Reflections on Ghana scoping visit – May 2019

On the scoping visit I was joined by two colleagues from our partnership: Andrew Seaton, ID Consultant from Glasgow and Chair of the Scottish Antimicrobial Prescribing Group (SAPG); and Rachel McKinney, Antimicrobial Nurse from Edinburgh. Lucie Byrne-Davis and Jo Hart from The Change Exchange and Chloe Tuck from CPA also joined us for the hospital visits. Travel between Accra and Keta was by private minibus and we saw some interesting sights en route.

Overall I think the visit went really well, we learned lots, everything went to plan and we found everyone we met very engaged and welcoming. Some lighter moments from the trip included a walk on the beach at the hotel in Keta, a guided tour of Jamestown in Accra with police escort (staff from Ghana Police Hospital) and being guests of honour at the staff social day at Ghana Police Hospital.

We thought it would be helpful to share some of our experience with other teams.

General information

Provision of healthcare in Ghana – a National Health Insurance Card is available which covers consultations and medicines. Those without a card can access healthcare on a ‘cash and carry’ basis which means they pay for consultations and medicines when they need them. There is also a social welfare system for those who cannot afford healthcare. All government hospitals have Drug and Therapeutics Committees (DTC) and all hospitals follow the national Standard Treatment Guidelines 2017. Guidelines are a 1400 page book laid out by clinical condition. Medicines guidance is dispersed throughout chapters and finding antibiotic guidance was challenging. The number of patients with co-infection with HIV, TB and malaria was very low.

Pharmacies play a major role in providing advice and medicines as there is no community healthcare system like GP Practices. Pharmacies are not permitted to sell antibiotics but many do. Patients seeking medical advice must attend a hospital out-patient department which is akin to OOH service in UK but no appointments just turn up and wait to be seen. If patients are admitted to hospital their family often must assist in taking care of them due to inadequate staffing and sometimes permitted to provide food.

Keta Municipal Hospital

KMH is a Government Hospital in Volta District built in 1926 and relocated in 1935 with 110 beds across 6 wards. There are also clinics where patient attend for planned appointments – Eyes, ENT, Dental. Lab, X-Ray Dept and Theatre also available. They have links with UK and Belgium for teaching on surgery. Main conditions treated are malaria, pneumonia and sepsis. 273 staff, mix of permanent and temporary with 1 pharmacist, 4 doctors, 23 midwives and 84 registered nurses. Also have pharmacy technicians and physician assistants who perform roles that pharmacists and doctors would have in UK. Medical officers and physician assistants prescribe medicines. Nurses in clinics prescribe and nurses on wards can also prescribe if required and do so regularly.

We were welcomed by Israel, Chief Pharmacist, and Emmanuel, Hospital Administrator and were asked to each sign Visitors Book. Then attended a meeting with Hospital Management Committee including the Nurse Director (Matron) and other clinical staff to discuss the purpose of the partnership and what we would be doing on scoping and teaching visits. Relaxed meeting and everyone invited to ask questions. We then had a tour of the hospital to see wards and meet ward staff. Each ward has an ‘In Charge’ or ‘IC’ nurse and also a ‘2 IC’ as deputy/acting IC. We met the Medical Director briefly but he was mostly in the operating theatre during our visit. There is a Monitoring and Evaluation Nurse who supports quality improvement work across all wards.

The DTC meets quarterly and discusses any topics related to medicines, often focus is shortages and national medicines use indicators which involves small survey of practice. Antibiotic indicator is % of out-patients receiving an antibiotic and target is <30%.  An In-service training programme is held every Friday on a clinical topic or mortality review.

Supplies of medicines – there is a government medicines store in each region as main source for stock. Hospitals can also buy stock on open market with DTC inviting tenders and deciding on what to buy (price and quantity). Shortages are common but they try to have more than one supplier to avoid problems. Pharmacy stock system recently computerised but for now also keep a manual ledger.

On visit to wards we noted that all documentation is kept within a patient folder including medical notes and medicines prescribing/administration charts. IV antibiotics prescribed for 48 hours then reviewed and duration is documented on chart for all antibiotic prescriptions. Surgical prophylaxis is routinely given for 48 hours. The Out-patient department has computerised records and prescriptions and they use pre-labelled ‘To take out’ (TTO) packs common medicines.

Barriers to stewardship are that it is new practice in Ghana, no IPC specialists (but do have IPC programme) and staff turnover.

The PPS went well. We collected data from patient notes then convened as a group to discuss compliance with guidelines. There was no guidance for some infections. Bed capacity – official and actual bed numbers in most wards as often demand exceeded the official number of beds. The prevalence of antibiotic use in adult wards was 55.6% and in the children’s ward was 100%.

Ghana Police Hospital

GPH is a 100 bed hospital in Accra set up primarily to provide healthcare for police officers and their families in 1976. It also serves the local populace, expatriates, and person who is in contact with police who requires medical attention e.g. RTAs, crime suspects. The hospital has a core medical staffing strength of 175 personnel (medical consultants, medical specialist, general practioners, dentists, specialist pharmacists and pharmacists, nurses, midwives) and 102 allied health and administrative staff. Majority of patients seen (about 85%) are not police staff/families. There are similarities between the police and military hospitals in Ghana, as most staff are trained police officers and wear police uniform. Nurses can wear police or nurse’s uniform. GPH has many doctors and pharmacists plus physician assistants and pharmacy technicians. The hospital also trains many nursing and pharmacy interns, students on clinical attachment. Nurses do not routinely prescribe medicines but can do so if required.

In Paediatrics branded products are preferred as deemed to be ‘more effective’ than generics which may be of dubious quality. No computerised records or prescribing. The hospital has a Main Pharmacy which provides non out-of -pocket services to entitled patients i.e. police personnel and family members, national health insurance holders, RTA victims. It also has a Chemist on-site which provides medicines at close to cost price on cash and carry basis, and is open 24 hours a day 7 days a week to augment the main pharmacy services.

We were welcomed by Daniel, Director of Pharmacy, and taken to meet with the Hospital Management Committee. Formal meeting in Boardroom with detailed introductions to roles and information about GPH. The Medical Director is the Lead Officer and she is a Consultant Paediatrician. Other key staff present were Directors of Nursing Services, Audit, Finance, Administration, and Clinical Education Lead. Administrative meetings held each Monday and Clinical Education meetings each Wednesday. A large proportion of staff are trained Police Officers and wear full uniform at work. Key aspect of GPH is discipline and ‘chain of command’.  No regular in-service education programme for all staff but there are weekly management and clinical meetings. CPD is mandatory for medical staff, pharmacists and nurses, and staff mostly access CPD opportunities via external training.

The main focus of DTC meetings is selection of required drugs and medical consumables, procurement, analysing tender results to ensure efficacious and reliable drugs/consumables are procured, consider new medicines and can meet on an ad-hoc basis to deal with complaints. Any issues identified by DTC are brought to Management Team and may be addressed by a Clinical Education session. They also use ‘Signal letters’ approved by Medical Director which are memos requesting action. These are actioned via heads of department and cascaded to all staff – chain of command approach means that implementation is successful as staff must follow orders.

The PPS went well. Some difficulties in accessing notes due to ward rounds. No national guideline for some common infections e.g. sepsis, wound infection, so it was difficult to assess compliance with guidelines for some patients. Overall prevalence of antibiotic use was 57.1% in adult wards, 70% in the children’s ward and 100% in the neonatal ward.