] 58.4 [38.7 - 75.8] cy-related symptoms Counseled on pregnancy danger signs 56.2 [47.8 - 64.3] 87.2 [79.6 - 92.3] Advised on exclusive breastfeeding 39.8 [30.2 - 50.3] 68.4 [53.7 - 80.2] All services above were performed 0.0 [0.0 - 0.0] 12.1 [6.1 - 22.5] Note: Values in brackets are the 95% confidence intervals. 1 Percentages are calculated with the sample of patients who had a BP measured in this visit and this or a previous visit, respectively. 2 Percentages are calculated with the sample of patients who were recommended to take iron or folic acid in this or a previous visit. Figure 51 shows the proportion of ANC patients at more than 20 weeks gestation who received specified services at the current antenatal visit. It primarily includes procedures that are most often administered during the second trimester of pregnancy to check for complications such as gestational diabetes and assess fetal development. Among those women more than 20 weeks pregnant, 41.7 percent (95% CI: 24.3 - 61.4) reported receiving all of these services. Most patients reported that their abdomen was palpated (96.1 percent; 95% CI: 86.3 - 99.0), the uterine height was measured (97.7 percent; 95% CI: 93.1 - 99.3), and that they received an ultrasound scan (93.1 percent; 95% CI: 82.7 - 97.5). However, only 58.6 percent (95% CI: 33.6 - 79.8) had their blood glucose level measured and 46.4 percent (95% CI: 26.8 - 67.2) were informed of the result. 134 Figure 51. Proportions of ANC patients, > 20 weeks gestation, who received each (and all together) of the specified services at this or a previous visit (N = 154) Patients who reported receiving health care for diabetes or hypertension in this visit were asked whether they received a range of services related to risk factor assessment, physical and biomarker examinations, and counselling services in either the current or a previous visit. Table 43 shows the percentage of patients who received each service by facility tier. Close to 95% or more patients reported receiving each risk factor assessment. Most patients also received each physical and biomarker examination and counselling services, with little variation by facility type. However, of those with diabetes, 65.8 percent (95% CI: 35.3 - 87.1) had their feet examined and 66.8 percent (95% CI: 38.1 - 86.8) had their eyes examined. While almost all patients underwent a blood glucose test, only 48.0 percent (95% CI: 18.5 - 79.0) had their cholesterol and lipids tested. In all, only 0.5 percent (95% CI: 0.1 - 2.0) of patients received all of the services recommended for diabetes or hypertension. 135 Table 43. Percentage of patients reporting NCD services performed at current or previous visit (%) (N = 225) Tier Diabetes or Hypertension Service Community Sub-District District Ghana (N = 7) (N = 92) (N = 126) Risk Factor Assessment Asked about current medica- 100.0 99.4 99.3 99.3 tions [100.0 - 100.0] [97.0 - 99.9] [94.8 - 99.9] [97.4 - 99.8] Asked medical history 100.0 92.6 98.3 96.1 [100.0 - 100.0] [63.0 - 98.9] [88.8 - 99.8] [84.1 - 99.1] Asked family history 100.0 90.4 99.1 96.1 [100.0 - 100.0] [53.2 - 98.7] [94.0 - 99.9] [81.5 - 99.3] Asked about tobacco use 100.0 89.3 97.3 94.4 [100.0 - 100.0] [53.8 - 98.3] [89.0 - 99.4] [81.9 - 98.4] Asked about alcohol use 100.0 87.2 98.8 94.9 [100.0 - 100.0] [57.0 - 97.2] [94.7 - 99.7] [83.3 - 98.6] Asked about physical activity 100.0 97.9 96.1 96.9 [100.0 - 100.0] [87.9 - 99.7] [82.1 - 99.3] [89.4 - 99.1] Asked about diet 100.0 97.9 100.0 99.1 [100.0 - 100.0] [88.0 - 99.7] [100.0 - 100.0] [95.3 - 99.8] Asked about occupation 100.0 97.8 100.0 99.1 [0.0 - **] [88.4 - 99.6] [100.0 - 100.0] [95.2 - 99.8] Physical and Biomarker Examinations Checked breathing and heart 100.0 90.7 94.8 93.1 w/ stethoscope [100.0 - 100.0] [66.9 - 97.9] [79.5 - 98.9] [81.8 - 97.6] Examined abdomen 100.0 83.0 92.2 88.5 [100.0 - 100.0] [48.2 - 96.3] [71.9 - 98.2] [72.0 - 95.8] Examined feet1 NA 43.6 78.6 65.8 [9.4 - 85.3] [39.3 - 95.4] [35.3 - 87.1] Examined eyes1 100.0 56.4 74.7 66.8 [** - **] [14.9 - 90.5] [36.0 - 93.9] [38.1 - 86.8] Checked blood glucose via 100.0 100.0 100.0 100.0 sample [100.0 - 100.0] [100.0 - 100.0] [100.0 - 100.0] [100.0 - 100.0] Received blood glucose result2 100.0 100.0 99.6 99.8 [0.0 - **] [100.0 - 100.0] [97.3 - 100.0] [98.3 - 100.0] Discussed blood glucose result2 100.0 100.0 100.0 100.0 [100.0 - 100.0] [100.0 - 100.0] [100.0 - 100.0] [100.0 - 100.0] Cholesterol/lipids tested NA 33.8 62.7 48.0 [5.3 - 82.1] [13.4 - 94.8] [18.5 - 79.0] Received cholesterol/lipids NA 92.6 82.4 86.4 result3 [33.3 - 99.7] [27.7 - 98.3] [46.8 - 97.9] Discussed cholesterol/lipids test NA 92.6 78.6 84.7 results3 [33.3 - 99.7] [27.6 - 97.2] [43.8 - 97.5] Measured blood pressure 100.0 100.0 100.0 100.0 [100.0 - 100.0] [100.0 - 100.0] [100.0 - 100.0] [100.0 - 100.0] 136 Tier Diabetes or Hypertension Service Community Sub-District District Ghana (N = 7) (N = 92) (N = 126) Discussed blood pressure 100.0 99.7 100.0 99.9 result4 [100.0 - 100.0] [97.6 - 100.0] [100.0 - 100.0] [99.0 - 100.0] Counseling Services Counseled on dangers of 100.0 86.5 97.2 93.4 tobacco [100.0 - 100.0] [54.4 - 97.2] [88.7 - 99.4] [81.3 - 97.9] Counseled on dangers of 100.0 88.8 98.7 94.8 alcohol [100.0 - 100.0] [64.9 - 97.1] [94.2 - 99.7] [83.0 - 98.6] Counseled on physical activity 100.0 98.3 96.0 97.0 [0.0 - **] [87.6 - 99.8] [81.6 - 99.2] [89.4 - 99.2] Counseled on diet 100.0 99.7 96.9 98.1 [100.0 - 100.0] [97.6 - 100.0] [79.9 - 99.6] [88.7 - 99.7] All services above were per- 0.0 0.0 0.9 0.5 formed [0.0 - 0.0] [0.0 - 0.0] [0.2 - 3.8] [0.1 - 2.0] Note: Values in brackets are the 95% confidence intervals. 1 Analysis for this service was performed only on patients who reported visiting for diabetes-related care, n = 47. 2 Percentages are calculated with the sample of patients that had a blood sample taken for a blood glucose test only. 3 Percentages are calculated with the sample of patients that had a blood sample taken for a blood cholesterol test only. 4 Percentages are calculated with the sample of patients that had their blood pressure measured. NA indicates that a robust estimate of the proportion was not provided given that it was not estimable given missing data. ** There were insufficient data for the calculation of robust 95% confidence interval bounds. These estimates should be interpreted with caution. The next area of focus is pediatric health care services. Table 44 shows the percentage of caregivers who reported their sick child aged four years or younger received each type of service in the current visit, categorized by age group. Less than one percent (0.6 percent; 95% CI: 0.1 - 4.0) of caregivers reported that the patient received all of the services, relevant to the age group, listed. Apart from asking the age of the child and the symptoms, most background information indicators were asked from around half or fewer of the caregivers. Only 30.8 percent (95% CI: 21.4 - 42.2) of caregivers were asked about the child’s immunization history, with little variation across age groups of the sick child. Whilst close to three-quarters of relevant caregivers in Ghana received advice on exclusive breastfeeding (77.1 percent; 95% CI: 61.1 - 87.9) and giving complementary foods to the child (71.4 percent; 95% CI: 45.9 - 88.0), about a third or less reported being asked about child growth, observed the child’s growth being plotted, or received counselling on feeding. Counseling on signs and symptoms to watch for was provided to 53.0 percent (95% CI: 40.5 - 65.2) and 52.3 percent (95% CI: 39.5 - 64.8) were given a date or time to return for follow-up. Overall, only 52.1 percent (95% CI: 43.0 - 61.0) of caregivers were informed about the child’s disease or diagnosis. Table 71 in Annex A provides reasons for pediatric patients to seek care on the day of the survey. 137 Table 44. Percentage of patients reporting sick child services performed at current visit (%), by tier (N = 331) Under 6 6 months - Above 2 years Sick child service months 2 years Ghana (N = 174) (N = 69) (N = 88) Background information Asked age of child 72.7 [45.7 - 89.4] 87.7 [74.9 - 94.5] 72.6 [51.7 - 86.7] 78.5 [67.7 - 86.5] Asked about child's symp- 99.5 [97.0 - 99.9] 99.5 [96.4 - 99.9] 96.8 [86.1 - 99.3] 98.4 [94.1 - 99.6] toms Asked if first or follow-up 71.0 [52.7 - 84.3] 38.6 [21.7 - 58.7] 61.9 [43.4 - 77.4] 54.5 [43.9 - 64.8] visit Asked about immunization 37.4 [19.7 - 59.2] 26.5 [14.5 - 43.4] 31.9 [17.9 - 50.1] 30.8 [21.4 - 42.2] history Told to watch for signs or 65.3 [45.8 - 80.7] 57.4 [39.9 - 73.2] 43.6 [27.8 - 60.8] 53.0 [40.5 - 65.2] symptoms Given date/time to return 63.1 [41.9 - 80.3] 53.8 [35.6 - 71.1] 46.1 [30.6 - 62.4] 52.3 [39.5 - 64.8] for follow-up Asked about child's moth- 29.2 [14.1 - 51.0] 35.0 [18.0 - 56.8] 20.4 [11.0 - 34.8] 27.8 [18.9 - 38.9] er's health Nutrition-related and general counseling Advice on giving child com- NA 71.4 [45.9 - 88.0] NA 71.4 [45.9 - 88.0] plementary foods Asked about feeding 51.9 [30.7 - 72.4] 32.6 [17.6 - 52.3] 38.1 [23.5 - 55.2] 38.6 [27.4 - 51.0] Asked about child growth 25.2 [11.1 - 47.7] 25.5 [12.0 - 46.2] 17.6 [10.3 - 28.4] 22.1 [13.9 - 33.2] Plotted growth 7.5 [2.9 - 17.9] 16.2 [6.6 - 34.5] 10.9 [5.2 - 21.4] 12.3 [6.9 - 21.1] Counseled on feeding 54.9 [34.1 - 74.1] 30.4 [15.8 - 50.3] 30.1 [18.3 - 45.4] 34.9 [23.5 - 48.4] Advised on exclusive breast- 69.9 [37.3 - 90.1] NA NA 69.9 [37.3 - 90.1] feeding Informed on disease/diag- 50.0 [29.2 - 70.7] 54.3 [36.0 - 71.5] 51.1 [34.2 - 67.7] 52.1 [43.0 - 61.0] nosis Received nutritional supple- 4.0 [1.0 - 14.9] 14.7 [5.8 - 32.6] 4.8 [2.0 - 11.1] 8.5 [4.3 - 16.2] ment for child All services above were 0.0 [0.0 - 0.0] 1.6 [0.2 - 11.4] 0.0 [0.0 - 0.0] 0.6 [0.1 - 4.0] performed Note: Values in brackets are the 95% confidence intervals. NA indicates service not applicable for age group. 4.1.2 Referral, continuity, integration This section presents findings on referral patterns between health facilities in Ghana, along with insights into patient and provider experiences during referrals and the transfer of patient information across facilities. Continuity of care is more likely when patients receive services consistently from the same facility or provider. Referral patterns may reflect patient 138 preferences—whether for more specialized care or for services available at a more convenient location. Ideally, information about the patient’s medical history and the reasons for the referral should be communicated directly between providers or facilities, without placing the responsibility on patients to carry this information themselves. The analysis that follows explores aspects of continuity of care and referral systems within Ghana’s health sector. It begins by examining how often patients visit the same health facility and how often they are seen by the same provider, the frequency of referrals as reported by providers, and finally outlines referral practices, highlighting patterns of referral, common reasons for referral and how patient information is transferred during the process. Table 45 presents the distribution of how often patients reported that they visit the health facility at which they were interviewed. More than half the patients (65.0 percent; 95% CI: 62.8 - 67.2) reported they typically (always or often) used the same health facility for care. Table 45. Distribution of frequency (always, often, sometimes, rarely, never) with which patients visit the health facility at which they were interviewed, for care (%), by tier (N = 2758) Always Often Sometimes Rarely Never Tier 60.8 16.3 17.0 4.7 1.2 Community [42.8 - 76.3] [3.4 - 51.6] [3.8 - 51.5] [0.1 - 66.5] [0.0 - 87.5] 43.2 26.9 17.3 9.3 3.4 Sub-District [39.2 - 47.2] [22.6 - 31.6] [13.0 - 22.6] [5.4 - 15.6] [0.8 - 13.1] 28.3 31.2 24.9 12.8 2.8 District [24.0 - 33.0] [26.9 - 35.8] [20.6 - 29.8] [8.6 - 18.6] [0.5 - 13.8] 36.2 28.8 21.0 10.9 3.1 Ghana [33.3 - 39.2] [25.8 - 32.0] [17.9 - 24.5] [7.9 - 14.9] [1.0 - 9.2] Note: Values in brackets are the 95% confidence intervals. Table 46 presents another measure of continuity of care from the patient perspective: it shows the distribution of patients who reported always, often, sometimes, rarely, or never seeing the same health care provider. While 48.8 percent (95% CI: 46.1 - 51.4) of patients reported typically (always or often) seeing the same provider, more patients at community facilities (79.2 percent; 95% CI: 63.8 - 89.1) reported typically seeing the same provider compared to patients at sub-district (55.1 percent; 95% CI: 51.6 - 58.7) and district (41.2 percent; 95% CI: 37.2 - 45.4) facilities. This finding may reflect the smaller number of health care providers in community facilities (median: 3) compared to sub-district (15) and district (42) facilities (Foundations, 3.4.1). 139 Table 46. Distribution of frequency (always, often, sometimes, rarely, never) with which pa- tients see the same provider when they seek care at this health facility (%), by tier (N = 2758) Tier Always Often Sometimes Rarely Never 30.2 49.0 17.5 2.5 0.9 Community [12.8 - 55.9] [30.3 - 68.0] [4.0 - 51.5] [0.0 - 77.6] [0.0 - 90.5] 23.5 31.6 34.5 6.5 3.9 Sub-District [19.2 - 28.4] [27.4 - 36.2] [30.4 - 39.0] [2.9 - 13.6] [1.1 - 12.9] 15.6 25.6 38.7 16.4 3.7 District [11.3 - 21.1] [21.3 - 30.5] [34.6 - 42.9] [12.1 - 21.8] [1.0 - 13.1] 19.8 29.0 36.3 11.2 3.7 Ghana [16.6 - 23.3] [26.0 - 32.3] [33.4 - 39.3] [8.2 - 15.2] [1.4 - 9.4] Note: Values in brackets are the 95% confidence intervals. Figure 52 shows the provider-reported median number of outpatient referrals made by providers during October - December 2023. An outpatient referral occurs when a health care provider at this health facility recommends that an outpatient should seek additional inpatient or outpatient care at another health facility (any level) or from another health care provider. The same outpatient may receive multiple referrals. Overall, 50 percent of providers reported making five or more referrals, with a quarter of providers making twelve or more referrals during the same time period. Providers in community and sub-district facilities made more referrals than those in district facilities: half the providers in community facilities made four or more referrals with a quarter making seven or more referrals, while half the providers in sub-district facilities made eleven or more referrals. Meanwhile, half the providers in district facilities made no referrals, while a quarter of providers made seven or more referrals to another health facility (higher or lower level) or health care provider. Figure 52. Median number of referrals providers report making from October - De- cember 2023, by tier (N = 1174) 140 The percentage of patients who reported receiving a referral to another provider at the same facility is shown in figure 53. Overall 9.8 percent (95% CI: 6.8 - 14.1) of patients reported receiving such a referral. There was some variation by facility tier, with only 1.1 percent (95% CI: 0.2 - 5.7) of patients in community facilities receiving an in-facility referral compared to 11.7 percent (95% CI: 6.5 - 20.0) of patients in sub-district facilities. This may be because community facilities are typically staffed by far fewer providers. Figure 53. Percentage of patients referred for care within the same health facility on the day of the survey, as reported by the patients (%), by tier (N = 2758) Table 47 presents information on patients who reported being referred by the health care provider to another health facility on the day of the survey. Among the patients who were referred to another health facility, the percentage that stated an inability of the current health facility to provide specialized care as the reason for the referral is also presented. Only 1.4 percent (95% CI: 0.8 - 2.5) of patients reported being referred to another facility on the day of the interview. Of those who were referred to another facility, 75.4 percent (95% CI: 42.5 - 92.7) reported it was because services or specialized care was not available in the current facility, with all patients at community facilities reporting this to be the case. 141 Table 47. Percentage of patients who report being referred to outside facility during the day of their visit, by tier (%), by tier (N = 2758) Among the patients referred, % where Percentage of patients reason for referral was services/spe- Tier referred to another facility cialized care not available from current (N = 2758) health facility (N = 38) 1.1 100.0 Community [0.4 - 3.4] [100.0 - 100.0] 2.2 74.9 Sub-District [1.1 - 4.5] [32.9 - 94.8] 0.6 75.3 District [0.3 - 1.5] [30.2 - 95.6] 1.4 75.4 Ghana [0.8 - 2.5] [42.5 - 92.7] Note: Values in brackets are the 95% confidence intervals. Table 48 shows the most common reasons for referrals from the facility to lower-, higher- or same-level facilities, as reported by the facility managers. The most common reasons for referral to a higher-level facility were related to the availability of specialized services, equipment, supplies, providers and medicines. The reasons for referral to lower-level facilities were primarily related to increased convenience and affordability of care for the patient at another facility. Reasons for referral to the same level of facility were related to the availability of required equipment and providers. Table 48. Distribution of most common reasons for referral outside facility as report- ed by the facility manager (N = 350) Referrals to Higher Level Facili- Referrals to Lower Level Facili- Referrals to Same Level Facili- ties (N = 347) ties (N = 18) ties (N = 13) The services needed were beyond The services needed were beyond The required equipment was the scope of this health facility's the scope of this health facility's not available/stocked out or not care mandate (94.1% [89.2 - care mandate or specialized care functional at this health facility 96.9%]) was only available at another (77.6% [65.6 - 86.4%]) health facility (51.9% [18.2 - 84.0%]) The required equipment was The services could also be The needed health care provid- not available/stocked out or not provided at a lower-level health er(s) were absent/not available functional at this health facility facility in a way that was more at this health facility (50.8% [5.8 (39.1% [31.9 - 46.8%]) affordable for the patient (39.7% - 94.6%]) [13.4 - 73.7%]) The needed health care provid- The required equipment was The services needed were beyond er(s) were absent/not available not available/stocked out or not the scope of this health facili- at this health facility (21.4% [15.9 functional at this health facility ty's care mandate or specialized - 28.2%]) (38.2% [7.7 - 82.0%]) care was only available at an- other health facility (46.2% [4.7 - 93.7%]) 142 Referrals to Higher Level Facili- Referrals to Lower Level Facili- Referrals to Same Level Facili- ties (N = 347) ties (N = 18) ties (N = 13) The services needed were within The services could also be The required supplies were the scope of this health facility's provided at a lower-level health not available/stocked out at care mandate, but the required facility that was more convenient this health facility (37.3% [2.8 - supplies were not available/ for the patient to access (37.3% 92.4%]) stocked out at this health facility [13.1 - 70.1%]) (20.5% [14.8 - 27.6%]) The required medicine was Patient or patient’s family re- The services could also be pro- not available/stocked out at quested referral to other health vided at another health facility this health facility (12.5% [8.2 - facility (17.5% [5.3 - 44.6%]) in a way that was more afford- 18.7%]) able for the patient (34.4% [2.3 - 92.2%]) Note: Values in brackets are the 95% confidence intervals. To capture patient information transfer during outpatient referrals, health care providers and patients were asked several questions. Providers were asked to estimate how often patient information was shared to the provider or facility to which patients were being referred to in a three-month period (October - December 2023). Figure 54 shows the percentage of providers who indicated that such information was shared at varying degrees of frequency. Most providers (80.1 percent; 95% CI: 76.7 - 83.2) reported sending referral information at least 80 percent of the time. In comparison, a relatively smaller percent of providers reported not sharing any referral information at all or sharing at a low frequency. Figure 54. Frequency of outpatient referral information sharing, as reported by the providers (%), by tier (N = 850) 143 Table 49 shows the most common method that providers reported using to send patient information when they referred a patient to another provider or facility during the three- month period from October - December 2023. The majority of providers reported that information was transferred by the patients themselves (86.0 percent; 95% CI: 83.1 - 88.5). Smaller percentages of providers reported that information was most commonly transferred by phone (9.1 percent; 95% CI: 4.2 - 18.5) and in person by health facility staff (3.9 percent; 95% CI: 0.7 - 18.1). Less than 1.0 percent of providers reported using electronic means for information transfer. Table 49. Mode of patient information transfer for outpatient referrals as reported by providers, by tier (%) (N = 850) Information Information trans- Information trans- Information trans- transferred elec- ferred by health Tier ferred by the pa- ferred by staff via tronically (e.g., fax, facility staff in tients themselves phone web, secure online person portal, etc.) 80.0 15.0 4.1 0.0 Community [39.6 - 96.1] [0.6 - 84.4] [0.0 - 93.7] [0.0 - 0.0] 93.0 4.0 2.7 0.4 Sub-District [89.9 - 95.2] [0.5 - 25.6] [0.2 - 30.4] [0.0 - 73.7] 77.6 15.3 5.4 0.8 District [72.0 - 82.3] [7.8 - 27.9] [0.9 - 26.1] [0.0 - 60.7] 86.0 9.1 3.9 0.5 Ghana [83.1 - 88.5] [4.2 - 18.5] [0.7 - 18.1] [0.0 - 50.0] Table 50 shows the mode of information transfer as reported by facility managers at health facilities that had a record of the total number of outpatient referrals received by the facility, and reported at least one such referral. It confirms the patterns of information transfer reported by providers. Again, the most commonly reported method was information carried by the patients themselves (95.0 percent; 95% CI: 85.7 - 98.4), with a small percentage reporting that information was transferred by staff via phone (3.8 percent; 95% CI: 0.1 - 66.6). Less than one percent of managers reported that information was transferred electronically. 144 Table 50. Mode of patient information transfer for outpatient referrals as reported by the facility managers (%), by tier (N = 106) Information Information trans- Information trans- No patient infor- transferred elec- Tier ferred by the pa- ferred by staff via mation was trans- tronically (e.g., fax, tients themselves phone ferred web, secure online portal, etc.) 100.0 0.0 0.0 0.0 Community [86.6 - 100.0] [0.0 - 0.0] [0.0 - 0.0] [0.0 - 0.0] 89.7 8.4 1.9 0.0 Sub-District [70.1 - 97.0] [0.3 - 71.6] [0.0 - 90.2] [0.0 - 0.0] 95.0 2.5 0.0 2.5 District [61.5 - 99.6] [0.0 - 95.0] [0.0 - 0.0] [0.0 - 95.0] 95.0 3.8 0.8 0.4 Ghana [85.7 - 98.4] [0.1 - 66.6] [0.0 - 90.0] [0.0 - 94.8] Note: Values in brackets are the 95% confidence intervals. Table 51 shows the mode of transfer of patient information, as reported by the patients themselves, for those who had a referral to another health facility in a preceding three-month period (October - December 2023), by facility tier. The majority of patients (98.7 percent; 95% CI: 89.6 - 99.8) reported that they transferred the information themselves by a referral note, patient handbook or patient card. Others stated that their information was shared over the phone by health facility staff (1.0 percent; 95% CI: 0.0 - 89.9) or not transferred at all (0.3 percent; 95% CI: 0.0 - 96.6). These findings are consistent with the methods of information transfer reported by providers (table 49) and facility managers (table 50) and suggest that patients primarily bear the burden of information transfer when they are referred for care. Table 51. Mode of patient information transfer for outpatient referrals to other fa- cilities as reported by the patients (among those having a referral in a three-month period from October - December 2023) by tier (%) (N = 71) Information transferred Information transferred No patient information Tier by the patients them- by staff via phone was transferred selves 89.4 8.7 1.9 Community [22.6 - 99.6] [0.0 - 96.9] [0.0 - 99.2] 98.8 0.9 0.3 Sub-District [87.5 - 99.9] [0.0 - 93.0] [0.0 - 97.4] 100.0 0.0 0.0 District [70.6 - 100.0] [0.0 - 0.0] [0.0 - 0.0] 98.7 1.0 0.3 Ghana [89.6 - 99.8] [0.0 - 89.9] [0.0 - 96.6] Note: Values in brackets are the 95% confidence intervals. 145 Health records are important for continuity of care, whether a patient is visiting the same health care provider or being referred to another, by providing a comprehensive history of a patient’s medical conditions, treatments, and test results, as appropriate. Table 52 displays the availability of health documents among patients, by facility type. Only 33.3 percent (95% CI: 27.4 - 39.6) reported bringing their treatment card or handbook, while 12.6 percent (95% CI: 9.4 - 16.7) had brought a patient folder. Of patients who visited the facility for sick child services or antenatal care, 55.4 percent (95% CI: 45.1 - 65.2) brought the MCH records book, though only 30.2 percent (95% CI: 21.7 - 40.3) of patients in community facilities did so. Of those who visited the facility for diabetes care, only 8.6 percent had brought the diabetes self-care handbook and follow-up record. Three-quarters of patients brought a digital or physical National Insurance Card (76.2 percent; 95% CI: 72.0 - 80.0), with little variation across facility tiers. A small percentage of patients (5.2 percent; 95% CI: 3.7 - 7.4) had not brought any record or document with them. Table 52. Health record availability among patients (multiple-select), by tier (%) (N = 2758) Community Sub-District District Ghana 10.1 34.5 32.8 33.3 Treatment Card/Handbook1 [4.7 - 20.5] [25.3 - 45.0] [25.8 - 40.7] [27.4 - 39.6] 0.9 1.5 0.6 1.0 Prescription sheet1 [0.3 - 2.8] [0.4 - 5.0] [0.3 - 1.4] [0.4 - 2.5] 7.3 10.5 14.9 12.6 Patient folder1 [3.1 - 16.3] [6.7 - 16.1] [10.1 - 21.5] [9.4 - 16.7] National Insurance Card (digital or 73.6 78.0 74.5 76.2 physical)1 [65.0 - 80.7] [71.6 - 83.3] [68.3 - 79.8] [72.0 - 80.0] Private Insurance Card (digital or 0.7 0.1 5.6 2.8 physical)1 [0.2 - 3.4] [0.0 - 0.3] [3.5 - 9.0] [1.8 - 4.4] 10.2 5.4 4.9 5.2 Nothing1 [6.3 - 16.3] [3.0 - 9.4] [3.2 - 7.3] [3.7 - 7.4] Maternal and Child Health (MCH) 30.2 54.1 58.8 55.4 records book2 [21.7 - 40.3] [37.6 - 69.8] [49.2 - 67.8] [45.1 - 65.2] Diabetes self-care handbook and follow- 0.0 10.9 7.1 8.6 up record3 [** - **] [1.7 - 46.6] [2.0 - 22.0] [0.0 - **] Note: Values in brackets are the 95% confidence intervals. ** There were insufficient data for the calculation of robust 95% confidence interval bounds. These estimates should be interpreted with caution. 1 All patients were used as the denominator for computing percentages for these documents, N = 2758. 2 Patients who visited the facility for sick child-services or antenatal care were used as the denominator for computing percentages for these documents, n = 547. 3 Patients who visited the facility for diabetes-mellitus care were used as the denominator for computing percentages for these documents, n = 47. 146 4.1.3 Safety, prevention, detection This subsection reports on practices in place to detect and prevent the spread of contagious diseases and health care-acquired infections, and other metrics of facility-level emergency preparedness. This section focuses on practices and protocols in place, while the Foundations chapter covers facility-level IPC infrastructure indicators. Table 53 presents the proportion of facilities that reported surveillance and IPC systems and practices, including: testing for any national notifiable diseases, and of those, reporting any cases to a higher level authority; maintenance of a cleaning record, where data collectors verified there was at least one entry in the preceding seven days; a register to track the quantity and types of antibiotics prescribed; at least one staff having received training on AMR or antibiotic stewardship in the two years before the survey (January 2022 - December 2023); and at least one provider having received in-service training on IPC in the two years before the survey. The overall percentages of implementation was low across indicators. Only 23.5 percent (95% CI: 19.1 - 28.7) of facilities tested for national notifiable diseases, although, of the facilities that did test, 93.5 percent (95% CI: 83.4 - 97.7) reported notifiable diseases to a higher-level authority. Cleaning records with a recent entry were seen in 26.2 percent (95% CI: 21.6 - 31.5) of facilities. Only 36.3 percent (95% CI: 31.0 - 41.9) of facilities had a register to track antibiotic use. While 50.7 percent (95% CI: 44.7 - 56.6) of facilities had at least one provider who had received in-service IPC training, only 11.6 percent (95% CI: 8.9 - 15.1) of facilities had a staff member who received training on AMR. There was variation by facility tier, with district facilities having higher percentages than sub-district and community facilities across most indicators. Table 53. Surveillance and IPC systems and practices, by tier (%) (N = 500) System and practices Community Sub-District District Ghana Test for any national notifiable diseases 16.7 35.0 61.0 23.5 [11.6 - 23.4] [25.8 - 45.4] [52.5 - 68.9] [19.1 - 28.7] Report cases of any national notifiable diseas- 88.5 99.1 97.6 93.5 es to higher-level authority [67.9 - 96.5] [93.3 - 99.9] [90.6 - 99.4] [83.4 - 97.7] At least one cleaning record with one entry 18.0 41.4 65.4 26.2 from the past week [12.7 - 24.9] [31.7 - 51.9] [57.0 - 73.0] [21.6 - 31.5] Facility has a record/register tracking quantity 25.0 58.6 83.1 36.3 and types of antibioitics dispensed [18.8 - 32.5] [48.2 - 68.2] [75.7 - 88.6] [31.0 - 41.9] At least one staff received training on antimi- 2.6 28.3 54.4 11.6 crobial resistance (AMR) or antibiotic stew- [1.0 - 6.7] [19.6 - 39.1] [45.9 - 62.7] [8.9 - 15.1] ardship in last 2 years At least one provider received in-service 42.3 68.3 80.9 50.7 training on infection prevention and control [34.7 - 50.3] [57.8 - 77.3] [73.3 - 86.7] [44.7 - 56.6] (IPC) in last 2 years Note: Values in brackets are the 95% confidence intervals. Reporting of national notifiable diseases to higher authorities is asked only for facilities that test for these diseases. The percentages reported in this table for this indicator are calculated from among the facilities that conduct testing for national notifiable diseases. Last 2 years is the period from January 2022 - December 2023. 147 Table 54 shows elements of emergency preparedness by facility tier, including if facilities had guidelines or protocols to: access backup human resources; access essential medicines, consumables and equipment from medical buffer stores; access financing; and to communicate with other health facilities, communities, and the public. It also shows whether facilities have, in the past two years (January 2022 - December 2023): conducted a drill on safety procedures in the event of a natural disaster or weather event; conducted an assessment of vulnerability in event of natural disaster or weather event; conducted drills on managing surge capacity; conducted a drill or simulation on fire safety and prevention; and conducted an assessment of vulnerability to fire. Although 68.4 percent (95% CI: 62.4 - 73.8) of facilities had protocols to communicate with other health facilities, communities and the public in the event of a disaster, and 61.9 percent (95% CI: 55.8 - 67.6) had protocols to access backup human resources during emergencies, the adoption of other measures was less than 20 percent. For example, only 16.8 percent (95% CI: 12.9 - 21.5) of facilities had protocols to access essential medicines, consumables and equipment from medical buffer stores, and 16.9 percent (95% CI: 13.1 - 21.5) had protocols to access additional financing during emergencies. Emergency preparedness protocols and guidelines in primary care facilities are important, as these facilities play a crucial role in serving local populations during emergencies. These facilities, being situated closest to communities, possess inherent advantages in providing timely assistance. Therefore, establishing clear protocols for accessing resources is imperative to enhance their effectiveness in emergency response and aid provision. Additionally, assessing vulnerabilities to emergencies is essential for effective preparedness, alongside conducting drills to ensure staff readiness in response scenarios. By identifying weaknesses and practicing response protocols, organizations can enhance their capacity to mitigate risks and respond efficiently to emergencies when they arise. While 20.2 percent (95% CI: 16.4 - 24.6) of facilities conducted on assessment of vulnerability to fire in the preceding two years (January 2022 - December 2023) , and 13.1 percent (95% CI: 10.4 - 16.4) had a drill on fire safety, other drills were done in less than 10 percent of facilities in the same time period. Table 54. Emergency preparedness protocols, by tier (%) (N = 500) Community Sub-District District Ghana Protocols/Drills/Assessments (N = 157) (N = 207) (N = 136) (N = 500) Guidelines/protocols to access backup 55.1 75.2 89.7 61.9 human resources during emergencies [47.2 - 62.8] [65.8 - 82.7] [83.3 - 93.8] [55.8 - 67.6] Protocols to access essential medicines, 12.8 24.0 36.0 16.8 consumables, and equipment from medi- [8.4 - 19.1] [16.3 - 33.9] [28.3 - 44.5] [12.9 - 21.5] cal buffer stores during emergencies Guidelines/protocols to access financing 11.5 26.7 42.6 16.9 during emergencies [7.4 - 17.6] [18.5 - 36.8] [34.5 - 51.2] [13.1 - 21.5] 148 Community Sub-District District Ghana Protocols/Drills/Assessments (N = 157) (N = 207) (N = 136) (N = 500) Protocols to communicate with other 67.3 68.1 83.1 68.4 health facilities, communities, and public [59.5 - 74.3] [57.5 - 77.1] [75.7 - 88.6] [62.4 - 73.8] during emergencies Conducted drill on safety procedures in 1.3 5.0 33.1 4.0 the event of a natural disaster and/or [0.3 - 5.1] [3.0 - 8.3] [25.6 - 41.5] [2.8 - 5.7] weather event in the past 2 years Conducted an assessment of vulnera- 5.8 9.8 39.0 8.6 bility in event of natural disaster and/or [3.0 - 10.8] [5.9 - 15.9] [31.1 - 47.5] [6.2 - 12.0] weather event in the past 2 years Conducted drills on managing surge 3.8 15.3 32.4 8.2 capacity in the past 2 years [1.7 - 8.4] [8.8 - 25.2] [24.9 - 40.8] [5.7 - 11.6] Conducted drill/simulation on fire safety 3.2 27.7 74.3 13.1 and prevention in the past 2 years [1.3 - 7.5] [19.4 - 37.8] [66.2 - 81.0] [10.4 - 16.4] Conducted an assessment of vulnerability 8.3 41.2 79.4 20.2 to fire in the past 2 years [4.9 - 13.9] [31.3 - 51.9] [71.7 - 85.5] [16.4 - 24.6] Note: Values in brackets are the 95% confidence intervals. The past 2 years refers to the period between January 2022 - December 2023. 4.2 Positive user experience The second domain explored in this chapter is “positive user experience,” which gauges patients’ experience during their visit to a facility. First, the analysis highlights the interpersonal skills of the health care providers and seeks to understand patients’ level of comfort during the consultation. Next, the analysis aims to measure the overall user experience during facility visits, including experience with wait times, infrastructure, and more. 4.2.1 Respect and autonomy This subsection explores different indicators that record the patient’s review and experience with the aspects of care provided at the health care facility. Patients were asked to rate different aspects of their experience at the health facility. Figure 55 shows the percentage of patients who rated their experience for these aspects as “good” or “very good” by facility tier. In most metrics, facilities fare well, garnering a patient rating of either “good” or “very good.” The aspect that had the lowest percentage of “good” or “very good” rating in Ghana was patient involvement in decisions about their care (87.2 percent; 95% CI: 84.6 - 89.4). Furthermore, there was heterogeneity in experience of care across facility tiers. Only 78.3 percent (95% CI: 58.9 - 90.1) rated auditory privacy and 78.6 percent (95% CI: 59.3 - 90.3) rated visual privacy favorably in community facilities, compared to 93.1 percent (95% CI: 89.4 - 95.6) and 93.6 percent (95% CI: 90.6 - 95.7) of patients respectively in district facilities. 149 Figure 55. Percentage of patients rating different aspects of their experience (auditory privacy, visual privacy, communication, greetings and introduction, patient involve- ment in care) as “good” or “very good”, by tier (N = 2758) Figure 56 shows the percentage of patients reporting that all of their questions were answered during the consultation, by facility tier. Close to all patients reported that all their questions were answered, with little variation between facility tiers. Figure 56. Percentage of patients that reported all their questions were answered dur- ing their consultation, among patients who received services/care, by tier (N = 2758) 150 4.2.2 User focus User-centered health care systems are designed around the needs and preferences of patients, aiming to make high-quality care easily accessible. They proactively identify and address potential obstacles that patients may face from the point at which they decide to seek care. This subsection highlights key indicators of user-centered care, focusing on how patients experience accessing primary care services at health facilities. Appointment systems can reduce the time spent by patients at health care facilities, improve follow-up, and ensure services are available for patients, improving efficiency and workflow. Table 55 shows the functioning of the appointment system in Ghana by facility tier. Most patients (73.9 percent; 95% CI: 71.9 - 75.7) had come to the facility without an appointment, with little variation among facility tiers. However, 16.9 percent (95% CI: 13.8 - 20.6) had been given a specific date, 7.1 percent (95% CI: 4.3 - 11.6) of patients had been given a specific date and time, and 2.0 percent (95% CI: 0.4 - 9.9) were asked to return after a certain time interval, without mention of a specific date or time. Table 55. Percentage of visits based on appointments and without an appointment, by tier (N = 2758) Visited with- Was given a Was given a Was asked to visit the health facility Tier out an ap- specific date specific date after a certain time interval without pointment but not time and time mention of a specific date/time 64.4 21.4 12.4 1.6 Community [46.7 - 78.9] [6.4 - 52.2] [1.8 - 52.8] [0.0 - 84.3] 73.2 17.4 8.2 1.2 Sub-District [70.4 - 75.8] [13.1 - 22.7] [4.4 - 14.8] [0.1 - 20.4] 74.9 16.3 5.8 2.7 District [72.1 - 77.5] [12.0 - 21.8] [2.4 - 13.3] [0.5 - 14.0] 73.9 16.9 7.1 2.0 Ghana [71.9 - 75.7] [13.8 - 20.6] [4.3 - 11.6] [0.4 - 9.9] Note: Values in brackets are the 95% confidence intervals. Table 56 presents the patient-reported median length of time patients spent waiting at the health facility after arrival but before being seen by a health care provider and the total duration of their consultation(s). The median waiting time between arrival at the facility and being seen by a health care provider was 10.0 minutes, with minimal variation between facility tiers. The median consultation time was 15.0 minutes, with patients in community facilities reporting a shorter consultation time (10.0 minutes) than patients in sub-district and district facilities (15.0 minutes). The patient-reported total estimated time at the facility had a median of 50.0 minutes, which also included time taken to receive lab tests and to retrieve prescriptions, for example. Table 72 in Annex A provides the facility manager reported average waiting and consultation times. 151 Table 56. Median wait time and consultation time as reported by patients (in minutes), by tier (N = 2758) Tier Waiting time Consultation time Total time at facility Community 10.0 (2.6 - 30.0) 10.0 (10.0 - 15.0) 40.0 (27.9 - 60.0) Sub-District 10.0 (4.0 - 15.0) 15.0 (10.0 - 30.0) 45.0 (30.0 - 60.0) District 10.0 (5.0 - 20.0) 15.0 (10.0 - 30.0) 60.0 (40.0 - 120.0) Ghana 10.0 (5.0 - 20.0) 15.0 (10.0 - 30.0) 50.0 (30.3 - 90.0) Note: Values in parentheses are the 25th and 75th percentile values. Figure 57 presents the results for patients who rated different aspects of their user experience as “good” or “very good”, by facility type. Overall, patients rated the various aspects of care related to their needs and preference highly — most patients across facility tiers rated the duration of consultation positively (91.9 percent; 95% CI: 89.9 - 93.6), as well as the convenience of the hours of operation (91.1 percent; 95% CI: 88.4 - 93.3). Travel time was rated positively by 74.8 percent (95% CI: 71.1 - 78.2) of patients. Of the aspects of user experience, the availability of medicines, supplies and functioning equipment had the lowest percentage of positive responses, with considerable variation between facility tiers. Overall, 65.6 percent (95% CI: 60.2 - 70.7) of patients gave positive ratings, with only 59.1 percent (95% CI: 49.2 - 68.3) giving positive ratings in sub-district facilities compared to 72.4 percent (95% CI: 66.9 - 77.2) in district and 63.7 percent (95% CI: 36.9 - 84.1) in community facilities. Figure 57. Percentage of patients rating different aspects of their experience as “good” or “very good” (N = 2758) 152 Chapter 5: Person-centered outcomes This chapter presents findings that explore person-centered outcomes to assess whether a patient is at the “center of care.” Person-centered care involves sharing all the relevant information and resources with patients so they can consider their choices and make an informed decision. Most data have been sourced from patient interviews. To understand patients’ confidence that the health system will provide timely and high- quality care, two primary components were considered: satisfaction and recommendation. In particular, the following was assessed: patients’ satisfaction with the various aspects of care that they receive and the likelihood that they would recommend a health facility/ health care provider to others based on their experience; and care uptake and retention – patients’ reason for receiving and continuing care with the current or other facility. Two other components were assessed to quantify the various financial costs that patients bear in receiving care: out-of-pocket costs and opportunity costs such as income lost and time taken away from work, which arise from seeking care. Box 3 highlights some of the key findings related to person-centered outcomes in primary health care facilities in Ghana. Definitions of sub-domains and in-depth analysis of their associated indicators are presented in due order within this chapter. Box 3. Key observations on primary health care person-centered outcomes in Ghana Confidence in system Care uptake and retention • Overall, all patients reported receiving the intended care and would return to the same facility for service (97.7 percent; 95% CI: 96.4 - 98.5). Only 0.7 percent (95% CI: 0.5 - 1.2) of the patients intended to get a second opinion. • For ANC visits, on average, 19.9 percent (95% CI: 13.6 - 28.3) of women in their second or third trimester, who attended two or more ANC visits had visited more than one facility for ANC services, with the most common reason being a preference for a facility that is convenient to access (74.0 percent). • For NCD care, on average, 51.7 percent (95% CI: 39.5 - 63.7) percent of the patients had visited more than one facility for NCD care, with the most common reasons being that the services needed or specialized care was not available from a health facility or convenience. 153 Satisfaction and recommendation • Almost all patients (97.8 percent; 95% CI: 96.4 - 98.7) would recommend the facility to a family or friend. More than 90 percent of the patients rated the overall quality of care (94.3 percent; 95% CI: 92.3 - 95.8) and health care provider skills (95.0 percent; 95% CI: 93.6 - 96.1) positively as “good” or “very good”, whereas the ability to choose a provider was rated positively by 82.5 percent (95% CI: 79.8 - 84.9) of patients. • The most common reason for choosing the health facility for care was convenience of accessing (community and sub-district tiers) and availability of specialized care (district tier). The most common areas identified by patients as needing improvement was the infrastructure, amenities or cleanliness (community tier) and availability and functioning of equipment (sub-district and district tiers). However, 22.6 percent (95% CI: 20.0 - 25.5) of patients did not identify any area that needed improvement. Financial Protection Opportunity costs • The median travel time reported by patients to reach the facility was 15.0 minutes. • On average, 8.2 percent (95% CI: 6.8 - 9.8) of patients reported having lost income to seek care on the day of the survey. Out-of-pocket costs • Overall, 83.1 percent (95% CI: 80.6 - 85.3) incurred direct costs on consultation fees, medicines, laboratory tests, travel or child- or elderly-care. On average, 47.5 percent (95% CI: 43.8 - 51.2) of patients reported that medicine costs was the category that they spent the most on, costing GH¢ 50 on average for patients who reported incurring any costs for their visit. • The top two sources of funding reported by patients for the current health visit was savings or the regular household budget (83.8 percent; 95% CI: 80.5 - 86.6), and health insurance (40.7 percent; 95% CI: 35.0 - 46.7). 154 5.1 Confidence in system 5.1.1 Care uptake and retention Table 57 presents the proportion of interviewed patients who reported receiving the intended care, the percentage who plan to seek a second opinion, and those who would return to the same facility for future care. The intention to seek a second opinion was assessed among patients who did not receive a direct referral from their provider on the day of the interview. The intention to revisit the same facility for care was asked of all patients. Almost all patients reported receiving the care they intended to receive. Less than one percent of patients reported intending to seek a second opinion from another health care provider. Nearly all patients also reported returning to the same health care facility for future services, with responses similar across facility tiers. Table 57. Proportion of patients reporting receipt of intended care, intention to seek a second opinion, and indicating they would return to same facility for a similar ser- vice, by tier (%) (N = 2758) Plan to Visit Another Plan to Revisit this HF Received Intended Care Tier HCP for Care for Care in the Future (N = 2758) (N = 2720)1 (N = 2758) 100.0 1.5 97.8 Community [100.0 - 100.0] [0.6 - 3.8] [94.7 - 99.1] 100.0 0.5 97.4 Sub-District [100.0 - 100.0] [0.2 - 1.1] [94.7 - 98.8] 100.0 0.9 98.0 District [100.0 - 100.0] [0.5 - 1.7] [96.6 - 98.8] 100.0 0.7 97.7 Ghana [100.0 - 100.0] [0.5 - 1.2] [96.4 - 98.5] Note: Values in brackets are the 95% confidence intervals. 1 Includes only respondents/patients who were not referred to another facility by the HC provider at their current visit. Figure 58 shows, by facility tier, the proportion of women in their second or third trimester of pregnancy with two or more ANC visits who sought ANC at another facility. On average, 19.9 percent (95% CI: 13.6 - 28.3) of patients in Ghana sought ANC at multiple facilities. A higher percentage of patients at district (20.2 percent; 95% CI: 11.9 - 32.2) and sub-district (20.5 percent; 95% CI: 11.6 - 33.5) facilities sought ANC at multiple facilities, compared to patients at community facilities (1.3 percent; 95% CI: 0.2 - 9.8), where the lowest proportion of multiple facility visits was reported. 155 Figure 58. Percentage of ANC patients who have visited other health facilities for ANC (N = 216) Table 58 shows the top five reasons in Ghana for visiting multiple facilities for ANC, by facility tier. This was a multiple-choice question so numbers may not add up to 100 percent. The most common reason for visiting multiple facilities in Ghana (74.0 percent), and across health facility tiers was due to a preference for a health facility that was more convenient to access. Table 58. Distribution of reasons for visiting more than one facility for ANC (N = 39) Community Sub-District District Ghana Reason (N = 2) (N = 19) (N = 18) (N = 39) Preference for a HF that is convenient to 100.0 77.9 69.3 74.0 access Preference for clear communica-tion from 0.0 0.0 23.8 11.0 HCP Preference for short waiting time in the HF 0.0 0.0 22.1 10.2 Preference for a HF that has good infra- 0.0 9.7 10.9 10.2 structure, amenities, and/or cleanliness Services needed or specialized care not 0.0 10.2 3.5 7.1 available at this HF Note: There were insufficient data for the calculation of robust 95% confidence interval bounds. These estimates should be interpreted with caution. Figure 59 shows, by health facility tier, the proportion of patients who visited more than one health facility for NCD (diabetes and/or hypertension) care. On average, 51.7 percent (95% CI: 39.5 - 63.7) of patients in Ghana reported seeking NCD care at multiple facilities. Half of the patients at sub-district facilities (64.0 percent; 95% CI: 45.2 - 79.3) sought NCD care at 156 multiple facilities, followed by 41.7 percent (95% CI: 27.0 - 57.9) at district facilities and 30.1 percent (95% CI: 3.4 - 84.1) at community facilities. Figure 59. Percentage of NCD care patients who have visited other health facilities for NCD care (%) (N = 225) Patients who sought care for diabetes and hypertension at multiple facilities were asked a multiple-select question to understand their reason for seeking care at multiple facilities. Table 59 shows the top five reasons reported for visiting more than one facility for NCD care in Ghana. The most common reason given by the patients was a lack of availability of specialized care (indicated by 37.6 percent of patients) followed by preference for a health facility that was more convenient to access (indicated by 35.5 percent of patients). Table 59. Distribution of reasons for visiting more than one facility for NCD care (%) (N = 90) Community Sub-District District Ghana (N = 3) (N = 44) (N = 43) Services needed or specialized care not 32.5 37.4 37.9 37.6 available at this HF [0.1 - 99.7] [21.3 - 56.9] [22.3 - 56.5] [26.0 - 50.9] Preference for a HF that is convenient to 0.0 34.0 37.5 35.5 access [0.0 - 0.0] [15.1 - 59.8] [23.8 - 53.5] [22.7 - 50.8] Required equipment, supplies, or med- 32.5 5.9 17.3 10.9 icine were either not available, stocked [0.1 - 99.7] [0.9 - 30.1] [5.7 - 42.2] [4.4 - 24.8] out, or not functional at the HF Preference for a HF that has good infra- 0.0 12.7 14.7 13.6 structure, amenities, and/or cleanliness [0.0 - 0.0] [4.1 - 33.1] [4.8 - 37.1] [6.4 - 26.6] 157 Community Sub-District District Ghana (N = 3) (N = 44) (N = 43) Preferences relating to clinical compe- 0.0 7.7 3.5 5.9 tence of HCP(s) [0.0 - 0.0] [1.5 - 32.1] [0.8 - 14.9] [1.7 - 18.2] Note: Values in brackets are the 95% confidence intervals. Patients were also asked whether there was another health facility—regardless of tier—that would have been more convenient to access for receiving the same services they received on the day of the interview. Bypassing a more accessible facility may be due to dissatisfaction with the care in these facilities, and can result in an uneven distribution of workload among facilities. Figure 60 shows the percentage of patients who reported they bypassed a more convenient facility, with 38.9 percent (95% CI: 34.5 - 43.5) of patients reporting that there is a health facility that was more convenient to access to receive the same services. This percentage varies across facility tiers, with 45.7 percent (95% CI: 40.0 - 51.6) of patients at district facilities bypassing a more accessible health facility, compared to 32.7 percent (95% CI: 26.1 - 40.0) at sub-district facilities and 26.2 percent (95% CI: 20.2 - 33.1) at community facilities. The reasons given by patients for accessing this health facility despite having a closer health facility, are presented in table 62. Figure 60. Percentage of patients who state there is a health facility closer to them where they could receive the same services sought for the visit the day of the survey (N = 2758) 158 5.1.2 Satisfaction and recommendation Patients who received care were asked if they would recommend the facility to a friend or family member. Figure 61 presents patients’ rate of recommendation of the facility. On average, 97.8 percent (95% CI: 96.4 - 98.7) of patients in Ghana indicated they would recommend the facility to others for the same services they had received, with minimal variation across health facility tiers. Figure 61. Percentage of patients who would recommend facility to a friend or family member who needed the same service they received that day, by tier (N = 2758) Figure 62 presents patients’ ratings of overall quality of care, health care provider skills, and their ability to choose a health care provider, disaggregated by health facility tier. Patients rated these aspects on a 5-point scale from “very bad” to “very good.” Overall, 94.3 percent (95% CI: 92.3 - 95.8) of patients rated the quality of care at the facility as “good” or “very good.” Health care provider skills received similar ratings, with 95.0 percent (95% CI: 93.6 - 96.1) of patients reporting a positive experience. However, the ability to choose a health care provider was rated lower, with 82.5 percent (95% CI: 79.8 - 84.9) of patients indicating satisfaction in this area. 159 Figure 62. Percentage of patients satisfied with different aspects (overall quality of care, health care provider skills, choice of health care provider) of the quality of care received during their visit, by tier (N = 2758) Table 60 presents the top five areas for improvement identified by patients at the health facility they visited that day. Each individual was allowed to select only one area they considered the most important for improvement. Notably, a significant percentage of people—25.1 percent (95% CI: 12.7 - 43.6) in community, 20.0 percent (95% CI: 15.9 - 25.0) in sub-district, and 25.2 percent (95% CI: 22.0 - 28.7) in district facilities—did not specify particular areas in need of improvement. The most commonly reported area for improvement across all facility tiers in Ghana was the availability and functioning of required equipment, supplies, and medicine, with 27.3 percent (95% CI: 24.6 - 30.3) of patients highlighting this issue. This was followed by 19.4 percent (95% CI: 16.6 - 22.5) of patients identifying infrastructure, amenities and cleanliness in facilities as an area needing improvement, with this being identified as the primary area for improvement by 34.9 percent (95% CI: 21.8 - 50.9) of patients in community facilities. 160 Table 60. Top five areas for facility improvement according to patient feedback, by tier (%) (N = 2758) Community Sub-District District Ghana (N = 483) (N = 1201) (N = 1074) (N = 2758) Good infrastructure, Availability and func- Nothing (25.2% [22.0 - Availability and func- amenities, and/or tioning of required 28.7%]) tioning of required cleanliness (includ- equipment, supplies, or equipment, supplies, or ing disability- friendly medicine (33.3% [28.6 - medicine (27.3% [24.6 - infrastructure, comfort 38.3%]) 30.3%]) of waiting area) (34.9% [21.8 - 50.9%]) Availability and func- Good infrastructure, Availability and func- Nothing (22.6% [20.0 - tioning of required amenities, and/or tioning of required 25.5%]) equipment, supplies, or cleanliness (includ- equipment, supplies, or medicine (26.5% [18.9 - ing disability- friendly medicine (21.4% [18.4 - 35.8%]) infrastructure, comfort 24.7%]) of waiting area) (24.2% [19.4 - 29.7%]) Nothing (25.1% [12.7 - Nothing (20.0% [15.9 - Good infrastructure, Good infrastructure, 43.6%]) 25.0%]) amenities, and/or amenities, and/or cleanliness (includ- cleanliness (includ- ing disability- friendly ing disability- friendly infrastructure, comfort infrastructure, comfort of waiting area) (13.9% of waiting area) (19.4% [11.4 - 16.9%]) [16.6 - 22.5%]) Specialized services or Specialized services or Short waiting time in Short waiting time in care availability (4.1% care availability (6.8% the health facility before the health facility before [2.5 - 6.5%]) [4.7 - 9.6%]) being seen for consul- being seen for consul- tation by health care tation by health care provider(s) (12.3% [9.8 provider(s) (7.8% [6.2 - - 15.4%]) 9.8%]) Days facility is open/ Days facility is open/ Specialized services or Specialized services or hours of operation (3.0% hours of operation (4.1% care availability (5.7% care availability (6.2% [1.6 - 5.5%]) [2.6 - 6.4%]) [4.1 - 7.9%]) [4.9 - 7.9%]) Note: Values in brackets are the 95% confidence intervals. Table 61 shows the top five reasons given by patients for why they sought health care at the facility they were interviewed at. Patients were asked for the single most important reason for their choice. The convenience of accessing the health facility was reported as the top reason across Ghana (30.5 percent; 95% CI: 27.5 - 33.7). This was the most common reason among patients in community facilities (57.2 percent; 95% CI: 43.1 - 70.3) and sub-district facilities (37.9 percent; 95% CI: 32.8 - 43.3). The availability of specialized services or care availability was the second most common reason in Ghana (16.6 percent; 95% CI: 14.4 - 19.2) and the most common reason reported by patients at district facilities (24.4 percent; 95% CI: 21.1 - 28.0). 161 Table 61. Top five reasons for choosing this facility, as reported by patients, by tier (%) (N = 2758) Community Sub-District District Ghana (N = 483) (N = 1201) (N = 1074) (N = 2758) Convenience of access- Convenience of access- Specialized services or Convenience of access- ing this health facility ing this health facility care availability (24.4% ing this health facility (57.2% [43.1 - 70.3%]) (37.9% [32.8 - 43.3%]) [21.1 - 28.0%]) (30.5% [27.5 - 33.7%]) Clinical competence of Clinical competence of Convenience of access- Specialized services or health care provider(s) health care provider(s) ing this health facility care availability (16.6% (14.1% [4.8 - 34.6%]) (14.2% [10.7 - 18.7%]) (22.1% [18.9 - 25.6%]) [14.4 - 19.2%]) Short waiting time in Specialized services or Clinical competence of Clinical competence of the health facility before care availability (9.6% health care provider(s) health care provider(s) being seen for consul- [6.9 - 13.2%]) (15.6% [13.0 - 18.7%]) (14.9% [12.6 - 17.5%]) tation by health care provider(s) (6.3% [4.1 - 9.6%]) Level of respect/cour- Level of respect/cour- Availability and func- Availability and func- tesy from health facility tesy from health facility tioning of required tioning of required staff (5.5% [3.4 - 8.7%]) staff (8.7% [5.8 - 12.9%]) equipment, supplies, or equipment, supplies, or medicine (11.5% [9.2 - medicine (9.4% [7.6 - 14.3%]) 11.6%]) Clear communication Availability and func- Level of respect/cour- Level of respect/cour- (listening or explaining) tioning of required tesy from health facility tesy from health facility with health care provid- equipment, supplies, or staff (4.4% [3.1 - 6.2%]) staff (6.6% [4.9 - 8.7%]) er(s) (3.6% [2.2 - 5.8%]) medicine (7.5% [4.9 - 11.3%]) Note: Values in brackets are the 95% confidence intervals. Additionally, table 62 gives the top five reasons given by patients for why they sought health care at the facility they were interviewed at, among patients who indicated that there is a health facility closer to them where they could receive the same services sought for the visit the day of the survey. The most commonly reported reason for visiting this facility among patients in this subpopulation was the availability of specialized services or care, reported by 25.8 percent (95% CI: 21.2 - 30.9). The next most common reason was the clinical competence of the health care providers (16.7 percent; 95% CI: 12.9 - 21.4). 162 Table 62. Top five reasons for choosing this facility, as reported by patients who indi- cated that there is a health facility closer to them where they could receive the same services, by tier (%) (N = 935) Community Sub-District District Ghana (N = 103) (N = 345) (N = 487) (N = 935) Convenience of access- Convenience of access- Specialized services or Specialized services or ing this health facility ing this health facility care availability (34.1% care availability (25.8% (36.8% [12.4 - 70.5%]) (19.4% [13.1 - 27.8%]) [28.5 - 40.2%]) [21.2 - 30.9%]) Clinical competence of Clinical competence of Clinical competence of Clinical competence of health care provider(s) health care provider(s) health care provider(s) health care provider(s) (25.0% [4.9 - 68.1%]) (16.8% [10.1 - 26.9%]) (16.5% [12.7 - 21.1%]) (16.7% [12.9 - 21.4%]) Short waiting time in Specialized services or Convenience of access- Convenience of access- the health facility before care availability (14.9% ing this health facility ing this health facility being seen for consul- [8.5 - 24.8%]) (10.3% [7.3 - 14.3%]) (14.4% [11.1 - 18.4%]) tation by health care provider(s) (9.8% [4.5 - 20.1%]) Availability of health Level of respect/cour- Availability and func- Level of respect/cour- care provider(s) who are tesy from health fa- tioning of required tesy from health facility likely to prescribe med- cility staff (14.5% [7.9 equipment, supplies, or staff (8.7% [5.6 - 13.3%]) icine(s) or treatment(s) - 25.1%]) medicine (8.2% [5.5 - (9.2% [2.2 - 31.0%]) 12.0%]) Affordability of receiving Short waiting time in Affordability of receiving Availability and func- services at this health fa- the health facility before services at this health fa- tioning of required cility (6.9% [2.4 - 18.2%]) being seen for consul- cility (5.3% [2.8 - 9.5%]) equipment, supplies, or tation by health care medicine (8.2% [5.5 - provider(s) (8.8% [5.0 - 11.9%]) 15.1%]) Note: Values in brackets are the 95% confidence intervals. 5.2 Financial protection Financial protection is the last domain in person-centered outcomes. Financial protection refers to costs, whether they be directly or indirectly incurred costs, related to seeking health care. The SDI measures key costs from both categories. It focuses on direct (“out-of-pocket”) costs such as costs incurred for travel, consultation, laboratory tests and arranging care for dependent children or the elderly whilst the patient is seeking health care. It also collects data on indirect (“opportunity”) costs, such as the time spent travelling to health care facilities, and income lost as a result of seeking care. This insight helps to shed light on how travel time and travel cost affect access to primary health care. Together, the two sections that follow describe a range of costs incurred by patients throughout the care-seeking journey, beginning with opportunity costs such as time spent on transportation, followed by direct out-of-pocket expenditures like fees paid at the point of service. 163 5.2.1 Opportunity costs Figure 63 shows the median time (minutes) reported by patients to reach the health facility, by facility tier. Overall the median patient-reported time taken to reach the health facility was 15 minutes. Travel times ranged from 10 minutes for patients at community facilities to 15 minutes at sub-district facilities and 20 minutes at district facilities. Figure 63. Median time (minutes) to reach facility as reported by the patients, by tier (N = 2758) In addition to indirect costs in the form of travel time, patients also face indirect costs in the form of lost income due to seeking health care. Figure 64 shows the proportion of patients who lost income when seeking care at the facility. Overall, 8.2 percent (95% CI: 6.8 - 9.8) of patients in Ghana lost income due to seeking health care. Similar to the patterns seen in travel time, a smaller percentage of patients in community facilities reported losing income (2.7 percent; 95% CI: 1.5 - 4.9) compared to 6.0 percent (95% CI: 4.3 - 8.4) at sub-district facilities and 10.5 percent (95% CI: 8.4 - 13.1) at district facilities. 164 Figure 64. Percentage of patients who report losing income due to the time it took to visit the health facility, by tier (N = 2758) 5.2.2 OUT-OF-POCKET COSTS Figure 65 shows the percentage of patients who incurred any expenses on the day of the survey for travel, consultation fees, medicine costs, laboratory tests, or child- or elderly-care. The majority of patients in Ghana (83.1 percent; 95% CI: 80.6 - 85.3) incurred such direct costs with nearly three-quarters of those in sub-district facilities (77.3 percent; 95% CI: 72.9 - 81.3) and 90.0 percent (95% CI: 87.7 - 92.0) of those in district facilities incurring direct costs. However, less patients in community facilities reported incurring direct costs (49.1 percent; 95% CI: 35.1 - 63.1) compared to other facility tiers. 165 Figure 65. Percentage of patients who incurred expenses on travel, consultation, med- ications, laboratory tests, or childcare/elder care costs (%) (N = 2758) Among the patients who reported incurring any cost in seeking care on the day of the survey, figure 66 shows which type of cost (travel, medicine, laboratory or consultation fees) was reported as the biggest expense by patients. Medicine costs (47.5 percent; 95% CI: 43.8 - 51.2) and travel costs (24.2 percent; 95% CI: 21.1 - 27.6) were reported as the two categories with the highest direct costs, followed by costs for laboratory tests (16.9 percent; 95% CI: 14.3 - 19.8) and consultation fees (11.4 percent; 95% CI: 9.1 - 14.2). The cost distribution mostly remained the same across facility tiers. Figure 66. Category of highest cost among patients who incurred costs on their visit, by tier (%) (N = 2098) 166 The presence of health insurance can reduce out-of-pocket costs. Patients were asked what type of health insurance they had, if any, and whether it was currently active. Figure 67 shows the distribution of active insurance coverage, by tier. On average, 79.1 percent (95% CI: 77.3 - 80.7) of patients reported being covered by only national (public) insurance, 2.6 percent (95% CI: 0.7 - 9.3) reported being covered by only private insurance, and 17.6 percent (95% CI: 14.4 - 21.2) reported having no active health insurance Figure 67. Percentage of patients who reported having different active insurances, by tier (N = 2752) While the percentage of individuals who incurred out-of-pocket expenses was similar between those with active health insurance (82.3 percent; 95% CI: 78.0 - 85.9) and those without (86.5 percent; 95% CI: 81.0 - 90.6), there were some differences in individual cost categories by insurance status. Table 63 shows the percentage of patients who incurred any cost (when indicated) for consultation fees, laboratory tests, medicines and travel. More patients without active insurance reported incurring consultation fees (42.9 percent; 95% CI: 34.7 - 51.6) than those with active insurance (19.0 percent; 95% CI: 15.2 - 23.6), while 79.1 percent (95% CI: 69.9 - 86.1) of patients without active insurance reported incurring costs for medicines, compared to 58.4 percent (95% CI: 53.0 - 63.5) of patients with active insurance. Overall, 23.2 percent (95% CI: 19.5 - 27.5) of patients incurred consultation fees; 72.3 percent (95% CI: 66.8 - 77.2) paid for laboratory tests and 61.8 percent (95% CI: 56.7 - 66.7) paid for medicines if these were prescribed; and 59.1 percent (95% CI: 53.8 - 64.1) paid out-of-pocket to travel to the facility. 167 Table 63. Percentage of patients incurring costs by tier and insurance status (self-re- ported) (N = 2758) With active insurance (N = 2243) Community Sub-District District Ghana 7.3 15.9 22.6 19.0 Consultation fees1 [2.9 - 17.0] [10.8 - 22.9] [17.0 - 29.4] [15.2 - 23.6] 25.1 64.7 78.7 72.3 Laboratory tests2 [5.8 - 64.6] [53.6 - 74.5] [71.8 - 84.3] [66.1 - 77.8] 33.8 50.8 66.3 58.4 Medicines3 [18.2 - 54.0] [42.7 - 58.8] [59.8 - 72.2] [53.0 - 63.5] 32.6 46.8 72.8 59.2 Travel [27.9 - 37.6] [37.8 - 56.0] [66.8 - 78.0] [53.4 - 64.8] Without active insurance (N = 509) 29.5 33.7 53.3 42.9 Consultation fees1 [18.2 - 44.0] [23.5 - 45.6] [40.7 - 65.4] [34.7 - 51.6] 10.9 57.9 84.4 72.2 Laboratory tests2 [1.6 - 47.4] [31.9 - 80.1] [69.7 - 92.7] [57.8 - 83.2] 65.4 82.1 77.0 79.1 Medicines3 [45.9 - 80.9] [65.1 - 91.8] [65.5 - 85.5] [69.9 - 86.1] 28.4 47.8 69.8 58.0 Travel [18.2 - 41.3] [34.6 - 61.3] [59.7 - 78.4] [49.2 - 66.4] All (N = 2758)4 10.2 19.1 27.9 23.2 Consultation fees1 [4.6 - 21.1] [14.0 - 25.5] [22.5 - 34.2] [19.5 - 27.5] 24.1 63.5 79.8 72.3 Laboratory tests2 [6.9 - 57.7] [55.1 - 71.2] [73.1 - 85.1] [66.8 - 77.2] 36.7 55.5 68.2 61.8 Medicines3 [20.1 - 57.2] [47.3 - 63.5] [62.2 - 73.7] [56.7 - 66.7] 31.9 47.0 72.3 59.1 Travel [27.4 - 36.7] [39.2 - 54.9] [66.4 - 77.5] [53.8 - 64.1] Note: Values in brackets are the 95% confidence intervals. Analysis is restricted to patients who, respectively, 1received a service, 2were prescribed a laboratory test, or 3were prescribed a medicine on the day of the survey. 4 6 patients are missing data on whether their insurance is active. The median costs incurred for each cost category for those who incurred a cost, in GH¢, is shown by facility tier and active insurance status in table 64. Overall, the median costs incurred for patients who paid out-of-pocket for these services, included GH¢ 20 in consultation costs, GH¢ 50 in medicine costs, GH¢ 30 in laboratory costs and GH¢ 10 in travel costs. The median amount spent for those with insurance compared to those without was lower for each category, such as for medicines (GH¢ 50 compared to GH¢ 66). Along with having a higher percentage of patients spending out-of-pocket for direct costs in district facilities, the median amount spent by patients in district facilities was also generally higher for each category than for patients in other tiers. 168 Table 64. Median costs (in Cedis) incurred and reported by patients who incurred costs on their visit, by cost category and tier (N = 2098) With active insurance Community Sub-District District Ghana (N = 1703) Consultation fees 24.8 (17.4 - 63.5) 15.0 (10.0 - 35.0) 20.0 (10.0 - 76.6) 20.0 (10.0 - 50.0) Laboratory tests 57.0 (48.5 - 65.5) 15.0 (10.0 - 25.0) 40.0 (20.0 - 85.1) 30.0 (15.0 - 52.0) Medicines 50.0 (37.3 - 57.9) 45.0 (25.0 - 70.0) 55.0 (30.0 - 105.0) 50.0 (25.0 - 94.0) Travel 5.0 (5.0 - 11.1) 6.0 (5.0 - 10.0) 10.0 (5.0 - 20.0) 10.0 (5.0 - 15.0) Without active insurance (N = 390) Consultation fees 59.9 (37.5 - 82.4) 20.0 (15.0 - 35.0) 33.9 (12.7 - 50.0) 25.0 (13.1 - 45.0) Laboratory tests 25.0 (25.0 - 25.0) 10.0 (6.0 - 40.0) 57.0 (30.0 - 97.4) 40.0 (20.0 - 65.0) Medicines 104.0 (74.5 - 133.5) 55.0 (48.0 - 105.0) 70.0 (43.0 - 126.4) 65.7 (45.0 - 117.0) Travel 30.8 (21.4 - 40.2) 6.0 (5.0 - 10.0) 12.6 (5.0 - 20.0) 10.0 (5.0 - 20.0) All (N = 2098)* Consultation fees 19.2 (9.8 - 54.9) 20.0 (10.0 - 35.0) 25.0 (10.0 - 53.4) 20.0 (10.0 - 50.0) Laboratory tests 46.0 (30.5 - 61.6) 15.0 (10.0 - 30.0) 45.0 (21.0 - 90.0) 30.0 (15.0 - 55.0) Medicines 50.0 (40.0 - 60.0) 50.0 (25.0 - 80.0) 60.0 (30.0 - 110.0) 50.0 (29.6 - 100.0) Travel 5.0 (5.0 - 12.8) 6.0 (5.0 - 10.0) 10.0 (5.0 - 20.0) 10.0 (5.0 - 15.0) Note: Values in parentheses are the 25th and 75th percentile values. *5 patients who incurred costs are missing data on whether their insurance is active. Table 65 shows the different sources of money the patients used to pay for expenses for the current health visit. This includes expenditure for their consultation and diagnostics, medicine, child/elder care and travel. While 6.9 percent (95% CI: 4.9 - 9.5) of patients reported not having to pay for health care that day, the most common source of funding, both nationally (83.8 percent; 95% CI: 80.5 - 86.6) and across tiers, was savings or the regular household budget. Health insurance was the next most commonly reported source of funding, with 40.7 percent (95% CI: 35.0 - 46.7) of Ghanaians indicating that they used it. Other less common sources of funding in Ghana included borrowing from a friend or relative (4.1 percent; 95% CI: 2.5 - 6.5), or using funds gifted from someone outside of the household (1.2 percent; 95% CI: 0.6 - 2.3). Table 65. Distribution of the sources of funds to pay for current health care visit as reported by the patients, by tier (%) (N = 2098) Community Sub-District District Ghana (N = 243) (N = 898) (N = 957) (N = 2098) Savings or regular Savings or regular Savings or regular Savings or regular household budget household budget household budget household budget (75.4% [60.3 - 86.0%]) (82.1% [76.6 - 86.6%]) (85.3% [81.4 - 88.6%]) (83.8% [80.5 - 86.6%]) Health insurance (35.4% Health insurance (37.4% Health insurance (43.8% Health insurance (40.7% [26.2 - 46.0%]) [28.5 - 47.3%]) [36.8 - 51.0%]) [35.0 - 46.7%]) 169 Community Sub-District District Ghana (N = 243) (N = 898) (N = 957) (N = 2098) Did not pay for health Did not pay for health Did not pay for health Did not pay for health care today (7.6% [3.7 - care today (7.4% [4.5 - care today (6.4% [4.0 - care today (6.9% [4.9 - 15.0%]) 12.0%]) 9.9%]) 9.5%]) Borrowed from a friend Borrowed from a friend Borrowed from a friend Borrowed from a friend or relative (3.2% [1.0 - or relative (3.7% [1.5 - or relative (4.4% [2.7 - or relative (4.1% [2.5 - 9.7%]) 9.2%]) 7.0%]) 6.5%]) Borrowed from some- Gift from someone out- Borrowed from some- Gift from someone out- one other than a friend side of household (1.8% one other than a friend side of household (1.2% or relative (0.7% [0.2 - [0.8 - 4.2%]) or relative (1.1% [0.5 - [0.6 - 2.3%]) 2.3%]) 2.4%]) Note: Values in brackets are the 95% confidence intervals. 170 Chapter 6. Conclusion Key findings from this survey highlight several achievements, as well as areas of improvement for the PHC system in Ghana to ensure that every citizen has access to high- quality health care services. Key achievements such as high patient-reported satisfaction with care, low unexcused absence rates of primary health care providers, and physical accessibility to facilities are admirable. Based on the results of simulation cases, health care providers were able to accurately diagnose and treat cases of diabetes, diarrhea, and hypertension. Further, while a high proportion of patients reported that they incurred direct costs of care, the cost for services and transport to the health facility were low. While these achievements are worthy of celebration, there are several key areas for consideration in continued efforts to strengthen the Ghanaian primary health care service delivery system, detailed below. Availability and interruption of key health facility infrastructure A functioning electricity source was available in only 73.4 percent (95% CI: 67.6 - 78.6) of health facilities. Further, power disruptions were experienced by 81.3 percent (95% CI: 74.9 - 86.3) of the facilities during the three-month period from October - December 2023, with 41.7 percent (95% CI: 35.1 - 48.6) experiencing over 10 interruptions during this period. While most facilities had a functional improved water source available (79 percent; 95% CI: 73.4 - 83.7), only 53.9 percent (95% CI: 47.8 - 60.0) of health facilities also had interrupted water supply during October - December 2023. LMIS was used by 49.9 percent (95% CI: 39.7 - 60.1) of sub-district and 71.3 percent (95% CI: 63.1 - 78.4) of district facilities. A functional telephone or mobile phone that was paid for by the facility was available in 61.9 percent (95% CI: 55.9 - 67.6) of the facilities, but only 25.2 percent (95% CI: 20.8 - 30.3) had functional internet on the day of the survey. Interruptions in internet access were common with less than 40 percent of facilities at district, sub-district, or community tier having uninterrupted internet access during October - December 2023. Patients bore the burden of information transfer for referrals in all tiers, which could be reduced by transition to digital systems. While scale up of digital health solutions may be facilitated by high availability of IT hardware, especially at sub-district and district tiers, consistent internet access may be a barrier. Facility accessibility and infrastructure to facilitate access for persons with disabilities While 93.0 percent (95% CI: 89.2 - 95.6) of the facilities were connected to a motorable road, only 64.6 percent (95% CI: 58.6 - 70.3) of facilities were assessed to be within a 10-minute walking distance of a public transportation stop. While road availability is an important and basic measure of access, connectivity through public transport is also beneficial to improve equitable access for different socioeconomic groups. Only 30.9 percent (95% CI: 25.7 - 36.6) of facilities had tactile flooring, 14.1 percent (95% CI: 10.7 - 18.3) of facilities had an improved functional toilet for persons with disabilities, 35.6 percent (95% CI: 30.1 - 41.4) of facilities with steps or inclines to enter any parts of 171 the health facility or within the health facility had ramp, and 3.6 percent (95% CI: 2.1 - 6.3) had assistive technology for the people with visual impairment. Among the facilities with more than one floor, only 7.6 percent (95% CI: 4.9 - 11.7) had a functional lift. Availability of these infrastructural components was not uniform across facility tiers, indicating that where people with disabilities seek care notably impacts the likelihood that they will have access to the infrastructure necessary to facilitate and support their access to services. Emergency preparedness and infection prevention and control infrastructure Only 2.8 percent (95% CI: 1.7 - 4.5) of the facilities had undertaken all measured infectious disease prevention and control measures. Physical barrier at one point of initial patient contact (15.9 percent; 95% CI: 12.7 - 19.6), separate entrance for patients with contagious diseases (9.1 percent; 95% CI: 6.6 - 12.5), designated site for patient isolation (10.1 percent; 95% CI: 7.7 - 13.2) and record maintenance of point-of-care cleaning (26.2 percent; 95% CI: 21.6 - 31.5) were the least prevalent measures observed. Only 16.8 percent (95% CI: 12.9 - 21.5) of facilities had access to protocols to access essential medicines, consumables, and equipment from medical buffer stores, 16.9 percent (95% CI: 13.1 - 21.5) had protocols to access financing, and only 4.0 percent (95% CI: 2.8 - 5.7) had conducted a drill on safety procedures in the event of a natural disaster between January 2022 - December 2023. These are particularly important after the lessons of the COVID-19 pandemic and serve as key safeguards for stymying health emergencies. Prevalence of various fire safety measures were also low, with less than one in four having a functional fire extinguisher (23.0 percent; 95% CI: 19.4 - 27.2) and 13.5 percent (95% CI: 10.7 - 16.9) having a functional fire alarm. Furthermore, in the two years between January 2022 - December 2023, assessment of fire vulnerability was undertaken in only 20.2 percent (95% CI: 16.4 - 24.6) of the facilities and only 8.4 percent (95% CI: 5.8 - 12.0) of facilities had undergone a ventilation performance assessment during this time. Assessing vulnerabilities to various types of emergencies is vital for risk mitigation, while staff readiness through drills and clearly defined protocols for resource management and communication can significantly enhance the capability to respond efficiently during emergencies. These measures collectively strengthen the country’s preparedness and response effectiveness, ensuring a more robust and coordinated approach to emergency situations. Facility management and supervisory structures While most facilities (90.3 percent; 95% CI: 85.8 - 93.4) had at least one supervisory visit from central or external leadership in the past 12 months (January 2022 - December 2023), only a third of these visits (34.8 percent; 95% CI: 29.0 - 41.1) included all components required to consider the visit “supportive” by WHO standards. One of the key components of supportive supervision in need of improvement is the provision of written feedback to health facilities from the external supervisors (only 37.8 percent; 95% CI: 29.0 - 41.1) of facilities reported that they received written feedback as part of their most recent supportive supervision visit. Additionally, fewer than two-thirds (64.8 percent; 95% CI: 58.8 - 70.4) of facility managers 172 received performance review between January - December 2023. The results suggest that there may be opportunities to strengthen management and supervision that may in turn also improve provider satisfaction and capacities. Human resources for health Providers were least satisfied with their pay (20.4 percent; 95% CI: 15.7 - 26.1), benefits (22.5 percent; 95% CI: 17.4 - 28.6), functioning of equipment/ supplies and medicine (35.7 percent; 95% CI: 29.7 - 42.2), infrastructure amenities (39.9 percent; 95% CI: 33.2 - 46.9). Additionally, 21.7 percent (95% CI: 17.0 - 27.3) of providers were dissatisfied with the balance of work between clinical and administrative work. Interventions to support providers and improve job satisfaction should be designed and implemented to facilitate retention. The survey also identified key areas of improvement in provider performance on simulated intrapartum emergency cases. These findings were corroborated by results from patient interviews that highlighted certain areas where ANC, NCDs, and sick-child care were not fully comprehensive. Given the persistent burden of maternal and child health conditions (including childhood undernutrition), and the growing burden of NCDs, interventions such as refresher trainings and job aids may help strengthen provider capacities and ensure that patients receive the highest quality care. Using SDI data to inform decision making The ability to measure and assess primary care service delivery is a core component of health systems strengthening. The SDI health survey has provided a structured approach to the measurement of primary care services and presents information that is immediately relevant and actionable. While the results highlighted in the report are not meant to provide an exhaustive list of all areas of relative success and potential improvement, they do act as examples of information that may be immediately leveraged from this study by policymakers hoping to bolster Ghana’s primary care system. This SDI health survey has only captured a cross-sectional synopsis of Ghana’s primary care service delivery system, but the standardized nature of the survey lends itself well to future similar assessments in the country. A key goal of the SDI health survey is to not only inform top-down approaches to primary health care and health systems strengthening, but also to pay special attention to person- centered outcomes. While many of these data may be readily pertinent to policymakers, citizens and groups advocating for primary care strengthening in Ghana can also leverage the data presented in this study. These data and this report may hopefully serve as a baseline to anchor dialogue related to primary health care and health systems strengthening across Ghana and the rest of the region. 173 Appendix Annex A. Additional Statistics Table 66. Median outpatient volume, by service type and tier (%) Disease Community Sub-District District Ghana Adult Hyperten- 0.0 20.0 146.5 0.0 sion (0.0 - 2.0) (5.0 - 80.5) (43.7 - 447.5) (0.0 - 23.5) 0.0 0.0 3.0 0.0 Adult TB (0.0 - 0.0) (0.0 - 2.0) (0.0 - 26.0) (0.0 - 0.0) 25.0 121.6 388.1 58.0 ANC (0.0 - 111.7) (45.4 - 305.6) (104.9 - 1039.0) (7.0 - 167.0) Child Growth 206.0 295.8 419.4 214.8 Monitoring (91.0 - 416.6) (87.4 - 665.7) (32.0 - 1348.6) (90.0 - 502.0) 0.0 0.0 7.1 0.0 Dental Services (0.0 - 0.0) (0.0 - 0.0) (0.0 - 75.5) (0.0 - 0.0) 0.0 0.0 0.0 0.0 Herbal Medicine (0.0 - 0.0) (0.0 - 0.0) (0.0 - 0.0) (0.0 - 0.0) 81.3 217.0 423.3 106.0 Malaria (14.5 - 172.0) (84.4 - 546.8) (165.1 - 1059.3) (28.5 - 268.8) 0.0 0.0 12.8 0.0 Mental Health (0.0 - 0.0) (0.0 - 8.5) (0.0 - 72.4) (0.0 - 0.0) Note: Values in brackets are the first and third quartiles. Figure 68. Proportion of facilities with at least one patient consultation room with a functional light source (N = 500) 174 Figure 69. Proportion of facilities with at least one patient consultation room with a functional air conditioning (AC) unit or ventilating fan (N = 500) Table 67. Availability of all 23 required guidelines, by tier (%) Guideline Community Sub-District District Ghana Consolidated Guideline on TB 13.5 29.5 46.3 19.1 Treatment 2022 version 4 [8.9 - 19.8] [21.3 - 39.2] [38.0 - 54.8] [15.1 - 23.9] Consolidated Guidelines for 16.7 33.6 50.0 22.6 HIV Care in Ghana, 2021 [11.6 - 23.4] [24.9 - 43.6] [41.6 - 58.4] [18.2 - 27.7] Essential Medicines list 7th 36.5 69.1 87.5 47.1 edition, 2017 [29.3 - 44.5] [58.8 - 77.8] [80.7 - 92.1] [41.3 - 53.0] Ghana Breastfeeding Promo- 35.9 42.5 52.2 38.4 tion Regulation 2000 [28.7 - 43.8] [33.0 - 52.7] [43.7 - 60.6] [32.7 - 44.4] Ghana Guidelines for Non- 19.9 35.2 44.1 24.9 communicable Diseases [14.3 - 27.0] [26.1 - 45.6] [35.9 - 52.7] [20.2 - 30.3] Screening Ghana MIP Guidelines, 2020 5.1 15.5 36.8 9.4 [2.6 - 10.0] [10.2 - 23.0] [29.0 - 45.3] [6.9 - 12.7] Ghana National Safe Moth- 26.3 54.3 56.6 34.6 erhood Service Protocol 2nd [19.9 - 33.8] [44.0 - 64.3] [48.1 - 64.8] [29.3 - 40.4] edition, 2016 Ghana New-born Care Strat- 20.5 39.9 46.3 26.6 egy 2014 [14.8 - 27.7] [30.3 - 50.3] [38.0 - 54.8] [21.8 - 32.0] Ghana Standards for Improv- 23.1 24.9 37.5 24.3 ing The Quality of Care for [17.1 - 30.4] [17.4 - 34.3] [29.7 - 46.0] [19.6 - 29.8] Children and Adolescents 175 Guideline Community Sub-District District Ghana Ghana Standards For Improv- 18.6 24.3 50.7 21.8 ing the Quality of Care for [13.2 - 25.6] [17.2 - 33.3] [42.3 - 59.1] [17.4 - 26.9] Small and Sick Newborns in Health Facilities, 2021 Guidelines for the treatment 16.0 32.2 42.6 21.4 of Symptomatic STI 2021 [11.0 - 22.7] [23.4 - 42.5] [34.5 - 51.2] [17.1 - 26.5] Version 5 National guidelines for Com- 7.1 28.8 44.9 14.4 prehensive Abortion Care, [3.9 - 12.4] [20.9 - 38.3] [36.6 - 53.4] [11.2 - 18.3] 2021 National Guidelines for 14.7 24.8 50.7 19.2 Health Care Waste Manage- [10.0 - 21.3] [17.1 - 34.7] [42.3 - 59.1] [15.1 - 24.1] ment in Ghana – 2020 National Kangaroo Mother 13.5 26.2 41.2 18.1 Care Training Manual, 2021 [8.9 - 19.8] [18.3 - 36.0] [33.1 - 49.7] [14.1 - 22.9] National Operational Guide- 25.7 26.4 36.8 26.5 lines and Standards for Ad- [19.4 - 33.2] [18.8 - 35.8] [29.0 - 45.3] [21.5 - 32.1] olescent and Youth-Friendly Health Services 2010 National Policy and Guide- 37.2 46.7 69.9 41.3 lines for Infection Prevention [29.9 - 45.1] [36.7 - 56.9] [61.5 - 77.1] [35.6 - 47.3] and Control in Health Care Settings, 2015 National Reproductive Health 28.2 37.6 45.6 31.4 Service policy and standards [21.7 - 35.9] [28.3 - 48.0] [37.3 - 54.1] [26.2 - 37.2] - 2014 PMTCT Handbook for health- 21.8 45.0 61.0 29.5 care providers in Ghana 2014 [15.9 - 29.0] [35.3 - 55.1] [52.5 - 68.9] [24.7 - 34.9] Standard Treatment Guide- 53.9 83.5 93.4 63.1 lines, 2017 [45.9 - 61.6] [73.0 - 90.4] [87.7 - 96.5] [57.0 - 68.8] Standards for Newborn 19.2 40.1 54.4 26.2 Health Services in Ghana, [13.7 - 26.3] [30.7 - 50.3] [45.9 - 62.7] [21.5 - 31.5] June 2020 User Guide for Maternal and 46.2 64.7 74.3 52.2 Child Health Record Book – [38.4 - 54.1] [54.1 - 74.1] [66.2 - 81.0] [46.1 - 58.2] 2021 WHO Guidelines on Men- 3.8 15.8 33.1 8.4 tal Health Gap Action Pro- [1.7 - 8.4] [10.9 - 22.3] [25.6 - 41.5] [6.2 - 11.2] gramme (mhGAP), 2020 WHO Handbook on IMCI 20.5 32.0 42.6 24.5 [14.8 - 27.7] [23.6 - 41.8] [34.5 - 51.2] [19.9 - 29.8] Note: Values in brackets are the 95% confidence intervals. 176 Table 68. Proportion of facilities with listed equipment, by tier (%) (N = 500) Category Equipment Community Sub-District District Ghana 17.3 39.1 60.3 24.9 Bandage, elastic adhesive [12.1 - 24.1] [29.4 - 49.6] [51.7 - 68.3] [20.3 - 30.2] 32.0 53.6 63.2 38.9 Bandage, gauze rolled [25.1 - 39.9] [43.3 - 63.6] [54.7 - 71.0] [33.3 - 44.8] 4.5 9.3 35.3 7.4 Upper limb splint sets [2.1 - 9.2] [5.0 - 16.9] [27.6 - 43.8] [5.1 - 10.6] 64.1 69.3 75.7 66.0 Weighing scale (Adult) [56.2 - 71.3] [58.7 - 78.2] [67.7 - 82.3] [59.9 - 71.6] Weighing scale ( for 67.9 66.7 75.7 68.1 babies) [60.1 - 74.9] [55.7 - 76.0] [67.7 - 82.3] [62.1 - 73.6] Stadiometer (height 48.7 58.7 64.0 52.0 measuring stand) [40.9 - 56.6] [48.2 - 68.6] [55.5 - 71.7] [45.9 - 58.0] BP apparatus/ Sphygmo- 58.3 62.8 68.4 60.0 manometer [50.4 - 65.9] [52.1 - 72.3] [60.0 - 75.7] [53.8 - 65.8] 42.3 59.3 69.1 47.8 Stethoscope [34.7 - 50.3] [48.7 - 69.1] [60.8 - 76.4] [41.9 - 53.9] 60.2 66.3 69.1 62.2 Thermometer [52.3 - 67.7] [55.8 - 75.4] [60.8 - 76.4] [56.1 - 67.9] Masks, face shields, and 41.7 60.8 65.4 47.6 goggles [34.1 - 49.6] [50.6 - 70.3] [57.0 - 73.0] [41.6 - 53.6] 59.0 69.6 69.1 62.1 Measuring tape General/ [51.0 - 66.5] [59.3 - 78.3] [60.8 - 76.4] [56.0 - 67.8] Acute care 49.4 60.0 68.4 53.0 Methylated Spirit [41.5 - 57.2] [49.7 - 69.4] [60.0 - 75.7] [46.9 - 59.0] 55.1 61.2 66.2 57.2 Alcohol Hand Rub [47.2 - 62.8] [50.8 - 70.7] [57.7 - 73.7] [51.1 - 63.1] Oxygen Cylinder and 5.1 32.0 64.0 14.9 Mask [2.6 - 10.0] [23.1 - 42.6] [55.5 - 71.7] [11.7 - 18.7] 28.2 55.6 66.2 36.8 Needles/sutures [21.6 - 35.8] [45.1 - 65.6] [57.7 - 73.7] [31.4 - 42.6] 23.1 58.6 65.4 33.9 Needle/suture holders [17.1 - 30.4] [48.1 - 68.3] [57.0 - 73.0] [28.8 - 39.4] 57.0 61.6 69.9 58.9 Disposable syringes [49.1 - 64.7] [51.0 - 71.2] [61.5 - 77.1] [52.7 - 64.7] 28.8 57.0 63.2 37.5 Forceps, dressing [22.2 - 36.5] [46.6 - 66.8] [54.7 - 71.0] [32.0 - 43.3] 32.7 59.0 64.0 40.7 Galipots [25.7 - 40.5] [48.6 - 68.6] [55.5 - 71.7] [35.0 - 46.6] Malaria Rapid Diagnostic 46.1 58.2 59.6 49.8 Test [38.4 - 54.1] [47.8 - 68.0] [51.0 - 67.6] [43.7 - 55.8] HIV Rapid Diagnostic 36.5 57.3 67.6 43.2 Test [29.3 - 44.5] [46.7 - 67.4] [59.2 - 75.1] [37.5 - 49.2] Glucometer (for glucose 21.8 54.4 68.4 32.2 handheld test) [15.9 - 29.0] [44.0 - 64.5] [60.0 - 75.7] [27.2 - 37.6] 177 Glucometer test strips/ 17.3 60.5 68.4 30.4 discs [12.1 - 24.1] [49.9 - 70.1] [60.0 - 75.7] [25.7 - 35.6] 24.4 57.7 72.1 35.0 Urine dipstick for protein [18.2 - 31.8] [47.2 - 67.6] [63.8 - 79.0] [29.8 - 40.5] 19.2 55.4 69.1 30.6 Urine dipstick for glucose [13.7 - 26.3] [45.0 - 65.3] [60.8 - 76.4] [25.8 - 35.9] 12.8 50.7 69.9 25.0 Urine dipstick for ketones [8.4 - 19.1] [40.5 - 60.9] [61.5 - 77.1] [20.8 - 29.8] 47.4 64.6 71.3 52.9 Urine pregnancy test kit [39.6 - 55.3] [53.9 - 74.1] [63.1 - 78.4] [46.8 - 58.9] 40.5 67.6 45.9 Pulse oximeter NA [30.9 - 50.9] [59.2 - 75.1] [37.8 - 54.2] 40.3 64.7 45.2 Nebulizer NA [30.6 - 50.8] [56.2 - 72.4] [37.0 - 53.5] 17.3 52.2 24.2 Auroscope NA General/ [10.6 - 27.0] [43.7 - 60.6] [18.1 - 31.5] Acute care 30.0 58.8 35.7 Tongue depressor NA [21.4 - 40.4] [50.3 - 66.9] [28.3 - 43.9] 54.1 54.1 Oxygen delivery point NA NA [45.5 - 62.4] [45.5 - 62.4] 22.4 51.8 64.7 31.8 Macintosh rubber sheet [16.5 - 29.7] [41.6 - 62.0] [56.2 - 72.4] [26.8 - 37.3] 51.1 66.9 54.3 Wheelchair NA [40.9 - 61.3] [58.5 - 74.4] [45.9 - 62.4] 30.7 64.7 37.4 Stretcher NA [21.8 - 41.3] [56.2 - 72.4] [29.8 - 45.7] 17.3 50.9 66.9 28.1 Suture Kits [12.1 - 24.1] [40.7 - 61.0] [58.5 - 74.4] [23.4 - 33.3] 12.2 46.5 65.4 23.3 Patient trolley (s) [7.9 - 18.4] [36.4 - 56.9] [57.0 - 73.0] [19.1 - 28.2] Immobilization devices 3.2 16.3 43.4 8.6 (splint, slings) [1.3 - 7.5] [9.7 - 26.1] [35.2 - 51.9] [6.2 - 11.9] 17.3 39.5 58.8 24.9 Headgear [12.1 - 24.1] [29.9 - 49.9] [50.3 - 66.9] [20.4 - 30.1] 38.5 55.8 66.9 44.2 Chlorine for disinfection [31.1 - 46.4] [45.3 - 65.7] [58.5 - 74.4] [38.3 - 50.2] 26.9 51.6 62.5 34.8 Plastic Aprons [20.5 - 34.5] [41.3 - 61.7] [54.0 - 70.3] [29.5 - 40.5] Infection Puncture proof/resistant 43.6 58.6 65.4 48.4 Prevention waste containers for [35.9 - 51.5] [48.1 - 68.3] [57.0 - 73.0] [42.4 - 54.4] and control needles/syringes 60.0 60.0 Coveralls NA NA [51.4 - 68.0] [51.4 - 68.0] Electric autoclave (pres- 91.1 91.1 NA NA sure & wet heat) [84.9 - 94.9] [84.9 - 94.9] 17.0 17.0 Nonelectric autoclave NA NA [11.5 - 24.4] [11.5 - 24.4] 178 Electric boiler or steamer 42.2 42.2 NA NA (no pressure) [34.1 - 50.8] [34.1 - 50.8] Infection 34.1 34.1 Prevention Electric dry heat sterilizer NA NA [26.5 - 42.6] [26.5 - 42.6] and control Nonelectric pot with cov- 7.7 10.4 16.2 8.8 er for boiling/steam [4.4 - 13.1] [5.9 - 17.9] [10.8 - 23.5] [6.0 - 12.7] Colourimeter or haemo- 54.1 54.1 globinometer (for anae- NA NA [45.5 - 62.4] [45.5 - 62.4] mia handheld test) Malaria smear microsco- 70.4 70.4 NA NA py reagents [62.0 - 77.5] [62.0 - 77.5] 71.1 71.1 Micropipettes NA NA Laboratory [62.8 - 78.2] [62.8 - 78.2] and Equip- 73.3 73.3 ment and Light microscope NA NA [65.1 - 80.2] [65.1 - 80.2] Supplies 70.4 70.4 Haematology analyser NA NA [62.0 - 77.5] [62.0 - 77.5] Blood coagulation analy- 40.0 40.0 NA NA ser (PT/PTT) [32.0 - 48.6] [32.0 - 48.6] 56.3 56.3 Blood chemistry analyser NA NA [47.7 - 64.5] [47.7 - 64.5] 12.8 49.8 63.2 24.4 Speculum – Sim's [8.4 - 19.1] [39.6 - 60.0] [54.7 - 71.0] [20.2 - 29.3] 20.5 54.5 61.8 30.9 Delivery pack/set [14.8 - 27.7] [44.1 - 64.5] [53.2 - 69.6] [26.0 - 36.3] Resuscitation Kit: Neo- 64.4 64.4 NA NA Natal [55.9 - 72.1] [55.9 - 72.1] 28.8 57.6 64.0 37.6 Foetoscope [22.2 - 36.5] [47.1 - 67.5] [55.5 - 71.7] [32.2 - 43.4] 18.6 52.0 59.6 28.8 Reproductive Bowl to receive placenta [13.2 - 25.6] [41.7 - 62.1] [51.0 - 67.6] [24.1 - 34.1] and Child Health Family planning equip- 44.9 45.3 55.1 45.6 ment Demonstration tray [37.2 - 52.8] [35.5 - 55.5] [46.6 - 63.4] [39.6 - 51.7] 59.0 50.9 55.9 56.9 Growth monitoring chart [51.0 - 66.5] [40.6 - 61.1] [47.3 - 64.1] [50.8 - 62.8] Refrigerator thermom- 29.5 59.6 55.9 38.1 eter [22.8 - 37.2] [49.0 - 69.4] [47.3 - 64.1] [32.6 - 43.9] 53.2 52.0 57.4 53.1 Vaccine carrier [45.3 - 61.0] [41.7 - 62.1] [48.8 - 65.5] [47.0 - 59.2] 41.5 41.5 Blood bank NA NA [33.4 - 50.1] [33.4 - 50.1] 57.8 57.8 Surgical Surgical theatre NA NA [49.2 - 65.9] [49.2 - 65.9] Note: Values in brackets are the 95% confidence interval. Values are marked as NA when an equipment is not required at a particular tier. 179 Table 69. Proportion of facilities with listed medicines, by tier (%) (N = 500) Medicine Community Sub-District District Ghana Diazepam 5 mg/mL injection (2 mL) avail- NA 90.5 94.1 91.4 able [80.8 - 95.6] [88.1 - 97.2] [84.5 - 95.4] NA 33.7 61.3 41.0 Phenobarbital 30 mg tablet available [22.2 - 47.4] [52.2 - 69.8] [31.6 - 51.1] NA 18.0 80.7 34.5 Morphine Injection, 10 mg/mL available [9.1 - 32.5] [72.5 - 86.9] [26.2 - 43.8] Morphine Sulphate Tablet, (any dosage) NA 4.8 30.3 11.5 available [1.2 - 17.0] [22.6 - 39.2] [7.2 - 17.9] NA NA 37.3 37.3 Midazolam Tablet, 15 mg available [28.9 - 46.5] [28.9 - 46.5] NA NA 28.0 28.0 Dihydrocodeine Tablet, 30 mg available [20.5 - 36.9] [20.5 - 36.9] 61.5 66.3 63.2 62.8 Condoms available [53.6 - 68.9] [55.2 - 75.9] [54.7 - 71.0] [56.6 - 68.5] 68.0 65.2 75.0 67.7 Depo-Provera (DMPA) available [60.1 - 74.9] [53.8 - 75.1] [66.9 - 81.6] [61.6 - 73.2] Noristerat 200mg, Norigest 200mg (NET-EN) 15.4 19.6 30.9 17.3 available [10.5 - 22.0] [13.0 - 28.5] [23.6 - 39.2] [13.3 - 22.2] Norygnon: NET-EN 50 mg + Estradiol valer- 44.2 41.2 50.7 43.9 ate 5 mg available [36.6 - 52.2] [32.0 - 51.1] [42.3 - 59.1] [38.0 - 50.0] 42.3 63.9 83.1 49.8 Distilled Water available [34.7 - 50.3] [53.6 - 73.2] [75.7 - 88.6] [43.8 - 55.8] 34.0 80.2 95.6 48.4 Oxytocin Injection 5/10 units/mL available [26.9 - 41.8] [70.1 - 87.5] [90.4 - 98.0] [42.7 - 54.2] 53.2 76.7 89.0 60.8 Tetanus Toxoid available [45.3 - 61.0] [66.3 - 84.6] [82.4 - 93.3] [54.7 - 66.6] Furosemide Injection, 10 mg/mL in 2 mL NA 45.1 88.2 53.7 available [35.0 - 55.7] [81.6 - 92.7] [45.4 - 61.7] NA NA 85.9 85.9 Hydralazine Injection, 20 mg available [78.9 - 90.9] [78.9 - 90.9] Insulin premixed (30/70) HM Injection, 100 NA NA 76.3 76.3 units/mL in 10 mL available [68.3 - 82.8] [68.3 - 82.8] Insulin Soluble HM, 100 units/mL in 10 mL NA NA 76.3 76.3 available [68.3 - 82.8] [68.3 - 82.8] Isophane Insulin Injection (HM), 100 units/ NA NA 38.5 38.5 mL in 10 mL available [30.6 - 47.1] [30.6 - 47.1] 30.1 67.6 89.7 42.4 Vitamin K available [23.4 - 37.9] [56.8 - 76.8] [83.3 - 93.8] [36.9 - 48.1] NA 92.5 97.8 93.6 Normal Saline solution 0.9% available [84.7 - 96.5] [93.3 - 99.3] [87.4 - 96.8] NA 87.7 97.8 89.7 Ringer's lactate solution available [79.2 - 93.0] [93.3 - 99.3] [82.9 - 94.0] NA NA 55.6 55.6 Potassium Chloride (KCL) Infusion available [47.0 - 63.8] [47.0 - 63.8] NA 89.6 97.8 91.2 Dextrose Saline (Adult) available [82.1 - 94.1] [93.3 - 99.3] [85.2 - 94.9] 180 Medicine Community Sub-District District Ghana 1/5 Normal Saline in 4.3% Dextrose (pediat- NA 48.4 69.9 52.7 ric) available [38.3 - 58.7] [61.5 - 77.1] [44.3 - 60.9] NA 18.2 30.9 20.7 Cholera replacement fluid (5:4:1) available [12.5 - 25.8] [23.6 - 39.2] [15.6 - 26.9] NA 35.8 84.6 45.4 50% Dextrose available [26.4 - 46.3] [77.4 - 89.8] [37.5 - 53.6] 30.1 48.9 72.8 37.0 Albendazole Syrup, 100 mg/5 mL available [23.4 - 37.9] [38.8 - 59.2] [64.6 - 79.7] [31.5 - 42.9] 25.0 48.7 54.4 32.3 Chloramphenicol Eye Ointment 1% available [18.8 - 32.5] [38.6 - 58.9] [45.9 - 62.7] [27.1 - 38.0] Co-trimoxazole Suspension, (200+40) mg/5 28.9 47.6 63.2 35.3 mL available [22.2 - 36.5] [37.6 - 57.9] [54.7 - 71.0] [29.9 - 41.1] 25.7 54.3 69.9 35.0 Cotrimoxazole Tablet, (400+80) mg available [19.4 - 33.2] [44.1 - 64.2] [61.5 - 77.1] [29.7 - 40.7] Ferrous Sulphate + Folic Acid Tablet, 50 mg 36.5 51.4 60.3 41.4 + 400 microgram (Adult) available [29.3 - 44.5] [41.1 - 61.5] [51.7 - 68.3] [35.6 - 47.4] Ferrous Fumarate Tablet, 60/100 mg (Adult) 25.6 32.3 50.0 28.6 available [19.3 - 33.1] [24.0 - 41.8] [41.6 - 58.4] [23.6 - 34.2] Ferrous Sulphate Tablet, 60 mg (Adult) 30.1 53.9 71.3 38.1 available [23.4 - 37.9] [43.6 - 63.9] [63.1 - 78.4] [32.6 - 44.0] Ferrous Sulphate (BPC) Syrup, 60 mg/5 mL 17.9 33.1 42.6 22.9 (Paediatric) available [12.6 - 24.9] [24.1 - 43.6] [34.5 - 51.2] [18.4 - 28.2] 41.7 76.8 85.3 52.5 Albendazole Tablet, 200/400 mg available [34.1 - 49.6] [67.8 - 83.8] [78.2 - 90.4] [46.5 - 58.3] 50.0 79.6 86.0 59.0 Folic Acid Tablet, 5 mg (Paediatric) available [42.1 - 57.9] [71.2 - 86.0] [79.0 - 91.0] [53.0 - 64.8] Mebendazole Suspension, 100 mg/5 mL 17.3 33.3 52.2 23.1 available [12.1 - 24.2] [24.1 - 44.0] [43.7 - 60.6] [18.6 - 28.4] Mebendazole Tablet, 100 mg or 500mg 27.6 62.9 70.6 38.4 available [21.1 - 35.2] [52.5 - 72.2] [62.3 - 77.7] [32.9 - 44.1] Metronidazole Suspension 100/200 mg/5ml 51.3 72.7 88.2 58.5 available [43.4 - 59.1] [62.6 - 81.0] [81.6 - 92.7] [52.4 - 64.3] 45.5 75.3 89.0 55.1 Metronidazole Tablet, 200 mg available [37.8 - 53.5] [65.9 - 82.8] [82.4 - 93.3] [49.0 - 60.9] NA NA 83.0 83.0 Misoprostol Tablet 200mg available [75.6 - 88.5] [75.6 - 88.5] 59.0 72.5 91.9 64.1 Multivitamin Drops/syrup available [51.0 - 66.5] [62.0 - 81.0] [85.9 - 95.5] [58.0 - 69.8] 51.9 81.5 96.3 61.5 Multivitamin Tablet available [44.0 - 59.7] [72.5 - 88.0] [91.4 - 98.5] [55.4 - 67.2] 41.7 72.5 88.2 51.6 Caps Amoxicillin 250/500mg available [34.1 - 49.6] [63.1 - 80.3] [81.6 - 92.7] [45.7 - 57.5] 54.5 76.4 91.2 61.8 Zinc Tablet, 10/20 mg available [46.5 - 62.2] [66.6 - 84.1] [85.0 - 95.0] [55.7 - 67.5] 67.3 89.3 96.3 74.2 Paracetamol Syrup available [59.5 - 74.3] [81.9 - 93.9] [91.4 - 98.5] [68.4 - 79.2] 181 Medicine Community Sub-District District Ghana 64.1 86.4 98.5 71.3 Paracetamol Tablet 500mg available [56.2 - 71.3] [78.0 - 91.9] [94.2 - 99.6] [65.4 - 76.6] Sulfadoxine 500 mg/Pyrimethamine 25 mg 35.3 66.3 88.2 45.6 Co-formulated Tablet available [28.1 - 43.2] [55.4 - 75.7] [81.6 - 92.7] [39.9 - 51.5] 76.9 65.7 64.7 73.6 Vitamin A 100,000 IU available [69.6 - 82.9] [54.1 - 75.7] [56.2 - 72.4] [67.8 - 78.7] 74.4 58.0 64.7 70.0 Vitamin A 200,000 IU available [66.9 - 80.7] [46.9 - 68.4] [56.2 - 72.4] [64.0 - 75.3] Amoxicillin Suspension, 125 mg/5 mL avail- 43.0 71.5 86.0 52.2 able [35.3 - 50.9] [61.4 - 79.8] [79.0 - 91.0] [46.2 - 58.1] 59.6 77.5 91.9 65.7 Oral Rehydration Salts available [51.7 - 67.1] [68.6 - 84.5] [85.9 - 95.5] [59.7 - 71.3] 11.5 43.7 79.4 23.0 Methyldopa Tablet, 250 mg available [7.4 - 17.6] [33.8 - 54.0] [71.7 - 85.5] [18.9 - 27.7] Atenolol + Hydrochlorthiazide Tablet, 50 mg NA 24.2 47.8 28.9 + 25 mg available [15.7 - 35.3] [39.4 - 56.3] [21.6 - 37.4] NA 31.9 82.4 41.9 Atenolol Tablet, 25/50 mg available [22.4 - 43.2] [74.9 - 87.9] [34.0 - 50.3] NA 11.4 39.0 16.8 Bisoprolol Tablet 5/10 mg available [5.8 - 21.0] [31.1 - 47.5] [11.6 - 23.8] NA 52.6 82.4 58.5 Furosemide Tablet, 20/40 mg available [42.4 - 62.5] [74.9 - 87.9] [50.3 - 66.3] NA 18.1 41.9 22.8 Hydralazine Tablet, 25 mg available [10.7 - 29.0] [33.8 - 50.5] [16.3 - 31.0] NA 23.5 42.6 27.3 Labetalol Tablet, 200 mg available [14.8 - 35.1] [34.5 - 51.2] [19.9 - 36.1] NA 55.8 90.4 62.7 Lisinopril Tablet,( any dosage) available [45.9 - 65.3] [84.1 - 94.4] [54.8 - 69.9] Artemether + Lumefantrine Suspension / 46.8 69.3 78.7 53.9 Powder (Paediatric) available [39.0 - 54.7] [59.5 - 77.6] [70.9 - 84.8] [47.9 - 59.9] NA 54.4 73.5 58.2 Magnesium Sulphate Salt available [44.1 - 64.3] [65.4 - 80.3] [49.7 - 66.2] Nifedipine Tablet, 10/20mg (slow release) NA 63.7 83.8 67.7 available [54.1 - 72.3] [76.5 - 89.2] [60.0 - 74.5] NA 49.2 80.9 55.5 Nifedipine Tablet, 30 mg (GITS) available [39.0 - 59.4] [73.3 - 86.7] [47.2 - 63.4] NA 14.2 46.3 20.6 Propranolol Tablet 10/40/80 mg available [7.9 - 24.3] [38.0 - 54.8] [14.8 - 28.0] NA NA 75.6 75.6 Atorvastatin Tablet, 10/20 mg available [67.5 - 82.1] [67.5 - 82.1] NA NA 45.2 45.2 Gliclazide Tablet, 80 mg available [36.9 - 53.7] [36.9 - 53.7] NA NA 70.4 70.4 Glimepiride Tablet, 1/2/3/4 mg available [62.0 - 77.5] [62.0 - 77.5] Artemether + Lumefantrine Tablet, 20 mg + 60.9 88.7 93.4 69.3 120 mg available [53.0 - 68.3] [80.2 - 93.9] [87.7 - 96.5] [63.4 - 74.7] 182 Medicine Community Sub-District District Ghana Lisinopril + Hydrochlorthiazide Tablet avail- NA NA 51.9 51.9 able [43.3 - 60.3] [43.3 - 60.3] NA NA 85.9 85.9 Losartan Tablet, 25/50/100 mg available [78.9 - 90.9] [78.9 - 90.9] NA NA 23.0 23.0 Metoprolol Tartrate Tablet 100 mg available [16.6 - 30.9] [16.6 - 30.9] NA NA 34.8 34.8 Pioglitazone Tablet available [27.2 - 43.3] [27.2 - 43.3] NA NA 22.2 22.2 Simvastatin Tablet, 10/20/40 mg available [15.9 - 30.1] [15.9 - 30.1] NA NA 49.6 49.6 Spironolactone Tablet, 25/50 mg available [41.2 - 58.1] [41.2 - 58.1] NA NA 84.4 84.4 Tranexamic Acid available [77.2 - 89.7] [77.2 - 89.7] NA NA 21.5 21.5 Verapamil Tablet available [15.3 - 29.3] [15.3 - 29.3] Artemether + Lumefantrine Dispersible Tab- 39.1 60.9 65.4 45.8 let (Adult) available [31.7 - 47.1] [50.5 - 70.4] [57.0 - 73.0] [39.9 - 51.8] Amodiaquine + Artesunate Granular Powder, 10.3 14.9 19.1 11.9 75 mg + 25 mg available [6.3 - 16.2] [9.2 - 23.2] [13.3 - 26.7] [8.6 - 16.2] 16.0 18.6 21.3 16.9 Amodiaquine + Artesunate Tablet available [11.0 - 22.7] [12.8 - 26.2] [15.2 - 29.1] [13.0 - 21.8] 61.5 83.2 95.6 68.6 Paracetamol Suppository available [53.6 - 68.9] [73.5 - 89.9] [90.4 - 98.0] [62.6 - 74.1] BCG vaccine (freeze dried) and diluent (1 64.7 70.4 66.9 66.2 mL) powder for injection available [56.9 - 71.9] [58.4 - 80.1] [58.5 - 74.4] [60.1 - 71.8] Conjugate Meningococcal A Vaccine avail- 67.3 63.3 61.8 66.1 able [59.5 - 74.3] [51.8 - 73.5] [53.2 - 69.6] [60.0 - 71.7] 71.8 67.2 64.7 70.3 Oral polio vaccine available [64.2 - 78.4] [55.2 - 77.4] [56.2 - 72.4] [64.3 - 75.7] DTP-Hib + HepB (pentavalent) vaccine injec- 69.2 73.3 64.0 69.9 tion (0.5 mL) available [61.5 - 76.0] [61.5 - 82.6] [55.5 - 71.7] [63.9 - 75.3] 21.8 17.4 25.7 21.0 Human papilloma vaccine available [15.9 - 29.0] [11.3 - 25.6] [19.0 - 33.8] [16.5 - 26.3] 73.1 67.7 61.8 71.2 Pneumococcal vaccine available [65.5 - 79.5] [55.8 - 77.7] [53.2 - 69.6] [65.2 - 76.5] 72.4 67.1 61.8 70.6 Rotavirus vaccine available [64.8 - 78.9] [55.3 - 77.1] [53.2 - 69.6] [64.6 - 75.9] 73.7 64.3 63.2 70.9 Measles-Rubella vaccine available [66.2 - 80.1] [52.5 - 74.6] [54.7 - 71.0] [64.9 - 76.2] 28.2 27.9 39.7 28.8 Malaria vaccine available [21.7 - 35.9] [20.6 - 36.5] [31.7 - 48.3] [23.7 - 34.5] 69.9 62.7 63.2 67.8 Yellow fever vaccine available [62.1 - 76.6] [51.3 - 72.9] [54.7 - 71.0] [61.8 - 73.3] 21.2 31.4 38.2 24.6 Gentian violet, 5% available [15.4 - 28.3] [22.3 - 42.3] [30.4 - 46.8] [19.8 - 30.1] Note: Values in brackets are the 95% confidence interval. Values are marked as NA when a medicine is not required at a particular tier. 183 Table 70. Proportion of providers reporting being satisfied across different aspects of work, by tier (%) (N = 1227) Aspect Community Sub-District District Ghana Clarity in work responsi- 98.1 [93.8 - 99.4] 91.0 [82.7 - 95.5] 98.5 [96.5 - 99.3] 95.7 [92.3 - 97.6] bilities Work likeability 98.1 [94.6 - 99.3] 89.5 [77.9 - 95.3] 98.4 [95.1 - 99.5] 95.0 [90.2 - 97.5] Decision-making and 90.5 [83.4 - 94.7] 73.3 [62.3 - 82.0] 85.1 [77.9 - 90.3] 80.7 [74.8 - 85.5] instructions Opportunities for profes- 78.4 [66.3 - 87.0] 68.4 [58.0 - 77.2] 80.4 [69.6 - 88.0] 75.8 [68.5 - 81.9] sional development Pay 14.9 [8.8 - 24.1] 12.3 [7.4 - 19.9] 25.5 [18.6 - 33.8] 20.4 [15.7 - 26.1] Benefits 20.2 [13.5 - 29.3] 9.7 [5.1 - 17.9] 29.8 [22.2 - 38.7] 22.5 [17.4 - 28.6] Promotion system 53.4 [36.0 - 70.0] 63.0 [52.8 - 72.1] 69.7 [62.0 - 76.5] 67.1 [61.0 - 72.6] Transfer system 49.5 [42.0 - 57.0] 41.0 [31.1 - 51.6] 54.4 [44.2 - 64.3] 49.3 [42.3 - 56.5] Supervisor support 87.9 [80.1 - 92.9] 82.4 [75.1 - 87.9] 87.3 [81.3 - 91.6] 85.5 [81.0 - 89.0] Staff feedback system 75.9 [64.4 - 84.6] 58.8 [47.7 - 69.0] 65.0 [56.0 - 73.1] 62.8 [56.0 - 69.1] Response to feedback 74.6 [63.1 - 83.4] 51.1 [40.4 - 61.7] 63.0 [54.0 - 71.1] 58.6 [51.9 - 65.0] Relationship with cowork- 97.7 [94.5 - 99.0] 98.0 [95.8 - 99.1] 98.9 [96.7 - 99.6] 98.5 [97.2 - 99.2] ers Meaningfulness of job 97.6 [92.7 - 99.2] 97.9 [93.4 - 99.4] 99.8 [99.5 - 99.9] 99.1 [97.5 - 99.7] Manageable workload 69.8 [60.0 - 78.0] 73.6 [64.7 - 81.0] 74.0 [67.5 - 79.5] 73.8 [68.8 - 78.3] Staff allocation 61.6 [53.8 - 68.8] 46.6 [37.0 - 56.5] 64.9 [52.8 - 75.3] 58.0 [50.2 - 65.4] Functioning of equip- 37.0 [29.4 - 45.5] 23.5 [15.6 - 33.8] 43.1 [34.3 - 52.5] 35.7 [29.7 - 42.2] ment/ supplies/ medicine Infrastructure amenities 21.1 [13.5 - 31.5] 27.9 [18.8 - 39.2] 47.4 [37.7 - 57.3] 39.9 [33.2 - 46.9] Patient abuse system 70.4 [57.7 - 80.5] 51.0 [41.0 - 60.8] 63.5 [55.2 - 71.1] 58.9 [52.6 - 64.8] Note: Values in brackets are the 95% confidence intervals. Table 71. Reasons for visit for pediatric patients (%) (N = 906) Visit Reason Ghana Fever 37.4 [29.5 - 46.1] Routine health checkup (vaccination) 25.7 [17.3 - 36.4] Cough/sore throat 18.2 [12.7 - 25.4] Vomiting 14.8 [10.7 - 20.2] Stomach/abdominal pain 12.2 [8.8 - 16.7] Headache/migraine 10.9 [7.4 - 15.7] Diarrhea 10.3 [7.2 - 14.5] Skin infection/condition 6.2 [4.1 - 9.3] Runny nose/nose congestion 6.0 [3.9 - 9.1] Fatigue 5.0 [2.2 - 11.2] 184 Visit Reason Ghana Eye infection/pain/vision difficulties 3.5 [1.4 - 8.4] Family planning/reproductive health 2.6 [0.5 - 11.6] Burn/cut/fall 2.5 [1.4 - 4.5] Epilepsy/seizures/convulsions 1.9 [0.4 - 7.9] Dizziness/vertigo 1.7 [0.4 - 6.3] Note: Values in brackets are the 95% confidence intervals. Table 72. Facility-reported median waiting times (minutes) (N = 500) Community Sub-District District Ghana Median waiting time 10.0 (5.0 - 15.0) 10.0 (5.0 - 15.0) 15.0 (10.0 - 20.0) 10.0 (5.0 - 15.0) Median consultation 10.0 (10.0 - 15.0) 10.0 (10.0 - 15.0) 15.0 (10.0 - 19.4) 10.0 (10.0 - 15.0) time Note: Values in parentheses are the 25th and 75th percentiles. Annex B. Description of SDI Subdomains 1. Foundations Systems Policies and protocols: The successful operation of a health care facility relies on adherence to operational and process guidelines, including safety and human resources protocols, and high-quality clinical care aligned with international and local clinical guidelines for patient examination/consultation, diagnosis, and treatment. While appropriate implementation of and adherence to guidelines can be difficult to measure, part of the health facility environment that enables adherence to guidelines includes the physical availability in the facility of such guidelines for reference by staff. Against this backdrop, the SDI health survey includes the physical verification of the presence of the most up-to-date written guidelines on both operations/processes (such as IPC, waste management, emergency preparedness, human resource guidelines, etc.) and clinical practice (such as family planning consultation protocols, and diagnosis and treatment of hypertension, pneumonia, etc.). Institutions tasked with accountability for quality: Ensuring accountability for quality requires not only routine data collection by facilities on indicators capturing high-quality clinical and interpersonal care, but also frequent review, analysis, and dissemination of this information. To promote transparency and quality improvement, information on performance should be shared not only with facility management and higher-level administrators, but also with facility staff and the population that the facility serves. The SDI health survey captures the frequency with which facility-level performance indicators are collected, reviewed, and shared, and it also provides information on whom the data are shared with. The survey also measures how and how often feedback is solicited from the population served by the facility. 185 Finally, the survey captures the institutions and practices in place for external supervision (such as supportive supervision visits from central authorities) and the extent to which any supervisory activities adhere to the WHO definition of “supportive.” Management and supervision: It is not just the broader accountability architecture that influences the quality of primary care service delivery, but also the direct management and supervision of staff members. The management and supervision domain focuses on the procedures and practices within a health facility to review staff performance and provide feedback and support for improvement. These include measuring how frequently staff are provided with performance feedback, and using certain indicators and protocols to measure performance and conduct staff evaluations. Financing: The financing systems in health facilities have implications for facility-level and provider-level incentives, efficiency, and accountability. Information on financing at the facility tier includes the sources and amount of revenue that facilities generate. Funds flowing into a facility may come from government or other sources (including private or donor sources) and may be in the form of cash or in kind. The extent to which health care providers receive payment in the form of gifts (such as from patients) or other incentives for outcomes/performance may influence staff behavior and facility functioning. Physical infrastructure: This component measures the availability and functioning of key physical infrastructure required for operation of the health facility, especially in cases of emergency. This includes the availability and functioning of infrastructure to facilitate utilization of services by individuals with disabilities (such as ramps, lifts, tactile flooring, toilets for clients with limited mobility, and assistive technologies for people with visual impairment); provisions for auditory and visual privacy for patients; improved, functioning, accessible, and private toilet facilities; handwashing facilities; uninterrupted electricity; ambient temperature management infrastructure (heaters and air conditioners/fans); refrigerators for vaccine and blood storage; functioning fire safety infrastructure (alarm, extinguisher); and ICT (telephone, radio, computer, internet, etc.). Care Organization Service delivery organization: This domain captures the high-level organization of care— i.e., how primary care services are delivered in the country and how facilities are situated to serve their catchment populations. Specifically, this domain includes description of the types of facilities that deliver primary health care, their location (including their connectivity to the population through local public transportation and motorable roads), the size of the population they serve and how accessible they are to this population (i.e., the average time it takes for the catchment population to reach the facility), outreach practices, and facilities’ opening hours/hours of operation. Facility connective networks: In many cases, service delivery can be strengthened by connective networks between health facilities that allow seamless transfer of patients and information. Facility connective networks refer to systems that allow for inter-facility 186 communication and enable health facilities to connect patients to other facilities or practitioners for further care. Facilities may be part of formal designated networks that share staff and infrastructure and/or are part of formal referral systems. Facilities may also be connected by systems for communicating with one another during emergencies, or may have an ambulance or other form of transportation on site that facilitates linkage of patients to other facilities. This domain captures the existence of these connective systems, but does not cover the performance or effectiveness of these facility networks. Service and case mix: This domain captures the number and types of primary health care services that are available at the facility, including availability of laboratory services. Services may be available (infrastructure, human resources, equipment, and supplies are present), but this does not necessarily mean that they are utilized by patients. This domain captures both availability and utilization, hence measuring allocative efficiency (whether facilities provide mandated services and whether these services are utilized). This domain also includes measures of outpatient volume, stratified by case type (such as births, NCD visits, and childhood immunization visits, among others). This domain captures which facilities are overburdened by which types of cases and therefore what additional resources or referral patterns are required. Workforce Availability: This domain captures the de facto and de jure human resources at the health facility. It includes counts of staff of different cadres, counts of providers of different types of care (e.g., outpatient care, inpatient care, antenatal care, and so on), and the number of administrative/support staff. Particularly in large facilities, the number of health care providers on the staff roster may not truly reflect the number of health care providers present on a given day. This discrepancy may arise for many reasons—including shift systems, on-call protocols, arrangements where health care providers perform home visits or provide care at subsidiary facilities, and the presence of individuals in management roles who have medical training but serve as facility administrators or managers who are not patient-facing. The literature has also indicated that staff may be absent from health facilities for unauthorized reasons, which affects performance management and accountability. This domain measures these aspects. Education and training: Beyond just the availability of staff, the distribution of educational attainment and training of health care providers has implications for quality of clinical and interpersonal care. This domain measures the preservice education level of providers at each facility, along with recent service-specific in-service trainings. Combined with information on the types and volume of cases, this domain measures whether certain trainings are being administered where needed. Workload: A high workload impacts the ability of health care providers to provide high- quality care. Overworked and burnt-out health care providers are more likely to misdiagnose, provide incorrect treatment, not counsel patients, etc. It is therefore essential to better 187 understand health care providers’ workload. In low- and middle-income countries, it is common for health care providers to be involved in administrative activities like filling out insurance paperwork, managing medical supplies, etc. This role becomes even more common in small health facilities that are run by just one or two staff members. Therefore, in measuring the workload among health care providers, both their clinical caseload and their nonclinical work are accounted for. This domain also provides an understanding of how the time of health care providers is distributed across various activities. Satisfaction and retention: Individuals’ job satisfaction is closely related to their work performance and their motivation to continue to learn and grow at their workplace. For health care providers, satisfaction affects the quality of care, their interaction with patients, absence, and willingness to continue to work, especially in high-stress environments. Thus providers’ job satisfaction affects patients’ satisfaction and influences their decisions on accessing and continuing care. There is a need to improve job satisfaction among the health care workforce to build effective, efficient, and resilient health systems. This domain measures health care providers’ satisfaction across various relevant domains, including pay/ benefit package, workload, and promotion and transfer system. Tools Medical equipment and supplies: Availability of functioning medical equipment and supplies is required to provide high-quality health care. Health care providers might not be able to diagnose and treat patients or might do so incorrectly if the health facilities do not have the most essential medical items like stethoscope, syringe, etc. When medical conditions like TB and other communicable diseases go undiagnosed/misdiagnosed, the effect on the individual and community can be catastrophic. In some cases of shortage/ unavailability of essential medical supplies, providers try to optimize the current stock or reuse medical supplies that should be disposed of after single use (like syringes, gloves, etc.). This can lead to hospital-acquired infections. Patients also tend to lose trust in health systems, seek care elsewhere, or not seek care at all when they are not able to receive care due to supply shortage. This component provides a comprehensive picture of whether health facilities are stocked with essential medical equipment and supplies by making direct observations and checking for functionality. A health facility is recorded as having a given medical supply/piece of equipment if the field team can physically verify even one such item. Medicines and Vaccines: This domain provides information on availability of unexpired essential medicines for primary health care. Unavailability of medicine can influence patient’s behavior on care uptake and continuation. In remote areas where health facilities are the only source of affordable medicine, unavailability/shortage of medicine can keep patients from following up with the recommended treatment or can cause them to incur a high out- of-pocket expenditure, which can also impact patients’ economic well-being. If patients start considering health facilities “unreliable,” they may turn to traditional sources of care, which they deem to be more accessible and dependable. This component provides a comprehensive picture of whether health facilities have essential primary care medicines by making direct 188 observations. This component also records whether the available medicines are expired to provide information not just on their availability but also on their usability. A health facility is recorded as having a said medicine if the field team can physically verify even one full prescription of that unexpired medicine. Information systems: Use of information systems to record and manage relevant data is essential for health facilities to make data-driven decisions, whether for tracking patient history or managing supply of medical items. For example, health facilities that do not use an LMIS or any other logistics system to manage their medical supplies are more likely to face stock-outs as it becomes difficult to manage inventory. Further, such facility-level data when aggregated at macro level provide important insights about the health system in the country, such as the country’s current disease burden. Having this information helps shed light on the state of the health system and ongoing challenges and also helps in design of targeted interventions to improve the quality of health care. This domain measures various kinds of information systems used in health facilities (e.g., data reporting systems), staff trained in using these information systems, and other systems in place to share information with other health facilities and/or authorities. 2. Processes of Care Competent Care Systems Diagnosis, treatment, counseling: While inputs (like medical equipment, medicine, clinical guidelines, etc.) and basic infrastructure (like electricity and water supply, telephone, etc.) are essential to provide high-quality care, their availability does not guarantee the same. It is common for patients to receive subpar care (including misdiagnosis of medical conditions) or not receive any care even at well-equipped health facilities. This possibility has led to a gradual shift to incorporate other measures along with availability of inputs to better understand the performance of health systems. This domain sheds light on the level of competent care provided for common medical conditions like diabetes, hypertension, and others. It also measures incompetent care like incorrect diagnosis, treatment delays, and overprescription of drugs, all of which can have harmful short-term and long-term effects. A two-pronged approach is used wherein not only test providers’ knowledge is tested in diagnosing and treating specific medical conditions through clinical case simulations, but also the actual experience of patients in receiving care for these medical conditions. This allows the assessment of whether health care providers have appropriate medical knowledge for providing high-quality care and to capture any “know-do” gap (the gap between providers’ knowledge and their actual practice) by comparing their performance on clinical case simulations to the actual experience of patients. Through both the clinical case simulations and the outpatient exit interview, other aspects of care quality are captured as well, like whether the health care provider counseled the patient about any lifestyle change, whether they explained the frequency and dosage of medicine, and others. 189 Referral, continuity, integration: This domain triangulates information from all three SDI questionnaires—facility, health care provider, and outpatient exit interview—to provide a comprehensive picture of the way referrals work within the health system, the likelihood of patients receiving care from the same health facility/provider, and the extent to which health facilities are connected to one another. For a better understanding of the referral system, the following are also reported on: the number of referrals made from/to health facilities, common reasons for referrals, type of health facility from/to which referrals are made, and how patient information is transferred from/to health facilities. This information identifies gaps in the overall functioning of the referral system. For example, better guidelines and systems would need to be set up if health facilities lacked a well-defined structure to share patient information to the referred health facility. By improving referral systems, this ensures that health facilities provide high-quality care according to their service mandate, and patients can navigate the health system with ease. Patients’ willingness to continue to receive care from the same health facility/provider is an important measure of health systems that provide high-quality care. Such continuation of care builds provider-patient relationships, creates expectations around care, and increases the likelihood that patients will follow through with the treatment process in a timely manner. When sharing medical history with different health facilities/providers is difficult—as it may be in low- and middle-income countries, where “central” systems that record and share such information with ease are often absent or do not function optimally—patients may experience delays in diagnosis and treatment. Safety, prevention, detection: Along with providing timely diagnosis and treatment to patients, primary care systems also need to have mechanisms and guidelines in place for early detection of an outbreak, prevention of health care–associated infections, and response to emergencies. The COVID-19 pandemic showed the importance of resilient health systems that can aid in early detection and surveillance of an epidemic/pandemic and can respond to health emergencies along with providing routine health services. This domain provides an understanding of the IPC measures in health facilities (e.g., patient isolation room), guidelines on emergency response (e.g., guidelines to request emergency medical supplies), and preparedness against fire and natural disasters. For this domain, the following are also captured: in-service trainings (like training on antimicrobial resistance) and disaster assessments and drills that have been conducted in health facilities. Positive User Experience Respect and autonomy: Along with providing timely treatment, high-quality health systems must also treat patients with respect, account for their needs and preferences, and involve them in decisions regarding their health and treatment. Whether patients seeking care feel empowered and respected or belittled and disrespected influences their care-seeking behavior and trust in the overall health system. Even with all the required resources and systems in place, good health outcomes would be difficult to achieve if patients refrain from seeking care to avoid a negative and disrespectful experience. 190 This domain measures the extent to which patients are treated with respect at various stages of their consultation with the health care provider. Indicators of respectful care include whether providers greet and introduce themselves, how well providers explain things to patients, whether providers obtain their consent before a procedure, etc. This information from the patients’ experience is also compared to the relevant sections from clinical case simulations (such as whether providers introduce themselves, whether they counsel the patient on medicine dosage/next steps, etc.) to highlight any gaps between providers’ knowledge and their practice. User focus: “User-centered” health care systems focus on patients’ needs and preferences to ensure that they can receive high-quality care with ease. Such systems anticipate various bottlenecks that can arise right from the time that a patient decides to seek care, and they design measures to address those challenges. Measurement of user-focused care includes average wait time to see a health care provider, average travel time to the health facility, care provided in patient’s primary language, and others. Information from the three surveys is also triangulated to identify areas that may better cater to patients’ needs, like facility- reported hours of operation and patient-reported satisfaction with facility’s operating hours. 3. Person-Centered Outcomes Confidence in System Satisfaction and recommendation: Patient satisfaction is essential for high-quality primary health care systems, as it influences care-seeking behavior and hence health outcomes. Patients bypass health facilities when they are not satisfied with the care—a result that can unevenly distribute workload and patient volume across health facilities, thus disrupting the effectiveness of health systems. Patient dissatisfaction may worsen in close-knit communities, where word of mouth spreads perceptions easily, and people consider other people’s experiences and recommendations when seeking care. There are several factors (such as average wait time, out-of-pocket expenditure, etc.) apart from access to health care and timely diagnosis and treatment that impact patient satisfaction. This domain reports on the level of patients’ satisfaction with care and whether patients would recommend others to seek care from their provider. Attempts were also made to try to identify patients’ reasons for seeking care from a particular health facility and the areas that should be improved at the health facility. Care uptake and retention: This domain captures patients seeking care at more than one facility and their reasons for doing so. Additionally, patients’ intention to return to the health facility for care are captured—for example, pregnant women willing to give birth in the same health facility where they received ANC services. In high-quality primary care systems, patients continue to seek care at one facility unless referred to another facility. This ensures that patients do not bypass specific health facilities and that they can also seek care from providers who are familiar with their medical history, needs, and preferences. 191 Financial Protection Out-of-pocket costs: Patients may face barriers or trade-offs in seeking primary care, which can reduce care utilization and have long-term economic impact, resulting in poor health outcomes. For example, patients receiving primary care at a health facility may incur costs to reach the health facility itself (including transport) or for care of family members while they receive care (such as costs for childcare or elderly care). Once at the health facility, patients may pay out-of-pocket for consultation fees (or gifts to providers), medicine, supplies, etc. This domain captures out-of-pocket costs and the source of these funds, including whether patients needed to borrow money or take out a loan to afford the services received. Opportunity costs: In addition to direct out-of-pocket costs, patients often incur opportunity costs to visit a health facility, such as lost income due to time taken off from work. These costs may be particularly burdensome for patients who work in informal labor markets and/ or do not have paid medical leave. By quantifying these costs along with the out-of-pocket expenditure, the true financial burden of care seeking can more accurately be measured. Annex C. Sampling Methodology and Representativeness Health facility Selection The first objective of the survey was to draw a sample of primary health care facilities that was representative both nationally and by facility type in Ghana. Since the SDI Health Survey focuses on PHC, only primary health facilities along with the health facilities earmarked for the NoP model (for monitoring and evaluating the NoP model) were eligible for inclusion in the survey. The other strata were defined by the three levels of primary health care in Ghana – Level A (community), Level B (sub-district) and Level C (district). Since the DHIMS database of facilities shared by the MoH did not include a measure of facility size or indicate which facilities were functional, a super-sample of approximately twice the required size (1,000 facilities in total) was allocated into the same strata and selected with equal probabilities within each stratum. A pre-survey was conducted in the super sample to identify the functional facilities. The final sample 500 facilities was selected from among the functional facilities with equal probabilities, with the exception of the 26 NoPs, which were selected with 100% probability. An additional 100 reserve facilities were initially included as potential replacements with a similar distribution across strata to the sample facilities. However, during the fieldwork it became apparent that the sample frame had included a type of sub-facility (Mobile CHPS) that were not eligible for the survey as they did not have a permanent location and therefore were not able to answer a large proportion of the questions. Due to the ineligibility of a larger than expected proportion of Level A CHPS facilities an additional 100 potential reserve facilities were provided, which included a greater proportion of CHPS than in the original sample frame. 192 Health Care Provider Selection Health workers who were deemed “eligible” (i.e, the ones who provide outpatient primary care) were randomly chosen to participate in the survey in each selected health facility. Different cadres of health workers were proportionately sampled based on the sizes of the cadres of staff in the selected health facilities. The number of health care providers to be interviewed in each facility depended on the facility type and the staff size as shown in the table below. Table 73. Target number of health care providers to be surveyed in each selected health facility, by provider and facility Type Number of Number of Number of Number of physician Facility tier Facility type doctors per nurses per midwives per assistants per facility facility facility facility CHPS - - 1 1 Community Maternity - - 1 1 Home Health Centre - 1 1 1 Sub-District Clinic - - 1 1 Polyclinic 3 1 1 1 District Hos- 3 1 1 1 District pital Hospital 3 1 1 1 Earmarked - 1 1 1 Clinical Vignette Assignment Each health care provider was assigned one or two out of the five clinical vignettes. These clinical vignettes were randomly selected out of the ones for which each provider was deemed eligible based on the types of patients they typically treat. This was done to ensure that that the “average patient’s experience” of receiving care was captured, reflecting care provision by providers who diagnose and treat the vignette conditions under normal circumstances and according to their medical background and local guidelines. Table 74 provides details on the criteria used to assign clinical vignettes to different provider cadres across different facility types. Providers were considered “eligible” for only those vignettes that aligned with their typical practice and medical expertise. Consultation with medical experts along with reference to local guidelines were used to identify relevant departments that provide primary health care within each type of health facility. Next, provider positions/titles for personnel such as general physician and clinical nurse within each department who provide primary health care regularly were shortlisted. 193 Table 74. Criteria for assigning clinical vignettes to selected health providers Provider Case I: Case II: Case III: Case IV: Case V: Facility tier Provider position department Diarrhea Diabetes PPH Hypertension Birth Asphyxia General Nurse eligible - eligible - eligible Midwifery Professional (midwife and nurse-midwife eligible Community N/A eligible - eligible - professional) Community Health Nurse/ Officer eligible - - - - Medical Officer (general) / General Practitioner (non- eligible eligible eligible eligible eligible specialist) General Nurse eligible - - - - Sub-district OPD/ER and RCH Midwifery Professional (midwife and nurse-midwife eligible eligible - eligible - professional) Physician Assistant/Medical Assistant eligible eligible eligible eligible eligible OPD eligible eligible - eligible - Medical Officer (general) / General Practitioner (non- Emergency - - eligible - - specialist) OBGYN - - eligible - eligible 194 Pediatrics eligible - - - eligible OPD eligible eligible - eligible - Family Physician (including Residents) Pediatrics eligible - - - eligible Obstetrician/Gynecologist (Including Residents) OBGYN - - eligible - eligible Pediatrician (including Residents) Pediatrics eligible - - - eligible District Emergency Physician Emergency eligible eligible - eligible - OPD eligible - - - - General Nurse Pediatrics eligible - - - eligible Nurse Specialist OPD eligible - - - - Pediatric Nurse Pediatrics eligible - - - eligible Midwifery Professional (midwife and nurse-midwife eligible OBGYN - - eligible - professional) OPD eligible eligible - eligible - Physician Assistant/Medical Assistant Emergency - - eligible - - Patient Selection The third objective of the SDI survey was to measure the experience of patients and their satisfaction with care using a simple random sample of patients availing themselves of care at all eligible facilities. To avoid any potential bias arising from recruiting patients as they exited the facility, patients were instead recruited upon arrival into the facility and were interviewed after they sought care but before leaving the facility premises. The survey implementation team used the protocol below, which was based on the size of the field team, and which started before the beginning of the workday. The steps are as follows: • Anticipate the total number, N, of patients who will arrive to be seen by doctors at the facility in the workday. This was done by taking an arithmetic mean of the number of outpatient visits to the health facility on each of the 3 previously completed days prior to the survey (this information was collected in the facility questionnaire). • Define the number of interviews that each interviewer can be expected to conduct in the workday. For instance, if the facility is open for health appointments for six hours and the survey take 30 minutes on average, then the number of expected outpatient interviews to be conducted by 1 Patient Interviewer = 12. • Determine the total number of patient interviews (n) that the field team can conduct in the facility using the following formula: Number of expected outpatient interviews to be conducted by 1 Patient Interviewer × Number of Patient Interviewers. • Compute the sampling step, s = N/n, rounding to an integer. • Give each patient a serially numbered tag upon arrival and ask him/her to contact the patient handler after the consultation. • Determine the serial number, f, of the first patient to be interviewed as a random integer between 1 and s. The patients to be interviewed will be those with serial numbers, f, f+s, f+2s, etc. The protocol was designed to select a simple random sample from among all incoming patients. Some survey practitioners could consider it too laborious and complicated because it required the collaboration of two fieldworkers (the interviewer and the patient handler) and the anticipation of the total number of patients who would arrive at the health facility, which implies contacting the facility managers before the workday begins. Facility managers could thus be tempted to ask the interviewer to simply start interviewing the first outgoing patient, and then the next outgoing patient as soon as the first interview was complete. However, this alternative is vulnerable to several selection biases that can seriously affect the credibility of the study, namely: • Interviewer subjectivity when selecting the next outgoing patient (especially when multiple patients exit the facility simultaneously) • Differential non-response depending on various patient-related circumstances (such as need to leave the facility after the appointment, or, more importantly, satisfaction 195 with the appointment) • Exclusion of the incoming patients who abandon the facility before being treated (possibly discouraged by long waiting times) • The demonstrated intrinsic tendency of this alternative to select the patients whose appointments take longer Survey Weights Given the multi-respondent nature of the SDI survey, weights were developed at multiple levels, depending upon how certain units of observation were nested within existing entities. Facilities from each tier were selected with equal probabilities, with the exception of the 26 NoPs, which were selected with 100% probability. The probability of selecting a facility (f_i ) in each tier is as follows: fi = (si / ni ) * (ti / si ) Where, n = the total number of facilities in stratum i s = number of facilities selected in stratum i t = number of facilities successfully interviewed in stratum i The probability of selecting a provider in each cadre (doctor, physician assistant, nurse or midwife) in a given facility was determined as follows: pi = (si / ni ) * (ti / si ) Where, n = total number of eligible providers in the cadre in facility i s = number of providers selected in the cadre in facility i t = number of providers in the cadre successfully interviewed in facility i The above provider weight is meant to serve as a means to adequately weight the selection of providers for the provider survey interview. However, part of the weight, (ti / si ) , overlaps with the potential absence of providers in the facility on the day of the interview. Thus, weighting for the provider absence indicator at the facility must exclude this term and be weighted as follows for the probability of a provider being selected (ai ): ai = si / ni where, n = total number of eligible providers in the cadre in facility i s = number of providers in the cadre selected in facility i Selection of patients was similar to selection of providers, though rather than being based upon a preexisting roster, patient selection was based upon a sampling fraction developed 196 using the expected patient volume in the facility. The survey weights for patients in a given facility (i ) in district (d ) is expressed using the following: pti = (si / ni ) * (ti / si ) * ( fi ) * (Popd ) where, n = number of patients on the day of interview in facility i s = number of patients selected for interview in facility i t = number of patients successfully interviewed in facility i Pop = Population of district (taken from 2021 population and housing census) Survey weights were calculated as the inverse probability of selection, as follows: Facilities = 1/fi Providers = 1/pi Provider absence = 1/ai Patient = 1/pti Interpretation of results All providers who provided primary care services at the time of the survey were eligible for the survey. For facilities that provided both primary care and specialized services, only providers that regularly provided outpatient primary care were selected. This was done by identifying relevant departments within each health facility type that provided outpatient primary care (such as general OPD, emergency, pediatrics, OBGYN etc.) and then relevant provider positions/titles (such as general physician, clinical nurse, etc.) within those departments. This eligibility criteria ensured that providers (such as cardiologists, general surgeons, etc.) that were regularly engaged in secondary or tertiary care services did not get selected to participate in the survey. With respect to interpretation of the results from patient interviews, the sampling strategy and enrollment method were designed to reduce bias as much as possible and generate a sample that was representative of primary health care seekers. Although response rates among patients were relatively high, it is important to note that the results may not fully represent the experiences of those who refused to participate, and potential differences between participants and non-participants remain unknown. Furthermore, as this survey is facility-based, the interviewed patients are limited to those who had empirical access to the facility and actively sought primary health care. Consequently, the findings may not be entirely representative of the broader population, including individuals who do not utilize health facilities. 197 Annex D. Description of Indicators Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Care organization Facility connective Emergency % of facilities with at least one Number of facilities that own a All facilities networks transport ambulance or other four-wheeled four-wheeled motor vehicle or capacity motor vehicle provided by the health vehicle operational from facility facility for emergency that has fuel and authorized staff to drive at time of visit. transportation present and functional (able to start and move) with authorized staff to drive at the time of the survey (vehicle, functional, fuel, driver) Foundations Care organization Service and case Outpatient Outpatient visits per day over a Number of outpatient visits over Number of days health mix volume 3-month period a 3-month period (October - facility was open between December, 2023). October - December, 2023. Foundations Care organization Service and case Outpatient Visits by service type Number of outpatient visits over All facilities mix volume by (noncommunicable diseases [NCDs], a three-month period (October 198 service growth monitoring, etc.) - December, 2023) by service type (child growth monitoring, adult tuberculosis [TB], adult hypertension, Malaria etc). Foundations Care organization Service and case Proportion of % of facilities able to provide services Number of facilities able to Facilities where the service mix health facilities (and all services together) required provide the required services is required as per local able to provide at Primary Health Center (PHC) level during October - December, guidelines the required for each of these service categories: 2023 at PHC level PHC services, by Adolescent Health Services and category Interventions, Maternal and Newborn Health, Child Health and Nutrition Services, Family Planning services, Prevention, control and management of communicable diseases and risk factors, Risk Factor Assessment Services, Other primary care services Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Care organization Service and case Proportion of % of facilities able to provide Number of facilities able to Facilities where the mix health facilities laboratory services (and all provide the required laboratory laboratory service is able to provide laboratories together) required services during October - required as per local the required at PHC level for each of these December, 2023 at PHC level guidelines laboratory service categories: Communicable, non-communicable, routine OPD services, by laboratories category Foundations Care organization Service delivery Facility Catchment population distribution Total catchment population All facilities organization catchment (min, lower quartile, median, upper population quartile, max) Foundations Care organization Service delivery Facility operating Proportion of facilities operating on Number of facilities open each All facilities organization days each day of the week. day of the week Foundations Care organization Service delivery Facility opening Average duration of operation per day Average hours open per All facilities organization hours day, average hours for non- emergency OPD and average hours for emergency care Foundations Care organization Service delivery Connectivity to Proportion of facilities connected to a Number of facilities connected All facilities organization motorable road motorable road to motorable road (verified) 199 Foundations Care organization Service delivery Connectivity Proportion of facilities with public Number of facilities with a public All facilities organization (public transport) transport station/stop within a transportation station/stop 10-minute walk within a 10-minute walk Foundations Systems Financing Revenue Proportion of facilities receiving Number of facilities that All facilities received revenue from various sources in past received revenue from different 12 months sources Foundations Systems Financing Revenue Amount Average revenue received from Amount of revenue received Number of facilities that government and non-government from different sources in the received any revenue sources past 12 months (January - from any source in the December 2023) past 12 months Foundations Systems Financing In-kind Revenue Proportion of facilities receiving in- Number of facilities that All facilities kind revenue from various sources in received in-kind revenue from past 12 months different sources Foundations Systems Financing In-kind Revenue Average in-kind revenue received Amount of in-kind revenue Facilities that received in- from govt and non-government received from different source kind revenue sources in the past 12 months (January - December 2023) Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Systems Financing patient fees Proportion of facilities receiving Number of facilities that All facilities revenue from patient fees in past 12 received revenue through months patient fees Foundations Systems Institutions for Community Proportion of facilities with Number of facilities with All facilities accountability for advisory board community advisory boards community advisory boards quality Foundations Systems Institutions for Community Frequency of community board Number of facilities where the Number of facilities with accountability for advisory meetings administrative board met weekly, a community advisory quality board meeting monthly, every 3 months, every board frequency 6 months, annually and never in the past 12 months (January - December 2023) Foundations Systems Institutions for Facility quality Proportion of facilities that conducted Number of facilities that All facilities accountability for improvement quality improvement activities in the conducted quality improvement quality activities past 12 months activities in the past 12 months (January - December 2023) Foundations Systems Institutions for Facility quality Proportion of health facilities with Number of health facilities with Number of facilities that accountability for improvement quality improvement targets quality improvement targets in reported conducting quality targets the past 12 months (January - quality-improvement 200 December 2023) activities between January - December 2023 Foundations Systems Institutions for Facility quality Proportion of health facilities with Number of facilities that shared Number of facilities accountability for improvement quality improvement data shared with quality improvement results that conducted quality quality data sharing: external leadership with external leadership (DHO, improvement activities external leaders MoH, community advisory board or community management committee) Foundations Systems Institutions for Facility Proportion of health facilities with at Number of health facilities with All facilities accountability for supervision visits least one supervisory visit in past 12 at least one supervisory visit quality months in past 12 months (January - December 2023) Foundations Systems Institutions for Facility Proportion of facilities reporting Number of facilities whose Facilities that had accountability for supportive supportive supervision visits that supportive supervision visit supervision visits in the quality supervision included sharing challenges, issues included sharing challenges, past 12 months components identified, collective problem solving, issues identified, collective written feedback, and all together. problem solving, written feedback, and all together. Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Systems Institutions for Feedback Proportion of health facilities that Number of health facilities All facilities accountability for collection from sought feedback from their catchment that sought feedback from quality community community their catchment community in the past 12 months (January - December 2023) Foundations Systems Institutions for Community Proportion of health facilities utilizing Number of health facilities that Facilities that collected accountability for feedback data community feedback data including utilized community feedback feedback from catchment quality use review at least every 6 months, sharing data, through: review at least population in the past 12 with external leadership, sharing with every 6 months, sharing with months facility management/staff, sharing external leadership, sharing with with patients. facility management/staff, and sharing with patients. Foundations Systems Institutions for Improvement Most common community feedback Five most common areas for Facilities that collected accountability for community about area(s) of improvement for the facility improvement according community feedback quality feedback types health facility (frequency of different to community feedback feedback) Foundations Systems Institutions for Positive Most common community positive Five most common favorable Facilities that collected accountability for community feedback about the health facility aspects of facilities according to community feedback quality feedback types (frequency of different feedback) community feedback 201 Foundations Systems Management and Components Proportion of facilities with each Number of facilities that have for 1,2,3,4 -> all facilitites supervision of facility component: manager with degree in each attribute: management management, manager has attended for 5,6 -> facilities with capacity management training, facility conducts more 1 than staff/ support provider performance reviews, facility staff respectively (i) Manager with degree in conducts support staff performance management reviews, facility uses assessment tools (ii) Manager has attended management training (iii) Manager has at least a management degree or has attended a management training (iv) Facility conducts provider performance reviews (v) Facility conducts support staff performance reviews (vi) Facility manager receiveed performance review between January-December, 2023 Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Systems Management and Tools to Distribution of different type of Number of facilities that used All facilities that conduct supervision support staff tool(s) and criteria used to assess staff each of the tools to assess staff performance assessment performance performance performance and have more than 1 staff Foundations Systems Management and In-service Distribution of selection criteria for Number of facilities that used All facilities with more supervision training selection selecting staff for in-service training each of the different processes than 1 staff to determine which health care provider(s) receive in-service training Foundations Systems Management and Provider’s Proportion of providers who report Number of providers that report All providers supervision satisfaction with being satisfied with direct supervisor agreeing or strongly agreeing to support from support being satisfied with the amount supervisors of support and guidance received from their supervisor Foundations Systems Physical Accessibility Proportion of attributes in place for Number of attributes each All facilities infrastructure of facility for patients with disabilities (ramp, lift, facility has for patients with people with tactile flooring, assistive technologies disabilities (verified) disabilities for persons with visual impairment, toilet accessible for people with ramp (for facilities with incline or 202 limited mobility) step at entrance), lift (for facilities with more than one floor), tactile flooring, assistive technologies for persons with visual impairment, toilet accessible for people with limited mobility. Foundations Systems Physical Consultation Proportion of facilities with at least Number of facilities that have All facilities infrastructure room with visual one consultation room with auditory at least one consultation room and auditory and visual privacy with auditory and visual privacy privacy (verified) Foundations Systems Physical Functioning, Proportion of facilities with available, Number of facilities with primary All facilities infrastructure uninterrupted functioning, uninterrupted electricity source of power available, electricity (from any source) – meaning: power (verified) functional main source source available, functioning on day of of electricity, no interruptions the survey, no interruptions in the past in last 3 months (October - three months December 2023) Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Systems Physical Electricity Frequency of electricity interruptions Number of interruptions to Facilities that experienced infrastructure interruption electricity facilities had between at least 1 elecricity frequency October - December 2023 interruption in the past 3 months (October - December 2023) Foundations Systems Physical Electricity Average longest duration (hours) of Longest electricity interruption Number of facilities infrastructure interruption electricity interruption over a 3-month (hours) between October - experiencing at least one duration period December 2023 interruption in electricity in the past 3 months (October - December 2023) Foundations Systems Physical Refrigerator % of facilities with least one functional Number of facilities with at All facilities infrastructure (vaccine storage) refrigerator used for storing vaccines least one refrigerator available (with temperature within appropriate and functioning for the storage range as measured during survey) of vaccines with recorded temperatures of 2–8°C (verified) Foundations Systems Physical Refrigerator % of facilities with least one functional Number of facilities with at All facilities infrastructure (blood storage) refrigerator used for storing blood least one refrigerator available (with temperature within appropriate and functioning for the 203 range as measured during survey) storage of blood with recorded temperatures of 2–8°C (verified) Foundations Systems Physical Water quality % of facilities with improved, Number of facilities with All facilities infrastructure and availability functioning, uninterrupted, on- available and functional water premises water source (functioning source located on premises today, no interruptions in last three that have not experienced months October - December 2023, on interruptions during 3 months premises) Foundations Systems Physical Water % of facilities by frequency of % of facilities by number of All facilities that report infrastructure interruption interruptions between October - water interruptions experienced an interruption in water frequency December 2023 by facilities supply during October - December 2023 Foundations Systems Physical Water Median longest duration (days) of Duration of longest interruption Facilities that experienced infrastructure interruption water interruption between October - in water supply experienced water interruption duration December 2023 between 3 months between October - December 2023 Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Systems Physical Toilets Proportion of health facilities with (i)Number of facilities with at All facilities infrastructure toilets with various characteristics least one improved, functional, and accessible toilet within the premises in functioning condition for use by staff and patients, (ii) health facility staff only (verified), (iii) for females only (verified), (iv) females only that has menstrual hygiene facilities (verified) Foundations Systems Physical WaSH Proportion of facilities with available Number of facilities that have All facilities infrastructure infrastructure WaSH infrastructure including: each attribute verified: - Improved, functioning, (i) At least one improved, uninterrupted, on-premises water functioning, uninterrupted, on- source. premises water source 204 - Improved, functioning, accessible (ii) At least one improved, toilet. functioning, accessible toilet. - Functioning handwashing facility (iii) At least one functioning with soap within 5-meters from toilet. handwashing facility with soap within 5 meters from toilet. - Point of care with hand hygiene facility (iv) At least one point of care with hand hygiene facility. - All above WasH infrastructure (v) All combined Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Systems Physical Service % of facilities with selected infection Number of facilities with all IPC All facilities infrastructure readiness: prevention and control (IPC) infrastructure verified: infection infrastructure (physical barriers where prevention patients present, separate waiting area for contagious patients, designated (i) Physical barriers at one or site for patient isolation, functional more points of initial patient handwashing facility at atleast one contact. point of care, adequate infectious waste disposal system, all measures) (ii) At least one separate waiting area for patients with contagious disease (iii) At least one designated site for patient isolation (iv) At least one functional hand hygiene facility at at least one point of care (v) Appropriate waste disposal 205 (infectious medical waste other than sharps is not visible, or waste is disposed in a protected area). (vi) All measures are present. Foundations Systems Physical Ventilation % of facilities with at least one (i) Number of facilities with at All facilities infrastructure infrastructure consultation room with ventilation least one consultation room with and has had at least one ventilation ventilation performance assessment done in the past 2 years (ii) Number of facilities that had at least one ventilation performance assessment done in the past 2 years (January 2022 - December 2023) Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Systems Physical Fire safety % of facilities with fire safety Number of facilities with each All facilities infrastructure infrastructure (functioning alarm, functioning component of fire safety: extinguisher, conducted fire assessment in the past 2 years , (i) functioning alarm, conducted at least 1 fire drill in the (ii) functioning extinguisher, past 2 years (iii) conducted fire assessment in the past 2 years (January 2022 - December 2023), (iv) conducted at least 1 fire drill in the past 2 years (January 2022 - December 2023) Foundations Systems Physical IT infrastructure Proportion of facilities with Number of facilities with at All facilities infrastructure functioning information technology least one functional (and facility infrastructure items on the day of the owned) survey 1) landline telephone, mobile phone, or smartphone 206 2) Printer 3) Computer 4) Internet Foundations Systems Physical Functioning, Proportion of health facilities with Number of facilities with All facilities infrastructure uninterrupted internet available and functioning (on internet day of the survey) internet that did not experience any interruptions in internet access during October - December 2023 Foundations Systems Policies and IPC guidelines Proportion of facilities with physically Number of facilities with All facilities protocols present up-to-date IPC guidelines physically present up-to-date IPC guidelines Foundations Systems Policies and guidelines Median proportion of observed up-to- Proportion of up-to-date All facilities protocols date clinical guidelines guidelines available at facility (out of 23 guidelines) Foundations Systems Policies and LMIS system Proportion of facilities using LMIS Number of facilities using LMIS All facilities protocols system system Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Systems Policies and LMIS system Proportion of facilities with LMIS Number of facilities using paper Number of facilities using protocols format using different formats (paper based, based only, electronic only or LMIS system electronic or some combination of combination of paper-based and both) electronic LMIS system Foundations Systems Policies and Quality Proportion of facilities with quality Number of facilities which: All facilities Protocols assurance of inspection protocol, "first-expired, inventory first-out" protocol, and which 1. have quality inspection physically seperate and dispose protocol damaged/expired inventory 2. have "first-expired, first-out" protocol 3. physically seprate and dispose damged/expired inventory Foundations Systems Policies and Indentation Proportion of facilities which indent Number of facilities which: All facilities Protocols for inventory medicine and medical supply management inventory, have protocols for 1. indent medicine and medical emergency indenting in case of a supply inventory stock-out or near stock-out 2. have protocols for emergency indenting in case of a stock-out 207 or near stock-out Foundations Systems Policies and Inventory receipt Duration between when facility Frequency of avg. durartion Facilities that indent Protocols duration indented medicine or medical supply (weeks) between indenting and medicine and medical inventory and when it received it when the facility received the supply inventory supplies Foundations Systems Policies and emergency Duration between when emergency Frequency of avg. duration Facilities that placed Protocols Inventory receipt indentation of medicine or medical (weeks) between emergency emergeny indents over duration supply inventory and when it received indenting and when the facility the past 12 months it received the supplies Foundations Tools Medical Equipment Proportion of equipment available Proportion of equipment All facilities equipment and availability + functioning (wherever required) items in each category that are supplies in each equipment category defined available and functional at time (MCH and reproductive health, of visit laboratory, IPC, acute care) Foundations Tools Medical Test availability Proportion of patients prescribed Number of patients that Number of patients equipment and laboratory test(s) who report receipt received prescribed laboratory prescribed a laboratory supplies of all tests test(s) test on survey day Foundations Tools Medicines Medicine Proportion of measured medicines Number of medicines in All facilities that are availability available (meaning that the facility category that are unexpired at required to have the has at least one observed, unexpired time of visit medicine medicine) Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Tools Medicines Medicine % of patients prescribed medicines Number of patients that Number of patients availability who report receipt of all medicines received prescribed medicines who were prescribed medicines Foundations Workforce Availability Staff availability Median staff availability: Number of All facilities - health care providers - health care providers - clinical support staff (pharmacists - clinical support staff and technicians) (pharmacists and technicians) - administrative support staff - administrative support staff (administrative and clerical staff) (administrative and clerical staff) - total staff - total staff - providers per 1000 catchment population - total staff per 1000 catchment population Foundations Workforce Availability PHC provider Median number of doctors, nurses, Number of doctors,nurses, All facilities 208 availability midwives, physician assistants midwives, physician assistants Foundations Workforce Availability PHC providers % of sampled (from roster) PHC Number of doctors, nurses, Number of sampled NOT present at providers NOT at the facility providing midwives, physician assistants providers by cadre health facility care on the day of the unannounced not present at facility at the time (overall % visit (“absence" metric) of the unannounced visit absence) Foundations Workforce Availability Provider absence Distribution of reasons for absence Distribution of reasons for Number of providers reasons of PHC providers on the day of the absence of doctors, nurses, absent at time of unannounced visit (include both midwives, physician assistants unannounced visit by authorized reasons + unauthorized cadre reasons) Foundations Workforce Education and Provider Median years in the current position, Number of years in the current All providers training retention (proxy) in current facility and in clinical service position, in current facility and in clinical service Foundations Workforce Education and Service-specific Proportion of health facilities that Number of facilities that were All facilities training training were able to offer each service in the able to offer each service in the 3 months prior to the survey and with 3 months prior to the survey and at least one provider that received with at least one provider having in-service training in the last 2 years in been trained in each laboratory each service service in the past 2 years Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Workforce Education and Laboratory Proportion of health facilities that Number of facilities that were All facilities training service-specific were able to offer each laboratory able to offer each laboratory training service in the 3 months prior to the service in the 3 months prior to survey and with at least one provider the survey and with at least one that received in-service training in the provider having been trained in last 2 years in each laboratory service each laboratory service in the past 2 years Foundations Workforce Education and Service-specific Proportion of health facilities with Number of facilities with at All facilities training training: at least one provider trained in least one provider having been specialized specialized services and topics in the trained in each service category services and last 2 years in each category in the past two years topics (facility) Foundations Workforce Education and Service-specific Distribution of recipt and modality Number of providers mentioning All providers training training: of specialized training received by receipt and modality of training specialized providers in specialized services services and topics (provider) Foundations Workforce Education and Professional Distribution, by cadre, of professional Number of doctors, nurses, All providers training training degrees midwives, physician assistant, 209 Allied Health Professionals who attained each of the relevant professional degrees Foundations Workforce Satisfaction and Job satisfaction Proportion of providers reporting Number of providers reporting All providers retention being satisfied across different aspects being satisfied (who agree or of work strongly agree with statements presented) across different aspects of work Foundations Workforce Workload Time distribution Proportion of time spent by provider Time (in hours) in the most Total hours worked by across different on different activities in most recent recent work week spent by provider in most recent activities typical work week: providing care provider in different activities work week to patients, administrative clinical (providing care to patients, tasks, education activities, community administrative clinical tasks, outreach, management activities, education activities, facility other activities by provider cadre administration, and other activities) Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Foundations Workforce Workload Time distribution Proportion of time spent by provider Time in hours spent by provider Total hours worked by across different on different activities in most recent in different activities (providing provider in most recent activities typical work week: providing care care to patients, administrative work week to patients, administrative clinical clinical tasks, education tasks, education activities, community activities, facility administration, outreach, management activities, and other activities) other activities by tier Foundations Workforce Workload Provider Median number of hours worked in 1. Number of hours worked in All providers workload in the the most recent typical work week the most recent typical work most recent week typical work Median outpatient contacts per day in week the most recent typical work week 2. Number of outpatient contacts per day in the most % of providers who are dissatisfied recent typical work week with the balance between clinical and administrative work 3. Number of providers who disagreed or strongly disagreed with the following statement, “In my current role at this facility, I am satisfied with the balance 210 I have between clinical and administrative work" Processes of care Competent care Diagnosis, Clinical Vignette-average performance in Number of providers who Total number of providers systems treatment, knowledge: indicating primary and complete selected the correct primary and who completed the counseling primary diagnosis correctly complete diagnosis by case: vignette by case: diarrhea, diagnosis diarrhea, diabetes, hypertension diabetes, hypertension and complete diagnosis Processes of care Competent care Diagnosis, Clinical Vignette-specific distribution of Number of providers who Total number of providers systems treatment, knowledge: diagnosis (correct + incorrect) selected each type of potential who completed the counseling diagnosis diagnosis by cases including vignette by case: diarrhea, correct and incorrect options diabetes, hypertension Processes of care Competent care Diagnosis, Clinical Vignette-average performance in Number of providers who Total number of providers systems treatment, knowledge: indicating primary and complete selected the correct primary and who completed the counseling primary treatment correctly complete treatment by case: vignette by case: diarrhea, treatment diarrhea, diabetes, hypertension diabetes, hypertension and complete treatment Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Processes of care Competent care Diagnosis, Clinical Vignette-specific distribution of Number of providers who Total number of providers systems treatment, knowledge: treatment (correct + incorrect) selected each type of potential who completed the counseling treatment treatment by cases including vignette by case correct and incorrect options Processes of care Competent care Diagnosis, Clinical Vignette-specific and average Number of providers who Number of providers who systems treatment, knowledge performance in correct primary selected the correct primary competed the vignette by counseling diagnosis + primary treatment diagnosis and treatment by case: case: diarrhea, diabetes, together diarrhea, diabetes, hypertension hypertension Processes of care Competent care Diagnosis, Intrapartum Diagnostic accuracy for emergency Number of providers who Total number of providers systems treatment, Emergency response simulations selected the correct diagnosis who completed the counseling Response: for PPH and neonatal asphyxia vignette by case Diagnosis Processes of care Competent care Diagnosis, Intrapartum Treatment accuracy for postpartum Each treatment step with the key Total number of providers systems treatment, Emergency hemorrhage simulation correct treatment steps (as per who completed the counseling Response (PPH): local guidelines) bolded in the vignette Treatment table Processes of care Competent care Diagnosis, Intrapartum Treatment accuracy for neonatal Each treatment step with the key Total number of providers systems treatment, Emergency asphyxia simulation correct treatment (as per local who completed the counseling Response (Birth guidelines) bolded in the table vignette 211 Asphyxia): Treatment Processes of care Competent care Diagnosis, Competent ANC At this or previous visit for ANC: % Number of ANC patients who Number of patients who systems treatment, care: this or patients who report - received each (and all) of the visited the facility for ANC counseling previous visit specified services for this visit, care. provider asked for maternal and child and separately for this or a health handbook; estimated the due previous visit. date; measured weight; informed whether weight was normal/higher/ Services include: informed lowerthan expected; measured height; whether weight was normal/ measured blood pressure; informed higher/lower than expected, BP was normal/higher/lower than the denominators for "this visit" expected; urine sample; screened and "this or a previous visit" for HIV; screened for syphilis; blood were patients who had a BP group; recommended to take iron or measured in this visit, and this or folic acid; informed on side effects a previous visit, respectively. For of iron or folic acid; counseled on informed on side effects of iron alcohol; counseled on tobacco; or folic acid, the denominator counseled on drug use; counseled on for "this visit" and "this or a physical activity; counseled on diet; previous visit" was patients who counseled on pain relief; counseled on were recommended to take iron pregnancy danger signs; advised on or folic acid in this or a previous exclusive breastfeeding; all togther visit. Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Processes of care Competent care Diagnosis, Competent ANC Percentage of women over 20 weeks Number of ANC patients over Patients visiting for ANC systems treatment, care: 20 weeks pregnant who received essential 20 weeks pregnant who received care who are more than counseling over ANC services at this or a previous each (and all) of the specified 20 weeks pregnant visit: measured uterine height; services across all visits provider palpated abdomen; received ultrasound scan; provider measured blood glucose level; patient informed blood glucose was normal/higher/ lower than expected; all together Processes of care Competent care Diagnosis, Competent NCD At this or previous visit for diabetes Number of diabetes or Number of patients systems treatment, care: this or or hypertension, percentage of hypertension patients who who visited the facility counseling previous visit patients who report they received received each (and all together) for diabetes and/or the following services: asked about of the specified services across hypertension treatment/ current medications, medical history, all visits. management. family history, tobacco use, alcohol use, physical activity, diet, occupation; had specific examinations including Services include: examined feet breathing and heart checked with or eyes (restricted to patients stethoscope, examination of the who reported visiting for abdomen, feet, and eyes; blood 212 diabetes-related care); received glucose tested via sample; received and discussed blood glucose blood glucose result; discussed result restricted to patients that blood glucose result; cholesterol/ had a blood sample taken for a lipids tested; received cholesterol/ blood glucose test only; received lipids result; discussed cholesterol/ and discussed cholesterol results lipids test results; blood pressure restricted to patients that had a measured; discussed blood pressure blood sample taken for a blood result; counseled on dangers of cholesterol test; discussed blood alcohol; counseled on physical activity; pressure result restricted to counseled on diet; all together patients that had their blood pressure measured. Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Processes of care Competent care Diagnosis, Competent sick Percentage of interviewed patients Number of patients who visited Number of patients who systems treatment, child care visiting facility for sick child care a facility for sick child care visited the facility for counseling receiving each (and all together) of received each (and all together) sick child care. Advice the following for this visit by child of the specified services this visit. on complementary age group: asked age of child; asked foods only applicable for about child’s symptoms; asked if children aged 6 months first or follow-up visit; asked about - 2 years; advice on immunization history; asked about exclusive breastfeeding mother’s health ; told to watch for only applicable for signs and symptoms, given a date/ children under 6 months. time to return for follow-up ; advice on giving child complementary foods; asked about feeding; asked about child growth; plotted growth; counseled on feeding; counseled on exclusive breastfeeding; informed on diagnosis; received nutritional supplement for child Processes of care Competent care Referral, Frequency of Distribution of frequency (always, Frequency (always, often, All patients systems continuity, visiting health often, sometimes, rarely, never) with sometimes, rarely, never) with 213 integration facility which patients visit the health facility which patients visit the health at which they were interviewed when facility they seek care Processes of care Competent care Referral, Frequency of Distribution of frequency (always, Frequency (always, often, All patients systems continuity, seeing the same often, sometimes, rarely, never) with sometimes, rarely, never) with integration provider which patients see the same provider which patients see the same when they seek care at this health provider when they seek care facility Processes of care Competent care Referral, Provider referral Median provider-reported referral Number of referrals providers All providers systems continuity, frequency counts during October to December report making over during integration 2023 October to December 2023 Processes of care Competent care Referral, Referral within Percentage of patients referred for Number of patients referred All patients systems continuity, facility: patient care within the same health facility on for care within the same health integration reported the day of the survey as reported by facility on the day of the survey the patients Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Processes of care Competent care Referral, Referral outside Percentage of patients referred for Number of patients referred for Patients that received systems continuity, facility: patient care to another facility on the day of care to another facility on the services on the day of integration reported the survey; and percentage referred day of the survey; and number the survey; and patients because ‘services/specialized care not of patients referred for care referred to another facility available from current health facility’, to another facility because on day of the survey as reported by patients “services/specialized care not respectively available from current health facility”, respectively Processes of care Competent care Referral, Reason for Distribution of most common reason Number of facility managers per Facilities that made systems continuity, referral outside for referral outside facility as reported reason patient referrals over 3 integration facility: facility by the facility manager month period, by facility manager tier. reported Processes of care Competent care Referral, Provider- Frequency of outpatient referral Distribution of frequency of Providers who made systems continuity, reported information sharing, as reported by sending information for referrals referrals during October - integration frequency of the providers as estimated by providers December 2023 information (>80%, 60 - 80%, 40 - 60%, 20 - sharing for 40%, > 0 - 20%, 0%) referrals 214 Processes of care Competent care Referral, Provider- Distribution of ways that patient Frequency of ways that patient Providers who made systems continuity, reported information was sent to the health information was sent to the referrals during October - integration informed referral facility or health care provider to facility or health care provider December 2023 modality which they were referred, as reported to which patient was referred, as by the providers reported by providers Processes of care Competent care Referral, Facility-reported Information transfer mode for referrals Frequency of mode that patient Facilities that had any systems continuity, informed referral from external facilities, as reported by information was sent to the patients referred from integration modality facility managers facility for patients referred from another health facility other facilities, as reported by during October - facility managers December 2023 Processes of care Competent care Referral, Patient-reported Information transfer mode for referrals Frequency of mode that patients Patients who received systems continuity, informed referral to external facilities, as reported by believed their information was referral during October - integration modality patients sent to the facility to which they December 2023 were referred to most recently Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Processes of care Competent care Referral, Health document Availability of specific health records Number of patients with the All patients. MCH records systems continuity, availability amongst patients following health documents: book applicable to integration patients seeking care for treatment card/handbook, antenatal care or for a sick prescription sheet, patient child. Diabetes records folder, national insurance card applicable to patients (digital or physical), private seeking care for diabetes. insurance card (digital or physical), maternal and child health (MCH) records book, diabetes self-care handbook and follow-up record, nothing Processes of care Competent care Safety, IPC surveillance: Percentage of facilities with protocols Number of facilities with All facilities systems prevention, protocols to test to test for any national notifiable protocols to test and report to detection for notifiable diseases higher level authorities of any diseases national notifiable diseases Processes of care Competent care Safety, IPC surveillance: Percentage of facilities reporting Number of facilities that report Facilities that test for systems prevention, reporting national notifiable diseases (among to higher level authorities of any any national notifiable 215 detection the ones that test) to higher level national notifiable diseases diseases authorities Processes of care Competent care Safety, IPC point-of-care Percentage of facilities where point of Number of facilities where point All facilities systems prevention, cleaning care are cleaned regularly of care are cleaned regularly detection Processes of care Competent care Safety, IPC antibiotic Percentage of facilities that maintain Number of facilities that All facilities systems prevention, tracking record to track the antibiotics maintain record to track the detection prescribed/dispensed antibiotics prescribed/dispensed Processes of care Competent care Safety, IPC AMR training Percentage of facilities where at Number of facilities where at All facilities systems prevention, least one staff received training on least one staff received training detection antimicrobial resistance (AMR) or on antimicrobial resistance antibiotic stewardship in last 2 years (AMR) or antibiotic stewardship in last 2 years Processes of care Competent care Safety, IPC training Percentage of facilities where at least Number of facilities where at All facilities systems prevention, one provider received in-service least one provider received in- detection training on IPC in last 2 years service training on IPC in last 2 years Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Processes of care Competent care Safety, Emergency Percentage of facilities with Number of facilities with All facilities systems prevention, preparedness: guidelines/protocols to access backup guidelines/protocols to access detection Human human resources during emergencies backup human resources during resources emergencies guidelines Processes of care Competent care Safety, Emergency Percentage of facilities with protocols Number of facilities with All facilities systems prevention, preparedness: to access essential medicines, protocols to access essential detection Medical supply consumables, and equipment medicines, consumables, and guidelines from medical buffer stores during equipment from medical buffer emergencies stores during emergencies Processes of care Competent care Safety, Emergency Percentage of facilities with Number of facilities with All facilities systems prevention, preparedness: guidelines/protocols to access guidelines/protocols to access detection Financing financing during emergencies financing during emergencies guidelines Processes of care Competent care Safety, Emergency Percentage of facilities with protocols Number of facilities with All facilities systems prevention, preparedness: to communicate with other health protocols to communicate detection Risk facilities, communities, and the public with other health facilities, communication during emergencies communities, and public during guidelines emergencies 216 Processes of care Competent care Safety, Emergency Percentage of facilities that conducted Number of facilities that All facilities systems prevention, preparedness: a drill on safety procedures in the conducted drill on safety detection Natural event of a natural disaster and/or procedures in the event of a weather event in the past 2 years natural disaster and/or weather disasters event in the past 2 years and weather events drill/ simulation Processes of care Competent care Safety, Emergency Percentage of facilities that conducted Number of facilities that All facilities systems prevention, Preparedness: an assessment of vulnerability in the conducted an assessment of detection Natural event of a natural disaster and/or vulnerability in event of natural disasters and weather event in the past 2 years disaster and/or weather event in weather event the past 2 years vulnerability assessment Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Processes of care Competent care Safety, Emergency Percentage of facilities that conducted Number of facilities that All facilities systems prevention, Preparedness: drills on managing surge capacity in conducted drills on managing detection Surge capacity the past 2 years surge capacity in the past 2 management years drills Processes of care Competent care Safety, Emergency Percentage of facilities where a Number of facilities where a All facilities systems prevention, Preparedness: drill/simulation on fire safety and drill/simulation on fire safety and detection Fire safety drill/ prevention has been conducted in the prevention have been conducted simulation past 2 years in the past 2 years Processes of care Competent care Safety, Emergency Percentage of facilities that conducted Number of facilities which All facilities systems prevention, Preparedness: an assessment of vulnerability to fire conducted an assessment of detection Fire vulnerability in the past 2 years vulnerability to fire in the past 2 assessment years Processes of care Positive user Respect and Patient rating of Percentage of patients satisfied with Number of patients rating Patients who received care experience autonomy their experience different aspects of their experience: different aspects of their auditory privacy, visual privacy, experience (auditory privacy, communication, greetings and visual privacy, communication, introduction, patient involvement in greetings and introduction, care patient involvement in care) as 217 “good” or “very good” Processes of care Positive user Respect and Patient-reported Percentage of patients reporting all Number of patients that Patients who received care experience autonomy questions questions were answered during reported all their questions answered consultation were answered during their consultation Processes of care Positive user User focus Visits based on Percentage of visits based on Number of visits based on All patients experience appointments appointments (and type of appointments (with specific day/ appointment) and without an time given, or were asked to visit appointment as reported by the the health facility after a certain patients time interval without mention of a specific date/time) and without an appointment Processes of care Positive user User focus Patient-reported Median time waited, consultation Time spent waiting at the health All patients experience waiting time, time and total time at the facility as facility after arrival and before consultation reported by the patients being seen by one of the health time and total care providers, consultation time time at the and total time at the facility facility. Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Processes of care Positive user User focus Patient rating of Percentage of patients satisfied with Number of patients rating All patients experience aspects of facility different aspects of their experience aspects of their experience (waiting time, travel time, physical condition of rooms, duration of consultation, convenience of hours of operation, cleanliness of rooms, availability/functioning of equipment/ supplies/ medicines) as “good” or “very good” Person-centered Confidence in Care uptake and Patients who Proportion of patients reporting 1. Number of patients that All patients outcomes system retention received receipt of intended care, intention to received the intended services intended care seek a second opinion, and indicating during their visit they would return to same facility for a similar service 2. Number of patients who plan to visit another health care provider within the same or another health facility for further care for the same reason they visited the facility that day 218 3. Number of patients who would come back to the same facility if they needed care for a similar health concern Person-centered Confidence in Care uptake and Choice of ANC Percentage of patients who have Number of patients who have Women in their second outcomes system retention facilities visited other health facilities for ANC visited any other health facility/ or third trimester of care facilities for ANC care pregnancy with two or more ANC visits Person-centered Confidence in Care uptake and Reasons for Distribution of reasons for visiting Distribution of reasons for Patients who have visited outcomes system retention choice of ANC more than one facility for ANC care as seeking care at another facility any other health facility/ facility reported by the patients facilities for ANC care Person-centered Confidence in Care uptake and Choice of NCD Percentage of patients who have Number of patients who have Patients seeking NCD outcomes system retention facilities visited other health facilities for NCD visited any other health facility/ care (diabetes treatment/ care as reported by the patients facilities for diabetes and/or management and/or hypertension care hypertension treatment/ management) at facility Person-centered Confidence in Care uptake and Reasons for Distribution of reasons for visiting Number of patients who Number of patients who outcomes system retention choice of NCD more than one facility for NCD care as selected each reason for visiting visited another facility facility reported by the patients more than one facility for to seek diabetes and/or diabetes and/or hypertension hypertension care care. Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Person-centered Confidence in Care uptake and Care seeking Percentage of patients who bypassed Number of patients who state All patients outcomes system retention bypass care as reported by the patients there is a health facility closer to them where they could receive the same services sought for the visit the day of the survey Person-centered Confidence in Satisfaction and Recommend Percentage of patients who would Number of patients who would Patients who received care outcomes system recommendation facility recommend facility to a friend or recommend facility to a friend family member who needed the same or family member who needed service they received that day the same service they received that day Person-centered Confidence in Satisfaction and Patient ratings Percentage of patients satisfied with Number of patients rating Patients who received care outcomes system recommendation for quality of different aspects (overall quality of different aspects (overall quality care care, health care provider skills, choice of care, health care provider of health care provider) of the quality skills, choice of health care of care received provider) of the quality of care as “good” or “very good” Person-centered Confidence in Satisfaction and Top thing to be Distribution of responses (top 5) to Frequency of selection of each All patients outcomes system recommendation improved "What is the top thing that could be response to what could be improved in this health facility?" improved in the health facility, as 219 reported by the patients Person-centered Confidence in Satisfaction and Reasons for Distribution of reasons (top 5) for Frequency of response to why All patients outcomes system recommendation choosing this choosing this facility for healthcare, as the patient chose this PHC facility reported by patients facility Person-centered Confidence in Satisfaction and Reasons for Distribution of reasons (top 5) for Frequency of response to why Patients who indicated outcomes system recommendation choosing this choosing this facility for healthcare the patient chose this PHC that there is a health facility, among facility facility closer to them those with a where they could receive closer facility the same services Person-centered Financial Opportunity costs Median time to Median time to reach facility as Time it took patient to reach All patients outcomes protection reach facility reported by the patients facility from home (minutes) Person-centered Financial Opportunity costs Patients Percentage of patients with lost Number of patients with lost All patients outcomes protection reporting lost income due to seeking care income due to the time it took income to visit the health facility Person-centered Financial Out-of-pocket Patients Percentage of patients incurring cost Number of patients who All patients outcomes protection costs incurring cost in seeking healthcare incurred expenses on travel, due to care consultation, medications, laboratory tests, or childcare/ elder care costs Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Person-centered Financial Out-of-pocket Highest cost Category corresponding to the highest Number of patients in each Patients who incurred outcomes protection costs category, cost (travel, medicine, laboratory tests, cost category (travel, medicine, costs in seeking among patients or consultation) laboratory tests, or consultation) healthcare incurring costs that reported that category being their highest in terms of expenses associated with the visit Person-centered Financial Out-of-pocket Active insurance Percentages of patients who reported Number of patients reporting All patients outcomes protection costs distribution having different active insurances no health insurance, private insurance only, public insurance only, or a combination of both. Person-centered Financial Out-of-pocket Patients Percentages of patients incurring cost Number of patients who Patients within each outcomes protection costs incurring cost in seeking healthcare, by insurance incurred expenses on travel, insurance status category due to care, by status and category of costs consultation, laboratory tests, or insurance status medication costs and category of costs Person-centered Financial Out-of-pocket Median costs Median costs incurred and reported Median expense incurred on Patients who incurred outcomes protection costs incurred due by patients who incurred costs on travel, consultation, laboratory costs in seeking 220 to care, by their visit, by the category of costs tests, or medication costs healthcare insurance status and category of costs Person-centered Financial Out-of-pocket Source of money Distribution of sources of funds to Number of patients who Patients who incurred outcomes protection costs for costs pay for current health care visit as selected each source of money costs in seeking reported by the patients used to pay for health care- healthcare related expenses on the day of the visit Annex Median Median outpatient volume over Number of outpatient visits All facilities outpatient 3 month period by service type over a three-month period volume (noncommunicable diseases [NCDs], (October - December, 2023) by growth monitoring, etc.) service type (child immunization, child growth monitoring, adult tuberculosis [TB], adult diabetes, hypertension, cancer screenings). Annex Consultation Proportion of facilities with at least Number of facilities with All facilities room with light one patient consultation room with a a consultation room with functional light source functional light Annex Consultation Proportion of facilities with at least Number of facilities with All facilities room with AC/ one patient consultation room with a consultation room with fan functioning fan or AC functional fan/AC Domain level 1 Domain level 2 Domain level 3 Indicator name Definition Numerator Denominator Annex Availability % of facilities with each guideline Number of facilities with up-to- All facilities of individual available (up-to-date) date guideline available guidelines Annex Equipment % of equipment available + Number of facilities with each All facilities that are availability functioning (wherever required) individual equipment available required to have the and functioning equipment Annex Medicine Proportion of facilities with required Number of facilities with each All facilities that are availability medicines individual medicine available required to have the and unexpired medicine Annex provider Proportion of providers reporting Number of providers satisfied All providers satisfaction being satisfied across different aspects across different aspects of work of work Annex Visit reasons sick Reason for visit for pediatric patients Number of patients reporting All patients under age of child different reason for visit 18 Annex Facility wait Facility reported median wait time and Waiting and consultation time All facilities times consultation time (in minutes) 221