CONSOLIDATED FINDINGS REPORT HEALTH SYSTEM TECHNICAL SUPPORT TO GOVERNMENT OF GHANA: PATIENT PATHWAY ANALYSIS AND SUMMATIVE NETWORK ANALYSIS Table of Contents Acknowledgments 1 Introduction 2 Methodology 3 Findings 6 © 2024 International Bank for Conclusion 29 Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org Figures Figure 1. Hub and Spoke Model of Network of Practice (NoP) 3 This work is a product of the staff Figure 2. Categorization of PPA-SNA findings 5 of The World Bank with external contributions. The findings, Figure 3. Pathway of care for Maternal and Neonatal Health respondents interpretations, and conclusions (N = 136 MNH) 7 expressed in this work do not Figure 4. Drivers of health facility preference for MNH clients 8 necessarily reflect the views of The Figure 5. Rural vs Urban MNH Provider Use Pattern 9 World Bank, its Board of Executive Directors, or the governments they Figure 6. Pathway of care of Hypertension patients (N = 420) 10 represent. Figure 7. Drivers of health facility preference for HTN patients 11 Figure 8. Rural vs Urban HTN Patient Facility Preference 12 The World Bank does not guarantee Figure 9. Dimensions of accessibility to healthcare for MNH and HTN clients 13 the accuracy of the data included in this work. The boundaries, colors, Figure 10. Modified HQHS Framework showing health system factors denominations, and other information observed in NoP districts 15 shown on any map in this work do not Figure 11. Components of spatial analysis of health facilities and networks 18 imply any judgment on the part of The Figure 12. Schema for community validation of findings from primary data World Bank concerning the legal status collection 25 of any territory or the endorsement or acceptance of such boundaries. Figure 13. Possible strategies for optimal NoP performance 27 Figure 14. Practical suggestions from the Consulted Stakeholders for better Rights and Permissions operationalization of NoPs in Ghana 28 The material in this work is subject Figure 15. NoP Implementation-challenges and positive impact 29 to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full Tables attribution to this work is given. Table 1. Districts for the PPA-SNA Study in Ghana 4 Any queries on rights and licenses, Table 2. Data Collection Modalities for the PPA-SNA Study in Ghana 4 including subsidiary rights, should be Table 3. Comparing health centers utilization between pairs of NoP and addressed to World Bank Publications, non-NoP districts across MNH touchpoints 8 The World Bank Group, 1818 H Street Table 4. Comparing health centers utilization between pairs of NoP and NW, Washington, DC 20433, USA; fax: non-NoP districts across HTN touchpoints 11 202-522-2625; e-mail: pubrights@ worldbank.org. Table 5. Self-reported effects of the NoP program by health care workers 16 Table 6. Performance of NoPs in implementing the NoP guiding principles 17 Photo credits Table 7. Primary findings validated by healthcare providers 26 Front and back covers: (left to right) School of Public Health, University of Table 8. Primary findings validated by health system users 26 Ghana Table 9. Primary findings not validated by health system users 27 CONSOLIDATED FINDINGS REPORT Acknowledgments This knowledge product from the Ghana Patient Pathway We would also like to thank Dorothee Chen and Patrick Analysis and Summative Network Analysis was developed Mullen (World Bank) for providing strategic and technical under the leadership of Zara Shubber, Nicole Fraser-Hurt support to successfully implement the study. Tommy and Kojo Twum Nimako, as part of the Primary Healthcare Wilkinson, Michael Peters, Jessica Watson and Mengxiao Reimagination and Health System Redesign Analytics and Wang from the World Bank provided technical inputs and Technical Assistance Program. review during study design, Katie McWilliams provided We would like to express our sincere gratitude to all members spatial mapping services, and Neena Kapoor carried out of the Ghana Health Services (GHS) for strategic guidance of data quality assurance. We are also grateful to Owen Smith this research aimed at understanding care-seeking behaviors, (Lead Health Economist, HAWH3), Huihui Wang (Senior health service delivery and provider networks in Ghana. The Health Economist, HHNGE) and Navneet Manchanda insights and lessons from the implementation of Networks of (Health Economist, HSAHN) for their review and comments Practice can inform the scale-up of this intervention across the on the report. country. GHS officials have played a crucial role in providing We are extremely thankful to all the respondents who technical inputs in all phases of this research and facilitated participated in the Patient Pathway and Summative Network communication across health facilities during data collection. Analysis, and the ground truthing exercise conducted in the We are grateful to the Ghana Health Service Ethics Review community. We are equally thankful to the district health Committee (GHS-ERC) for authorizing data collection and team and all the health staff in the selected districts for their providing research clearance. support in the data collection activity. 1 CONSOLIDATED FINDINGS REPORT Introduction Ghana’s health sector is regarded as one of the most 2021 to explore a long-term PHC model that could sustainably developed in West Africa, and the government is actively deliver equitable, efficient, affordable, and high-quality PHC working to become the hub for high-quality health service services. This was informed by experience in other contexts delivery in the Economic Community of West African States that the formation and support of PCPNs is an innovative (ECOWAS). Relative to other countries in the region, Ghana approach to catalyse individual providers with relatively weak commits the highest proportion of government expenditure to capacity to form more robust organizations that can deliver health1, has made significant progress in decentralizing its the complete package of PHC services5. In early 2024, the healthcare system, has made far-reaching reform of its Government of Ghana launched Implementation Guidelines national health insurance scheme, and is leading in the for Networks of Practice to serve as reference material for all adoption of digital technology innovations in health (including health sector stakeholders and to provide a step-by-step introducing telemedicine and mobile payment systems2 in its process for the operationalization of NoP intervention.6 It is health insurance system). However, despite these significant planned that the intervention is scaled up to encompass all advances, Ghana’s healthcare sector still experiences key districts nationwide within the near term. operational challenges including insufficient facility NoPs are a coordinated system of interlinked health service infrastructure, inefficient provider-payment mech­ anisms, delivery sites that can reduce fragmentation in coordinating inadequate capacity to deliver the basic package of primary referrals and services, strengthen accessible PHC for diverse health care (PHC) services, and poor facility collaboration, communities, and leverage limited resources better7. These referral and continuity of care. Most communities in the rural networks aim to promote collaborative learning and teamwork areas of Ghana tend to be underserved. The health sector amongst health workers, including those at the community requires intervention to meet people’s healthcare needs and level, to better health outcomes. The networks focus on achieve Universal Health Coverage (UHC).3 integrating care at the district level that goes beyond the To address the gaps in PHC delivery, the Ghana Health regular structural arrangement of the district health system. Service (GHS) and the Ministry of Health (MoH) conducted, They comprise various healthcare levels and seek to ensure from 2017 to 2019, a pilot project on Primary Care Provider better coverage and quality of prevention, health promotion, Networks (PCPN) with support from Systems for Health treatment, care, and support, including mental health care, Project funded by the United States Agency for International emergency care, palliative and rehabilitative care. NoPs Development (USAID)4. The resulting better collaboration and should therefore improve access to quality health services for mutual technical and operational support among the the population, regardless of people’s socio-economic status. networked facilities increased the range of service delivery Ghana’s NoPs use a hub-and-spokes design, with the hub activities, thus demonstrating that networks had the potential typically being a health center, as seen in Figure 1. The hubs of delivering an equitable, higher-quality PHC while serving as provide comprehensive primary care services, while the a key mechanism for pursuing UHC. The pilot project was spokes offer more limited services, routing patients requiring subsequently scaled up to 10 additional districts from 2020 to additional care to the hub. NoPs include various health facilities, such as community health planning and services 1 Adebisi, Y.A., Alaran, A., Badmos, A. et al. How West African countries (CHPS), clinics, maternity homes, and pharmacies, all prioritize health. Trop Med Health 49, 87 (2021). https://doi.org/10.1186/ s41182-021-00380-6 interconnected to enhance resource distribution and service 2 D Opoku, AK Edusei, P Agyei-Baffour, G Teddy, K Polin, W Quentin, access. The key objectives of implementing NoPs, as Ghana: health system review 2021, European Journal of Public Health, outlined by the GHS, include ensuring universal access to Volume 31, Issue Supplement_3, October 2021, ckab164.577, https:// doi.org/10.1093/eurpub/ckab164.577 3 The Limitations of Ghana’s Rural Healthcare Access. Maria Polychronis. 5 Birdsell, J., Mathias S., and Colleagues (2003). Networks and their roles Global Futures. Rutgers University in enhancing research impact in Alberta, Canada. Alberta Heritage 4 Systems for Health Ghana. (2019). Universal Health Coverage through Foundation for medical Research. PHC: Preferred Primary Healthcare Provider Networks in Ghana. 6 Ghana Health Service (2024). Implementation Guidelines for Networks Network Models for Improved Organizational Management and of Practice. https://ghs.gov.gh/policy-document/# Service Delivery. Systems for Health, Accra, Ghana. 7 taken from GHS, Feb 24 RAG meeting presentation 2 CONSOLIDATED FINDINGS REPORT FIGURE 1. HUB AND SPOKE MODEL OF NETWORK OF PRACTICE (NoP) District Hospital quality healthcare services, reducing maternal, adolescent, and child mortality and disabilities, and enhancing access to clinical and public health emergency services. Emergency Other To assess the effectiveness of the early NoP implementation Services HEALTH Health Resources and inform the NoP roll-out nationwide, a Patient Pathway CENTRE Analysis (PPA) and Summative Networks Analysis (SNA) (Model) CHPS Health were conducted in selected districts across Ghana. The Centre analytics aimed to understand differences in service delivery and user behavior in settings with or without NoPs and Market Pharmacies Sick Clinics gather stakeholder perspectives. The lessons gained from Bay this study can contribute to improvements in how NoPs are planned, configured, maintained, and promoted to the catchment populations. Methodology PPA AND SNA selected from the same regions as the NoP districts and matched on socioeconomic status and health outcomes To evaluate the effects of NoPs on patient and provider using Multidimensional Poverty Indicators and health scores experiences within the health system in Ghana, patient from the 2021 District League Table. Additionally, two urban pathways regarding maternal and neonatal health (MNH) and districts were included in the study as part of the formative hypertension (HTN) care and network analysis were carried research regarding Ghana’s NoP roll-out in urban areas. out. The PPA traced people’s care journeys from initial care These districts are described in Table 1. contact to either the final contact in the maternal continuum The DHIMS and routine data from the study health facilities (=postnatal care) or the treatment maintenance contacts in helped characterize the networks in the four rural districts. hypertension care. The study identified facilitators and barriers For instance, in 2022, they had a combined out-patient for care utilization and assessed the utilization of healthcare department (OPD) attendance of 711,272 (or an average of providers and levels across the MNH/HTN care continuum in 3,420 OPD patients per study district and survey week). both NoP and non-NoP settings. The network analysis delved into the structural and relational dynamics of health service delivery points. By assessing the spatial distribution of the hubs DATA COLLECTION METHODS and spokes in a network and that of the networks in a district, SNA provided actionable insights for optimizing network design The study used a combination of quantitative and qualitative to enhance outcomes and operational efficiency. data collection techniques. Primary data was gathered through facility exit interviews with women who had given birth in the last 12  months and people living with DESCRIPTION OF THE DISTRICTS hypertension at health service providers, including private PPA and SNA were conducted in six districts across four clinics, and through community-based interviews with regions in Ghana. Four of these districts were rural, with two eligible respondents in the areas surrounding the study implementing NoPs and two not. The non-NoP districts were facilities. Qualitative data collection involved in-depth 3 CONSOLIDATED FINDINGS REPORT TABLE 1. DISTRICTS FOR THE PPA-SNA STUDY IN GHANA Name of the district Region Setting NoP status # of Networks assessed Population** Hohoe Volta Rural NoP 4 (Established 2020) 114,472 Dormaa Central Bono Rural NoP 3 (Established 2020) 112,702 Ketu North Volta Rural non-NoP 4 (Potential future networks) 114,846 Tain Bono Rural non-NoP 4 (Potential future networks) 115,568 Ayawaso Central Greater Accra Urban non-NoP 4 (Potential future networks) 94,831 Atwima-Nwabiagya Ashanti Urban non-NoP 4 (Potential future networks) 155,025 ** Ghana 2021 Population and Housing Census – General Report Volume 3A. interviews with health providers and focus group ANALYTICAL APPROACH discussions (FGDs) with officials from the District Hospital and District Health Teams. The data collection process The study wanted to answer three main questions: spanned one and a half months, followed by meticulous 1. How do different groups of patients move data transcription and cleaning. The various data collection through the health system while seeking care? modalities are detailed in Table 2: Facility-level exit interviews and community-based interviews were done with respondents who could The study sample for patient pathway interviews represented report on either their MNH or their HTN care journey, only a share of eligible MNH clients but all eligible HTN respectively. This included 565 MNH respondents patients coming to the network’s study health facilities (of which 136 with complete pathway data including during their week of survey. For instance, the average PNC), and 566 HTN respondents (of which 420 who weekly attendance number per rural study district site for had accessed care along the entire pathway from ANC+PNC was 427, compared to 95 MNH respondents first contact, diagnosis, treatment initiation, treatment enrolled per rural study district during the week of survey. maintenance and monitoring). These pathways were For HTN, an average of 41 registered HTN cases received visualized through flow (or Sankey) diagrams for the out-patient care per rural district and week. To enroll 95 HTN MNH and HTN care journeys. respondents, the community sample was therefore required 2. Which factors influenced the patients’ care to meet the target sample size. pathway choices? The analysis was conducted using Microsoft applications, Healthcare utilization, traditionally used as a Atlas.ti, QGIS, and Python. The overall approach was to proxy for access to healthcare, is a function of assess health service utilization, network operations, and both the demand and supply of health services. patient care patterns within the selected districts and Here ‘supply’ refers to the resources, structures, integrate quantitative and qualitative insights, which also procedures, regulations through which health underwent stakeholder validation. services are delivered. ‘Demand’ refers to patient TABLE 2. DATA COLLECTION MODALITIES FOR THE PPA-SNA STUDY IN GHANA Health system users – MNH (50%) and HTN (50%) Health care providers Data collection modality No. of samples Data collection modality No. of samples Exit interview on care seeking pathways 780 Key Informant Interviews on care delivery 210 and service satisfaction and network operations Community-based interviews on care 351 Focus Group Discussions on care delivery 12 seeking pathways and network operations Shadowing during facility visits 156 4 CONSOLIDATED FINDINGS REPORT perceptions, health-seeking behavior, and health factors like home births or skipped ANC visits were literacy, boosted by enabling factors such as health therefore mitigated by the community-based sampling for insurance, and a transport network that enables pathway interviews. patients to seek care from the health system. In the analysis of pathways, the study team took into 3. What patterns can be discerned for the care consideration Ghana’s essential health services package pathway between patient groups and care and where services are expected to be provided along the settings? continuum of care for the conditions assessed. Beyond While many of the findings were similar for the MNH applying this normative standard, the reporting also tried to and HTN care pathways, some specific differences reflect how some more contemporary trends in the concept were noted between these two groups of users. of ‘right-place care’ could be taken up in the context of Likewise, findings from the urban districts had some Ghana, including devolving basic NCD care to lower levels of distinct features that have also been documented. the health system and ensuring availability of care for MNH The sampling strategy for the pathway interviews was complications in higher-level facilities within a safe timeframe. designed to enroll individuals with diverse care seeking Analysis frameworks: The Lancet Global Health Commission behaviors: The exit interviews were done at district on High Quality Health Systems’ ‘High-quality health systems hospitals (14% of sample), health centers (23%), clinics (HQHS) framework’ was modified to show the effect of the (21%), CHPS posts/compounds (32%), and pharmacies/ NoP intervention as per this study’s findings. The ‘Quality drug sellers (9%). Community-based sampling was carried Impacts’ have been modified to show a) the changes seen in out at markets (32%), bus stops (35%), lorry parks (11%), health systems under ‘Intermediate Outcomes’ and b) ‘Final among traditional healers/practitioners (8%), parks (6%) Expected Outcomes’ of the NoP program in the future. In and restaurants etc. (7%). The limitations of exit interviews this framework, ‘Foundations’ of high-quality health systems such as not capturing non-utilization and underlying refers to the population and their health needs and FIGURE 2. CATEGORIZATION OF PPA-SNA FINDINGS Pathways adopted by How do different Pathways adopted by MNH groups of patients HTN patients participants move through the health system while Care continuum shown for 136 Care continuum shown for 420 seeking care? MNH respondents with HTN patients who completed completed deliveries entire pathway. Health system related Utilization related factors2 Which factors factors1 influenced the patients Enabling to adopt the specific - Approachability - Foundations factors - Acceptability pathways that they did? - Processes of care - Availability and accommodation; - Intermediate outcomes - Affordability - Appropriateness. Divergence What were some Factors specific Divergence between pathway features and between rural to Networks of MNH and influencing factors that and urban stood out as exceptions? Practice HTN pathways pathways 1- High Quality Health Systems Framework ; 2- Levesque Conceptual Framework 5 CONSOLIDATED FINDINGS REPORT expectations, governance of the health sector and partnerships across sectors, platforms for care delivery, workforce numbers and skills, and tools and resources, from medicines to data; ‘Processes of care’ refer to competent care and systems, and positive user experience; and ‘Quality Impacts’ refer to the impact on health outcomes, efficiency of the health system and trust of the public.8 To demonstrate the various patient-related and enabling factors, the ‘Levesque Framework’ 9 was adopted. It provides a multidimensional view of healthcare access with dimensions of approachability, acceptability, availability, affordability and appropriateness. All available data from quantitative and qualitative sources were used to identify these healthcare utilization drivers. Findings Key results for the 565 MNH respondents who were sampled abdominal pains (10%) and other pains such as waist/ in either their antenatal or postnatal phase were: lower back ache, blurred vision (4%), swelling (4%), vaginal bleeding (2%) and anaemia (2%) ■ ANC1 was near-universal with 62% receiving ANC1 within the first 3 months of pregnancy, 35% in months ■ The proportion of women seeking complication care 4–7 and 3% in months 7–8. was slightly higher in NoP districts than their comparator districts (chi2 p-value 0.12) ■ Further ANCs were taken up by most women, 64% had had ANC4+ (much lower in this sample than the The findings of the pathway analysis are presented for MNH 88% in the 2022 DHS10) (136 individuals) and then for HTN (420 patients), arranged ■ A high proportion of MNH respondents had received under the following categories: birthing counselling and delivery planning ■ Visualization of the patient pathway and preferred health ■ Labour started at home for three quarters of the facility respondents (77%) and 74% reached the health facility/provider within 30  minutes with almost all ■ Comparison of health centre utilization between NoP (94%) being attended to within 60 minutes and non-NoP districts ■ 94% of the women had a facility delivery (compared ■ Drivers of patient pathways to the 2022 DHS result of 86%) ■ Dimensions of accessibility of care ■ 30% had health issues and complications during ■ Comparison of provider use patterns between rural pregnancy; of these, 78% sought care with a provider; and urban areas the most common issues were headaches (11%), This is followed by health-system-related factors, and findings from the network analysis. 8 High-quality health systems in the Sustainable Development Goals era: time for a revolution. Kruk M, Gage AD, Arsenault C, et al. The Lancet. Global health. 2018; 6 (11) : e1196–e1252. 9 Levesque, JF., Harris, M.F. & Russell, G. Patient-centered access to PATHWAY ANALYSIS FOR MNH CLIENTS health care: conceptualizing access at the interface of health systems and populations. Int J Equity Health 12, 18 (2013). https://doi. High utilization of hospitals for MNH care across the org/10.1186/1475-9276-12-18 maternal continuum 10 Ghana Statistical Service (GSS) and ICF. 2024. Ghana Demographic and Health Survey 2022. Accra, Ghana, and Rockville, Maryland, USA: ■ The pathway interviews with MNH respondents GSS and ICF. indicated a preference for hospitals (Figure 3) even 6 CONSOLIDATED FINDINGS REPORT FIGURE 3. PATHWAY OF CARE FOR MATERNAL AND NEONATAL HEALTH RESPONDENTS (N = 136 MNH) Care at Onset First ANC Regular ANCs of Labour Delivery Regular PNC Hospital (H) H 54 H 44 H 65 H 71 H 56 Health Centre (HC) HC 39 HC 34 HC 30 HC 27 HC 37 Clinic (CI) CI 18 CI 18 CI 23 CI 25 CI 12 Health Post (HP) HP 15 HP 12 HP 12 HP 9 HP 14 Maternity Home (MH) MH 2 MH 1 MH 1 MH 1 MH 1 Traditional (TH) TH 1 31 5 Unassisted Don’t Know delivery at home 4 Did not visit a health 2 1 No PNC provider (NP) NP 1 No regular NP 10 Delivered on the way ANCs to the facility 4 Assisted delivery at home for the 1st ANC contact- a service expected to be HIGHER UTILIZATION OF HEALTH CENTERS available and sought at a lower level of care. As the FOR MNH CARE IN NoP DISTRICTS AS clients progressed in their maternity journey, there COMPARED TO NON-NoP DISTRICTS was a notable increase in hospital service utilization, accompanied by a slight decrease in utilization of In the study sample, there was a trend towards higher health centre and health post services. Hospital utilization of health centers in NoP districts than in the utilization peaked for childbirth, with 71 of 136 (52%) paired utilization in non-NoP districts, and this held across respondents opting for hospital delivery (67 by most MNH touchpoints (Table  3, green arrows). While personal choice despite often greater travel distance, several comparisons within matched district pairs had and four upon referral by health providers). differentials of greater than 10  percentage points, the small sample sizes limited detection of statistically ■ This preference for hospitals declined slightly for PNC significant differences. Only the 19-percentage point visits since some women transitioned to health posts difference in health centre use for ANC1 in the Volta Region and clinics. pair reached statistical significance (chi2 test, ■ Overall, the MNH clients mostly stayed with the p-value=0.033). Overall, these findings suggest that same facility they initially sought ANC at, with some strengthened health centers through the NoP program transitioning to higher-tier facilities and minimal attracted more women for maternal care. This pivot movement to lower-tier ones. towards NoP health centres was primarily an effect of ■ Across most touchpoints, the NoP districts showed a decreased care-seeking at lower-level health facilities, i.e. higher utilization of health centers than their paired MNH clients coming directly to the health centre hub non-NoP districts. instead of the spoke. In Dormaa Central, there was also a 7 CONSOLIDATED FINDINGS REPORT TABLE 3. COMPARING HEALTH CENTERS UTILIZATION BETWEEN PAIRS OF NoP AND NON-NoP DISTRICTS ACROSS MNH TOUCHPOINTS NoP status District 1st ANC visit Regular ANC Onset of labour Delivery PNC NoP (Bono) Dormaa 17 (31%) ↑ 4 pp 30 (39%) ↑ 11 pp 8 (35%) ↑ 15 pp 8 (35%) ↑ 13 pp 7 (30%) ↑ 5 pp Central Non-NoP Tain 15 (27%) 22 (28%) 8 (20%) 9 (22%) 10 (25%) (Bono) NoP (Volta) Hohoe 24 (48%) ↑ 19 pp 43 (55%) ↑ 11 pp 17 (33%) ↑ 5 pp 11 (22%) ↓ 6 pp 18 (33%) ↑ 1 pp Non NoP Ketu 18 (29%) 31 (44%) 11 (28%) 11 (28%) 14 (32%) (Volta) North small shift away from seeking MNH care at the hospital As figure  4 shows, provider choice was driven by a level. In Hohoe District, women preferred hospital-based preference for quality care and proximity of the health facility deliveries including at the Volta Regional Hospital. Overall, to the MNH respondents’ homes. the pattern of shifting MNH pathways was mixed and Perceived quality of care and proximity to health facility sample numbers too small to reliably detect trends of are primary drivers of health facility preference among by-passing spokes vs. pivoting away from hospital care. MNH clients. FIGURE 4. DRIVERS OF HEALTH FACILITY PREFERENCE FOR MNH CLIENTS MHN CLIENTS 39% 25% 1st visit for 39% 10% pregnancy 15% Good quality of service N=314 10% 17% Well-behaved provider 25% Previous good experience 19% 9% My only choice Changing facility 35% 1% Close to home for regular ANC 1% Advised by friends/ family N=136 0% 10% Trust in the provider 25% 38% Others 23% Pregnancy 37% 21% complications 11% N=133 13% 8% 23% 28% HF different 8% 45% from planned 19% delivery HF 9% 0% N=53 4% 33% For MHN clients, most provider 21% choices along the maternal pathway 17% prioritized “quality of service”. 19% The facility visited on the day of the Regular PNC 8% survey was most often chosen for N=224 0% proximity reasons. 5% 4% 24% 29% 23% 55% Current visit 14% N=390 14% 0% 14% 24% 0% 10% 20% 30% 40% 50% 60% 8 CONSOLIDATED FINDINGS REPORT Provider Use Pattern across the Maternal Care Continuum in Rural and Urban Areas Despite hospitals being the most preferred health facility in rural and urban areas for MNH services, provider use patterns differed between rural and urban settings. There was much greater health center use in rural areas compared to urban areas, where private, mission, and NGO care providers were preferred. The results demonstrate that the make-up of the urban healthcare ecosystem needs to be considered when the NoP intervention is rolled out to Ghana’s cities and towns. While the sampling strategy in this study (at facility exits and in community hubs) limits the representativeness of these MNH pathway findings, the results do represent the care preferences of MNH clients in the network areas. FIGURE 5. RURAL VS URBAN MNH PROVIDER USE PATTERN 1% 5% 6% 4% 2% 2% 3% 8% 7% 7% 10% 14% 14% 12% 15% 18% 16% 12% 14% 19% 14% 12% 19% 9% 9% 6% 6% 6% 15% 8% Others (maternity 30% homes, regional 25% hospitals,alternative) 29% 33% 27% 27% 43% Health Post (CHPS) 39% 41% 7% 42% 26% 32% Health Centre 5% 5% Clinic (incl. private/ NGO/mission/ 10% private provider) 8% District Hospital/ 6% other hospital 47% 48% 47% 48% 44% 41% 38% 34% 36% 29% 32% 27% First ANC Regular ANC Pregnancy complications Delivery PNC First ANC Regular ANC Pregnancy complications Delivery PNC Onset of labour Onset of labour RURAL URBAN PATHWAY ANALYSIS FOR HTN CLIENTS ■ Entry into the HTN pathway often involved chance detection during a routine blood pressure check at a Hospital-centric HTN care pathway despite service hospital visit for other reasons (71%). Another 24% of availability at primary care level respondents entered hypertension care when visiting ■ The HTN care pathway is predominantly centered for a hypertension-related illness such as severe around hospitals. Hospital utilization peaked for HTN headaches, shortness of breath or palpitations, and treatment initiation (232, 55%). 4% when seeking emergency care. Only 1.2% of 9 CONSOLIDATED FINDINGS REPORT FIGURE 6. PATHWAY OF CARE OF HYPERTENSION PATIENTS (N = 420) Treatment Treatment Monitoring First contact Diagnosis initiation maintenance facility type Hospital (H) H 219 H 228 H 232 H 210 H 165 Health Centre (HC) HC 88 HC 88 HC 89 HC 92 HC 116 Clinic (CI) CI 63 C 65 CI 67 CI 56 CI 64 Health Post (HP) HP 34 HP 30 HP 19 HP 8 HP 46 Maternity Home (MH) MH 6 MH 3 MH 3 MH 3 MH 6 Pharmacy (Ph) Ph 5 Ph 3 Ph 4 Ph 40 Ph 11 Home based non-physician health NHW 4 NHW 1 NHW 1 NHW 2 worker (NHW) Traditional (TH) TH 1 TH 1 TH 3 TH 2 TH 2 Community Health Worker (CHW) CHW 1 1 2 9 7 No diagnosis No initiation of No maintenance of No treatment treatment monitoring respondents entered hypertension care thanks to a Higher utilization of health centers for HTN care in NoP preventative screening activity. districts as compared to non-NoP districts ■ Monitoring services were readily available at the Similar to the maternal care pathway, HTN clients showed lower-level health facilities, including health posts, higher utilization of health centres in the two NoP districts and were not dependent on health insurance cover. compared to their matched non-NoP pairs (Table 4). This However, hospitals remained the preferred location suggests that some of the HTN care seeking has pivoted for HTN monitoring. towards the health centres that have been strengthened ■ Similar to the MNH care pathway, HTN clients tended through the NoP intervention. Due to small sample sizes, to continue their HTN care in the same facility where only the 20-percentage point difference in health centre they initially sought care, use for treatment monitoring in the Volta Region pair reached statistical significance (chi2 test, p-value=0.006). ■ Limited instances of down-referral were noted for The pivot towards NoP health centres was primarily an treatment maintenance and monitoring to health effect of decreased care-seeking at lower-level health centres and health posts. facilities, i.e. HTN patients coming directly to the health ■ Across all touchpoints, the NoP districts show a centre hub instead of the spoke. In Dormaa Central, there higher utilization of health centres than their paired was also a small shift away from seeking care at the non-NoP districts. hospital level for MNH. However, the picture was mixed and sample numbers too small to reliably detect shifts in patterns of by-passing spokes vs. pivoting away from hospital care. 10 CONSOLIDATED FINDINGS REPORT TABLE 4. COMPARING HEALTH CENTERS UTILIZATION BETWEEN PAIRS OF NoP AND NON-NoP DISTRICTS ACROSS HTN TOUCHPOINTS NoP Treatment Treatment Treatment District 1st contact Diagnosis status initiation maintenance monitoring NoP Dormaa 25 (27%) ↑ 6 pp 25 (27%) ↑ 6 pp 23 (25%) ↓ 1 pp 23 (25%) ↑ 1 pp 27 (30%) ↑ 5 pp (Bono) Central Non-NoP Tain 20 (21%) 20 (21%) 24 (26%) 20 (24%) 21 (25%) (Bono) NoP Hohoe 21 (22%) ↑ 9 pp 19 (20%) ↑ 6 pp 17 (18%) ↑ 5 pp 19 (24%) ↑ 11 pp 33 (40%) ↑ 20 pp (Volta) Non-NoP Ketu 12 (13%) 13 (14%) 12 (13%) 8 (13%) 13 (19%) (Volta) North Figure 7 shows that provider choice among HTN respondents Perceived quality of service and previous good was driven by a preference for quality care and previous experience at the health facility are primary drivers good experience at the health facility. of health facility preference among HTN patients FIGURE 7. DRIVERS OF HEALTH FACILITY PREFERENCE FOR HTN PATIENTS HTN CLIENTS 46% 45% For MHN clients, most provider Initial contact 40% choices along the maternal pathway 23% prioritized “quality of service”. for HTN 21% The facility visited on the day of the 17% N=151 9% survey was most often chosen for 34% proximity reasons. 47% 47% Good quality of service 34% HTN diagnosis 24% Well-behaved provider 22% N=152 17% Previous good 10% experience 22% Clean 48% 41% Close to home Treatment 27% 29% One-stop initiation 19% 16% Trust in the provider N=146 12% 35% Others Treatment 62% 53% maintenance 39% 41% in the past 33% 3 months 28% 7% N=506 38% 55% HTN monitoring 53% in the past 50% 40% 12 months 36% 30% N=491 4% 28% 51% 44% Current visit 59% 37% N=390 25% 29% 2% 32% 0% 10% 20% 30% 40% 50% 60% 11 CONSOLIDATED FINDINGS REPORT Provider Use Pattern across the Hypertension Care Continuum in Rural and Urban Areas For HTN, rural care provision was more hospital-centric in our study sample, and urban provision had more clinic involvement. The first HTN contact (1st bar) was most often elevated BP found during a routine screen. In urban areas, cases identified at clinics often sought full diagnosis at a hospital or health center. For treatment monitoring (5th bar), rural patients often used health centers while urban patients used more clinics. In both settings, 40% of respondents used hospitals for treatment monitoring. While the sampling strategy in this study (at facility exits and in the surrounding communities) limits the representativeness of these HTN pathway findings, the results do indicate the care preferences of HTN patients in the network areas. FIGURE 8. RURAL VS URBAN HTN PATIENT FACILITY PREFERENCE 2% 1% 1% 4% 3% 4% 3% 5% 6% 2% 5% 5% 8% 5% 3% 12% 6% 8% 12% 6% 12% 3% 1% 13% Others (maternity 20% 14% 26% 27% 20% 12% homes, alternative, 21% 22% etc.) 11% 29% Pharmacy/OTC 11% 10% drug seller 9% 37% 37% 23% 24% 36% Health Post (CHPS) 11% Health Centre Clinic (incl. private/ NGO/mission/ 56% 58% 60% 53% private providers) 43% 43% 40% 37% 37% 40% District Hospital/ other hospital contact Diagnosis Treatment maintenance monitoring contact Diagnosis Treatment maintenance monitoring Treatment Treatment initiation initiation Treatment Treatment First First RURAL URBAN Dimensions of Access for MNH clients scaling the NoP intervention has the potential to improve Figure 9 summarizes the study findings around access to access by bringing healthcare closer to the patient, healthcare for both MNH and HTN using the Levesque enhancing the quality of care, and reducing OOPE by Framework; Figure 9 shows how the NoP interventions can reducing indirect expenses incurred on transportation to effectively address access barriers faced by patients. It can health facilities. be inferred from the study findings that strengthening and 12 CONSOLIDATED FINDINGS REPORT FIGURE 9. DIMENSIONS OF ACCESSIBILITY TO HEALTHCARE FOR MNH AND HTN CLIENTS AVAILABILITY + APPROACHABILITY ACCEPTABILITY ACCOMMODATION AFFORDABILITY APPROPRIATENESS • Strong hospital • Cultural and social • Disparities exist in • Affordability did not • Varied quality of preference for norms potentially the availability of emerge as a major care, with some services. impact services. determinant. facilities lacking acceptability, e.g. necessary • Limited • NHIS gives some DIMENSIONS OF ACCESSIBILITY preference for • Hospitals are more equipment and approachability of traditional birth utilized for health cover. trained staff. decentralized attendants. deliveries, while services in rural • Out-of-pocket • NoP districts lower-tier facilities areas due to • Preference for expenditures showed better are used for inadequate hospital-based care remain significant alignment of postnatal care. information. due to trust in concern for services with providers and • Long travel times, patients, patient needs. • HTN patients previous good often on foot, are a particularly in urban become aware of experiences. major barrier for areas with high • Patients will seek HTN only during MNH care in rural private practice out district hospitals hospital visits for • NoPs can improve areas. presence. (and in urban areas other reasons. linkage between private hospitals) in TBAs and health • High cost of search of a clinics through healthcare can lead guaranteed quality collaboration. to delays or of care. avoidance of care. Health Care Perception of Healthcare Healthcare Healthcare Healthcare Needs needs and seeking reaching utilization consequences desire for care • Health • Satisfaction • Economics Facilitators: Facilitators: Facilitators: Facilitators: Facilitators: • Community • Culturally sensitive • Equipping primary • Expanding • Implementing engagement care, involving carefacilities for insurance standard care strategies community leaders, HTN management. coverage, financial protocols. DIMENSIONS OF ABILITIES (implemented via and educating support schemes, NoP interventions), communities about • Hub and spoke and subsidizing • Continuous training and public health the benefits of model of NoPs maternal health for healthcare campaigns to formal healthcare enable resource services. providers. improve services. sharing and collaboration, • Involving patients in awareness. their care • Building trust strengthen overall • Implementing through patient primary care, and processes through community based education and can lower barrier to community screening improving the access facilities. engagement programs and quality of care at feedback. health education lower-tier facilities. initiatives. ABILITY TO ABILITY TO ABILITY TO ABILITY TO ABILITY TO PERCEIVE SEEK REACH PAY ENGAGE 13 CONSOLIDATED FINDINGS REPORT QUOTES SHOWING DIFFERENT DIMENSIONS OF ACCESS AFOR PATIENTS Affordability “I: Okay. So, even for the poor, when they come in, do they still have to pay regardless of the fact that they don’t have health insurance? R: Yes, if they do not pay how are we going to pay for them, unless maybe you are being compassionate, you want to pay for him or her aside that without health insurance you have to do the cash and carry.” — Midwife, GHS health centre (Hub), NoP district Availability of Standardized Care “We make sure that we go with the standard protocols “We have personnel from the district health directorate to take care of our clients. Then we also use our who come in every month to assess the services of every infection prevention procedures to prevent infecting department. Auditors also come in from the regional the mothers and the babies. We also help educate health office to assess us. DHS also sometimes come in them to take care of themselves physically, mentally, to assess us, examine us and award marks. We belong emotionally, spiritually, and their nutrition. So that they to CHAG.” will be fit to take care of their children. We make sure — Clinical Officer, CHAG Health centre (spoke), the children get the vaccinations and immunizations non-NoP district they need.” — Sr Nursing Officer, GHS Health Post (Spoke), non-NoP urban district Accessibility “We have an information center in the town. From time to time, we go there to give some education. Sometimes we visit churches to also “For the lower-level facilities, I think give education on certain topics of importance. From time to time, we we are cool. Some of them are our organize outreach in the community and also do the home visits”. friends. For the higher level, like District Hospital we have a link. We — Physician Assistant, CHAG facility (Spoke), NoP district have formal and informal relationship with them because I have colleagues there and we do communicate, so do other staff.” “We make them aware through advertisement. I don’t know if — Registered General Nurse, Private you noticed, OK, we don’t have it playing now, but then we have Clinic, NoP district audio-visuals playing on our OPD televisions.” — Nurse In-charge, Private health facility (Spoke), non-NoP urban district”. 14 CONSOLIDATED FINDINGS REPORT SYSTEM-RELATED FACTORS improved referral gatekeeping - indirectly indicating growing confidence in the health system. Figure  10 and table  5 below use the ‘High-quality health The intermediate outcomes of increased health centre systems (HQHS) framework’ to summarize how the NoP- utilization in NoP districts, along with ‘down referrals’ from related health system strengthening interventions fare hospitals to health centres and health posts for primary across the ‘foundations/inputs’, ‘processes of care’ and care services like PNC for postpartum mothers and BP ‘quality impact’ components of the health system in the monitoring for HTN patients, hint at the benefits of NoP study districts with NoPs. implementation already beginning to reflect in PHC Figure 10 shows that ‘Foundations’ of health systems in NoP utilization patterns. districts such as a well-trained workforce, availability of all This further strengthens the study’s inference that with tools and resources to provide healthcare to the community, increasing optimization of the ‘foundations’, the NoP proactive engagement of the community to seek feedback, operations and, consequently, the outcomes will also see and a robust governance structure to oversee all activities and significant improvement. review performance are all in place, but they have consider­ Table 5 describes some of these effects of NoPs compared able scope for improvement. These are the building blocks of to non-NoP districts, as reported by the health providers the health system and strengthening them will be crucial to from the study districts. Conditions in the two urban districts the successful implementation of the NoP program. were found to be similar to the rural non-NoP districts. Despite suboptimal ‘foundation’ strength, there was However, there were some urban-rural differences evidence that NoPs had increased resource sharing and observed, such as little formal cross-facility communication collaboration between networked health facilities and in the urban districts. Patients in urban districts reported FIGURE 10. MODIFIED HQHS FRAMEWORK SHOWING HEALTH SYSTEM FACTORS OBSERVED IN NoP DISTRICTS Processes of Care Intermediate Outcomes Final Expected Outcome • Improved HCW collaboration, resource & • Down referral • Decentralized system knowledge sharing • Higher utilization of NoP • Better HCW working conditions • Some referral gatekeeping facilities relative to • Better user experience • Higher confidence in network facilities non-NoP facilities • Less out-of-pocket relative to non-NoP facilities health-seeking spend QUALITY IMPACTS Community Engagement Tools & Logistics Governance HRH/Workforce • Limited use of community • Insufficient equipment and • Relative more district-level • Shortage of workforce scorecard ambulances review meetings • Staff attrition leads to • CHMCs in place — limited • Use of IM apps for • Active feedback loss of expertise meetings inter-facility coordination mechanism • Soft-skill capacity building required FOUNDATIONS 15 CONSOLIDATED FINDINGS REPORT TABLE 5. SELF-REPORTED EFFECTS OF THE NoP PROGRAM BY HEALTH CARE WORKERS Effects of NoP Description Foundations Workforce The NoP Program has provided training on collaboration, resource sharing and referral mechanisms. Compared to health workers in non-NoP districts, those working in NoPs therefore tend to be better primed for collaboration and information sharing among staff at intra-facility and intra-network levels, as well as for referral gatekeeping and logistics of providing referral and emergency services. Governance NoP districts conduct more frequent and effective district-level review meetings as compared to non-NoP districts, which enhances feedback and improvement mechanism. Tools and logistics Comparing rural NoP district to non-NoP districts, hub facilities in NoP districts show better equipment availability (using availability of BP measuring and glucose measuring equipment as indicators). Community engagement Community engagement is more targeted towards health system objectives and feedback in NoP districts – there is some use of the community scorecard to evaluate the performance of each network; CHMCs are in place and conduct some meetings. Non-NoP districts have less organized mechanisms of community engagement at district and sub-district levels. Processes of Care- NoP Operations HCW collaboration, resource & NoP districts experience better collaboration between facilities (including knowledge sharing establishing partnerships with health facilities from other networks) and teamwork in service delivery compared to non-NoP districts. Referral gatekeeping Some referral gatekeeping observed in NoP districts seen mostly in the form of a higher health centre utilization across patient pathway touchpoints, can be attributed to NoP interventions. Quality impacts: Intermediate and final expected outcomes Decentralized system NoP implementation is working towards increasing number of health services to be decentralized to the health center level. Through greater awareness generation among the public, and better collaboration between health facilities in a network, more services will be brought closer to the patient and under insurance coverage. The study showed a greater utilization of health centres across most MNH and HTN touchpoints in NoP districts as compared to non-NoP districts for essential services like BP monitoring. With improved operations and continued scale-up of NoPs increased service decentralization is expected. Better HCW working conditions Compared to Non-NoP districts, NoP districts had better communication between staff, a clear understanding of the need for working together more strongly, regular training/meetings at network and district level. Better health / better user experience NoP district providers reported a higher quality of service as compared to before NoP implementation in terms of availability of drugs, staff (through intra-NoP resource sharing and health facility collaborations), and service affordability (through insurance applicability), leading to a generally better user experience of the health system. Less out of pocket healthcare Patient accessing care in NoP districts generally spend less out-of-pocket. This could spending be due to greater range of health services under NHIS coverage available at the NoP Hub-health centre. 16 CONSOLIDATED FINDINGS REPORT greater out-of-pocket spending than those in the rural In addition to the NoP effects reported by health care districts, which is due to higher utilization of private health workers (Table 5), information was also collected from care facilities—another feature specific to the urban districts in providers on whether and how they adhered to NoP guiding the study. principles (Table 6). TABLE 6. PERFORMANCE OF NoPS IN IMPLEMENTING THE NOP GUIDING PRINCIPLES NoP guiding principles Summary of NoP implementation and effect on healthcare provision Equity NoP implementation is working towards enabling an increasing number of health services to be decentralized to the health centre level. NHIS credentialing of specific services at the health centre level accompanied the implementation of NoPs. Through such improvements, the NoPs have expanded accessibility and affordability, which is likely to enhance equity. Patient centeredness While reported to be a feature of health provision across all study districts, patient centeredness could not be validated through the community engagement exercise. In NoP districts, the networked health facilities ensured patients receive drugs through resource sharing between facilities. Quality of care Self-assessment by NoP district providers reported a higher quality of services as compared to before in terms of availability of drugs, treatment providers and affordability through insurance applicability. However, this finding could not be validated during the community engagement exercise. Certain features such as availability of telemedicine in Hohoe have reportedly contributed to improving patient experience. Strengthened referral All study districts showed streamlined referral processes including referral notes, calling up the system referral facility ahead of referring the patient, and escorting the patients when needed. However, gatekeeping by Hubs was not significantly noticed in either of the two NoP districts. Internal collaboration The NoP districts reported better intra-network collaboration and teamwork in service delivery than before. Whenever staff was not sure of a line of management or needed additional staff or drugs, support was taken from other facilities in the network. Partnership at the NoPs have been partially successful in establishing partnerships with health facilities from operational level other sectors, something not seen in non-NoP districts, however, there is still much scope of improvement, e.g., partnerships can be established with pharmacies who are not yet included in NoPs. Private and CHAG health facilities are included in NoPs, but in some instances the level of engagement and resource sharing, participation in review meetings is less than what is seen between government facilities. Commitment to working Most health staff of the two NoP districts clearly understood the need for intra-network cooperation together and supporting and were committed to transparency in their dealings and support to other members of the network. each other Through WhatsApp communication channels established especially for their network, the staff kept abreast of any new information shared. Regular communication over WhatsApp groups and phone calls also enabled the staff to highlight shortage of drugs, HR, and coordinate within the network to mobilize resources. Referrals were communicated through these channels. Some features of such cooperation were also noted in Tain, which is in preparation to roll out NoP. This points to a perceptible relation between NoP implementation and collaboration across health facilities. Community engagement All districts were found to be conducting different types of community engagement activities including leveraging ‘Community Information Centres,’ use of ‘gong beaters,’ etc. Community durbars and CHMC (Community Health Management Committee) meetings were more commonly observed in Hohoe than in other districts. Likewise, the use of Community Scorecards to measure the performance of the health facilities was most commonly reported by Hohoe as compared to other districts, indicating better community engagement in Hohoe. Continuous learning and Regular meetings for knowledge and information sharing were reported by both NoP districts. adaptation Such activities to learn and adapt to newer information were only conducted by the district level in non-NoP districts but at district and ‘network’ level in NoP districts. 17 CONSOLIDATED FINDINGS REPORT NoP implementation is based on nine key guiding principles envisaged by the GHS. Health provider interviews suggested that performance was moderately good regarding some of the NoP guiding principles, such as ensuring equity in healthcare, collaboration, and communication across all districts. In the two NoP districts, owing to the hub and spoke structure and the improved resource-sharing and coordination, performance across these guiding principles was found to be relatively better. Table  6 shows the performance of the NoP districts across each NoP guiding principle. NETWORK ANALYSIS The study looked at how networks were structured in the districts and the relationship and interactions between hubs and spokes to analyze the effectiveness of network operations. There was a focus on the two NoP districts, Dormaa Central and Hohoe since health facilities in these districts are officially grouped into networks. Some inferences were drawn for the potential future networks proposed by the other districts. This part of the report presents the different networks in the study, how they are spatially arranged, possible overlaps in their catchment areas, and the type of facilities included. The spatial distribution of the health facilities was determined regarding a) degree of node, b) overlap due to proximity, and c) centrality (Figure 11). FIGURE 11. COMPONENTS OF SPATIAL ANALYSIS OF HEALTH FACILITIES AND NETWORKS DEGREE OF NODE 1 OVERLAP DUE TO PROXIMITY 2 CENTRALITY 3 • Refers to the number of connections • Patient preference of node of a • ‘Betweenness centrality’ — a node a node has in the network. different network can occur if two lying on the shortest path between • Number of spokes linked per hub networks, especially 2 or more other nodes in the network nodes (hubs or spokes) of different should be suitable to avoid • ‘Eigenvector centrality’ — influence overcrowding/ overburdening of networks are in close proximity. of a node based on its connections hubs. This would also avoid under • This may lead to over utilization of to other influential nodes. (patient utilization of hub resources. the 'favored' hub/spoke and under may select a HF from where utilization of the less favored possible referrals to higher centers facility. or other hubs may be easier) 18 CONSOLIDATED FINDINGS REPORT DORMAA CENTRAL • In Dormaa, the centrality of hubs seems suboptimal, affecting proximity, time spent traveling to the facility, cost of transport, and overall access. • Proximity of the catchment area of networks led by Kofiasua Health Centre and St. Kyeadee Clinic, may lead to some overlap in populations. • The Kofiasua Health Center is also closer to the District Hospital (the Presbyterian Hospital), which may mean that patients from its spokes may opt to go directly to the District Hospital. • Some spokes of the Danyame Health Centre are closer to both the Kofiasua Health Centre and the District Hospital, which may lead to bypassing the Danyame Health Centre. Therefore, the capacity of the Kofiasua Health Centre must be significant for its efficient utilization and for it to reduce the workload at the district hospital. 19 CONSOLIDATED FINDINGS REPORT HOHOE • Proximity between Alagbui and Hohoe networks can lead to patient movement across the nearby health facility spokes/hubs. • The proximity between the Volta Regional Hospital and the two network hubs may motivate patients going to the hubs, to rather opt for the larger regional hospital with more services. 20 CONSOLIDATED FINDINGS REPORT TAIN • Despite not officially being an NoP district, Tain’s district management has organized its health facilities into three potential networks as a preparatory step to the NoP launch. • Tain has one hub that is close to the district hospital. Therefore, some patients may continue to prefer the district hospital over the hub unless this specific hub, based on its influential position (centrality) is strengthened significantly to share the district hospital’s workload. 21 CONSOLIDATED FINDINGS REPORT KETU NORTH • Ketu North was a non-NoP district at the time of this study. The networks depicted here are based on possible future configurations discussed with district health managers. • Network-level commodity needs could be difficult to estimate for networks servicing overlapping population areas. Other issues like planning community outreach services could be similarly affected. • Some hubs would only have one spoke and this could lead to suboptimal resource utilization at the strengthened hubs. • The close proximity between the Volta Regional Hospital and the two network hubs could lead patients to bypass the hubs for the regional hospital with more services. 22 CONSOLIDATED FINDINGS REPORT AYAWASO CENTRAL • Urban district, which has proposed three potential networks, with one being centered around their district hospital as a hub. • Takes into consideration that the district hospital has an existing catchment area, with as many as five clinics/ maternity homes, and is already a referral center for them. • The other two hubs are also in proximity, and upgrading a distant spoke as a potential hub may further help. 23 CONSOLIDATED FINDINGS REPORT ATWIMA NWABIAGYA • The potential networks depicted here are based on initial discussions with health system managers. The district hospital is proposed as a hub so it may continue catering to the catchment population directly. Three other mapped networks show some overlap. • Clustering of spokes leading to three dense networks very close by, including the one where the district hospital is the hub. • The proposed Akropong and Asuofua networks have a high number of spokes, whereby upgrading of health posts to health centres could be considered. Upgrading GHS-funded facilities with expanded insurance coverage may be the key to devolving workload and footfall from the district hospital. 24 CONSOLIDATED FINDINGS REPORT COMMUNITY ENGAGEMENT FIGURE 12. SCHEMA FOR COMMUNITY VALIDATION OF FINDINGS FROM PRIMARY DATA COLLECTION Recommendation surfaced from our participatory research approach will lead to greater agency for communities and better inform policy and investment in healthcare at the district and community-level. Analysis Make Recommendations Analyse collected data to Make policy recommendations surface key findings rooted in community agency and insight Primary Data Collection 'Groundtruth’ Findings Using collaborate designed Retum to the communities of methods and tools, identity primary data collection to verify communities & Collect Data and validate findings The community is actively involved in Community/Vulnerable Group (25/group) Health Facilities (15/group) the monitoring and implementation of key healthcare delivery interventions 4 from disabled persons, 3 from Drivers Union, 3 from Hairdressers and 6 healthcare workers, 2 through mechanisms such the Sub-district 1 Dressmakers Association, 3 from administrative staff community health management Pensioners Association committees (CHMC) etc. 3 from disabled persons, 3 from Ghana Private Road Transport Union, 3 from 5 healthcare workers. 2 Sub-district 2 Hairdressers and Dressmakers’ administrative staff Association, 3 from Pensioners Association Community engagement is a key part of GHS’s approach to achieve UHC. Community members are empowered through mechanisms such as community health manage­ ment committees and district-level meetings to provide accountability for the kind of services they receive and the performance of interventions like the NoP program. In acknowledgement of this, the PPA/SNA study employed a participatory approach that centered on the voice and agency of community members, including those who may be marginalized. To do this, there was a post-primary data collection ‘ground truthing’ step to validate findings and surface the community’s voice. 25 CONSOLIDATED FINDINGS REPORT The health providers validated all primary findings related to health care provision, service delivery and NoP functioning. TABLE 7. PRIMARY FINDINGS VALIDATED BY HEALTHCARE PROVIDERS Non-NoP urban NoP districts Non-NoP rural districts districts Referral Recommendations Confirmed Confirmed finding that Confirmed finding Confirmed finding of weak Provided finding that NoP perceived benefits of NoP of the dominant referral gatekeeping at lower- recommendations implementation implementation are focused role of private tier facilities and tendency on the resolution has helped in on resource sharing of health facilities, by healthcare providers incl. of challenges such resource sharing drugs/ commodities/ HR. and population has health posts to directly refer as transportation, of drugs, other Sought information on shown a preference to district hospitals even if HR shortage, commodities, HR. priority preparations for for ‘clinics’ for health center strengthened. drugs/equipment NoP roll-out and challenges healthcare, including Confirmed finding on referral shortage, any expected in NoP roll-out. MNH care. processes using referral others. notes, calls to referral facility. Most primary findings related to community/health system users were validated. TABLE 8. PRIMARY FINDINGS VALIDATED BY HEALTH SYSTEM USERS Health Challenges Health facility NoP faced by facility Health By-passing networking/ roll out Benefits of service selection insurance primary level collaboration preparation NoPs users Suggestions Confirmed Confirmed Patient Confirmed Confirmed Confirmed Confirmed Users made finding that finding that preference finding that a certain finding that finding suggestions closeness insurance for higher-tier collaboration level of the main that long on how to to home applicability facilities primarily seems to community benefits of distance/ address the and quality is very due to a better exist between awareness NoPs were time taken identified of services important perceived quality health about resource to reach the challenges. is a major to patients of care including facilities in networks sharing and facility, and factor for and better access servicing in NoP collaboration long waiting health influences to services, patients. districts. between time after facility their drug availability, health reaching selection. provider professionalism facilities. the facility choice. of providers, are major and avoidance challenges. of incorrect prescriptions. Higher-tier facility preference is also influenced by circumstances like urgency, need for laboratory/ diagnostics, NHIS considerations. 26 CONSOLIDATED FINDINGS REPORT The following findings from the primary study could not be verified. TABLE 9. PRIMARY FINDINGS NOT VALIDATED BY HEALTH SYSTEM USERS Patient satisfaction with quality of care Referral facilities Finding from primary data collection (patient interviews): Finding from primary data collection (patient interviews): perceived quality of care in the health facilities is generally referrals made by health providers are patient centered and good and overall patients are treated well at the health consider factors such as availability of transport, services at facilities. referral facility etc. Primary finding not validated, health care users found to be Primary finding partially validated but referrals likely less less satisfied with quality of care and health staff’s conduct determined by patient choice and more by service capacity (this was also mirrored by the care shadowing which showed considerations of referrer. mixed care provision quality). POSSIBLE STRATEGIES TO ENHANCE THE population at large are crucial to determining its success. NoP INTERVENTION Strong advocacy is needed by the State to enable optimal performance of NoPs and to reap the full benefits of this NoP implementation has been largely beneficial for the districts initiative. Strategies that could be considered by the GHS to where they have been implemented and has shown promising maximize the benefits of this strategy in delivering the full changes in the pre-rollout preparation stages. Ownership of package of PHC services and move towards UHC have been the intervention by the health staff and acceptance by the summarized in Figure 13. FIGURE 13. POSSIBLE STRATEGIES FOR OPTIMAL NoP PERFORMANCE Advocacy Patient-centered NoP expansion Continuous Routine system Implement review campaign mapping of in urban areas learning about strengthening mechanism for networks NoPs network performance Informing the Considering Upgrading facilities Surfacing insights Conducting Implementing public about the patient preference (and incorporating using feedback routine reviews mechanisms (like capacity of the while mapping the private sector) mechanisms for and improvement score cards) to spokes and hubs networks for future to ensure better better cycles to ensure improve efficiency in providing quality NoPs access to free or understanding, quality health and interaction primary care affordable maintenance of services between NoP healthcare NoPs are available facilities 27 CONSOLIDATED FINDINGS REPORT Suggestions from healthcare actors were also sought during the Community Engagement phase following the primary data collection. Service providers and community members mentioned various challenges with corresponding suggestions for solutions: FIGURE 14. PRACTICAL SUGGESTIONS FROM THE CONSULTED STAKEHOLDERS FOR BETTER OPERATIONALIZATION OF NoPs IN GHANA Inadequate Insufficient/poor Transport/ Lack of essential Inadequate resources and distribution of connectivity issues equipment community infrastructure healthcare workers participation • Provision of waiting • Community-led initiatives • Implementing a “one to build infrastructure facility, one ambulance” rooms in health facilities • Recruitment of more system • Equipping health centers • Health information health staff • Involving key system upgrades stakeholders and • Facilitated transport • Provision of adequate • Deploying and providing organizations arrangements with resources and equipment • Strengthening the drug incentives for healthcare commercial taxis supply chain workers in rural areas • Involving the community in supporting and • Expansion of the National • Upgrading diagnostic • Government policies to motivating healthcare Ambulance service equipment address workforce staff shortages • Community designed • Conducting community ambulances education initiatives NoP Lack of/inadequate Poor NoP Sustainability/ NoP preparedness implementation and Funding limitation Poor referral Maintenance and awareness effectiveness of NoP mechanism • Regular workshops to improve knowledge • Comprehensive education • Recruitment of more • Resourcing health • Reducing medication centers to better serve sharing and skill of the healthcare staff health staff taxes as referral centers development • Capacity building and • Provision of resources and • Improving the NHIS to • Reassessing and appointment of a refresher training • Educating patients on broaden coverage and proper referral optimizing existing dedicated NoP focal programs make healthcare mechanisms networks person • Provision of specific accessible • Community involvement • Community education equipment like scan • Strengthen collaboration • More government with district hospitals initiatives and machines • Provision of necessary funding equipment engagement activities 28 CONSOLIDATED FINDINGS REPORT Conclusion NoP implementation has shown positive effects on healthcare delivery, but some challenges remain. FIGURE 15. NoP IMPLEMENTATION-CHALLENGES AND POSITIVE IMPACT CHALLENGES TO NoP IMPLEMENTATION POSITIVE IMPACTS OF NoP IMPLEMENTATION Client preference for higher-tier health Infrastructure development facilities • With NoP implementation comes service • High uptake of hospitals across most touch points enhancement, insurance accreditation, and in both HTN and MNH patient pathways possibility to reorient patient care seeking • Clients tend to seek care in the same tier facility, from district hospital to health centre, which with little movement between facility types brings higher quality care closer to the user. Limited referral gatekeeping at Increased collaboration and lower-tier health facilities coordination • Most CHPS directly refer to their respective • NoP implementation brought improved district hospitals in both NoP and non-NoP knowledge sharing, better trust building, districts. and facilities' joint sense of ownership of pursuing health system targets instead of • May be justified in some emergency referrals individually. In both Hohoe and Dormaa Central, network formation, referral systems, increased access to and utilization of training, and NoP implementation have been ongoing healthcare services, and better resource management. for about three years. The study findings suggest The PPA/SNA study demonstrates that the scale-up that there is still more transition needed to break old of the NoP program across Ghana needs to align with patterns of referrals and healthcare seeking. Staff local contexts especially in Ghana’s urban healthcare attrition, combined with a lack of frequent training settings. However, in all settings, close collaboration or mentoring could have contributed to suboptimal between government agencies, partner organizations, performance. Also, the health system is still recovering and local communities will be essential for the from the COVID-19 pandemic and could perhaps not sustainable success of this initiative. adopt all strategic aspects of the NoP implementation The implementation of NoPs represents a significant during that initial period. With better advocacy, ongoing step towards strengthening Ghana’s healthcare system. health system strengthening, regular reviews, and By fostering collaboration, improving service delivery, support from GHS, the NoP initiative can perform and enhancing access to care, NoPs contribute to better and has the potential to lead to significant the nation’s goal of achieving UHC and better health improvements, such as more effective sub-district outcomes for all citizens. 29 World Bank 1818 H Street, NW Washington DC 20433 USA https://www.worldbank.org