Ghana's COVID-19 response: Questioning 'robustness' of health information system
“It is that constancy, that robustness of the data that we have in Ghana, that is inspiring our decisions,” President Akufo-Addo had said as he announced that the country will be lifting the partial lockdown. But the indicators used to determine that “robustness of data” weren’t clear. While Ghana's initiatives to improve the quality of health-related information to tackle COVID-19 are noteworthy, more needs to be done to enhance integration and transparency of its health information system.
Ever since the beginning of the COVID-19 pandemic arrived in Africa, Ghana's response to the outbreak has stood out in the region. It was not only one of the first African countries to implement a lockdown but also the first African country to lift the lockdown and promised to utilize advanced technologies instead of strict lockdowns to fight against the pandemic.
But eight months into the pandemic, it's safe to say that Ghana's fight against COVID-19 hasn't been a particularly smooth ride. From experts questioning the "robustness of data" as claimed by President Nana Akufo-Addo to a 'super-spreader' being linked to as much as 10 percent of the country's cases, the pandemic has exposed shortcomings in the country's health system, more particularly the health information system.
To tackle the pandemic, Ghana took some notable steps to improve the flow of information to better support its fight against COVID-19. Those initiatives have shown that an integrated health information system can have significant benefits in improving healthcare. However, those initiatives have largely been limited to COVID-19, and setting the same standards for other repositories in the health information system and making them interoperable requires significant work.
In this research-based analysis, we will evaluate Ghana's response against COVID-19 and discuss the potential of an integrated, technology-powered information system that can enable the real-time flow of healthcare data.
Ghana's COVID-19 response
On March 12, Health Minister Kwaku Agyemang-Manu announced that Ghana has recorded its first two COVID-19 cases and both of the infected individuals had traveled abroad recently. Within a couple of days of the first cases, President Akufo-Addo instituted several measures that were to be implemented over the next couple weeks and would kickstart Ghana's fight against COVID-19.
By March 30, schools were closed, social gatherings were banned, borders were closed and a partial lockdown was implemented in the Greater Accra and Ashanti Regions.
Just three weeks later, Ghana also became the first African country and one of the first countries in the world to lift its coronavirus-related lockdown on April 20 but the ban on large gatherings was continued and schools remained closed.
Ghana Health Service was the key agency that led the country's response to the pandemic and it anchored the response on tracing, testing, and treatment instead of strict lockdowns. As of October 1, Ghana has performed more than 488,000 tests, which puts it among countries with the highest testing rates across Africa.
The country's ability to quickly ramp up testing is largely being attributed to its "pooled sampling" approach where samples from multiple individuals are put together and tested as one pool instead of testing one person at a time. Each member of the pool is retested individually only if the result of the pooled test comes back positive. Otherwise, everyone is declared negative.
Pooled sampling has not only helped Ghana ramp up its PCR testing capacity, it is also cost-effective as it uses less testing reagents and also shortens the waiting time for results. However, in areas with high COVID-19 transmission, pooled testing can give more positive results and reduce testing sensitivity as specimens can dilute when grouped.
Ghana also garnered global attention by using drones to collect COVID-19 samples from rural areas and transport them to laboratories in the capital Accra and Kumasi.
But despite these interventions, there have been gaps in the country's response that have proven deadly. Even the much-acclaimed "pool sampling" approach might have caused problems as the outbreak disproportionately affected southern Ghana with the majority of cases being concentrated in Greater Accra and Ashanti regions. As mentioned before, large outbreaks can reduce the effectiveness of pooled sampling.
In another instance in Ghana's Atlantic seafront city of Tema, a worker at a fish-processing factory infected 533 of his colleagues. These cases pushed Ghana's total to 4,700 on May 10 which means the super-spreader alone was linked to more than 10 percent of cases in the country at the time. Here are some other shortcomings that reduced the effectiveness of Ghana's COVID-19 response:
'Premature' lifting of lockdown
"It is that constancy, that robustness of the data that we have in Ghana, that is inspiring our decisions," President Akufo-Addo had said as he announced that the country will be lifting the partial lockdown. But the indicators used to determine that "robustness of data" weren't clear to stakeholders outside of the government and experts have raised concerns about the science behind the decisions.
Reactions to the decision to lift lockdown were mixed. Many people including both experts and the general public said the move was premature. A former Director-General of the Ghana Health Service, Professor Agyeman Badu Akosa, had expressed disappointment over the decision to lift the lockdown. "I expected probably two weeks to the end of April and I expected that at least all regional capitals should have been locked down as well," he had said.
Many people, however, also supported the strategy. Ghana's Trade Union Congress had pressed to reopen the country for the sake of workers in the informal economy. "Nearly 90% of Ghanaians work in the informal economy," the secretary-general, Anthony Baah had said. "In a lockdown, the impact can become unbearable, so we are happy with what the government has done."
Ghana was among the first few countries in the world to lift the lockdown and the first African country to do so when it had only 1,042 cases. But within 10 days since the lockdown was lifted, the number of COVID-19 cases almost doubled to 2,074 on April 30. The tally of cases was six times higher on May 20 at 6,269.
An integrated health information system that can provide reliable, real-time information could have helped in giving the authorities a clearer picture of how the outbreak is unfolding and enabled them to make informed, targeted actions along with providing clear evidence to other stakeholders that the science supports those actions.
One of the reasons for imposing the lockdown was to give the government enough time step up preparedness and thus the response. Ghana's information minister, Kojo Nkrumah, had said that the lockdown had helped the government to assess its health systems and its requirements, based on increased data collection from COVID-19 tests. "We decided not to wait but to do a precautionary lockdown early and within that period get mass findings and data to help us," he said.
But the Ashanti Regional Divisional Chairman of the GMA, Dr. Paa Kwesi Baidoo lamented on April 27 that there are not enough PPEs which has led to healthcare workers being infected. He also expressed concern about the lack of reliable data on infections among healthcare workers.
Supply chain management tools integrated with the health information system can help authorities in evaluating demand and supply to ensure the most efficient utilization of healthcare resources.
On May 11, Ghana also allowed hotels, bars, and restaurants to reopen provided they comply with safety measures. Restrictions were eased further in June when religious activities, private burials, weddings, and other social gatherings were allowed with no more than 100 persons attending while taking adequate security measures. Schools were also partially reopened from June 15.
Shortages of PPEs, beds, and testing kits have been a recurring issue in Ghana's fight against COVID-19, and GMA, at various points of time, has expressed concern about the implications of these shortages.
Ghana's much-acclaimed COVID-19 testing also suffered glitches due to shortages which resulted in backlogs of as much as three weeks at various laboratories. Backlogs pending up to days and even weeks mean that infected individuals are already in advanced stages of the infection and testing and tracing cannot be effective no matter how many tests are conducted.
An integrated health information system that includes healthcare supply chain management and inventory management tools can help authorities better evaluate demand and ensure healthcare equipment reaches those who need it the most.
As the cases soared and health facilities started becoming overburdened, the president also approved the construction of additional Intensive Care Unit (ICU) bed facilities in the Greater Accra region while another treatment center was already being set up in the Ashanti region. These regions have the majority of cases in Ghana.
Ghana also adopted a new discharge policy in June that allows for asymptomatic COVID-19 persons to be discharged after 14 days without a test. This policy was reportedly in line with WHO's recommendations and among other reasons, was also meant to decongest the country's isolation centers.
COVID-19 app fiasco
Ghana was among the first countries in the world to have launched an app to support tracking and tracing efforts but ever since its launch, the app has been mired in controversies and there is no reliable data on how it has supported the country in tackling COVID-19.
Launched in mid-April, the app was not initially available on Google Play Store or Apple App Store. Even now when the app is available on these stores, they have only been downloaded about 5,000 times on each platform but Ghana's population is almost 30 million.
A significant number of people could have installed the app through an apk file rather than through the Google Play Store but in absence of official statistics, it's impossible to put a figure of the number of downloads or users.
Moreover, Ghana hasn't released crucial data that can be used to evaluate the usefulness of the app like how many contacts have been traced with the app and how many of them have turned out positive.
Diverted attention from other deadly diseases
This dilemma is faced across many countries as the virus not only claims the lives of health workers and others directly but is also causing huge disruptions to the treatment and prevention of other deadly diseases as it has diverted resources and is overwhelming fragile health systems.
Like many countries in sub-Saharan Africa, Ghana also has a prevalence of deadly diseases like malaria, HIV AIDS, meningitis among others. COVID-19 and associated restrictions could curtail treatment efforts and stall widespread prevention programs for these diseases.
On April 20 – just a little over a month into the outbreak in Ghana, GHS reported at least 409 cases of meningitis in five regions with 40 deaths. These figures make the disease much deadlier than COVID-19 and investigation showed that the high fatality was due to the late reporting of cases, which was at least partly because the government was mainly focused on COVID-19.
An integrated health information system that enables the real-time flow of information can help authorities in keeping track of all diseases and the overall health system.
Ghana health information system
Operating under the M&E Department of GHS, the Centre for Health Information Management (CHIM) is the focal unit responsible for the collection, analysis, reporting, and presentation of health information in Ghana.
District Health Information Management System 2 (DHIMS2) is the backbone of the national health information system and thousands of facilities are registered onto it. Having established DHIS2 as an HMIS tool for providing data for basic health service indicators, CHIM has been evolving into an internal service provider, offering and encouraging stakeholders and development partners to use the existing DHIMS2 infrastructure for their corresponding data needs.
The DHIMS2 e-Tracker modules have also been developed for TB, HIV AIDS ART, and Maternal and Child Health services (MCH) including antenatal care, postnatal care, delivery, and family planning.
These modules, however, aren't yet operational at many facilities that still rely on paper-based systems for data collection. This results in large delays that pose a grave problem especially in the context of pandemics like COVID-19 which requires timely, complete, and reliable health information across regions to make informed decisions.
WHO has also acknowledged that data management for COVID-19 was "very laborious" due to challenges like underutilization of electronic surveillance data collection platforms and over-reliance on paper-based data collection.
To tackle the problem, Ghana utilized the Surveillance, Outbreak Response Management, and Analysis System (SORMAS) to collect health data for outbreak response management and analysis. Additionally, the completeness of surveillance data into SORMAS and other electronic data collection platforms was increased. With the support of WHO, healthcare workers were also quickly trained on application use, and the electronic system allowed for rapid analytics to communicate the current status of COVID-19 for prompt decision making.
Conclusion and agenda for discussion
The public health system of the country is relatively weak compared to that of countries with similar population densities in Europe and Asia. Moreover, just like most of Africa, communal living an integral part of the culture in Ghana which poses another challenge for the country to handle a rapidly spreading pandemic as social distancing is not feasible.
In a public health emergency like COVID-19 where a large number of people can get sick in a short span of time, it is important to ensure the most efficient utilization of Ghana's health system by undertaking informed and targetted actions.
The country has taken some notable initiatives to improve the flow of information that is essential in tackling COVID-19 especially because Ghana's response relies heavily on tracing and testing instead of strict lockdowns. But problems ingrained into the health system make it difficult to fully realize the benefits of such initiatives. For instance, the existence of multiple information systems in healthcare pose interoperability challenges as these systems don't easily communicate with each other and operators might even need to separately feed data into multiple systems.
An integrated health information system is one of the core building blocks of any health system and provides information needed for other components. Such a system that enables real-time availability of all the critical information in one place can help policymakers in taking targeted actions.
VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.
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