Health system barriers and facilitators of integration of tuberculosis(TB) and HIV services in Ghana Dr Gloria Akosua Ansa MBChB MBA PhD Senior Medical Officer University of Ghana Hospital, Legon Accra, Ghana

Outline Introduction TB/HIV in Ghana Methods Findings Study Rigour Barriers Facilitators Study Rigour Acknowledgments

Introduction Ghana 25, 758,108 population Democracy (1992) LMIC (2010) GDP $3500 TB NTP/WHO DOTS (1994) 92/100,000 prevalence (2012) HIV 1st case in 1986 NACP (1987), GAC (2005) Prevalence 1.3% (2012) ART in 2003

TB/HIV in Ghana Integration Policy (2007, under review) Access to comprehensive care Reduce fragmentation, improve quality Increased collaboration, not fusion Policy (2007, under review) Strengthen health system Reduce the burden of TB and HIV Study objective Explore health system barriers and facilitators

Methods I Qualitative approach Purposive sampling 3 District Hospitals 3 service delivery models Ethics Approval obtained Informed consent Voluntary participation Participant Number Service providers 8 TB/HIV Patients 18 National Managers 3

Methods II Semi-structured one-on-one interviews Analysis Interview guide, audio recorded Analysis Thematic, a-priori and emergent themes Participant Explored themes TB/HIV patients Living with TB and HIV Accessing care Experiences and perspectives Service providers TB/HIV work experience Delivering TB/HIV services Management Implementation, monitoring and evaluation of the policy

Barriers I Workforce Inadequate capacity Development of local focus “...we forget that we have to merge some of our activities and plan them together. So...I plan to...visit my TB sites. But I forget...that in the same TB clinic, I could be looking at the HIV clinic and ...reporting to the HIV programme when I get back...” (Manager).

Barriers IIÍ – Service delivery Protecting functional territories “They say we should go and help them...When you go… eh, that nurse...would change the face as if you are coming to collect the money. She would frown.” (TB nurse at RS).

Barriers II – Service Delivery Difference in access The challenge is that we tend to have … a lot more of DOTS treatment centres than ART centres.” (Manager)

Facilitators I Financing Workforce ARVs on credit Enabler package Standardisation of skills & knowledge Direct supervision

Facilitators II: Medicines & Health Products No stock-outs “as for the drugs, we never run short” (Female patient at PIS) “the drug for the disease itself I always get there” (Female patient at RS) Fixed Drug Combinations

Facilitators III - Governance Leadership and political will “... it’s (HIV patient booklet) gone through a lot of phases. And it’s been revised about twice. What we have now makes room for you to say...whether the patient has been screened or not” (Manager) Standardisation of work: policy & guidelines

Facilitators Service delivery Privacy and confidentiality “...privacy and confidentiality in our unit... I assure you...it’s very good. We don’t sell our clients out to people….”(VCT nurse/HIV prescriber at RS).

Rigour Sampling sufficiency Reflexivity Relevance Methodological openness Researcher background and influence on interactions Patient recruitment process Political will Relevance Transparency: clear account of process

Acknowledgements Individual participants and facilities Prof. John Walley, University of Leeds, Dr Kamran Siddiqi, University of York Dr Xiaolin Wei, Chinese Univ. of H. Kong NTP & NACP Ghana University of Ghana, Legon University of Leeds Commonwealth Scholarships, UK