Addressing the gaps in childhood pneumonia diagnosis and management in Ghana- Report on stakeholders’ perspectives

Data collection and analysis

The stakeholders were divided into two groups for the stakeholder group discussion. One group had three participants, and the other had four; discussions lasted one hour, and saturation was achieved. The stakeholder group discussions were conducted with the aid of an interview guide in private rooms. The discussions were recorded and later transcribed. An inductive thematic analysis approach was applied to derive themes directly from the data. Credibility was ensured through triangulation of data sources (transcripts and field notes from the principal investigators), and reflexivity was practiced through journaling. Participants reviewed the analyzed data to confirm the accuracy of identified themes and to validate the interpretations and conclusions drawn. The thematic areas identified are outlined in the results below.

Ethical clearance

Ethical clearance for the study was granted by the Committee on Human Research, Publication and Ethics with the reference number CHRPE/AP/1180/24. Consent was also obtained from all participants.

Challenges identified with childhood pneumonia care in Ghana

Human resource challenges

The experts noted the absence of personnel and varying levels of skill sets, as well as the lack of training to identify signs and symptoms of severe pneumonia in young children using the Integrated Management of Childhood Illness (IMCI) algorithms in primary healthcare settings. Stating that monitoring and evaluation in these centers were minimal/ non-existent due to the absence of specific initiatives, such as Roll Back Malaria^[12] and oral rehydration therapy,^[13] which were done for malaria and diarrhea, respectively.

Logistic challenges

Another challenge was the absence of critical point-of-care diagnostic devices such as pulse oximeters, oxygen, and oxygen delivery devices in primary healthcare settings. Since these primary healthcare facilities are the first point of call for children with pneumonia, children may be wrongly diagnosed or missed, and treatment or referrals are significantly delayed, contributing to poor outcomes.

Quality of care challenges

Critical care service provision is woefully inadequate in the country, and in addition, most intensive care units (ICUs) are mostly located in tertiary centers that serve the southern and middle sectors of the country. Furthermore, stakeholders highlighted other quality-of-care challenges present at higher-level centers (secondary and tertiary level centers) that may be responsible for more deaths within the first 48 h of admission, including the following;

1. Sub-standard emergency response when children arrive critically ill. This includes a weak triaging process and deficient systems inimical to the quick provision of care

2. Insufficient logistics and equipment, such as noninvasive respiratory support devices, such as continuous positive pressure devices, and patient monitors

3. Inexpedient policies in certain facilities that prevent life-saving interventions or medications from being accessed until out-of-pocket payments are made can hamper good management outcomes.

Strategies recommended

Training and capacity building among health workers across all levels of healthcare

There was an overwhelming consensus on the need for training, and discussions held around training have been summarized below.

Stakeholders emphasized the need to strengthen existing training initiatives, such as the IMCI program, to enhance capacity at lower levels of healthcare delivery’ to improve clarity. The IMCI program was introduced in 1999, but stakeholders bemoaned the fact that the program has been largely dormant in recent times. One stakeholder cited a recent report by the United States Agency for International Development (USAID), which indicates that only 11 out of 216 districts within the country actively implement IMCI, and these districts are only able to do so with support from international partners.^[15] Participants collectively called for the government and development partners (UNICEF, USAID, and the WHO) to strengthen the IMCI program, which trains healthcare workers in primary care facilities on how to care for sick children. They cited the significant impacts of a recent training at Amansie West on mortality due to better insight into diagnosis, management, and prompt referral. One participant cited the recently launched Network of Practice and Model Health Centers as part of the government’s strategy to reform and strengthen the primary health care system^[16] and alluded to the fact that it served as a good framework to utilize to ensure increased access to quality essential healthcare provision.

Improving quality of care across all institutions

All stakeholders recommended that guidelines on the diagnosis, classification, and management of childhood pneumonia should be developed for all levels of health care and disseminated to all facilities. One stakeholder in particular stressed the need to critically evaluate the emergency response at the higher-level facilities. Participant 1 from group 1, in his submission, enquired “how quickly are patients attended to when they arrive in critical condition, and what level/calibre of expertise attends to these patients when they arrive at tertiary level care facilities”? Other stakeholders further went on to place emphasis on the need to adopt policies to ensure that patients referred to higher-level facilities e.g. tertiary level care, receive care in a timeous manner with one participant from group 2 also adding that “there is a need to ensure that at the higher centres of care, senior and experienced health professional are part of the emergency response team to ensure that life-saving decisions and interventions are carried out timeously. We also need to advocate for policies where patients presenting with emergencies can have medications and life-saving interventions provided, for payments to be done later.”

Provision of standard essential logistics and equipment

All stakeholders unanimously agreed that closely related to training is the availability of essential tools and logistics to facilitate quality health care provision. They emphasized that it was crucial to align these calls with existing program frameworks such as the Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH&N), which seeks to ensure that all facilities have the appropriate equipment needed to deliver quality RMNCAH&N services as part of its strategic objectives in its strategic plan for 2020–2025.^[17] Another strong recommendation was the need for policymakers to engage with all relevant stakeholders, including clinicians (who are the end users) and biomedical engineers, to ensure that the equipment procured meets the standards set by the WHO and is useful in the context of quality service provision. The stakeholders recommended that, for the diagnosis and management of childhood pneumonia at primary care facilities, such as community-based health planning and services (CHPS) and health centers, pulse oximeters should be available. Oxygen supply must also be available in all other levels of healthcare. For secondary and tertiary level facilities, additional equipment includes X-ray machines for chest X-rays, bedside ultrasound devices and point of care ultrasound services, continuous positive airway pressure devices, and mechanical ventilators. They noted with concern the recent data, which revealed that there are only 36 pediatric ICU beds available nationwide, translating to 0.32 beds/100,000 children^[18,19] and called for more to be done to improve pediatric critical care capacity in our facilities. Adequate laboratory support for microbiology and serology for C-reactive protein and procalcitonin assays was also suggested by stakeholders. The higher-level facilities must have the most sophisticated devices.

Quality data collation that can inform policy in the future

Stakeholders collectively agreed that there was a need for quality data on childhood pneumonia across all levels of healthcare that can be utilized to generate national data to inform policy decisions and interventions. It was noted that although there was surveillance on childhood pneumonia, there were significant gaps that posed challenges with the analysis and utilization of the data. The evidence from two published studies from the Savelugu-Nanton Municipality^[20] and the Tema Metropolis^[21] both concluded that although useful, the current surveillance is only partly meeting its objectives, citing shortcomings such as the absence of laboratory data, poor classification into pneumonia and severe pneumonia, and poor reporting from facilities, especially private health facilities. This meeting of stakeholders brought hope and excitement since there is a special need for primary data to inform policy decisions going forward. The stakeholders then outlined the next steps to be the selection of sentinel sites for primary data collection, training health workers at the sentinel sites on diagnosis and management of pneumonia, and providing the selected sites with all resources available for pneumonia management. Furthermore, to assess the impact of services on diagnosing and managing childhood pneumonia and report on data to policymakers. The final recommendation of the stakeholders was that the sentinel sites should be selected from each zone of the country- northern, middle, and coastal zones to ensure that the data obtained is representative.

Strengths of this study

This was the first time major stakeholders in the Ghana Health Service and International partner agencies met to deliberate on childhood pneumonia. We capitalized on the collaborative environment of the stakeholders’ meeting to enrich deliberations and facilitate effective decision-making. The group acknowledged the gains made by the country, highlighting the general decline of childhood illness, specifically malaria, pneumonia, and diarrheal disease and the concerted efforts by the Government and international partners to ensure universal health care coverage by adopting policies aimed at strengthening primary healthcare. They, however, admitted that the rate of decline in deaths related to childhood pneumonia significantly lagged behind that of malaria and diarrhea. All stakeholders agreed that it would be prudent to reevaluate and adopt strategies that reduce childhood pneumonia-related deaths.

As part of the strategies, stakeholders unanimously agreed that there was a need to establish a national pneumonia surveillance program that would help focus on the national agenda on childhood pneumonia case detection and management. This will provide critical data for policymakers to utilize for planning appropriate and targeted interventions. They gave assurances to support the initiative of establishing a national pneumonia surveillance program.

The group also recommended the establishment of an advisory board, as well as a monitoring and evaluation team that will prospectively monitor the data and provide policymakers with timely feedback on the trends in pneumonia in children under 5 years.

Finally, at the end of deliberations, all stakeholders present pledged their individual support, as well as support from the institutions they represent, for the establishment of the surveillance network.

Limitations

Participants were purposively selected, which may restrict the generalizability of the findings. However, the diverse spectrum of stakeholder expertise and experience allows us to generalize the conclusions cautiously to the Ghanaian healthcare context. The composition of the stakeholder group limited the scope of data collection, and therefore, the study did not solicit the opinions of caregivers with children with a previous history of pneumonia. Information from key informants on pneumonia, we believe, could shed more light on the situation from the patient’s perspective.