Ghana: An innovative community scorecard and local media allows the community to demand better services

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Practical steps address: 2-3-5-6-7

Insights

  • National roadmaps for universal health coverage should account for quality of care, acknowledging that access means little without attention to the quality of health services delivered.
  • A national, costed strategy provides the blueprint for all activities and allows progress to be monitored over time.
  • Greater alignment efforts and collaboration across health programmes/actors is a key success factor towards reinforcing standards and training approaches.
  • Multimodal interventions can increase sustainability of incremental improvements in WASH services and IPC behaviours, including training for the health workforce.
  • Including WASH and IPC indicators in regular health systems monitoring and facility regulation and accreditation strengthens accountability and understanding of needs.

Context and triggers

The establishment of a national joint IPC and WASH Taskforce in 2016 drove greater leadership and clearer strategic direction on WASH in health care facilities. The taskforce has led the development of a technical guide with standards, operation and maintenance procedures and cleaning protocols, worked to adapt and implement WASH FIT and led efforts to integrate WASH and IPC indicators into the national health systems monitoring framework. These efforts resulted in WASH standards being included in the National Healthcare Quality Strategy (2017–2021), the national AMR strategy, the national guidelines on supportive supervision, IPC policy guidelines,

waste management policy, health facility regulator policy and the occupational health and safety policy. Furthermore, the employer requirement policy for hospital construction and infrastructure development explicitly outlines that health facilities under construction must have a waste management systems/equipment and a main and back-up supply of water including possibly a reservoir, borehole, rain gutter system to harvest rainfall and piped water supply from Ghana Water company.

 

More recently, the COVID-19 pandemic sparked the need to rapidly understand gaps and better target resources. A cross-sectional assessment (including WASH/IPC indicators) of facility preparedness for COVID-19 was conducted in April 2020. This identified priority facilities with poor WASH/IPC services and where rapid installation of hand hygiene facilities and WASH/IPC training was needed.

 

Set targets and define roadmap

The Ghana National Healthcare Quality Strategy calls for having the fundamentals (i.e. WASH) in place in order to improve the health and well-being of Ghanaians through the development of a better-coordinated health system that places patients and communities at the centre. To support these efforts, a national, costed strategy on WASH in health care facilities, with a comprehensive blueprint for coordination and implementation, was published in 2020 and is currently being disseminated across districts and regions. It lays out the legal and regulatory framework that includes quality, IPC, WASH and health care waste standards. It also links WASH in health care facilities to national activities to reduce maternal mortality, and specifically, the work of the Quality of Care Network, which aims to improve quality of care for mothers and newborns in selected learning districts. Finally, costs for WASH infrastructure and recurrent operation and maintenance are set out in the strategy, with 80% of the projected costs financed from domestic resources. At the district level, partners have supported the development of long-term WASH plans, making budget commitments to address shortfalls.

Establish standards and develop health workforce

Standards on WASH, IPC, and health care waste management have recently been updated to include climate-resilient considerations and reflect latest evidence. WASH and IPC standards have been included in regular health systems monitoring (DHIS-2), health facility regulation and accreditation. Compliance is overseen by the infrastructure unit of the MoH. Pre-service curricula have been reviewed to include WASH/IPC in order to create and develop a culture and institutionalize issues regarding WASH/IPC. Regular in-service training for facility staff on WASH, IPC, health care waste management, safe burial practices and contact tracing and surveillance also helps implementation of standards. Additionally, regular supportive supervision and annual peer review systems have strengthened prioritization and the implementation of standards including environmental or climate-smart WASH solutions. The existence of IPC focal persons in all regions and facilities has contributed to continued implementation of WASH/IPC programmes and quality improvement.

Engage communities

The community serves a unique and influential role in Ghana’s journey to improve quality, uphold health users’ respect and dignity and improve WASH and IPC. Developed in 2018, the community scorecard is an innovative accountability tool that engages and empowers community members to regularly give feedback and propose solutions for addressing quality areas, including WASH. The

semi-quantitative community feedback is linked to the electronic DHIS-2 system and can be immediately reviewed at the facility, district and national level. Community members also propose ideas for improvements. Simple but important contributions that community members have made include building a fence around the health care waste area to protect children and keep out animals, planting flowers and beautifying the outdoor space of health care facilities and working with other community members to help them understand their rights for, and demand access to, better WASH and IPC services and practices. Ghana Health Services is now planning for a national rollout of the community scorecard and engagement.

Furthermore, WASH is a key component of several engagement and advocacy efforts. It is included in the annual patient safety campaign, the celebration of Global Handwashing Day and focused efforts to improve quality of care for mothers and newborns. These include a public and community engagement component to increase awareness and understanding of possible actions.

Ongoing challenges and gaps

  • Ghana (as with many countries) has a high turnover of health care workers and thus there is a continual need to update skill sets and empower staff.
  • The supportive supervision tool is an effective way to bring together quality, WASH and IPC but needs more frequent use as it is currently limited to twice a year. Information gained during such visits needs more rapid follow up at every level.