Past Study

Individually randomized trial of rapid diagnostic tests in rural Ghana

The study showed that when microscopy is available, the introduction of rapid diagnostic test (RDT) had limited impact on prescriber behavior. In settings without microscopy, using RDT led to a significant reduction in the over prescription of antimalarials, without any evidence of clinical harm, and to a better targeting of antibiotics.

Interviewees’ perception was that the study had a policy impact at the national level. The type of policy influenced was on clinical practice policies on the diagnosis and management of malaria cases. The nature of policy impact was a supportive way: there was already an international movement changing the use of cloroquine to an ACT (artemisinin combination therapy) and looking at the best way to use RDT to target treatment. Researchers participated in policy networks through the dissemination mechanisms at the district and regional level. In terms of political capital, the researcher was member of a task force for malaria diagnostics in Ghana, being involved in the elaboration of theGuidelines for Laboratory Diagnosis of Malaria and in the training of trainers. She also participated in the ACT consortium, a global research partnership that study how best to deploy ACTs (34). ref. Research results can be found in at least two documents (32, 35). (Table 4).

 

 INDIVIDUALLY RANDOMIZED TRIAL OF RAPID DIAGNOSTIC TESTS  IN RURAL GHANA
Analysis areas Key topics Key dates
Research project focus and funding Research aim: the project aimed to study the impact of RDT on prescribing behaviour of clinicians in two types of health facility settings serving the same population: one where microscopy is routinely available and the other where diagnosis is mainly presumptive. It also explored perceptions of clinicians and patients on the use of RDT in the two settings and its cost-effectiveness. 2007
Geopolitical context: Dangme West District, Ghana.
Funders and funding process: Bill and Melinda Gates foundation through the Gates Malaria Partnership (GMP) and the ACT Consortium based at LSHTM.

Budget: 177,500US$

Research project evolution/ process Conception: The initiative came from the researcher. The national malaria control program (NMCP) was contacted at this stage.

Justification: Ghana changed the first line drug from cloroquine to an ACT. Given that ACTs though highly effective, are substantially more expensive than the previous antimalarial, the economic implications of over diagnosis are considerable. RDTs could improve targeting of malaria treatment and could be cost-effective if clinicians prescribe based on test results. There was also the need to understand how best to support the introduction of RDTs for the management of febrile illness, understanding both clinician and patient’s perspectives of the tests The study is considered by the researcher and policy maker as addressing an important, urgent and complex issue.

Study design/Research methods: Randomized controlled trial. The design was defined as good quality study.
Research collaborators: GMP, LSHTM, NMCP, the district research team, DHRC and ACT consortium for the qualitative work.
Key project events/concerns: Nothing to mention.
Main findings/recommendations: Where microscopy already exists, introducing RDT had limited impact on prescriber behaviour. In settings without microscopy, using RDT led to a significant reduction in the over prescription of antimalarials, without any evidence of clinical harm, and to a better targeting of antibiotics. The researcher and the policy maker believed that results were clear and concrete.

Dissemination of findings: results were presented to the community, the district authorities, and the regional health management review. Project report was sent to the national level (NMCP). Presentation at international level-American Society of Tropical Medicine & Hygiene Annual Conference. The researcher believed the results have been communicated effectively but more could have been done (a policy brief).

Main research products Project report and Power point presentation. Done. No policy brief. 2010
Articles: Four articles were published (25, 28, 29, 36).
Policy impacts Level of policy making: National and international level.
Type of policy impact: clinical practice
Nature of policy: supportive way: there was an international movement in this direction being done by the ACT Consortium.
Policy networks: The researcher was a member of a Task Force to develop guidelines for laboratory diagnosis of malaria and participated in the training of trainers. Also, she participated in the ACT consortium.
Political capital: The researcher participation in the task force helped to value the research evidence as well as the researcher.
Policy discourse and debate: discussions about the need of rationalization on the use of antimalarial. Hospitals with microscopy wanted to use the RDT even though the guidelines indicated that they should be used in health facilities where microscopy was unavailable. The NMCP compromise on this was to use the RDTs when the laboratory was not functioning or laboratory technicians were unavailable.
Inclusion in policy documents: National guidelines for laboratory diagnosis for malaria, and guidelines for case management of malaria.

Who benefited: Community and the health system in terms of cost effectiveness of interventions.

Unexpected/intended outcomes: malaria prevalence was less than expected.

2008

2009

 


 

 

Home management of fevers in children under-five: a cluster randomized controlled trial in southern Ghana

The study showed that mortality was reduced by 30% in those using antimalarial and by 44% in those using antimalarial and antibiotic at community level, compared to the standard care. The reduction of mortality between antimalarial treatment alone or adding an antibiotic was not statistically significant (26, 27).

Interviewees’ perception was that the study had a policy impact at the national level. The type of policy influenced was on service policies and clinical practice policies. The nature of policy impact was a supportive way, bringing more evidence of the efficacy of the Home Based Care (HBC) strategy in Ghana. In terms of Policy Networks, authors belong and have links with INDEPTH, TDR/WHO and iCCM (integrated community case management of childhood illness) task force. In terms of political capital, interviewees believed that the project have increased the respect and power of authors on policy dialog. Research results produced evidence on the efficacy of the HBC strategy, in coherence with the existing HBC policies in Ghana which include amoxicillin only in case of respiratory symptoms (33). (Table 5).

 


HOME MANAGEMENT OF FEVERS IN CHILDREN UNDER-FIVE: A CLUSTER RANDOMIZED CONTROLLED TRIAL IN SOUTHERN GHANA

 

Analysis areas

Key topics

Key dates

Research project focus and funding Research aim: to evaluate the impact of adding an antibiotic (amoxicillin) to an antimalarial (artesunate amodiaquine) for treating fever among children 2-59 months of age within the HBC strategy.
Geopolitical context: Dangme West district, Ghana
Funders and funding process: WHO call

2007-2009

Budget: 856,000$

 

Research project evolution/ process Conception: Researchers from DHRC applied to the call.

Justification: Under five mortality increased in Ghana from 1999 to 2003 and remained stagnant in 2006. Main causes of death were malaria (16%) and diarrhoea (15%). This research wanted to see if adding an antibiotic to an antimalarial in the HBC strategy could reduce child mortality more effectively.

Study design/Research methods: Cluster randomized control trial. The study is considered by the researcher and policy makers as addressing an important health problem, an urgent matter and a complex issue. The design was defined as good quality study although they used historical controls due to money and time limitations.
Research collaborators: WHO, Makerere university (Uganda), GHS (malaria and child health programs), DHRC, university of Amsterdam, university of Maastricht.
Key project events/concerns: During the project implementation, RDTcame into the picture, giving an opportunity to distinguish between malaria and pneumonia.
Main findings/recommendations: mortality reduced by 30% in those using antimalarial and by 44% in those using antimalarial and antibiotic, compared with the standard care. The reduction of mortality between antimalarial alone or adding an antibiotic was not statistically significant. These findings are considered to be replicable in similar settings.
Dissemination of findings: to the community, at national level, to WHO and at the Global Health Forum in Geneva in 2008: “Development of a Strategy for Home and Community Management of Malaria and Pneumonia in Children Under Five in Southern Ghana”. To other stakeholders only informally.

 

Main research products Project report and Power point presentation. Done. No policy brief.
Articles: Two articles were published (26, 37).

 

Policy impacts Level of policy making: the study added more evidence on the efficacy of malaria home base care in Ghana that was already being implemented.
Type of policy impact: The level of influence is at national level, on service policies and clinical practice policies.
Nature of policy: research evidence supported the existing policies on HBC.
Policy networks: authors belong and have links with INDEPTH, TDR/WHO and iCCM task force. The project contributed to increase those links.
Political capital: The researcher believed the project have increased the respect and power of authors on policy dialog.
Policy discourse and debate: how to better manage fever at community level, reducing child mortality being cost effective. RDT are not included yet on the HBC, so adding an antibiotic could have been an option at community level.
Inclusion in policy documents: research results supported the HBC strategy in Ghana. The malaria, diarrhoea and pneumonia home based care guidelines prescribes amoxicillin only when there are respiratory signs of pneumonia.

Who benefited: the community and the health system level, having community based agents trained for the HBC strategy.

Unintended outcomes: None.

 

2010

 


 

Assessments of male involvement in family planning decision making and practice and its influence on the uptake of family planning in the Dangme West district.

The study showed that men are not generally involved in family planning (FP) although they are the decision makers in the family. Reasons why FP was not accepted were perceptions on manhood and female promiscuity. Recommendations made were the inclusion of male health staff in FP services, and the sensitization of men and social groups on FP.

One of the two interviewees’ perception was that the study had a policy impact at the district level. The type of policy influenced was on service policies related to FP. The nature of policy impact was redefining and widening accepted beliefs and practices related to FP. Researchers participated in policy networks through the dissemination mechanisms (district and national level). In terms of political capital, the researcher believed that no impact on political capital has been achieved due to the project. District annual reports from 2009 and 2010 mentioned “an increase of FP community campaigns” (38-42). Sessions were organized in the community trying to involve males with the objective to eliminate misconceptions. The use of FP increased in the district (from 8.67% in 2007 to 47% in 2011).

 

ASSESSMENTS OF MALE INVOLVEMENT IN FAMILY PLANNING DECISION MAKING AND PRACTICE AND ITS INFLUENCE ON THE UPTAKE OF FAMILY PLANNING IN THE DANGME WEST DISTRICT

 

Analysis areas

Key topics

Key dates

Research project focus and funding Research aim: the project aimed to assess the extent and nature of male involvement in FP in order to increase family planning utilization.

2005

Geopolitical context: Dangme West District, Ghana.
Funders and funding process: Ghana- Dutch collaboration
Budget: 5.400$

 

Research project evolution/ process Conception: The Ghana- Dutch collaboration helped the GHS to develop research priorities and to finance some projects. This topic is one of the areas the family division works on: repositioning male involvement on FP.

Justification: The study is considered by the researcher and policy makers as addressing an important health problem, an urgent matter (except for 1 policy maker) and a complex issue.

Study design/Research methods: Cross sectional study (household survey) and Qualitative methods (focus groups discussions, in-depth interviews and case studies). The design was defined as good quality study by the researcher and policy makers.
Research collaborators: Dutch government and district team with its health facilities. Those collaborators were involved in the study from the conception until the dissemination of results. The Ghana-Dutch collaboration gave financial and technical support.
Key project events/concerns: the project was identified to address a district program challenge. No national impact was expected.
Main findings/recommendations: the study produced evidence that men are not generally involved in FP while they are the decision makers. Reasons for not accepting FP were perception on manhood and women promiscuity. Some recommendations made where inclusion of man health staff in FP services, and sensitization of men and social groups on FP. Results are considered to be enough clear and concrete and replicable in other settings.
Dissemination of findings: results were presented to the district authorities and at the research dissemination forum reaching around 100 people. A study report was included in the DHRC annual report. The researcher believes that the results could have been communicated more effectively, especially at national level, for example communicating directly the results to family planning division.

 

Main research products Project report and Power point presentation: Done

2006

Articles: no article has been produced.

 

Policy impacts Level of policy making: Researcher expressed that if there was an impact at district level that was due to different studies done at the same time and not exclusively to that one. However, the former district director explained that after that study, health education sessions were organized in the community, inviting males to eliminate misconceptions. The use of FP has increased in the district (from 8.7% in 2007 to 47% in 2011), mainly due to community campaigns conducted in 2009 and 2010.
Type of policy impact: the study influenced service policies on the use of FP.
Nature of policy: redefining/wider the influence in accepted beliefs and practices.
Policy networks: The researcher believed that no impact on policy networks was achieved due to the project. The PM thinks it had an impact at district level.
Political capital: researcher believes that no impact on political capital was achieved due to the project.
Policy discourse and debate: At the point of the study, there was a national concern on the low utilization of FP methods. Low male involvement could be one of the reasons for the low utilization and needed to be addressed.
Inclusion in policy documents: the 2009 and 2010 district annual reports showed realization of more extensive community campaigns on FP.

Who benefited: Directly, men and women in the communities of Dangme West district. Indirectly, their children as well as the research capacity.

Unintended outcomes: None

 

 

2009

2010

 


 

Deployment of rectal artesunate in the Dangme West district for severe malaria in children under five.

The study showed evidence of the feasibility of deployment of rectal artesunate at community level. 

Interviewee’s perception was that the study had a policy impact at the national level. The type of policy influenced was on clinical practice policies regarding the management of malaria cases. The nature of policy impact or the way research influenced policy was in a supportive way (as described in section 4.3): evidence of the efficacy of this strategy existed already (30). Researchers participated in policy networks through the dissemination mechanisms (district, regional and national). In terms of political capital, PI believes researchers gained value in reaching policy agreements: one of the authors was part of the technical committee to elaborate Home management of Malaria, ARI, and Diarrhoea guidelines that includes rectal artesunate on the referrals. Research results can be found in at least three documents (31-33).

 

DEPLOYMENT OF RECTAL ARTESUNATE IN THE DW DISTRICT FOR SEVERE MALARIA IN CHILDREN UNDER FIVE
Analysis areas

Key topics

Key dates

Research project focus and funding Research problem: the project aims to assess the feasibility of the deployment of rectal articulate at community level.

2004

Geopolitical context: Ghana, Tanzania and Mozambique.
Funders and funding process: WHO through a call process.
Budget: 258.000$

 

Research project evolution/ process Conception: WHO put a call on the website.

Justification: Studies on the efficacy of rectal articulate were conducted in Ghana in Navrongo research centre. Dodowa conducted the only study in Ghana to look at the feasibility of deployment rectal artesunate in a real context. The study was considered by the researcher and by the policy makers as addressing an important health problem, an urgent matter and a complex issue.

Study design/Research methods: Observational study with 2 phases (formative and intervention). The design was defined as good quality study.
Research collaborators: WHO, Tanzania and Mozambique research centres, malaria control program, district health director and health centres. Those collaborators were involved in the study from the conception until the dissemination of results giving financial and technical support.
Key projects events/concerns: turnover of staff already trained and difficulties with following systematically all procedures (at community or health facility) were challenges during the implementation of the study.
Main findings/recommendations: the study produced evidence on the feasibility of administrating artesunate at community level, and the compliance of referral to health facility after the drug administration. Results are considered to be clear and concrete.
Dissemination of findings: results were presented to the community, to the district authorities, at the regional health management review, at the national dissemination forum, at the 6th INDEPTH scientific in Burkina Faso (“Using community members to dispense rectal artesunate for the initial management of severe malaria in under-five children in a rural district in Ghana”) and at the Global Health Forum in Geneva in 2008 (“Reaching the Un-Reached in the Event of Severe Malaria in Under Five Children in a Rural District in Ghana”). PI believes that the results have been communicated effectively. More than 400 hundred people received the research results.

 

Main research products Project report and Power point presentation: Done. No policy brief.

2006

Articles: no article has been produced yet.
Policy impacts Level of policy making: the project had an impact at national level, at health managers and at health providers’ level.
Type of policy: the study influenced clinical practice policies on the management of malaria cases.
Nature of policy impact: This was a mobilization of support where research findings supported the feasibility of including rectal articulate on guides and protocols in Ghana.
Policy networks: researchers informed policy makers through the dissemination mechanisms (district, regional and national dissemination forum).
Political capital: the researcher believes they gained value in reaching policy agreements. Research results were considered in policy documents. The researcher expressed that the more research is conducted, the more influence researchers gained.
Inclusion in policy documents: Recommendations are included in the Anti- malaria Drug Policy (MoH), Guidelines for Case Management of Malaria and the Home management of Malaria, ARI, and Diarrhoea guidelines

Who benefited: all children in Ghana and health managers through capacity building.

Unintended outcomes: None.

 

2007

2009

2010

 

 

Inclusion in policy documents: the 2009 and 2010 district annual reports showed realization of more extensive community campaigns on FP.

Who benefited: Directly, men and women in the communities of Dangme West district. Indirectly, their children as well as the research capacity.

Unintended outcomes: None

2009

2010

 


 

Examination of the TB Enablers Package in the Dodowa sub-district of the Dangme West District in the Greater Accra Region of Ghana.

The study showed that 50% of TB cases did not receive any enabler package. Home visits were irregular and the involvement of the community in the program was low.

One of the two interviewees’ perception was that the study had a policy impact at the district level. The type of policy influenced was on governance of the intervention, the way the enabler’s package has to be distributed and supervised. The nature of policy impact was redefining practices related to the management of TB enablers. Researchers participated in policy networks through the dissemination mechanisms at district level. In terms of political capital, the good relationship between the research centre and the program, resulted in another research project in 2011. Finally, The 2011 district annual report described for the first time who (patients and staff) benefited from the enablers package (42).

 

EXAMINATION OF THE TB ENABLERS PACKAGE IN THE DODOWA SUB-DISTRICT OF THE DANGME WEST DISTRICT IN THE GREATER ACCRA REGION OF GHANA

Analysis areas

Key topics

Key dates

Research project focus and funding Research aim: the project aimed to explore the effectiveness of the enabler’s package in Dodowa, looking at the provision, accessibility and patient’s usage.

2009

Geopolitical context: Dangme West District, Ghana.
Funders and funding process: George Town University.
Budget: 6,000$
Research project evolution/ process Conception: The initiative came from the district and research centre, in coherence with the research agenda set with the support of the Ghana- Dutch collaboration. The TB national control program encourages districts to conduct their own research. The strategic plan 2009-2013 specifies that one of the activities is to conduct a situation analysis on enablers.

Justification: The TB program received complains about TB package abuse. TB enablers is one of the core activities of the program. The study is considered by the researcher and policy makers as addressing an important health problem, an urgent matter and a complex issue.

Study design/Research methods: Cross sectional study, with qualitative and quantitative data. The design was defined as good quality study.
Research collaborators: District team and DHRC.
Key project events/concerns: small number of cases (12 cases in the district).
Main findings/recommendations: 50% of cases interviewed did not receive any package. Home visits were irregular and the involvement of the community in the program was low. No recommendations made. Findings cannot be generalized to other districts.
Dissemination of findings: Dissemination was local. Informal communication to the TB program.

2010

Main research products Project report and Power point presentation: Done. No policy brief
Articles: None
Policy impacts Level of policy making: mainly at district level, affecting heath managers and providers.
Type of policy impact: governance of the intervention, the way the enabler’s package has to be distributed and supervised.
Nature of policy: Redefining and widening influence: research leads to a change in current practices of TB enablers.
Policy networks: Participation in the local dissemination mechanism.
Political capital: the study increased the relationship between the research centre and the program, resulting in a new research collaboration 2011.
Policy discourse and debate: There was a need to evaluate the TB package in the country.
Inclusion in policy documents: The 2011 district annual report described for the first time who benefited from the enablers package, suggesting some influence from the project.

Who benefited: district managers and TB patients. It helped to verify miss use of enablers and the need to improve supervision.

Unexpected/intended outcomes: None

2011

 


 

Mutual health Organizations in Ghana and implications for improving the success of health Insurance in Ghana.

The main conclusions were that private schemes had more autonomy in setting premiums and benefit packages, and had higher community participation. Schemes had fewer measures to control moral hazard (mainly through referral letters) and adverse selection (mainly though encouraging household registration) but more measures to control fraud and cost escalation. The following recommendations were made: importance of schemes regulation, building trust and allowing enough autonomy to adapt to local situations.

Interviewees were not sure if the study had a policy impact in terms of inclusion of research findings in policy documents but they do in terms of policy networks and political capital. The influence was at national level and at provider’s level. The type of policy impact was on governance policies. The nature of policy impact was an instrumental use of the research in implementing the national insurance scheme. Researchers participated in policy networks through the dissemination mechanisms at national level. Also, one of the authors belong to a team created to roll out the national insurance. In terms of political capital: one of the authors is a reference person on NHIS in Ghana.

 

MUTUAL HEALTH ORGANIZATIONS (MHO’S) IN GHANA AND IMPLICATIONS FOR IMPROVING THE SUCCESS OF HEALTH INSURANCE IN GHANA

Analysis areas

Key topics

Key dates

Research project focus and funding Research aim: to prepare an inventory of risks mechanisms and other technical features of mutual health schemes in Ghana and its effects on economic sustainability of schemes.
Geopolitical context: Ghana
Funders and funding process: Ghana- Dutch collaboration
Budget: 6,081$

2004

Research project evolution/ process Conception: The initiative came from researchers, after a previous study on community satisfaction, accessibility and sustainability of Dangme West mutual scheme.

Justification: The National Health Insurance Scheme (NHIS) was about to start. Experience from existing MHO’s may benefit the new NHIS. The study is considered by the PI and Policy makers as addressing an important health problem, an urgent matter and a complex issue.

Study design/Research methods: review of the existing MHO’s looking at the structure, financial management and financial position of schemes. The design was defined as good quality study.
Research collaborators: DHRC, Erasmus University (iMTA), district health research team, research division (GHS), and Dutch government. MHO’s were contacted as well during the study design.
Key project events/concerns: difficult communication in the whole country (roads and phone), inclusion criteria, mistrust of MHO (due to political issues).
Main findings/recommendations: Private schemes had more autonomy in setting premiums and benefit package, with higher community participation. Schemes had few measures to control moral hazard (mainly though referral letters) and adverse selection (mainly though encouraging household registration) but more to control fraud and cost escalation. Recommendations: regulation of schemes, building trust and allowing enough autonomy to adapt to local situations. Results are considered to be clear and concrete.
Dissemination of findings: 4 presentations: at University of Ghana (SPH), at Dissemination forum, Public dissemination and at Erasmus University. Not dissemination to participants due to limited money. More than 300 hundred people received the research results at the end of the study.
Main research products Project report and Power point presentation. Done. Policy brief was done and sent to the GHS (Policy, Planning, Monitoring and Evaluation).

2006

Articles: One article was published (43).
Policy impacts Level of policy making: At national level, at provider’s level.
Type of policy impact:  On governance policies
Nature of policy: instrumental use of the research: the knowledge of the PI was used to help the design and implementation of the NHIS.
Policy networks: One of the authors belong to a team created to roll out the national insurance.
Political capital: one of the authors is a reference person on NHIS in Ghana.
Policy discourse and debate: At this stage, the NHIS was starting. The NHIS dates from 2003, the regulation from 2004 and the implementation from 2005.
Inclusion in policy documents: The NHIS act was created in 2003 and its regulation in 2004. Real implementation started in 2005. Interviewees could not show policy documents were research results were included.

Who benefited: academics, policy makers, politicians (NPP as initiating NHIS), NGOs (advocating for the NHIS), CHAG (advocating for access for the poor) and community members.

Unintended outcomes: None

 

© Copyright 2015.Dodowa Health Research Centre, All Rights Reserved.

© 2015. Dodowa Health Research Centre. All Rights Reserved.