BackgroundWeak health information systems (HIS) are a critical challenge to reaching the health-related Millennium Development Goals because health systems performance cannot be adequately assessed or monitored where HIS data are incomplete, inaccurate, or untimely. The Population Health Implementation and Training (PHIT) Partnerships were established in five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) to catalyze advances in strengthening district health systems. Interventions were tailored to the setting in which activities were planned.Comparisons across strategiesAll five PHIT Partnerships share a common feature in their goal of enhancing HIS and linking data with improved decision-making, specific strategies varied. Mozambique, Ghana, and Tanzania all focus on improving the quality and use of the existing Ministry of Health HIS, while the Zambia and Rwanda partnerships have introduced new information and communication technology systems or tools. All partnerships have adopted a flexible, iterative approach in designing and refining the development of new tools and approaches for HIS enhancement (such as routine data quality audits and automated troubleshooting), as well as improving decision making through timely feedback on health system performance (such as through summary data dashboards or routine data review meetings). The most striking differences between partnership approaches can be found in the level of emphasis of data collection (patient versus health facility), and consequently the level of decision making enhancement (community, facility, district, or provincial leadership).DiscussionDesign differences across PHIT Partnerships reflect differing theories of change, particularly regarding what information is needed, who will use the information to affect change, and how this change is expected to manifest. The iterative process of data use to monitor and assess the health system has been heavily communication dependent, with challenges due to poor feedback loops. Implementation to date has highlighted the importance of engaging frontline staff and managers in improving data collection and its use for informing system improvement. Through rigorous process and impact evaluation, the experience of the PHIT teams hope to contribute to the evidence base in the areas of HIS strengthening, linking HIS with decision making, and its impact on measures of health system outputs and impact.

Introduction The COVID-19 pandemic has compounded the global crisis of stress and burnout among healthcare workers. But few studies have empirically examined the factors driving these outcomes in Africa. Our study examined associations between perceived preparedness to respond to the COVID-19 pandemic and healthcare worker stress and burnout and identified potential mediating factors among healthcare workers in Ghana. Methods Healthcare workers in Ghana completed a cross-sectional self-administered online survey from April to May 2020; 414 and 409 completed stress and burnout questions, respectively. Perceived preparedness, stress, and burnout were measured using validated psychosocial scales. We assessed associations using linear regressions with robust standard errors. Results The average score for preparedness was 24 (SD = 8.8), 16.3 (SD = 5.9) for stress, and 37.4 (SD = 15.5) for burnout. In multivariate analysis, healthcare workers who felt somewhat prepared and prepared had lower stress (β = -1.89, 95% CI: -3.49 to -0.30 and β = -2.66, 95% CI: -4.48 to -0.84) and burnout (β = -7.74, 95% CI: -11.8 to -3.64 and β = -9.25, 95% CI: -14.1 to –4.41) scores than those who did not feel prepared. Appreciation from management and family support were associated with lower stress and burnout, while fear of infection was associated with higher stress and burnout. Fear of infection partially mediated the relationship between perceived preparedness and stress/burnout, accounting for about 16 to 17% of the effect. Conclusions Low perceived preparedness to respond to COVID-19 increases stress and burnout, and this is partly through fear of infection. Interventions, incentives, and health systemic changes to increase healthcare workers’ morale and capacity to respond to the pandemic are needed.

BackgroundKangaroo mother care (KMC) is a safe and effective method of caring for low birth weight infants and is promoted for its potential to improve newborn survival. Many countries find it difficult to take KMC to scale in healthcare facilities providing newborn care. KMC Ghana was an initiative to scale up KMC in four regions in Ghana. Research findings from two outreach trials in South Africa informed the design of the initiative. Two key points of departure were to equip healthcare facilities that conduct deliveries with the necessary skills for KMC practice and to single out KMC for special attention instead of embedding it in other newborn care initiatives. This paper describes the contextualisation and practical application of previous research findings and the results of monitoring the progress of the implementation of KMC in Ghana.MethodsA three-phase outreach intervention was adapted from previous research findings to suit the local setting. A more structured system of KMC regional steering committees was introduced to drive the process and take the initiative forward. During Phase I, health workers in regions and districts were oriented in KMC and received basic support for the management of the outreach. Phase II entailed the strengthening of the regional steering committees. Phase III comprised a more formal assessment, utilising a previously validated KMC progress-monitoring instrument.ResultsTwenty-six out of 38 hospitals (68 %) scored over 10 out of 30 and had reached the level of ‘evidence of practice’ by the end of Phase III. Seven hospitals exceeded expected performance by scoring at the level of ‘evidence of routine and institutionalised practice.’ The collective mean score for all participating hospitals was 12.07. Hospitals that had attained baby-friendly status or had been re-accredited in the five years before the intervention scored significantly better than the rest, with a mean score of 14.64.ConclusionThe KMC Ghana initiative demonstrated how research findings regarding successful outreach for the implementation of KMC could be transferred to a different context by making context-appropriate adaptations to the model.

IntroductionPerson-centredness, including patient experience and satisfaction, is a foundational element of quality of care. Evidence indicates that poor experience and satisfaction are drivers of underutilisation of healthcare services, which in turn is a major driver of avoidable mortality. However, there is limited information about patient experience of care at the population level, particularly in low-income and middle-income countries.MethodsA multistage cluster sample design was used to obtain a nationally representative sample of women of reproductive age in Ghana. Women were interviewed in their homes regarding their demographic characteristics, recent care-seeking characteristics, satisfaction with care, patient-reported outcomes, and—using questions from the World Health Survey Responsiveness Module—the seven domains of responsiveness of outpatient care to assess patient experience. Using Poisson regression with log link, we assessed the relationship between responsiveness and satisfaction, as well as patient-reported outcomes.ResultsWomen who reported more responsive care were more likely to be more educated, have good access to care and have received care at a private facility. Controlling for respondent and visit characteristics, women who reported the highest responsiveness levels were significantly more likely to report that care was excellent at meeting their needs (prevalence ratio (PR)=13.0), excellent quality of care (PR=20.8), being very likely to recommend the facility to others (PR=1.4), excellent self-rated health (PR=4.0) and excellent self-rated mental health (PR=5.1) as women who reported the lowest responsiveness levels.DiscussionThese findings support the emerging global consensus that responsiveness and patient experience of care are not luxuries but essential components of high-performing health systems, and highlight the need for more nuanced and systematic measurement of these areas to inform priority setting and improvement efforts.

Background: Healthcare workers' (HCWs) preparedness to respond to pandemics is critical to containing disease spread. Low-and middle-income countries, however, experience barriers to preparedness due to limited resources. In Ghana, a country with a constrained healthcare system, we examined HCWs' perceived preparedness to respond to coronavirus disease 2019 (COVID-19) and associated factors. Methods: The 472 HCWs completed questions in a cross-sectional self-administered online survey. Perceived preparedness was assessed using a 15-question scale (Cronbach alpha = 0.91) and summative scores were created (range = 0-45). Higher scores meant greater perceived preparedness, with scores ≥ 30 considered prepared. We used linear regression with robust standard errors to examine associations between perceived preparedness and potential predictors. Results: About 27.8% of HCWs felt prepared to respond to COVID-19. The average perceived preparedness score was 24 (standard deviation = 8.9). In multivariate analysis, factors associated with higher perceived preparedness were: training (β = 3.35, 95% confidence interval [CI], 2.01-4.69); having adequate personal protective equipment (PPE; β = 2.27, 95% CI, 0.26, 4.29), an isolation ward (β = 2.74, 95% CI, 1.15, 4.33), and protocols for screening (β = 2.76, 95% CI, 0.95, 4.58); and good perceived communication from management (β = 5.37, 95% CI, 4.03, 7.90). When added to the model, perceived knowledge decreased the effect of training by 28.0%, although training remained significant, suggesting a partial mediating role. Perceived knowledge was associated with a 6-point increase in perceived preparedness score (β = 6.04, 95% CI, 4.19, 7.90). Conclusion: HCWs reported low perceived preparedness to respond to COVID-19. Training, clear protocols, PPE availability, isolation wards, and communication play an important role in increasing preparedness. Government and other stakeholders must institute interventions to increase HCWs' preparedness to respond to the ongoing pandemic and prepare for future pandemics.

Women in many sub-Saharan African countries are at elevated risk of depression during pregnancy. However, there are still gaps in the estimates of antenatal depression and associated risk factors in very low-resource settings such as Northern Ghana. This study describes the prevalence of depression among rural pregnant women, participating in a maternal and child health program, in Ghana, and examines associated risk factors for depression. Pregnant women who were registered for group-based maternal and child health community programs were recruited for study participation from 32 communities in two rural districts in Northern Ghana (n = 374). Baseline surveys were conducted and depression was assessed using the Patient Health Questionnaire (PHQ-9). Bivariate and multivariable analyses used a modified Poisson and generalized estimating equations (GEE) model. Of the women in our study population, 19.7% reported symptoms indicative of moderate to severe depression (PHQ-9 score ≥ 10), with 14.1% endorsing suicidal ideation in the last 2 weeks. Bivariate analyses revealed that lower hopefulness, moderate and severe hunger, experiences of emotional, physical, and/or sexual intimate partner violence (IPV), and insufficient social support from female relatives were associated with symptoms indicating moderate to severe depression. In the multivariable analyses, low hopefulness, household hunger, emotional IPV, physical and/or sexual IPV, and insufficient female relative support remained significantly associated with depression. Antenatal depression is associated with unmet basic needs and safety. Perinatal mental health programming must take an ecological perspective and address personal, familial, and community-level factors.

In the first years of the new century, the Ministry of Health/Ghana Health Service determined to reduce abortion‐associated morbidity and mortality by increasing access to safe care. This was accomplished by interpreting Ghana's restrictive law so that more women qualified for legal services; by framing this effort in public health terms; by bundling abortion together with contraception and postabortion care in a comprehensive package of services; and by training new cadres of health workers to provide manual vacuum aspiration and medical abortion. The Ministry of Health/Ghana Health Service convened medical and midwifery societies, nongovernmental organizations, and bilateral agencies to implement this plan, while retaining the leadership role. However, because of provider shortages, aggravated by conscientious objection, and because many still do not understand when abortion can be legally provided, some women still resort to unsafe care. Nonetheless, Ghana provides an example of the critical role of political will in redressing harms from unsafe abortion.

Adequate supervision is critical to maintain the performance of health workers who provide essential maternal and child health services in low-resource areas. Supportive supervision emphasizing problem-solving, skill development and mentorship has been shown to improve the motivation and effectiveness of health workers, especially at the community level, but it is not always routinely provided. Previous studies have assessed the uptake of supportive supervision among volunteer health workers and paid health centre staff, but less is known about the supervision experiences of paid community-based staff, such as community health nurses (CHNs) in Ghana. This mixed-methods study explores the frequency and content of CHN supervision in five districts in the Greater Accra and Volta regions of Ghana. We analysed quantitative data from 197 satisfaction surveys and qualitative data from 29 in-depth interviews (IDIs) and four focus group discussions (FGDs) with CHNs. While the majority of CHNs received supervision at least monthly, they reported that supervision was primarily focused on meeting clinical targets (48%) rather than on handling specific cases or patients (23%). Over a third (34%) of CHNs did not agree that supervisors help them with job-related challenges and nearly half (43%) were unsatisfied with their jobs. When asked about their mentorship needs, CHNs reported wanting feedback on how to improve their job performance (40%) and encouragement (30%). There were only slight variations in the frequency and content of supervision based on type of supervisor. During IDIs and FGDs, CHNs offered ideas for how to improve supervision, including more frequent field visits so that supervisors could see the on-the-ground realities of their work, greater respect and positive reinforcement. Overall, CHN motivation and job satisfaction may be strengthened by aligning supervision more closely with the principles of supportive supervision.