1. 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

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

3. 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

4. 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

5. 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

6. 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

7. 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).

8. 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).

9. 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)

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

11. 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

12. 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

13. 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).

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

15. 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