report - who · of a dtc aligns with all the essential of a typical dtc in the ghanaian setting....

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Medicines Transparency Alliance Phase 2 Project

REPORT

Strengthening of Drug and Therapeutics Committees

in Public and Private Health Facilities in Ghana

Office of Director of Pharmaceutical Services (ODPS)

Ministry of Health Ghana

March 2015

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Copyrights Medicines Transparency Alliance Ghana (MeTA Ghana) © 2015 Any part of this document could be freely cited or referenced in any form for all technical and/or academic work. Acknowledgements We are grateful to the United Kingdom Development for International Development (DfID) for funding this assessment through the World Health Organization. Technical Support was provided by World Health Organization (WHO) Headquarters as well as Country office for Ghana, under a joint MeTA International secretariat, with Health Action International. We appreciate the support of the Governing Council as well as the Technical and Advocacy sub-group of the Ghana Medicines Transparency Alliance Initiative (MeTA Ghana). All Health Facilities (public, private and faith-based) who contributed to this product are highly appreciated (including all Deputy Directors of Pharmaceutical Services who facilitated access to data). This includes District Pharmacists, Hospital Pharmacists and All health personnel who supported this assessment, Research team from Ghana Health Service. The Ghana Health Service, the Office of the Director of Pharmaceutical Services, Society of Private Medical and Dental Practitioners, are also acknowledged for various inputs into this work. Special thanks goes to the following persons/groups of persons for their technical and administrative support towards the success of this study. Dr Gilles Bernard Forte, WHO Headquarters Geneva Dr Jane Robertson, WHO Headquarters Geneva Deirdre Dimancesco, WHO Headquarters Geneva Dr Tim Reed, Health Action International, Amsterdam Renee Vasbinder, Health Action International, Amsterdam Dr Richelle Harris, DfID, United Kingdom Dr Magda Robalo, WHO Country Office for Ghana Mrs Edith Andrews Annan, WHO Country Office for Ghana Dr Isaac Morrison, MeTA Ghana Chairman Martha Gyansa-Lutterodt, MeTA Ghana Deputy Chairperson, Director of Pharmaceutical Services, Ministry of Health Ghana

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Ms Edith Gavor, Programme Manager, Ghana National Drugs Programme, Ministry of Health Mr Brian Adu Asare, Coordinator for MeTA Phase 2 project in Ghana, Ghana National Drugs Programme, Ministry of Health. Staff of the Office of the Chief Pharmacist. MeTA Ghana Technical sub group MeTA Ghana Administrative sub group MeTA Ghana Governing Council The following agencies are also acknowledged: Ministry of Health National Health Insurance Authority Ghana National Drugs Programme International MeTA Secretariat World Health Organisation, Country office for Ghana, Accra World Health Organisation, Headquarters Geneva Health Action international Conflict of interest statement None of the authors of this report, or anyone who had influence on the conduct, analysis or interpretation of the results has any competing financial or other interests. Authors, key contributors and reviewers Mrs Martha Gyansa-Lutterodt Mrs Edith Andrews Annan Mr Brian Asare Mr Saviour Yevutsey Mr George Hedidor

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Executive Summary A Drug and Therapeutics Committee (DTC) (or equivalent) is a multidisciplinary committee with a commitment to the overall governance of the medicines management system in their health service organization to ensure the judicious, appropriate, safe, effective and cost-effective use of medicines. The World Health Organization (WHO) clearly defines the typical goal of DTCs as; to ensure that patients are provided with the best possible cost effective and quality of care through determining what medicines will be available, at what cost, and how they will be used. Drug Management functions are clearly the core essence of what a DTC is and the functions it should perform. It is a justifiable expectation that functional DTCs should be able to play an important role in promoting rational use of medicines in health facilities based on the definitions and objectives above. Ghana’s health system embraces the DTC concept as a management intervention to ensure correct, efficient, and cost-effective management of drugs. The National Drug Policy 2004 outlines a clear policy direction for DTCs.

The National Drugs policy defines the DTC (within the Ghana health system) to be multidisciplinary in line with above definitions and spells out the expected roles of DTCs in the health system as well as its fundamental interactions with other entities (e.g. central medical stores). The roles of DTCs are even extended to support peripheral health units. The policy also emphasizes, efficient and cost-effective drug management as a key role of the DTCs as well as the contextualization of the national EDL or EML within the health facility. MeTA would therefore partner existing institutions to ensure that DTCs are strengthened to offer the best value for policy implementation in Ghana with respect to health facilities in the country. Objectives The overall goal of this assessment is to strengthen the capacity and the role of DTCs in improving RUM in public and private health facilities. This will be achieved through the implementation of activities in three phases. The objective of this assessment is to assess baseline characteristics of DTC operations in selected health facilities. Methods This assessment determines the state of DTCs in Ghana with respect to the core functions defined in the WHO/MSH DTC manual, which is also in line with the Ghana NDP 2004. It combines quantitative and qualitative methodologies using structured rapid assessment tools including indicator based RUM determinants. Rapid DTC and RUM assessment tools were developed based on WHO/MSH DTC manual. A rapid assessment (census) of which DTCs were functional and which DTC were non-functional was done to determine the ratio of functional to non-functional DTCs. This was done in all 10 regions of Ghana. The DTC/RUM tools were then administered to key officials from sampled health facilities to determine the reasons, underlying factors, the local context and barriers underpinning functionality or non-functionality. Results and analyses The results from the assessment showed that: - in ~59% of health facilities there was a DTC document that indicates its terms of reference including

goals, objectives, functions and membership in the hospital; - in ~74% of health facilities the agenda of the last DTC meeting was available

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- in ~ 75% of health facilities the minutes of the last DTC meeting was available - the earliest date for the last DTC meeting was April 2015, meanwhile 10 facilities had their meetings

in Dec 2014 - an institutional formulary list was available in 90% of facilities - more than 85% of DTC members attended more than half of DTC meetings in 2014 - ~62% of DTCs held 2, 3 or 4 meetings in 2014 - ~74% of DTCs met quarterly Also, - ~73% of DTCs did not have a policy for evaluating new requests for the institutional formulary list in

their health facility - ~74% of DTCs did not have documented criteria for addition and deletion to the formulary in the

health facility - in ~53% of health facilities there was no budget for DTC activities - ~over 80% of DTCs did not have any documented policy for controlling access of pharmaceutical

representatives and promotional literature to hospital staff - ~38% of DTCs had not done any interventions studies to improve medicine use in their health

facilities. The next ~30% had done 1 or 2 interventions studies; and 25% had done 3 or 4 interventions studies.

- ~77% of DTCs had 0-5 educational programmes for staff and patients were presented in 2014 year Recommendations and conclusions DTCs are performing appreciably in some areas and also under performing in other areas of functionality. Thus the benefits possible from the existence of DTCs in the facilities where they exist is not being realized. Specific and targeted training in key areas of DTC functionality where little has been achieved. These include: - medicines interventions studies; - policy and guideline development at the health facility level, on medicines promotion etc. - review of requests for addition and deletion to the institutional formulary; - active engagement of key staff on the benefits of DTCs in reduce lack of interest and apathy There is the need for a clear central level policy on funding of DTC activities. The medicines policy review, which is currently ongoing, offers an opportunity to streamline this area of DTC action. Regular peer review and sharing of best practices is important. This would ensure that DTCs, which are performing appreciably, are able to share their innovation with others to help them implement. There are health facilities without any DTC structures. These require complete setup actions with the necessary monitoring to ensure they develop. From this assessment it has been established that even functional DTCs are underperforming with respect to the scope of the expected functionalities of DTCs according to standard DTC guidelines and according to national medicines policies. These functional DTCs must be supported to expand their functional areas to offer the best outcomes for healthcare delivery.

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Table of Contents Table of Contents ....................................................................................................................................... 2 List of Tables............................................................................................................................................... 6 List of Figures ............................................................................................................................................. 6

1 Introduction ............................................................................................................................................. 7 1.1 Background ...................................................................................................................................... 7 1.2 Policy implementation Gaps for the DTC policy in Ghana ............................................................... 9

2 Goals and Objectives ............................................................................................................................. 10 3 Methodology ......................................................................................................................................... 10 4 Results ................................................................................................................................................... 11

4.1 Regional census on functional and non-functional DTCs ............................................................... 11 4.2 In-depth assessment of functional and non-functional DTCs ........................................................ 12

4.2.1 DTC Process indicators ______________________________________________________ 13 4.2.2 RUM indicators ____________________________________________________________ 15 4.2.3 Impact and outcome indicators- quality of care and adherence to documented policies _ 15

4.3 Factors determining (enhancing or limiting) DTC functionality ..................................................... 16 4.3.1 Challenges of DTCs limiting DTC functionality in health facilities _____________________ 16 4.3.2 Best practices enhancing DTC functionality in health facilities _______________________ 16

4.4 General comments and suggestions from facilities on how to improve on DTCs ......................... 16 5 Discussions ............................................................................................................................................ 17 6 Recommendations and Conclusions...................................................................................................... 20 7 Acknowledgements ................................................................................................................................. 2 8 References ............................................................................................................................................. 21 9 Annexes ................................................................................................................................................. 21

9.1 Annex 1: DTC rapid assessment tool- Initial assessment, census .................................................. 21 9.2 Annex 2: Indicator-based performance assessment tool for drugs and therapeutic committees 22 9.3 Annex 3: DTC Status in 121 Health Facilities in 6 regions .............................................................. 24

List of Tables Table 1: Number and regional distribution of health facilities included in the census ................................ 11 Table 2: Regional distribution of Health Facilities included in the in-depth assessment ............................. 12 Table 3: Regional distribution of Health Facilities included in the in-depth assessment ............................. 13 Table 4: DTC meeting attendance in 2014 ................................................................................................... 14 Table 5: Number of DTCs meetings held in 2014 ......................................................................................... 14 Table 6: Intervention studies carried out by DTCs ....................................................................................... 14 Table 7: Educational programmes carried out by DTCs ............................................................................... 14 Table 8: Frequency of DTC meetings ............................................................................................................ 14 Table 9: Indicators for rational use of medicines in health facilities [n=61]................................................. 15 Table 10: Indicators for consulting and dispending time in health facilities [n=61] ..................................... 15 Table 11: DTC impact and outcome indicators in health facilities [n=61] .................................................... 15 List of Figures Figure 1: Percentage of outpatient encounters with an antibiotic prescribed from 1999 to 2013 in Ghana

(Pharmacy Unit, Annual Report, 2014) .................................................................................................. 8 Figure 2: Regional distribution of Health Facilities included in the census ................................................. 11 Figure 3: Health Facilities with Functional or non-functional DTCs, by percentage ..................................... 12 Figure 4: Ratio of Total Facilities with Functional DTCs to Total Facilities with non-functional DTCs .......... 12

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1 Introduction

1.1 Background A Drug and Therapeutics Committee (DTC) (or equivalent) is a multidisciplinary committee with a commitment to the overall governance of the medicines management system in their health service organization to ensure the judicious, appropriate, safe, effective and cost-effective use of medicines (Australian Commission on Safety and Quality in Health Care, 2012). This definition of a DTC aligns with all the essential of a typical DTC in the Ghanaian setting. However for the purposes of this report, the contextual interpretation is that of a DTC within the hospital or health facility setting at regional and district levels of Ghana. The World Health Organization (WHO), clearly defines the typical goal of DTCs as; to ensure that patients are provided with the best possible cost effective and quality of care through determining what medicines will be available, at what cost, and how they will be used. WHO also defines the objectives of the typical DTC to be as follows: – to develop and implement an efficient and cost-effective formulary system which includes

consistent standard treatment protocols, a formulary list and formulary manual – to ensure that only efficacious, safe, cost-effective and good quality medicines are used – to ensure the best possible drug safety through monitoring, evaluating and thereby

preventing, as far as possible, adverse drug reactions (ADRs) and medication errors – to develop and implement interventions to improve medicine use by prescribers, dispensers

and patients; this will require the investigation and monitoring of medicine use. (Holloway & Green, 2003)

Drug Management functions are clearly the core essence of what a DTC is and the functions it should perform. It is a justifiable expectation that functional DTCs should be able to play an important role in promoting rational use of medicines in health facilities based on the definitions and objectives above. Ghana’s health system embraces the DTC concept as a management intervention to ensure correct, efficient, and cost-effective management of drugs. The National Drug Policy 2004 outlines a clear policy direction for DTCs. The policy states that – The MOH shall provide guidelines and ensure the establishment of Drug and Therapeutics

Committees (DTCs) in all major health facilities (government, quasi-government and private) in the country in order to ensure correct, efficient, and cost-effective management of drugs.

– The membership shall include representatives of the medical, pharmaceutical, nursing and administrative services of the institution.

– The committees, shall amongst other duties, be responsible for: Selection of drugs for use based on the National EDL; Accurate estimation of pharmaceutical requirements for both the hospital itself and any peripheral health units served by the hospital; Control and management of drug-related expenditure; Monitoring of the use of the therapeutic guidelines and overall drug utilization; Institution of appropriate measures for the prompt, safe and efficient disposal of expired drugs; Instituting measures to be employed in cases of drug shortage; and Any other matters relating to the rational use of drugs.

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– The MOH shall ensure, through the DTCs and in collaboration with the Central Medical Stores (CMS) and other agencies where appropriate, the redistribution of unwanted, but otherwise unexpired medicines, in public sector health facilities. (Ministry of Health, Ghana National Drugs Programme , 2004)

The policy defines the DTC (within the Ghana health system) to be multidisciplinary in line with above definitions and spells out the expected roles of DTCs in the health system as well as its fundamental interactions with other entities (e.g. central medical stores). The roles of DTCs are even extended to support peripheral health units. The policy also emphasizes, efficient and cost-effective drug management as a key role of the DTCs as well as the contextualization of the national EDL or EML within the health facility. Based on the above, it could be deduced that the DTCs are expected to serve as a platform for implementation of policies on selection and procurement of essential medicines, rational use of medicines etc., as well as implementation of treatment protocols and guidelines (such as Standard Treatment Guidelines-STGs) in health facilities. DTCs thus could be said to play a role in ensuring efficiency in health care delivery and drug management to offer the best value as well as the best health outcomes for the patient at a reasonable cost. The above provisions and definitions have yielded some benefit in implementation. In Ghana, the DTC platform at some health facilities have been used to promote the stocking, prescribing and dispensing of zinc tablet together with ORS in the treatment of diarrhea in children. (MOH,GNDP/WHO, Better Medicines for Children Project, 2012) Also data from the Office of the Chief Pharmacist, Ghana Health Service, suggest that in vestments in DTCs align with increases and decreases in antibiotic prescribing at the OPD level in health facilities (Office of the Chief Pharmacist, 2014). DTC workshops, sensitizations and trainings are able to ensure that existing DTCs become active and improve drug management. However, with irregular and paucy nature of investments in DTCs, the gains are not sustainable. Clearly, sustainable approaches to DTC investments and interventions could play a role in ensuring the preservation of any benefits gained.

Figure 1: Percentage of outpatient encounters with an antibiotic prescribed from 1999 to 2013 in Ghana (Pharmacy

Unit, Annual Report, 2014)

56.3

40.5 41.4 43.1

36.4

45.2 40.7

37.6

48.7 49.5

42.0 43.6 43.3 41.4 39.9

15.0

25.0

35.0

45.0

55.0

65.0

75.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

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Recent reports from the Regional and District Hospitals under GHS do indicate that very few of them have established DTCs. Furthermore, those which have them have implementation difficulties, with the majority of them regrettably lagging behind. In hospitals where these committees are not in existence or do not function well, it is obvious that the decisions on the therapeutic management of patients are left in the hands of a few individuals. The consequences of this situation could be far reaching. Again, by their very absence, reports on the negative impact or adverse events on drug use are not available. These problems could be far worse-off in private facilities where DTC concept had not been institutionalized. As part of the strategy for improving rational use of medicines in Ghana, MeTA sought to collaborate with the Ministry of Health and the private sector to promote the rational use of medicines concepts and to strengthen existing DTCs as partners to improve prescribing, dispensing and use of medicines by health workers and clients. This is intended to bring to bear possible innovations to ensure sustainable system wide approaches are employed to sustain the gains made in DTC strengthening exercises. This is a report on a baseline assessment of DTCs in Ghana, focusing on DTC status (functional or non-functional), factors leading to non-functional DTCs, factors leading to functional DTCs (best practices), and recommendations on possible sustainable interventions for improving DTC functionality in the health system. (Office of the Director of Pharmaceutical Services, 2014) MeTA would therefore partner existing institutions to ensure that DTCs are strengthened to offer the best value for policy implementation in Ghana with respect to health facilities in the country. (Medicines Transparency Alliance Ghana, 2012) 1.2 Policy implementation Gaps for the DTC policy in Ghana

The number of functional DTCs in private hospitals as well as in district hospitals in the public sector is unclear.

Whereas there are functional DTCs in all Regional Hospitals, existing reports suggest that a few out of the functions of DTCs as stated in the WHO framework for the implementation of DTCs, are being implemented. (Office of the Chief Pharmacist, 2012) (Holloway & Green, 2003)

One of the contributing factors is the continuous attrition of health workers. Also, there is recruitment of newly qualified health professionals who do not have the rudiments of DTCs. This is partly due to the fact that the training curriculum does not emphasize the importance of DTCs. There is therefore the need to continuously train and retraining health care providers.

The non-functioning of some DTCs has been attributed to lack of buy-in by heads of health facilities; hence low or no support for DTC activities.

Some of the best practices ensuring the proper functioning of DTCs in some hospitals are not being shared with other DTCs in other regions and health facilities.

Lack of capacity of DTC members to identify and address drug management problems in the facilities has also contributed to poor performance of some DTCs in the country.

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The direct implication of the above challenges has been the resulting drug management problems, which impact both clinical and public health outcomes. Studies have revealed that 6 out of 10 inpatients receive more than 1 antibiotic in some facilities. At the OPD level, some prescribers prescribe antibiotics to more than 6 out of 10 outpatients. Reports from the monitoring activities of the Pharmacy Unit, MOH, confirmed by reports from the NHIA reveals an ever increasing cost (>50% of the value of claims) and high consumption of medicines in health facilities. (Office of the Chief Pharmacist, 2012)

2 Goals and Objectives The overall goal of this assessment is to strengthen the capacity and the role of DTCs in improving RUM in public and private health facilities. This will be achieved through the implementation of activities in three phases. The objective of this assessment is to assess baseline characteristics of DTC operations in selected health facilities.

3 Methodology This assessment determines the state of DTCs in Ghana with respect to the core functions defined in the WHO/MSH DTC manual, which is also in line with the Ghana NDP 2004. It combines quantitative and qualitative methodologies using structured rapid assessment tools including indicator based RUM determinants. Rapid DTC and RUM assessment tools were developed based on WHO/MSH DTC manual. A rapid assessment (census) of which DTCs were functional and which DTC were non-functional was done to determine the ration of functional to non-functional DTCs. This was done in all 10 regions of Ghana. The DTC/RUM tools were then administered to key officials from sampled health facilities to determine the reasons, underlying factors, the local context and barriers underpinning functionality or non-functionality. The data was entered into a spreadsheet application based on MS Excel 2010, and analyzed with IBM SPSS statistic version 21. The data was analysed for ‘Bottle necks’ and challenges as well as potential best practices for operating DTCs in the local setting. Best practices of functional DTCs were documented for replication in other DTCs. The potential for sustainable DTC models were also explored. Functional areas under investigation: DTCs were assessed based on the functional framework provided by WHO/MSH as indicated below: 1. Providing advice on all aspects of drug management 2. Developing drug policies

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3. Evaluating and selecting drugs for the formulary list 4. Developing (or adapting) and implementing standard treatment guidelines 5. Assessing drug use to identify problems 6. Conducting interventions to improve drug use 7. Managing adverse drug reactions and medication errors 8. Informing all staff members about drug use issues, policies and decisions

4 Results

4.1 Regional census on functional and non-functional DTCs Out of 10 regions targeted, consistent data was obtained from 6 regions as indicated in the figure below. Respondents: Deputy Directors of Pharmaceutical Services (DDPSs), Ghana Health Service, 2014

N=121 health facilities from 6 regions including public, private and mission/faith-based sectors

Table 1: Number and regional distribution of health facilities included in the census

Sectors Southern zone - Regions Northern zone - Regions

Greater Accra

Western Volta Brong Ahafo

Northern Upper East

Total

Public 21 14 15 19 16 5 90

Private 0 3 0 0 7 0 10 Mission/faith-based 1 4 7 1 7 1 21 Total 22 21 22 20 30 6 121

Figure 2: Regional distribution of Health Facilities included in the census

Out of 121 health facilities included in the census, 69% were reported on as having a DTC in place. The majority, 73% (i.e. 61 out of 121 facilities) of this 69% (i.e. 83 out of 121 facilities), was reported as being functional DTCs.

19 21

16

5

15 14 90

1 1

7

1

7

4 21

0 0

7

0 0

3 10

Brong Ahafo

Region

Greater Accra

Region

Northern

Region

Upper East

Region

Volta Region Western

Region

Total

Public (district hospitals) Mission/faith-based hospitals Private hospitals

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Respondents: Deputy Directors of Pharmaceutical Services (DDPSs), Ghana Health Service, 2014

Figure 3: Health Facilities with Functional or non-functional DTCs, by percentage

The Ratio of Functional to Non-Functional DTCs in all regions reported on, is as indicated below Respondents: Deputy Directors of Pharmaceutical Services (DDPSs), Ghana Health Service, 2014

Figure 4: Ratio of Total Facilities with Functional DTCs to Total Facilities with non-functional DTCs

4.2 In-depth assessment of functional and non-functional DTCs Table 2: Regional distribution of Health Facilities included in the in-depth assessment

Region Number of Health Facilities %

Ashanti Region 8 13%

Brong Ahafo Region 7 12%

Eastern Region 13 21%

Greater Accra Region 8 13%

Northern Region 7 12%

Upper East Region 3 5%

Volta Region 6 10%

Western Region 9 15%

Total (N) 61

No 31%

Yes 69%

Does the facility have a DTC

No 27%

Yes 73%

For facilities that have DTCs are the DTCs active

0.6

1.0

0.3

0.8

1.0

0.2

0.7

Brong Ahafo Region

Greater Accra Region

Northern Region

Upper East Region

Volta Region

Western Region

Total

Ratio: Presence of DTC: Satus-Active

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4.2.1 DTC Process indicators Table 3: Regional distribution of Health Facilities included in the in-depth assessment

Process Indicator Number of Facilities %

Is there a DTC document that indicates its terms of reference including goals, objectives, functions and membership in your hospital?

No 24 39% Yes 36 59%

Availability of agenda of last DTC meeting * No 15 25%

Yes 45 74%

Availability of minutes of last DTC meeting* No 14 23%

Yes 46 75%

Date of last DTC meeting* Earliest date for the last DTC meeting

Furthest date for the last DTC meeting (8 facilities had their last meeting in Mar-15, 10 in Dec-14, 7 in Nov-14 and 4 in Sep-14)

Apr-15 Jun-08

Is there a DTC Budget? No 32 53%

Yes 28 46% Yes and No 1

Availability of institutional formulary list (IFL) No 6 10%

Yes 55 90%

Do you have policy for evaluating new requests for the institutional formulary list in your facility? *

No 44 73% Yes 16 26%

Are there documented criteria for addition and deletion to the formulary in your facility? *

No 45 74% Yes 15 25%

Is there any documented policy for controlling access of pharmaceutical representatives and promotional literature to hospital staff? **

NA 4 7% No 45 74% Yes 12 20%

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What percentage of DTC members attend more than half of meetings in 2014? Table 4: DTC meeting attendance in 2014

Range of percentages

Number of Facilities

%

0-25 4 8% 25-50 2 4% 50-75 12 23% 75-100 34 65%

* 3-6 facilities did not respond, possibly did not have the data

How many DTC meetings have been held in 2014? Table 5: Number of DTCs meetings held in 2014

Number of meetings

Number of Facilities

%

None 11 3% One meeting 7 3% Two meetings 10 16% Three meetings 14 23% Four meetings 14 23% Five meetings 1 2% Ten meetings 1 2%

* 3 facilities did not respond appropriately and were excluded from the analysis, possibly did not have the data

How many intervention studies to improve medicine use have been conducted? Table 6: Intervention studies carried out by DTCs

Number of interventions studies

to improve RUM

Number of Facilities *

%

0 21 38% 1 to 2 17 30% 3 to 4 14 25% 5 to 6 1 2% 7 to 10 0 0% 11 to 15 3 5% Greater than 15 0 0%

* 5 facilities did not respond, possibly did not have the data

How many educational programmes for staff and patients were presented in 2014 year? Table 7: Educational programmes carried out by DTCs

Number of educational programmes for staff and

patients

Number of Facilities*

%

0 to 5 47 77% 6 to 10 5 8% 11 to 15 2 3% 16 to 20 1 2% 21 to 25 1 2% 26 to 30 0 0% Greater than 30, several 2 3%

* 3 facilities did not respond appropriately and were excluded from the analysis, possibly did not have the data

Table 8: Frequency of DTC meetings

Frequency of DTC meetings

Number of

Facilities

%

Monthly 1 2% Quarterly 44 75% Biannually 2 3% Not frequent 4 7% None 8 14%

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4.2.2 RUM indicators Table 9: Indicators for rational use of medicines in health facilities [n=61]

Minimum Maximum Average Median Standard deviation

Number of medicines in the hospital formulary list

85 590 236.2 223 99.1

Number of antimicrobials in the formulary

12 103 37.5 35.5 16.7

Average number of drugs per encounter

1.90 13.5 3.43 3.20 1.43

Percentage drugs prescribed by generic names

8.4 100 76.98 82.7 20.0

Percentage of encounters with an antibiotic prescribed

12.5 80 41.2 36.9 18.15

Percentage of encounters with an injection prescribed

1.4 36.7 13.2 11.85 8.23

Percentage of drugs prescribed from the EML

40 100 89.1 93.6 13.3

4.2.3 Impact and outcome indicators- quality of care and adherence to documented policies Table 10: Indicators for consulting and dispending time in health facilities [n=61]

Minimum Maximum Average Median Standard deviation

Average duration of consultation (in minutes)

2.3 120 13.4 5 24.3

Average duration for dispensing of drugs (in minutes)

0.5 30 6.64 3 8.1

Table 11: DTC impact and outcome indicators in health facilities [n=61]

Impact and outcome indicator Number of

Health Facilities %

Policy for evaluating adverse drug reactions

No 24 39.3% Yes 35 57.3%

Policy to assure drug product quality No 33 54.1%

Yes 26 42.6%

Policy to assure drug procurement from approved sources * No 16 26.2%

Yes 44 70.5%

Policy to monitor medication errors No 27 44.2%

Yes 33 54.1%

Policy to conduct antimicrobial resistance surveillance* No 54 88.5%

Yes 5 8.2%

* 2 facilities did not provide data on this

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4.3 Factors determining (enhancing or limiting) DTC functionality

4.3.1 Challenges of DTCs limiting DTC functionality in health facilities 1. …” Some midwives are still prescribing antibiotics other than the routine pregnancy drugs

with the excuse to lessening the burden of prescribers and also some prescribers writes two months (60days) supply of drugs which makes consumption paten erratic which can cause over stocking leading to expiring of the drugs”…

2. ...”With only two pharmacists on the committee, sometimes activities that need to be pursued are delayed because of the work load”…

3. …” Lack of staff to stand in for members during meeting periods”… 4. …”No formal training on DTC for members”… 5. …”Lack of commitment of some members towards the activities of DTC”… 6. …”Budgetary proposals are often times not approved”… 7. …”No allowance for committee members and the investigating team”… 8. …”Low remuneration compared to other facilities”… 9. …”Clinical activities mostly clash with meeting days, hence affecting the attendance of most

prescribers and ward managers”… 10. ...”Lack of participation of some core management staff due to busy schedules”…

4.3.2 Best practices enhancing DTC functionality in health facilities 1. …”Renovation and expansion works of pharmacy block is ongoing for more space and

privacy of our clients”… 2. …”Availability of essential medicines in spite of NHIS delays in reimbursement”… 3. Follow up interventions revealed that this has been made possible through timely

interventions with stocking arrangements from regional medical stores. 4. …”Institution of clinical meetings has improved knowledge of prescribers which has

enhanced rational use of medicines”… 5. …”Without a diagnosis, no staff will attend to any prescription (i.e. Every prescription comes

only after a clear diagnosis)”… 6. …”With the support of management, air conditioners have been installed to maintain a

conducive storage system for the medicines. Fridges and thermometers have also been procured to maintain the cold chain system”…

7. …”Regular discussions of internal NHIS vetting results at DTC has reduced rejections of claims”…

4.4 General comments and suggestions from facilities on how to improve on DTCs 1. …”Each members view must be respected. Also key stakeholders in the hospital must be on

the committee”… 2. …”There should be regular interaction among DTC members from other facilities, so as to

promote sharing ideas”… 3. ...”Conduct more training on medication use. Improve on communication among DTC

members “… 4. …”Ministry of Health should provide terms of reference as a manual for DTC operation in

the country”…

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5. …“1. Prompt and regular NHIS reimbursements to reduce stock outs of some essential medicines. 2. More educational presentations can be done 3. Members should be encouraged to report on time for meetings”…

6. …“To mobilize every resource to get a bigger space for storing medicines, in order to have enough stocks of essential drugs all year round”…

7. …“Management should take keen interest in DTC”…I also need further training to equip me with current skills to manage the activities of the DTC

5 Discussions The initial census based on data from 6 regions is constituted mainly of public health facilities. This reflects the proportion of health facilities from these sectors in the health system. This could be extrapolated to imply that Health Services are being offered predominantly in public health facilities, however in the Northern and Volta regions, there could be a stronger (~47%) contribution from mission/faith-based and private health facilities together. This is due to the availability of these facilities in the districts to provide the needed healthcare. Actual data on hospital attendance would confirm the level of patronage/consumption of services proportionally between these sectors. There is by default, one regional hospital in every region of Ghana, which is known to have functional DTCs. The next hurdle has been with scaling the DTC concept fully at the district level, which is constituted of a larger number of facilities, a wider spread of these facilities, as well as complex challenges, ‘bottlenecks’ and capacity constraints; which has been the main subject of this assessment. From [Figure 3: Health Facilities with Functional or non-functional DTCs, by percentage], the responses indicate that 69% of health facilities at the district level had DTCs with 73% being functional. This leaves 31% health facilities without DTCs and 27% of the 69% DTCs which require strengthening. These categories of health facilities default as targets for specific investments in DTC strengthening programmes. It must also be noted, that 73% functional DTCs (out of 69% HF with DTCs), could be less, because functionality is defined as the extent to which the DTC performs those functions defined by (Holloway & Green, 2003) in the WHO/MSH DTC manual as well as those functions defined in the National Drugs Policy on DTCs (Ministry of Health, Ghana National Drugs Programme , 2004). This made an in-depth assessment relevant using responses from key informants working at the district level to give information of the functions and operations of DTCs at the health facility level. A table of HF requiring DTC setup as well as those requiring specific DTC strengthening interventions, is defined in Annex 3: DTC Status in 121 Health Facilities in 6 regions. This would serve as data for further actions on this programme. Table 2: Regional distribution of Health Facilities included in the in-depth assessment, indicates a fair distribution of the health facilities between the regions included in the in-depth assessments. DTC structures and processes:

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Process indicators were assessed, which investigates the mechanisms and provisions for DTCs and whether these provisions are resulting in any simple desired outputs. The results from the assessment showed that: - in ~59% of health facilities there was a DTC document that indicates its terms of reference

including goals, objectives, functions and membership in the hospital; - in ~74% of health facilities the agenda of the last DTC meeting was available - in ~ 75% of health facilities the minutes of the last DTC meeting was available - the earliest date for the last DTC meeting was April 2015, meanwhile 10 facilities had their

meetings in Dec 2014 - an institutional formulary list was available in 90% of facilities - more than 85% of DTC members attended more than half of DTC meetings in 2014 - ~62% of DTCs held 2, 3 or 4 meetings in 2014 - ~74% of DTCs met quarterly The above does show the existence of some structures in place and some level of activity within the DTCs in a majority of health facilities, which have DTCs as per the DTC census and the process indicators discussed above. Other questions remains: are the structures in place, delivering the actual essence of what the national drug policy (NDP) DTC policy for Ghana stipulates? Are the primary objectives being achieved? Indeed in ~90% of DTCs assessed; there has been the development of an institutional formulary list (IFL), which is a good outcome for DTC functionality. In other areas, DTCs were not functioning at the expected levels in line with the guidelines and national policies.

- ~73% of DTCs did not have a policy for evaluating new requests for the institutional formulary list in their health facility

- ~74% of DTCs did not have documented criteria for addition and deletion to the formulary in the health facility

- in ~53% of health facilities there was no budget for DTC activities - ~over 80% of DTCs did not have any documented policy for controlling access of

pharmaceutical representatives and promotional literature to hospital staff - ~38% of DTCs had not done any interventions studies to improve medicine use in their

health facilities. The next ~30% had done 1 or 2 interventions studies; and 25% had done 3 or 4 interventions studies.

- ~77% of DTCs had 0-5 educational programmes for staff and patients were presented in 2014 year

From the above, inasmuch as some DTC activity seems to exist, many of the core functions of DTCs are underperformed. The development of Institutional formularies seem to be a strong area for DTCs but the formulary management structures would need some strengthening with 74% of DTC not having a clear documented policy for addition and deletion form their formularies. DTCs could be exposed to unethical promotion in the absence ~over 80% of a documented policy for controlling direct access of medicine promotion activities to hospital staff. There is room for improvement in drug intervention studies with ~38% DTC doing no intervention studies on medicine use. In deed the some respondents have indicated ……”Some midwives are still prescribing antibiotics other than the routine pregnancy drugs with the excuse to lessening the burden of prescribers and also some prescribers writes two months (60days) supply of drugs which

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makes consumption paten erratic which can cause over stocking leading to expiring of the drugs”… With the above problems and similar challenges, it is clear that drug interventions studies would give the DTC the necessary data to change certain trends in prescribing behaviour. Some respondents have also indicated the lack of training of DTC members. …”no formal training

on DTC for members”… Since a lot of the DTC functions are of a technical nature, staff would need the required skills to be able to perform them confidently. Also respondents have indicated, that due to low staffing levels, the workload on staff makes it challenging to perform certain DTC activities. ...”with only two pharmacists on the committee, sometimes activities that need to be pursued are delayed because of the work load”… In such settings it is clear that DTC activities especially, meetings may have to be held at off-peak times or other practically workable times as determined by a committed team of DTC members. Respondents did indicate the…”lack of staff to stand in for members during meeting periods”… and also…”clinical activities mostly clash with meeting days, hence affecting the attendance of most prescribers and ward managers”… In ~53% of health facilities there was no budget for DTC activities, there seems to exist, some levels of funding challenges with implementation of DTC planned budgets. Whiles some respondents indicated …”budgetary proposals are often times not approved”…others indicated that…”no allowance for committee members and the investigating team”…as well as …”low remuneration compared to other facilities”…. Rational use of medicines was measured by the standard WHO recommended indicators. Table 9: Indicators for rational use of medicines in health facilities [n=61], gives the full details of the RUM indicators assessed. Table 10: Indicators for consulting and dispending time in health facilities [n=61] also gives some quality of care indicators; which could be impacted directly by functional DTCs. What is immediately evident is the variation in these indicators amongst health facilities. This would support the peer review mechanism ongoing in Ghana and also recommended under the MeTA DTC programme. The table confirms that there are facilities with better RUM profiles than others. Thus cross sharing and cross learning of best practices could yield potential benefits. These must be measured over time to assess which practices are being implemented in other health facilities/DTCs, as well as the impact of these interventions on the RUM indicators. From Table 11: DTC impact and outcome indicators in health facilities [n=61], a number of very important policies are absent in health facilities. These gaps could be bridged with the extension of the functions of DTCs to other important areas in addition to the development of formulary lists. DTC capacity building interventions should therefore expand the scope of work of DTCs especially in those facilities who have the fundamental structures. It thus appear that a clear policy on funding of DTC activities at the health facility level would enhance the drug management functions and could have a potential for net gains comparing the costs of inefficient drug management in health facilities. In deed respondents have indicated in the successes of DTCs that, …”regular discussions of internal NHIS vetting results at DTC has reduced rejections of claims”…This development

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constitutes a huge gain in value to the health facility and is associated with a functional DTC paying attention to NHIA claims. The investments in DTCs could be justified by the value gained at health facilities where DTCs are performing some appreciable levels of functionality. - In some health facilities, in the case of temporary delays in reimbursements, innovations by

the DTC ensures…”availability of essential medicines in spite of NHIS delays in reimbursement”…

- In other health facilities DTCs have embarked on infrastructural project to improve the quality of healthcare delivery in their health facilities. These include …”Renovation and expansion works of pharmacy block is ongoing for more space and privacy of our clients”… as well as the purchase of some useful resources for the health facility…”with the support of management, air conditioners have been installed to maintain a conducive storage system for the medicines. Fridges and thermometers have also been procured to maintain the cold chain system”…

- Another best practice identified in functional DTCs is the concept of clinical meetings which seek to improve the knowledge of health professionals within the health facility leading to improved rational use of medicines …”Institution of clinical meetings has improved knowledge of prescribers which has enhanced rational use of medicines”…

6 Recommendations and Conclusions DTCs are performing appreciably in some areas and also under performing in other areas of functionality. Thus the benefits possible from the existence of DTCs in the facilities where they exist is not being realized. Specific and targeted training in key areas of DTC functionality where little has been achieved. These include: - medicines interventions studies; - policy and guideline development at the health facility level, on medicines promotion etc. - review of requests for addition and deletion to the institutional formulary; - active engagement of key staff on the benefits of DTCs in reduce lack of interest and apathy - There is the need for a clear central level policy on funding of DTC activities. The medicines policy review, which is currently ongoing, offers an opportunity to streamline this area of DTC action. Regular peer review and sharing of best practices is important. This would ensure that DTCs, which are performing appreciably, are able to share their innovation with others to help them implement. There are health facilities without any DTC structures. These require complete setup actions with the necessary monitoring to ensure they develop. The list provided in Annex 3: DTC Status in 121 Health Facilities in 6 regions, serves as a starting point for implementation of such interventions. This list also defines health facilities where DTCs exist but are not functional. Non-functional DTCs must be revived.

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From this assessment it has been established that even functional DTCs are underperforming with respect to the scope of the expected functionalities of DTCs according to standard DTC guidelines and according to national medicines policies. These functional DTCs must be supported to expand their functional areas to offer the best outcomes for healthcare delivery.

7 References 1. Australian Commission on Safety and Quality in Health Care. (2012). Safety and quality

improvement guide. Standard 4: medication safety. Sydney: ACSQHC.

2. Holloway, K., & Green, T. (2003). Drugs and Theraputic Committees: A Practuical Guide. Geneva: World Health Organisation.

3. Medicines Transparency Alliance Ghana. (2012). MeTA Phase 2 Project Workplan for Ghana. Accra, Ghana: World Health Organisation, Health Action International, MeTA Ghana Governing Council.

4. Ministry of Health, Ghana National Drugs Programme . (2004). Ghana National Drug Policy (2nd Edition ed.). Accra, Ghana: Yamens Press.

5. MOH,GNDP/WHO, Better Medicines for Children Project. (2012). The Role of Drugs and Therapeutic Committees in Promoting Access to Child specific medicines. Accra, Ghana: World Health Organisation.

6. Office of the Chief Pharmacist. (2012). Monitoring Report on Rational Use of Medicines. Accra, Ghana: Ghana Health Service.

7. Office of the Chief Pharmacist. (2014). RUM indicator reports. Accra, Ghana: Ghana Health Service.

8. Office of the Director of Pharmaceutical Services. (2014). Protocol for Strengthening Drug and Therapeutics Committees in Health Facilities in Ghana. Accra, Ghana: Medicines Transparency Alliance Ghana.

8 Annexes 8.1 Annex 1: DTC rapid assessment tool- Initial assessment, census

Office of the Chief Pharmacist DTC / RUM strengthening programme

Census on the status of DTCs in district public, private and mission/faith-based facilities in all 10 Regions of Ghana 1. Region: ..................

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Name of Health Facility Does the facility

have a DTC?

For facilities that

have DTCs, are

the DTCs active or

not active

Any notes or comments

1=Yes

0=No

1=Active

0=Not active

e.g.

Yendi Hospital

1

1

Public (district hospitals)

Private hospitals

Mission/faith-based hospitals

NB: You may add more rows as appropriate

8.2 Annex 2: Indicator-based performance assessment tool for drugs and therapeutic

committees

INDICATOR-BASED PERFORMANCE ASSESSMENT OF DRUGS & THERAPEUTICS COMMITTEES (DTCs)

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NAME OF HEALTH FACILITY ………………………………………………………… TOWN /CITY …………………………………… NAMES OF RESPONDING OFFICER …………………………………………………………DATE ……….……………………………………. TELEPHONE NUMBER OF RESPONDING OFFICER……………………………………… EMAIL: …………………..…………………

A. Process indicators Response

1. Is there a DTC document that indicates its terms of reference including goals, objectives, functions and membership in your hospital? (yes / no)

2. How many DTC meetings have been held in 2014?

3. How frequent does the DTC meet?

4. What percentage of DTC members attend more than half of meetings in 2014?

5 Availability of agenda of last DTC meeting (yes / no)

5. Availability of minutes of last DTC meeting (yes / no)

6. Date of last DTC meeting

7. Is there a DTC budget? (yes / no)

8. Availability of institutional formulary list (IFL) (yes / no)

9. Do you have policy for evaluating new requests for the institutional formulary list in your facility (yes / no)

10. Are there documented criteria for addition and deletion to the formulary in your facility? (yes / no)

11. How many educational programmes for staff and patients were presented in 2014 year?

12. How many intervention studies to improve medicine use have been conducted?

13. Is there any documented policy for controlling access of pharmaceutical representatives and promotional literature to hospital staff? (yes / no)

14 State two main achievements of the DTC

1.

2.

15 State two main challenges the DTC is facing

1.

2.

B.1 Impact and outcome indicators-quality of prescription

16 Number of medicines in the hospital formulary list

17 Number of antimicrobials in the formulary

18 Average number of drugs per encounter

19 Percentage drugs prescribed by generic names

20 Percentage of encounters with an antibiotic prescribed

21 Percentage of encounters with an injection prescribed

22 Percentage of drugs prescribed from the EML

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B.2 Impact and outcome indicators- quality of care

23 Average duration of consultation

24 Average duration of dispensing of drugs

B.3 Impact and outcome indicators- adherence to documented policies

25 Policy for evaluating adverse drug reactions (yes / no)

26 Policy to assure drug product quality (yes / no)

27 Policy to assure drug procurement from approved sources (yes / no)

28 Policy to monitor medication errors (yes / no)

29 Policy to conduct antimicrobial resistance surveillance (yes / no)

B.4 How can you improve on the functioning of DTCs?

Any other comments

8.3 Annex 3: DTC Status in 121 Health Facilities in 6 regions

Does the facility have a DTC? 1=Yes 0=No

For facilities that have DTCs, are the DTCs active or not active 1=Active, 0=Not active

Name of Health Facility Sector Region

1. 0 0 SDA Hospital Mission/faith-based hospitals Brong Ahafo Region

2. 0 0 Drobo Hospital Public (district hospitals) Brong Ahafo Region

3. 0 0 Wenchi Hospital Public (district hospitals) Brong Ahafo Region

4. 0 0 Nkoranza Hospital Public (district hospitals) Brong Ahafo Region

5. 0 0 Yeji Hospital Public (district hospitals) Brong Ahafo Region

6. 0 0 Duayaw Nkwanta Hospital Public (district hospitals) Brong Ahafo Region

7. 0 0 Saboba Medical Centre Mission/faith-based hospitals Northern Region

8. 0 0 Tatale Polyclinic Mission/faith-based hospitals Northern Region

9. 0 0 St. Lucy Polyclinic Mission/faith-based hospitals Northern Region

10. 0 0 Baptist Medical Centre Mission/faith-based hospitals Northern Region

11. 0 0 ECG Hospital Mission/faith-based hospitals Northern Region

12. 0 0 King’s Medical Centre Mission/faith-based hospitals Northern Region

13. 0 0 SDA Hospital Mission/faith-based hospitals Northern Region

14. 0 0 ABF Medical Centre Private hospitals Northern Region

15. 0 0 Gods Care Hospital Private hospitals Northern Region

16. 0 0 Fuo Community Hospital Private hospitals Northern Region

17. 0 0 Alshifaa Hospital Ltd Private hospitals Northern Region

18. 0 0 Kabsad Scientific Hospital Private hospitals Northern Region

19. 0 0 Tania Specialist Hospital Private hospitals Northern Region

20. 0 0 Tizaa Royal Hospital Private hospitals Northern Region

21. 0 0 Bimbilla Hospital Public (district hospitals) Northern Region

22. 0 0 Tamale Central Hospital Public (district hospitals) Northern Region

23. 0 0 Damongo Hospital Public (district hospitals) Northern Region

24. 0 0 Zabzugu Hospital Public (district hospitals) Northern Region

25. 0 0 Janga Polyclinic Public (district hospitals) Northern Region

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26. 0 0 Chereponi Polyclinic Public (district hospitals) Northern Region

27. 0 0 Daboya Polyclinic Public (district hospitals) Northern Region

28. 0 0 Karaga Polyclinic Public (district hospitals) Northern Region

29. 0 0 Kpandai Polyclinic Public (district hospitals) Northern Region

30. 0 0 EIKWE CATHOLIC HOSP Mission/faith-based hospitals Western Region

31. 0 0 ASANKRAKWA CATH HOSP Mission/faith-based hospitals Western Region

32. 0 0 AHMAYHA MISSION HOSP DABOASE Mission/faith-based hospitals Western Region

33. 0 0 ST JOHN OF GOD ASAFO Mission/faith-based hospitals Western Region

34. 0 0 GHAPOHA Private hospitals Western Region

35. 0 0 GNMC NSUTA Private hospitals Western Region

36. 0 0 ABA HOSP, TARKWA Private hospitals Western Region

37. 0 0 PRESTEA Public (district hospitals) Western Region

38. 0 0 ESSAM Public (district hospitals) Western Region

39. 1 0 Dormaa Hospital Public (district hospitals) Brong Ahafo Region

40. 1 0 Techiman Hospital Public (district hospitals) Brong Ahafo Region

41. 1 0 Kintampo Hospital Public (district hospitals) Brong Ahafo Region

42. 1 0 Jema Hospital Public (district hospitals) Brong Ahafo Region

43. 1 0 Goaso Hospital Public (district hospitals) Brong Ahafo Region

44. 1 0 Hwidiem Hospital Public (district hospitals) Brong Ahafo Region

45. 1 0 Bole Hospital Public (district hospitals) Northern Region

46. 1 0 Gushegu Hospital Public (district hospitals) Northern Region

47. 1 0 Salaga Hospital Public (district hospitals) Northern Region

48. 1 0 Savelugu Hospital Public (district hospitals) Northern Region

49. 1 0 Walewale Hospital Public (district hospitals) Northern Region

50. 1 0 Bawku West District Hospital, Zebilla Public (district hospitals) Upper East Region

51. 1 0 HALF ASSINI Public (district hospitals) Western Region

52. 1 0 AXIM Public (district hospitals) Western Region

53. 1 0 DIXCOVE Public (district hospitals) Western Region

54. 1 0 TAKORADI Public (district hospitals) Western Region

55. 1 0 ESIKADO Public (district hospitals) Western Region

56. 1 0 TARKWA Public (district hospitals) Western Region

57. 1 0 SEFWI WIAWSO Public (district hospitals) Western Region

58. 1 0 JUABOSO Public (district hospitals) Western Region

59. 1 0 BIBIANI Public (district hospitals) Western Region

60. 1 0 KWASIMINTIM Public (district hospitals) Western Region

61. 1 1 Berekum Hospital Public (district hospitals) Brong Ahafo Region

62. 1 1 Sampa Hospital Public (district hospitals) Brong Ahafo Region

63. 1 1 Nsawkaw Hospital Public (district hospitals) Brong Ahafo Region

64. 1 1 Kwame Danso Hospital Public (district hospitals) Brong Ahafo Region

65. 1 1 Atebubu Hospital Public (district hospitals) Brong Ahafo Region

66. 1 1 Bechem Hospital Public (district hospitals) Brong Ahafo Region

67. 1 1 Regional Hospital Public (district hospitals) Brong Ahafo Region

68. 1 1 Municipal Hospital Public (district hospitals) Brong Ahafo Region

69. 1 1 Pentecost Hospital, Madina Mission/faith-based hospitals Greater Accra Region

70. 1 1 P.M.L. Hospital Public (district hospitals) Greater Accra Region

71. 1 1 Tema General Hospital Public (district hospitals) Greater Accra Region

72. 1 1 Ridge Hospital Public (district hospitals) Greater Accra Region

73. 1 1 Lekma Hospital Public (district hospitals) Greater Accra Region

74. 1 1 La General Hospital Public (district hospitals) Greater Accra Region

75. 1 1 Achimota Hospital Public (district hospitals) Greater Accra Region

76. 1 1 Maamobi General Hospital Public (district hospitals) Greater Accra Region

77. 1 1 Shei Osudoku Hospital Public (district hospitals) Greater Accra Region

78. 1 1 Ada East Hospital Public (district hospitals) Greater Accra Region

79. 1 1 Ga West Hospital Public (district hospitals) Greater Accra Region

80. 1 1 Ga South Municipal Hospital Public (district hospitals) Greater Accra Region

81. 1 1 Tema Polyclinic Public (district hospitals) Greater Accra Region

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82. 1 1 Prampram Polyclinic Public (district hospitals) Greater Accra Region

83. 1 1 Ashaiman Polyclinic Public (district hospitals) Greater Accra Region

84. 1 1 Lekma Polyclinic Public (district hospitals) Greater Accra Region

85. 1 1 Mamprobi Polyclinic Public (district hospitals) Greater Accra Region

86. 1 1 Dansoman Polyclinic Public (district hospitals) Greater Accra Region

87. 1 1 Kaneshie Polyclinic Public (district hospitals) Greater Accra Region

88. 1 1 Ussher Polyclinic Public (district hospitals) Greater Accra Region

89. 1 1 Madina Polyclinic, Kekele Public (district hospitals) Greater Accra Region

90. 1 1 Madina Polyclinic, R/C Public (district hospitals) Greater Accra Region

91. 1 1 Tamale West Hospital Public (district hospitals) Northern Region

92. 1 1 Yendi Municipal Hospital Public (district hospitals) Northern Region

93. 1 1 Presbyterian Hospital, Bawku Mission/faith-based hospitals Upper East Region

94. 1 1 Regional Hospital, Bolgatanga Public (district hospitals) Upper East Region

95. 1 1 War Memorial Hospital, Navrongo Public (district hospitals) Upper East Region

96. 1 1 Builsa North District Hospital, Sandema Public (district hospitals) Upper East Region

97. 1 1 Bongo District Hospital, Bongo Public (district hospitals) Upper East Region

98. 1 1 St Anthony’s Hosp, Ketu North, Dzodze Mission/faith-based hospitals Volta Region

99. 1 1 Comboni Hospital, Sogakope Mission/faith-based hospitals Volta Region

100. 1 1 Battor Hospital (North Tongu) Mission/faith-based hospitals Volta Region

101. 1 1 Margaret Marquart Catholic Hosp. Kpando Mission/faith-based hospitals Volta Region

102. 1 1 Anfoega Catholic Hospital Mission/faith-based hospitals Volta Region

103. 1 1 Mary Theresa Hosp. Papase Mission/faith-based hospitals Volta Region

104. 1 1 St. Joseph’s Hosp. Nkwanta Mission/faith-based hospitals Volta Region

105. 1 1 Keta Municipal Hospital Public (district hospitals) Volta Region

106. 1 1 Ketu South, Aflao, Hospital Public (district hospitals) Volta Region

107. 1 1 Akatsi South Dist. Hosp. Akatsi Public (district hospitals) Volta Region

108. 1 1 South Tongu, Dist Hosp. Sogakope Public (district hospitals) Volta Region

109. 1 1 Central Tongu Dist Hosp. Adidome Public (district hospitals) Volta Region

110. 1 1 Ho Polyclinic Public (district hospitals) Volta Region

111. 1 1 Volta Regional Hospital, Ho Public (district hospitals) Volta Region

112. 1 1 Municipal Hospital, Ho Public (district hospitals) Volta Region

113. 1 1 Soth Dayi Dist Hosp. Peki Public (district hospitals) Volta Region

114. 1 1 Kpando Health centre Public (district hospitals) Volta Region

115. 1 1 Worawora Hospital, Public (district hospitals) Volta Region

116. 1 1 Hohoe Municipal Hosp Public (district hospitals) Volta Region

117. 1 1 Jasikan Hospital Public (district hospitals) Volta Region

118. 1 1 Nkwanta Dist. Hosp Public (district hospitals) Volta Region

119. 1 1 Kete-Krachi Hospital Public (district hospitals) Volta Region

120. 1 1 Effia Kwanta Regional Hospital Public (district hospitals) Western Region

121. 1 1 Enchi Government Hospital Public (district hospitals) Western Region

report - who · of a dtc aligns with all the essential of a typical dtc in the ghanaian setting....

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