USING THE PROGRAMME GUIDANCE TOOL TO CONTROL RTIS IN GHANA
BACKGROUND—RAPID ASSESSMENT— RECOMMENDATIONS—EVALUATION
Printed in February 2007
© 2007 World Health Organization and Population Council All rights reserved. Copies of this publication can be obtained from:
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The World Health Organisation is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through the organization, which was created in 1948, the health professions of member countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world of a level of health that will permit them to lead a socially and economically productive life. The Reproductive Health and Research Programme (RHR) focuses specifically on identifying sound interventions for and providing technical assistance to the implementation of reproductive health programmes.
Horizons is a global operations research programme designed to identify components of effective HIV/AIDS programmes and policies; test potential solutions to problems in prevention, care, support, and service delivery; and disseminate and utilize findings. Horizons is implemented by the Population Council under cooperative agreement HRN-A-00-97-00012-00 with the United States Agency for International Development (USAID). Horizons partners are: International Center for Research on Women, International HIV/AIDS Alliance, PATH, Tulane University, Family Health International, and Johns Hopkins University.
Suggested citation: WHO and Horizons Program. 2007. Using the Programme Guidance Tool to Control RTIs in Ghana: Background—Rapid Assessment—Recommendations—Evaluation. Washington, D.C.: World Health Organization and Population Council.
ACKNOWLEDGEMENTS
The authors wish to thank Dr. Placide Tapsoba of the Population Council for his unrelenting support and input, and the staff of the Health Research Unit for their administrative support. We acknowledge the support of the Regional and District Health Administrations, especially their Directors, for facilitating this study. The role of all the data collectors and supervisors is also acknowledged. The data processing team of the Health Research Unit especially Delali Osei, Cecilia Amoakwao, Dominic Kobina, and Gertrude Owusu-Banahene played a key role in the data management of the study. We are also grateful to Janet Tornyei and Mercy Abbey for their role in training the data collectors.
The background paper was written by: Agnes Dzokoto, Nana Mensima Essah, Margaret Amanua Chinbuah, John Gyapong, and Kwaku Yeboah. The authors would like to express their gratitude and appreciation to the heads of various institutions who willingly provided reports and data for the background study. Worthy of note is Dr. Nzambi Khonde of the West African Project to Combat AIDS, who provided many documents for the study.
The following people contributed to the assessment: Health Research Unit, Ghana Health Service: Dr John Gyapong, Principal Investigator; Dr Margaret Amanua Chinbuah: Study Coordinator; Mrs Bertha Garshong, Social Scientist; Mrs Jane Amponsah, Data Manager; National AIDS Control Programme, Ministry of Health, Ghana: Dr Kwaku Yeboah, Technical Advisor; Horizons: Dr Placide Tapsoba, Technical Advisor; Dr Johannes Van Dam, Technical Advisor; WHO, Geneva: Mrs Bidia Deperthes, Technical Advisor; Other collaborators: Dr Agnes Dzokoto, Background Document; Ms Nana Essah, Background Document.
The evaluation report was written by: Dr. E. Kuor Kumoji, Johns Hopkins University School of Public Health; Dr. John Gyapong, Health Research Unit, Ghana Health Service; Dr. Placide Taposba, Population Council, Ghana; Dr. Lisanne Brown, Tulane University, USA; and Dr. Johannes van Dam, Horizons Program/Population Council, USA.
We would like to thank the following people who have contributed to this set of documents: Nathalie Broutet, Hor Bun Leng, Bidia Deperthes, Isabel de Zoysa, Chris Elias, Peter Fajans, Antonio Gerbase, John Gyapong, Sarah Hawkes, Fang ke Juan, Sau Kessana, Janis Kisis, Gunta Ladzane, Francis Ndowa, Nancy Newton, Kevin O’Reilly, Telma Queiroz, Guida Silva, Placide Tapsoba, Johannes van Dam, Guang Zeng.
TABLE OF CONTENTS
Introduction 5
Background of social and 9 health conditions
Rapid assessment 21
Recommendations: 37 Priority interventions
Evaluation 41
Annex 1: 71 List of major stakeholders
INTRODUCTION
Putting RTIs and STIs on the policy agenda
Reproductive tract infections (RTIs)—which include endogenous, iatrogenic, and sexually transmitted infections (STIs)—contribute substantially to the global burden of disease. Recent analysis shows that STIs collectively rank among the five most important causes of unhealthy reproductive life in developing countries. The HIV pandemic is integrally related to this problem: HIV/AIDS is synergistically influenced by the presence of other RTIs (for example, transmission is increased in the presence of other infections).
These infections cause varying degrees of morbidity. Untreated or inappropriately managed RTIs can result in severe consequences for women, men, and neonates. Complications and sequelae of RTIs include pelvic inflammatory disease, ectopic pregnancy, infertility, and adverse outcomes of pregnancy, neonatal morbidity, and death (in the case of HIV/AIDS and genital cancers).
Worldwide, over 34.3 million people are estimated to be HIV positive, and over 333 million new STI cases are added each year.
Appropriate, timely, and systematic management of these infections has thus become a priority intervention. While primary prevention efforts remain imperative, there is growing recognition that prevention work alone cannot eradicate RTIs. These efforts should be complemented with secondary and tertiary prevention activities, including appropriate management, care, and support for infected persons.
The forms such interventions should take will differ from country to country, depending on the epidemiological environment and the social, cultural, and economic contexts that shape transmission and health-seeking patterns.
The RTI/STI Programme Guidance Tool
The RTI /STI Programme Guidance Tool (PGT) identifies and addresses the management, technical, sociocultural, and economic issues that affect the ability of a health system to deliver effective interventions.
The PGT is based on the experiences of countries implementing the Strategic Approach to Improving the Quality of Care of Reproductive Health Services—a methodology that has been implemented by WHO and its partners in 18 countries to date. This approach promotes the concept that appropriate decisions concerning policy and programme development should be based on an understanding of the relationships between those infected with RTIs or at risk of RTI infection, the service delivery system, and the mix of services and interventions being provided.
The goal of the PGT is to obtain a comprehensive mix of interventions for RTI/STI control, which may differ with locations or national programmes. The PGT addresses RTIs (including STIs), examines service capacity, and highlights clients’ perspectives and needs while focusing on quality of care. This locally-led process of programme design encourages collaboration and partnership among a broad range of stakeholders concerned about RTI/STI control and reproductive health.
The World Health Organization and Population Council’s Horizons Program have been working in close collaboration with the Government of Ghana to implement and evaluate the decision-making process and to assist programme managers in prioritizing interventions for establishing programmes for control of RTIs and STIs. The goal of this project was to develop, implement, and evaluate a strategic process for decisionmaking to prioritize interventions for established sexually transmitted and other reproductive tract infections.
The first stage of the Ghana project was characterized by the implementation of the following activities: Formation of a core assessment team; Situation analysis; Review of secondary literature on RTIs/STIs; Dissemination of findings to all stakeholders and identification of gaps and research needs; Discussion and completion of the protocol/instrument to fill gaps for research areas; Rapid field assessment; Preparation of the draft report; and National RTI dissemination workshop.
These activities included: Development of a background paper on RTI/STI to describe the situation and to identify gaps in RTI/STI programmes, based on surveillance data, knowledge about health/illness beliefs, sexual behaviors, and a review of available health services; Review of RTI/STI issues with policymakers and the identification of additional data needs; Implementation of a rapid qualitative field assessment to fill those gaps; and Organization of a dissemination workshop with stakeholders to reach consensus on priorities for interventions.
This document includes these reports:
A background review of demographic, socioeconomic, and reproductive health conditions in Ghana, focusing on STIs, HIV/AIDS, and other infections; Results of a rapid assessment of RTIs conducted in Ghana; Recommendations for priority interventions; and Evaluation of the PGT process.
BACKGROUND OF SOCIAL AND HEALTH CONDITIONS
Preparation of a background paper summarizing the available information on RTIs is invaluable for directing the course of the development, implementation, and evaluation of interventions to address established sexually transmitted and other reproductive tract infections. By reviewing and synthesizing all existing research and service delivery data in the country, a background paper not only constitutes an important document in its own right, it also insures that all those involved in the assessment process have ready access to a common body of knowledge.
The process sought to answer these the key questions: What is the magnitude and nature of RTIs? What is the current national response? What interventions should be included in the national program for addressing prevalent cases of RTIs?
A large part of this study involved a desktop review of available data on RTIs. The data for this paper were gathered from various sources, including: RTI prevalence surveys; KAP studies; policy documents; reports of donors and situation assessments; operations research reports; evaluation of sexual, reproductive, and family planning services; service delivery guidelines; sociological and ethnographic studies; analyses of laws and legislation on reproductive health and gender; and published and unpublished reports on RTIs/HIV/AIDS.
Experts in reproductive health and key personnel of public health projects also were interviewed to obtain additional information and data on RTIs. Some NGOs and governmental institutions were a source of information. The areas for the data collection were discussed by the core assessment team composed of representatives of various units of the Ministry of Health, Society of Private Medical And Dental Practitioners, National Council on Women and Development, Horizons Program/Population Council, National Population Council, and the Ghana Registered Midwives Association, among others.
Economic and social indicators
Ghana is located within the tropics on the West Coast of Africa, occupying a total land area of 238 537 sq. km. Ghana is bordered by Cote D’ Ivoire in the west, Burkina Faso in the north, Togo in the East, and the Atlantic Ocean in the south. Agriculture is the mainstay of the economy, but the country is also rich in mineral deposits such as gold, diamond, bauxite, and manganese. Cocoa and gold for a long time have constituted the main export commodities in the country. The gross domestic product of Ghana, estimated at US$390, is growing on average 5.3 percent per year. One-third of the population, however, is reported to be living below the poverty line. Currently, the economy is going through difficulties attributed mainly to a decline in world market prices for cocoa and gold, the main foreign exchange earners, and against a backdrop of rising fuel prices.
Ghana’s population of 18.4 million has grown at a rate of 2.5 percent a year since 1984. With 44 percent of the population under the age of 15, and more than one-third of the population between the ages of 10 to 24, the country has built-in momentum for further growth. Over 51 percent of the population is female. The adult literacy rate was estimated at 53 percent for women and 76 percent for men in 1995.
Health indicators
The country’s infant morality rate was 57 per 1 000 live births in 1998; the mortality rate for children under five is 108 per 1 000. The maternal mortality rate also is high—214 per 100 000 live births. The total fertility rate was 4.6 in 1998, with the contraceptive prevalence rate for all methods at 22 percent.
Despite these statistics, the health of Ghanaians is improving, although preventable diseases such as malaria and respiratory tract infections are common, often arising from poor environmental sanitation, poverty, low educational status, and limited access to health care and services. In turn, health care delivery is hampered by limited geographical and financial access to health services, poor quality of the services provided, significant wastage, and inadequate resources.
To address these problems, the Ministry of Health has sought to decentralize health services to ensure responsiveness to local needs and increase access to services. A five-year program also provides exemptions for vulnerable groups, providing a basic package of cost effective services.
Documentation of RTIs and STIs
While the incidence of HIV/AIDS is well documented, information is sparse on RTIs, especially iatrogenic and endogenous infections. Although a variety of medical procedures can lead to the development of iatrogenic infections, unsafe abortion poses a particularly common risk. The vast majority of unsafe abortions take place in the developing world, and complications occur after 10 to 50 percent of them.
The number of STIs is increasing, but the reporting and surveillance of these conditions is poor. The prevalence of HIV/AIDS and other STIs show a rapidly increasing rise in Ghana: from one AIDS case in 1986 to 41 229 reported cases by September 2000. The adult prevalence rate increased from 2.6 percent in 1994 to 4.6 percent in 1999; the 1999 rate increased 60 percent over the previous year. Figure 1 shows the rise of AIDS cases in Ghana from 1986 to 2000.
HIV is transmitted mostly (75 to 80 percent) through heterosexual contact; mother-to-child transmission accounts for 15 percent of the cases, and transmission through blood products accounts for 5 percent of the cases. The female to male ratio in 1999 was found to be 2:1 compared to 6:1 in 1987, suggesting an evening out of the epidemic between the sexes. Nearly 90 percent of all people with AIDS are 15 to 49 years old, with the 25 to 34-peak age group accounting for over 42 percent of the total of cases. About half the population is under the age of 15; consequently, a large number of young men and women will be initiating sexual activity.
Figure 1 Reported AIDS cases by year from 1986 to September 2000
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0 6 8 9 0 1 2 3 4 5 6 7 8 9 -8 -8 -8 -9 -9 -9 -9 -9 -9 -9 -9 -9 -9 ec ec ec ec ec ec ec ec ec ec ec ec ec ep-00 D D D D D D D D D D D D D S Dec1987 YEAR
Many factors contribute to the high prevalence in this age group, including early sexual debut, multiple sexual partners, and short-term relationships. In addition, biologically younger women appear to have increased susceptibility and lack of immunity, have less access to STI care, lack awareness, and have little money. The contributory factors include gender inequalities in economic power, marriage, and access to education, information, and health care.
STI prevalence is difficult to ascertain, because diagnosis is highly problematic, especially in women, who are often asymptomatic. Initially STIs as a whole were not recorded on the Communicable Disease 1 (CD1) forms; gonorrhoea was the only notifiable disease. Other RTIs were captured under gynaecological disorders. Thus, no data exist that truly measure the prevalence of these infections in Ghana. The number of gonorrhoea cases reported in the CD1 forms can no longer be accepted as the number of STI cases.
Figure 2 demonstrates the rise of cases of gonorrhoea in Ghana from 1983 to 1999.
Figure 2 Rise of cases of gonorrhoea in Ghana from 1983 to 1999
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Existing data indicate that recurrent candidiasis is a problem and herpes papilloma virus infections are common. Reliable data about other STIs are available for commercial sex workers and women who visited family planning clinics in 1993 and 1997. Female commercial sex workers had an HIV prevalence of over 76 percent, gonorrhoea 34 percent, candidiasis 24 percent, and T. vaginalis over 31 percent. Women at the family planning clinics showed a 7 percent rate for Hepatitis B, high enough to warrant immunization of newborn babies against this disease.
A sentinel sero-surveillance system, instituted in 1990 by the Ministry of Health at 22 sites, provides the trend of HIV infections in particular areas, and when properly applied to the nation as a whole, is an important aid to policymakers and implementers of HIV/AIDS policies in Ghana. With the introduction of syndromic management in 1996, Ghana has trained medical officers and medical assistants to diagnose STIs using this approach.
Use of the syndromic management monitoring forms has resulted in an increase in the number of reported STI cases to the MoH: more cases were reported in 1999 in the Greater Accra Region alone than were reported in the entire country in 1993.
Table 1 STI prevalence, selected populations
Population STIs Percentage
Accra FP attendees, 1993 N. Gonorrhoeae 7
C. Trachomatis 8
Urethral discharge, Ghana facilities N. Gonorrhoeae 52.4
C. Trachomatis 10.5
T. Vaginalis 19
M. Genitalium 10.5
Commercial sex workers HIV 76.6
N. Gonorrhoeae 33.7
C. Trachomatis 10.1
Candidiasis 24.4
T. Vaginalis 31.4
Bacterial vaginosis 2.3
Genital ulcers 10.6
Syphilis 4.6
Pregnant women, sentinel sites Syphilis 0–1.8
Kumasi antenatal attendees Hepatitis B 20
Socioeconomic and cultural norms Until recently, traditional norms and rules in Ghana have restricted people’s sexual behaviour. Among the many ethnic groups, sexual activity before marriage was prohibited and frowned upon. However, the Ghanaian society has undergone a period of transition and has become more permissive. The anonymity of urban life and subsequent reduction in parental supervision has resulted in young people behaving more promiscuously. Various ethnic groups accept polygamy; where spouses are not faithful, the potential is great for rapid spread of RTIs. Polygamy also impinges on gender inequalities within the society, since promiscuity is accepted among men but is abhorred in women. It has implications for issues such as partner notification in case of STI management or positive HIV status.
Sexual networks are crucial to the rate of spread of RTIs in Ghana. Sexual debut and the number and type of sexual partners are important in defining those at risk and the scope and type of interventions necessary. The high prevalence of RTIs, especially HIV, in commercial sex workers enhances the spread of the infection. In populations in which a small number of individuals have a high number of sexual partnerships, the greatest impact on STI control is achieved by interventions directed at this group. This holds true until prevalence reaches a certain threshold rate at which time it becomes endemic in the population and programs cannot concentrate on only core transmitters.
Vulnerable groups
Groups identified as particularly vulnerable are women, youth, police, and other service personnel. Instruments used in such practices as female genital mutilation, hairdressing, manicuring, traditional birth deliveries, and unsafe abortions also increase the risk of transmission of HIV/AIDS and reproductive tract infections.
Women are seen as vulnerable because they are disadvantaged culturally and financially and in education and employment, thus making negotiation in sexual matters difficult.
Among commercial sex workers in Accra who roamed bars and hotels or were street-based, clients were reported to come from varying occupations and educational background; some women serviced only foreigners. Some women turn to commercial sex as a means of coping with difficult economic circumstances.
Police and other service personnel (military, immigration) are at risk of STIs/HIV/AIDS because their operational duties take them away from home for long periods. Other vulnerable groups are homosexuals, bisexuals, long distance truck drivers, and drug addicts, who are especially at risk of contaminated needles. Additional vulnerable groups are mechanics and apprentices, street children, porters, and migrants.
Patterns of health-seeking behaviour
A significant number of individuals still self-medicate using traditional remedies and drugs from chemical sellers. Many people self-medicate with inappropriate antibiotics or improper doses. They obtain the drugs mainly over-the-counter from pharmacies and chemical shops or they use drugs left over from previous prescriptions and those donated by friends and relatives. Many individuals also seek to improve their health through use of local herbs, prayers from priests, or rituals.
The health-seeking behaviour of the community greatly influences the health system’s ability to deliver interventions aimed at STI control. Delay in seeking health care increases the period of infectivity and increases the risk of complications. The known utilization rates of STI management services indicate that MoH facilities are underutilized. The private sector seems to be providing a greater proportion of STI services, although the number of STI clinics in Ghana has risen from four in 1992 to 22 in 2000. Each unit is staffed with a “prescriber” trained in the syndromic management of STI. In addition, other individuals have been trained in syndromic management, thus making STI management available to patients even at level B institutions, pharmacies, and some chemical shops.
Numerous training sessions have been held in syndromic management of STIs; however, there still is need to improve service quality and standards. Monitoring and supervision of health service providers also have to be strengthened in order to provide continuous feedback to make improvements.
Knowledge, awareness, and perception
People know how HIV/AIDS is transmitted and prevented but do not perceive how their own behaviour puts them at risk; as a result condom use is low and behaviour change is slow. In addition, people who live with HIV/AIDS are discriminated against and stigmatized.
The latest Ghana Demographic and Health Survey (GDHS) reveals that 97 percent of women and 99 percent of men are aware of AIDS, but they have an unrealistic perception of the disease. Up to 75 percent of female respondents and 82 percent of male respondents correctly believed that seemingly healthy persons could be carrying the virus causing AIDS. Up to 80 percent of the respondents rightly thought that a woman with HIV could transmit the virus to her child during birth or through breastfeeding. However, they also held that HIV is contracted through promiscuity, that is, many partners. This has led to stigmatization and discrimination towards people living with HIV/AIDS. Because of this belief, infected people are rejected and isolated.
Smaller percentages (22 percent of women and 40 percent of men) knew that condom use could prevent AIDS and less than 10 percent of both men and women knew that abstinence from sex also could prevent HIV infection. However, two-thirds of women and men thought that they could avoid infection by having sex with only one partner. Initially, condom use had a negative image; by 1998, however, more than 90 percent of the respondents in the survey knew about condoms, although only 29 percent of the men and 19 percent of the women knew where to get them and only 15 percent of the men and 6 percent of the women had used it during their last sexual act.
While awareness of HIV/AIDS is universal, knowledge of sexually transmitted infections is low. This is puzzling considering the fact that there are about 25 common STIs in the population. Most Ghanaians (61 percent of women and 73 percent of men) have heard of gonorrhoea, 13 percent of women and 21 percent of men had heard of syphilis, but few have heard of herpes, hepatitis, and other sexually transmitted infections.
Where Ghanaians seek treatment
About 90 percent of patients who contract reproductive tract infections seek initial treatment from the private sector rather than going to public heath facilities. The reasons for non-utilization of MoH facilities include: lack of privacy, inaccessibility of service delivery points, poor quality of care, and high cost of treatment. In addition, sociocultural beliefs and the practices and attitudes of reproductive health providers also influence decisions to seek treatment.
Absent treatment at health facilities, many individuals self-medicate or perform rituals, using local herbs, chemical shops, drug peddlers, and pharmacies.
Drugs for the treatment of STIs are available on the Essential Drug List and are generally affordable within the MoH structure, but the prices sometimes are prohibitive for those buying in the private sector. Effective drugs for STI treatment seem to be available in 60 percent of pharmacy outlets. However, there is no effective system in place to monitor distribution, utilization, or cost recovery. Neither is there a formal mechanism for pricing drugs.
A problem that has recently emerged is that some conditions have become resistant to antibiotics like penicillin and tetracycline. This has made the treatment of gonorrhoea and chancroid more complicated and more expensive. There is no surveillance system to consistently monitor these changes, a necessity for syndromic management of STIs. A system is needed to monitor antimicrobial resistant strains of STIs as they develop, so that drugs that are more effective can be found and procured and providers are updated periodically about current recommendations.
Drugs
Availability of effective and affordable drugs is a major condition for successful STI management. The current cash and carry system instituted by the Ministry of Health transfers the cost of drug treatment of STI patients to the patient; thus, pricing of drugs becomes important in STI management. The system has been plagued with the high depreciation/inflation rate of the currency. If mark-up levels were to increase to sustainable levels, cost to the patient would be over three times the buying price, rendering them unaffordable.
There is no effective system for monitoring distribution, utilization, or cost recovery. Even though recommended STI drugs are included in the essential drug list (EDL), the private sector outlets report that they are not bound by the pricing mechanisms used by the MoH. Since a great proportion of STIs are reported to the private sector facilities and there is no formal mechanism for subsidizing the costs of these drugs, STI medication is often affordable only by those in high-income groups. This leaves low-income groups at risk to the sequelae of STIs. In addition, the issue of STI management by chemical sellers and pharmacy outlets is not properly spelled out; to do this would require collaboration between the Ministry of Health and the Pharmacy Board.
Good environment for reform
In the 1990s, Ghana embarked on a mission to improve the standard of living of its people and developed sequenced five-year development strategies to achieve its Ghana-Vision 2020 goals. The first five-year programme of work, from 1997-2001, focused on improving access to health services especially in the rural areas; efficiency in health delivery; quality of care; collaboration and partnership between the health sector and communities, and other sectors and private providers; and overall equitable and efficient distribution of resources.
Reproductive health, including family planning services and essential and emergency obstetric care, and endemic diseases-sexually transmitted infections were short-listed as priority health service interventions that were to be made available in all health centers. In addition, the essential package of health services included AIDS control, clinical services for sexually transmitted infections, and maternity services.
At the end of 2001, although there were significant improvements made in the delivery of public health services, the gains were considered slow and unevenly achieved. The report acknowledged continuing problems with HIV/AIDS and concluded that this health issue received inadequate attention at lower levels. Appropriate and measurable targets were set as benchmarks to measure progress.
Under the new health sector 5-Year Programme of Work 2002–2006, STIs/HIV/AIDS and reproductive, maternal, and child health services were designated as priorities for intervention, with emphasis on prevention, health promotion, and education. The national surveillance of STIs and HIV/AIDS needed improvement. Few clinics for STIs existed and the majority of clients seeking health care services for STIs in public facilities were deterred by the lack of privacy for consultation, insensitive and judgmental attitudes of health care providers, stigmatization, prohibitive costs, and long waits at the point of service.
In spite of evident progress in the health sector in the area of reproductive health, stakeholders believe that the service delivery aspect of the management of RTIs in Ghana remains unchanged. Although reproductive health was a concept that was mentioned in some policies and service delivery protocols, the term reproductive tract infections is not commonly used and the focus appeared to be on STIs and HIV/AIDS as separate health issues.
Ghana has a good policy environment with respect to RTIs. All the current policies have objectives aimed at prevention and control of RTIs and their contributing factors. The current response of the Ministry of Health to HIV/AIDS has involved such strategies as advocacy; blood screening and testing; epidemiological surveillance; clinical nursing and home-based care; counselling; STI control and management; prevention of mother-to-child- transmission; and targeting of young people, women, and other high risk groups.
There is also a good legal framework supporting RTI prevention in Ghana. Laws exist that provide harsher punishment for physical crimes against females, including female circumcision, rape, protection of children against early marriage and prostitution, and solicitation for sex. In addition, laws can be used to support the prosecution of offenders for willful transmission of HIV/AIDS. The Law Reform Commission periodically reviews all existing laws that relate directly or indirectly to adolescent reproductive health. Deficiencies exist, however, in the legal framework to protect people living with HIV/AIDS in the workplace.
Both the public and private sectors have been very active in promoting interventions to prevent and control reproductive tract infections in Ghana. Almost all donor agencies and nongovernmental organizations have integrated aspects of HIV/AIDS prevention and control into their programmes, but the effectiveness of these interventions has been hampered by lack of coordination. With new policies in place, collaboration and coordination of activities will improve.
RAPID ASSESSMENT
The rapid assessment, which utilized both qualitative and quantitative methods, was conducted from February to April 2001 in twenty villages with varied ethnicity in seven regions in Ghana. The team interviewed service providers, including clinicians, private midwives, traditional birth attendants (TBAs), herbalists, drug vendors, chemical sellers, NGO leaders, and community members. Focus group discussions also were conducted with youth, men, and women.
The goal was to be able to answer these key questions: What is the magnitude and nature of RTIs? What is the current national response? What interventions should be included in the national program for addressing prevalent cases of RTIs?
Study design A multidisciplinary research team carried out the rapid assessment to look at the extent of RTIs in the country, factors contributing to the problem, and ways to target RTI/STI programs. Specific objectives were to:
Investigate and document the role of traditional healers, traditional birth attendants, drug vendors, and other health providers in the management of RTIs in Ghana; Investigate the social, cultural, and behavioral practices, such as herbal insertions, that may aggravate the problem; Describe the type of health providers and available care for RTIs in the communities; Identify reasons for the wide disparity in knowledge and practice by community members despite ongoing information and education programs and to solicit from communities ways of bridging the gap between knowledge and practice; and Make recommendations to all stakeholders in the management of RTIs in the country.
The descriptive cross-sectional study used both qualitative and quantitative data collection methods. Data were gathered using focus group discussions, sample surveys, records review, and in-depth interviews.
The country was zoned into the three main geographical areas: in the northern sector, Upper West and upper East Regions; in the middle belt, the Eastern and Ashanti Regions; and in the coastal belt, parts of the Greater Accra Region and the Southern part of the Volta region. Table 2 shows the actual sites visited.
Table 2 Sites and communities visited Region District Urban Community Rural Community
Ashanti Sekyere West Mampong Kofiase
Central Mfanteman Mankessim Nkwanta
Eastern Mampong Akwapem Mampong Adawso East Akim New Tafo Kukurantumi
Greater Accra Danmgbe East Big Ada/ Ada Foah Akplabanya Ashiedu Keteke James Town Anyamam,Totopey Ga Amasaman
Upper East Bolgatanga Bolgatanga Vea
Upper West Wa Wa Charia
Volta Keta Keta Dzita
In each urban and rural community visited, at least one focus group discussion was held with a male or female group of about eight persons. Participants were mainly older and younger men, older and younger women, and adolescents.
The team surveyed a cross section of the selected communities to find out the magnitude of some of the key issues investigated in the qualitative assessment. Some 1 999 interviews were conducted, including discussions with one man and one woman in 50 households in each community. In half of these households, people less than 20 years of age were interviewed, while people older than 20 years were interviewed in the other half of the households. The objective was to capture the views of adolescents.
RTI records were reviewed in some health centres and private midwives’ facilities to document the type of RTIs seen and how they were managed. In-depth interviews were held with traditional healers, private midwives, traditional birth attendants, chemical sellers, and drug vendors. The team consulted with representatives of nongovernmental organizations working in reproductive health, to ascertain their activities in RTI management in the communities. In-depth interviews also were held with heads of public health facilities within some of the communities visited.
Two teams of four experienced data collectors were recruited, trained, and supervised by Health Research Unit researchers to conduct the fieldwork, which took 35 days covering the period March to May 2001.
Demographic characteristics
Participants in focus group discussions were mainly men and women between 15 to 60 years of age. Most of them had lived in the community for the greater part of their lives, were married, and had children. Those who did not have any children were mainly unmarried adolescents, although some of them had sexual partners. Respondents were in various occupations: fishermen, farmers, traders, artisans, government workers, and a few people who were unemployed. Some of the adolescents were students. Most respondents had had some formal education, but some had never been to school. Respondents were predominantly Christian or Muslim.
Survey participants
Chemical sellers were mostly men who had had some formal education. Some had their main jobs in addition to the chemical shops. The Pharmacy Council, Ghana Social Marketing Foundation (GSMF), and the Health Care Service Limited had trained some chemical sellers in the identification of STIs; some shopkeepers had trained themselves by reading books like “Where there is no doctor.” While the owners had been trained and displayed their certificates in the shops, they employed others (some as young as 13 years) to run the shops, sometimes for brief periods when the owners were away. Even though chemical sellers have been trained to identify RTIs, they are not permitted to dispense antibiotics and are expected to refer clients to pharmacy shops or to the nearest health facility. This regulation was flouted regularly.
Most of the private midwives were older women who had been trained in STI management using the syndromic approach by the Ghana Registered Midwives Association in conjunction with the Ministry of Health. The midwives had drugs to treat STIs. Four herbalists and three traditional birth attendants were interviewed, all people over 50 years of age who had little or no education. All but one were female.
Representatives of three NGOs working in the communities under study were interviewed: Rural Health Integrated (RHI) in the Upper East Region; Amasachina Self Help Association in the Upper West Region, and NEKO TECH in the Greater Accra Region. These NGOs were involved in development activities, including community health education and reproductive health services targeting mainly youth. They had received training in family planning, STIs/HIV/AIDS, and safe motherhood from the Ministry of Health or from non- governmental organisations like the Planned Parenthood Association of Ghana. Table 3 describes the demographic composition of the respondents.
Table 3 Demographic characteristics of respondents, n = 1 999
Male Male Female Female % N % N
Marital Status
Single 70.9 708 54.7 547
Married 27.1 271 39.5 395
Divorced/separated 1.6 16 3.2 32
Widowed 0.4 4 2.6 26
Religion
Christian 80.4 803 84.3 843
Muslim 12.7 127 8.7 87
African tradition 2.8 28 3.9 39
None 4.1 41 2.1 21
Ethnicity
Akan 34.6 346 34.2 342
Ga/adangbe 19.4 194 19.1 191
Ewe 12.7 127 14.7 147
Dagomba 0.7 7 0.4 4
Sisala 0.7 7 0.6 6
Kusasi 0.3 3 0.1 1
Others 31.5 315 30.9 309
Education
JSS/tech/vocational 51.4 514 44.1 441
SSS 19.8 198 12.1 121
Primary 161.0 161 21.8 218
None 6.4 64 19.7 197
Tertiary 6.2 62 2.3 23
Local perceptions of STI causes and treatment practices
From the focus group discussion results, it can be inferred that community members recognized the existence of genital infections in their respective areas. Babaso, the common name for gonorrhoea, is mentioned in all the regions irrespective of the dialect commonly spoken in the area. (In the northern sector babaso is also referred to as zintoore or pongumbaa.) The common name for vaginal discharge in women in most communities in the middle and coastal parts of the country is odeepua, while it is referred to as guunle among the Frafras in the Upper East region. Other conditions mentioned by residents of the northern sector include poola, obriga, and badogiron, the latter being the Wala translation of babaso kraman, the Akan terminology for syphillis. Women often mentioned menstrual problems and vaginal discharge as being their common reproductive health problems. It may be significant to note that some women, especially in the Volta region, also mentioned dudzor, a condition that they claimed resulted in infertility because of the inability of semen from the man to stay in the women after sexual intercourse.
Causes of genital infection
The survey respondents cited sex with an infected person as the main cause of genital infection. Other perceptions about causes of genital infection include eating sweets, “begins on its own,” sharing toilets, and witchcraft. This was confirmed during group discussions with community members. While most discussants believe that genital infections are sexually transmitted, the male groups said that the disease is transmitted from women to men. Some women believe the opposite is true while others support the men’s contention that women spread the disease. As one community member put it, “It is sexually transmitted usually from women to men.” Genital infections were often attributed to things that occurred during intercourse, reflected in the following statements: “When you get a new girl because she is new, you may not take your time to enter her, then the erected penis will go to a wrong place and the penis may curve as a result and you get the disease.”
“When an erect penis is bent or curved during sex it causes sore in the inside of the penis and you can get ‘afuoa.’”
While 82 percent of the respondents mentioned intercourse with an infected person as a cause of RTI/STI, other reasons often given included sharing blades with others (35 percent) and being promiscuous (18 percent). Some statements made during group discussions on causes of RTI/STI follow: “When women do not wash their panties well they can infect a man with babaso.”
“Eating too much sweet things and too much tiger nuts and palm kernel nuts can cause discharge from the vagina.”
Even though most of the chemical sellers interviewed had gone for STI management training, some of them still had wrong perceptions on causes of infection. Some chemical sellers said that, in addition to sex, gonorrhoea and vaginal discharge were caused by poor personal and environmental hygiene and poor nutrition. Herbal practitioners as well as traditional birth attendants had the same erroneous perceptions as the general community.
Table 4 Perceptions of causes of RTI/STI*
Causes (n = 1 999) % n
Intercourse with infected person 82.1 1 641
Sharing blades with others 34.7 694
Promiscuity 17.9 358
Eating sweets 5.9 117
Lack of hygiene 4.9 98
Don’t know 4.9 98
Blood transfusion 4.3 86
Starts on its own 3.7 74
Intercourse with prostitute 2.8 56
Sharing toilets 2.8 55
Supernatural/witch 1.8 35
Sharing tooth brushes 1.7 34
Certain foods 1.5 30
Crossing infected urine 1.0 19
Bath in the river 0.9 17
Hair entering vagina/penis 0.9 18
Cough during sex 0.7 13
Kissing 0.6 12
Contraceptive use 0.2 4
Other 1.3 25
*Percentages may sum to over 100 percent as more than one response was allowed
Vaginal discharge (odeepua) is believed to lead to infertility if not treated promptly. Causes of vaginal discharge were cited as: eating too many sweets, chewing too much palm kernel and tiger nuts, sitting on the bare floor without any underwear (particularly in younger children), and poor personal and environmental hygiene. Odeepua is also perceived as being normal, especially a few days before menstruation. However, when the discharge is excessive and offensive most women perceive it as abnormal and would seek care.
In communities where bilharzia (gonorrhoea) is a health problem, community members say that bathing in the river causes it. Some people believe that blood in the urine is a more serious form of gonorrhoea, proof to them that the condition is not only acquired through sex.
When asked to mention a sexually transmitted infection, all groups readily mentioned HIV/AIDS. In fact, it was the only sexually transmitted infection known to adolescents. All discussants could mention the main causes of HIV/AIDS, but misconceptions abounded: Some believed that ”It’s an old disease with a new name. It’s been with us since time immemorial.” Others have taken a fatalistic attitude, “If you will get it, you will get it. There is nothing you can do.”
Signs and symptoms
Sixteen percent of survey respondents had experienced genital infections symptoms in the past. When asked about the signs and symptoms of genital infection, respondents mentioned genital discharge, genital itching, and diarrhoea, but almost two-thirds of the women and 55 percent of the men mentioned weight loss—an obvious confusion with HIV/AIDS.
Most of the male participants in the focus group discussions shared personal experiences of being infected with gonorrhoea after they had had an affair with a woman, often referred to as a casual partner. They indicated that pain in the penis started three to four days after sexual intercourse. The men said it was difficult to find a girl who did not have the disease. In fact, one man indicated that “Women are like lotto numbers. It’s by chance; some have the disease, others do not. If you pick the right one, you do not get the disease.”
Modes of management of RTI/STI
Respondents were asked where they would go if they had a genital infection. The vast majority (90 percent) said they would go to the clinic or hospital, followed by 8 percent who would go to traditional healers. Those men who had actually experienced a genital infection were asked where they had sought treatment at that time. Although 43 percent said they had gone to hospitals or clinics—the most common source of treatment—20 percent had gone to chemical sellers and 13 percent had not sought treatment at all. A large number of respondents with a history of STIs (39 percent), made use of chemical sellers, traditional healers, vendors, or peddlers, or sought advice from co-workers which confirms that community members are self-medicating, with sometimes lethal mixtures. Though some claimed that the mixtures cured them, others indicated that they had to go to the health facilities after their local preparations failed to work.
Modern treatment
The modern health care option is considered expensive for most communities. Care in a health facility can cost between fifteen thousand and twenty thousand cedis. In addition to the medical charges, transport costs between the rural community and the district capital where health facilities are located can be exorbitant. The cost of treatment for pregnant women is not affordable in most communities.
Chemical sellers and private midwives play a vital role in the management of RTIs. They serve as a first line of contact for patients who have genital infections. Chemical sellers sell the antibiotics in inadequate and sometimes unsafe quantities.
Private midwives serve mainly females, especially pregnant women attending antenatal services. Very few cases were found in the records of private maternity homes.
Local treatment regimens
Treatment of STIs consists of herbal and orthodox drugs, prayers, or the pacification of the gods. Orthodox drugs, herbs, and alcoholic beverages are often mixed and ingested orally. In fact, mixing antibiotics with alcohol appears to be the most popular means of managing STIs in the Southern communities. This treatment option is especially popular among men with painful urination who believe that drinking the mixture induces frequent urination, thereby flushing out the disease from the penis and the stomach. Some of the treatment regimes reported by community members are given below: “Dissolve 20 to 30 tablets of Ampicillin in quinine tonic or Akpeteshie (local gin) and drink at a go. You can also mix it with orange juice but Akpeteshie is more effective.”
“Go to the drug store for 4 to 6 tablets of ‘Abombelt’ (antibiotic capsules) and take them for two days. [The pain] will stop.”
“Put 10 capsules of Ampicillin in water and add 500 cedis worth of Akpeteshie. Put 30 capsules of ‘abombelt’ in water plus headache tablets in Akpeteshe and drink it.”
Local treatments for women with vaginal discharge were mentioned as followed: “The drug vender sells some herbs and creams; when you insert them, the water comes out and your vagina becomes dry.”
“Some herbs are moulded into balls and you can insert that too.”
“You can grind pepper and other spices together with orange and drink the mixture. It will stop.”
“You can mix different spices together, put them into cotton wool and insert.”
All the herbalists interviewed confirmed that genital infections were present in their communities. Herbal preparations are made for drinking, bathing, via enema, and for inhalation. Herbal smears are also made to spread on the external genitalia. Some herbalists said that these conditions were not their specialties and they referred clients to other herbalists or to the health facility. Herbalists from the Northern parts of Ghana said herbal insertions were not common practice in their area.
Below are some of the preparations of purely herbal mixtures for males with painful urination and discharge: “Mix herbs and add palm wine together, allow mixture to stand in the sun for a few hours and drink for about a week.”
“Mix fermented corn dough with water, let it stand for some time in the sun, pour the water that settles at the top, and drink for 3 to 5 days, morning and evening. You urinate frequently and this clears the penis and the pain stops.”
Herbal insertions
One of the specific objectives of this study was to investigate sociocultural practices related to herbal insertions—the main type of insertion used by women: reasons for this practice, type of herbs inserted, the age of onset for inserting herbs, and the effect of this practice on users. Over 50 percent of herbal insertions were used by women aged 15 to 19, over 26 percent by girls under 15, and over 22 percent by women aged 20 to 45.
Herbal insertions were preferred by 79 percent of the women. Herbs used for insertions range from hot spices, roots, leaves, salts, and local ointments sold by drug vendors. These are used singly or in combinations with other herbs. Other things inserted include TCP (antiseptic) drops, Omega oil, and Mecca Toffee.
The most common reason for inserting herbs was to treat ‘white’ (candidiasis). Seventeen percent of the women used herbal insertions to keep the vagina dry, a practice that could lead to abrasions during intercourse, facilitating HIV transmission. Other reasons mentioned were tightening the vagina (15 percent) and keeping it clean (14 percent). Older women used herbal insertions to heal the reproductive tract after delivery, to treat infertility, to keep the vagina dry, clean, and tight, to prevent vaginal discharge, and to stop vaginal itching. They also used insertions for abortion, to prevent pregnancy, and to keep a partner perpetually attracted to you.
Below are some of the comments of mothers in a group discussion in some of the communities in the Ashanti and Eastern Regions: “There are some children, when they fall sick you will take them to the hospital, but it won’t work unless you insert some herbs and then everything will be okay.”
“Some of the children frequently scratch their genitals; this may be because the place is sore. So when you put the ginger there, it stops the itching. For the boys, you can open the small opening on the penis and put a little there.”
Most women indicated that they experienced no problems with inserting herbs. As one woman stressed: “We insert herbs to prevent disease, so how can it also give us another disease?” A few women, however, reported that they had had problems with inserting herbs. One woman said, “My vagina is now too tight; when my husband is coming near me I am disturbed. I have difficulty when I have sex with him.”
Disparity between personal risk assessment and behaviour change
Community members think behaviour change is a process that takes time. They feel that continuous education must take place before people change their behaviour. Although their responses indicate that there is a high awareness of the existence of HIV/AIDS, people seem to need more proof that the disease affects individuals like themselves. As it is, the disease seems distant and not real, as these comments from participants suggest: “Seeing is believing. If you do not see, you do not believe. We have to see an AIDS patient.”
“Hearing always and not seeing an infected person would not help much.”
Some believe that they are safe from HIV infection, often because of their faith in God or in their partner. They therefore see no need for behaviour change.
“I have only one sexual partner.”
“We trust our partners.”
“God protects us and will not let such a disease affect us if we are true and obedient to Him.”
Factors such as poverty and gender could make a person change his behaviour. Men often have more power in decision-making, leaving women with little or no room to negotiate for condom use or to control their partner’s sexual relationships with other partners: “It is survival now. AIDS is later. Some say 1 to 15 years before it can be diagnosed.”
“As a wife and an only wife, my husband will not agree that I use a condom. If I insist, he will not agree and beat me.”
Risk perceptions and condom use
The study explored the population’s perceptions of risk based on age, gender, marital status, education, and urban or rural residence. The study population believes that condoms are for unmarried, not married, couples, and for the young. Married men use condoms for casual partners, not their wives. Married couples use condoms to prevent pregnancy, not necessarily to protect against STIs and HIV/AIDS. There was little difference in risk perception between those who live in urban areas compared with rural areas. However, condom use in urban communities appears to be higher than in rural areas.
The perception that one is at risk of contracting an STI increases with age, peaking in the late twenties and thirties and subsiding in later years. About two thirds of respondents aged 10 to 14 and half of the 15- to 19-year-olds see themselves as having no chance of getting an STI. About two-thirds of people aged 20 to 45 consider themselves at some risk of getting an STI.
As age increases, so does the percentage of people who have never used condoms. This trend reflects the tendency for people aged 25 to 45 to be married and not see the need for condoms, a tendency that is supported by the qualitative data. Among the sexually active, about three-quarters do not perceive themselves to be at risk of contracting an STI.
Nearly half of men and women consider themselves at no risk of contracting an STI. At the same time, patterns of condom use between males and females differ markedly. Males were more than twice as likely to report always using condoms compared to females. Over 50 percent of females reported never using a condom compared to one third of males. Such differences in patterns of condom use could reflect women’s diminished ability to negotiate or enforce condom use compared to men.
Education does not seem to make a major difference in risk perception of contracting STIs. Condom use shows a slight increase with increases in education and the percentage of those who never used condoms decreases as education level increases.
Risk perception among the married and unmarried appears to be similar. Most married couples (72 percent) report that they never use a condom. Almost half of single respondents (45 percent) reported never using a condom, possibly because they were not sexually active.
Female and male condoms
While female condoms are well known, they are not used widely. More than two-thirds of respondents (68 percent) are aware of the female condom, but less than 2 percent had ever used it. Reasons for non-use are not immediately clear, but they could be related to availability, accessibility (including cost), or acceptability to couples.
Male condoms are available in most of the chemical shops visited in both urban and rural communities. Female condoms are available in most chemical shops but are not popular. Chemical shops have a greater variety of condoms than do health facilities. The number of chemical shops and their flexible opening hours make them more accessible to clients.
Condom sales are reportedly high during funerals or when there is a big social activity in the community (periods in which Health Centres are likely to be closed). Prices range between 100 to 150 cedis per male condom, while the female condom sells for 500 to 1000 cedis.
Some NGOs in the communities surveyed distribute male and female condoms in communities where they operate. Private midwives provide a wide range of reproductive health services including the provision of male and female condoms. A few do not provide female condoms because they lack training in how to use them.
The Ghana Social and Marketing Foundation (GSMF) supplies condoms in a few cases directly to the premises of chemical sellers. Most of the time, however, chemical sellers have to travel to Accra or the regional capital to purchase condoms. The local association of chemical sellers also supplies condoms to association members at meetings. Private midwives get their supplies at Ghana Registered Midwives Associations (GRMA) meetings or from the open market. NGOs get their condom supply from the Ministry of Health, GSMF, or Planned Parenthood Association of Ghana.
Condom/health education
Some midwives are involved in health education, working with adolescents, dressmakers, and hairdressers. Topics at these group meetings cover antenatal care, condoms, abortions, and STI/HIV/AIDS.
Chemical sellers are willing to educate their clients but do not normally do so, because they have not been trained and do not have the necessary support from the MoH. In addition, chemical sellers said that they could provide education on STIs and condom use at their local churches. Herbalists do not provide any education on STIs but are willing to be trained to distribute condoms.
Suggestions from community members
Survey respondents were asked to suggest how community members could be encouraged to protect themselves. While 15 percent of the respondents did not have any suggestions, 42 percent cited public education, 13 percent mentioned being faithful to one’s partner, and 9 percent proposed showing films of AIDS patients. Some also suggested showing AIDS patients to the public—“Seeing is believing”— so that they can witness the disease firsthand.
Ongoing education is seen as paramount, presented either by outsiders or community members. During discussions with women’s groups, it became clear that women have very little power to negotiate condom use. They therefore advocated that men and boys must be encouraged to use condoms with their partners. Men should be encouraged to educate their peers: “When women or their wives talk to them about condom use and HIV prevention they do not take them seriously.”
Community members also saw the need for parents and teachers to educate youth on condom use, including how to use them and how to dispose of them, and to make condoms widely available. Men and boys who have multiple sexual partners should be targeted. Community members felt that society’s attitude toward people who use condoms continues to be negative, making it uncomfortable for people to buy condoms when others are around. This attitude, they felt, must be minimized through education. They also called for the manufacture of durable condoms that do not tear, to allay fears that condoms can break; for the distribution of free condoms; and for a wider availability of condoms among small shop owners, such as sellers of milk and sugar.
Table 6 Community suggestions for behaviour change
Suggestions from communities n = 1 999 % No
More public education 41.7 839
Don’t know 14.8 295
Stick to one partner 12.9 257
Show HIV/AIDS patients to communities 9.1 181
Use condoms 8.4 168
Abstinence 5.0 100
Go for HIV testing before marriage 2.2 44
Quarantine infected persons 1.8 36
Make HIV/AIDS medicines available 1.4 27
Create more jobs for women 1.2 24
Pray to God 0.3 5
Health workers should sterilize needles 0.1 1
RECOMMENDATIONS
Priorities and interventions
In January 2002, findings from the field assessment were disseminated to the wider group of stakeholders and consensus was reached on strategic recommendations for the programme. See Annex 1 for a list of major stakeholders who participated in the PGT process.
Determining the most appropriate set of interventions for a public health programme to meet the needs of men, women, and adolescents requires setting priorities. In the past, the debate has been focused primarily on selecting approaches for the case management of symptomatic individuals—that is, syndromic management. This approach leaves out a large number of people who have STIs but exhibit no symptoms. It also omits interventions for different epidemiological, social, and health delivery settings. These circumstances require a process to prioritize the development of locally relevant interventions for addressing established RTIs.
Information exists about RTIs in Ghana, but most of it is focused on HIV/AIDS. Very little information exists about STIs and other endogenous infections. The legal and policy environments are favourable for expanding research and policy efforts, and most of the necessary mechanisms for carrying out recommendations already are in place. Strategic plans are also in place; however, large gaps exist in our data capture systems. Fieldwork findings confirmed many of the issues raised during the document review. There were still misperceptions of the causes of STIs and risk perception and condom use were low. Herbal insertions in the vagina were common in some communities. Treatment of STIs in the communities by care providers and community members was inappropriate.
A comprehensive mix of interventions should focus on enhanced symptom recognition and health care-seeking behaviour, effective outreach programmes to identify symptomatic men and their sexual partners, and improved quality of clinical services for women and men.
The appropriate mix of interventions for each local and/or national programme is determined by:
The prevalence and incidence of RTIs and STIs; Cultural and social norms of sexual and health behaviours; Local perceptions and belief concerning reproductive morbidity; Patterns of health care-seeking behaviour; Utilization of public and private sector health services; Resources available at country level; Existing structure of public health programmes; and Patterns of antimicrobial use and resistance.
Typically, programme managers have imperfect data on many or all of the above factors. Furthermore, when data do exist, programme managers rarely have a clear process for deciding what actions might be indicated.
Gaps in information
The assessment demonstrated that important gaps exist in available information about prevalence of RTIs and STIs, behaviour of at-risk populations, and the need for expanded surveillance systems. These deficiencies include:
Lack of population-based prevalence and incidence data on reproductive tract infections, including HIV/AIDS and all STIs, as well as iatrogenic and endogenous infections; Little information on endogenous and iatrogenic reproductive tract infections compared to HIV/AIDS and STIs; No efficient surveillance system to capture STIs and RTIs in Ghana as a whole by all health facilities and the private sector; Poor understanding of why individuals do not perceive themselves at risk from HIV/AIDS and STIs, and why they do not prevent infections by the use of condoms; Poor documentation of health-seeking behaviour, including the proportion of symptomatic clients who seek any care and the proportion of individuals who are treated through private versus public health care services; Need for broader-based studies to elucidate the antimicrobial resistance patterns in population groups; Few institutions working with sex workers, who have been shown to have a high prevalence of HIV; and Need to evaluate the impact of untreated STIs (such as pelvic inflammatory disease, urethral stricture, and cervical cancer).
Recommendations for improvement
The assessment process recommended numerous areas for improvement in research, surveillance, and gender issues, among many others. Below are some of the outstanding needs of the Ghana program: Research Collect and analyse data on endogenous infections and iatrogenic infections from post-abortion infections, insertions of IUCD, and surgical procedures among others, and their outcomes; Conduct population-based studies to ascertain the true prevalence of HIV and the true incidence of various STIs; and Undertake studies to determine the burden of complications of RTIs in Ghana and the changing patterns of antimicrobial susceptibility of STI. Provide additional information on the control of endogenous infections.
Training Provide innovative STI management training specifically tailored for various categories of health care providers; Provide ongoing training in the management of STIs for medical, pharmacy, and nursing students; and Conduct periodic reviews of the pre-service curriculum with a view to incorporating emerging issues.
Programme needs
Health service
Emphasize RTIs as a whole and not only HIV/AIDS and STIs and incorporate their prevention and management into RTI programmes; Develop and implement an integrated approach to STI management in both public and private facilities; Improve the quality assurance program; Improve supervision in both the private and public sectors; Reintroduce STI screening for antenatal attendants (e.g. syphilis and hepatitis); Put in place a system of monitoring antimicrobial strains of STIs as they develop; Step up monitoring and supervision of syndromic management of MoH facilities, with a view to motivating implementers and providing programme managers with programme needs such as refresher training; Enhance efforts to increase AIDS & STI surveillance reporting levels in the country; Undertake population-based studies to ascertain the true prevalence of HIV /STI infection; and Initiate strategies to increase commercial sex worker access to interventions that reduce RTIs.
Health education and behavioural change communication
Promote continuous education and access to drugs for control of STIs; Address endogenous infections such as candidiasis in behaviour change communication programmes; Implement strategies to address the inappropriate treatment by community members and chemical sellers; Initiate behavioral change communication and health education to address erroneous perceptions on the cause and transmission of RTIs, problems associated with partner notification, and the stigma related to some of these infections; Train and motivate chemical sellers to provide appropriate counseling and information on condom use and relevant health education to clients; Intensify education on the complications of STIs and their relation to HIV/AIDS; Design and implement educational strategies on STIs involving men; Promote further education on the use of the female condom; and Emphasize more effective and sustained marketing strategies to promote female as well as male condoms.
Cultural practices
Address strategies to assess the probable risk of RTIs following complications of herbal insertions; and Explore existing practices, especially among special groups, to design targeted and culturally appropriate programmes.
Inter-sectoral collaboration
Improve the coordination and collaboration between the MoH and the Private Medical Association, pharmacies, the Laboratory Board, and chemical sellers; and Implement immediate action to target populations practicing herbal insertions and use of local cocktails of drugs to treat STIs.
Policy review Address human rights and the work environment of people living with HIV/AIDS in Ghana; Address and support the private sector in the management of RTIs in Ghana, including private pharmacists and chemical sellers, and define their role in RTI management; Review policy guidelines for laboratory practice; and Review the policy that prohibits the sale of antibiotics by chemical sellers.
EVALUATION OF THE RTI/STI PROGRAMME GUIDANCE TOOL
The utility and programme outcomes of the RTI/STI Programme Guidance Tool in Ghana were assessed by interviewing key stakeholders from the public and private sector who are involved in the process, and by visiting practitioners in a few districts.
The coordinators of the process in Ghana remain committed to using the process to develop a comprehensive reproductive health programme that meets the country’s needs.
Evaluation objectives
To assess the potential usefulness of the PGT in other countries, it is important to evaluate its implementation in the countries where it was pilot-tested. The evaluation of the programmatic outcome and utility of the PGT can be considered as Step 11 of the PGT process. It is not possible now to assess the ultimate impact of the PGT process on the prevalence of RTIs. This is due to a number of factors, foremost of which is the fact that the PGT process is not complete in any of the countries where it was pilot-tested. Therefore, the present evaluation is considered an interim or mid-term evaluation.
The evaluation protocol used in Ghana focused on the programmatic outcome of the PGT process and its perceived utility to those involved and affected by the process. Programmatic outcome was assessed based on the extent of implementation of the specific activities developed to achieve the strategic recommendations.
The overall evaluation objective was to assess the programmatic outcome and utility of a decision-making tool to assist programme managers in prioritizing interventions for addressing established RTIs.
The primary objectives of the PGT evaluation in Ghana were:
To assess the extent to which strategic recommendations arising from the PGT process have been implemented (programmatic outcome); and To assess the perceived utility of the PGT tool by programme managers and other country level stakeholders (utility).
Secondary objectives of the PGT evaluation included the following:
To identify key contextual factors that may influence RTI programmes and the PGT process in particular, such as ongoing health sector reform issues; and To assess the extent to which the guiding principles of the PGT process were met with respect to inter and intra-sectoral collaboration achieved for RTI control, the country-led process, and the multidisciplinary process.
To judge the effectiveness of the PGT, we sought to determine: whether the recommendations and activities that were defined as part of the PGT process have been implemented; whether all key national staff and stakeholders felt that it was useful; and whether the PGT process could be influenced by other factors outside the process itself, such as health sector reform.
Three guiding principles
For the PGT process to be successful, three guiding principles must be followed: (1) collaboration among all stakeholders involved in STI care in the country; (2) local country ownership of the PGT process; and (3) multidisciplinary involvement. Stakeholders within the health sector and between sectors are expected to collaborate in the process, with collaboration defined as active and regular meetings where information is shared between key stakeholders and programmes and implementation are jointly planned.
Stakeholders involved in RTI care in the country should play a leadership role in the PGT process, to ensure that the procedure is not perceived as an external intervention. In a country-led process, key stakeholders should be involved in each step; they organize meetings of the country team which is actively involved in trying to implement recommendations. The PGT process should continue without involvement of outside consultants.
The PGT process should involve managers and service providers involved in RTI care at all levels of both the public and private health care system.
Stakeholders includes those groups and individuals that were or are currently involved in STI programmes in the country and/or the PGT process in particular:
Governmental ministries, agencies; Representatives of key donor organizations, both bilateral and multilateral; Key nongovernmental and community-based organizations involved in RTI programmes; Health care providers; and Others as defined in each country.
See Annex 1 for a list of stakeholders involved in the evaluation.
Four strategic recommendations
A wide range of stakeholders representing the public and private sector helped to prioritize a long list of recommendations into a shorter one based on urgency, feasibility, and expected impact.
They selected four recommendations for implementation based on their expected impact and feasibility:
Strengthen service delivery by all public and private sector providers who are involved in reproductive health care, in the areas of training, use of generic drugs, introduction of pre-packaged therapy, and a policy dialogue. (Since the issue of pre- packaged therapy might be controversial, it was proposed to implement this as an operations research (OR) project in two to three regions, and use the results to inform policy development.) Identify and implement appropriate training strategies; Use education and advocacy to address the issue of vaginal insertions; and Strengthen STI surveillance.
Methodology
The methodology for the evaluation in Ghana differed by evaluation objective. To determine whether the four strategic recommendations arising from the PGT have been implemented, the team created a matrix that lists projects, progress, and comments. They conducted interviews with key stakeholders and service delivery staff involved in RTI/STI programme activities to learn how they perceived the issues that affected successful completion of the process. The progress matrix and the matrix detailing implementation of the PGT are in Tables 7 and 8 located at the end of this paper.
Findings
Utility of the PGT process
Although all stakeholders were aware that the National AIDS Control and the Health Research Unit were the drivers of the PGT process in Ghana, the majority were unaware of how the process was initiated. A few commented that decisions to initiate the process had been handled externally, and they questioned whether it was demand-driven. The general feeling was that the demand for the use of the tool itself had not been clearly identified at the onset, and that stakeholders’ perceptions regarding the concept of RTIs in practice had not been polled. Nevertheless, the majority of stakeholders perceived the process as a necessary guidance tool with desirable outcomes for RTI programming, but voiced some scepticism about the controls.
A few stakeholders did not support the PGT process. They commented that new ideas were constantly being introduced in the country that did not build on the successes or failures of earlier programmes; thus, the country was in a constant state of planning. They opined that many HIV/AIDS and STI programmes were currently in effect, and that it was not practical to introduce new strategies that could conflict with successful programmes in which resources have been invested.
High employee turn-over rates resulted in short tenure for many of the stakeholders within their current organizations; therefore the majority had not been participants in the process from its onset, and a few had not personally attended the stakeholders’ and/or the dissemination workshop. Several new participants admitted they had been confused about the “PGT process” referred to at the recent meetings they had attended. Many others could not remember the activities of the workshops or if they had even attended one, but all those who did attend described the activities as being well-planned with diverse and multi- disciplinary representation. A few stakeholders believed that the process was perceived to be a public health-sector project and there was not much compelling the private sector to attend either of the workshops.
The majority of stakeholders who were not part of the initial process or members of the core team said that although the PGT was a planning tool, it had not resulted in significant changes in the way RTIs were conceptualized or in RTI planning and programme development in Ghana.
Perceived advantages of the PGT process
The stakeholders identified the following as advantages of the PGT process:
It refocuses the attention of health planners on the issue of STIs. Many stakeholders believed that STIs had been overlooked as a way to prevent HIV/AIDS and the PGT refocused attention on it; It encourages the involvement of all major stakeholders; It minimizes problems and accelerates progress through the multi-sectoral participation approach to planning; It has clear steps that serve as an organizational aid for achieving goals; It fosters collaborative work and dynamic interaction with bilateral donors; and It identifies a rich resource in donors and stakeholder representatives.
Perceived disadvantages of the PGT process
Overall, participants perceived more disadvantages than advantages to the PGT process in Ghana. They identified the following disadvantages:
It relies on frequent multi-disciplinary collaborative meetings—the main disadvantage. It was difficult to get all key stakeholders together so often. Busy schedules and travel plans impeded the consistent involvement of stakeholders, and waiting for individual input and endorsement slowed the entire process down; It takes too much time to achieve goals in a work culture where getting things to move can be a major problem. There are ten steps to the process and different individuals appeared to be in charge of different steps with little coordination; It is too research focused; some stakeholders commented that the country did not invest much in the outputs of their research. For example, the major activity after the rapid assessment appears to be additional operational research; It encouraged different viewpoints but no consensus building or attempts to bring them into a forum; It implied (through its 10 steps) an externally imposed time-line that was prone to frustrate people, since it did not consider contextual issues that could cause deviations; and It was initiated as a national programme that is centralized through the MoH. However, the GHS is decentralized to the regional level and each sector is encouraged to develop its own multi-sectoral health planning for HIV and STIs. If implementation had progressed as expected, each region would have had to decide where RTIs fit in their health priorities and agenda, thus impeding the development of a unified national programme.
Contextual factors influencing the PGT process in Ghana
Several inter-related issues affected the completion of the PGT process in Ghana. The majority of the stakeholders agreed that more factors impeded progress than facilitated it.
Perceived facilitators of process Political will: Stakeholders perceived that the current political environment supported programming that was related to HIV/AIDS and STIs, but this did not necessarily mean that funds would be dedicated to all activities. Core team members were all very enthusiastic about and committed to the goals of the PGT process and its anticipated benefits to health in the country.
Leadership: Stakeholders characterized the drivers of the PGT process in Ghana as strong and influential individuals who are trusted and well respected. They commented that this was necessary to facilitate the process in the Ghanaian work environment, as well as to attract and secure the participation and cooperation of specific key stakeholders who could make a difference
Government endorsement: Stakeholders perceived that it was important that government had demonstrated support for the process and had integrated it into the national activities of the NA/SCP, the major RTI-related organization in the country. This act informed stakeholders that although it may have been externally derived, the MoH had a vested interest in the goals of the process.
Perceived obstacles Scheduling: Difficulties scheduling meetings with top-level individuals were considered the major obstacles to the PGT process. Consistent participation of stakeholders throughout the process was difficult to achieve due to busy and conflicting schedules and the need to attend to a lot of concurrent activities unrelated to the PGT. Many stakeholders were described as having too many simultaneous responsibilities, and the majority of participants referred to the then NACP as being a ‘one-man show’ that was overworked, overwhelmed, and severely understaffed. Timeliness was also perceived to be a problem: meetings in Ghana habitually start much later than scheduled, and are even expected to start late. Inherent traffic jams in the country also make it occasionally difficult for well-intentioned individuals to get to meetings on time.
Timing: The timing of the introduction of the PGT process in Ghana was also perceived to have affected its completion. The PGT process was started when numerous government and nongovernmental agencies in the country had already initiated many HIV/AIDS and STI programmes. A few stakeholders commented that their organizations should not be expected to modify their funded and established programmes to accommodate the programming activities resulting from the PGT.
Consistent participation: The inability of many stakeholders to remain consistent participants resulted in alternate representatives attending meetings. Alternates usually were subordinates who did not know about all the activities of their organizations, were intimidated by senior personnel, could not contribute meaningfully, and did not have the autonomy or empowerment to make decisions at the meeting. These factors slowed the process down. A very high rate of employee turnover in the Ghanaian workplace also influenced consistent participation. All the new stakeholders who were interviewed reported that they had not been debriefed on the PGT by their departing counterparts, and had not been able to locate information on it within their organizations.
Political factors: The government elections held in 2000 resulted in a changeover in the ruling party after two decades. Many stakeholders commented that, in anticipation of the results, not many individuals were ‘working mentally’ and that many government related activities slowed down. The leadership of the PGT encouraged stakeholders to believe that the process was local and centrally based within the Ministry of Health. However many perceived that the MoH’s presence at the stakeholders’ and dissemination workshop was not sufficient to maintain RTIs on the priority agenda. The lack of a person dedicated to the process from within the MoH was perceived to have possibly influenced the government’s support for implementation of recommendations.
Health system issues: Many stakeholders commented that Ghana Health Service-Health Research Unit (HRU) was an overburdened institution with few personnel: a small unit/department that is charged with handling the country’s research needs. In addition to their local health agenda, their collaboration and participation is sought after by most of the external agencies seeking to conduct research activities in the country. The increased workload and responsibilities of the department result in problems scheduling multiple research studies and coordination activities. Stakeholders perceived that HRU’s resources, especially personnel and time, are strained and exhausted, with the same people involved in many different projects at the same time. This makes efficient coordination difficult to achieve.
The general perception was that the formation of the Ghana AIDS Commission caused a redirection of energies and focus of stakeholders to this new organization, making it difficult for National AIDS and STI Control Program (NA/SCP) to secure consistent participation of some stakeholders in the PGT process. Nevertheless, all stakeholders concluded that the NA/SCP had done a good job facilitating the PGT process in Ghana.
Most stakeholders outside the core team still conceptualise RTIs separately as either HIV/AIDS or STIs. The participants disagreed on whether the concept should be combined or separated. Stakeholders felt that the term RTIs detracts from the urgency and priority that should be given to HIV/AIDS and STIs. They also believed that for this reason, RTIs are not considered to be a national priority; even the NA/SCP programme still makes a distinction between them.
Coordination: Although both NA/SCP and HRU are acknowledged as the drivers of the RTI/STI PGT process in Ghana, there appears to have been an informal split in the coordinating responsibility along the lines of expertise of the two agencies—i.e. research and programming—in lieu of assuming overall responsibility for coordinating the process in its entirety. A change in the NA/SCP leadership occurred when the PGT process was preparing to move into the implementation phase. The new director reported he had not been briefed on this activity, could not locate information on it within the organization, and had had no knowledge of the PGT before being contacted for an interview.
Technical process: Stakeholders commented that from the onset the PGT process did not involve key decisionmakers and planners from the other regions, although the current health system charges each region with developing its own programmes for HIV/AIDS and STIs based on their assessed needs.
The overwhelming majority believed that the rapid assessment was conducted over too long a period and it had interrupted the momentum of activities and the flow of progress of the PGT. A few believed that the background paper and the stakeholder’s workshop provided the necessary information for programme planning. A few stakeholders commented that they could not buy-in to the results of the rapid assessment and the rest of the process for the following reasons: The rapid assessment methods were not rigorous and the results have some unintentional inaccuracies and misrepresentations; Stakeholders external to HRU did not participate in the assessment; The private medical community was not assessed in the assessment; The assessment did not provide data on the limitations of the health care system and service related needs.
The steps of the PGT process were described as fragmented and lacking a consolidated team effort, with different individuals managing the different steps. An example given was that one individual did the background paper, another did the field research, another wrote the findings, etc.
A formal and time-linked work plan that outlined specific activities to achieve each of the strategic recommendations, expected outputs, and identifiable institutions and individuals responsible for specific activities was not developed when the rapid assessment report was completed.
Process meetings were not regularly conducted after the dissemination workshop and there was a lag of almost a year between a meeting in 2002 and 2003. The reason for this is not clear, but is probably a combination of many of the aforementioned issues. A few stakeholders commented that the lack of a local Population Council office(r) based in Ghana to assist in redirecting energies to maintain the momentum of the process could have contributed to the stagnancy of the process. They commented that although the goal was to develop a country-led process, the hectic environment characterized by so many simultaneous and competing activities made it necessary to have an ‘external push’ now and then.
The focus of recent PGT process meetings appears to have shifted to operational research instead of efforts to resume and complete the process. This may be a reflection of both the leadership’s expertise and the partitioning of coordination roles.
Work culture: The work culture in Ghana was described as one that does not facilitate process. Many stakeholders reported that it is traditionally very difficult to get things moving in Ghana and there is always a lot of discussion with good ideas and intentions but minimal follow-up and action.
The practice of debriefing superiors as well as new employees on active projects does not appear to be consistently done by staff of local agencies or by donor missions and locally- based international agencies. Coupled with the high attrition rate, this results in a lot of lost information and interrupted participation.
Communication: Communication issues also influenced the progress of the PGT process. Stakeholders reported that local reports and documents were not freely available to all who sought them, affecting the comprehensiveness of the situation analysis and the ability to complete it in a timely manner. Minutes or meeting summaries and reports were not prepared regularly for distribution to stakeholders and this impeded the flow and quality of information. The majority of the stakeholders interviewed reported seeing the final rapid assessment report for the first time shortly after they were asked to be interviewed for the evaluation.
A few stakeholders reported that some stages of the process were delayed while waiting to receive feedback and approval from superiors of supporting donor agencies. Stakeholders commented that the rapid assessment proposal was started before it was approved, and dissemination of the final draft of the rapid assessment findings was delayed until the time of the evaluation because staff were waiting for comments from the head office.
Funding: An important factor that impeded the implementation of the PGT process was the implicit assumption by stakeholders that the agencies that pioneered its inception in the country would support it through to completion, including funding the resultant strategic recommendations that were developed. Since MoH policy warrants that all activities in the sector be budgeted at the beginning of the fiscal year, there were no extra funds for additional projects like those stemming from the PGT process. Stakeholders commented that programmes are driven by funds that are set up for them from the beginning, and the omission of this kind of support would inherently interrupt the process. The resources of the common basket fund of the MoH are limited and competitively allocated.
Achievement of principles of the PGT process
Multi-sectoral collaboration Representatives from within the health and other sectors of Ghana were encouraged and invited to be active participants in the PGT process. Participation from within the MoH and the Ghana Health Service included the chairing and endorsement of the workshops by the Director General and Deputy Director General of the MoH, plus representation from the Health Research Unit, the National AIDS and STI Control Program, the Ghana Aids Commission, the Ghana Registered Midwives Association, and the Reproductive and Child Health Unit. Representation from other sectors included nongovernmental agencies, external missions, and the private sector. Some stakeholders perceived that organizations concerned with the welfare of women and children lacked adequate representation.
Interrupted and irregular communication among stakeholders impaired effective collaboration, as did frequent use of alternate representatives and the lack of consensus- building activities. A few stakeholders also commented that friction was apparent between some stakeholder groups from the private sector (chemical sellers and pharmacists). No stakeholders collaborated in the fieldwork even though they were encouraged to do so. Nevertheless, the general perception regarding the meetings and workshops was that stakeholders were always encouraged to express themselves freely and diverging opinions and criticism were respected.
Multi-disciplinary involvement Although it proved difficult to maintain continuous participation of specific representatives, a diverse group of professionals involved with RTI programmes and service delivery were represented at the workshops and the majority of process meetings. Stakeholder involvement was sought from all levels of the health system and from both the public and private health sector. A diverse group was involved in the PGT process, including: researchers, health care providers, programme planners, managers, evaluators, project directors, country representatives, donors, technical advisors, and professional officers.
Private physicians were not adequately represented; this was perceived to have resulted from conflicts between work schedules and workshops and an anticipated loss of income, not necessarily disinterest. Stakeholder representatives from the regional and district level did not actively participate in the process beyond contributing data to the rapid assessment.
Local ownership of process The greater part of the discussion on the principles of the PGT focused on ownership of the process. Every effort was made to present the programme as local and not external and the issue was stressed during workshop presentations. In addition, the leadership of MoH chaired each of the workshops to demonstrate the ministry’s commitment to the process. However, almost all the stakeholders doubted that total local ownership of the process would be achieved because the process was generated from outside the country. Other factors detracted from local ownership, including external controls such as timelines, the need to defer to external authority for approval at some stages, and a dependence on indefinite external funding.
A few stakeholders related buy-in to ownership; they commented that it was difficult to achieve local ownership if no one perceives the need for RTI prevention. They believed that the demand for services had not been clearly identified and the PGT programme was delivered to the larger body of stakeholders as a package that came with limited opportunities to vote it out.
The PGT process at the sub-national (district) level
No information was available to evaluate the PGT process at this level since none of the eight health care providers interviewed at the district levels had either heard of the PGT or participated in the rapid assessment activity. All were relatively new to their positions with a range of service between ten months and two and a half years.
Programmatic outcomes
Programme outcomes were not assessed because none of the PGT strategic recommendations progressed to the implementation phase. Core team members strongly believed that the majority of the strategic recommendations have been incorporated into other national and private initiatives, but there was no evidence to support this claim. No validation existed that the team had approached organizations regarding incorporating the recommendations into their institutional programmes. Table 7 summarizes collated information reported by all stakeholders on the progress made to date to achieve the strategic recommendations.
Findings show that the tool is perceived to be both necessary and useful, and its guiding principles are desired and valued. The tool helped to refocus national attention on STI and provided an organized and systematic framework for managing a complex public health problem with many interrelated components. However, there is limited awareness of the process outside the central level, and the management of RTIs is still approached from its individual components. More work is needed both to inform stakeholders and engender their cooperation. Support for and participation in the process might be enhanced if it took less time and placed less emphasis on research activities. More work is needed to engage the private sector and regional health systems.
In Ghana, however, the tool resulted in minimal planning. The process did not progress to the formal implementation of activities to achieve the strategic recommendations. Several contextual issues impeded the completion of the process including: timing, inconsistent participation, coordination issues, limitations in the technical process, and a lack of funding. Numerous reproductive health programmes exist in the country that relate to the strategic recommendations derived from the PGT; however, these programmes were developed outside the process and appear not to have been influenced by it at this time. The tool may provide the framework to coordinate the integration of current established activities and organize them into a national effort with converging goals.
Discussion/Conclusions
The RTI/STI Programme Guidance Tool was introduced in Ghana in 2000 at a time when the country’s political and health leadership was committed to improving reproductive health for its citizens. The tool resulted in the production of a country background paper and a rapid assessment activity that led to the development of strategic recommendations to improve RTI services in the country. The Health Research Unit of the Ghana Health Service and the former National AIDS Control Program (NACP) of the Ministry of Health drove the PGT process, with the collaboration of many local and external stakeholders. These included government agencies, external aid missions, nongovernmental organizations, and private professional organizations involved with RTI services. Most of the participants were from the central level and the Greater Accra Region, where the process was initiated and coordinated, with little if any representation from other regions. New representatives involved in the process knew little about the goals of the tool and about the process at the district level. Stakeholders perceived the process to be necessary in Ghana, but opposing opinions persist regarding the concept it addresses. Nevertheless, the process was embraced enthusiastically and progressed rapidly through to the second dissemination workshop, after which it appeared to lose its momentum and eventually stagnated. Several contextual issues were identified as being responsible for the loss of momentum in the process including: Busy and overworked team members; Extended time to finalize the rapid assessment report; Broad and somewhat vaguely defined strategic recommendations for action; Change in the leadership of the NACP—the main implementing agency; Absence of a formal action workplan; Lack of funds for implementing the strategic recommendations; and Recent re-focus on additional operations research in lieu of resuming and completing the process.
In general, the PGT was perceived to be a step in the right direction to developing a strong planning base for RTI programming in the country. Many acknowledged that it had produced some very important and useful outputs, such as multi-sector involvement, collaboration, and a refocusing of attention on STIs. The country background paper was whole-heartedly embraced as a very useful document, a rich resource that had integrated a lot of hard-to-get information into one available source for stakeholders. Both workshops were important ways to familiarize and update stakeholders on national reproductive health activities; they also afforded opportunities for networking.
None of the strategic recommendations had progressed to the implementation phase. Overall perceptions of stakeholders were that although the PGT was a strategic planning tool, it had not contributed much to planning programmes or to changing the way RTIs were currently managed in the country. However, core team members perceived that the tool had been beneficial in identifying programme needs for RTIs, and had provided the systematic process to validate that the current efforts underway in the country were necessary. Given the introduction of the PGT in Ghana at a time when the health environment was saturated with different RTI programmes and activities, the tool may be more useful to coordinate the existing multiple fragmented and repetitious efforts into a singular over-arching national programme, rather than as a means to plan new development. Although the PGT is a strategic planning tool for both identifying and developing new programme activities and coordinating existing efforts, it has been conceptualized locally more towards the latter than the former. The PGT in Ghana was not effective in emphasizing the coordination aspect of programme planning. Therefore, the final strategic recommendations developed do not need to harmonize and coordinate existing country programmes towards enhanced efficiency and effectiveness.
The core team believed that the majority of the strategic recommendations had been achieved by their incorporation into related national initiatives. However, excluding collaboration associated with the chemical seller proposal, there was no information that linked the PGT to current reproductive health programmes, or verified that stakeholders had been formally approached to incorporate PGT recommendations into their current programmes and activities. The existence of such programmes is sufficient evidence that the recommendations have been met to some extent. Not all stakeholders were aware of all current activities related to each recommendation, indicating a gap in information sharing.
An important point of note is that although the list of strategic recommendations developed from the RA has been reprioritized to four broad areas, all the stakeholders referred to the original list when discussing achievement of recommendations. Clearer lines of communication are needed to ensure clear direction and planning. The final list of recommendations is weighted towards service delivery improvements, although policy and OR recommendations may need to precede or be planned concurrently with some of the programme activities. The final report acknowledges that some research and a policy dialogue are needed; these needs are not cited as strategic recommendations, but are included as supplementary notations.
Nevertheless, the most recent efforts of the PGT core team have centred on developing operations research to test the feasibility of training chemical sellers to dispense pre- packaged antibiotics to treat STIs. The evaluation revealed underlying disagreement among some stakeholders regarding this proposal in a research or programme form. It would be beneficial to address this concept with the larger stakeholder group even at this stage, since it might take time to convince them of the need for this approach to manage STIs. Early intervention would also facilitate a united approach to introducing any future programmes developing from the operations research, which will be crucial for public buy-in. It may also be beneficial to consider developing this activity as an intervention with a small operations research component embedded in it, but there are distinct policy implications that need to be addressed first.
Although the process, especially the rapid assessment activity, was perceived to be a long one with too many meetings, it was not originally designed to be so. The original intent of the rapid assessment activity was to facilitate commitment to the process by providing top- level stakeholders and decision-makers (including government officials) the opportunity to experience the complex real-life issues presented by RTIs, through their exposure and interactions with health care providers and service users. It was meant to have been a shorter activity of field visits by key stakeholders who could make a difference. In Ghana, however, the rapid assessment activity was conceptualized and formally designed as research to supplement information in the country background paper, and it was conducted in seven of the ten regions. The core team acknowledged that they proceeded with the rapid assessment before receiving feedback from the Horizons Program to avoid delay. On the other hand, it is challenging to offer technical advice that may be perceived as control, while also attempting to foster a country-led process with local ownership.
All stakeholders interviewed perceived the rapid assessment as research; this conceptualization transferred the focus from programme planning to research. Some stakeholders commented that the country background paper together with information from stakeholders participating in the first dissemination workshop provided adequate baseline information for programme planning; they did not understand why the rapid assessment was conducted. This misunderstanding of the purpose of the rapid assessment should be clarified.
Very few stakeholders participated in the rapid assessment even though they were encouraged to; perhaps they perceived it to be research, which was not their domain or expertise, and this together with the length of time it took to complete the final report may have led to a disengagement from the process. Stakeholders were dissatisfied with the length of time needed to move the process; some perceived the need to adhere to a timeline that was unsympathetic to all the contextual issues influencing the process. In spite of this, however, the PGT in Ghana was allowed to proceed at its own pace; the length of time devoted to completing the rapid assessment contributed to the loss of momentum in the process. The prolonged separation from the PGT process and the problem of RTIs may have influenced stakeholders to refocus their attention to other activities.
Disagreement persists among stakeholders regarding issues that are crucial to the success to the PGT process, such as the concept of RTIs versus HIV/AIDS and STIs, the need for and use of the rapid assessment, some of the strategic recommendations, and additional proposed operation research. Although collaborative participation was respected and personal opinions were sought at both of the workshops, there was little attempt if any to reach accord on issues of disagreement. Many stakeholders felt that a lot of resources used to facilitate the PGT had been wasted on unnecessary activities to identify the areas to target for change, and that there was an increased emphasis on conducting research that would not be used. Although all stakeholders perceived the principles of the process to be commendable, the majority of the stakeholders external to the core team were dissatisfied with the recommendations. Many unresolved issues suggest the need for consensus-building activities to be a major part of the process so that a greater buy-in may be achieved.
The concept of RTIs in itself must be discussed among stakeholders to engender commitment and ownership. Many stakeholders still separate HIV/AIDS and STIs. None of the stakeholders discussed endogenous and iatrogenic infections, which were not specifically included in the reprioritized recommendations list; no information was provided on current activities in the country related to this health issue. In this respect, the tool was ineffective in influencing stakeholders to truly embrace the RTI concept. The general perception was that key decisions about integrating all infections of the reproductive tract had been made prior to the first dissemination workshop and that the RTI concept was given to them as an established issue.
RECOMMENDATIONS: PRIORITY INTERVENTIONS
The following specific recommendations were offered:
Address the status of the current health environment and the characteristics of the health issue to be addressed. For Ghana, this would include the concept of embracing all infections of the reproductive tract and including STIs under RTIs, and describing the scope of on-going efforts in the country to address them. This would mean providing preliminary information on the major direction of the tool, which is planning for new development versus coordination of existing efforts; Consider initiating the programme at the regional level so it is supported by the decentralized health system in Ghana. This would also facilitate the identification of relevant health priorities and strategies and the development of a programme that can be more easily integrated into district health planning; Establish a need for the tool by involving major stakeholders in the decision-making process to initiate it in the country. Convene an initial stakeholder meeting after the formation of the core team to discuss the need for the tool and the concept of RTIs. This will facilitate a country-led demand-driven approach to the process, which may also improve perceptions of local ownership of the process. Consider inviting participants from the national level so all regions can be informed from the onset; Select a programming institution, such as the National AIDS and STI Control Program, as the programme’s lead organization, with technical and research support from the Health Research Unit. A strong, influential, and respected leader is necessary to coordinate the process and to garner consistent participation. It would be beneficial if the local Population Council representative involved with the process has prior experience with the PGT process. Although securing commitment of team members may be difficult because of the contextual issues in Ghana, team members’ participation should be assessed in terms of current and projected availability to ensure continuity; Incorporate active consensus-building activities into dissemination workshops; Clarify the intent of the rapid assessment activity, its experiential (versus empirical) nature, and the goals of stakeholder participation. Stress that the rapid assessment is better conducted over a short period to maintain momentum of the process. It may be beneficial to change the name of this activity to minimize or eliminate perceptions that “assessment” is linked to research; Emphasize communication and mechanisms for sharing information throughout the process. This should occur within the team and from the team to government levels and stakeholder organizations; Include an activity that emphasizes the development of action work-plans in anticipation of future evaluations. They should include the development of specific activities that are realistically timed and measurable, with the assignment of responsible individuals and institutions; Write the strategic recommendations clearly with distinct and well-developed goals. Each recommendation should be identified within the area of impact it serves to improve, such as operations research, service delivery, and policy; and Maintain commitment and facilitate progress into the implementation phase by obtaining pre-secured funding. Implementation must be timed to coincide with the development of the health budget and regional allocation of monetary resources for health activities.
Table 7 Summary of progress made in implementing strategic recommendations
Operations research
Strategic Recommendation Progress Comments
OR1: Data on endogenous No information. and iatrogenic infections: from post-abortion infections, insertions of intrauterine device, surgical procedures, etc and their outcomes should be collected and analyzed to inform policy.
OR2: Population-based Proposal submitted in June 2002 WAPTCAS conducted a study studies are needed to to EU (partially funded). and then in Accra and in Kumasi on the ascertain the true prevalence to NACP. causes of male urethral of HIV and the true incidence In Dec 2002, by HRU and discharge in 1998, and female of various STIs. Noguchi Research Institute: A discharge in 2002. Study on the Current Prevalence of Sexually Transmitted Infections in Certain Population Groups and Risk Factors for Cervicitis in Ghana. PI: Dr. J. Gyapong.
OR3: Studies should be Revised and consolidated Noguchi Research Institute undertaken to determine the proposal (OR2 & OR3) presented working on a similar study to burden of complications of to WHO in Dec. 2002. They are identify effective and RTIs in Ghana and the committed to providing the ineffective drugs for RTIs, changing patterns of resources for study from funds merging their effort with OR2 antimicrobial susceptibility of earmarked for NACP research. above and redesigning into STIs; further information one study. should be provided on the control of endogenous infections.
Summary of progress made in implementing strategic recommendations (cont)
Training needs
Strategic Recommendation Progress Comments
STI management training NA/SCP is overseeing this activity Traditionally it has been very should be provided for various with assistance from the National difficult to engage the care providers. STI Program and WAPTCAS. medical community, They provide training for health especially private physicians. care providers, including nurse Doctors in the medical school educators, nurses, and remain predominantly physicians. unconvinced that syndromic Private practitioners in Accra and management is the best way Tema were trained in syndromic to treat STIs in Ghana. management of STIs in 2002 and Private physicians are difficult 2003. to get involved in GAC has funded training of workshops—they worry about midwives since 2001. lost business during time at GSMF, MSH, and the Pharmacy workshop. Team considering Society have been conducting designing a training session training for pharmacists and for them using the chemical sellers. pharmaceutical approach— food, free samples, etc. Proposal for training program has been submitted to the Department for International Development (DFID). PI is Dr. Dzokoto.
On-going training should be Final-year medical and pharmacy Medical school in Greater- provided to medical, students in Kumasi have received Accra not yet receptive to pharmacy, and nursing training in SM of STIs. idea, so progress slower students in management of SM training already incorporated there. STIs. into the curriculum of nursing There are no pharmacy students. students in Accra. Midwifery students are not recommended for training by PGT. Currently not all midwives receive training, which depends on funds available.
Periodic reviews of the pre- No information. JHPIEGO reportedly service curriculum should be assisting medical school to undertaken with a view to review their curriculum. incorporating emerging issues. Unable to verify follow-up.
Summary of progress made in implementing strategic recommendations (cont)
Program needs—Health service
Strategic Recommendation Progress Comments
There is a need to emphasize Attempts are being made to Current focus is predominantly RTIs as a whole, not only refocus on STIs. on HIV/AIDS. Stakeholders HIV/AIDS and STIs, and to Name change of NACP to verbalized extreme differences incorporate their prevention NA/SCP and the appointment of of opinion over whether or not and management into RTI a National STI Coordinator to the HIV/AIDS should be dealt with programs. organization. separately from STIs and other infections. Regional STI coordinators already exist.
An integrated approach to RCHU has developed and Private facilities have minimal STI management in both disseminated reproductive health involvement. RCHU involved public and private facilities practice standards and protocols. in a SM training program for should be developed and STI management guidelines private physicians that is part implemented. revised by MoH in September of of the Country UNFPA 2002. Reproductive Program: 2001-5 cycle. NACP and WAPTCAS have been training the public sector: FP Supervision and monitoring nurses, medical assistants, and aspect of all programs is weak midwives. or absent. GAC has funded the SM training of staff at a few private clinics in Accra.
Quality assurance programs No information. WAPTCAS uses external should be improved. consultant to perform quality control checks in randomly selected clinics.
Improve supervision in both Midwives report training teams in the private and public sectors. facilitative supervision who go out to supervise maternity homes.
STI screening for antenatal Syphilis screening being done for Supervisory and monitoring attendants, such as syphilis is antenatal attendees only, but system needed. needed. hepatitis screening is not being Hepatitis screening should be done anywhere, although the test re-introduced. is available. Hepatitis vaccination program initiated in 2002.
Summary of progress made in implementing strategic recommendations (cont)
Program needs—Health service (cont)
Strategic Recommendation Progress Comments
There is a need to step up the Training of trainers workshops Unable to obtain specifics: monitoring and supervision of conducted by NACP in information on number of syndromic management of September 2002. Funded by workshops, where they were MoH facilities with a view to WHO. conducted, who attended, etc. motivating implementers and Monitoring and supervision providing program managers aspect needed. with program needs such as refresher training.
Efforts to increase AIDS and STI reporting forms developed in Ready to disseminate pre-test STI surveillance reporting conjunction with NACP and data and information on levels in the country need to National Surveillance Unit of the be enhanced. GHS. efficacy of forms. AIDS reporting added to Attempts are being made to Integrated Disease Surveillance integrate STI and HIV sentinel and Response form. sites. Surveillance sites increased from 20 to 24. MoH developed monitoring forms with technical assistance from WAPTCAS, and pre-tested the forms in five regions between September and December 2002. HIV and syphilis (only) reporting collected from sentinel sites.
Population-based studies HIV incorporated into DHS as On-going feasibility issues should be undertaken to pilot for 2003 data. regarding HIV testing in the ascertain the true prevalence No population-based STI data. field in a society with specific of STI/HIV infection beliefs about blood. Proposal submitted in June 2002
to WHO HRU and Noguchi Proposal was revised and Research Institute: A Study on integrated with Noguchi the Current Prevalence of Institute study to assess anti- Sexually Transmitted Infections in microbial sensitivity. See Certain Population Groups and information on OR2 & OR3 Risk Factors for Cervicitis in Ghana. PI: Dr. J. Gyapong.
Strategic Recommendation Progress Comments
Strategies to increase Committee (FHI, GAS, WAPCAS, Two behavioral research commercial sex worker access NACP) on transactional sex work studies conducted on the to interventions that reduce looking into the legal issues of roamer sex worker by: 1) the RTIs should be initiated. sex work University of Ghana Medical WAPTCAS operating STI clinics School – Department of for CSW in ten regions—offers Community Health; 2) the education and treatment. Adabraka STI clinic in conjunction with WAPTCAS. NACP, GAC, WAPTCAS conducted two workshops in FHI Ghana conducted a study Accra on transactional sex work of the home-based/sitter sex in Ghana. worker. Draft National HIV/AIDS and STI WAPTCAS clinics from CSW Policy (August 2000) developed also offer services to PLWHA by the MoH, recognizes CSW as a vulnerable group.
Summary of progress made in implementing strategic recommendations (cont)
Program Needs – Health Education and Behavioural Change Communication
Strategic Recommendation Progress Comments
Continuous education and Community Health Dept. of the Stakeholders verbalized access to drugs is paramount MoH involved in outreach opposing opinions regarding for control. education. the idea of chemical sellers GSMF involved in extensive dispensing pre-packaged multi-media campaign and social- antibiotics. Study perceives marketing of STI related issues trained chemical sellers as a and services. means to increase access to STI drugs. They are estimated JHU-CCP training peer to be the first line of help for educators. about 80% of the population OR Proposal developed by HRU seeking treatment for STIs. and NACP on feasibility of Collaborators for study are training chemical workers to HRU, RCHU, NACP, GSMF, dispense pre-packaged antibiotic MSH, WHO, Pharmacy therapy for STIs. ‘Pilot-testing Council, and Horizons Pre-Packaged Therapy for Male Program / Population Council. Urethral Discharge Syndrome in Ghana. Proposal submitted to PC for possible funding. USAID Mission reportedly possibly interested in providing TA and supporting the distribution of drugs. This OR is to be conducted over 18 months.
Endogenous infections such GSMF involved in community as Candidiasis should be outreach education and BCC addressed in Behavior programming. Change Communication PPAG, GRMA, and FP & programs WAPTCAS-run clinics include information on this specific STIs in their client education activities.
Strategies to address the No information Stakeholders perceive that inappropriate treatment of the proposal to train chemical STIs by community members sellers is the first step to and chemical sellers must be achieving this addressed with urgency recommendation.
Strategic Recommendation Progress Comments
Behavior change GSMF involved in community communication and health outreach education and BCC education is needed to programming address erroneous perceptions about RTI, problems with partner notification, and stigma related to STI infections.
Chemical sellers must be Pharmacy Society conducting No information on when trained and motivated to training sessions for their specific training done and provide appropriate members and also for chemical topics covered. Unable to counseling, education, and sellers (who then become schedule a meeting to meet information on condom use. franchised). with a representative from the Pharmacy Society.
Education on the NACP, GAC, and PPAG have GAC reports they are complications of STI and its developed IEC information. providing funding to NGOs relationship to HIV/AIDS throughout the country to should be intensified. meet this goal but unable to verify who has received funding.
Educational strategies on STI Rotary clubs in Ghana may be GAC in collaboration with the involving men should be implementing programs in this Commonwealth Secretariat designed and implemented. area. (UK) coordinated a workshop PPAG working with males. in Ghana with the Rotary clubs of West Africa (January GSMF have a program for long- 2003) on male involvement in distance truck drivers, who are HIV prevention. primarily male. Planning clinics for males GRMA designing an STI program only. One already functional for males as part of their Golden in Greater Accra and another Jubilee activities. to open in the Ashanti Region RCHU involved in outreach before the year’s end. program ‘Men as Partners’ coordinated by Engender Health Organization (formerly AVSC).
Further education on the use PPAG, GRMA, GSMF, and the GSMP launched training in all of the female condom should Society of Women in Africa the regions. be promoted. against AIDS are involved with this.
Strategic Recommendation Progress Comments
Emphasis should be placed on GSMF involved in social more effective and sustained marketing approach male and marketing strategies for the female condoms. promotion of the both the male Life Choices’ advertising. and the female condom.
Program Needs – Cultural Practices
Strategic Recommendation Progress Comments
Strategies to address the No information probable risk of RTI following complications of herbal insertions must also be addressed.
Further exploration of existing Research report submitted to the There is possibly a program practices is needed – GAC July 31, 2002: ‘Belief in the Northern regions especially among special Systems and the Control of organized by CEDPA to groups – with a view to HIV/AIDS’. Author: Professor address this. However, designing targeted and Twumasi CEDPA left the area in 2003. culturally appropriate No information on how the programs. information has been used
Program Needs – Inter-sectoral Collaboration
Strategic Recommendation Progress Comments
Improve the coordination and No information collaboration between the MoH, Private Medical Association, Pharmacy, Laboratory Board, and chemical sellers.
Implement immediate action Discussions initiated with new to target populations NA/SCP leadership about practicing herbal insertions whether to conduct exploratory and use of local cocktails of OR or to begin health education in drugs for the treatment of STI. this area.
Summary of progress made in implementing strategic recommendations (con’t)
Program Needs – Policy Review
Strategic Recommendation Progress Comments
Human Rights and the work National HIV/AIDS and STI Policy WAPTCAS ran a home-based environment of PLWHA in has a brief section on disclosure program for PLWHA in the Ghana must be addressed. to employers. Eastern region from 1997- In 2002, Ghana Employers 2003, then transferred Association and GAC, in operations and management collaboration with ILO, conducted to FHI. a Workplace Assessment. Submitted the final report to GAC in 2003. Consultation on-going to develop the findings from the report into workplace policy to be incorporated into the overall National Policy on HIV/AIDS Unilever developed an HIV/AIDS Workplace Program.
There is a need to address and Included in section: STI Control Advocates for formal and support the private sector in the and Management of National informal courses on STIs for management of RTIs in Ghana, HIV/AIDS and STI policy. all health workers and including private pharmacists prescribers including and chemical sellers, and define pharmacists, but does not their role in RTI management. include chemical sellers. Reported that the National Policy on HIV/AIDS and STIs was complete and had been sent to cabinet for approval prior to the receipt of RTI- PGT recommendations.
Policy guidelines for laboratory Blood screening and testing, practice should be reviewed home self-testing, transfusion protocols, and testing principles covered in National HIV/AIDS and STI Policy.
The policy that prohibits the sale No information of antibiotics by chemical sellers should be reviewed.
Stakeholders provided information on progress for the original list of strategic recommendations and not the four re-prioritized recommendations described on page 3-4 of this report.
Table 8 Implementing the program guidance tool: a review of activities and progress in Ghana
Name of Person Completing Report: ‘Kuor Kumoji Country: Ghana Date Completed: May 22nd, 2003
Steps and Admini- Still Date of Expected Comments Activities strator Curr- Completion Date of ent? Completion
Formation of Core Yeboah, No Oct 2000 PC Program Associate Team Gyapong new to Ghana and not familiar with major stakeholders in country
Identification of Tapsoba No Oct 6, 2000 Resources for funding of Stage One activities
Writing Dzokoto No Jan 2001 With support from HRU Background Paper staff
1st Dissemination Yeboah, No Feb 2, 2001 Feb 1 – presented PGT Workshop Gyapong & background paper Feb 2 – core team planned rapid assessment activities
Rapid Assessment Garshong No April 20, With support from HRU 2001 staff. Conducted in ten regions between Feb 27 and April 20.
2nd Dissemination Yeboah, No Jan 23, Presented and Workshop Gyapong 2002 discussed Rapid assessment
Identification of Yeboah, No Jan 24, Core team meeting Strategic Gyapong 2002 immediately following Recommendations workshop to prioritize and finalize strategic recommendations. Identification of strategic recommendations for research, service- delivery and policy not clearly defined in final paper.
Operations Gyapong No April 15 Collaborative effort with Research 2003 HRU and RCHU (GHS), proposals written: WHO, GSMF, MSH, ‘Pilot Testing Pre- Pharmacy Council, and packaged Therapy Horizons Program / for Male Urethral Population Council. Discharge Syndrome in Ghana
Operations Tapsoba Yes Submitted to Population Research Council for funding proposals funded consideration
Operations Gyapong Yes 18 months Funding pending Research from start underway date
Operations No information Research Yes evaluated
Programmatic Yeboah, No Jan 24 2002 Core team prioritized recommendations Gyapong strategic identified recommendations following second workshop
Mechanisms for Yeboah, Yes April 2 2002 May 30, Preliminary action plan implementing the Gyapong 2002 discussed. (See Table programmatic 1: page 40 for recommendations information) identified Not completed
Policy Yeboah, No Not clearly identified in recommendations Gyapong final list identified
Mechanisms for Yeboah, Yes April 2, 2002 Not completed implementing Gyapong policy change identified
Mechanisms for NACP, Yes Operations Research upscaling effective Gyapong not yet conducted interventions (as defined through operations research component) identified
Implementation of NACP Yes NACP under new policy and leadership. New programmatic Director reports being recommendations unaware of RTI-PGT
Consultant for van Dam No March 2003 evaluation identified
Methods and L. Brown No April 2003 No evaluation of Indicators for Kumoji programmatic outcomes evaluation agreed done as no implantation upon driven by PGT underway. No indicators agreed on - no action plan with specific activities to meet strategic recommendations was developed.
Monitoring and Kumoji No May 23, Data collected from May evaluation 2003 12- 23 (12 days only) activities underway
Evaluation report Kumoji No June 2003 submitted
ANNEX 1 EVALUATION PARTICIPANTS
Interviews
The following representatives and institutions were interviewed at the national level: Program Associate, Population Council, Ghana Social Scientist, HRU Country Director, Family Health International Director, Health Research Unit, Ghana Health Service STI Coordinator, National AIDS Control Program; Regional AIDS Coordinator, Greater- Accra HIV/AIDS Team Leader & Monitoring and Evaluation Specialist Health Programs, USAID Principal Nursing Officer, Reproductive and Child Health Unit, Ghana Health Service Research Coordinator, Ghana AIDS Commission Senior Research Officer, Health Research Unit, Ghana Health Service Resident Technical Advisor, The Futures Group International; Manager, The Policy Project President, Ghana Registered Midwives Association National Project Professional Officer, UNFPA Ghana Assistant Manager for Programming, Ghana Social Marketing Foundation Executive Director, Ghana Social Marketing Foundation Research and Evaluation Manager, Planned Parenthood Association, Ghana Research Officer, Planned Parenthood Association, Ghana Project Coordinator, West African Project to Combat AIDS National Family Planning Program Manager, Reproductive and Child Health Unit Program Officer, UNAIDS, Ghana Country Representative, World Health Organization, (briefing) National Professional Officer for HIV/AIDS, World Health Organization Vice Chairman, Director, Association of Private Medical and Dental Practitioners, Ghana Director, National AIDS Control Program (Brief telephone contact)