NETWORKS OF PRACTICE IN GHANA: LEARNING FROM IMPLEMENTATION IN TWO DISTRICTS Key Lessons from Research in Dormaa Central and Hohoe Districts HEALTH SYSTEM TECHNICAL SUPPORT TO GOVERNMENT OF GHANA: PATIENT PATHWAY ANALYSIS AND SUMMATIVE NETWORK ANALYSIS Highlights of the Brief This policy brief presents key insights and lessons gained from recent research conducted in seven Networks of Practice (NoP) across two districts in Ghana: Dormaa Central and Hohoe. The four NoPs in Dormaa Central were established in November 2020 with USAID/R4D support, the three NoPs in Hohoe were started in January  2021 with KOFIH support. The research included Patient Pathway Analysis (PPA) to map and compare patient journeys between these two districts with NoPs and other matched districts © 2024 International Bank for without NoPs. The study also included Summative Network Analysis Reconstruction and Development / The (SNA) to understand network configuration and function. World Bank The aim was to learn more about how the NoPs work for patients and 1818 H Street NW Washington DC 20433 care providers, and feed this knowledge into Ghana’s scale-up of the Telephone: 202-473-1000 Internet: www.worldbank.org NoP program. This work is a product of the staff The number and composition of spokes varied across the seven of The World Bank with external NoPs with some using other health centres as spokes, some having contributions. The findings, interpretations, and conclusions pharmacies or over-the-counter drug sellers as spokes, as well as expressed in this work do not Community-Based Health Planning and Services (CHPS) and clinics/ necessarily reflect the views of The World Bank, its Board of Executive maternity homes. Directors, or the governments they represent. The study identified notable positive effects of NoPs in the delivery The World Bank does not guarantee of health services including facility level improvements, service the accuracy of the data included in enhancements, and increased collaboration between health facilities. this work. The boundaries, colors, denominations, and other information Some key goals of NoPs such as strong referral gatekeeping to shown on any map in this work do not reduce the patient load at higher tier facilities were not fully achieved imply any judgment on the part of The World Bank concerning the legal status in the studied NoPs, and patient preference for higher-tier facilities of any territory or the endorsement or acceptance of such boundaries. persisted due to a mix of reasons including perceived quality, and the spectrum of services available at the different levels of care. However, Rights and Permissions The material in this work is subject throughout the patient pathway, districts with NoPs compared to to copyright. Because The World matched non-NoP districts showed a shift towards increased Bank encourages dissemination of its knowledge, this work may be utilization of health centers which were NoP hubs. reproduced, in whole or in part, for noncommercial purposes as long as full The NoP districts also showed improved awareness of the hub and attribution to this work is given. spoke model of care, willingness and evidence of cross-facility Any queries on rights and licenses, collaboration and sharing of resources. including subsidiary rights, should be addressed to World Bank Publications, It can be inferred that the NoP intervention represents an extensive The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: system change that may require several years of implementation, 202-522-2625; e-mail: pubrights@ continued investment and mentoring of the facility level providers worldbank.org. before the full impact can be attained. Photo credits All photos courtesy of School of Public Health, University of Ghana. NETWORKS OF PRACTICE IN GHANA: LEARNING FROM IMPLEMENTATION IN TWO DISTRICTS Introduction Strong primary health care (PHC) systems are vital for universal health coverage (UHC). Networks of primary care KEY INSIGHTS providers have the potential to improve people’s service access, extend the range of services available, strengthen ■ NoPs can reorient patient care- seeking towards patient referral, and help integrate primary care with wider health centres through improved service offers health and community services. In Ghana, health indicators closer to home, thereby helping to improve access tend to be worse in rural compared to urban areas. The to quality care. However, referral gatekeeping in 2022 Demographic and Health Survey1 found that four or NoPs needs further attention. more antenatal care visits (ANC4+) were 85% prevalent in ■ NoPs link a diversity of healthcare providers rural areas (91% in urban), and health facility delivery was including pharmacies to a hub facility; spatial and 79% in rural areas (94% in urban). The Ghana Health Service patient-centered mapping can support network (GHS) initiated the Primary Care Provider Network (PCPN) configuration. pilot project in 2017 in Volta Region, and early review and ments, ■ NoP implementation supports facility improve­ evaluation of networks in Volta and Bono Regions have infrastructure development, service enhancement, been positive2. These networks, now known as Networks of and insurance accreditation. Practice (NoP), are structured around a hub-and-spoke ■ NoPs create a framework for increased model with a designated “Model Health Centre” serving as collaboration and coordination between facilities, the central hub3. The approach specifically seeks to enhance improved knowledge transmission, the sharing of collaboration among healthcare providers, improve health commodities, HR and other resources, better trust outcomes, and support Ghana in achieving UHC. building, and for facilities jointly pursuing health To further learn about the effects of NoP implementation on system targets instead of individually. However, the patients and care providers, GHS and the World Bank study found that network collaboration could be conducted in-depth research in two NoP districts namely further strengthened. Dormaa Central (Bono Region) and Hohoe ( Volta Region). The study included Patient Pathway Analysis on the Maternal and Neonatal Health (MNH) and hypertension (HTN) care continua and Summative Networks Analysis (SNA). It paired the two study districts with non-NoP districts for comparison. This brief focuses on the learning from Dormaa Central with its four NoPs established in November 2020 with USAID/ R4D support, and Hohoe with its three NoPs established in January 2021 with KOFIH support. 1 Ghana Statistical Service (GSS) and ICF. 2024. Ghana Demographic and Health Survey 2022. Accra, Ghana, and Rockville, Maryland, USA: GSS and ICF. 2 Ghana Health Service, Results for Development, & Health Systems Strengthening Accelerator. (2023). Leaving no one behind: The role of primary care provider networks in advancing equitable universal health coverage in four districts of Ghana. 3 Ghana Health Service. (2024). Implementation guidelines for networks of practice. 1 NETWORKS OF PRACTICE IN GHANA: LEARNING FROM IMPLEMENTATION IN TWO DISTRICTS Data Collected in the Two NoP Districts ■ For patient pathway interviews and service satisfaction, For the NoP to non-NoP comparisons, Dormaa Central was 187 MNH clients and 188 HTN patients were paired with Tain (also in Bono Region) and Hohoe with Ketu interviewed in Dormaa Central and Hohoe districts. North (also in Volta Region). Selection and matching of districts The pathways were assessed with the interview were done using Multidimensional Poverty Indicators and respondents by using specific ‘touchpoints’ with the health scores from the 2021 District League Table. In the non- care system such as the first antenatal care (ANC) visit, NoP districts, the district officials helped the researchers to the visit at which HTN was diagnosed, etc. identify groups of health facilities which could become ■ For care observations, 26 MNH clients and 26 HTN networks in future (‘potential networks’) to enable comparisons. patients were shadowed during a full health facility In the data analysis and interpretation phase, the quantitative visit in the two districts. and qualitative data were triangulated, and findings validated through community engagement. Network analysis ■ For learning from health care providers, 70 key determined the number of connections and positioning of informant interviews and four focus group discussions network hubs, as well as the spatial coverage of networks and with 4-5 participants each were carried out. potential overlaps in their coverage areas. The collection of these quantitative and qualitative data in the two study districts was conducted from mid-July to end- August 2023. Results on the Care Pathways in Dormaa Central and Hohoe ⊲ Based on the pathway interviews, there was a strong not a key driver of choice, implying that patients were preference for hospital-level services across all MNH willing to accept more out-of-pocket expenditure and HTN care touchpoints including care that can be (OOPE) to get better quality of care, even if it was sought at the primary care level such as ANC check- distant and travel more costly. ups ⊲ However, the most significant challenges while ⊲ In the two NoP districts, patient pathways had a seeking care were long travel time to the health better orientation towards health center use facility and long waiting time at crowded hospitals. compared to non-NoP districts, suggesting that the ⊲ NoPs were found to improve collaboration between strengthened health centres (NoP hubs) were able networked facilities through the sharing of resources to attract MNH and HTN clients. including knowledge and personnel. ⊲ Referral gatekeeping in the NoPs was found to be weak with many CHPS posts referring directly to hospitals. ⊲ Perceived quality of care and proximity to clients’ homes were the primary drivers of health facility selection by these users. Affordability of services was 2 NETWORKS OF PRACTICE IN GHANA: LEARNING FROM IMPLEMENTATION IN TWO DISTRICTS Configuration of the Networks in the Two NoP Study Districts Six of the seven NoPs had a health centre as hub whereas spokes, some having pharmacies or over-the-counter the Pure Gyst network used a clinic as hub (Table  1, drug sellers as spokes, as well as a mix of Community- Table 2). The number and composition of spokes varied Based Health Planning and Services (CHPS) and clinics/ across the NoPs with some using other health centres as maternity homes. TABLE 1. DORMAA CENTRAL DISTRICT: FOUR HUBS, A TOTAL OF 20 SPOKES AND ONE DISTRICT HOSPITAL No. Facility name Facility type Sub district name NoP Name 1 Presbyterian Hospital District Hospital Dormaa Sub-municipal District Hospital 2 Kofiasua Health Centre* Health Centre 3 Antwirifo Health Centre Health Centre 4 Denmida Health Services Clinic Dormaa Sub-municipal Prudential 5 Sromani/Bonoyaw CHPS CHPS 6 Atesikrom CHPS CHPS 7 St. Kyeadee Clinic* Clinic 8 Pure Heart Maternity Home and Clinic Maternity Dormaa Sub-municipal Pure Gyst 9 Gonokrom CHPS CHPS 10 Yawkrom /KKK CHPS 11 Danyame Health Centre* Health Centre Danyame Sub-municipal 12 MSGR. Mensah Abrampah Clinic Clinic Danyame Sub-municipal 13 Abonsrakrom CHPS CHPS Dormaa Sub-municipal 14 Twumkrom CHPS CHPS 15 Asunsu No.1 CHPS CHPS Danyame Sub-municipal Danyame 16 Adu Rubin OTC (Abonsrakrom) Pharmacies/OTCs Dormaa Sub-municipal 17 Batanigya OTC (Asunsu) Pharmacies/OTCs 18 Sankara OTC Pharmacies/OTCs Danyame Sub-municipal 19 Brafo Kwasi Martin OTC Pharmacies/OTCs 20 Amasu Health Centre* Health Centre Amasu Sub-municipal 21 Asikasu/Nsuhia Health Centre Health Centre Asikasu Sub-municipal 22 Aboabo Health Centre Health Centre Favour 23 Kwameasua Health Centre Health Centre Aboabo Sub-municipal 24 Tronang CHPS CHPS 25 Manteware CHPS CHPS * Network hub facility 3 NETWORKS OF PRACTICE IN GHANA: LEARNING FROM IMPLEMENTATION IN TWO DISTRICTS TABLE 2. HOHOE DISTRICT: THREE HUBS, A TOTAL OF 18 SPOKES AND ONE DISTRICT HOSPITAL No. Facility name Facility type Sub-district Network 1 Volta Regional Hospital District Hospital Hohoe sub-district District Hospital 2 Fodome Helu Health Centre* Health Centre 3 Wli Central Health Centre Health Centre 4 Fodome Ahor Health Centre Health Centre Agumatsa sub-district Agumatsa network 5 Fodome Woe CHPS CHPS Compound/Zone 6 Fodome Hlorma CHPS CHPS Compound/Zone 7 Gbi-wegbe Health Centre* Health Centre Gbi-Wegbe sub-district 8 Alavanyo wudidi health centre Health Centre Alavanyo sub-district 9 Alavanyo Dzogbedze CHPS CHPS Compound/Zone 10 GBI Akplamafu CHPS CHPS Compound/Zone 11 Gbi Kpoeta CHPS CHPS Compound/Zone Gbi-Wegbe sub-district Alagbui network Pharmacy/Over the Counter 12 Adzato Emmanuel Chemical Shop Medicine sellers Pharmacy/Over the Counter 13 Amexo Selorm Chemical Shop Medicine sellers Alavanyo sub-district Pharmacy/Over the Counter 14 Buasilenu Samuel Chemical Shop Medicine sellers 15 Hohoe Adabraka Health Centre* Health Centre 16 HEPSS School Clinic Clinic/Maternity Home 17 Hohoe (RCH) Clinic Clinic/Maternity Home 18 GBI-Kodzofe CHPS CHPS Compound/Zone 19 Gbi Kpeme CHPS CHPS Compound/Zone Hohoe sub-district Hohoe network 20 Hohoe Blave CHPS CHPS Compound/Zone 21 Hohoe Low Cost CHPS CHPS Compound/Zone Pharmacy/Over the Counter 22 Celchemist Pharmacy Medicine sellers * Network hub facility 4 NETWORKS OF PRACTICE IN GHANA: LEARNING FROM IMPLEMENTATION IN TWO DISTRICTS Spatial Properties of The spatial analysis of the networks provided numerous insights and demonstrated the value of using GIS the NoPs in the Two NoP methodology when networks are being developed. Study Districts DORMAA CENTRAL The proximity of some spokes with the district level hospital could deter completion of referrals from these spokes to their respective hubs. Significant capacity strengthening of hubs, therefore, should be prioritized, to ensure patient flow to hubs (instead of hospitals that are closer to reach), and consequent reduction in primary care patient load at hospitals. NoP review Community Health Management Committee meetings and feedback with community scorecards are all implemented but need further monitoring and ongoing support. Staff at one networked Christian Health Association of Ghana/CHAG facility was not aware of their NoP status. 5 HOHOE As with Dormaa Central, proximity of spokes to the district hospital could impair referral completion to hubs. Significant capacity strengthening of hubs will help decentralize PHC and reduce patient load at district hospitals. Regular monitoring and review by district health team, CHMC meetings and use of community scorecard were reported more frequently by the staff in the three NoPs in Hohoe as compared to those in Dormaa Central. Telemedicine services operated from the Volta Regional Hospital contributed to decentralization of quality care and towards building trust in the health system. 6 NETWORKS OF PRACTICE IN GHANA: LEARNING FROM IMPLEMENTATION IN TWO DISTRICTS What are the Key Insights on NoP Implementation? NoP implementation has generally proven successful, Some quotes from health care providers serving in aligning with the initial conceptualization, and adhering to networked facilities in Dormaa Central and Hohoe that key guiding principles of equity, internal collaboration, indicate NoP implementation is in accordance with its operational partnership and community engagement. guiding principles: “I think it has brought about “Our numbers have started dwindling from an average of 200 per month teamwork, because initially, we to somewhere 140, 150, 160. It used to be (higher), but since we started referred complicated cases to the NoP, the lower facilities are doing more. We're on the top of the hub, Hohoe and the PA only works here. so we give a lot of support (to) the lower level to deliver (and refer only) But because of the NoP, he now that's necessary referring, so it helps reduce our (burden)....at least our goes round to other CHPS and maternal (cases)- it is supervised deliveries, which we don't see it as a health centers for consultation and problem. It has also improved the way maternal conditions are managed sometimes to teach them what to within the network. We are able to offer skills and support the lower level do in case there is any emergency”. to manage the maternal conditions better”. — Nurse, GHS Health Centre — Acting medical director, GHS-Regional Hospital (Hub), NoP district (serving as District Hospital), NoP district Do you think the Network of Practice has had any effect on community engagement in thet district? How has it been? “Referrals have improved within the networks and outside the networks. So, mortality has generally “Yeah, with the help of the network, the CHMC are trained so reduced when it comes to maternal/ neonatal.” these people together with volunteers help to inform the community during town meetings about any health service — Acting medical director, GHS-Regional Hospital we intend to run in the facility”. (serving as District Hospital), NoP district How do you think community engagement can be improved? “I will say holding regular community durbar can help to “In cases where they go the Municipal Hospital improve community engagement. During the durbar, issues and they are put on medication, they are normally among the problems of the people are raised and discussed” referred to this place so they can check for their — Staff nurse, GHS clinic (Spoke), NoP district BP for about a week or five days”. So, that is the only thing you do for them. You do not prescribe any medications? “In the network of practice, we want to improve quality of “They have their one medication from the work and it is only the indicators that give us a prof that we Municipal Hospital. They only come here to get are actually doing well in providing quality health care. The their BP checked”. indicators give us the information in every quarter about any information that we may need to know.” — Community Health Nurse, GHS Health Post (Spoke), NoP district — Physician Assistant, GHS Health Centre (Hub), NoP district 7 NETWORKS OF PRACTICE IN GHANA: LEARNING FROM IMPLEMENTATION IN TWO DISTRICTS Key lessons learnt from studying seven NoPs in the Volta and Bono region, which can inform the scale-up of NoPs across the country are: 1 – Hospital preference persists among health system users. ‘Proximity to home’ and ‘quality of care’ were strong drivers for health facility selection, however, care clients across NoPs in Dormaa Central and Hohoe prioritized the quality of care received at a health facility over the distance from their homes. Despite high OOPE being cited as a challenge to seeking healthcare, higher expenditure in return for better quality of care was a trade-off users were willing to make. The persistence of this pattern in NoP settings implies that the NoP initiative is highly relevant with its aims of improving care quality, decentralizing PHC further, and reducing OOPE. Patients prioritized good quality care. This includes the technical/clinical quality and good attitude and behavior of the staff. Surety of finding drugs, Patients reported the preference diagnostics, equipment, HR play a role. of health facilities closer to home, QUALITY OF however this was not evident in CARE health utilization data which indicated a higher preference of Affordability was not a driver for hospitals, higher use of transport HEALTH health facility selection, but high and consequent higher OOPE. FACILITY transportation cost, out of pocket SELECTION expenditure was reported across study districts. AFFORDABILITY PROXIMITY 2 – Sub-optimal referral gatekeeping A persistent pattern of lower tier health facilities making direct referrals to hospitals was reported in some settings by health providers in NoPs. This could be reflective of waning awareness on NoP referral guidelines owing to lack of regular training combined with attrition of already trained staff. It could also be an outcome of lack of sufficient resources/ capacity at the health centre as per norms. Referrals were frequently not patient centered and did not take into consideration aspects like transportation availability. 3 – Scope for improvement in health facility collaboration Collaboration between networked facilities and team-oriented working was reportedly better in Dormaa Central than Hohoe. Communication channels (WhatsApp) exist, but there are limited platforms beyond review meetings and CHMC meetings to share knowledge within health facilities and communities. Operational partnerships with private/ non-government sector were limited. 8 NETWORKS OF PRACTICE IN GHANA: LEARNING FROM IMPLEMENTATION IN TWO DISTRICTS Which Strategies Should be Adopted while Scaling-Up NoPs? Insights gained from studying seven NoPs and comparing to all is the underpinning of the NoP model. Five takeaways the health system utilization patterns in these NoPs with that from the research are shown in the figure below, adopting in non-NoP districts can be used to inform the ongoing which can lead to ownership of the intervention by the scale-up of NoPs across Ghana. Health system strengthening stakeholders and consequently a successful execution of and making all necessary services available and accessible the NoP model of primary health care. ENHANCED HR MONITORING & RESOURCING OF STRENGTHENING MAINTENANCE HEALTH CENTRES A strong team of health staff as per Regular review meetings of all Resourcing health centres with GHS norms to cater to all the needs facilities in a network to align on drugs, equipment, infrastructure as of hubs and spokes. Take into network functions, and ongoing per norms is imperative to ensure consideration need for district oversight to monitor optimal that they have the capacity to serve administrative support, outreach functioning is needed to ensure as referral centres for the lower tier work and referral. Regular clinical sustainability of interventions. facilities. This is a pre-requisite to and soft skills training and sessions implementing NoPs. on NoP guidelines are needed for smooth implementation. PATIENT CENTERED ADVOCACY MAPPING CAMPAIGN Mapping of networks should include A strong multi channel advocacy pharmacies, chemical shops, and campaign owned by the GHS and other traditional practitioners that implemented in partnership with all may be part of the patients’ pathways. health and non-health stakeholders Likewise, existing preference for must be conducted, targeting the certain clinics/CHAG facilities should public to increase awareness about be taken into consideration while the availability of services at the assigning hubs to reduce the need Hub level which are covered under for change management. their insurance. Conclusion The NoP districts exhibited heightened awareness of the hub- substantial systemic change that may take several years to fully and-spoke model of care, along with a demonstrated willingness implement. Continuous investment and ongoing mentoring of and evidence of cross-facility collaboration and resource facility-level providers by both district and national authorities sharing. This suggests that the NoP intervention signifies a will be necessary before the complete impact is realized. 9 World Bank 1818 H Street, NW Washington DC 20433 USA https://www.worldbank.org