Laar et al. BMC Health Services Research          (2019) 19:693 
https://doi.org/10.1186/s12913-019-4571-6
RESEARCH ARTICLE Open Access
Health system challenges to hypertension
and related non-communicable diseases
prevention and treatment: perspectives
from Ghanaian stakeholders
Amos K. Laar1*† , Alma J. Adler2,3†, Agnes M. Kotoh1, Helena Legido-Quigley2,6, Isabelle L. Lange4,
Pablo Perel2 and Peter Lamptey2,5
Abstract
Background: Hypertension, itself a cardiovascular condition, is a significant risk factor for other cardiovascular
diseases. Hypertension is recognized as a major public health challenge in Ghana. Beginning in 2014, a collaborative
team launched the community-based hypertension improvement program (ComHIP) in one health district in
Ghana. The ComHIP project, a public-private partnership, tests a community-based model that engages the private
sector and utilizes information and communication technology (ICT) to control hypertension. This paper, focuses on
the various challenges associated with managing hypertension in Ghana, as reported by ComHIP stakeholders.
Methods: A total of 55 informants – comprising patients, health care professionals, licensed chemical sellers (LCS),
national and sub-national policymakers – were purposively selected for interview and focus group discussions
(FGDs). Interviews were audio-recorded and transcribed verbatim. Where applicable, transcriptions were translated
directly from local language to English. The data were then analysed using two-step thematic analysis. The protocol
was approved by the two ethics review committees based in Ghana and the third, based in the United Kingdom.
All participants were interviewed after giving informed consent.
Results: Our data have implications for the on-going implementation of ComHIP, especially the importance of
policy maker buy-in, and the benefits, as well as drawbacks, of the program to different stakeholders. While our
data show that the ComHIP initiative is acceptable to patients and healthcare providers – increasing providers’
knowledge on hypertension and patients’ awareness of same- there were implementation challenges identified by
both patients and providers. Policy level challenges relate to task-sharing bottlenecks, which precluded nurses from
prescribing or dispensing antihypertensives, and LCS from stocking same. Medication adherence and the
phenomenon of medical pluralism in Ghana were identified challenges. The perspectives from the national level
stakeholders enable elucidation of whole of health system challenges to ComHIP and similarly designed
programmes.
Conclusions: This paper sheds important light on the patient/individual, and system level challenges to
hypertension and related non-communicable disease prevention and treatment in Ghana. The data show that
although the ComHIP initiative is acceptable to patients and healthcare providers, policy level task-sharing
bottlenecks preclude optimal implementation of ComHIP.
Keywords: Hypertension prevention and treatment, Non-communicable diseases, Stakeholders, Challenges, Ghana
* Correspondence: aklaar@yahoo.com
†Amos K. Laar and Alma J. Adler are co-first authors
1Department of Population, Family, & Reproductive Health, School of Public
Health, University of Ghana, LG 13, Legon, Accra, Ghana
Full list of author information is available at the end of the article
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Laar et al. BMC Health Services Research          (2019) 19:693 Page 2 of 13
Background introduction to the challenges and priorities of Ghana’s
Raised blood pressure, has since 1972 been acknowl- health service delivery system is necessary. Since the
edged as a risk factor for cardiovascular disease and founding of the current national health system – post in-
mortality [1]. It is one of the top ten causes of death glo- dependence, key actors in the health policy making
bally; estimated in 2010 to have contributed to 9.4 mil- process have tended to be the same actors that play key
lion deaths [2]. Data from the 2005, 2010, and 2015 roles in health agenda setting, design, adoption, imple-
Global Burden of Disease (GBD) studies call on stake- mentation and sustainability in Ghana. The main gov-
holders to address the heavy burden that raised blood ernmental actors have been the Ministry of Health
pressure exacts on global public health [3–5]. The 2015 (MOH) and key agencies such as the Ghana Health Ser-
GBD analysis identified raised blood pressure (commonly vice (GHS). Lately, however, other actors such as multi-
defined as systolic blood pressure over 115), among four lateral agencies, bilateral/development partners, and
others (smoking, high blood sugar, high body mass local faith-based health service delivery actors, such as
index, and childhood undernutrition), to be the world’s the Christian Health Association of Ghana (CHAG) have
leading risk factors for premature death [5]. If not man- emerged. The local civil society, and a few lay advocates,
aged, hypertension (commonly defined as a systolic although wielding minimal influence, advocate for finan-
blood pressure ≥ 140 or diastolic blood pressure ≥ 90), cial resources to be made available for priority interven-
can cause several health problems including heart attack, tions. Despite some successes in terms of such advocacy,
stroke, heart or kidney failure, and blindness [6]. Raised a number of challenges continue to confront Ghanaian
blood pressure affects approximately 22% of adults over health policy formulation and implementation – espe-
the age of 18 years, with low and middle-income countries cially prioritization and resource allocation. Although
(LMIC) bearing the largest burden where it is estimated the sector considers NCDs an emerging public health
that by 2020, 80% of the cardiovascular disease burden problem, longstanding health challenges such as infec-
will reside [6]. The World Health Organization (WHO) tious diseases, maternal, neonatal and new-born deaths,
further notes that by 2020, three out of four of all deaths malaria, and sanitation continue to receive a significant
in Africa may be attributable to raised blood pressure [6]. proportion of health system allocation.
Despite the high global burden of hypertension, aware- Aside from the prioritization and system-level chal-
ness and treatment are low, with only 34% of Africans lenges, there are acknowledged inequities in health ser-
aware of their hypertension, 31.3% receiving treatment vice delivery or receipt of same. To address some of
and only 6.5% with their hypertension considered to be these inequities, the National Health Insurance Scheme
under control [7]. In Ghana, between one-quarter to (NHIS), Ghana’s first social protection efforts that ad-
one-third of adults have hypertension, though only a mi- dressed NCDs, was born [14]. The NHIS aims to in-
nority of those with the disease are aware of their status: crease access to health care and improve the quality of
approximately 37% of women and 20% of men according basic health care services for all persons living in Ghana,
to recent local surveys and reviews [8–13]. These studies but especially for the poor and the vulnerable. Prior to
show that among those with hypertension in Ghana, the scheme, the majority of health care costs were paid
even a smaller proportion, between 1.7 and 12.7%, have out-of-pocket by individuals and families (a system that
their hypertension controlled. Unfortunately, having was referred to as ‘cash-and-carry’). Currently both pub-
traditionally focused its resources on addressing commu- lic and private health care providers throughout Ghana
nicable diseases and maternal and child health, there is provide healthcare through the scheme [15]. The
inertia in refocusing and reprioritization of the Ghana scheme’s benefit package covers about 95% of diseases
healthcare system to emerging challenges. in Ghana including hypertension.
The current paper presents perspectives of Ghanaian
stakeholders involved in a multi-facetted community- The ComHIP project
based hypertension improvement initiative – herein re- With funding from the Novartis Foundation, Basel,
ferred to as the community-based hypertension im- Switzerland, FHI360 in 2014 collaborated with the
provement program (ComHIP). The paper reports a Ghana Health Service (GHS) to launch the community-
nuanced understanding of the patient-level and context- based hypertension improvement program (ComHIP) in
ual challenges associated with managing hypertension one health district in Ghana (the Lower Manya Krobo
and related NCDs in a Ghanaian district. Municipality, Eastern Region). ComHIP, which delivers a
series of implementations, is being evaluated for impact
Ghana’s health service delivery system challenges and and cost-effectiveness. The intervention comprises a pack-
priorities age of evidence-based interventions that were adopted,
To provide a nuanced understanding of the various chal- adapted, and implemented in Ghana. Key components of
lenges associated with managing NCDs in Ghana, an the intervention include community-based blood pressure
Laar et al. BMC Health Services Research          (2019) 19:693 Page 3 of 13
screening, management of hypertensive clients by challenges and propose solutions as they explore scale
community-based nurses (community cardiovascular dis- up options. Beyond ComHIP, the study findings may
ease nurses), blood pressure monitoring and supportive provide guidance to similarly-designed interventions.
messaging to clients and service providers using informa-
tion and communication technology (ICT) tools. Envis- Methods
aged to be implemented by community pharmacists, and Study design
Licensed Chemical Sellers (LCS), dispensing of anti- The ComHIP evaluation is conducted in two peri-urban
hypertension drugs could not be implemented. The over- districts in Ghana – the Lower Manya Krobo Municipal-
all community-based intervention and evaluation strat- ity (intervention site), and the Akuapim South District
egies are detailed in [12]. Currently referred to as over- (comparison site). The comparison district, which pro-
the-counter medicine practitioners, LCS in Ghana are per- vides the current GHS hypertension services, is distant
mitted to supply retail restricted drugs other than Class A enough to minimize contamination. The evaluation em-
or B drugs. Community pharmacists, per local guidelines ploys before-after population-based surveys (in interven-
are higher cadre private service providers. They supply tion and control districts), and a prospective cohort
medicines in accordance with a prescription or, when le- study in the intervention district (for details, see Lamp-
gally permitted, sell them without a prescription. Unlike tey et al. [12]. Conducted among hypertensive patients
the LCS, the main activities of community pharmacists in- enrolled in the cohort are a series of patient centered-
clude processing of prescriptions, care of patients, moni- ness surveys and qualitative investigations among vari-
toring of drug utilization, and health promotion. ous ComHIP stakeholders.
Prior to ComHIP, the FHI360, the GHS, and others The design of the qualitative study is informed by the
developed and implemented a general education and WHO Health Systems Assessment Framework [17] and
CVD screening programme in the district in which the WHO’s identification of five interacting dimensions
ComHIP was implemented. As part of this earlier that affect adherence [18]. This framework depicts
programme, counselling, health education and lifestyle health systems using six interrelated units or building
modification interventions were provided alongside blocks. These are service delivery, health workforce, in-
screening for hypertension. The study revealed hyperten- formation, medical products, vaccines and technologies,
sion as a major problem in the setting – reporting a financing, and leadership/governance. Having been pre-
prevalence of 32% among females and a little over 34% viously used to analyse the relationships between health
among males [16]. Baseline data from the ComHIP pro- system levels for cardiovascular or hypertension condi-
ject show similar prevalence of hypertension- 32.4%. The tions [19], this framework facilitated the identification of
data further show that although 46.2% of those diag- systems-level barriers to hypertension care in Ghana.
nosed to be hypertensive were aware of their hyperten- The five interacting dimensions of adherence [18] en-
sion status, only 9% were treated and 1.3% of patients compass social and economic factors, health systems fac-
had their blood pressure under control. Furthermore, we tors, condition-related factors (in the current case,
found in-depth knowledge of hypertension risk factors hypertension or NCD), treatment-related factors, and
to be low despite the high level of knowledge about the patient-related factors. As hypertension care and associ-
burden of the condition. Overall, close to 50% of the ated challenges are determined by the interplay of sev-
adult population were overweight or obese [12]. Thus, eral factors, the study tools were fashioned with these
challenges revealed by these surveys is the high mis- dimensions in mind. The two frameworks facilitated the
match between hypertension knowledge and hyperten- exploration and appreciation of the multiplicity of fac-
sion diagnosis, treatment or control. The existence of tors impacting hypertension care. Thus system-level fac-
low blood pressure control rates in the intervention dis- tors such as governance and prioritization of NCDs
trict despite previous generalized education programs within the Ghana health service delivery system; human
[16] suggests that such programs have little impact on resource constraints, policy-informed task-sharing chal-
hypertension control. lenges; and patient-level challenges such as life-long
Following the baseline study, we qualitatively assessed management of hypertension, adherence to medications
ComHIP implementation barriers, enablers, and factors and medication side effects; and socio-political questions
influencing adherence (this is reported elsewhere; see of medical pluralism were investigated.
Adler et al., forthcoming). This paper focuses on health
system factors, service provision factors and service user Study respondents
factors that impact hypertension prevention, manage- A total of 55 informants were purposively selected to
ment, and control in Ghana. Publicizing the findings not represent the characteristics of each category of study
only shares implementation experiences, it also offers participants (see Table 1 below). We selected registered
stakeholders the opportunity to appreciate identified patients and ensured a mix of gender, age, district, and
Laar et al. BMC Health Services Research          (2019) 19:693 Page 4 of 13
Table 1 Categories of informants care for hypertension; e) factors influencing adherence.
Informants Semi-structured Focus Group Total For licensed chemical sellers (focus group discussion
interviews Discussion (FGD) guide), the topics included a) their experience and percep-
Patients 15 16 31 tions of the programme b) scalability. These tools are con-
Health care 10 – 10 solidated and appended to the manuscript as a
professionals supplementary material (see Additional file 1).
Licensed chemical – 7 7 Using the above tools, three experienced multilingual
sellers qualitative field researchers –fluent in English, Krobo or
Policymakers 7 – 7 Twi carried out face-to-face semi-structured interviews
Total 32 23 55 and FGDs. Two researchers (co-authors AJA and AK)
conducted an intensive one-week training session for the
qualitative field staff to ensure that interviewers under-
socio-economic status. Health care providers were se- stood the objectives of the study and the questions. They
lected to ensure representativeness of hospitals, and LCS were trained to respond to any sensitive situations or signs
to ensure their representativeness of the studied com- of distress with appropriate wording, supportive state-
munities. Policymakers from the Ministry of Health/ ments and avoidance of excessive probing. The training
Ghana Health Service were selected based on the rele- included extensive role plays, and trialing of the tools. The
vance of their position within NCD control. They in- issues and experiences from the trial process were incor-
cluded the National Programme Managers, Regional porated into the tool prior to actual data collection.
Directors of Health Services, Policy, Planning, Monitor- Based on participant preference, interviews and FGDs
ing and Evaluation Officers. were conducted in English, Krobo or Twi and audio re-
corded. The categories of the study participants are sum-
Study tools development, field staff recruitment, training, marized in Table 1. We interviewed 15 hypertensive
and data collection patients enrolled in the intervention, 10 health care pro-
As described above, the design and the tools of this qualita- fessionals (seven CVD nurses, one pharmacist, one phys-
tive study benefit from the WHO Health Systems Assess- ician assistant, and one physician), seven health
ment Framework [17], and the WHO resource relating to policymakers. We conducted two FGDs with a total of
five interacting dimensions of medication adherence [18]. 16 patients (one group of men, and one of women). We
The framework and associated questions captured in our conducted a third FGD with seven LCS.
tool facilitated our identification of health systems-level
barriers to hypertension care in Ghana. We developed five Data analysis and quality assurance
separate, yet related tools – one tool for healthcare profes- The interviews were audio recorded and transcribed ver-
sionals (semi-structured interview guide); this tool covered batim. The transcriptions were translated directly from
topics such as: a) experience and tasks; b) how treatment the local languages to English by experts in English and
and care is provided and coordinated; c) how treatment Krobo or Twi, and wherever possible by the individual
has changed with the programme; d) their relationships who conducted the interview. Our quality assurance mea-
with patients; and e) areas for improvement at the health sures included recruitment of experienced multilingual
systems level). The second tool was used to engage health qualitative researchers, and conducting a one-week training
policymakers (a semi-structured interview guide). The in- on the study methods, tools, and ethics. During the tran-
terviews with policy-makers were tailored to their expert- scription process, co-author AK randomly sampled 10% of
ise and position. The interviews focused on understanding the translated transcripts and compared them with the ori-
NCD programmes, the key barriers in the implementation ginal recordings. The data were then analysed using the-
of hypertension programmes, key health systems-level fa- matic analysis techniques employing two steps. We started
cilitators, who the key actors are, aspects that need im- with a-priori chosen themes based on the ComHIP interven-
provement, and the commitment to scaling up the tion themes. We coded transcripts based on both the a-
ComHIP programme. For hypertensive patients, we devel- priori analysis and emergent and divergent themes that came
oped both a semi-structured interview guide, and a focus from the analysis. We then looked to find overarching con-
group discussion (FGD) guide. The specific interview and cepts in which the themes were interconnected. Co-authors
focus group discussion topics for hypertensive patients en- AJA, AK, AKL, and field assistants met to discuss major
rolled in the ComHIP intervention include: a) how treat- themes and issues that were not clear in the transcriptions.
ment and prevention of hypertension is provided; b)
health care experience and recommendations; c) know- Ethics
ledge of hypertension and its diagnosis; d) health system Our study protocol received ethics approval from the In-
barriers and facilitators to accessing services and receiving stitutional Review Boards (IRBs) of the London School
Laar et al. BMC Health Services Research          (2019) 19:693 Page 5 of 13
of Hygiene and Tropical Medicine (LSHTM) - Observa- current level of funding for NCDs interventions. Policy-
tional / Interventions Research Ethics Committee (Ref: makers consider NCDs as an emerging public health
10152), the Ghana Health Service – Ghana Health Ser- problem. Longstanding health challenges such as infec-
vice Ethics Review Committee (Ref: GHS-ERC 04/01/15) tious diseases, maternal, neonatal and new-born deaths,
and the Noguchi Memorial Institute for Medical Re- malaria, and sanitation continue to be health sector pri-
search, University of Ghana (Ethics clearance # orities. The current level recognition of NCDs is
IRB00001276). Participating in the study was preceded reflected in the government’s financing strategies. A sig-
by a written informed consent processes, which commu- nificant proportion of health system allocation goes to
nicated to prospective participants that their participa- maternal, child health and infectious disease pro-
tion in the study was voluntary. It also outlined grammes. However, the pendulum, in a foreseeable
measures that the researchers would put in place to en- future, is likely to swing toward NCDs, as their bur-
sure privacy, anonymity and confidentiality. Briefly, the den, particularly hypertension-related morbidity and
measures instituted by the study team to ensure that mortality are increasing. A GHS official at the district
participants’ confidentiality is maintained included the level explained the situation as follows:
following. Personal identifiers were not included in study
reports and manuscripts. All study records were secured Ghana being a developing country, our focus is more
to the extent provided by local and international regula- on how to combat communicable diseases. Now the
tions. Data collection forms were identified by codes; all number of NCDs is also increasing and the large
records containing names or other personal identifiers, number of clients that come to the facilities is a matter
such as informed consent forms were stored separately. of concern. Previously, we see older people having the
The required anonymization procedures were imple- disease. But now we find younger people coming. Also,
mented prior to depositing transcripts in Harvard Data- many people come with stroke or die suddenly. The
verse (an open access repository). Regarding privacy, increasing burden of hypertension in our communities
interviews were conducted in private and comfortable and facilities is gradually changing health sector
spaces that the participant deemed acceptable. All par- prioritization. (District-level GHS official).
ticipants consented to the publication of their data.
Beginning in 2012, the Ministry of Health developed a
Results national policy for the Prevention and Control of NCDs
Presented below are both health system level challenges in Ghana [20]. An accompanying strategy, the strategy
and patient level associated with managing hypertension for the Management, Prevention and Control of Chronic
in a district benefiting from the ComHIP intervention. Non-Communicable Diseases in Ghana 2012–2016 [21]
The health system level challenges span governance and was also developed. The NCD strategy outlines, amongst
prioritization of NCDs within the Ghana Health Service others, health promotion, community engagement and
delivery system; human resource and task-sharing chal- outreach and covers advocacy, creating awareness, screen-
lenges; and challenges of medical pluralism of illness ing for early detection, diagnosis and management and
and treatment. Hypertension-specific challenges relate to research.
integrating hypertension prevention and screening within Although Ghana’s national policy and accompanying
the health system, and provision of hypertension preven- strategy for NCDs have been in existence since 2012, in-
tion and treatment at primary care facilities. Also pre- adequate logistics and financial resources limit their im-
sented are several patient-level challenges including plementation. Policymakers revealed that unlike
inadequate understandings of medications, medication infectious diseases, or maternal and child health issues,
adherence, and side effects. there are no defined sources of funds from the Ghanaian
government for awareness creation, screening and pre-
Governance and prioritization of NCDs within the Ghana vention of hypertension. Policymakers reported that the
health service delivery system major challenge to the control of hypertension in Ghana
Key stakeholders of the GHS (national, regional, and dis- is the lack of awareness, or knowledge (on the part of
trict level policymakers, health professionals and clients) the populace) as well as the GHS’ lack of resources.
shared their perspectives on the systemic health system- Most of the GHS interviewees noted that GHS lacked
wide challenges as a whole, and in particular, manage- funds for awareness creation and community-based edu-
ment of NCDs within the Ghana health delivery system. cation. Health promotion is generally carried out through
In particular, the perspectives from the national level media campaigns, primarily radio, where knowledgeable
policymakers enabled elucidation of prevailing system- persons discuss risk factors for specific NCDs, clinical
wide challenges (beyond ComHIP intervention district) presentation, treatment, and possible complications. How-
such as a mismatch between prioritization of NCDs and ever, these programmes do not provide the opportunity
Laar et al. BMC Health Services Research          (2019) 19:693 Page 6 of 13
for people to call in and ask questions and clarify issues. The human resource challenge impacts nationwide in-
Many policymakers noted that at public health facilities, tegration of hypertension prevention and screening
only opportunistic screening is done due to a lack of within the health system. Aside from a shortage of ex-
screening facilities’ equipment and staff. This is seen perts, there are challenges of their distribution across
through the strain that the current ComHIP programme the country with varied regional and district disparities.
has put on the hospitals in the Lower Manya Krobo (the A common theme that emerged from conversations was
ComHIP intervention district). There is a concern that in- that facilities in deprived areas are severely understaffed.
creased screening may increase demand to greater than Many doctors are not willing to accept postings to rural
the health services’ capacity to treat the screened areas where more health care professionals are needed.
individuals. While the number of medical schools is increasing as
part of the national strategy to train more staff locally,
Human resource constraints and task-sharing challenges there are huge inequities of trained personnel, particu-
Related to inadequate logistics and financial resources is larly doctors with expertise. Many of them move to
the problem of human resource. Ghana’s precarious more desirable areas or leave the GHS.
health workforce situation, particularly its inadequate
number of doctors, is detrimental to effective health de- Deprived, hard-to-reach areas (sometimes referred to,
livery including NCD management. Three policymakers in Ghanaian parlance, as “overseas”) are severely un-
independently noted that the NCD unit, just as other derstaffed. When serious cases show up at the district
sectors of GHS, has serious human resource challenges. hospitals, they are referred to regional hospitals. Cur-
Throughout the country, particularly in remote settings, rently, these clinics are much less common, so if one
limited number of trained personnel exacerbate already does not live near a district or regional hospital, one is
existing service delivery inequities. A substantial chal- unlikely to get specialist care for NCDs including
lenge faced by the ComHIP project was the shortage of hypertension and other chronic conditions. That there
trained staff (particularly doctors) with hypertension is unequal geographical distribution of healthcare pro-
medication prescribing authority and expertise for fessionals is no news to us. (National-level policy
hypertension treatment and management. A CVD maker)
nurse’s complaints and the views of a service user par-
ticipating in a focus group illustrate this challenge. This inequitable distribution of high cadre health
workforce precludes integration of hypertension preven-
Unlike the situation with other drugs such as anti- tion and care into lower level service delivery points
malaria drugs and some antibiotics in pregnancy we where providers do not have antihypertensive prescrib-
prescribe, only doctors give prescription in the case of ing authority or lack hypertension management experi-
NCDs. This leads to long waiting and difficulties acces- ence. Alluded to earlier, unlike other conditions, in
sing needed medications. (Community based CVD Ghana management of hypertension is hospital-based
nurse) with doctors as prescribers, and service provided by spe-
cialised clinics run once or twice a week at district and
This complaint (below) about wait times at hospital regional hospitals. Lower cadre service providers such as
during visits for ordinary monitoring of blood pressure nurses do not have prescribing or dispensing power.
is emblematic of others recorded during the focus
groups. Discussants of the focus groups offer task- Hypertension treatment and access-related challenges
sharing suggestions to address this problem. Aside from task-sharing access-related challenges de-
scribed above, financial access is an important challenge.
For me, my major challenge is that sometimes you are Of note, hypertension is covered by the NHIS, therefore,
just in need of your BP drugs but you will get to the all patients theoretically have access to hypertension care
hospital very early and leave there very late, so to me in Ghana. The precondition, however, is to enrol in the
if they can arrange and group BP patients at one NHIS scheme and pay the subsidised annual premium
side so that you join that queue and go for your (GH25.00 about US$6.00). Exemptions are also provided
medicine immediately. Perhaps the nurses who for various vulnerable groups. Despite this initiative,
counsel us can be permitted to have the medicines so some health professionals in public health facilities
that once in a month when we go to see them they can expressed their frustration with the NHIS scheme and
give us the medicine. That will be simple. Imagine going the challenge of accessing hypertension medications.
to join the long queue just for medicine; I prefer to go to While the assumption was that most patients had health
the drug store to buy them myself. (A female FGD insurance cards, many informants felt that there were
participant) still many out of pocket costs including transport. This,
Laar et al. BMC Health Services Research          (2019) 19:693 Page 7 of 13
combined with the time spent by patients getting pre- Patient-level challenges: life-long management of
scriptions, led to substantial challenges. hypertension, adherence to medications and medication
Others pointed to the challenges of the NHIS as having side effects
a negative impact on hypertension treatment. One of the biggest challenges to effective hypertension
In particular, the delayed reimbursement of health fa- control mentioned by most informants was adherence to
cilities by the National Health Insurance Authority medications. Our results show that with the exception of
(NHIA) seriously affects health facilities’ stock of medi- a few, patients are aware of the necessity of the continu-
cines and other supplies. ous taking of medications but do not do so. Reasons
given for non-adherence included the inaccessibility and
Unfortunately, health insurance has not paid our unavailability of drugs, non-acceptance of life-long man-
claims for close to a year now. We are in April and the agement of hypertension, side effects associated with
last claim that was paid to all our health facilities the drugs and perceptions of traditional medicines as
was April last year, 2016. So that is 11 months that curative.
they haven’t paid us, and you know the drugs you All participants of the two focus groups knew that they
procure from regional medical stores or you procure should talk to their health care providers if they had any
from the open market and you have to pay for the side effects or problems with any hypertension medica-
drugs and the patient knows. If he or she is on health tions. No patient reported receiving incorrect doses of
insurance then antihypertensive drugs, the majority of drugs when prompted, and no nurse knew first hand of a
them, are on the inclusion list so they are provided to patient receiving the wrong dose. Both patients and nurses
him or her free of charge. Yes, when it comes to the had concerns about side effects, which included too fre-
facility level because they don’t have money to pay quent urination and erectile dysfunction for men. Nurses
supplies so then they have to put in maybe a payment cited side effects as the primary cause of non-adherence,
or co-payment. So maybe now the health insurance is and a few hypertensive focus group participants stated
not paying us so you have to pay half and the facility that they switched medications because of side effects.
is also paying half just for the facility to survive, or if The influence of side effects on medication adherence
they don’t have drugs in some of the facilities then they seemed greater in men, compared to women. One nurse
will just write prescription for you to go and buy at the noted. “Men are more reluctant to take antihypertensive
pharmacy shop or chemical shop. And you know some drugs because of the sexual side effects.” . Another nurse
of them because it is cash when they go they may not elaborated with a clarification:
buy it and take their drugs. (District level nurse)
… the main reason why males are likely to stop taking
A related access challenge identified by many infor- medications is side effects, while females stop if they
mants was the unavailability of essential drugs at lower feel their BP has gone down. They asked, ‘why should
level service delivery points. Community health nurses they continue taking the drugs if they are okay?’
reported that some patients only took one round of
medications and did not refill their prescriptions due to The above was corroborated by views of some hyper-
the cost of transport to NHIS accredited facilities. Also, tensive participants. One male participant expressed
many community pharmacists do not stock antihyper- their worry about the medicine's effect on his sex life.
tensive drugs, making it difficult for patients who are
able to purchase them to travel longer distances to ob- I had erectile dysfunction and had told the CVD
tain them. A service provider expressed her frustration nurse, but she laughed and did not change my
about getting medication for their patients in the follow- medicines. So, I chose to stay off the drugs for a while.
ing comments:
A nurse reported that patients would wait too long to
At the community level, you may have to travel to get report problems with their medications:
your medicines. What’s the point if I diagnose and I
can’t give medicine? If I go to the nearest health centre When they start experiencing side effects, instead of
and I diagnose someone to have hypertension then I’m reporting immediately, they stop taking their
working at the health centre, I don’t store medications and wait until their next visit. Some
antihypertensive drugs so I give you a prescription and will not even come to you at all.
you have to go to the regional hospital, that is a
problem. Why doesn’t the client just go to the regional We also explored the challenges associated with the
hospital for diagnosis and treatment? (Senior member life-long management of hypertension. For instance, ad-
of the GHS) herence was hampered as many patients did not realize
Laar et al. BMC Health Services Research          (2019) 19:693 Page 8 of 13
the medications were meant to be continued even after R: I take the medicine but stopped because I’m taking
their blood pressure was lowered. One participant gave the local one. Now I’m yet to start the foreign
an example of stopping taking the drugs once the symp- medication. I take it because the lady selling it told me
toms disappear. it’s good for hypertension.
I have seen that you can’t stop the medication. I’m I: So, you combine the two?
saying this because during Christmas I stopped taking
my medication so that I could enjoy the season but R: No, the seller told me to stop the hospital one for
after Christmas I realized that my heart started some time so that I won’t mix the two drugs till I
beating abnormally again. When I went to check it finish the local one. Recently when I came here, and
was around 200. The doctor told me that I have they checked my BP they asked me if I’m taking some
stopped taking my medication. I tried to lie but he other form of medicine in addition to the foreign ones
insisted that I had stopped. He gave me some and I told them yes. (Female participant)
medications that I took for three days. I went back and
the BP reduced to 130 and he told me it’s because I She used to be on the hypertensive drug and then she
have taken the medication this time. stopped before I met her. Some of them told me they
stick to some herbal medicine because when they
A pharmacist attributed the life-long hypertension checked and realised the BP is okay, they stopped the
treatment challenge to polypharmacy. hospital one. So, for me to diagnose again, it means
that the herbal medicine is not working so we have to
The quantity of drugs given to patients to take go and follow the orthodox way again. (Community
discourages them from adhering for a long time. The CVD nurse)
sheer number of drugs discouraged them, although it
was noted that if you gave patients too few
medications they would also complain. Discussion
We explored Ghanaian stakeholders’ perceptions of a
multi-facetted community-based hypertension improve-
ment initiative with task-sharing components. This paper
Reconciling two health systems and cultures: traditional presents and discusses several patient-level and contextual
medicine vs Western medicine challenges associated with the implementation of the ini-
The desire for curative drugs rather than management is tiative – focusing on the management of hypertension
a major barrier to adherence to antihypertensive medica- and related NCDs. The findings have implications
tions. There are many traditional or herbal medications on the implementation of ComHIP and on the design
in Ghana that are perceived to cure hypertension. While of related task-sharing strategies in Ghana. Publicizing
antihypertensive drugs are taken for life to manage the the findings not only shares implementation experiences,
condition, traditional/herbal medicines purport to be it also provides stakeholders an opportunity to appreciate
curative. This perception often discourages people from and address identified challenges as they explore possibil-
accessing allopathic care and if they do, continuation of ities of scaling up this initiative.
the treatment for life is a challenge. According to nurses, Although, our data show that the ComHIP initiative is
some of their clients reported taking traditional medi- acceptable to patients and healthcare providers (Adler
cines. Some of the patients also told us they took trad- et al, forthcoming) – increasing providers’ knowledge on
itional medicines but did not tell the CVD nurse and hypertension and patients’ awareness of same, the import-
admonished us not tell them. A participant said prior to ant challenges identified by both patients and providers
ComHIP he nearly had a stroke and started taking are worth discussing. The key policy level challenges relate
herbal medications that were made by his brother. How- to task-sharing bottlenecks. Existing policy precluded
ever, when he combined the herbal and allopathic medi- lower-cadre services providers such as nurses from pre-
cations, he experienced some negative effects, so he scribing or dispensing antihypertensives, and LCS from
stopped taking the local one. Another participant stated stocking them. Medication adherence, side effects, and the
that he only sought hospital care out of his concern of phenomenon of medical pluralism in Ghana are other
not having sufficient traditional medicines. challenges. Although focused on the ComHIP interven-
The illustrations below show the popularity of traditional tion currently being implemented in one health district,
medicines, which are sometimes taken concomitantly with views from national level stakeholders are reflected in this
allopathic antihypertensives or may be used as a substitute paper. Their perspectives enable elucidation of contextual
for the allopathic medications: and system-wide challenges such as a mismatch between
Laar et al. BMC Health Services Research          (2019) 19:693 Page 9 of 13
prioritization of NCDs and funding NCD interventions by Human resource and task-sharing challenges
the Ghana health delivery system. That the Ghana healthcare delivery system is belea-
guered with workforce challenges is not new and is not
Ghana’s health service delivery system challenges and restricted to the domain of NCDs. Ghana currently has a
priorities one doctor to 10,450 patients ratio. This falls below the
Like many LMICs, Ghana’s fragile health system is deal- one doctor to 1320 patients WHO recommendation. All
ing with multiple burdens of disease as well as non- policy level informants reiterated the lack of required
disease health system challenges. Thus, the emerging numbers of high calibre personnel as a major challenge.
challenge of NCDs (whose impact on the health system In particular, the distribution of the few qualified
is real) adds to existing layers of challenges that the personnel is concentrated in a few major cities, leaving
country’s health system has to contend with. Ama de- significant portions of the Ghanaian population to be
Graft Aikins [22] has recently discussed the impact of attended to by low cadre health personnel. However, the
CVD on primary healthcare (PHC) services in urban problem is more serious for NCD service provision. As
poor communities in Ghana – laying bare the significant one moves from the few endowed urban facilities toward
unmet need for CVD care in these communities. Na- urban poor communities, healthcare services for NCDs,
tional level stakeholders in the current study acknowl- particularly CVDs, are generally not accessible, equitable,
edged the growing challenge of NCDs. Like other nor responsive to the needs of the vulnerable [22].
countries in the sub-region, Ghana is experiencing rapid In the midst of these challenges, lie opportunities to
urbanisation, accompanied by increasing levels of obesity improve NCD prevention strategies, treatment and con-
and related NCDs [13, 23, 24]. Data from the Global trol in Ghana. For example, effective public-private part-
Burden of Disease studies rank raised blood pressure/ nerships (PPP), the deployment of technology, effective
hypertension, high fasting plasma glucose, dietary risks, exploitation of the Community-based Health Planning
and high body mass index among the top 10 risk factors Services (CHPS), and task-sharing provide important
that drive the most death and disability combined. Thus, frameworks to improve NCD care. To help address this
NCDs and their associated risk factors account for > 40% gap, the MOH and GHS in recent years have endea-
of total morbidity and adult mortality in Ghana. In recog- voured to capacitate the CHNs through the strengthen-
nition of the increasing burden of NCDs, Ghana has re- ing of the CHPS initiative. Currently there are about
cently politically recognised NCDs as a pressing health 3000 CHPS compounds in Ghana, and this is projected
concern, publishing national NCD prevention policies and to increase to 6000 by 2020. CHPS were originally
strategies, which identify interventions to address them formed to provide education to mothers, children and
[20, 21]. Closely related to the disease burden is the chal- households. The CHNs overseeing CHPS compounds or
lenge of funding. Although there is a growing national rec- zones have been trained to address key areas n commu-
ognition of NCDs, particularly hypertension, there is nity health (such as infectious disease preventative care
currently no commensurate funding response. Policy- and maternal and child health services). Similar training
makers lament that the Ghana national NCD policy and its on NCDs can enhance capacity, confidence, self-efficacy
accompanying strategy have been in place since 2012, but to provide basic care and support to those in need. This
their implementation has been suboptimal due to lack of approach has worked in other African countries such as
requisite resources and funding. Cameroon and South Africa [29]. Recognizing the value
To address this funding challenge, Ghana turns to do- of the ComHIP concept, some policymakers now see
nors or development partners who fund a significant CHPS as a missed opportunity for the prevention of
fraction of the health budget [25]. These development hypertension and NCDs . It is an attempt to bring inte-
partners play critical roles in policy design, implementa- grated hypertension management into the community
tion, and funding decision-making. The policymakers we through a system of community education and hyper-
interviewed said that current funding priorities are ma- tension screening by CHNs/CVD nurses’ referrals, and
ternal and new-born mortality, sanitation, malaria, and ICT support for participants. Prior to ComHIP the only
other infectious diseases. Thus, though NCDs are na- possibility for accessing hypertension care in a typical
tionally recognized as a major public health challenge, Ghanaian health district was in hospitals by physicians.
they are not given priority with the necessary funds to Given the low doctor-to-patient ratio, it is imperative
address them. To respond to this high burden of NCDs, that innovative methods of reorganising care – such as
and yet low resources to address them, studies recom- ComHIP – are utilised.
mend health systems-wide strengthening, which has Notwithstanding this, the significant challenges en-
positive externalities on persons with NCDs, as well as countered during ComHIP implementation need to be
their families, and communities [26–28]. Such an ap- discussed. One of the challenges encountered relates to
proach is in line with the current ComHIP model. task-sharing (described as the process of enabling lay or
Laar et al. BMC Health Services Research          (2019) 19:693 Page 10 of 13
low level healthcare personnel to fulfil a wider clinical successful, it does not fit into the current regulations
role and used interchangeable with "task-shifting" in this within the GHS. In light of these findings, policies should
paper), which has been acknowledged as a viable strategy be amended. Indeed, our study, and that by Iwelunmor
for responding to CVDs and other NCDs in LMICs [29– et al. [39], explore stakeholders’ perspectives of task-sharing
32]. Ogedegbe et al. [33] in their systematic review of tri- as a strategy for preventing, and managing hypertension in
als on task-shifting interventions for cardiovascular risk Ghana. Both studies show that for any task-sharing inter-
reduction in LMICs conclude that task-shifting strategies vention to be successful, a deliberate effort must be made to
are appropriate and deployable in many LMICs battling not only focus on patients, or individual level characteristics,
with infectious and chronic diseases. The WHO, for ex- but also to consider the role systems-level variables such as
ample, recommends task sharing where access to health policy, leadership, and stakeholder engagement play.
services is constrained by a lack of health workers [34].
Other programmes in sub-Saharan Africa have found at Patient-level challenges including multiple
least limited success when nurses were trained to man- understandings of illness and treatment and medical
age hypertension (for example in DRC [35], in Nigeria pluralism
[36], in Kenya [37], and Ghana [38]. In ComHIP, whilst Like many others in the sub-region, patients in Ghana
results on the overall programme impact and cost effect- have the opportunity to shop for healing from various
iveness are still forthcoming, the data from this and earlier systems/care providers: the allopathic health services de-
qualitative analysis (Adler et al. forthcoming) suggest that livery system, indigenous/traditional care delivery systems,
various components of ComHIP including its task-sharing as well as faith-based providers. Referred to as medical
experiment was acceptable to patients and nurses involved pluralism [40] or more recently, medical diversity [41], the
in the programme. use of multiple medical systems to address illness and
However, the Ghana health policy at present does not wellness, has been praised and criticised at the same time
permit nurses and other lower cadre health personnel to [42]. The medical sociology, and anthropological literature
prescribe most medications including antihypertensives. address the subject in-depth. Baer [43] and Goldstein [44]
Some of the policymakers we engaged in this study indi- discuss its evolving nature, persistence, resurgence and
cated the desire to expand who is able to prescribe med- concept contestations. We do not aim to interrogate the
ications. It would seem to us that this challenge is subject further. Instead, we focus on system-level factors
not particular to Ghana. The review by Ogedegbe et al. that motivate concommittant use of traditional remedies
[33] identified barriers to task shifting in LMICs as in- and modern medicine in Ghana [22, 45, 46].
cluding policy gaps on medication prescription; weak or As far as chronic disease care in Ghana is concerned,
non-existent referral systems to take care of complicated medical pluralism's contribution has begun to emerge
cases and the inability of non-physician providers to [47]. Hampshire [45] interrogates medical pluralism in
manage uncomplicated CVDs and their risk factors [33]. the context of globalization and new healing encounters
In the case of ComHIP, the inability of nurses to dis- in Ghana. For a long time, the practice of allopathy in
pense antihypertensives was a major challenge. Perhaps, Ghana is often framed to compete with alternative practices
identified enablers of task-shifting such as continuous such as traditional/indigenous and faith-based healing [22].
educational training and feedback from higher level It is common practice for community members to bypass
health professionals; bridging hospital care to home care allopathic public health facilities and access care from these
in order to ensure continuity of patient care; and provid- alternative providers or healers. Aside from inaccessibility
ing explicit training tools including medication/treat- challenges associated with allopathic healthcare, motiva-
ment algorithms [33] need to be exploited. At least two tions for uptake of indigenous health remedies, include
projects in Kenya and Ghana that allowed nurses to pro- trust (of indigenous healers), proximity, ease of use, previ-
vide antihypertensives have shown promising results [37, ous relationships, cost-value (sometimes) and poor percep-
38]. For instance, the Ghana study pilot-tested a task- tions of the level of competence of the low-cadre allopathic
shifting strategy for a hypertension study (TASSH), which health workforce [48, 49]. Awah and Phillimore [50] ex-
trained community health nurses to deliver hypertension plore and cast important light on the tension between
care. Although the nurses did not dispense antihyperten- clinic-based demands for patients’ ‘compliance’ with treat-
sives because they did not have prescribing/dispensing ment guidelines, including repeated strictures against
power, they (nurses) had access to antihypertensives resorting to ‘traditional’ medicine, and patients’ own will-
through the coordinating physician and could dispense ingness to alternate between biomedical and indigenous
them as needed based on the GHS hypertension treatment practitioners.
algorithm. Thus, the study was able to circumvent the Critics of indigenous medicine point out its implica-
legal limitations by having the coordinating physician sup- tions for service uptake and adherence to allopathic care.
ply the needed drugs to the nurses. While this project was In our study, potential barriers to uptake and adherence
Laar et al. BMC Health Services Research          (2019) 19:693 Page 11 of 13
to antihypertensives relate to the belief that traditional This qualitative study involved all the actors and com-
medicines could cure patients' hypertension. Our explor- ponents of ComHIP. In doing so, it has been possible to
ation, which involved a wider group (patients, service identify enablers and bottlenecks to implementation and
providers, and policymakers), concurs with the findings future scale up. The findings, however, need to be read
of de-Graft-Aikins [22], where the patients she engaged along with the following limitations. First, the data pre-
set out to seek a cure for their diabetes. Similar claims sented in this paper derives from purposively sampled
are rife in studies of other NCDs and in further African ComHIP stakeholders and thus precludes generalizability.
settings [47]. We note that, until all care providers in It ought to be noted however, that, typical of qualitative
this pluralistic healthcare system are made to understand inquiries, the study was not intended produce evidence
that there is as yet no cure, this phenomenon of seeking generalizable to other settings. Second, although the quali-
cures for ‘incurable’ health conditions will continue. tative research assistants were trained to handle courtesy
Therefore, programmes such as ComHIP may learn bias or socially desirable responses on the part of all re-
from these explorations of local approaches to care- spondents, we are not able to wholly rule them out. Des-
seeking and medication by understanding patients’ prior- pite these limitations, this paper sheds light on important
ities, motivations and preferences when designing inter- challenges to hypertension and other NCD prevention,
ventions – seeing traditional solutions as treatment, and control in Ghana. These have the potential
complementary to, rather than competing against, allo- to inform research uptake, as well as provide guidance to
pathic medications. The popularity of traditional remed- similarly-designed interventions.
ies among ComHIP clients is in line with data from
previously reported local studies [51, 52], where pa- Conclusions
tients sought care from multiple outlets. For example, Taken together, this paper reveals two layers of chal-
the Ghana Herbal Pharmacopoeia reveals that more than lenges associated with hypertension and related NCDs
70% of Ghanaians who receive allopathic care, also resort prevention and treatment in Ghana. These are the
to alternative health care practices to address their health healthcare system-level challenges relating to governance
needs [53]. Another local study linked such practices to and prioritization of NCDs within the Ghana Health
Ghana’s religious landscape and political history [52]. A Service care delivery system; human resource con-
relatively recent Ghanaian study reported prevalent use of straints, task-sharing bottlenecks; and patient-level chal-
non-prescription medications by persons living with HIV, lenges relating to non-adherence to medications and
a practice mostly self-initiated or implemented with the medication side effects. Our data show that the task-
acquiescence of some healthcare providers [51]. This sharing component of ComHIP is acceptable to patients
phenomenon has been documented in other African set- and healthcare providers, but not to policymakers, and
tings [54–57]. this has implications on the implementation of ComHIP
Like limited health workforce, limited funding, mis- and the design of related task-shifting strategies in
prioritization, and restrictive prescribing policies, the Ghana. Although there is no shortage of evidence on the
phenomenon of medical pluralism is an important con- clear need for such task-sharing strategies in LMICs,
textual challenge to the prevetion/treatment of hyperten- these challenges preclude their implementation. We rec-
sion and other NCDs in Ghana. The Ghana Food and ommend meaningful engagement of policy-level gate-
Drug Authority, the Ghana Standards Authority, and keepers, medical and other relevant professional
other regulatory bodies need to institute robust monitor- associations to buy into the concept of task-sharing.
ing and validation schemes that endorse or reject various
healing options on the formal and informal health deliv- Supplementary information
ery platforms. Furthermore, efforts at improving the Supplementary information accompanies this paper at https://doi.org/10.
health literacy of the Ghanaian populace may help pro- 1186/s12913-019-4571-6.
vide clarification on the effectiveness or otherwise of
Additional file 1: Study tools. Comprises the study’s five tools used in
these healing options. data gathering.
Study strengths and limitations Acknowledgements
ComHIP is one of the few comprehensive studies which We are grateful to all of our field researchers for their support in data
deploy a multilevel combination prevention-treatment- gathering, and to the Ghana Health Service for their political support.
control intervention that engages (patients, community, Authors’ contributions
and healthcare personnel), educates (patients and PL conceived of the project and contributed to the design of the ComHIP
family), and uses supportive tools to increase hyper- interventions. PL, PP, AKL, and AJA contributed to the design of ComHIP
evaluation. AKL, AJA, AMK, HL, and ILL designed this qualitative study. AKL,
tension literacy, service access, service uptake, and and AMK supervised the implementation of the field research, and data
linkages to care. management. AKL, AMK, and AJA drafted the manuscript, with significant
Laar et al. BMC Health Services Research          (2019) 19:693 Page 12 of 13
inputs from all co-authors. All authors reviewed and approved the final ver- 8. Amoah AG. Sociodemographic variations in obesity among Ghanaian
sion of the manuscript. adults. Public Health Nutr. 2003;6(8):751–7.
9. Cappuccio FP, Micah FB, Emmett L, Kerry SM, Antwi S, Martin-Peprah R,
Funding Phillips RO, Plange-Rhule J, Eastwood JB. Prevalence, detection,
The study was supported by the Novartis Foundation, Basel, Switzerland. management, and control of hypertension in Ashanti, West Africa.
Grant Recipient: Professor Peter Lamptey. The funder, however, played no Hypertension. 2004;43(5):1017–22.
role in the design, data collection, analysis, interpretation of data, writing of 10. Addo J, Agyemang C, Smeeth L, de-Graft Aikins A, Edusei AK, Ogedegbe O.
the manuscript, nor the decision to submit the manuscript for publication. A review of population-based studies on hypertension in Ghana. Ghana
Med J. 2012;46(2 Suppl):4–11.
Availability of data and materials 11. Lloyd-Sherlock P, Beard J, Minicuci N, Ebrahim S, Chatterji S. Hypertension
The dataset generated and/or analysed during the current study is available among older adults in low- and middle-income countries: prevalence,
in the Harvard Dataverse repository, https://doi.org/10.7910/DVN/JJHOTB. awareness and control. Int J Epidemiol. 2014;43(1):116–28.
12. Lamptey P, Laar A, Adler AJ, Dirks R, Caldwell A, Prieto-Merino D, Aerts A,
Ethics approval and consent to participate Pearce N, Perel P. Evaluation of a community-based hypertension
Our study protocol received ethics approval from the Institutional Review improvement program (ComHIP) in Ghana: data from a baseline survey.
Boards (IRBs) of the London School Hygiene and Tropical Medicine (LSHTM) BMC Public Health. 2017;17(1):368.
(Ref: 10152), the Ghana Health Service (Ref: GHS-ERC 04/01/15) and the No- 13. Ghana Statistical Service (GSS) GHSG aII. Ghana Demographic and Health
guchi Memorial Institute for Medical Research, University of Ghana (Ethics Survey 2014. Rockville: GSS, GHS, and ICF International; 2015.
clearance # IRB00001276). Participating in the study was preceded by a writ- 14. Government of Ghana: National Health Insurance Act: Act 852. Accra:
ten informed consent processes, which communicated to prospective partic- Government of Ghana; . 2012.
ipants that their participation in the study was voluntary. It also outlined 15. Witter S, Garshong B. Something old or something new? Social health
measures that the researchers would put in place to ensure privacy, anonym- insurance in Ghana. BMC Int Health and human rights. 2009;9:20.
ity and confidentiality. All participants consented to participate in the study 16. FHI360: Descriptive Analysis of NCD Risk Factors in Three Communities in
and to the publication of their data. Ghana: A pilot study [Unpublished Project Report]. . 2012.
17. World Health Organization: Everybody’s business--strengthening health
Consent for publication systems to improve health outcomes: WHO’s framework for action. 2007.
Not Applicable. 18. WORLD Health Organization. Adherence to long term therapies, time for
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Competing interests 19. Atun R, Jaffar S, Nishtar S, Knaul FM, Barreto ML, Nyirenda M, Banatvala N,
All of the authors declare that they do not have any competing interests. Piot P. Improving responsiveness of health systems to non-communicable
diseases. Lancet. 2013;381(9867):690–7.
Author details 20. MOH: National Policy for the prevention and Control of NCDs in Ghana
1Department of Population, Family, & Reproductive Health, School of Public 2012. Accra: Ghana Ministry of Health; 2012a.
Health, University of Ghana, LG 13, Legon, Accra, Ghana. 2Department of 21. MOH: Strategy for the Management, Prevention and Control of Chronic
Non-communicable Disease Epidemiology, London School of Hygiene & Non-Communicable Diseases in Ghana 2012–2016. Accra: Ghana Ministry of
Tropical Medicine, Keppel St, London WC1E 7HT, UK. 3Department of Global Health; 2012b.
Health and Social Medicine, Harvard Medical School, Boston, MA, USA. 22. de-Graft Aikins A. Healer shopping in Africa: new evidence from rural-urban
4Department of Infectious Disease Epidemiology, London School of Hygiene qualitative study of Ghanaian diabetes experiences. Bmj. 2005;331(7519):737.
and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. 5Family Health 23. Ofori-Asenso R, Agyeman AA, Laar A. Metabolic syndrome in apparently
International 360, DC, Washington, WA, USA. 6Saw Swee Hock School of "healthy" Ghanaian adults: a systematic review and meta-analysis. Int J
Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Chron Dis. 2017;2017:2562374.
Pulau Ujong, Singapore. 24. Ofori-Asenso R, Agyeman AA, Laar A, Boateng D. Overweight and obesity
epidemic in Ghana-a systematic review and meta-analysis. BMC Public
Received: 2 July 2018 Accepted: 30 September 2019 Health. 2016;16(1):1239.
25. Laar A, Aryeetey RN, Akparibo R, Zotor F, Ghana SUNAP. Nutrition sensitivity
of the 2014 budget statement of republic of Ghana. Proc Nutr Soc. 2015;
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