Supplement article
Research
Capacity assessment of selected health care facilities for 
the pilot implementation of Package for Essential Non-
communicable Diseases (PEN) intervention in Ghana
Kofi Mensah Nyarko1,2,&, Donne Kofi Ameme1, Dennis Ocansey2, Efua Commeh2, Mehitabel Tori Markwei3, Sally-Ann Ohene4
1Ghana Field Epidemiology and Laboratory Training Programme, School of Public Health, University of Ghana, Box LG 13, Legon, Accra, Ghana, 
2Disease Control and Prevention Department, Ghana Health Service, Box KB 493, Korle-Bu, Accra, Ghana, 3Yale University, New Haven, USA, 4World 
Health Organization, Ghana Country Office Box MB 42, Accra, Ghana
&Corresponding author: 
Kofi Mensah Nyarko, Ghana Field Epidemiology and Laboratory Training Programme, School of Public Health, University of Ghana, Box LG 13, 
Legon, Accra, Ghana
Cite this: The Pan African Medical Journal. 2016;25 (Supp 1):16. 
DOI: 10.11604/pamj.supp.2016.25.1.6252
Received: 02/02/2015 - Accepted: 07/02/2015 - Published: 01/10/2016
Key words: Capacity assessment, Non-Communicable Diseases, WHO-PEN, Ghana
© Kofi Mensah Nyarko et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons 
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original 
work is properly cited.
Corresponding author: Kofi Mensah Nyarko, Ghana Field Epidemiology and Laboratory Training Programme, School of Public Health, University of Ghana, Box LG 13, 
Legon, Accra, Ghana (konyarko22@yahoo.com)
This article is published as part of the supplement “Strengthening Surveillance, Outbreak Investigation and Response: the Role of 
Ghana FELTP” sponsored by GHANA Field Epidemiology and Laboratory Training Program
Guest editors: Donne Kofi Ameme, Kofi Mensah Nyarko
Available online at: http://www.panafrican-med-journal.com/content/series/25/1/16/full
Abstract
Introduction: non-communicable diseases (NCDs) continue to pose threats to human health and development worldwide. Though preventable, 
NCDs kill more people annually than all other diseases combined. The four major NCDs namely cardiovascular diseases, chronic respiratory diseases, 
diabetes and cancers share common modifiable risk factors. In order to prevent and control NCDs, Ghana has adopted the World Health Organisation 
Package for Essential NCD (WHO-PEN) intervention, to be piloted in selected districts before a nationwide scale-up. We assessed the capacity of these 
facilities for the implementation of the WHO-PEN pilot.
Methods: we conducted a cross-sectional health facility-based survey using a multistage sampling technique. We collected data on human resource, 
equipment, service utilization, medicines availability and health financing through interviews and observation. Descriptive data analysis was performed 
and expressed in frequencies and relative frequencies.
Results: in all, 23 health facilities comprising two regional hospitals, three district hospitals, nine health centres and nine Community-based Health 
Planning and Services (CHPS) compounds from three regions were surveyed. All the hospitals had medical officers whilst 4 (44.4%) of the health 
centres had physician assistants. Health financing is mainly by the National Health Insurance Scheme (NHIS). None of the health facilities had spacers 
and only one health centre had oxygen cylinder, glucometer and nebulizer.
Conclusion: gaps exist in the human resource capacity and service delivery at the primary care levels, the focus of WHO-PEN intervention. Adequately 
equipping the primary health care level with trained health workers, basic equipment, medications and diagnostics will optimize the performance of 
WHO-PEN intervention when implemented.
The Pan African Medical Journal. 2016;25 (Supp 1):16   |   Kofi Mensah Nyarko et al. 1
Introduction Gonja District in the Northern region representing the Northern zone, Dormaa District in the BrongAhafo region representing the middle zone 
Non-communicable diseases (NCDs) continue to be a major public health and Upper Manya district in the Eastern region representing the Southern 
problem worldwide posing threats to human health and development. zone of Ghana.
They are the leading cause of death worldwide killing more than 36 mil-  
lion people each year [1,2]. The four major NCDs namely cardiovascu- Selection of health facilities 
lar diseases (CVDs), chronic respiratory diseases (CRD), diabetes and The health system is organized at different levels from the lowest level 
cancers kill more people each year than all other diseases combined of care called the Community-based Health Planning and Services 
[3]. The bulk of the mortality burden falls disproportionately on low and (CHPS) compound which are manned by Community health nurses, 
middle-income countries where nearly 80% of all NCDs deaths and 90% through health centres which are manned by medical assistants, then 
of all deaths before age 60 years attributed to NCDS occur [1]. These district hospitals which are manned by medical officers and provide 
premature deaths deprive nations of economically active population. The general medical services, regional hospitals which provide some level 
economic impact is therefore substantially greater for low and middle-in- of specialized services and the teaching hospitals. Each region has one 
come countries (LMICs) because working-age adult accounts for the bulk regional hospital. There are three teaching hospitals, one in each zone. 
of the NCD burden. In sub-Saharan Africa, NCDs are projected to be the Approximately 58% of the population live within 30 minutes of a health 
commonest cause of death by 2030 [1, 3–5]. In Ghana, NCDs contribute facility with urban households having better geographical access (78.5%) 
significantly to the morbidity and mortality. Prevalence of hypertension compared to their rural counterparts (42.3%) [12].
in adults is between 24 % and 48% [6] whilst prevalence of diabetes  
in major cities is between 6%-9% [7, 8]. Also, NCDs kill an estimated In each of the selected regions, the regional hospital was purposively 
78,000 persons in Ghana annually, representing 354 deaths per 100,000 selected to reflect facilities with high caseload, high cadre of personnel 
population [1]. and advanced case-management skills. In each of the selected districts, 
the district hospital was selected in addition to three health centres and 
WHO estimates that up to 80% of NCDs are preventable through life- three Community-based Health and Planning Services (CHPS) zones in 
style changes [3]. The four most common NCDs (CVD, cancers, CRD, order to reflect the referral system. The health centres and the CHPS 
and diabetes) share modifiable risk factors namely tobacco use, physical zones were purposively selected based on their distances from the district 
inactivity, harmful use of alcohol and unhealthy diets [1]. Effective pri- hospital which served as the main referral centre in the district: one near 
mary prevention strategies exist and require risk assessment and man- and one far from the hospital and a third one in between these two.
agement. Though risk assessment and clinical decision support tools are  
readily used in high-income settings, these are hardly replicable in low Data collection
resource settings. The WHO-PEN intervention has been developed as a  
risk management package for NCDs to facilitate multiple risk factor as- The assessment had approval of the authorities of the Ghana Health Service 
sessment and treatment in low resource settings [9]. as part of the responsibilities of the NCD Control Programme. Permission 
 was also sought from the respective Regional Health Directors, District 
The WHO-PEN intervention is a prioritized set of cost-effective interven- Directors of Health Services as well as the medical directors and heads 
tions that provides clinical decision support for assessment and manage- of the health facilities. All of them willingly agreed for their facilities to be 
ment of NCDs at the primary care level in low resource settings [9]. It is included for data collection. Trained health workers collected data from 
designed to use cost-effective interventions for early detection, preven- each of the selected districts through a combination of self-administered 
tion and treatment of the major NCDs namely heart attacks and strokes, questionnaires and interviews. The authorities of the facilities and key 
diabetes, cancer, renal diseases and asthma. The package uses simple personnel who could provide information were trained and given self-
algorithms to stratify patients’ risk status based on age, clinical history, administered questionnaires to obtain information on human resource, 
comorbidities and blood pressure for care. Adaptation of WHO-PEN inter- infrastructure and equipment, service utilization, referrals, medicines and 
vention for primary healthcare level in Ghana has been suggested [10] health financing. The survey team reviewed the completed questionnaires 
with the expectation of reducing hospital admissions related to NCDs. with the respondents to ensure that the questionnaires were properly 
 filled. Where necessary, the responses to the questions were validated 
Ghana has therefore adopted this tool with a strategy of piloting it in by observation and inspection of the facilities. A rapid assessment tool 
selected health facilities and ultimately scaling up to cover the whole for primary healthcare facility capacity assessment for NCDs was adapted 
country. Since the successful implementation of this intervention will and used for data collection. All the facilities, except one regional hospital 
largely depend on the readiness of the health facilities, there is the need returned the completed questionnaire.
to determine the capacity of the health facilities in order to identify exist-  
ing and potential gaps that may hamper the smooth deployment of the Data processing and analysis 
package. Our study therefore responded to this need with the objec- We performed descriptive statistical analysis and expressed categorical 
tive of assessing human resource capacity, equipment, service utilization, variables as frequencies and relative frequencies. Data was entered 
medicines availability and health financing. cleaned and analysed using Epi Info version 7.
 
Methods Results
Design and setting In all, 24 health facilities from the three regions were surveyed. These 
include two regional hospitals, three district hospitals, nine health centres 
We conducted a cross-sectional health facility-based survey from 9th June and nine CHPS. Table 1 shows a breakdown of the health facilities 
to 28th June 2013 in three districts in Ghana, a West African country with included in the survey by ownership and setting. Majority 21 (92.0%) 
a population of 24,658,823 [11]. Ghana covers a land size of 238,533 of the health facilities were owned by the government of Ghana. Two 
square kilometres with a population density of 103 per square kilometre. were owned by not-for-profit faith-based organisations but supported by 
It is bounded to the north by Burkina Faso, east by Togo and west by government and therefore considered quasi-governmental.
Ivory Coast. The national capital, Accra, is located in the Greater Accra 
region. Administratively, the country is organized into regions, which are 
sub divided into districts, municipalities, or metropolitan areas based 
on their populations. At present there are 10 regions, 216 metropolis, Table 1: characteristics of the surveyed health facilities, Ghana, 2013 Facility Type
municipalities and districts. The ten regions of Ghana were zoned into Characteristics CHPS Health Centre District Hospital Regional
three namely southern, middle and northern zones based on their Hospital n = 9 n = 9 n = 3 n = 2
geographical location. In each of the zones, one region was randomly Ownership     
selected. Three regions namely, Eastern Region, BrongAhafo Region Public 9 8 1 2Private 0 0 1 0
and Northern Region were randomly selected to represent the southern, Quasi­ government 0 1 1 0
middle and northern zones respectively. In each of the selected regions, Setting     Rural 9 7 0 0
one district was randomly selected as the study site as follows: West Urban 0 2 3 2
 
2 The Pan African Medical Journal. 2016;25 (Supp 1):16   |   Kofi Mensah Nyarko et al.
Human resource Table 4: availability of selected essential medicines in surveyed facilities, Ghana, 2013
 
 Health Facility TypeAll the CHPS compounds have at least a trained nurse or health assistant Selected Essential CHPS Health District Regional
manning them. At the health centres however, four (44.4%) out of the nine Medicine Centre Hospital Hospital
had medical assistants. Trained nurses, mostly midwives, were managing n(%) n(%) n(%) n(%)Adrenaline injection 2(22.2) 4(44.4) 3(100.0) 2(100.0)
the rest. All the district hospitals had at least one medical officer in Aspirin 9(100.0) 5(55.5) 3(100.0) 2(100.0)
charge. The regional and teaching hospitals had physician specialists and Atenolol/Beta blockers 0(0.0) 1(11.1) 3(100.0) 2(100.0)
other specialist doctors delivering care. Other categories of staff working Beclomethasone inhaler 0(0.0) 0(0.0) 2(66.7) 2(100.0)Bendrofluazide 0(0.0) 1(11.1) 3(100.0) 2(100.0)
in all the primary health care setting included laboratory technicians, Benzathine Penicillin 5(55.6) 6(66.7) 3(100.0) 2(100.0)
pharmacy assistants or dispensing technicians, and community and Enalapril/ Lisinopril 0(0.0) 1(11.1) 3(100.0) 2(100.0)
public health nurses. In 5 out of the 9 (56%) health centres, there were Erythromycin 9(100.0) 3(33.3) 3(100.0) 2(100.0)Furosemide 0(0.0) 3(33.3) 3(100.0) 2(100.0)
health promoters who were involved in giving health education in the Glibenclamide 0(0.0) 1(11.1) 3(100.0) 2(100.0)
communities through house-to-house and other engagements such as Hydrocortisone (injection) 8(88.9) 8(88.9) 3(100.0) 2(100.0)
school and church programmes. Insulin (long acting) 0(0.0) 0(0.0) 2(66.7) 2(100.0)Insulin (soluble) 0(0.0) 0(0.0) 3(100.0) 2(100.0)
Ipratropium bromide 0(0.0) 0(0.0) 0(0.0) 1(50.0)
Equipment and diagnostics Isosorbidedinitrate 0(0.0) 0(0.0) 2(66.7) 2(100.0)
 Statins 0(0.0) 0(0.0) 1(33.3) 2(100.0)
Basic equipment for managing NCDs were not readily available in most of Metformin 0(0.0) 1(11.1) 3(100.0) 2(100.0)
the health facilities particularly the primary health care level. None of the Calcium channel blockers 6(66.7) 4(44.4) 3(100.0) 2(100.0)
CHPS centres had functional glucometers, oxygen cylinders or nebulizers Sodium chloride infusion 7(77.8) 9(100.0) 3(100.0) 2(100.0)Phenoxymethyl Penicillin 0(0.0) 4(44.4) 2(66.7) 2(100.0)
and only 1 out of the 9 (11%) health centres had these equipment. There Prednisolone 1(11.1) 3(33.3) 3(100.0) 2(100.0)
was no functional spacer in any of the health facilities (Table 2). All the Salbutamol inhaler 0(0.0) 4(44.4) 3(100.0) 2(100.0)
facilities had functional blood pressure measuring devices (BPMD) as well Salbutamol tablet 3(33.3) 7(77.8) 3(100.0) 2(100.0)Salbutamol injection 0(0.0) 0(0.0) 2(66.7) 2(100.0)
as weighing scales. Diagnostic tests were virtually non-existent in the Paracetamol 9(100.0) 9(100.0) 3(100.0) 2(100.0)
CHPS compounds and the health centres. With the exception of serum Ibuprofen 9(100.0) 9(100.0) 3(100.0) 2(100.0)
troponin levels for ischaemic heart disease, the regional hospitals have all Codeine 0(0.0) 0(0.0) 1(33.3) 2(100.0)Morphine (oral) 0(0.0) 0(0.0) 0(0.0) 2(100.0)
the basic diagnostic tests (Table 3). Morpine (injection) 0(0.0) 0(0.0) 1(33.3) 2(100.0)
 Glyceryltrinitrate 0(0.0) 0(0.0) 0(0.0) 2(100.0)
The two regional hospitals had almost all the essential medicines for Heparin 0(0.0) 0(0.0) 3(100.0) 2(100.0)Amoxycillin 9(100.0) 9(100.0) 3(100.0) 2(100.0)
managing NCDs (Table 4). The CHPS compounds and the health centres Cotrimoxazole 9(100.0) 9(100.0) 3(100.0) 2(100.0)
lacked most of the drugs. Glucose injectables were lacking in some of the Promethazine injection 7(77.8) 7(77.8) 3(100.0) 2(100.0)
health centres and the CHPS compounds. None of the CHPS compounds Glucose injectable 7(77.8) 8(88.9) 3(100.0) 2(100.0)Available means always or available within the last six months prior to the assessment
had salbutamol inhaler available. In the case of health centres, only four  
of them had salbutamol inhaler.
Service utilization and medical information system
 
All the facilities surveyed had medical registers where patients’ attendance 
Table 2:Availability of basic equipment in surveyed health facilities, Ghana, 2013 records were documented. The patients’ folders were retrieved each time 
 they visited the facilities using their unique folder identification numbers. 
Health Facility Type None of the facilities had a registry (computerized version) of patients’ 
Equipment Health District Regional records.
CHPS
Centre Hospital Hospital
 n (%) n (%) n (%) n (%) Attendance of the patients to the facilities was largely by “walk–in” in all 
Functional oxygen cylinder 0(0.0) 1(11.1) 3(100.0) 2(100.0) the facilities. A few 8 (34.8%) facilities use both ‘walk-in’ and ‘appointment’ 
Functional BPMD 9(100.0) 9(100.0) 3(100.0) 2(100.0) system where patients call and book appointments for attendance. This 
Functional weighing scale 9(100.0) 9(100.0) 3(100.0) 2(100.0) appointment system usually works in the CHPS compounds where the 
Functional Glucometer 0(0.0) 1(11.1) 3(100.0) 2(100.0) health workers are in direct contact with the community members. Most 
Functional Nebulizer 0(0.0) 1(11.1) 3(100.0) 2(100.0) of these appointments are not formalized and are based on the availability of the health worker. All the health facilities provided some education and 
Functional Spacer 00.0) 0(0.0) 0(0.0) 0(0.0) counseling of patients on risk factors for NCDs. A few, 8 (34.8%) of the 
Functional Peak Flow Meter 0(0.0) 0(0.0) 1(33.3) 2(100.0) 24 health facilities were performing clinical breast examination.
Functional Pulse oxymeter 0(0.0) 1(11.1) 3(100.0) 2(100.0)  
Functional Health education
1(11.1) 5(55.6) 2(66.7) 2(100.0) All the lower health facilities were able to refer patients to a higher level. 
materials The lower facilities usually used other means of transporting patients 
Functional tape measures 6(66.7) 9(100.0) 3(100.0) 2(100.0) apart from an ambulance. Some were able to arrange for ambulance 
Functional ECG 0(0.0) 0(0.0) 2(66.7) 2(100.0) to transport patients. Feedback on referred patients from the referral 
Functional Stethoscopes 9(100.0) 9(100.0) 3(100.0) 2(100.0) centres was a major challenge mentioned by all the primary health care 
Functional Thermometers 9(100.0) 9(100.0) 3(100.0) 2(100.0) facilities.
  
Health financing
 
Ghana has a National Health Insurance Scheme (NHIS) as part of the 
health financing schemes and those who register by paying a premium 
are eligible to benefit under the scheme. All the 23 health facilities are 
Table 3: availability of basic diagnostic tests in surveyed health facilities, Ghana, 2013 accredited by the NHIS. Services and medications that are covered by the 
Health Facility Type NHIS are therefore paid for through the NHIS except for individuals who 
Diagnostic Test Health District Regional
CHPS do not have valid National Health Insurance cards.
Centre Hospital Hospital  
 n(%) n(%) n(%) n(%)
Urine albumin/protein 0(0.0) 3(33.3) 3(100.0) 2(100.0)
Urine glucose 0(0.0) 3(33.3) 3(100.0) 2(100.0) Discussion
Urine ketones 0(0.0) 1(11.1) 3(100.0) 2(100.0)
Blood glucose 0(0.0) 1(11.1) 3(100.0) 2(100.0) The WHO-PEN is designed to deliver low-cost, high-impact interventions 
SerumTroponin 0(0.0) 0(0.0) 0(0.0) 0(0.0) through the primary health care approach. This requires prioritization of 
Blood cholesterol 0(0.0) 0(0.0) 2(66.7) 2(100.0) resources geared towards adequately equipping the primary health care 
Serum creatinine 0(0.00 0(0.0) 2(66.7) 2(100.0) facilities and providing the required capacity to deliver care. From the 
 
The Pan African Medical Journal. 2016;25 (Supp 1):16   |   Kofi Mensah Nyarko et al. 3
results, the health facilities lacked the capacity required for the smooth 
implementation of the WHO-PEN intervention. Inadequate capacity of Conclusion
primary healthcare facilities to serve NCD-related health needs have been 
widely reported [2, 10, 13, 14]. The inadequate staffing was a major The preparedness of the health facilities for the implementation of 
impediment. Since the successful functioning of the package will depend WHO-PEN intervention is unsatisfactory. Apart from health financing, 
largely on human resource, the observation of inadequate resourcing which seems to be uniform and somewhat adequate due to the NHIS, 
of the facilities was a major setback. It brings to focus the need to major gaps in the human resource capacity, availability of medications, 
empower non physician health workers to deliver NCD interventions diagnostics, equipment and medical information management system 
consistent with their level of care as has been done elsewhere with are likely to hamper the smooth implementation of the WHO-PEN 
satisfactory results [15, 16]. Though the package has been designed for intervention. Adequately addressing these gaps and other potential needs 
low resource settings, certain prerequisites such as fair financing, trained of the health facilities will optimize the implementation of the package. 
personnel, essential equipment, diagnostics and medications are key to 
its implementation [9].
Despite the fact that some basic equipment were found in all the facilities, Competing interests
some vital equipment were also missing. Capacity of the health facilities 
was strong in the area of health financing. This is largely due to the The authors declare no competing interest.
NHIS, which covers treatment of most diseases Ghanaians are afflicted 
with [17]. With regards to health financing, it seems the NHIS caters 
for almost all the basic drugs required for the smooth implementation 
of the package, thus reducing the out-of-pocket expenditure on health. Authors’ contributions
This contrasts with what was found in other LMICs [2]. Ghana’s NHIS 
therefore offers an opportunity to reduce the financial barriers that KMN conceptualised and designed the assessment plan. DKA contributed 
could have negatively affected the implementation of essential NCDs to the data synthesis and write-up of manuscript. All authors contributed 
interventions at the primary care level. to the design and revised the manuscript critically for important 
 intellectual content. All authors read and approved the final version.
Systems for managing patients’ information for continuity of care were 
inadequate in all the facilities surveyed. None of the facilities had a 
database of their patients that could facilitate follow up. Patients were 
referred when necessary, however feedback from the referral centres Acknowledgments
and adequate record on the patients were challenges. The records of 
the patients were not kept with sufficient care to enable tracking of their We acknowledge the support of the following district directors of health 
progress. This has effect on effective implementation of the WHO-PEN services for their support in data collection: Ms Florence Iddrisa, Dormaa 
intervention. Since NCDs require long-term care and tracking of patients’ Municipal Health Directorate, BrongAhafo Region; Dr. ChrysanthusKubio, 
progress, having a good data management system in place would have West Gonja District Health Directorate, Northern Region and Ms Sarah 
been an added advantage. Donkor, Upper Manya District Health Directorate, Eastern Region. We are 
 grateful to the WHO country office, Ghana for providing funding for the 
The results also highlight the unavailability of essential medicines assessment.
required for adequate management of NCDs at the various levels of care. 
The availability of the medicines reflected the capacity of the different 
levels of care. Since the different levels of health facilities have been 
mandated to cater for severity and complexity of diseases commensurate 
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