We explored Ghanaian stakeholders’ perceptions of a multi-facetted community-based hypertension improvement initiative with task-sharing components. This paper presents and discusses several patient-level and contextual challenges associated with the implementation of the initiative – focusing on the management of hypertension and related NCDs. The findings have implications on the implementation of ComHIP and on the design of related task-sharing strategies in Ghana. Publicizing the findings not only shares implementation experiences, it also provides stakeholders an opportunity to appreciate and address identified challenges as they explore possibilities of scaling up this initiative.
Although, our data show that the ComHIP initiative is acceptable to patients and healthcare providers (Adler et al, forthcoming) – increasing providers’ knowledge on hypertension and patients’ awareness of same, the important challenges identified by both patients and providers are worth discussing. The key policy level challenges relate to task-sharing bottlenecks. Existing policy precluded lower-cadre services providers such as nurses from prescribing or dispensing antihypertensives, and LCS from stocking them. Medication adherence, side effects, and the phenomenon of medical pluralism in Ghana are other challenges. Although focused on the ComHIP intervention currently being implemented in one health district, views from national level stakeholders are reflected in this paper. Their perspectives enable elucidation of contextual and system-wide challenges such as a mismatch between prioritization of NCDs and funding NCD interventions by the Ghana health delivery system.
Ghana’s health service delivery system challenges and priorities
Like many LMICs, Ghana’s fragile health system is dealing with multiple burdens of disease as well as non-disease health system challenges. Thus, the emerging challenge of NCDs (whose impact on the health system is real) adds to existing layers of challenges that the country’s health system has to contend with. Ama de-Graft Aikins [
22] has recently discussed the impact of CVD on primary healthcare (PHC) services in urban poor communities in Ghana – laying bare the significant unmet need for CVD care in these communities. National level stakeholders in the current study acknowledged the growing challenge of NCDs. Like other countries in the sub-region, Ghana is experiencing rapid urbanisation, accompanied by increasing levels of obesity and related NCDs [
13,
23,
24]. Data from the Global Burden of Disease studies rank raised blood pressure/hypertension, high fasting plasma glucose, dietary risks, and high body mass index among the top 10 risk factors that drive the most death and disability combined. Thus, NCDs and their associated risk factors account for > 40% of total morbidity and adult mortality in Ghana. In recognition of the increasing burden of NCDs, Ghana has recently politically recognised NCDs as a pressing health concern, publishing national NCD prevention policies and strategies, which identify interventions to address them [
20,
21]. Closely related to the disease burden is the challenge of funding. Although there is a growing national recognition of NCDs, particularly hypertension, there is currently no commensurate funding response. Policymakers lament that the Ghana national NCD policy and its accompanying strategy have been in place since 2012, but their implementation has been suboptimal due to lack of requisite resources and funding.
To address this funding challenge, Ghana turns to donors or development partners who fund a significant fraction of the health budget [
25]. These development partners play critical roles in policy design, implementation, and funding decision-making. The policymakers we interviewed said that current funding priorities are maternal and new-born mortality, sanitation, malaria, and other infectious diseases. Thus, though NCDs are nationally recognized as a major public health challenge, they are not given priority with the necessary funds to address them. To respond to this high burden of NCDs, and yet low resources to address them, studies recommend health systems-wide strengthening, which has positive externalities on persons with NCDs, as well as their families, and communities [
26‐
28]. Such an approach is in line with the current ComHIP model.
Human resource and task-sharing challenges
That the Ghana healthcare delivery system is beleaguered with workforce challenges is not new and is not restricted to the domain of NCDs. Ghana currently has a one doctor to 10,450 patients ratio. This falls below the one doctor to 1320 patients WHO recommendation. All policy level informants reiterated the lack of required numbers of high calibre personnel as a major challenge. In particular, the distribution of the few qualified personnel is concentrated in a few major cities, leaving significant portions of the Ghanaian population to be attended to by low cadre health personnel. However, the problem is more serious for NCD service provision. As one moves from the few endowed urban facilities toward urban poor communities, healthcare services for NCDs, particularly CVDs, are generally not accessible, equitable, nor responsive to the needs of the vulnerable [
22].
In the midst of these challenges, lie opportunities to improve NCD prevention strategies, treatment and control in Ghana. For example, effective public-private partnerships (PPP), the deployment of technology, effective exploitation of the Community-based Health Planning Services (CHPS), and task-sharing provide important frameworks to improve NCD care. To help address this gap, the MOH and GHS in recent years have endeavoured to capacitate the CHNs through the strengthening of the CHPS initiative. Currently there are about 3000 CHPS compounds in Ghana, and this is projected to increase to 6000 by 2020. CHPS were originally formed to provide education to mothers, children and households. The CHNs overseeing CHPS compounds or zones have been trained to address key areas n community health (such as infectious disease preventative care and maternal and child health services). Similar training on NCDs can enhance capacity, confidence, self-efficacy to provide basic care and support to those in need. This approach has worked in other African countries such as Cameroon and South Africa [
29]. Recognizing the value of the ComHIP concept, some policymakers now see CHPS as a missed opportunity for the prevention of hypertension and NCDs . It is an attempt to bring integrated hypertension management into the community through a system of community education and hypertension screening by CHNs/CVD nurses’ referrals, and ICT support for participants. Prior to ComHIP the only possibility for accessing hypertension care in a typical Ghanaian health district was in hospitals by physicians. Given the low doctor-to-patient ratio, it is imperative that innovative methods of reorganising care – such as ComHIP – are utilised.
Notwithstanding this, the significant challenges encountered during ComHIP implementation need to be discussed. One of the challenges encountered relates to task-sharing (described as the process of enabling lay or low level healthcare personnel to fulfil a wider clinical role and used interchangeable with "task-shifting" in this paper), which has been acknowledged as a viable strategy for responding to CVDs and other NCDs in LMICs [
29‐
32]. Ogedegbe et al. [
33] in their systematic review of trials on task-shifting interventions for cardiovascular risk reduction in LMICs conclude that task-shifting strategies are appropriate and deployable in many LMICs battling with infectious and chronic diseases. The WHO, for example, recommends task sharing where access to health services is constrained by a lack of health workers [
34]. Other programmes in sub-Saharan Africa have found at least limited success when nurses were trained to manage hypertension (for example in DRC [
35], in Nigeria [
36], in Kenya [
37], and Ghana [
38]. In ComHIP, whilst results on the overall programme impact and cost effectiveness are still forthcoming, the data from this and earlier qualitative analysis (Adler et al.
forthcoming) suggest that various components of ComHIP including its task-sharing experiment was acceptable to patients and nurses involved in the programme.
However, the Ghana health policy at present does not permit nurses and other lower cadre health personnel to prescribe most medications including antihypertensives. Some of the policymakers we engaged in this study indicated the desire to expand who is able to prescribe medications. It would seem to us that this challenge is not particular to Ghana. The review by Ogedegbe et al. [
33] identified barriers to task shifting in LMICs as including policy gaps on medication prescription; weak or non-existent referral systems to take care of complicated cases and the inability of non-physician providers to manage uncomplicated CVDs and their risk factors [
33]. In the case of ComHIP, the inability of nurses to dispense antihypertensives was a major challenge. Perhaps, identified enablers of task-shifting such as continuous educational training and feedback from higher level health professionals; bridging hospital care to home care in order to ensure continuity of patient care; and providing explicit training tools including medication/treatment algorithms [
33] need to be exploited. At least two projects in Kenya and Ghana that allowed nurses to provide antihypertensives have shown promising results [
37,
38]. For instance, the Ghana study pilot-tested a task-shifting strategy for a hypertension study (TASSH), which trained community health nurses to deliver hypertension care. Although the nurses did not dispense antihypertensives because they did not have prescribing/dispensing power, they (nurses) had access to antihypertensives through the coordinating physician and could dispense them as needed based on the GHS hypertension treatment algorithm. Thus, the study was able to circumvent the legal limitations by having the coordinating physician supply the needed drugs to the nurses. While this project was successful, it does not fit into the current regulations within the GHS. In light of these findings, policies should be amended. Indeed, our study, and that by Iwelunmor et al. [
39], explore stakeholders’ perspectives of task-sharing as a strategy for preventing, and managing hypertension in Ghana. Both studies show that for any task-sharing intervention to be successful, a deliberate effort must be made to not only focus on patients, or individual level characteristics, but also to consider the role systems-level variables such as policy, leadership, and stakeholder engagement play.
Patient-level challenges including multiple understandings of illness and treatment and medical pluralism
Like many others in the sub-region, patients in Ghana have the opportunity to shop for healing from various systems/care providers: the allopathic health services delivery system, indigenous/traditional care delivery systems, as well as faith-based providers. Referred to as medical pluralism [
40] or more recently, medical diversity [
41], the use of multiple medical systems to address illness and wellness, has been praised and criticised at the same time [
42]. The medical sociology, and anthropological literature address the subject in-depth. Baer [
43] and Goldstein [
44] discuss its evolving nature, persistence, resurgence and concept contestations. We do not aim to interrogate the subject further. Instead, we focus on system-level factors that motivate concommittant use of traditional remedies and modern medicine in Ghana [
22,
45,
46].
As far as chronic disease care in Ghana is concerned, medical pluralism's contribution has begun to emerge [
47]. Hampshire [
45] interrogates medical pluralism in the context of globalization and new healing encounters in Ghana. For a long time, the practice of allopathy in Ghana is often framed to compete with alternative practices such as traditional/indigenous and faith-based healing [
22]. It is common practice for community members to bypass allopathic public health facilities and access care from these alternative providers or healers. Aside from inaccessibility challenges associated with allopathic healthcare, motivations for uptake of indigenous health remedies, include trust (of indigenous healers), proximity, ease of use, previous relationships, cost-value (sometimes) and poor perceptions of the level of competence of the low-cadre allopathic health workforce [
48,
49]. Awah and Phillimore [
50] explore and cast important light on the tension between clinic-based demands for patients’ ‘compliance’ with treatment guidelines, including repeated strictures against resorting to ‘traditional’ medicine, and patients’ own willingness to alternate between biomedical and indigenous practitioners.
Critics of indigenous medicine point out its implications for service uptake and adherence to allopathic care. In our study, potential barriers to uptake and adherence to antihypertensives relate to the belief that traditional medicines could cure patients' hypertension. Our exploration, which involved a wider group (patients, service providers, and policymakers), concurs with the findings of de-Graft-Aikins [
22], where the patients she engaged set out to seek a cure for their diabetes. Similar claims are rife in studies of other NCDs and in further African settings [
47]. We note that, until all care providers in this pluralistic healthcare system are made to understand that there is as yet no cure, this phenomenon of seeking cures for ‘incurable’ health conditions will continue. Therefore, programmes such as ComHIP may learn from these explorations of local approaches to care-seeking and medication by understanding patients’ priorities, motivations and preferences when designing interventions – seeing traditional solutions as complementary to, rather than competing against, allopathic medications. The popularity of traditional remedies among ComHIP clients is in line with data from previously reported local studies [
51,
52], where patients sought care from multiple outlets. For example, the Ghana Herbal Pharmacopoeia reveals that more than 70% of Ghanaians who receive allopathic care, also resort to alternative health care practices to address their health needs [
53]. Another local study linked such practices to Ghana’s religious landscape and political history [
52]. A relatively recent Ghanaian study reported prevalent use of non-prescription medications by persons living with HIV, a practice mostly self-initiated or implemented with the acquiescence of some healthcare providers [
51]. This phenomenon has been documented in other African settings [
54‐
57].
Like limited health workforce, limited funding, misprioritization, and restrictive prescribing policies, the phenomenon of medical pluralism is an important contextual challenge to the prevetion/treatment of hypertension and other NCDs in Ghana. The Ghana Food and Drug Authority, the Ghana Standards Authority, and other regulatory bodies need to institute robust monitoring and validation schemes that endorse or reject various healing options on the formal and informal health delivery platforms. Furthermore, efforts at improving the health literacy of the Ghanaian populace may help provide clarification on the effectiveness or otherwise of these healing options.
Study strengths and limitations
ComHIP is one of the few comprehensive studies which deploy a multilevel combination prevention-treatment-control intervention that engages (patients, community, and healthcare personnel), educates (patients and family), and uses supportive tools to increase hypertension literacy, service access, service uptake, and linkages to care.
This qualitative study involved all the actors and components of ComHIP. In doing so, it has been possible to identify enablers and bottlenecks to implementation and future scale up. The findings, however, need to be read along with the following limitations. First, the data presented in this paper derives from purposively sampled ComHIP stakeholders and thus precludes generalizability. It ought to be noted however, that, typical of qualitative inquiries, the study was not intended produce evidence generalizable to other settings. Second, although the qualitative research assistants were trained to handle courtesy bias or socially desirable responses on the part of all respondents, we are not able to wholly rule them out. Despite these limitations, this paper sheds light on important challenges to hypertension and other NCD prevention, treatment, and control in Ghana. These have the potential to inform research uptake, as well as provide guidance to similarly-designed interventions.