NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION Key Lessons from Formative Research in Ayawaso Central and Atwima Nwabiagya Municipal HEALTH SYSTEM TECHNICAL SUPPORT TO GOVERNMENT OF GHANA: PATIENT PATHWAY ANALYSIS AND SUMMATIVE NETWORK ANALYSIS Highlights of the Brief This brief presents insights and lessons for the Networks of Practice (NoP) program in urban Ghana, based on formative research conducted in Ayawaso Central, Greater Accra Region and Atwima Nwabiagya Municipal, Ashanti Region. The research used Patient Pathway Analysis (PPA) and Summative Network Analysis (SNA) to understand and compare patient journeys in settings with and without NoPs. The NoP program has not yet expanded into urban areas, but studying patient journeys and the healthcare provider situation in urban settings provides essential information for patient- © 2024 International Bank for oriented NoP design. Features that were found to be specific to Reconstruction and Development / The World Bank urban districts include a higher density of health providers, a greater 1818 H Street NW role of private health facilities and clinics as compared to rural areas, Washington DC 20433 and higher out-of-pocket expenditure on healthcare. For successful Telephone: 202-473-1000 Internet: www.worldbank.org NoP implementation, network formation in urban areas will need to be tailored to the prevailing care delivery landscape and healthcare This work is a product of the staff of The World Bank with external utilization patterns. This may include upgrading selected public contributions. The findings, interpretations, and conclusions sector facilities to become network hubs and enhancing collaboration expressed in this work do not with private sector providers to strengthen urban networks. Urban necessarily reflect the views of The World Bank, its Board of Executive NoPs can advance Ghana’s ambition to increase access to quality Directors, or the governments they primary care, robust referral pathways, and financial protection for all represent. healthcare users in the country. Further research in various urban The World Bank does not guarantee the accuracy of the data included in and peri-urban districts of Ghana and implementation of urban NoP this work. The boundaries, colors, pilots will be beneficial for shaping an NoP program suited to urban denominations, and other information shown on any map in this work do not health systems. 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. 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 attribution to this work is given. Any 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. Photo credits All photos courtesy of School of Public Health, University of Ghana. NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION Introduction Ghana has an estimated 20.2 million people living in urban areas1 constituting 59% of the total population. Increasing URBAN AREAS: KEY INSIGHTS urbanization has led to increased demands for health care, sanitation, clean water and housing. Health indicators tend ■ Urban areas are markedly different from rural to be better in urban areas compared to rural areas. The districts in having a higher population and health 2022 Demographic and Health Survey2 found that four or facility density. more antenatal care visits (ANC4+) were 91% prevalent in ■ Geographical accessibility is therefore much better. urban areas (85% in rural areas), and facility-based delivery Long travel and waiting times at facilities were not was 94% in urban areas (79% rural areas). However, there reported to be major care seeking challenges. are still many gaps in the provision of affordable Primary ■ Urban patients prefer private clinics which are Health Care (PHC) services in urban settings, which is critical accom­panied by higher out-of-pocket expenditure for human development. Ghana Health Service (GHS) (OOPE). initiated the Primary Care Provider Networks (PCPN) pilot ■ Inclusion of all types of private health facilities in project in 2017 to enable equitable and affordable PHC NoPs will be crucial to bring primary care closer services in rural areas with the goal of Universal Health to the people while preventing catastrophic health Coverage (UHC). These networks, now known as Networks expenditure. of Practice (NoP), are structured in a hub-and-spoke model, ■ Upgrading selected public sector facilities to with a designated “Model Health Centre” serving as the network hubs and strong network collaboration with central hub for diverse, lower-level network spokes. The private sector providers, including pharmacies, will approach seeks to enhance collaboration among healthcare further strengthen the urban NoP intervention. providers, improve health outcomes, and strengthen the overall health system. The Patient Pathway Analysis and Summative Network Analysis (PPA/SNA) study is part of a larger multi-year research package led by the GHS to evaluate NoP implementation and rapidly translate the knowledge to optimize the NoP scale-up in rural Ghana, followed by expansion into urban areas. This study was carried out by The World Bank and its research partners IQVIA, University of Ghana School of Public Health and NTTData, with close oversight by GHS. 1 World Bank Data (https://data.worldbank.org/indicator/SP.URB. TOTL?locations=GH) based on UN Population Division’s World Urbanization Prospects: 2018 Revision. The Ghana 2021 Population and Housing Census presents population density data to indicate degree of urbanization. 2 Ghana Statistical Service (GSS) and ICF. 2024. Ghana Demographic and Health Survey 2022. Accra, Ghana, and Rockville, Maryland, USA: GSS and ICF. 1 NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION How was the Data Gathered and Analyzed? The study on patient pathways for maternal and neonatal based on Multidimensional Poverty Indicator data and health health (MNH) care and hypertension (HTN) care tracked scores from the 2021 District League Table as well as their journeys using ‘touchpoints’ of care. It was implemented in relatively large population numbers. They had similar levels conjunction with the analysis of networks of care providers. of multidimensional poverty but Ayawaso Central had a lower Overall, it covered six GHS-selected districts, including two health ranking compared to Atwima Nwabiagya Municipal rural districts with NoPs, two rural districts without NoPs, and and a significantly greater population density (Table 1). two urban districts. The two municipal districts of Ayawaso ‘Potential networks’, i.e., groups of health facilities that could Central and Atwima Nwabiagya Municipal were selected function as networks once the NoP program was introduced in these districts, were identified in consultation with district officials (see Annexure for the list of health facilities included in the study from the two urban districts). The PPA/SNA study used existing routine data and collected new data, in the form of exit interviews with MNH and HTN clients across different levels of healthcare facilities, shadowing of healthcare clients, and further interviews with health system users in the community (375 pathway interviews in the urban districts). The study also gained insights from health providers from all levels of healthcare through in-depth interviews and focus group discussions. The primary data collected over 6 weeks in July/August 2023 are summarized in Table 2 for the two urban districts (further PPA/SNA study findings across the six districts are covered in other reports and briefs). Health facilities included both public and private sectors. Private facilities here refer to all for-profit, and not-for- profit health facilities run by private companies, NGOs, or religious missions. TABLE 1. PROFILES OF THE URBAN DISTRICTS % household Population population in Total density4 multidimensional population3 (persons/km2) poverty Health score5 Health ranking6 Ayawaso Central 94,831 16,759 12.27 36.225 240 Atwima Nwabiagya Municipal 161,893 560 12.58 79.483 70 3 Ghana Statistical Service. 4 Ghana Statistical Service. 5 Dsitrict League Table Report 2021. National Development Planning Commission and UNICEF. November 2022. 6 Dsitrict League Table Report 2021. National Development Planning Commission and UNICEF. November 2022. 7 Multidimensional Poverty Report. Ayawaso Central. Ghana Statistical Service. May 2024. 8 Multidimensional Poverty Report. Atwima Nwabiagya Municipal. Ghana Statistical Service. May 2024. 2   NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION TABLE 2. DATA COLLECTION METHODS AND SAMPLE SIZES IN THE TWO URBAN DISTRICTS Data collection modality Ayawaso Central Atwima Nwabiagya Municipal Total urban Health system users (50% MNH, 50% HTN): Exit interview (care seeking pathways, visit feedback) 129 130 259 Community based interviews (care seeking pathways) 58 58 116 Shadowing of patient visit 26 24 50 Health care providers Key Informant Interviews 35 35 70 Focus Group Discussions 2 2 4 What were the Highlights on Patient Pathways in Urban Areas? ⊲ Strong preference for hospital-level services ⊲ Higher OOPE incurred as compared to rural districts. across all MNH and HTN care touchpoints including On average 1336 Ghanian cedis OOPE incurred for for services that can be sought at the primary care childbirth in Atwima Nwabiagya Municipal, and 973 Gh. level such as antenatal care (ANC). Cedis in Ayawaso Central (compared to rural district ⊲ High preference for private clinics/mission averages ranging from 387 to 816 Gh. Cedis). For hospitals and private providers across most HTN monitoring, the highest monthly expenditure touchpoints. MNH care users preferred health posts was reported from Ayawaso Central at 92 Gh. Cedis, (CHPS) over health centres (this was not the case in and Atwima Nwabiagya Municipal reported nearly the rural study districts). 75 Gh. Cedis (compared to averages of 14 to 36 Gh. Cedis in three of the four rural districts). Across ⊲ Physical access to health facilities was easier in patient types, suggestions of free or less costly urban areas as compared to rural districts. Most health services were common. MNH respondents reached health facilities within 30 minutes for different maternal health services ⊲ Some by-passing of the primary care level to directly (rural respondents reported travelling on average seek care at hospitals in both rural and urban areas. for more than 60 minutes). However, urban care seeking was also directed to health centres especially for HTN diagnosis and ⊲ Vehicle transport vs. walking - Preference for treatment initiation (Figure 1). Some MNH clients use of commercial taxis to reach health facilities frequented urban CHPS health posts rather than health was seen in Ayawaso Central respondents centres, even for giving birth. At the same time, some (79% for childbirth services). In the rural districts, urban MNH clients chose private clinics, mission ‘walking’ was cited as the most common mode hospitals, and private providers especially for ANC and of reaching facilities especially for ANC PNC. For HTN, these non-government providers were services. often the “first port of call” and, together with hospitals, ⊲ Perceived quality of care and proximity to home they played a major role in treatment maintenance of were the primary drivers of people’s health facility HTN patients. These pathways suggest that NoP design selection, similar to rural districts. Overall, urban in urban areas must not just replicate the network users experienced relatively fewer challenges with configuration of the rural program but be based on long travel and waiting times. the specific composition of the local health facility mix. 3   NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION FIGURE 1. PATIENT PATHWAYS: TOUCHPOINTS OF CARE FOR MNH (LEFT) AND HTN (RIGHT) 2% 2% 2% 1% 0% 5% 6% 4% 3% 6% 5% 5% 2% 12% 6% 12% 15% 18% 16% 6% 14% 19% 3% 13% 6% 14% 26% 27% 12% 9% 6% 6% 15% 8% 27% 27% 37% 42% 39% 26% 32% 37% 23% 24% 36% 47% 48% 43% 43% 41% 38% 37% 37% 40% 32% 36% First ANC Regular Pregnancy Onset of Delivery PNC First Diagnosis Treatment Treatment Treatment ANC complications labour contact initiation maintenance monitoring Others (maternity homes, regional hospital, alternative) Others (maternity homes, alternative, etc.) Health Post (CHPS) Pharmacy/OTC drug seller Health Centre Health Post (CHPS) Clinic (incl. private/NGO/mission) Health Centre District/other Hospital Clinic (incl. private/NGO/mission) District/other Hospital 4 NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION What did the Network Analysis Find in the Urban Study Districts? AYAWASO CENTRAL ATWIMA NWABIAGYA MUNICIPAL ■ Geospatial analysis of possible future networks in the referral center for them. This contrasts with the network urban setting shows compact and densely arranged design in rural areas, where the hub is usually a health networks especially in the high-density setting of centre with the district hospital only serving as a higher Ayawaso Central where most hub and spoke distances referral unit. would likely be 1–2 kilometers. ■ Enhancing the resources of clinics connected to ■ There is a high chance of overlapping catchment district-level hospitals can significantly improve PHC areas of networks due to their proximity. While this is services. Selective upgrading of certain CHPS to expected in the built-up urban setting, it does point health centers will further boost PHC access and to the need for detailed spatial exploration before coverage. These improvements at the spoke level will networks are configured. Two connected issues are prevent district hospitals from being overburdened going to be supply chain quantifications for networks, with PHC duties, allowing them to play their role and outreach activity planning to maximize service as referral centers. Such measures also bring access and coverage especially in low-income comprehensive PHC services closer to patients’ settlements. homes, especially if services are well accessible as ■ There are high footfall health facilities like Mallam Atta covered by the health insurance scheme. Clinic in Ayawaso Central and Dabaa Hope Hospital in ■ Pharmacies play a more prominent role in management Atwima Nwabiagya Municipal. Both these district level of HTN, and likely other NCDs, in urban areas. In hospitals could be well-placed to become network addition to being included in network configurations, hubs. They have an existing catchment area which a deliberate attempt should be made to obtain data from includes clinics and maternity homes and is already a them for tracking population management of NCDs. 5   NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION Conclusion Urban areas in Ghana have a health facility distribution that is distinct from the rural areas in terms of the density of the facilities and a preponderance of private clinics and hospitals. This impacts how and where patients seek care – often by affordable vehicle rides and at for-pay health facilities. The PPA found low utilization of urban health centres (which are the NoP hubs in rural districts) especially for MNH care and ongoing HTN treatment. The specifics of the urban healthcare setting translate to different challenges for users, with high OOPE at private health facilities being the most keenly felt one. If urban district level hospitals were to be considered as network hubs, they could have higher-capacity primary care facilities in the area as spokes to limit up-referrals. By aligning with existing referral patterns, such an urban network design could build on current health provider practices and have good acceptance among the users. Strengthening CHPS and even private clinics are also options. Popular facilities such as clinics and private health centres would require mapping and assessment before joining any network. Just like in the NoP intervention in rural districts, ensuring robust specific components of care, such as HR hiring12, and sharing of diagnostic capacity.13 Success of NoP implementation in partnerships at the operational level between hubs, their urban areas will also depend on well-developed monitoring spokes and the higher-level referral hospital will be key to and review mechanisms alongside regular trainings for the implementing urban NoPs. The overall findings from the PPA/ diverse mix of health facilities. SNA study also pointed to the importance of comprehensive initial training of all newly appointed staff on NoPs, as well as The NoP expansion in urban areas should go hand in hand ongoing mentoring and monitoring by the district health with the upgrading of health centres (or even health posts, team. If private clinics were to be part of urban NoPs, specific as applicable in the setting) and then enhancing their mechanisms of collaboration would need to be established. maturity to become “Model Health Centres” where NHIA This may include shared access to data platforms with credentialing has been conducted for MNH, HTN and ethical checks and balances in place9, public-private other primary care services. This, along with transportation partnerships (PPP) for healthcare delivery10,11, MoUs around through ambulance, will result in a larger pool of government health facilities granting better access to free and insurance supported care and preventing catastrophic health expenditure, as can occur in the absence of strong public sector care provision. Some of these key design elements that can be considered while planning the scale-up of NoPs 9 Landers, C., Ormond, K.E., Blasimme, A. et al. Talking Ethics Early in in urban Ghana are illustrated in Figure 2. Health Data Public Private Partnerships. J Bus Ethics 190, 649–659 (2024). https://doi.org/10.1007/s10551-023-05425-w 10 Ampong-Ansah, F. B., Maloreh-Nyamekye, T., Otchere, L. N., Boateng, A. K., & Antwi-Boasiako, J. (2020). Partnership and collaboration in 12 IntraHealth. Voices From The Capacity Project: Kenya’s Health Care healthcare delivery in Ghana. Journal of Public Affairs. doi:10.1002/ Crisis—Mobilizing the Workforce in a New Way. (2006) pa.2175 13 Akram Baniasadi, Ali Akbari Sari, Ebrahim Jaafaripooyan et al.. Real-life 11 Kofi Aduo-Adjei. (2017). Public-Private Partnership Approach to incentives driving Public-Private Partnership in diagnostic services. Non-Communicable Diseases Prevention in Ghana.MOJ Public Health. Ethiop J Health Sci. 2020;30(3):409.doi:http://dx.doi.org/10.4314/ejhs. Volume 6 Issue 3 - 2017 v30i3.12 6 NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION FIGURE 2. DESIGNING NoPs IN URBAN DISTRICTS PATIENT CENTRED & MONITORING SPATIAL MAPPING Customized formats and monitor- Adapting the existent referral ing mechanisms to include private patterns and using geospatial sector facilities in monitoring visualizations to guide mapping. efforts. WELL-PATRONIZED STRENGTHENED HEALTH FACILITIES EMERGENCY TRANSPORT Well-patronized public and private Increase density of free, public health facilities, and pharmacies; ambulances for emergency should be NHIA-credentialled transportation. to reduce OOPE. INCREASED INSURANCE ENHANCED OPERATIONAL COVERAGE PARTNERSHIPS Regular optimization of National Acknowledge private sector Health Insurance norms to cover preponderance and preference by large range of services at more including private/NGO/mission facilities. Facilitating accreditation clinics and pharmacies in networks. of facilities. The NoP program will need to adapt the approach to the urban healthcare ecosystem and form provider networks which are compatible with the urban healthcare ecosystem. This may require further research in various urban and peri- urban settings on issues like institutional capacities and strategic collaborations, health insurance accreditation, means of financing the network structure, service planning in the hub-and-spoke model, etc. Akin to the rural NoP program, piloting the NoP approach in urban communities may have an important role in learning what works for patients and care providers. NoP expansion in urban areas will add much value to primary health care provision in Ghana, especially for services like maternal and chronic/NCD care which rely on continuity and successful referrals for good health outcomes. The NoP expansion to Ghana’s urban areas should be informed by the ground realities of health system characteristics in these urban settings. Preponderance of private health facilities is a key feature of urban areas which leads to a chain of effects such as private clinic preference, high OOPE and transport costs. The lessons from rural NoP implementation can be drawn on for the urban roll-out, but the NoP program will also require some new mechanisms to accommodate the specifics of Ghana’s urban health system. 7   NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION Annexure 1. List of government and private facilities in the ‘potential networks’ in Atwima Nwabiagya Municipal Govt or private S. (private/mission/ no. Facility name Facility type Subdistrict Hub NGO) 1 Akropong Polyclinic Clinic/Maternity Home Akropong Akropong Government polyclinic 2 Mount Sinai Hospital Hospital Akropong Akropong polyclinic Private 3 Episcopal Divine Clinic Health centre Akropong Akropong polyclinic Private (CHAG) 4 Koforidua Antwi’s Maternity Home Clinic/Maternity Home Akropong Akropong polyclinic Private 5 Najet Medical Centre* Health centre Akropong Akropong polyclinic Private 6 Healthy Care Medical Centre Health centre Akropong Akropong polyclinic Private 7 Asuofua Polyclinic Clinic/Maternity Home Asuofia Asuofia Polyclinic Government 8 Cedar Crest Hospital Hospital Asuofia Asuofia Polyclinic Private 9 Asamang Hospital Hospital Asuofia Asuofia Polyclinic Private 10 Adankwame CHPS Compound CHPS Compound/Zone Asuofia Asuofia Polyclinic Government 11 Amoaman CHPS Compound CHPS Compound/Zone Asuofia Asuofia Polyclinic Government 12 Cindike Pharmacy and Mart Pharmacy/Over the Asuofia Asuofia Polyclinic Private Counter Med 13 Barekese Health Centre Health centre Barekese Barekese Health Government Center 14 Barekuma CHPS Compound CHPS Compound/Zone Barekese Barekese Health Government Center 15 Abira CHPS Compound CHPS Compound/Zone Barekese Barekese Health Government Center 16 Wurapong CHPS Compound CHPS Compound/Zone Barekese Barekese Health Government Center 17 BCODCO Pharmacy Pharmacy/Over the Barekese Barekese Health Private Counter Med Center 18 Teacher A. K. Over the Counter Med Pharmacy/Over the Barekese Barekese Health Private Counter Med Center 19 Dabaa Hope Hospital District Hospital Dabaa Dabaa Hope Private (CHAG) Hospital 20 JILF Health Services Hospital Dabaa Dabaa Hope Private Hospital 21 Olivia Antwi’s Over the Counter Pharmacy/Over the Dabaa Dabaa Hope Private Med Counter Med Hospital *During data collection, this facility was known as Najet Medical Centre and its hub was Akropong Polyclinic. It has since been renamed to Najet Hospital and is in the Dabaa network with hub at Dabaa Hope Hospital. 8 NETWORKS OF PRACTICE IN URBAN GHANA: DESIGN AND IMPLEMENTATION 2. List of government and private facilities in the ‘potential networks’ in Ayawaso Central Govt or private S. (private/mission/ no. Facility name Facility type Subdistrict Hub NGO) 1 Anthon Memorial Hospital Hospital Kotobabi Anthon Memorial Private Hospital 2 Effan Victory Clinic Clinic/Maternity Kotobabi Anthon Memorial Private Hospital 3 Anthon CHPS CHPS Zones Kotobabi Anthon Memorial Government Hospital 4 Bright Star CHPS CHPS Zones Kotobabi Anthon Memorial Government Hospital 5 Ebony Junction CHPS CHPS Zones Kotobabi Anthon Memorial Government Hospital 6 Tobinco Pharmacy Pharmacy/Over the Kotobabi Anthon Memorial Private Counter Med Hospital 7 John Best Pharmacy Pharmacy/Over the Kotobabi Anthon Memorial Private Counter Med Hospital 8 Alajo Community Clinic Clinic/Maternity Home Alajo Alajo Community Private Clinic 9 Delape CHPS CHPS Zones Alajo Alajo Community Government Clinic 10 Alajo Park CHPS CHPS Zones Alajo Alajo Community Government Clinic 11 Polo Park CHPS CHPS Zones Alajo Alajo Community Government Clinic 12 Mallam Atta Clinic District Hospital Accra new town Mallam Atta Clinic Government 13 Anidasofie Clinic Clinic/Maternity Home Accra new town Mallam Atta Clinic Private (CHAG) 14 Mery Anna Maternity Clinic/Maternity Home Accra new town Mallam Atta Clinic Private 15 Entrance University Hospital Hospital Accra new town Mallam Atta Clinic Private 16 Mustard Health Systems Hospital Accra new town Mallam Atta Clinic Private 17 Clinix Hospital* Hospital Accra new town Mallam Atta Clinic Private 18 New Page CHPS CHPS Zones Accra new town Mallam Atta Clinic Government 19 Mrs Dua CHPS CHPS Zones Accra new town Mallam Atta Clinic Government 20 Anidasofie CHPS CHPS Zones Accra new town Mallam Atta Clinic Government 21 Jucad Pharmacy Pharmacy/Over the Accra new town Mallam Atta Clinic Private 22 Elikplim Pharmacy Pharmacy/Over the Accra new town Mallam Atta Clinic Private * During data collection, this facility was known as Clinix Hospital. It has since been renamed to Medylife Hospital. 9   World Bank 1818 H Street, NW Washington DC 20433 USA https://www.worldbank.org