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
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e-mail: [email protected])
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address.
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
health conditions
9
Rapid assessment
21
Recommendations:
Priority interventions
37
Evaluation
41
Annex 1:
List of major stakeholders
71
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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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
Accra FP attendees, 1993
Urethral discharge, Ghana facilities
STIs
Percentage
N. Gonorrhoeae
7
C. Trachomatis
8
N. Gonorrhoeae
52.4
C. Trachomatis
10.5
T. Vaginalis
Commercial sex workers
Pregnant women, sentinel sites
Kumasi antenatal attendees
19
M. Genitalium
10.5
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
Syphilis
0–1.8
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-childtransmission; 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
East Akim
Mampong
New Tafo
Adawso
Kukurantumi
Greater Accra
Danmgbe East
Ashiedu Keteke
Ga
Big Ada/ Ada Foah
James Town
Akplabanya
Anyamam,Totopey
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 nongovernmental 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
N
Female
%
Female
N
70.9
708
54.7
547
Marital Status
Single
Married
27.1
271
39.5
395
Divorced/separated
1.6
16
3.2
32
Widowed
0.4
4
2.6
26
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
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
Religion
Ethnicity
Education
JSS/tech/vocational
51.4
514
44.1
441
SSS
19.8
198
12.1
121
161.0
161
21.8
218
Primary
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


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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;



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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:

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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 prepackaged 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 multidisciplinary 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:

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

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 locallybased 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 consensusbuilding 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 prepackaged 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 toplevel 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
OR1: Data on endogenous
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.
No information.
OR2: Population-based
studies are needed to
ascertain the true prevalence
of HIV and the true incidence
of various STIs.
Proposal submitted in June 2002
to EU (partially funded). and then
to NACP.
In Dec 2002, by HRU and
Noguchi Research Institute: A
Study on the Current Prevalence
of Sexually Transmitted Infections
in Certain Population Groups and
Risk Factors for Cervicitis in
Ghana. PI: Dr. J. Gyapong.
Comments
WAPTCAS conducted a study
in Accra and in Kumasi on the
causes of male urethral
discharge in 1998, and female
discharge in 2002.
OR3: Studies should be
undertaken to determine the
burden of complications of
RTIs in Ghana and the
changing patterns of
antimicrobial susceptibility of
STIs; further information
should be provided on the
control of endogenous
infections.
Revised and consolidated
proposal (OR2 & OR3) presented
to WHO in Dec. 2002. They are
committed to providing the
resources for study from funds
earmarked for NACP research.
Noguchi Research Institute
working on a similar study to
identify effective and
ineffective drugs for RTIs,
merging their effort with OR2
above and redesigning into
one study.
Summary of progress made in implementing strategic recommendations (cont)
Training needs
Strategic Recommendation
Progress
Comments
STI management training
should be provided for various
care providers.
NA/SCP is overseeing this activity
with assistance from the National
STI Program and WAPTCAS.
They provide training for health
care providers, including nurse
educators, nurses, and
physicians.
Traditionally it has been very
difficult to engage the
medical community,
especially private physicians.
Private practitioners in Accra and
Tema were trained in syndromic
management of STIs in 2002 and
2003.
GAC has funded training of
midwives since 2001.
GSMF, MSH, and the Pharmacy
Society have been conducting
training for pharmacists and
chemical sellers.
Proposal for training program has
been submitted to the Department
for International Development
(DFID). PI is Dr. Dzokoto.
On-going training should be
provided to medical,
pharmacy, and nursing
Final-year medical and pharmacy
students in Kumasi have received
training in SM of STIs.
Doctors in the medical school
remain predominantly
unconvinced that syndromic
management is the best way
to treat STIs in Ghana.
Private physicians are difficult
to get involved in
workshops—they worry about
lost business during time at
workshop. Team considering
designing a training session
for them using the
pharmaceutical approach—
food, free samples, etc.
Medical school in GreaterAccra not yet receptive to
idea, so progress slower
students in management of
STIs.
SM training already incorporated
into the curriculum of nursing
students.
there.
There are no pharmacy
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 preservice curriculum should be
undertaken with a view to
incorporating emerging issues.
No information.
JHPIEGO reportedly
assisting medical school to
review their curriculum.
Unable to verify follow-up.
Summary of progress made in implementing strategic recommendations (cont)
Program needs—Health service
Strategic Recommendation
There is a need to emphasize
RTIs as a whole, not only
HIV/AIDS and STIs, and to
incorporate their prevention
and management into RTI
programs.
Progress
Attempts are being made to
refocus on STIs.
Name change of NACP to
NA/SCP and the appointment of
a National STI Coordinator to the
organization.
Comments
Current focus is predominantly
on HIV/AIDS. Stakeholders
verbalized extreme differences
of opinion over whether or not
HIV/AIDS should be dealt with
separately from STIs and
other infections.
Regional STI coordinators
already exist.
An integrated approach to
STI management in both
public and private facilities
should be developed and
implemented.
RCHU has developed and
disseminated reproductive health
practice standards and protocols.
STI management guidelines
revised by MoH in September of
2002.
NACP and WAPTCAS have been
training the public sector: FP
Private facilities have minimal
involvement. RCHU involved
in a SM training program for
private physicians that is part
of the Country UNFPA
Reproductive Program: 2001-5
cycle.
Supervision and monitoring
nurses, medical assistants, and
midwives.
aspect of all programs is weak
or absent.
GAC has funded the SM training
of staff at a few private clinics in
Accra.
Quality assurance programs
should be improved.
No information.
Improve supervision in both
the private and public sectors.
Midwives report training teams in
facilitative supervision who go out
to supervise maternity homes.
STI screening for antenatal
attendants, such as syphilis is
needed.
Syphilis screening being done for
antenatal attendees only, but
hepatitis screening is not being
done anywhere, although the test
is available.
Hepatitis screening should be
re-introduced.
WAPTCAS uses external
consultant to perform quality
control checks in randomly
selected clinics.
Supervisory and monitoring
system needed.
Hepatitis vaccination program
initiated in 2002.
Summary of progress made in implementing strategic recommendations (cont)
Program needs—Health service (cont)
Strategic Recommendation
Progress
There is a need to step up the
monitoring and supervision of
syndromic management of
MoH facilities with a view to
motivating implementers and
providing program managers
with program needs such as
refresher training.
Training of trainers workshops
conducted by NACP in
September 2002. Funded by
WHO.
Efforts to increase AIDS and
STI surveillance reporting
levels in the country need to
STI reporting forms developed in
conjunction with NACP and
National Surveillance Unit of the
Comments
Unable to obtain specifics:
information on number of
workshops, where they were
conducted, who attended, etc.
Monitoring and supervision
aspect needed.
Ready to disseminate pre-test
data and information on
be enhanced.
GHS.
efficacy of forms.
AIDS reporting added to
Integrated Disease Surveillance
and Response form.
Attempts are being made to
integrate STI and HIV sentinel
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
should be undertaken to
ascertain the true prevalence
of STI/HIV infection
HIV incorporated into DHS as
pilot for 2003 data.
No population-based STI data.
Proposal submitted in June 2002
to WHO HRU and Noguchi
Research Institute: A Study on
the Current Prevalence of
Sexually Transmitted Infections in
Certain Population Groups and
Risk Factors for Cervicitis in
Ghana. PI: Dr. J. Gyapong.
Strategic Recommendation
Progress
Strategies to increase
commercial sex worker access
to interventions that reduce
RTIs should be initiated.
Committee (FHI, GAS, WAPCAS,
NACP) on transactional sex work
looking into the legal issues of
sex work
WAPTCAS operating STI clinics
for CSW in ten regions—offers
education and treatment.
NACP, GAC, WAPTCAS
conducted two workshops in
Accra on transactional sex work
in Ghana.
Draft National HIV/AIDS and STI
Policy (August 2000) developed
by the MoH, recognizes CSW as
On-going feasibility issues
regarding HIV testing in the
field in a society with specific
beliefs about blood.
Proposal was revised and
integrated with Noguchi
Institute study to assess antimicrobial sensitivity. See
information on OR2 & OR3
Comments
Two behavioral research
studies conducted on the
roamer sex worker by: 1) the
University of Ghana Medical
School – Department of
Community Health; 2) the
Adabraka STI clinic in
conjunction with WAPTCAS.
FHI Ghana conducted a study
of the home-based/sitter sex
worker.
WAPTCAS clinics from CSW
also offer services to PLWHA
a vulnerable group.
Summary of progress made in implementing strategic recommendations (cont)
Program Needs – Health Education and Behavioural Change Communication
Strategic Recommendation
Continuous education and
access to drugs is paramount
for control.
Progress
Community Health Dept. of the
MoH involved in outreach
education.
GSMF involved in extensive
multi-media campaign and socialmarketing of STI related issues
and services.
JHU-CCP training peer
educators.
OR Proposal developed by HRU
and NACP on feasibility of
training chemical workers to
dispense pre-packaged antibiotic
therapy for STIs. ‘Pilot-testing
Pre-Packaged Therapy for Male
Urethral Discharge Syndrome in
Ghana.
Comments
Stakeholders verbalized
opposing opinions regarding
the idea of chemical sellers
dispensing pre-packaged
antibiotics. Study perceives
trained chemical sellers as a
means to increase access to
STI drugs. They are estimated
to be the first line of help for
about 80% of the population
seeking treatment for STIs.
Collaborators for study are
HRU, RCHU, NACP, GSMF,
MSH, WHO, Pharmacy
Council, and Horizons
Program / Population Council.
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
as Candidiasis should be
addressed in Behavior
Change Communication
programs
GSMF involved in community
outreach education and BCC
programming.
Strategies to address the
inappropriate treatment of
STIs by community members
and chemical sellers must be
addressed with urgency
No information
Strategic Recommendation
PPAG, GRMA, and FP &
WAPTCAS-run clinics include
information on this specific STIs
in their client education activities.
Progress
Stakeholders perceive that
the proposal to train chemical
sellers is the first step to
achieving this
recommendation.
Comments
Behavior change
communication and health
education is needed to
address erroneous
perceptions about RTI,
problems with partner
notification, and stigma related
to STI infections.
GSMF involved in community
outreach education and BCC
programming
Chemical sellers must be
trained and motivated to
provide appropriate
counseling, education, and
information on condom use.
Pharmacy Society conducting
training sessions for their
members and also for chemical
sellers (who then become
franchised).
No information on when
specific training done and
topics covered. Unable to
schedule a meeting to meet
with a representative from the
Pharmacy Society.
Education on the
complications of STI and its
relationship to HIV/AIDS
should be intensified.
NACP, GAC, and PPAG have
developed IEC information.
GAC reports they are
providing funding to NGOs
throughout the country to
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
designed and implemented.
implementing programs in this
area.
PPAG working with males.
GSMF have a program for longdistance truck drivers, who are
primarily male.
GRMA designing an STI program
for males as part of their Golden
Jubilee activities.
RCHU involved in outreach
program ‘Men as Partners’
coordinated by Engender Health
Organization (formerly AVSC).
Further education on the use
of the female condom should
be promoted.
PPAG, GRMA, GSMF, and the
Society of Women in Africa
against AIDS are involved with
this.
Strategic Recommendation
Emphasis should be placed on
more effective and sustained
marketing strategies for the
promotion of the both the male
and the female condom.
Progress
Commonwealth Secretariat
(UK) coordinated a workshop
in Ghana with the Rotary
clubs of West Africa (January
2003) on male involvement in
HIV prevention.
Planning clinics for males
only. One already functional
in Greater Accra and another
to open in the Ashanti Region
before the year’s end.
GSMP launched training in all
the regions.
Comments
GSMF involved in social
marketing approach male and
female condoms.
Life Choices’ advertising.
Program Needs – Cultural Practices
Strategic Recommendation
Progress
Strategies to address the
probable risk of RTI following
complications of herbal
insertions must also be
addressed.
No information
Further exploration of existing
practices is needed –
Research report submitted to the
GAC July 31, 2002: ‘Belief
Comments
There is possibly a program
in the Northern regions
especially among special
groups – with a view to
designing targeted and
culturally appropriate
programs.
Systems and the Control of
HIV/AIDS’. Author: Professor
Twumasi
organized by CEDPA to
address this. However,
CEDPA left the area in 2003.
No information on how the
information has been used
Program Needs – Inter-sectoral Collaboration
Strategic Recommendation
Progress
Improve the coordination and
collaboration between the
MoH, Private Medical
Association, Pharmacy,
Laboratory Board, and
chemical sellers.
No information
Implement immediate action
to target populations
practicing herbal insertions
and use of local cocktails of
drugs for the treatment of STI.
Discussions initiated with new
NA/SCP leadership about
whether to conduct exploratory
OR or to begin health education in
this area.
Comments
Summary of progress made in implementing strategic recommendations (con’t)
Program Needs – Policy Review
Strategic Recommendation
Human Rights and the work
environment of PLWHA in
Ghana must be addressed.
Progress
Comments
National HIV/AIDS and STI Policy
has a brief section on disclosure
to employers.
WAPTCAS ran a home-based
program for PLWHA in the
Eastern region from 19972003, then transferred
operations and management
to FHI.
In 2002, Ghana Employers
Association and GAC, in
collaboration with ILO, conducted
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
support the private sector in the
management of RTIs in Ghana,
including private pharmacists
and chemical sellers, and define
their role in RTI management.
Included in section: STI Control
and Management of National
HIV/AIDS and STI policy.
Policy guidelines for laboratory
practice should be reviewed
Blood screening and testing,
home self-testing, transfusion
protocols, and testing principles
covered in National HIV/AIDS
and STI Policy.
The policy that prohibits the sale
of antibiotics by chemical sellers
should be reviewed.
No information
Advocates for formal and
informal courses on STIs for
all health workers and
prescribers including
pharmacists, but does not
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 RTIPGT recommendations.
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
Date Completed: May 22nd, 2003
Country: Ghana
Expected
Date of
Completion
Comments
Steps and
Activities
Administrator
Still
Current?
Date of
Completion
Formation of Core
Team
Yeboah,
Gyapong
No
Oct 2000
Identification of
Resources for
funding of Stage
One activities
Tapsoba
No
Oct 6, 2000
Writing
Background Paper
Dzokoto
No
Jan 2001
With support from HRU
staff
1st Dissemination
Workshop
Yeboah,
Gyapong
No
Feb 2, 2001
Feb 1 – presented PGT
& background paper
Feb 2 – core team
planned rapid
assessment activities
Rapid Assessment
Garshong
No
April 20,
2001
With support from HRU
staff. Conducted in ten
regions between Feb 27
and April 20.
2nd Dissemination
Workshop
Yeboah,
Gyapong
No
Jan 23,
2002
Presented and
discussed Rapid
assessment
Identification of
Strategic
Recommendations
Yeboah,
Gyapong
No
Jan 24,
2002
Core team meeting
immediately following
workshop to prioritize
and finalize strategic
recommendations.
Identification of strategic
recommendations for
research, servicedelivery and policy not
clearly defined in final
paper.
PC Program Associate
new to Ghana and not
familiar with major
stakeholders in country
Operations
Research
proposals written:
‘Pilot Testing Prepackaged Therapy
for Male Urethral
Discharge
Syndrome in
Ghana
Gyapong
No
Operations
Research
proposals funded
Tapsoba
Yes
Operations
Research
underway
Gyapong
Yes
Operations
Research
evaluated
April 15
2003
Collaborative effort with
HRU and RCHU (GHS),
WHO, GSMF, MSH,
Pharmacy Council, and
Horizons Program /
Population Council.
Submitted to Population
Council for funding
consideration
18 months
from start
date
Funding pending
No information
Yes
Programmatic
recommendations
identified
Yeboah,
Gyapong
No
Jan 24 2002
Mechanisms for
implementing the
programmatic
recommendations
identified
Yeboah,
Gyapong
Yes
April 2 2002
Policy
recommendations
identified
Yeboah,
Gyapong
No
Mechanisms for
implementing
policy change
identified
Yeboah,
Gyapong
Yes
Core team prioritized
strategic
recommendations
following second
workshop
May 30,
2002
Preliminary action plan
discussed. (See Table
1: page 40 for
information)
Not completed
Not clearly identified in
final list
April 2, 2002
Not completed
Mechanisms for
upscaling effective
interventions (as
defined through
operations
research
component)
identified
NACP,
Gyapong
Yes
Operations Research
not yet conducted
Implementation of
policy and
programmatic
recommendations
NACP
Yes
NACP under new
leadership. New
Director reports being
unaware of RTI-PGT
Consultant for
evaluation
identified
van Dam
No
March 2003
Methods and
Indicators for
evaluation agreed
upon
L. Brown
Kumoji
No
April 2003
No evaluation of
programmatic outcomes
done as no implantation
driven by PGT
underway.
No indicators agreed on
- no action plan with
specific activities to
meet strategic
recommendations was
developed.
Monitoring and
evaluation
activities underway
Kumoji
No
May 23,
2003
Evaluation report
submitted
Kumoji
No
June 2003
Data collected from May
12- 23 (12 days only)
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, GreaterAccra
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)