Maximizing Access to Essential Medicines for Church Health Services and their clients in Ghana

Publication date: 2005

MAXIMIZING ACCESS TO ESSENTIAL MEDICINES FOR CHURCH HEALTH SERVICES AND THEIR CLIENTS IN GHANA Baseline Study for Ghana, December 2005 A collaborative study by the Catholic Drug Centre (CDC) and the Ecumenical Pharmaceutical Network (EPN) Researchers: ƒ Issac Annan, Head, Catholic Drug Centre ƒ Stephen Essuman, Head, Diocesan Hospital Pharmacy Sunyani Support consultant: ƒ Heather Budge-Reid <heatherbr@kclinfo.com> Maximizing access to essential medicines for church health services and their clients Ghana baseline study – executive summary This report of results provides the baseline for compliance with the ‘EPN guidelines’ in Ghana, and respondents represent over 2,545 beds and 694,500 outpatients. Faith-based health services in Ghana provide approximately 40% of the available health care. Church health service facilities number 56 hospitals and 83 clinics. Nine hospitals were visited for guided self-assessment workshops and focus groups. A self-assessment survey resulted in a 41% response rate from church health service facilities. Overall conclusions Taking into account the results from all the tools used, the overall trend for church health services in Ghana appears to be one of improvement. Good results were seen in a number of areas: • Government support for church health services (although it seems that some facilities are not taking up the opportunity of having salaries paid). • Information sharing and representation opportunities indicate that there is a good degree of integration between the government and church health services. • Good community involvement (although this could be improved at some hospitals where there is a link between lack of community involvement and a perception of poor staff– patient relations and nepotism). Where community links are strong, links to church leaders are also strong. • A functioning drug supply system is in existence. • High levels (compared with other African countries) of pharmacists, pharmaceutical technicians, and pharmaceutical assistants per hospital. On the more worrying side, the baseline does not cover the North of the country very well (an area understood to face bigger problems in health and health services) and there appear to be problems for a number of ‘guidelines’ even in the southern and central areas. • Only 50% of hospitals have a functioning DTC. • A large number of hospitals accept medicines donations, but there is almost no adherence to drug donation guidelines. • There is relatively low level of implementation of standard operating procedures, and while the main drug supply organizations do use SOPs, this is not reflected in the health services. • There appears to be almost no training of hospital board members in the issues and possibilities of their decision-making. • Health facilities themselves identified poor management and staff training as key problem areas that affect services. Lack of financial resources acted as a cause and an effect of these problems and thus a vicious circle is identified, whereby a lack of funds prevents a facility from improving itself in order to improve revenues and funding. CDC/EPN —Ghana baseline survey–summary— Page 2 Figure 1: ‘EPN Guideline’ compliance in Ghana1 EPN Guideline profile in CHSs in Ghana 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Disaster preparedness procedures in place Pharmaceutical function represented at all levels of discussion Church leaders' awareness of key messages [7] Regular assessment of pharmaceutical unit work [6] Access to key pharmaceutical information [5] At least one pharmaceutically-trained nurse per institution [4] At least one pharmaceutical assistant per institution At least one pharmaceutical technician per institution At least one pharmacist per institution Representation at regional and national levels in relevant debates Compliance with drug donations guidelines Cross-institutional information sharing Effective community involvement system in place Transparency mechanisms in place in support of 'Health for All' Tax exemptions available to CHSs Pro-poor ethic in evidence Government subsidies extended [3] Pricing policies in place and operationalized Quality assurance policy in place and implemented Access to medicines for an institution passed on to patients Implementation of standard operating procedures for procurement All 'owners' with maximum understanding [2] Functioning Drug and Therapeutics Committees (DTC) in hospitals Functioning medical supply system [1] Compliance with rational use of medicines 'guidelines' Compliance with best practices for drug storage and management 23 22 21 20 19 18 d 18 c 18 b 18 a 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 [Full im plem entation] 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% [1] Yes, but there is room for improvement in several areas. [2] Although focus groups indicated some knowledge, only one hospital trained its board. [3] 85% of respondents get a salary subsidy from the government, which is available to all CHSs. [4] Given the high numbers of other qualified staff, the low number of trained nurses is not significant here. [5] Availability of information varies, with few facilities having a full selection of documents [6] 58% said yes but only 42% gave a frequency of more than once a year [7] High awareness of issues and suggested solutions was shown in focus group discussions. 1 A zero value shows that no facility was found that complied with that EPN guideline – it is possible that a facility does exist, but was not surveyed. Thus, a zero value only indicates a very low number of compliant facilities. A ‘no’ value indicates that something does not exist on a national scale. CDC/EPN —Ghana baseline survey–summary— Page 3 Church health services (CHSs) The government offers subsidies to church health services for the payment of salaries of professional medical staff and tax exemption on medicines. It also reimburses costs for delivery of babies (making treatment free to mothers) and some facilities appeared to respond that health costs for children under five and adults over 70 were also reimbursed by the government. In recent months the Health Insurance Scheme has been helping to address problems of reimbursement. The government also contributes approximately USD 200,000 per year towards CHS infrastructure development. All pharmaceutical personnel are trained through publicly-funded institutions. CHSs, through CHAG, have contributed to debate around the national health insurance scheme, to ensure that it does not disenfranchise the poor nor collapse district-level mutual schemes. They have also lobbied for a better understanding between government and church health services, resulting in the signing of an Memorandum of Understanding in 2003. CHS staff have also been involved in regional and national debates around issues such as a new malaria policy and stakeholders in health. Ghana has a strong DSO sector, including government, faith-based, and commercial organizations. On the faith-based side, the Catholic Drug Centre also works closely with three Diocesan Hospital Pharmacies to supply and distribute medicines. Medicines management • The government and church-related DSOs experience stock outs of 10–20% of essential medicines, which is significantly more than the commercial DSOs. • Expired stock is generally cleared out regularly, although the government-run Central Medical Stores states this is done once per year. All responding DSOs use bin and stock cards. • Responding DSOs all have written SOPs for procurement and receiving delivery of medicines, and a quality assurance policy in place. This is in strong contrast with most of their customers in the church health services. Pricing All DSOs claim that pricing policies are in place, but most were unable to state that they have a documented pricing policy (formula and accounting process, and accounting for windfalls), although price lists are in evidence. The ‘EPN Guidelines’ project is part of the EPN programme entitled ‘Maximizing access to essential medicines for church health services and their clients’. The first phase of the project identifies the baseline in each ‘EPN guideline’ area and feeds this information back to an in-country group that can then decide which ‘EPN guidelines’ should be prioritized and what further work should be undertaken. The baseline is drawn from the use of four tools: church health service self-assessment survey; guided desk review; guided self-assessment workshop and focus group; and drug supply organization self- assessment survey. A full report is available from EPN – Dr. Eva Ombaka, epn@wananchi.com, http://www.epnetwork.org EPN is an independent, apolitical, non-profit Christian organization that works in a situation of increasing poverty and need for health services. Trend analysis A spider diagram was developed by each hospital for the self-prioritized factors affecting the hospital. Scores were allocated for each factor “as it is now” and “as it was 3–5 years ago”. As a result, it is possible to see which are the key factors and their trend over time. This is an important part of the effort to identify the baseline and a trend analysis. CDC/EPN —Ghana baseline survey–summary— Page 4 Overall combined spider diagram for Ghana Availability of medicines Finances Geo- graphical access Personnel Quality of medicines Affordability of medicines Cultural beliefs Inventory management 3-5 years ago 2005 Best situation A system of effective community involvement – from focus group work There is an interesting link between community involvement and positive perceptions of the facilities. Six focus groups described a significant level of community involvement. ƒ We usually work hand-in-hand with the hospital. ƒ The community periodically provides communal labour on hospital premises, at least twice a year. ƒ The youth in the community have provided security in the event of threats of armed robbery attacks. ƒ The church periodically donates blood to the hospital. There is significant respect for hospital staff, their treatment of patients, their availability in emergencies, and the lack of nepotism. ƒ The services are about the best. ƒ Staff are hard working and caring. ƒ There is a committed hospital team. ƒ Staff are very caring and friendly. ƒ There are always doctors on night duty. ƒ Attendance is sometimes as high as five hundred people per day, yet the hospital staff respond to them all. ƒ Prescriptions are always fulfilled. ƒ Patients do not have to pay extra money to get treated well and are treated efficiently without hurrying through the processes. ƒ Nepotism is not observed in their service delivery – even if it is present, it is negligible. ƒ Staff are dedicated and are not involved in any suspicious activities. Three focus groups described a lack of community involvement These groups also showed less understanding of the issues and poorer perceptions of services. ƒ There is a perceived lack of respect for the people in the community by hospital staff. ƒ Hospital staff often shout at them. ƒ Even when the community embarks on communal labour and a member sustains any injury, he is made to bear the cost of treatment. Hence, the community is no longer willing to undertake such activities. ƒ The community feels the hospital is neglecting their social responsibility by not allowing the school children to drink from their well. ƒ No opportunity to register concerns, i.e., no suggestion box. It has long been removed. With these groups, the perception is that staff do not care about the people, treatment is slow and substandard even in emergencies, others may get treated in preference, and medicines do not work. ƒ Hospital staff are known not to give the best services to patients. ƒ Favouritism in treatment of patients by nurses. ƒ Leaking of information on patients to community. ƒ Drugs given to patients mostly do not work because most patients complain even after treatment. ƒ The community believes that there are a lot of bureaucratic bottlenecks at the hospital. CDC/EPN —Ghana baseline survey–summary— Page 5 Overall conclusions Church health services (CHSs) Medicines management Pricing Trend analysis A system of effective community involvement – from focus group work

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