Availability and quality of health services are integral to achieving Ghana’s Universal Health Coverage (UHC) and the health-related Sustainable Development Goals (SDGs). Health sector reviews and evidence-based decision-making are required for strengthening country health services.

The World Health Organisation (WHO) 2020 SCORE Assessment for Ghana revealed that Ghana has only 66% of data available to monitor the SDGs hence a deficit of 34% data gap and capacity for systematic assessment of indicators to assess progress towards UHC.

Ghana for the past years has engaged key health partners for support to conduct a comprehensive health facility assessment. Although this was communicated at various national fora, it was during a side meeting at the 75th World Health Assembly held in Geneva, Switzerland that the Minister of Health engaged the Regional Director of the World Health Organisation for Africa, Dr Matshidiso Moeti, for support to undertake a comprehensive assessment of service availability and readiness for Ghana. The request was approved and it became one of  Ghana’s core deliverables to conduct the Harmonised Health Facility Assessment (HHFA) in 2022.

Following this, a series of stakeholder engagements with the Ministry of Health (MoH) and Ghana Health Service (GHS) started with the WHO Ghana Office. This culminated in the identification and establishment of the steering committee involving major health sector agencies under the MoH including GHS, Christian Health Association of Ghana (CHAG), the Private Alliance of Health Practitioners and other key development partners such as USAID, WHO, and FCDO. The steering committee provided oversight and governance for the HHFA implementation, mobilised resources and defined the objectives and scope for the HHFA implementation in the country.

A Technical Coordinating Committee was also set up, involving representatives from the steering committee and other stakeholders such as the Deputy Director General, Director Policy Planning Monitoring and Evaluation Division, Directors of the Institutional Care and Public Health Divisions, Survey Manager, Assistant Survey Manager, Statistician, Data Manager, Head of Monitoring and Evaluation of the Ministry of Health with technical assistance from WHO AFRO and Country Office. This team was set up to facilitate and enhance the overall coordination and implementation of the G-HHFA, provide technical inputs on survey tools and protocols and guidance in accessing facilities, as well as guide adaptation of the data collection tools.

The overall coordination was led by the GHS as the major service delivery entity in Ghana responsible for the operations of all the public health facilities across the country at Regional, District, Sub District and Community levels. The GHS also has the leverage to ensure the use of the survey data to define and update policy and planning to address gaps in health service provision in the country. 

Ghana used the WHO HHFA comprehensive guide as the key reference document for the overall preparation and implementation of the G-HHFA. This gave the country team a thorough understanding and grasp of the concept of HHFA, the modules, questionnaires, related indicators,  data collection tools and analysis platform as well as the overall step-by-step process of conducting HHFA in Ghana.

The outline and brief description of the activities undertaken by the country included:

  1. Stakeholder engagement and Orientation
  2. Tools Adaptation Workshop
  3. Training of Data Managers on CSPro
  4. Trainers of Trainees (ToT) on HHFA Workshop
  5. HHFA Data Collectors and Regional Supervisors Training Workshop
  6. Pilot Testing in 13 Facilities
  7. Data Collection Phase
  8. Fieldwork Monitoring and Validation

Stakeholders Orientation Workshop

The stakeholder engagement and orientation workshop was held on 7th November 2022 at the Volta Hotel, Akosombo. It served as a high-level engagement and broad-based consensus building of the major stakeholders (Divisional Directors and Program Managers) for the Ghana HHFA. The workshop also provided an opportunity for Directors and Senior Managers to make recommendations for the successful implementation of HHFA in Ghana.

Tools Adaptation Workshop

The workshop was used to review and adapt the revised questionnaire for HHFA implementation in Ghana, conduct test runs and validation of the tools as well as document additions and timelines for consolidating all adaptations. The configuration of the questionnaire adaptation comprised the combined core questionnaire for 3 modules namely availability, readiness and management, and finance. Participants in the workshop included Regional Directors, Deputy Directors Clinical Care, HHFA technical implementation team, CSPro experts and data managers/analysts.

Training Of Data Managers On Census And Survey Processing System (Cspro)

A data managers’ training workshop was organised for key data managers on the Census and Survey Processing System (CSPro) Tool adaptation and server configuration. This formed part of the ongoing schedule of activities for the implementation of the Harmonized Health Facility Assessment (HHFA) in Ghana. The workshop served as an in-depth training and capacity-building forum for Statisticians and Data Managers on the CSPro Tools and also outlined their respective responsibilities and expectations for the data collection phase.

Trainers of Trainees (ToT) on HHFA Workshop

A trainer of trainees (ToT) workshop was organised for key persons from the Ministry of Health, Ghana Health Service, the HHFA technical implementation team, and CHAG as well as representatives from WHO. The objectives of the training were to:

  • Describe the HHFA objectives, content, methods, and processes;
  • Explain the content and structure of the questionnaire.
  • Recommend interviewing practices.
  • Explain the basics and the process of data collection in the digital application.
  • Explain how to ensure consistency in data collection.
  • Explain the data collection process and responsibilities.
  • Use the supporting tools and documents for data collection training.
  • Describe how to organize the data collection training and facilitate training sessions in HHFA data collection.

The ToT workshop took place in the Eastern region from the 21st to the 22nd of November 2022 and was facilitated by consultants from WHO. The consultants took participants through the contents and structure of all the sections of the HHFA. All the ToT members were assessed through a series of questions on areas of the questionnaire to enhance their understanding and knowledge of the questions, the reasoning behind the questions, and how to obtain accurate answers. The sessions also provided participants with the skills to conduct and facilitate training sessions appropriately.

HHFA Data Collectors and Regional Supervisors Training Workshop

The Ghana Health Service with support from WHO organized a training workshop for HHFA data collectors and regional supervisors from 23rd November to 2nd December 2022. Participants of the training workshop included Deputy Directors of Clinical Health, Health Information Officers, Health Service Administrators, Regional Health Research Focal Persons and Nurses.

The objective of the workshop was to achieve a common understanding of the Harmonized Health Facility Assessment (HFFA) by all participants. It served as a platform to train data collectors and team leaders in administering the HHFA questionnaire (including electronic versions) and in their roles and responsibilities in data collection. The training approach adopted was participatory and interactive. Practical sessions with hands-on practice with the CSPro were embedded in the training sessions.

Pilot Testing in 13 Facilities

As part of the data collectors’ training, a field test was conducted in 13 facilities in the Eastern region. The pilot test provided an opportunity for trainees to apply the knowledge and skills from the training in conducting interviews in the test facilities. Participants were divided into 10 main groups headed by a team leader and a regional supervisor and provided with tablets for the interview. With support from the Eastern Regional Director of Health Service, 13 facilities were selected for the pilot test which comprised a government hospital, a private hospital, a CHAG hospital, health centres and CHPS. A feedback session was held to share observations from the field and also recommend strategies to address bottlenecks and fine-tune data tools to address field challenges.

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Data Collection Phase

The data collection commenced immediately after the training with about 80 data collectors and 16 regional supervisors grouped into 10 regional teams deployed to the regions. The data collection was planned to be conducted in twenty-two (22) days across the entire country in about 1,443 sampled facilities. Data collection was undertaken between the 5th and 31st of December 2022. Letters of introduction, consent forms, checklist, hard copies of the HHFA questionnaire, country-adapted list of policies and guidelines, ID cards, tablets, power banks and financial support were made available to the data collection teams.

The tablets for data collection were enabled with Ghana Health Service registered sim cards loaded with data to facilitate internet connection and transfer of data to the server. A dedicated cloud server with security features to safeguard against cyber threats was provided for the HHFA exercise. This was monitored daily to check the progress of data collection and check on completeness of information submitted.

Fieldwork Monitoring and Validation

The regional and national supervisors randomly selected and visited teams in the various regions to supervise and monitor activities on the field.  They ensured that the data collectors visited the listed facilities and followed laid down procedures for data collection. Daily debriefing sessions were held (via phone or WhatsApp) to discuss challenges with the administration of the questionnaire using the tablets and uploading of completed forms. An HHFA data collection report was generated twice weekly and shared among the data collectors, team leaders, HHFA technical team and WHO AFRO.

Key Challenges

  • The last quarter of the year is often a busy time for health workers and the core management teams of some facilities visited were not available to coordinate the facility-level interviews.
  • The use of public transportation was a major challenge for some data collectors as it caused delays in reaching the facilities to undertake the assessment.
  • Saturdays and Sundays were included in the assessment period; however, most public health facilities do not have the full complement of staff available on weekends. The absence of the requisite staff to respond to the survey during weekends delayed data collection.
  • Some private facilities refused to answer the section on finance because NHIA does not reimburse them on time.

Recommendations

  • Consider offloading the fuel and transportation components and arrangements to the regional health administrations. This will allow for the organization and management of transport at the regional level based on regional conditions.
  • District health directorates should be involved in the validation of facilities to be assessed in subsequent surveys.
  • The timing of data collection should be carefully planned to avoid the holiday season in any future data collection.

Patrick Kuma-Aboagye, Anthony Adofo Ofosu, Alberta Biritwum-Nyarko, Cornelius Debpuur, Maame Esi Amekudzi, Edith Mansah, Dominic Atweam, Asrat Sofonias, and Francis Kasolo