Health Systems Effectiveness for Malaria Treatment in Health Facilities in Kintampo North and South Districts of Ghana

Abstract

Background: The 21st century has witnessed more efficacious and effective health interventions than ever, yet the proportion of effective coverage of these interventions remain poor. The interconnectedness of the health system is central for an effective delivery of interventions. Delivering malaria interventions to achieve desired health system effectiveness has remained a challenge without the understanding of the contribution of each building block indicator to effectiveness. Efficacious ACTs and the test-treat-track policies have been implemented in Ghana. However, the contribution of building blocks interaction to the overall health systems effectiveness of malaria treatment is less known in Ghana in the era of ACTs and measuring the effect of the health system effectiveness indicators on these policies are also unclear. This study seeks to measure effectiveness of the health system to deliver ACT through the interaction of building blocks to establish the building blocks that strengthen or weaken the delivery of malaria treatment. The study will assess the health systems effectiveness in malaria treatment in the Kintampo North and South districts of Brong Ahafo region. Identifying and understanding these context specific health system factors may contribute to the delivery of effective malaria treatment in Ghana. Methods: The design of this study was an analytical cross-sectional using a mixed method approach. The qualitative and quantitative approaches were used to gather primary and secondary data for this study. The secondary data involved two sets of survey data; first from the In-depth Network effectiveness studies of Anti-malarials in Africa project (INESS) data gathered in 2011. Secondly, data from routine District Health Information System with gray literature on published malaria data. The INESS data gathered information by modules through surveys on 1) care-seeking and prompt access to malaria treatment with a sample size of 1222 participants, 2) Diagnostic targeted of suspected malaria cases tested and 3) provider compliance to malaria treatment with a combined survey sample of 762 patients and 4) adherence of patients to recommended malaria treatment with a sample size of 400 patients. Routine health facility data was also gathered on similar modules such as routine utilization data on malaria, laboratory confirmed malaria, treatment provided through malaria drug stocks at the facility at the time of this study to establish possible trends in diagnosis and compliance from 2012 to 2017 after the 2011 INESS surveys were conducted. Records were gathered from 30 health facilities. Routine data was obtained from the District Health Information Management System 2 (DHIMS 2). Primary data was then gathered qualitatively among managers in health facilities and at the district/municipal health directorates to understand the health system challenges from health managers’ perspectives based on the six World Health Organization (WHO) health system building blocks that could affect the health systems effectiveness in delivering an efficacious ACT drug through the routine health system. Sixteen in-depth interviews were conducted with the health managers. The statistical software STATA version 14 was used to analyze data and to generate descriptive and inferential statistics to explain the determinants of health system effectiveness in delivering efficacious ACTs. Principal Component Analysis was used to determine trends in systems effectiveness and the impact of the various building blocks indicators in systems effectiveness for malaria treatment. Results: Presenting the results by module, analysis of 1219 patients with fever in households were interviewed in the care-seeking and prompt access to malaria treatment module in the INESS study showed only 55.9% (682/1219) sought care from formal or appropriate and recommended care provider. Only 7.7% (94/1219) of the participants who had fever had access to ACTs within 24 hours of fever onset. Malaria diagnostic tests were carried out for only 39.2% (303/762) of patients who were suspected to have malaria at the health facility in the targeting and accuracy module. In the provider compliance to malaria treatment module, 61.1% (102/167) of patients confirmed to have malaria were provided with ACT treatment as recommended. In the patient adherence module, close to half 48.0% (189/377) of patients adhered completely to treatment regimen. Systems effectiveness for malaria treatment in the study area in the INESS 2011 survey was as low as 6.3% which is far from the projection of 65% effective access ACT in routine health care systems. Thus though ACT was 98% efficacious in 2011, the system was able to treat only 6.3% of patients effectively. An increase to 29.3% was observed in 2017. The routine health care data showed an increase in diagnostic targeting from 32% in 2012 to 94.5% in 2017 and provider compliance from 24.3% to 92.3% over the same period. The principal component analysis however, showed an increasing trend in the systems effectiveness to treat malaria which was from a score of 0.478 in 2012 to a score of 1.401 in 2017 with diagnostic targeting and provider compliance scores being the highest contributors to systems effectiveness for malaria treatment. Results from the qualitative interviews showed that health providers were well informed in terms of policy guidelines of the test, treat and track as management tool, diagnostic supplies had improved in the area of Rapid Diagnostic Test supplies for diagnostic targeting. The health managers also reported that the health workforce situation had also improved. Health information management had improved with the online DHIMS 2 and availability of information on confirmed malaria cases for management decision making had improved. Service delivery by way of tests being conducted to confirm malaria before treatment was also observed. In the area of health care finance, inadequate funding and undue delays in health insurance re-imbursements which happened to be the main source of health financing were the challenges encountered. Conclusion: The Systems effectiveness to treat malaria is still low in routine health care settings despite an efficacious ACT. However, the substantial improvement in diagnostic targeting and provider compliance indicators for the technology and leadership and governance building blocks for malaria treatment over the 2011 INESS survey demonstrates the effect of the implementation of the test treat and track policy. These two building blocks are strengthening the health system to deliver malaria treatment. Strategies to improve systems effectiveness in malaria treatment should focus on service delivery building block on care-seeking and prompt access and patient adherence which remain low.