National 20 Quality 20 Strategy 20 Ghana

REPORT : Ghana National Healthcare Quality Strategy
Table of Contents
Figures ii
List of Acronyms iii
Preface iv
Foreword vi
Acknowledgments vii
Executive Summary viii
Part 1: Strategy
Chapter 1: Introduction 1
Chapter 2: Vision for Healthcare Quality in Ghana 4
Chapter 3: Situation Analysis 6
Chapter 4: Prioritizing for Improvement 16
Chapter 5: Strategic Direction 18
Chapter 6: Strategic Interventions 21
Chapter 7: Making This Happen 25
Chapter 8: Measuring Improvement 31
Chapter 9: Conclusion 36
References 37
Part 2: Coordination and Accountability Framework

Chapter 1: Introduction 40
Chapter 2: Coordination and Accountability 39
Chapter 3: Financial Management for Interventions 51
Appendices
Appendix 1: Stakeholders Targeted for Interview and/or Interviewed 52
Appendix 2: National Quality Strategy Steering Committee Members 53
Appendix 3: National Quality Strategy Core Working Group (NQS-CWG) Members 54
Appendix 4: Synopsis of Interview Guide for National Quality Strategy 55
Appendix 5: The Juran Trilogy 57
Appendix 6: Health Sector Medium Term Development Plan in Relation to the NQS 58
Appendix 7: Driver Diagram 59
Appendix 8: Data Systems and Reporting Feedback Flow 60
i
Figures
Table 1: Ideal State of Quality in Ghana ................................................................................... ix
Table 2: Key Areas to Address in Leadership and Functionality ............................................... x
Table 3: Key Areas to Address in Quality Improvement Initiatives ........................................... xi
Table 4: Key Strategies and Activities of the National Healthcare Quality Strategy ................ xiii
Figure 1: Ghana NHQS Development Framework .................................................................... 3
Table 5: Ideal State of Quality at All Levels of the Ghanaian Health System ............................ 5
Table 6: Quality Initiatives Across the Ghanaian Health System ............................................ 12
Table 7: Health System and Population Health Priorities ........................................................ 16
Table 8: Strategic Interventions (Short-Term and Long-Term) ................................................ 22
Figure 2: Quality Coordination Organizational Structure ......................................................... 26
Table 9: Synopsis of Roles of Quality Management Units (QMUs) ......................................... 27
Table 10: Indicator Set ............................................................................................................. 32
Table 11: Action Plan for Coordination .................................................................................... 40
Table 12: Stakeholder Roles in Implementation ...................................................................... 47
Table 13: Key Cost Elements .................................................................................................. 51
Table 14: Members of the National Quality Strategy Steering Committee .............................. 53
Table 15: Members of the Core Working Group ...................................................................... 54
Figure 3: The Juran Trilogy ...................................................................................................... 57
Figure 4: Data Systems Flow ................................................................................................... 60
ii
List of Acronyms
AIDS Acquired Immunodeficiency Syndrome
ART Antiretroviral Therapy
BMGF Bill & Melinda Gates Foundation
CHAG Christian Health Association of Ghana
CHPS Community-based Health Planning and Services
CPD Continuing Professional Development
CPPA Community Pharmacists Practice Association
CSM Cerebrospinal Meningitis
CWG Core Working Group
DANIDA Danish International Development Agency
DHIMS District Health Information Management System
DHMT District Health Management Team
DQMU District Quality Management Unit
GAQHI Ghana Association of Quasi-Government Health Institutions
GHS Ghana Health Service
HEFRA Health Facilities Regulatory Agency
HIV Human Immunodeficiency Virus
HRD Human Resource Directorate
HSMTDP Health Sector Medium Term Development Plan
HTC HIV Testing and Counselling
IGF Internally Generated Funds
IHI Institute for Healthcare Improvement
IPT Intermittent Preventive Treatment
ITN Insecticide Treated Net
LMICs Low- and Middle- Income Countries
M&E Monitoring and Evaluation
MEBCI Make Every Baby Count Initiative
MOH Ministry of Health
NCD Non-communicable Disease
NCHS National Catholic Health Service
NHIA National Health Insurance Authority
NHIS National Health Insurance Scheme
NQD National Quality Director
NHQS National Healthcare Quality Strategy
NQSSC National Quality Strategy Steering Committee
PEPFAR President’s Emergency Plan for AIDS Relief
PPME Policy, Planning, Monitoring and Evaluation
QA Quality Assurance
QC Quality Control
QI Quality Improvement
QMT Quality Management Team
QMU Quality Management Unit
RHMT Regional Health Management Team
RQMU Regional Quality Management Unit
SPMDP Society of Private Medical and Dental Practitioners
UNICEF United Nations Children’s Fund
USG United States Government
WHO World Health Organization
iii
Preface
In September 2015, Ghana held its first National Quality Forum under the auspices of the Health
Ministry. At this Forum, stakeholders representing agencies of the Ministry and key partners
underscored the need to develop a National Healthcare Quality Strategy. Prior to this, the need
for an integrated national strategy for improving the quality of care and patient safety had been
identified in our national medium-term strategy. Our medium-term strategy also specifically
called out mental healthcare and traditional medicine for attention.
Subsequent to the National Quality Forum, the Ministry escalated the development of a National
Healthcare Quality Strategy into the 2016 Aide Memoire. By so doing, we indicated our clearest
intention at the highest policy levels, and with the active support of all our development partners,
to mainstream the National Healthcare Quality Strategy development and implementation into
the operations of all the agencies of the Ministry, including the private sector and richly
incorporating patient perspectives.
After extensive consultations with various stakeholders in the Northern, Middle, and Southern
belts of the country, we have achieved a significant milestone with the development and launch
of Ghana’s National Healthcare Quality Strategy, with the following population-level priority
areas: maternal health, child health (neonate, infant, under five), malaria, epidemic-prone
diseases (cerebrospinal meningitis, cholera), non-communicable diseases (hypertension,
diabetes), mental health, and geriatric care.
Overall, our vision is to create a health system that places the client at the centre of health care
and ensures continuously improved measurable health outcomes. Achieving this vision will
require stronger leadership and coordination from the Ministry of all its agencies to address
identified gaps inhibiting improved patient care and outcomes. It will also require stronger
partnership directly with patients themselves, to understand what truly matters most to them.
The development of this five-year strategy (2017 – 2021) is only one part of this story. Beyond
the launch of the strategy, the Ministry is keen to proactively coordinate the process of
implementation within its agencies at all levels of the health system. Ultimately, we aim to see
improved health outcomes in a health system that listens to, amplifies, and respects the voice of
the patient.
I call on all agencies of the Ministry, patients and patient support groups, the private health
sector, regulatory and service agencies, expert development partners, health training
institutions, agencies with accreditation and credentialing roles that all have full representation
on the proposed National Healthcare Quality Strategy governance structure to fully dedicate
themselves to fulfilling their mandate. Through the accompanying Coordination and
Accountability framework, the Ministry at its highest levels plans to hold wholly accountable all
stakeholders critical to the successful implementation of this strategy.
iv
Finally, the Ministry recognizes that the finalization of this strategy does not represent a fresh
start in Ghana. Rather, it signifies a diligent attempt to improve the quality of care by
harmonizing and building on previous efforts with a whole system approach under the proactive
leadership of the Ministry itself. To this extent, we recognize and celebrate every identifiable
organization and indeed everyone, both past and present, whose various and diverse roles have
played no small part in bringing us this far. We look forward to improved health outcomes
through integrated quality planning, quality assurance, and continuous quality improvement
functions that ensure better and more reliable care in a sustainable fashion.
HON. ALEXANDER P. SEGBEFIA
Minister for Health
1st December, 2016
v
Foreword
Our vision is to create a health system that places the client at the centre of health care and
ensures continuously improved measurable health outcomes. More specifically, this means
stronger leadership and coordination from the Ministry of all its agencies to address identified
gaps inhibiting improved patient care and outcomes. It also means more partnership directly
with patients themselves, to understand what truly matters most to them.
The National Healthcare Quality Strategy has been developed through a collaborative approach
led by a steering committee of key stakeholders representing various perspectives of the health
care system, managed by a core team within the Ministry of Health, and incorporating input
and feedback from patients/clients and providers at all levels of the health care system. As part
of this process, multiple stakeholder meetings were held, including a patient forum to directly
solicit patient inputs to inform successful design and implementation of the strategy in a true
spirit of partnership.
Indeed, in implementing this National Healthcare Quality Strategy, we aim to partner with a
full spectrum of stakeholders, including patients and providers, and the larger Ghanaian
community in our quest to improve the quality of care. Overall, the strategy has been iteratively
developed through many in-depth interviews and multiple key stakeholder meetings.
While there have been previous initiatives to improve quality, these have generally focused on
one particular area (e.g., newborn health and preventing under-five mortality), one particular
geography, or one particular sector. Other quality initiatives have suffered the effect of not
sufficiently addressing critical governance issues with an eye on careful integration into the
structures of the existing health system. This National Healthcare Quality Strategy aims to
coordinate the system of health and health care quality at all levels of the health system, across
both the public and private sectors, and all areas of health – with a particular focus on the
following priority health areas:
 Maternal health
 Child health: neonate, infant, under-five
 Malaria
 Epidemic-prone diseases: cerebrospinal meningitis, cholera
 Non-communicable diseases: hypertension, diabetes

 Mental health
 Geriatric care
The Ministry will work closely with all its agencies and patient groups through the newly formed
National Quality Strategy Steering Committee to oversee successful and robust implementation
of the strategy.
vi
Acknowledgments
The Ministry of Health is indebted to the many partners, individuals, and organizations that
helped to shape this National Healthcare Quality Strategy. We thank the stakeholders who
shared their thoughts on the current state of quality in Ghana and the way forward, through key
informant interviews, focus group discussions, and other forums. Appendix 1 lists all who were
targeted as respondents, the majority of whom endeavoured to make time within their busy
schedules to talk to us.
The Ministry of Health further acknowledges the hard work of the Core Working Group that put
the document together, and the supervisory efforts of the National Quality Strategy Steering
Committee.
We also acknowledge the Ubora Institute for their technical expertise in quality improvement
and logistical support in mobilizing interviewees in the field, engaging stakeholders, and liaising
across partners.
We also acknowledge the Institute for Healthcare Improvement, which funded the development
of this strategy through a grant from the Bill & Melinda Gates Foundation, for their technical
assistance in the development of the strategy.
vii
Executive Summary
The definition of quality adopted in this National Healthcare Quality Strategy (NHQS) was
derived collaboratively with key stakeholders of the nation’s health care system:
“Health care quality is the degree to which health care interventions are in accordance with
standards and are safe, efficient, effective, timely, equitable, accessible, client-centred, apply
appropriate technology and result in positive health outcomes, provided by an empowered
workforce in an enabling environment.”
The ultimate goal of the Ghana National Healthcare Quality Strategy is:
To continuously improve the health and well-being of Ghanaians through the

development of a better-coordinated health system that places patients and
communities at the centre of quality care. (MOH, Ghana 2016)
The specific goals of this strategy are to:
viii
Introduction
The National Healthcare Quality Strategy (NHQS) seeks to build upon useful lessons from
previous health care quality improvement initiatives.
Quality is embedded within a larger global movement towards universal health coverage. This is
addressed in Sustainable Development Goal 3, which aims to ensure healthy lives and promote
well-being for all at all ages. This global agenda explicitly sets forth the idea that quality is
essential to achievement of safe, effective care and improved health outcomes, especially as
access to care expanded (WHO, 2016). In the local context, the Health Sector Medium Term
Development Plan (HSMTDP), 2014-2017 seeks to improve the quality of health service delivery.
The National Quality Forum of September 2015 and the 2016 Aide Memoire issued by the health
sector give further impetus to the development of the NHQS.
Besides secondary data from the literature review, multiple stakeholders within and outside the
health sector were interviewed to gather primary data to inform this strategy.
Vision for Healthcare Quality in Ghana
With the definition of quality as stated above, the “ideal state” of quality was defined to reflect
key aspects to achieve optimal health system performance, as defined by stakeholders across the
three dimensions of Quality Planning, Quality Control, and Quality Improvement (Juran &
Godfrey, 1999), as shown in Table 1 below:
Table 1: Ideal State of Quality in Ghana
Quality Planning Quality Control Quality Improvement

 Leadership for quality in  Delivery of care in  Policy direction and health
health care accordance with evidence- prioritization
based standards
 A central quality management  Outcome-oriented goals
unit  Monitoring standards and based on health priorities
evaluating performance
 Culture of quality  Adaptation and scale-up of
 Data collation, review, and effective interventions based
 Logistical capability feedback on evidence
 Managerial skills  Uniform system for incentives  Feedback on performance
 Data use for evidence-based across facilities against targets
decision making  Supportive supervision;  Identification of gaps in health
 Human resource numbers collection of data to conduct outcomes and delivery based
and mix needs assessment on data
 Safe and effective medicines,  Reliable and timely data entry  Action planning based on gap
supplies, and equipment by public and private sector analysis
 Quality improvement and  Patient feedback through  Capability building

clinical skills patient satisfaction surveys
 Quality culture backed by
 Physical and financial access patient-centeredness
 Clear and cordial  Motivation for workforce

communication  Availability of medicines and
logistics
 Patient feedback
incorporated into the planning
of quality improvement
initiatives
 Client participation in quality
management committees
ix
Situation Analysis
The situation analysis was based on both primary sources (interviews) and secondary sources
(literature review) and was organized under the themes of health of the population; leadership
and functionality; quality improvement initiatives; and data systems and quality metrics.
Key successes in health of the population include significant reduction in under-five

mortality from 111 in 2003 to 80 per 1000 live births in 2014 (GDHS, 2015); reduction in infant
mortality rate from 64 in 2003 to 41 per 1000 live births in 2014 (GDHS, 2015); increased
financial access due to NHIS; free maternal care; increase in skilled birth attendant during
delivery from 59% in 2008 to 74% in 2014 (GDHS, 2015); reduction in HIV prevalence from
3.6% in 2007 to 1.3% in 2013 (GDHS, 2015); and introduction of Mental Health Act (WHO,
2016). Challenges in population health include near-stagnant neonatal deaths around 32/1000
live births (NNSAP, 2013); unacceptable levels of maternal mortality of 350/100,000 live births
(GDHS, 2015); shortages of logistics and equipment for delivery; high child stunting of a third
of children under 5 and 66% anaemia prevalence in children (GDHS, 2015); rising prevalence
and deaths due to non-communicable diseases (among top 10 causes of death); mental health
treatment gap of 98% (WHO, 2016); severe shortages of mental health staff; stock-outs of
essential mental health medicines; and delayed payment of NHIS claims and increasing
payments out of pocket.
In the area of leadership and functionality, the key successes and challenges are highlighted
in the table below:
Table 2: Key Areas to Address in Leadership and Functionality
Leadership and Functionality

Key Successes to Leverage with NHQS Key Challenges to Address with NHQS
 Building of in-country leadership, commitment,  Low levels of coordination among agencies;
and expertise over the years weak accountability, reward and recognition
 Establishment of regulatory bodies for the various mechanisms
professions and health facilities  Limited influence of the Ministry of Health
 GHS leadership in the development of a large (MOH) and its regulatory agencies on the
number of standards, protocols and guidelines private sector
including the Patient’s Charter, quality books and  Involvement of the private sector at the
patient safety guidelines regional and district level contingent on
 Existence of structures for the management of regional or district Ghana Health Service
quality at the various levels, which have been (GHS) leadership
functional to varying degrees  Focus on clinical care quality to the exclusion
 Exposure of most health workers to the concept of public health services quality
of quality and involvement in one or more quality  Restriction of accountability for policy
initiatives implementation to GHS
 Low accountability of teaching hospitals to
MOH
Key successes and challenges in quality improvement initiatives are highlighted in the table
below:
x
Table 3: Key Areas to Address in Quality Improvement Initiatives
Quality Improvement Initiatives

Key Successes to Leverage with NHQS Key Challenges to Address with NHQS
 Presence of several quality improvement  Little coordination among initiatives by
initiatives and willingness of development development partners
partners to support  Low quality culture and variation in
 Policies and plans developed perception of accountability for quality
 Private sector and teaching hospitals also  Protocols and manuals often do not come
implemented some initiatives along with clear strategy for implementation
 Health education has improved client knowledge  Irregular monitoring of identified quality
of their rights and responsibilities indicators and of adherence to standards
 Automation of medical records to reduce waiting  Increasing numbers of medico-legal issues
time in health facilities
With data and quality metrics, the landmark success is the development of the District
Health Information Management System (DHIMS) by the GHS. Challenges include low data use
at the site of collection; only 33% of facilities enter data into the DHIMS; few private facilities
and two out of the four teaching hospitals do not input data in the DHIMS; and low provider
knowledge about the capabilities of DHIMS (NHQS Interview, 2016).
The Strategy
The ultimate goal of the National Healthcare Quality Strategy is:

development of a better coordinated health system that places patients and
communities at the centre of quality care.
The specific goals of this strategy are to:
xi
While this strategy applies to all areas of health, there is a specific focus on the following key
health areas which have been chosen based on potential for impact in improving the lives of
Ghanaians nationwide:
 Maternal health
 Child health: neonate, infant, under-five
 Malaria
 Epidemic prone diseases: cerebrospinal meningitis, cholera
 Non-communicable diseases: hypertension, diabetes

 Mental health
 Geriatric care
In order to reach our ultimate goal of continuously improving health outcomes, this strategy
outlines an 8-point framework for action across all levels of the health system based on key
strategic objectives:
1) Improve the capacity of relevant health workers to manage identified priority health
interventions.
2) Promote a quality culture and accountability for quality in all health workers and sector
agencies.
3) Create a sustainable leadership and governance for quality planning, quality control, and
quality improvement at all levels of the health care system.
4) Strengthen coordination among all health sector agencies.
5) Standardize collection of data and improve use and analysis of data at all levels (including
by providers at the frontline) for evidence-based decision making.
6) Resource and strengthen regulatory agencies (especially Health Facilities Regulatory
Agency (HEFRA)) to roll out a nationwide accreditation process with clear links to facility-
based quality management teams for ongoing improvement action.
7) Improve client safety, satisfaction and participation in quality definition and quality
improvement.
8) Build a culture of “joy at work” (financing, logistics, recognition and reward) that creates
the context for health providers to treat clients with dignity and respect, deliver high-
quality care and be motivated to continuously improve quality.
More specifically, across this 8-point framework for action, the NHQS highlights seven key
strategies and a number of activities. The table below shows the strategies and high-level
activities; a detailed action plan is shown in the complementary document, National Healthcare
Quality Strategy 2017-2021: Part 2 – Coordination and Accountability Framework.
xii
Table 4: Key Strategies and Activities of the National Healthcare Quality Strategy
xiii
Making This Happen
MOH will lead the strategy implementation process, and operationalization at all levels will
largely involve leveraging existing structures. Capacity will be improved in quality improvement,
managerial and clinical skills.
A separate document (Part 2: Coordination and Accountability Framework) outlines an action

plan for coordination of implementation, assigns implementation roles to health sector agencies,
and discusses possible financing mechanisms. The short-term financing proposal is for all health
facilities and agencies to contribute to the implementation of this strategy using five percentage
points of the 15% agencies returns to the MOH, together with donor support. In the long term,
the proposal is that facilities and agencies use their internally generated funds (IGF).
Measuring Improvement
Indicators have been selected to measure progress in (i) health outcomes in the priority
population health areas; (ii) quality; (iii) systems improvement; and (iv) performance of health
sector agencies.
xiv
xv
Chapter 1: Introduction
1.1 Background and rationale
Ghana’s quality journey in brief
Initiatives to improve the quality of care are not new to Ghana’s health system. This National
Healthcare Quality Strategy (NHQS) builds on previous initiatives. At the start of formal health
care quality processes in the mid-1990s, there were two concurrent pilot projects in the country,
one in the Upper West with support from Danida, and the other in the Eastern Region supported
by the Liverpool School of Tropical Medicine (Offei, Bannerman, & Kyeremeh, 2004). These
projects were focused on process quality without ignoring structure and outcome quality. A
nationwide review of quality improvement initiatives conducted by MOH followed in 1998.
Recommendations from the review included: harmonization, institutionalization, and pre- and
in-service training on quality in health care (Offei, Bannerman, & Kyeremeh, 2004). In 2000,
under the Liverpool School of Tropical Medicine, a team of nine national trainers were sent for
a six-week course at the Royal Tropical Institute in Amsterdam (Offei, Bannerman, & Kyeremeh,
2004). Widespread training was then instituted and client satisfaction surveys became a useful
tool for health facilities to identify quality gaps with a view to implementing improvement
interventions.
Quality was mainstreamed in the mid-2000s with the setting up of a Quality Assurance (QA)
Department in the Institutional Care Division of the Ghana Health Service (GHS). Since then,
GHS has developed a Quality Assurance Strategy, produced a large number of standards,
protocols and guidelines, a Patient Charter and three editions of Quality Assurance Manuals,
culminating in the writing in 2013 of the book Quality and Patient Safety in Health Care. Besides
the initiatives by GHS, several development partners have experimented with various quality
assurance and quality improvement initiatives which have provided a number of lessons to build
upon.
Rationale and impetus for developing NHQS
The global context for quality, the basis for which is provided by the WHO, rests on two main
arguments for promoting a focus on quality in health systems today:
 “Even where health systems are well developed and resourced, there is clear evidence
that quality remains a serious concern, with expected outcomes not predictably
achieved and with wide variations in standards of health-care delivery within and
between health-care systems.”
 “Where health systems – particularly in developing countries – need to optimize

resource use and expand population coverage, the process of improvement and scaling
up needs to be based on sound local strategies for quality so that the best possible
results are achieved from new investment.” (WHO, 2006).
1
Quality is embedded within a larger global movement towards universal health coverage. This is
addressed in Sustainable Development Goal (SDG) 3, which aims to ensure healthy lives and
promote well-being for all at all ages. Specifically, SDG 3 states the following target: “Achieve
universal health coverage, including financial risk protection, access to quality essential health-
care services and access to safe, effective, quality and affordable essential medicines and vaccines
for all.” (WHO-SDG, 2015) This global agenda explicitly sets forth the idea that quality is
essential to achievement of safe, effective care and improved health outcomes, even as access to
care is expanded.
In spite of the numerous quality initiatives implemented in Ghana to date, a culture of quality
has not yet been institutionalized in the system. Weak links persist between clinical care and
public health at the district level, and unclear oversight and accountability structures have
resulted in fragmentation in quality approaches with limited impact on patient experience and
health outcomes (HSMTDP, 2014). Sector agencies work independently without any
coordination, and teaching hospitals and private sector players have largely been on the fringes,
with little involvement and little expectation of accountability (HSMTDP, 2014).
These shortcomings have however not escaped attention, and the Health Sector Medium Term
Development Plan (HSMTDP), 2014-2017 highlights quality in policy objective number 4,
seeking to “Improve quality of health service delivery including mental health services.” The
National Quality Forum of September 2015 determined to move this national quality agenda
forward through the development of a National Healthcare Quality Strategy to guide all quality
planning, quality assurance and quality improvement initiatives in the country.
Between October and December 2015, MOH and the Institute for Healthcare Improvement
(IHI) submitted a proposal to the Bill & Melinda Gates Foundation (BMGF) around developing
the foundations of a National Healthcare Quality Strategy, which was approved. Preparatory
work done by MOH and IHI between February and April 2016 included the preparation of a
concept note which spelled out the processes for developing the strategy. In April-May 2016, the
development of a NHQS was escalated unto the Aide Memoire of the 2016 Health Summit. The
aide memoire simultaneously called for the formation of a National Quality Strategy Steering
Committee (NQSSC). In May 2016, the NQSSC and the Core Working Group (CWG) were
established to lead the NHQS development process.
1.2 The strategy development process
The process, as shown in Figure 1, was led by a National Quality Strategy Steering Committee
(NQSSC), which gave direction to the development process. The NQSSC was chaired by the
Director of Policy, Planning, Monitoring and Evaluation (PPME) Directorate of the Ministry of
Health. Membership of the NQSSC was drawn from the agencies of MOH, including the private
sector and patient groups. The committee was tasked to guide the overall development and
implementation of the NHQS to improve national health outcomes. The NQSSC was to provide
technical leadership in driving quality improvement goals. In this regard, the NQSSC was to help
identify gaps, set ambitious goals and mainstream the implementation of QI plans within the
agencies to close the performance gaps identified.
The NQSSC delegated the day-to-day writing of the NHQS document to a Core Working Group
(CWG) which comprised experts selected from the public and private sectors. The CWG was
responsible for the literature review, the planning and conduct of interviews and the
development of the strategy document. The CWG adopted a wide mix of communication modes
to coordinate their work, including in-person meetings, weekly Skype/phone calls and the
exchange of an unending stream of emails.
2
Key stakeholders in health were all given the opportunity to contribute to the strategy.
Stakeholders targeted and/or interviewed are detailed in Appendix 1. Stakeholder contributions
were chiefly by way of in-person meetings and formal interviews, which comprised both key
informant and focus group discussions, including patient forums. Stakeholders were sampled
from three regions which were purposefully sampled for the interviews – Northern Region
representing the northern zone, Ashanti Region representing the middle zone, and Greater Accra
Region representing the southern zone. Besides representing the southern zone, the Greater
Accra Region is also the region with most of the central-level stakeholders. A further criterion
for selecting Ashanti Region is the existence of the capitation mode of provider payment, with
its unique quality challenges. Overall, the interview response rate was 82%.
The National Healthcare Quality Strategy articulates a vision, with related goals, objectives and
strategic interventions built on WHO and AFRO Health Systems Building blocks, and measured
by indicators. In addition, there is an implementation plan with activities that lead to changes in
health system performance, using quality planning, quality control and quality improvement
principles.
National Quality
Strategy Steering
Committee (NQSSC)
Core Working Group

(CWG)
CURRENT STATE OF
QUALITY IN GHANA
Ministry of NHIS, Private

PROCESSES
Health Insurance
1. LITERATURE REVIEW
2. INTERVIEWS
Training GEA, Other
Institutions 3. IN-PERSON MEETINGS Employers
4. EMAIL/SKYPE/PHONE CALLS
Regulators, 5. NHQS WRITE UP MOFEP, Dev.

Associations Partners
6. STAKEHOLDER CONSULTATION
7. NQS REVIEW, FINALIZATION

Service
Consumers
Providers
DESIRED STATE OF
QUALITY IN GHANA
Coordination &
Accountability
Framework
Figure 1: Ghana NHQS Development Framework
3
Chapter 2: Vision for Healthcare

Quality in Ghana
2.1 Stakeholder Definition of Quality
Determining the ideal state of quality is a vital step in understanding the current gaps in the
current Ghanaian health system, and setting forth priorities that align with this vision.
Stakeholder interviews revealed variation in the perspectives of policymakers, providers, clients,
and more as to what constitutes quality. These views have informed the adoption of the following
multi-dimensional definition of health care quality:
“Health care quality is the degree to which health care

interventions are in accordance with standards and are safe,
efficient, effective, timely, equitable, accessible, client-centred,
apply appropriate technology and result in positive health
outcomes, provided by an empowered workforce in an enabling
environment” (NHQS Interviewees & NQSSC, 2016)
Commonalities in stakeholder views emerged around the Donabedian principles of “structure,

process, and outcomes,” while also drawing on WHO and IOM definitions of quality and citing
the need for input availability, empowered and skilled health workers, access to safe and effective
care, and a client-centred approach to the delivery of care.
2.2 Ideal state of quality in Ghana
We now outline what the ideal state of quality looks like across all levels of the health care system
in Ghana. The ideal state reflects key aspects or levers to achieve optimal health system
performance, as defined by stakeholder. These levers are organized across the Juran trilogy of
Quality Planning, Quality Control, and Quality Improvement.
 Quality Planning: Policy, resources, accountability, coordination, execution

 Quality Control: Standards/guidelines, protocols, professional oversight,
accreditation, performance review
 Quality Improvement: Gap analysis, needs assessment, tools and methods to

develop, test, and measure change, feedback processes, change ideas for improvement,
administrative and frontline support to close the “gap”
The ideal state of quality is organized across these three dimension in the table below.
4
Table 5: Ideal State of Quality at All Levels of the Ghanaian Health System
5
Chapter 3: Situation Analysis

This chapter serves to analyse the current state of health care quality in Ghana through literature
review and stakeholder interviews. We highlight health priorities and existing initiatives and
structures that aim to improve health outcomes for the population. The analysis is organized
under four themes:
 Health of the population
 Leadership and functionality

 Quality initiatives
 Data systems and quality metrics
3.1 Health of the population
The population of Ghana is projected to grow from the current 26 million to around 50 to 60
million by 2050 (US Census Bureau, 2016). The life expectancy at birth in Ghana is 66.6 years
of age (Central Intelligence Agency, 2016). The country has made significant improvements in
health outcomes for the population over the past several years, though this progress has varied
(Science Daily, 2010). Given that the southern half of the country is more populated than the
northern regions, and more than half of Ghana’s population is urban, accessibility to quality care
is often dependent on geography.
Key health issues that continue to affect Ghana’s population are maternal and child health, child
nutrition, infectious diseases, non-communicable diseases, and mental health.
Maternal and Child Health
Significant reductions in under-five mortality rates have been made between 2003 and 2014,
decreasing from 111 per 1000 live births to 60 per 1000 live births (GDHS, 2015). Similarly,
improvements have been made in infant mortality, overall, with reductions from 64 per 1000
live births in 2003 to 41 per 1000 live births in 2014 (NNSAP, 2016). Interventions that
contributed to the improvement in these areas were the implementation of the National Health
Insurance Scheme, which guaranteed free maternal care, and an increase in the number of
skilled birth attendants during delivery increased from 59% in 2008 to 74% in 2014 (GDHS,
2015). However, high and somewhat stagnant rates of 32/1000 live births neonatal mortality
(NNSAP, 2013) and 350/100,000 live births maternal mortality (GDHS, 2015) persist,
indicating a need to reduce disparities and deliver high-quality care specifically targeted towards
these subpopulations.
Key challenges and hurdles have been identified in the delivery of maternal health services.
Improving deployment of skilled health workers, supply of medical equipment for birth and post
care, logistics, staff within the medical centres, transportation for women, quality health care
and ambulance services were all barriers that threatened the delivery of quality and safe
maternal health care. The Ministry is committed to addressing these priorities.
6
Child nutrition
As many as 1.2 million people (about 5% of the population) are considered food insecure and
chronically undernourished in Ghana (Ministry of Food and Agriculture, n.d.). Nearly one-third
of children nationwide are stunted and 66% are anaemic (GDHS, 2015), factors that also
contribute to under-five mortality.
Infectious diseases
There are 50,000 new cases of TB every year in Ghana (National TB control programme, 2013).
The National HIV and AIDS prevalence has fallen from 3.6% in 2007 to 1.3% in 2013 (GDHS,
2015); however, regional disparities still persist. With the implementation of antiretroviral
therapy (ART), there have been improvements for people living with HIV. Ghana has received
support from various bodies including the UN, USG, and PEPFAR to combat the transmission
of HIV, malaria and tuberculosis. To make further progress in this health priority area, we need
to address the unstable supply of antiretroviral medicines, risky sexual behaviour, stigmatization
of and discrimination against those living with TB and HIV.
Malaria remains the biggest cause of mortality and morbidity in Ghana (National Development
Planning Commission, 2015) despite efforts to tackle this disease, with the most vulnerable being
children under five, pregnant women and the poor. Challenges faced include limited access to
and proper use of ITNs, resource limitations for scale-up of malaria programs, and poor
sanitation and inadequate waste disposal.
Non-communicable diseases
Ghana’s health sector, like that of many African countries, is ill-equipped to deal with the
country’s double burden of disease (MoH, 2011). Due to socioeconomic and lifestyle changes,
the Ghanaian population faces a rising prevalence of non-communicable diseases. NCDs such as
hypertension, stroke, cancer and diabetes affect the young and old, urban and rural, and wealthy
and poor communities, featuring among the top ten 10 causes of death (MoH, 2011).
Globalization, urbanisation, ageing population and weak health systems have catalysed the
escalating emergence of non-communicable diseases. Deaths due to non-communicable
diseases (NCDs) in low- and middle-income countries (LMICs) including Ghana are expected to
increase from 30.8 million in 2015 to 41.8 million by 2030 (Piot et al., 2016).
Mental health
It is estimated that approximately 2.8 million people suffer from a severe to mild mental health
disorder, with a treatment gap of 98% of the affected population (WHO, 2016), yet only 1.4% of
the nation’s health expenditure is spent on mental health care in Ghana (Roberts, Mogan &
Asare, 2014). In 2012 the Mental Health Act was passed, creating a Mental Health Authority
tasked with the responsibility to coordinate the delivery of quality mental health care
nationwide. This recognizes mental health as an imperative issue to address. However,
implementation has been slow, exacerbated by the fact that acknowledgment and treatment of
mental health conditions are stigmatized. There are currently severe shortages in human
resource capacity (doctors, psychiatric nurses, community psychiatric nurses), weak data
systems with facility-level data not well integrated into national data systems, chronic reports of
under-resourcing and stock-out of essential drugs (Roberts, Mogan & Asare, 2014). In order to
improve treatment and outcomes in mental health and address both the social and psychological
causes of mental illness, a multi-sector approach is needed, with collaboration between state
programs and faith-based institutions to deliver culturally appropriate care in community
settings (NHQS Interview, 2016).
7
Health financing
In 2003 Ghana promulgated the National Health Insurance Act (650), which saw the
establishment of the National Health Insurance Scheme (NHIS) with the goal of providing
financial risk protection for all residents in Ghana. The bulk of the funding comes from a 2.5%
health insurance levy on Value Added Tax (VAT) (National Health Insurance Authority, 2016).
Three types of schemes were established under the law: district-wide mutual health insurance
schemes, private mutual health insurance schemes, and private commercial health insurance
schemes. Act 650 was replaced with Act 852 in 2012, which provides for a centralised national
scheme and private schemes (Blanchet, Fink & Osei-Akoto, 2012).
Utilization of health services increased since the introduction of the NHIS, which now covers
40% of the population (NHIA, 2012). However, while quantity and overall access have increased,
quality of care and equity remain significant issues to be addressed (NHQS Interview, 2016).
Delayed reimbursement of claims, and rejection of claims due in part to quality issues such as
mismatch between diagnosis and prescription, polypharmacy, and prescribing outside the
standard treatment guidelines have all raised significant concerns about the quality of care that
is delivered.
Capitation has recently been introduced as a provider payment method for an identified package
of primary care services (National Health Insurance Authority, 2016). A provider focus group in
the Ashanti Region, where capitation is being piloted, observed that while capitation has helped
bring competition into the health care marketplace to satisfy and retain clients, there have been
many implementation challenges. Low capitation rates have led to costs being borne by patients
and hospitals, and concerns have arisen about the unavailability of essential medicines and
supplies in facilities due to limited reimbursement. From the client perspective, capitation has
led to reduction in access to some drugs, and does not provide sufficient coverage for clients
when they travel outside of their home district.
3.2 Leadership and functionality
Driving Quality at the National Level
The Ministry of Health has led high-level planning with the Health Sector Medium Term
Development Plan (HSMTDP) (2014-2017), in which quality is recognised as a key strategic
focus area. To improve adoption and implementation of this plan, specific strategies to address
quality-related objectives need to be defined, at all levels of the system. The MOH is also
responsible for development of policy and identification of national priorities for the entire
health sector. Accountability for implementation of these service delivery-related policies and
programs has, to date, been largely restricted to the Ghana Health Service (GHS), to the
exclusion of the other service agencies, particularly teaching hospitals and private sector
providers.
The Ministry has largely exercised its quality assurance role through its regulatory agencies.
Most regulatory bodies are mandated to license and register practitioners in their respective
health professions and prescribe general standards of practice to ensure that professionals are
up to date through a system of renewal of licences based on continuing professional
development.
The now-defunct Private Hospitals and Maternity Homes Board (PHMHB), which did not
mandate regulation of public health facilities, has by law (Act 829) been replaced with the Health
Facilities Regulatory Agency (HEFRA) as of 2011. HEFRA has an expanded mandate covering
8
the accreditation and regulation of both private and public health facilities (Ministry of Health,
2013).
The key challenge among the various regulatory bodies is their operation under independent
policies, systems, and plans with standards that lack cross-coordination. Regulatory bodies
perform their mandated functions without collaborating across their individual efforts. In
addition, there is limited influence of the Ministry and other regulators such as the Ghana
National Drugs Programme, Food and Drugs Authority, Pharmacy Council and the Chief
Pharmacist's office over the private sector. The overarching authority of HEFRA can be leveraged
to enforce quality standards across public and private providers in future, although the agency’s
inception and the transition from numerous regulatory bodies to HEFRA has been slow to date.
Leadership in quality assurance has been shown by service provider groups, particularly the
Ghana Health Service (GHS) and the Christian Health Association of Ghana (CHAG), and to a
lesser extent, by private sector umbrella organizations such as the Society of Private Medical and
Dental Practitioners (SPMDP) and the Community Practice Pharmacists Association (CPPA). In
the GHS, the Quality Assurance Department within the Institutional Care Division has overall
oversight for quality within the entire GHS across the country. In line with this oversight
responsibility, the Ghana Health Service developed the Quality Assurance Strategic Plan (2007-
2011); this planning process has however not been continued beyond 2011. By 2011, the Strategic
Plan had led to the establishment of quality assurance teams in most facilities and regular client
satisfaction surveys with follow-up actions on gaps identified. Furthermore, the GHS produced
a large number of standards, protocols, and guidelines across the spectrum of health care
delivery. GHS also led the development of the Patient’s Charter for the country, three editions of
quality manuals, and more recently, the Quality and Patient Safety book (NHQS Interviewee,
2016).
The GHS normally disseminates and trains health staff on these standards to enable them to
implement them effectively, but training has not always benefited the bulk of frontline staff and
monitoring of implementation has often not been effective. Field interviews revealed that
improvements needed to be made to ensure that staff at the community level receive continuous
training, and have an ability to transfer knowledge to new staff.
According to a manager within the CHAG set-up, CHAG leadership influences quality through
continuous staff orientation, provision of the essentials needed to deliver service, motivation of
staff, good working environment and a safe environment for patients.
As a purchaser, the National Health Insurance Scheme (NHIS) was mandated by law (Act 650)
to accredit facilities that provide services to NHIS subscribers (Blanchet, Fink & Osei-Akoto,
2012). The National Health Insurance Authority (NHIA) has therefore been at the forefront of
the implementation of a national accreditation system that accredits all levels of health facilities
from CHPS compound (community level) to hospitals, from licensed chemical shops to
pharmacies, and diagnostic facilities. The accreditation role has since 2012 been ceded by law to
the Health Facilities Regulatory Agency (HEFRA); the new NHIS law (Act 852) has changed the
NHIA role to one of credentialing health facilities (National Health Insurance Authority, 2013).
Credentialing, which admits providers into the scheme based largely on accreditation by
HEFRA, is meant to be a less rigorous process to assure confidence that the health facility can
provide safe and quality services to NHIS subscribers.
Driving Quality at the Regional & District Level
In the Ghana Health Service, the clinical care units within the Regional Health Directorates are
responsible for the supervision of quality within the regions. The regional team adopts/adapts
9
plans and programs from the national level, disseminates them, and builds the capacity of the
district to implement them. Planning for dissemination and training are done at the regional
level, and the regions largely employ a train-the-trainer model, cascading the effects of training
from the districts even further downstream. The regional team further supervises and monitors
implementation across the different districts.
In order to move towards a more holistic approach and reach public health facilities and private
sector providers in each region, the mandate of the Clinical Care unit of the RHD must be
broadened to look beyond clinical care. Further, there is the need to standardize a broad view of
the mandate of Regional and District health directorates to look beyond Ghana Health Service
and CHAG facilities to specifically include private facilities. This will entail some redesign of the
current system to ensure more reliable reporting of the data generated from the work of private
providers for improved transparency and improvement action.
Leadership at the district level is key to implementation and performance within the district. The
districts supervise the facilities, sub-districts (health centres) and communities (CHPS), training
these lower levels and monitoring their adherence to standards through data inputted in DHIMS
by the sub-districts and facilities. The district health administration is an active player in quality
improvement activities, building capacity of providers in the health facilities and community
health providers to implement prioritized quality improvement activities. At the district level, as
well, the private sector is often not involved in quality initiatives and training, nor is it under
strict mandate to be accountable.
Driving Quality at the Facility & Community Level
Strong and committed internal facility leadership is the sine qua non of a successful quality effort
(NHQS Interviewee, 2016). Where the facility head is interested and committed to leading and
facilitating quality processes, the effort is sustained. In GHS and CHAG facilities, improvement
assignments are led by facility quality teams. Risks to quality improvement at the facility level
include poor knowledge management (knowledge sharing), turnover of committed leadership,
lack of logistical support, and a low degree of empowerment among staff to drive change. Quality
improvement efforts have therefore often resulted in slow improvements in outcomes of care –
both technical outcomes and outcomes from the client perspective.
Patients and communities help the service provider to identify gaps in service provision and care
through exit interviews, client complaints systems, and community engagements such as
community surveys and community durbars. This data provides a source of information for
facilities about how they can improve quality from a client perspective. Translating this feedback
into action and improvement will help to renew the public’s trust in and satisfaction with the
health care system.
Generally speaking, little quality planning occurs at the community level; planning is almost
always pre-packaged, ready for un-packaging at the community level for implementation. The
community is therefore essentially reduced to a passive implementer of quality improvement
initiatives and a source of data for higher levels or donors. The community level, being in touch
with the people and local culture, could be better leveraged to highlight local contextual
peculiarities to enrich quality planning.
Teaching Hospitals
Teaching hospitals are under the purview of the Ministry of Health, but there is variability in the
degree to which their plans are developed with recourse to the MOH. Accountability to the MOH
also seems to be low, with two of the four teaching hospitals regularly reporting performance to
10
the Ministry. A common forum exists for teaching hospitals, but knowledge sharing and cross-
fertilization of ideas around quality planning, quality assurance, and quality improvement could
be improved. The result is a system of effectively self-regulating, independent service providers
without a clear set of standards and protocols enforced or supervised by the Ministry of Health.
Supervisory tools and standards need to be agreed upon by all health facilities, in order that the
Ministry can extend to teaching hospitals.
Private Sector
The private sector is made up of private medical practitioners, most of whom are members of
the Society of Private Medical and Dental Practitioners (SPMDP); health facilities of both private
and public corporate organization associated with the Ghana Association of Quasi-Government
Health Institutions (GAQHI); private pharmacists under the umbrella of the Community
Practice Pharmacists Association (CPPA); private midwives associated with the Ghana
Registered Midwives Association (GRMA); and private diagnostic scientists within the
Association of Biomedical Scientists. About 51% of Ghana’s population use private health
facilities as their first point for health care (Morrison, 2016). The leadership of many of these
organizations integrate quality into their practice by building capacity of their members through
workshops and trainings. The Ghana Health Service also provides opportunities for private
sector operators to participate in essential technical training.
Leadership at the district level often determines the degree to which private providers report
into DHIMS. Strengthening the governance structure and supervisory capacity of the district
directorates will help to address the key challenge of better integrating the private health sector.
3.3 Quality improvement initiatives
Ghana has a history of a number of quality improvement initiatives, spanning from small steps
independently taken by staff at the facility level, to strategy plans to improve quality of care at
the national level. Currently, quality improvement initiatives address quality elements such as
patient safety, effectiveness, patient-centeredness, timeliness of service provided, efficiency,
accessibility, and equity, throughout the continuum of care. These quality improvement
approaches adopted various strategies and teaching models, but certain themes were common:
 Use of quality planning tools to identify performance gaps in systems and processes by
managers and frontline staff
 Prioritization of critical gaps for intervention

 Formation of multidisciplinary improvement teams, generation and use of innovative cost-
effective solutions
 Continuous data feedback loops and reflection on data through learning systems
 Coaching and mentoring follow-up visits

 Capacity building with embedded practical components including onsite activities
The organisation and implementation of quality in a nation can be analysed using three
interlinked categories of quality: Quality Planning, Quality Control and Quality Improvement.
Table 6 below lists quality initiatives and their level of influence across the health care system.
11
Table 6: Quality Initiatives Across the Ghanaian Health System
Quality Initiatives Level of the Health System
National Regional/District Facility Patient/Community

Quality Planning
National Health Policy, 2012 X X X X
Non-communicable Disease Policy, 2011 X X X X
Health Sector Medium Term Development Plan
X X X X
(HSMTDP) (2014-2017
Mental Health Act, 2012 X X
National Health Insurance Scheme (Act 2003) X X X
GHS-Quality Assurance Strategic Plan, 2007 X X X
Patient Charter, 2013 X X X
Code of Ethics X X X
Code of Conduct and Disciplinary Procedures X X X
Nutrition Policy X
Quality Assurance/Control
Client Satisfaction Survey X X
Clinical & Mortality Audits X X X
Child Care Guidelines X X X
Maternal Care Guidelines X X X
Patient Safety Guidelines X
Infection Prevention and Control X
Malaria Protocol X
Surgical Safety Guidelines X
Guidelines for Community Pharmacy Practice X
Health Facility Accreditation and Credentialing X X
Health Professional Licensing X X X
Certification by Food and Drugs Authority and
X X X X
Ghana Standards Board
Quality Improvement
Project Fives Alive! (IHI & NCHS) X X X X
Peer Review program X
Leadership Development Program X X X
Safe Motherhood taskforce X X
High Impact Rapid delivery (HIRD) X
HIV Coordinated National Response Program X X X
HIV Testing and Counselling (HTC) X X
HIV Prevention of mother-to-child transmission X X
Condom promotion and distribution alongside
X X
education on abstinence
Strengthening referrals and collaboration
between facilities and communities to increase X X
ART uptake and adherence
Intermittent Preventive Treatment (IPT) to
X X
provide chemoprophylaxis for pregnant women
Production of quality generic anti-malaria drug
X
by local pharmaceutical companies
Availability of over-the-counter malaria tests
X X X
contributing to rapid diagnosis
Provision of Insecticide Treated Nets (ITNs) to
X X X
pregnant women and children
12
The Ministry of Health has a number of policies and strategic plans well-written to promote
quality in health care. However, they often lack a deliberate prioritization process; an evaluation
method to assess implementation and results of these initiatives; and a strong dissemination
component to ensure that both public and private sector providers are aware of policy changes.
The result is fragmentation in the system, and little integration of efforts. Interviews
also revealed variation in perception of accountability for providing and driving quality health
care – from the government, to facility management, to health care professionals, to patients,
themselves.
“Lots of policies
at the GHS
website but they The Ghana Health Service has introduced standards, protocols and guidelines, and defined a set
are poorly of client-oriented and professional-oriented indicators (Kaba, 2016) for monitoring across GHS
publicized, for facilities, and these indicators have been adopted or adapted by the Christian Health Association
people to even of Ghana (CHAG) and some private sector operators. The key shortcoming is a reflection
know and of weak accountability and planning function within the health system: the
implement. protocols and manuals often do not come along with a clear strategy for
There is implementation at various levels of the health system. In effect, they become well-
written documents, the usage of which is largely left to the initiative of the individual leader.
commitment
Even with the introduction of peer review programs, mortality and clinical audits, not too many
with quality
health facilities have been regular in monitoring identified indicators. Moreover, failure to do so
policy
does not attract any significant sanctions, neither does compliance attract reward. Indeed,
formulation and
monitoring of adherence to standards has generally not been optimal.
strategy
development, but
not with Within the private sector, the Community Practice Pharmacists Association has just launched
monitoring of ''Guidelines for community pharmacy practice, quality standards for community pharmacy
implementation.” practice in Ghana” and has provided training on this to about 1,000 of its members nationwide.
The association called for policy change – separating services by hospital pharmacists (inpatient
- A Private Sector
care) from community pharmacist (outpatient care) (Allotey, 2016).
Provider
Ghanaian teaching hospitals have also instituted initiatives to improve quality. For example, in
the Korle Bu Teaching Hospital initiatives have included capacity building in quality
improvement, running of continuing professional development (CPD) programs, initiating
improvement processes in various departments, improving data systems, developing protocols
for referrals, and writing a quality strategy. The hospital has also introduced paediatrics and
obstetrics triaging at its children and obstetric outpatients & emergency rooms to reduce the
waiting time of clients in accessing care. Its surgical medical emergency is also using the triaging
system as a means of prioritizing cases. Komfo Anokye Teaching Hospital has implemented the
WHO Patient Safety initiative under the African Partnership on Patient Safety (APPS).
The regulatory arm of the Ministry of Health has initiated improvements in the quality of care.
Some of measures include:
 FDA initiative to reduce fake medicines coming into the country from 30% to 2.5%, and
introducing nurses to basic pharmacovigilance (Food & Drugs Authority, 2016);
 The Mental Health Authority coming up with a legislative instrument that will protect
their vulnerable patients;
 Nursing and Midwifery Council organizing workshops to sensitize nurses about the art
of health care (customer care); and
 Accreditation and renewal of licenses by facilities through HEFRA and by health

professionals through their respective regulatory bodies ensuring that the environment
in which the health service is being provided is standardized and staff are poised for
great outcomes.
13
MOH works closely with its development partners in the provision of quality health care to the
people of Ghana. Through these partnerships, a number of CHPS facilities have been built in
places with limited access to care, public health interventions have been adequately promoted,
and the capacity of health workers has been enhanced. Notwithstanding, the key challenge to
be addressed by this strategy is the lack of coordination among a number of quality
initiatives initiated by development partners. Different approaches and reporting
requirements result in duplication of efforts and loss of man-hours for public sector service
providers. On the other hand, the private sector is often not involved in these initiatives.
From a patient perspective, the impact of quality initiatives has not always been clear. A provider
observed that the increasing number of medico-legal issues is an indicator of poor quality of care,
despite efforts. Provider and patient interview respondents noted the low doctor-to-patient
ratios, long waiting times, unavailability of essential supplies, medicines, and diagnostics, which
lead to low client satisfaction especially in government facilities.
Other client and community focus groups identified additional issues that still need to be
addressed – for example, sub-optimal levels of professionalism which manifests in ways such as
breaches in privacy and confidentiality, health workers’ impatience with clients, disrespect, and
inadequate communication and transparency with clients and their families. Cultural change
in the health workforce is a necessary ingredient to drive change. “People have to
know that it is not enough to do just anything, but to ensure that the little that they do bears the
stamp of quality” (Alhaji Ibrahim, 2016). Defining interventions that build quality culture over
time, such as professional development, incentive packages for working in remote areas, and in-
service training are all mechanisms to help motivate the health workforce to pursue quality.
Some of these quality initiatives have had positive impact on the quality of health care in Ghana.
The Ministry of Health can report higher numbers of trained health professionals than ever
before, including specialists in various fields of health care. Through Project Fives Alive! (PFA!)
10 health staff were trained as regional improvement advisors, with over 400 quality
improvement coaches leading quality improvement work at the various levels of health care in
Ghana. Similarly, about 4000 frontline workers were also trained in quality improvement
methodology (Project Fives Alive!, 2015). Systems for Health Project (S4H) also supports health
staff in their improvement work. Health education by all stakeholders has improved client
knowledge about their health and how to be responsible for their health. The introduction of
capitation has led to an increased focus on providing value-based care. A number of hospitals
have automated their records department to reduce the long waiting time normally experienced
at the health records department. There is also triaging for children under five to receive prompt
care. Similarly, health providers, training institutions and professional bodies provide
opportunities to improve the capacity of health workers to provide services with desirable
outcomes.
3.4 Data systems and quality metrics
The current state of data collection and use within Ghana’s health system reflects the way in
which health as a whole is organised, namely the Policy, Planning, Monitoring and Evaluation
division within the Ghana Health Service (GHS) is charged with monitoring and evaluation as
well as data management of all activities under the GHS. In 2012, the GHS collaborated with the
University of Oslo in developing the District Health Information Management System
(DHIMS2) software used for reporting and analysing district health administration and health
facility needs. Data entered into DHIMS2 include measures on finance, laboratory, pharmacy,
disease control, maternal health, surgical operations and occupational health.
14
Currently, health information is uploaded into the DHIMS2 at the local level. Data is collected
and aggregated monthly by the facility health information officer or regional data officer, who
subsequently manually enters the aggregated data into the DHIMS2. Once the data has been
entered, the regional and central health management levels are able to access it in real time. At
“People say they the local level, data is used to monitor and plan clinical activities. At the regional level, the data
only use the data is used for supervisory and routine monitoring purposes. At the national level, data is only fed
for presentation, back to the regional level if there is some discrepancy in what has been submitted. Occasionally,
but I feel we use it members of the M&E unit at the national level conduct validation visits to the facility and
for more than regional level.
that; it is actually
being used for In spite of the great strides that have been made with the roll-out of the DHIMS2, the health
clinical reviews sector has identified weak integrated research, information and monitoring systems to support
and outcomes at evidence-based decision making and to track performance in priority areas. A policy maker
some facilities. We explained that about 33% of facilities, public and private, enter data directly into the DHIMS2
use it for “because they have a data information officer, computer and Internet access.” Currently, two of
planning. We have the four teaching hospitals nationally report into DHIMS2, while the other two have a parallel
developed the data electronic health records system that provides a challenge for the GHS to access their data.
utilization CHAG, which is responsible for up to 40% of the health care provided in Ghana, has some its
manual; people facilities currently using the Health Administrative System (HAMS) electronic database, where
don’t always know each health unit is able to enter their data as they see the clients. Although close to 60% of the
how to move data collected at CHAG facilities is being entered into the DHIMS2, this data is not entered in a
numbers to make timely manner. The MOH/GHS is currently working on several strategies to support the
interpretations or improvement of health information and data use throughout the health sector, as well as use of
support solutions, data at a local level.
so the purpose of
the data Private hospitals, which are not under the mandate of the GHS, largely collect data that is not
utilization manual linked or entered into the DHIMS2, although some of the facilities have the appropriate
is to help facilities, technology and capability to do so. In an effort to improve data management among the private
districts to use the facilities, the MOH has been working through the Health Facilities Regulatory Agency (HEFRA)
data.” that provides licenses to hospitals to encourage the availability of health informatics personnel
to support improved data collection, entry and abstraction.
-A policy maker
Currently, the culture for data demand and use is low. A provider focus group observed
that data recording is very challenging and software for collecting, analysing and interpreting
the data would be appreciated. This seems to show a disconnect between provider knowledge
and the current capabilities of the DHIMS, which is reported to be underutilized in terms of its
analytic capabilities. The group further advocated in-service training on data collection and
management. Facility health information officers report that many staff do not regard the data
as important or useful to their daily work. This leads to low demand for evidence-based policy
development and implementation, and decreased funding for initiatives that have been proven
effective.
Community-level facilities (CHPS) interact directly with homes and patients; hence this direct
disaggregated information is used to track patients within the community and to provide health
care at this level. However, building continued capacity to be able to go in and extract the data
from DHMIS2 and analyse it for themselves and identify their specific needs remains a priority.
The MOH also conducts performance reviews which provide feedback and information to the
regions. This also provides feedback to the GHS. Feedback to the lower levels, however, needs to
be strengthened.
15
Chapter 4: Prioritizing for Improvement

4.1 Key Issues from Analysis
Table 7 below summarizes the key health system priority issues and the key population health
priorities identified in the Health Sector Medium Term Development Plan (Appendix 6),
situation analysis and stakeholder interviews.
Table 7: Health System and Population Health Priorities
No. Source Health System Priority Areas Population Health Priority Areas
1. HSMTDP and  Leadership, governance and  Maternal health

Burden of management  Neonatal health
Disease  Health research and  Child health
information management  Malaria
 Human resource development  HIV/AIDS
 Regulation  Tuberculosis
 Financing  Epidemic-prone diseases
 Quality health service delivery  Neglected tropical diseases
 Response to emergencies  Non-communicable diseases
 Mental health services
 Geriatric care
2. Situation  Leadership and governance  Maternal and child health
Analysis  Harmonization of data  Malaria
(Primary and systems  HIV/AIDS
secondary data)  Data management  Tuberculosis
 Harmonization of quality  Epidemic-prone diseases
approaches (Cholera and CSM)
 Coordination among sector  Non-communicable diseases
agencies (hypertension, diabetes,
 Client-centeredness cancers)
 Mainstreaming of teaching  Mental health services
hospitals and private sector  Geriatric care
4.2 Priorities for improvement
From our crosswalk of the current state of health, policy context, and stakeholder interviews, the
following priority areas have been identified for the National Healthcare Quality Strategy to
focus on in order to improve the health care system and achieve improved health outcomes:
Population health priorities

 Maternal health
 Child health (neonate, infant, under 5)
 Communicable diseases (malaria; epidemic-prone diseases – cerebrospinal

meningitis (CSM) and cholera)
 Non-communicable diseases (hypertension, diabetes)

 Mental health
 Geriatric care
16
Systems strengthening priorities

 Leadership, governance, accountability, coordination, supervision and monitoring
 Data, measurement, data use and learning

 HRH strengthening (managerial skills, technical skills and quality culture),
recognition and reward
 Client and community experience (participation, patient safety, client satisfaction)
 Financing and logistics
17
Chapter 5: Strategic Direction

5.1 What is Our Aim?
Through the various consultative processes, the MOH set the following ultimate goal to drive the
National Healthcare Quality Strategy:

development of a better-coordinated health system that places patients and
communities at the centre of quality care. (MOH, Ghana 2016)
The elements of this goal were developed by the Ministry to consolidate the elements of the
“ideal” state of quality in Ghana into prioritized areas that:
 Focus on measurable improvements in health outcomes as the end goal;
 Seek to strengthen systems towards this end goal; and

 Place the client at the centre of care by focusing on improved client experience.
Continuously improving health outcomes requires a culture shift towards quality improvement
at all levels of the health system. To do this, a harmonized and coordinated health system would
be integrated across the elements of quality planning, quality control, and quality improvement
– utilizing a uniform health data system and quality indicators that not only get reported up to
MOH, but also are used by health providers at the front line to improve the quality of care
provided. Placing the client at the centre of care will entail being responsive to community and
client needs, delivering care with respect and dignity. Within these three high-level components
of the “aim” are also embedded the various building blocks of the WHO and AFRO Health,
particularly service delivery, health workforce, health information systems, access to essential
medicines, financing, leadership and governance, and health systems research.
18
5.2 Specific goals
The goals to address towards achieving the quality aim are to:
Within the next five years, by 2021, all health care service providers in the public, faith-based,
quasi-government teaching hospitals and the private self-financing sectors will have a common
approach to quality improvement and have a common reporting platform to report common
quality indicators and health data through implementation of this National Healthcare Quality
Strategy. Within the same period of time, agencies of the Ministry of Health such as the
regulatory bodies, health training institutions, health research institutions and health financing
agencies will coordinate their systems to facilitate quality improvement practice as an everyday
culture among service providers. The client and community should have a measurably improved
experience with health care and benefit from improved health outcomes within the next five
years.
5.3 Strategic objectives
The strategic objectives of this National Healthcare Quality Strategy are:
Goal 1.0: To continuously improve health outcomes in the population health

priority areas.
Strategic objectives:
 1.1: To improve the clinical skills of relevant health workers to manage identified
priority health interventions
 1.2: To promote a quality culture and accountability for quality in all health workers
and sector agencies
19
Goal 2.0: To develop a coordinated health care quality system in the areas of
quality planning, quality control, and quality improvement, including improved
use of data for evidence-based decision making.
 2.1: To create sustainable leadership and governance for quality planning, quality
control, and quality improvement at all levels of the health care system
 2.2: To strengthen coordination among all health sector agencies
 2.3: To standardize collection of data and improve use and analysis of data at all levels
(including by providers at the frontline) for evidence-based decision making
 2.4: To resource and strengthen regulatory agencies (especially HEFRA) to roll out a
nationwide accreditation process with clear links to facility-based quality management
teams for ongoing improvement action
Goal 3.0: To improve client experience by being responsive to the health needs
and aspirations of the patient and the community
 3.1: To sustain patient safety at all levels of health care delivery
 3.2: To improve client satisfaction and participation in quality definition and quality
improvement
 3.3: To build a culture of “joy at work” (financing, logistics, recognition and reward)
that creates the context for health providers to treat clients with dignity and respect,
deliver high-quality care and be motivated to continuously improve quality
20
Chapter 6: Strategic Interventions

6.1 Strategies
Seven strategies to achieve the strategic objectives are:
1) Establish structures at all levels of the health system to lead quality across planning, control
(assurance) and improvement
2) Develop and implement a uniform national policy on data reporting and data use by health
workers and all health sector agencies
3) Improve patient safety, client satisfaction, and participation of patients and the community
in quality governance structures at all levels
4) Improve quality culture in health workers through training in the requisite clinical skills
and in quality improvement methods and incorporation of quality-related performance
indicators in their job descriptions
5) Create the “joy at work” environment to enable health workers to consistently deliver safe
and high-quality care through the provision of essential inputs, incentives, recognition and
reward
6) Enhance transparency through the ranking of like facilities and agencies in league tables,
with awards at annual quality conferences that involve patients, communities and
providers
7) Institutionalize supportive supervision and monitoring across all agencies and all service
delivery sites in the public, private sub-sectors and teaching hospitals
21
6.2 High-level Activities
Table 8: Strategic Interventions (Short-Term and Long-Term)
Short Term Long Term

Strategy (2017-2019) (2020-2021) High-Level Activities Responsibility Indicator/Target
1. Establish structures at all levels of Q1/2017) 1(i). Appoint and inaugurate NQSSC, QMUs and MOH PPME and NQSSC, QMU, 10 RQMUs, 15
the health system to lead quality QMTs MOH HRD through agency quality teams inaugurated
across planning, control /assurance NQSSC, QMU,
and improvement Q2 to Q4 1(ii). Train QMUs, QMTs in quality management RQMUs, DQMUs 210 DQMUs, minimum of 2,500 QMTs
/2017 /quality improvement established
By Q3/2018 1(iii). Train facility managers in basic managerial

skills
From Q4/2018 X 1(iv). Monitor the performance of quality

management units/teams (QMUs/QMTs) at all levels
2. Develop and implement a uniform From Q1/2018 2(i). Develop national health data policy, train data MOH PPME, MOH Minimum of 2,000 data officers trained
national policy on data reporting and officers in public, private, teaching hospitals, agencies HRD supported by
data use by health workers and Q1-Q4/2018 X 2(ii). Monitor data policy implementation in sector QMU, NQSSC, 50% of sector agencies and facilities
health sector agencies agencies, districts and facilities (data collection, entry RQMUs/RHMTs, entering timely, accurate data into
/reporting, local use) DQMUs/DHMTs national system; local data use in 50%
(Broad consultation) of data collection sites
3. Improve patient safety, client From Q1/2017 X 3(i). Involve patients and the community in quality NQSSC, QMU, Patient and/or community participation
satisfaction, and participation of improvement through participation in health RQMUs, DQMUs, in NQSSC, 10 RQMUs; 210 DQMUs;
patients and the community in committees at all levels QMTs, health minimum of 2,500 QMTs
quality governance structures at all committees
levels
Q1/2018; X 3(ii). Involve patients in defining quality through QMTs, DQMUs, 50% facilities report client satisfaction
surveys from biannual client satisfaction surveys Community indicators twice a year
Q3/2018
From Q4/2018 X 3(iii). Scale up implementation of national patient MOH PPME, MOH Improvement in 50% of patient safety
safety policy to all public, private service delivery HRD, MOH through indicators nationwide between
sites and teaching hospitals; and monitor Procurement, Q1/2019 and Q4/2021
implementation Provider
organizations,
NQSSC, QMU,
RQMUs, DQMUs
22

4. Improve quality culture in health From Q4/2017 X 4(i). Provide in-service training on quality MOH HRD, MOH 1. 10,000 health workers trained in QI
workers through training in the improvement for workforce (in service provision sites PPME through by Q4/2018; 40,000 trained by
requisite clinical skills and in quality and within sector agencies) and incorporate ethics NQSSC, QMU, Q4/2020
improvement methods and and quality-related standards in the job description of RQMUs, DQMUs,
health workers; also train selected health workers in QMTs; Provider 2. Minimum 1,000 staff trained in sign
incorporation of quality-related sign language organizations, language
performance indicators in their job facility heads
descriptions 3. 50% of facilities and districts
appraise health staff on quality
From Q1/2020) 4(ii). Build quality into health workers’ training and Training institutions 70% training institutions deliver
deliver the training to health workers supported by training in quality by Q4/2021
NQSSC, QMU
From Q1/2020 4(iii). Apply sanctions for non-compliance with ethics Facility heads, No. of sanctions reduced by 50% by
or breeches of the Patient Charter or reporting false DDHSs, RDHSs, Q4 2021 compared to Q1 2020 levels
data, in accordance with the Code of Ethics and agency heads
Code of Discipline
Q1/2018 to X 4(iv). Adopt/adapt protocols for the management of Hon Minister, MOH 70% average adherence to identified
Q!/2019 health priorities (incl. traditional medical practice), PPME, MOH HRD, protocol
train relevant workers and monitor adherence to through experts,
protocols
NQSSC, QMU,
RQMUs, DQMUs,
HEFRA
5. Create the “joy at work” From Q1/2018 X 5(i). Provide medicines and logistics for service MOH Procurement; 1. Maximum of 5% stock-out rate for
environment to enable health provision at all levels, and incentives including rural MOH HRD, provider identified tracer drugs in all service
workers to consistently deliver safe incentives organizations delivery sites
and high-quality care through the
2. Over 50% of staff are satisfied with
provision of essential inputs,
incentives provided
incentives, recognition and reward
From Q2/2018 X 5(ii). Develop indicators and apply indicators to Chief Director Four annual awards at national level;
reward/award deserving staff at facility, district, through NQSSC, four in 100% regions; four in 50%
regional and national levels QMU, RQMUs, districts; four in 30% facilities
DQMUs, QMTs
23

6. Enhance transparency through From Q4/2017 X 6(i). Agree quality metrics, build the indicators into the MOH PPME Quality indicators built into all sector
the ranking of like facilities and like performance contracts of sector agencies and health supported by agencies and health facilities (public,
agencies in league tables, with facilities of all ownerships NQSSC, QMU, private, teaching hospitals)
awards at annual quality
From Q1/2018 X 6(ii). Maintain league tables for like health facilities MOH PPME League tables available for sector
conferences that involve patients,
and for other health sector agencies through NQSSC, agencies, regions, districts, facilities,
communities and providers
QMU, RQMUs, communities
DQMUs
X X 6(iii). Hold annual national quality conference to MOH PPME, QMU, Minimum of four annual awards held
evaluate NHQS implementation and to award NQSSC between 2018 and 2021
(From
Q4/2018) deserving agencies, health facilities and health
workers
7. Improve supportive supervision From Q1/2018 X 7(i). Adopt/adapt existing supportive supervision MOH PPME 100% MOH directorates 50% of
and monitoring across all MOH guidelines and tools, train supervisors and monitor through QMU, agencies, 100% regions, 80% districts
directorates, sector agencies and all implementation of supportive supervision in all MOH NQSSC, RQMUs, and 50% service delivery sites
service delivery sites in the public, implement SS
directorates, agencies and service delivery facilities DQMUs, provider
private sub-sectors and teaching and sites organizations
hospitals
From Q4/2018 X 7(ii). Adopt/adapt existing peer review guidelines and MOH PPME, 50% like agencies and like facilities
tools, train relevant managers and monitor the through QMU, participate in peer review
implementation among like agencies and like NQSSC, provider
providers organizations
From Q3/2017 X 7(iii). Develop reporting format for MOH directorates, MOH PPME 1. 50% sector agencies and MOH
sector agencies, facilities (public, private, teaching); through NQSSC, directorates report every quarter to
monitor reporting quarterly and provide feedback QMU, RQMUs, NQSSC
DQMUs
2. 80% health facilities report every
quarter to DQMUs/RQMU
3. 80% reporting agencies,

directorates and facilities given
feedback
From Q4/2017 X 7(iv). Undertake sector-wide reviews once a year MOH PPME Annual sector-wide reviews
supported through undertaken
NQSSC, QMU,
regulators, RQMUs,
DQMUs
24
Chapter 7: Making This Happen

To successfully implement this strategy, there is need to: (1) build functional structures at all
levels; and (2) build managerial capacity of leadership to lead quality and build technical capacity
of the health workforce to implement the clinical and public health interventions required to
improve outcomes in the population health priorities. Please see the accompanying document
Part 2 Coordination and Accountability Framework for a detailed implementation framework.
7.1 Functional structures at all levels
In the implementation of this strategy, the ministry will focus on its role of deciding priorities
and leading policy, planning, regulation and coordination. With regard to frontline
implementation, the ministry will work through the sector agencies whose mandate cover the
respective areas of implementation. The ministry however recognizes that the need for a
structure within the ministry responsible for coordinating quality, and it has commenced action
in this direction by prioritizing the formation of the NQSSC, chaired by the Director of Policy
Planning Monitoring and Evaluation and reporting directly to the Chief Director of the ministry,
to lead the development of this strategy. This step is in line with the 2016 Aide Memoire of the
health sector that requires the Ministry of Health to “set up a national Quality of Care
Steering Committee that oversees quality service issues at all levels by December
2016.” MOH has however outlined a full quality governance structure that reflects linkages
across all levels of the health system.
For the day-to-day running of the quality function, a national Quality Management Unit (QMU)
will be set up within the PPME Directorate. The QMU will be headed by a focal person, the
National Quality Manager (NQM), who may be a re-assigned existing public servant. The QMU
is expected to be both outward and inward looking, coordinating quality even within the
directorates of MOH. All agencies and the private sector must establish quality units/quality
teams at all levels of their establishments to implement the national strategy (Figure 2).
MOH does not intend to create parallel structures but, as much as possible, to integrate into
existing structures. The regional level and below will therefore leverage existing structures for
leadership. Hence at the regional level, an interagency Regional Quality Management Unit
(RQMU) will be set up under the Regional Health Committee with the Regional Director of
Health Services (RDHS) as the chair and the Deputy Director, Clinical Care as the focal person.
Membership will however be drawn from both public health and clinical care units. The team
will oversee quality in both clinical and public health services, and participation will involve both
the public and private sectors.
25
Minister of Health
Chief Director
National Quality Strategy Steering Quality Management Unit

Committee (NQSSC) (QMU), within MOH-PPME
MoH Directorates
Agencies of the Ministry of Health
Regional Quality Management Unit

Agencies (RQMU)
District Quality Management Unit Private, GAQHI,

Private Sector (Islamic, (DQMU) NGOs, etc.
CSOs, NGOs, self-
financing, traditional,
Media) Facility Quality Management Team Community
(FQMT)
Formation Arm Implementation Arm
Figure 2: Quality Coordination Organizational Structure
Similarly, a multi-stakeholder District Quality Management Unit (DQMU) will be formed in each
district under the District Health Committee, headed by the District Director of Health Services
(DDHS) and with public and private participation as well as community involvement. The sub-
district head will lead a community committee (the existing health committee), supported by the
DHMT and sub-district (SD) team, and with wide participation by the community and patient
groups. At the facility level, the facility Quality Management Team (QMT) shall be a
multidisciplinary team headed by the facility head.
Roles of Quality Management Units (QMUs) at the various levels
Table 9 below presents a snapshot of the roles expected of the Quality Management Units at the
various levels in the implementation of this strategy, which roles are largely in line with
stakeholders’ respective mandates. More detailed roles are spelled out in the Coordination and
Accountability Framework.
26
Table 9: Synopsis of Roles of Quality Management Units (QMUs)
STAKEHOLDER ROLES REMARK

(Roles are Summarized. Detailed roles are outlined in the Stakeholder Roles in Part 2: Coordination and
Accountability Framework)
1.0 NATIONAL
1.1 National Quality  Guide the implementation of the National Healthcare Quality Strategy (NHQS) including patient safety policy and  Technical experts
Strategy Steering subsequent variations of these supported by their
Committee (NQSSC)  Determine national quality priorities, policies and high level planning respective agencies
 Decide and apply indicators for monitoring the implementation of quality plans, policies and health outcomes in the  Committee chaired by
priority areas Director PPME, MOH
 Define data requirements for the measurement of quality at the various levels of the health system  Reports to Chief
 Provide guidelines/policy for compliance to data quality and reporting Director
 Strengthen leadership and ownership among stakeholders in the health system on quality planning, quality assurance
and quality improvement at all levels, in all sub-sectors and in all sector agencies
 Provide a platform for inter-agency knowledge sharing and learning
 Develop Terms of Reference for RQMUs, DQMUs, Facility QMTs
 Support regions to establish DQMUs
 Support MOH PPME and MOH HRD to train RQMUs
 Monitor implementation of NHQS in all agencies at all levels
 Establish criteria for identifying and celebrating teams and individuals improving health care and patient outcomes
1.2 National Quality  Day to day oversight of quality across all agencies, sub-sectors and all levels on behalf of Director PPME, MOH  Located in the MOH
Manager (NQM)  Implement a certification mechanism for data and information systems employed in the delivery of health care at all PPME
/Quality Management levels  Focal person is National
Unit (QMU)  Conduct operational research/National quality surveys/ Health systems research Quality Manager
 Publish an annual report on the state of healthcare quality in Ghana  Reports to Director of
 Support NQSSC to develop Terms of Reference for RQMUs, DQMUs, Facility QMTs MOH-PPME
 Coordinate with NQSSC to support regions to establish DQMUs
 Lead the monitoring of NHQS implementation
 Identify required policies, standards and protocols and initiate the development process
 Publish annual State of Quality in Ghana reports
2.0 REGIONAL
2.0 Regional Quality  Apply approved indicators for monitoring the implementation of quality plans, policies and health outcomes in the  Regional Health
Management Unit priority areas in the region Committee will be the
(RQMU)  Facilitate the implementation in the region of the harmonized approaches and data systems determined by the convener
national NQSSC  Reports to NQSSC
 Strengthen collaboration among agencies in quality planning, quality assurance and quality improvement initiatives
originating both locally and internationally and operating in the region
27
STAKEHOLDER ROLES REMARK

(Roles are Summarized. Detailed roles are outlined in the Stakeholder Roles in Part 2: Coordination and
Accountability Framework)
2.0 REGIONAL
2.0 Regional Quality  Strengthen leadership and ownership among stakeholders in the health system on quality planning, quality assurance  Regional Health
Management Unit and quality improvement in the region Committee will be the
(RQMU)
 Disseminate national standards to the districts and train staff of the districts convener
 Partner HEFRA to monitor the implementation of policies and plans, and health outcomes in the districts on behalf of  Reports to NQSSC
the NQSSC
 Use national standards to assess institutions and determine underperforming agencies, for mentoring and make
recommendations for improvements, with reward systems
 Establish and train DQMUs in all districts and supervise districts training of facility QMTs
 Monitor the functioning and performance of DQMUs
3.0 DISTRICT
3.0 District Quality  Strengthen leadership and ownership among stakeholders in the health system on quality planning, quality assurance  District Health
Management Unit and quality improvement in the district and sub-districts Committee, led by the
(DQMU)
 Lead quality planning in the district and sub-districts District Director of
 Disseminate national standards to the facilities and communities and train staff at the facility and community levels Health Services
(both public and private) (DDHS) will be
 Monitor the implementation of policies and plans, and health outcomes in the facilities and communities convener
 Use national standards to assess institutions and determine underperforming institutions, for mentoring and make  Reports to RQMU
recommendations for improvements, with reward systems
4.0 FACILITY
4.0 Quality  Exhibit leadership, participation and accountability at the health facility level  Quality Management
Management  Facility head to be responsible for the implementation of NHQS in the facility Team will be headed
Team (FQMT)  QMT to feedback to the DQMU (regional hospitals feedback to RQMUS) any implementation challenges or any by the head of the
other interesting development health facility
 Use national standards to assess departments of the facility and determine underperforming departments, for
mentoring and make recommendations for improvements, with reward systems
 Disseminate and continuously train staff on NHQS and Guidelines
 Oversee implementation of quality improvement activities across the facility
 Inculcate quality culture into health workforce
5.0 COMMUNITY
5.0 Community  Collaborate with other agencies, organisations and relevant stakeholders in integrative planning and implementation  Composition: CHPS,
of the National Healthcare Quality Strategy and create modalities for peer learning CHO, Health
 Use national and quality standards to plan and implement health programs Promotion Officer
 Establish Quality Improvement Teams/Committees at the community level  Supported by DHMT
28
7.2 Capacity development
To bring everyone involved in health care delivery to a common understanding of the National
Healthcare Quality Strategy (NHQS), there will be systematic training of health agencies and
quality teams at all levels in the basics of quality management and quality improvement, as well
as what the strategy seeks to accomplish and how it will be implemented. The capacity of the
entire health workforce will be built and enhanced around quality improvement to get them
better equipped to working towards achieving the desired health outcomes; in addition, facility
managers will undergo training in basic managerial skills.
Through rolling out this NHQS, the National Quality Strategy Steering Committee (NQSSC) and
the Quality Management Unit will be oriented to a common understanding of the concepts,
principles and practice of quality and made familiar with roles of the various agencies and levels
in quality planning, quality assurance and quality improvement.
In the short term, training of the existing health workforce in the management of priority health
conditions will mean that MOH will constitute expert technical teams in the various areas to
develop protocols and guidelines in the respective clinical and public health priorities. In the
medium and long term, these protocols and guidelines will be used in pre-service training and
in continuing professional development programmes. Training will involve health professionals
in the teaching, public and private facilities. Effective supportive supervision will be employed
to keep staff up to date on the implementation of priority health interventions.
7.3 Coordination and Accountability Framework
A separate Coordination and Accountability Framework accompanies this strategy. The

document describes general considerations for implementing the National Healthcare Quality
Strategy, provides a coordination action plan and outlines implementation responsibilities of
various health sector agencies.
7.4 Monitoring and evaluation of strategy implementation
The strategy will be monitored to determine whether implementation is on course and how much
progress is being made towards achieving the objectives of the strategy.
Routine monitoring
Quarterly monitoring of the strategy implementation process with a focus on whether activities
are being implemented according to plan and whether expected implementation milestones are
being reached will be the ultimate responsibility of the Ministry of Health (PPME), but
immediate responsibility will lie with the NQSSC/QMU which will report findings to the
ministry, with appropriate recommendations. The NQSSC/QMU will be fed from the regions
with data and information collated from district reports every quarter.
Monitoring of the progress and achievement of health outcomes will be through regular bi-
annual reports from the regions and agencies to the QMU using agreed indicators (see Indicator
set under the chapter on Measuring Improvement) and reporting formats. The QMU will in turn
synthesize the reports and apprise the NQSSC and the MOH (PPME). In addition, the QMU will
undertake validation through random surveys and monitoring visits.
29
Beyond monitoring by the QMU and the NQSSC, NHQS indicators will be integrated into
existing monitoring mechanisms within the ministry such as the Demographic and Health
Survey (DHS) and Multiple Indicator Cluster Survey (MICS).
Annual review
The NQSSC/QMU will receive annual reports from agencies and the regional level. Regional
reports will be based on district reports. Beyond that, annual reviews will be built into the
existing annual review mechanisms of the Ministry of Health including the Independent Annual
Reviews and Holistic Assessment.
30
Chapter 8: Measuring Improvement

8.1 Prioritization for Measuring Improvement
Areas selected for measurement of improvement are the focus areas of the broad quality goal
espoused in this strategy document, namely:
 Improvements in health outcomes as the end goal;
 Strengthening of systems towards this end goal; and
 Placing the client at the centre of care by focusing on improved client experience.
8.2 Indicator Set
The indicator set for measuring improvement are grouped in Table 10 below under non-health
care service providing agencies performance indicators, systems improvement indicators,
quality indicators, and health outcome/output indicators. These indicators have been selected
on the basis that they can be used to track improvement in the priority areas selected to be
addressed by this strategy, and that they are simple, measurable, achievable, reliable and time-
bound (SMART).
A number of the indicators have been selected from the Health Sector Medium Term
Development Plan (HSMTDP) because they are relevant to this strategy. Fresh indicators have
additionally been developed to cover aspects of the strategy which do not already have indicators
in the HSMTDP. In consultation with the PPME directorate of MOH, the NQSSC will review the
listed indicators and determine which of the indicators and which additional ones will be
monitored, and how frequently each indicator will be measured and reported.
31
Table 10: Indicator Set
NO. SPECIFIC AREA INDICATOR MEASUREMENT FREQUENCY
A. Health Outcome and Output Indicators (priority health conditions)
A1 Maternal health Proportion of deliveries No. of deliveries attended by a trained Quarterly

attended by a trained health health worker / number of deliveries
worker*1
A2 Maternal health Maternal Mortality Ratio* No. of maternal deaths / 100,000 live Quarterly
births
A3 Maternal health Institutional Maternal Mortality Institutional maternal deaths / Quarterly

Ratio* institutional live births
A4 Maternal health Eclampsia incidence rate Number of women who develop Quarterly
eclampsia / Total number of deliveries
A5 Maternal health PPH case fatality rate Number of women who die as a result Quarterly
of PPH / Total number of women who
experience PPH
A6 Maternal health Antenatal Care Coverage 4+ No. of women undergoing ANC service Quarterly
(*) by a skilled health provider at least four
times during pregnancy / total number
of expected pregnancies
A7 Neonatal health Still birth rate* Number of still births (fresh and Quarterly
macerated) / expected actual number of
deliveries
A8 Neonatal health Institutional Neonatal Mortality No. of institutional deaths of neonates Quarterly
Rate* before the age of 28 days / institutional
live births
A9 Neonatal health Neonatal Mortality Rate* No. of deaths within the first 28 days of Quarterly
life / 1,000 live births
A10 Neonatal health Postnatal care coverage for No. of newborn babies getting the Quarterly
newborn babies* services of skilled health providers
within 2 and 7 days of birth/ Total
number of live births
A11 Infant health Infant Mortality Rate* No. of deaths of infants below 1 year Quarterly
/1,000 live births
A12 Infant health Proportion of children fully Number received Penta 3 / projected Quarterly
immunized (proxy Penta 3 population of children under 1 years
coverage)*
A13 Infant health Exclusive breast feeding for No. of infants aged who are exclusively Quarterly
six months* breastfed / total no. infants
A14 Child health Under-5 Mortality Rate* No. of deaths of children below 5 years Quarterly
/ 1,000 live births
A15 Malaria Proportion OPD attendance No. of OPD attendants diagnosed as Quarterly
due to malaria* malaria / total OPD attendants
1 Indicators with asterisks were selected from the Health Sector Medium Term Development Plan.
32
A16 Malaria Institutional Malaria Under 5 No. of children U5 who die as a result Quarterly
Case Fatality Rate* of malaria per year / no. children
admitted and diagnosed with malaria
A17 Cerebrospinal CSM case-fatality rate Number of people who die from CSM / Quarterly
meningitis (CSM, total number of people diagnosed with
epidemic prone CSM
disease)
A18 Cholera (Epidemic Incidence of cholera Number of cholera cases reported / Quarterly
prone disease) Population
A18 Cholera (Epidemic Case-fatality rate for cholera Number of people who die from cholera Quarterly
prone disease) / total number of people diagnosed with
cholera
A19 Mental health Proportion of public hospitals No. of public hospitals offering mental Quarterly
offering mental health health services / total no. of public
services* hospitals (Trained clinical psychologist,
trained psychiatrist or psychiatric nurse,
availability of defined essential
medicines for psychiatric care)
A20 Hypertension Proportion of hypertensive Number of hypertensives on treatment Quarterly
(NCD) patients on treatment whose whose BP is within a defined normal
blood pressure is controlled range / Total number of hypertensives
on treatment
A21 NCD Uncontrolled hypertension Number of patients admitted with Quarterly
admission rate uncontrolled hypertension / Total
number of hypertensive patients
A22 NCD Diabetes, short-term Number of diabetics admitted with Quarterly
complications admission rate short-term complications / Total number
of diabetic patients (Diabetic
ketoacidosis, hypoglycaemia)
A23 NCD Uncontrolled diabetes Number of patients admitted with Quarterly
admission rate uncontrolled diabetes / Total number of
diabetic patients
B. Quality Indicators
B1 Responsiveness Outpatient waiting time Number of clients whose wait to be Biannual

seen by the doctor was within agreed
standard / Total number of clients
interviewed (or observed)
B2 Responsiveness Prompt attention in Number of clients who perceive that Biannual
emergencies (client they or their relatives received prompt
perception) attention in an emergency / Total
number of clients interviewed who had
reported in an emergency
B3 Responsiveness Prompt attention to Number of emergencies seen by a Annual
emergencies (objective doctor within three minutes of arrival in
measurement) the facility / Total number of patients
reporting with emergencies
B4 Interpersonal skills Staff attitude Number of clients perceiving staff Biannual
attitude as excellent / Total number of
clients interviewed
B5 Technical Physical examination Number of client folders showing Biannual
competence physical examination / Total number of
client folders sampled
B6 Interpersonal skills Information about client’s Number of clients who say they were Biannual
condition given satisfactory information about
their condition / Total number of clients
interviewed
33
B7 Access Availability of tracer drugs Number of tracer drugs available Biannual

throughout the last half year / Total
number of tracer drugs
B8 Rational medicine Percentage of prescribed Number of prescribed items relevant to Biannual
use items appropriate for diagnosis the diagnosis / Total number of items
prescribed
B9 Interpersonal skills Information about clients’ Number of clients who say they were Biannual
medicines given satisfactory information about all
their medicines / Total number of clients
interviewed who collected medicines at
the pharmacy or dispensary
B10 Continuity of care Completeness of labelling of Number of medicine envelopes meeting Biannual
medicines agreed labelling standards /Total
number of client’s medicine envelopes
inspected
B11 Environment Cleanliness of environment Number of clients who say the facility Biannual
(Amenities) environment is very clean /Total
number of clients interviewed
B12 Client satisfaction % clients satisfied with service Number of clients satisfied with Biannual
provision identified elements of service delivery /
Total number of clients interviewed
B13 Continuity of care Completeness of OPD records Number of OPD records meeting the Biannual
standard for completeness /Total
number of OPD records reviewed
B14 Continuity of care Completeness of admission Number of admission records meeting Biannual
records the agreed standard for completeness
/Total number of admission records
reviewed
B15 Continuity of care Completeness of referral Number of referral records meeting the Biannual
documentation standard for completeness /Total
number of referral records reviewed
B16 Patient safety Surgical site infection rate* No. surgical wound infected among Biannual
inpatients / total no. surgical
interventions among inpatients
B17 Patient safety Perioperative pulmonary Number of patients who develop Biannual
embolism or deep vein pulmonary embolism or deep vein
thrombosis rate thrombosis within the agreed hours of
surgery /Total number of post-operative
records reviewed
B18 Patient safety Perioperative haemorrhage or Number of patients who develop Biannual
hematoma rate haemorrhage or haematoma post-
operatively /Total number of post-
operative records reviewed
B19 Mental Health Availability of tracer mental Number of tracer mental health drugs Biannual
health drugs available throughout the last half year
/Total number of tracer mental drugs
C. System Improvement Indicators
C1 Accurate and % of data system with Number of health and community Biannual
complete reporting accuracy and completeness service delivery outfits reporting
of national health accurate data into the national health
data data system / Total number of health
facilities and community service
delivery outfits
C2 Financial access Proportion of population with Number of active NHIS members / Annual
active NHIS membership* population
34
C3 Efficiency % of MOH Agencies with Operating ratio = operating Quarterly

operating ratio less than 1 expenses/revenue
C4 Efficiency % of MOH Agencies with +/- Variance Analysis; deviations in Quarterly
10% variance from budgetary financial performance from the
allocations each quarter standards defined in MOH budgets
C5 Efficiency % of NHIA-credentialed Health # NHIA-credentialed facilities Quarterly

Facilities with prompt claims reimbursed within one month of
reimbursement per quarter statutory 90 day period/Total # of
credentialed facilities
C6 Emergency Percentage of public hospitals No. public hospitals with trained Annual
preparedness with trained emergency team* emergency team x 100 / total number of
public hospitals
C7 Physical access Average stock-out rate of Number of gap items, Quarterly

(essential identified basket of medicines
population size, number of facilities
medicines)
affected
C8 Improved Implementation of national Number of health sector agencies Annual
coordination quality conference decisions implementing all decisions of annual
among health national quality conference / Total
agencies number of health sector agencies
D. Indicators for Non-Health Care Service Providing Agencies
D1 Quarterly reports Timely submission of reports Quarterly

D2 Quarterly reports Completeness of report Quarterly
D3 Financial reports Completeness of financial Quarterly
reporting forms
D4 Customer Customer satisfaction index Biannual
experience
D5 Performance index Percentage of targets met Annual
D6 Financial Operating ratio Annual
efficiency
E. Additional Health Outcome and Output Indicators

E1 Overall Institutional all-cause All institutional deaths / all discharges Quarterly
institutional mortality* and deaths
mortality
E2 Inpatient mortality Number of inpatient deaths in an Quarterly
agreed period of time (e.g., quarter)
/Total number of patients admissions
within the same period
E3 Emergency department Number of inpatient deaths agreed Quarterly
mortality period /Total number of patients seen at
the emergency department within the
same period
E4 Outpatient attendance rate Total number of clients treated at the Quarterly
(private, public, teaching outpatient within an agreed period
hospitals) [Count each person once for multiple
visits within the period]
E5 Equity Per capita OPD attendance* Total OPD attendants / population Quarterly
E6 Inpatient admission rate Total number of admissions within an Quarterly
agreed period
E7 Bed occupancy rate Quarterly
E8 Average length of stay Quarterly
35
Chapter 9: Conclusion
It is often quoted that “Every system is perfectly designed to get the results that it gets” (Proctor,
2008). In order to significantly improve the health outcomes in our country – especially in the
priority areas of maternal health, child health, malaria, epidemic-prone diseases, non-
communicable diseases, and mental health – we need to improve the coordination of our health
care system itself in a holistic way that incorporates both the public and private health care
sectors, partners with patients and providers, and builds continuous feedback loops to improve
quality at all levels of the health care system.
This National Healthcare Quality Strategy builds on previous quality initiatives in Ghana and
helps bring these initiatives together under a common goal and approach to quality, through a
framework of quality planning, quality control, and quality improvement.
The clients of the Ghana health care system are our families, our relatives, ourselves. The time
is now to harmonize and coordinate a health care quality system that ensures the delivery of the
right care… in the right manner… in the right place… at the right time… ALL the time. This is
quality in health care and remains our north star.
36
References
1. 2012 NHIA Annual Report (Rep.). (n.d.). Retrieved October, 2016, from National Health Insurance
Authority website: http://www.nhis.gov.gh/files/2012 NHIA ANNUAL REPORT.pdf
2. 2013 NHIA Annual Report (Rep.). (n.d.). Retrieved October, 2016, from National Health Insurance
Authority website: http://www.nhis.gov.gh/files/2013%20Annual%20Report-Final%20ver%2029.09.14.pdf
3. Alhaji Ibrahim, B. (2016, July). NQS Interview with National Co-ordinator, Ahmaddiya Muslim Health
Service [Personal interview].
4. Allotey, C. (2016, June). NQS Interview with President of Community Practice Pharmacists Association
[Personal interview].
5. Blanchet, N. J., Fink, G., & Osei-Akoto, I. (2012). The Effect of Ghana’s National Health Insurance Scheme
on Health Care Utilisation. Ghana Medical Journal, 46(2), 76–84.
6. Central Intelligence Agency. (2016). The World Factbook. Retrieved November, 2016, from
https://www.cia.gov/library/publications/the-world-factbook/geos/gh.html
7. Food & Drugs Authority. (2016, June). Focus Group Discussion with Regulatory Bodies [Personal interview].
8. Ghana Demographic and Health Survey (GDHS) 2014. (2015). Ghana Statistical Service.
9. Juran, J. M., & Godfrey, A. B. (1999). Juran's Quality Handbook (5th ed.). Retrieved October 15, 2016, from
http://www.pqm-online.com/assets/files/lib/books/juran.pdf
10. Kaba, S. (2016, June). NQS Interview with Director of Institutional Care Division, GHS [Personal interview].
11. Ministry of Food and agriculture. (n.d.). Food Security situation in Ghana. Northern Region Agricultural
Development Unit. Retrieved June, 2016, from https://mofafoodsecurity.wordpress.com/food-security-
situation-in-ghana/
12. Ministry of Health. (2011). National Policy for the Prevention and Control of Chronic Non-Communicable
Diseases in Ghana.
13. Ministry of Health. (2013). Private Health Sector Development Policy. Retrieved October, 2016, from
http://www.ghanahealthservice.org/downloads/private_health_sector_development_policy.pdf
14. Ministry of Health. (2014). Health Sector Medium Term Development Plan 2014-2017.
15. Morrison, I. (2016, June). NQS Interview with President of Society of Private Medical and Dental Practioners
[Personal interview].
16. National Development Planning Commission. (2015, October 20). Malaria Remains Leading cause of
Mortality and Morbidity. Retrieved October, 2016, from http://www.ghananewsagency.org/health/malaria-
remains-leading-cause-of-mortality-and-morbidity-ndpc-report--95989
17. National Health Insurance Authority. (2016). Capitation. Retrieved October, 2016, from
http://www.nhis.gov.gh/capitation.aspx
37
18. National TB control programme. (2013, March). End-Term Comprehensive External Review of the Ghana
National Tuberculosis Health Sector Strategic Plan 2009–2013. Retrieved June, 2016, from
http://apps.who.int/medicinedocs/documents/s21996en/s21996en.pdf
19. National Newborn Strategy and Action Plan (NNSAP) 2014 - 2018. (2013). Ghana Health Service.
20. National Healthcare Quality Strategy [Personal interview]. (2016, June)
21. NHQS Interviewees, & NQSSC. (2016). National Quality Strategy [Interview].
22. Offei, A. K., Bannerman, C., & Kyeremeh, K. (2004). Healthcare Quality Assurance Manual for Subdistricts.
Retrieved October, 2016, from http://www.moh.gov.gh/wp-content/uploads/2016/02/Healthcare-Quality-
Assurance-Subdistrict.pdf
23. Partnership for Maternal, Newborn & Child Health. (2010, June). Lack of skilled birth care costs 2 million
lives each year worldwide, study estimates. ScienceDaily. Retrieved October, 2016, from
https://www.sciencedaily.com/releases/2010/06/100603193929.htm
24.
25. Piot, P., Caldwell, A., Lamptey, P., Nyrirenda, M., Mehra, S., Cahill, K., & Aerts, A. (2016). Addressing the
growing burden of non–communicable disease by leveraging lessons from infectious disease management.
Journal of Global Health, 6(1), 010304. http://doi.org/10.7189/jogh.06.010304
26. Proctor, L. (2008). Editor’s Notebook: A Quotation with a Life of Its Own. Retrieved November, 2016, from
http://www.psqh.com/analysis/editor-s-notebook-a-quotation-with-a-life-of-its-own/
27. Project Fives Alive! Technical Report (Rep.). (2015). Institute for Healthcare Improvement.
28. Roberts, M., Mogan, C., & Asare, J. B. (2014). An overview of Ghana’s mental health system: results from an
assessment using the World Health Organization’s Assessment Instrument for Mental Health Systems
(WHO-AIMS). International Journal of Mental Health Systems, 8, 16. http://doi.org/10.1186/1752-4458-8-
16
29. US Census Bureau. (2016, September 27). International Programs, International Data Base. Retrieved
November, 2016, from https://www.census.gov/population/international/data/idb/region.php?N= Results
&T=13&A=separate&RT=0&Y=2050&R=115&C=GH
30. WHO. (2016). Mental Health, Ghana - Situational Analysis. Retrieved October, 2016, from
http://www.who.int/mental_health/policy/country/ghana/en/
31. WHO (2006). Quality of Care - A Process for Making Strategic Choices in Health Systems. Retrieved October
2016, from http://www.who.int/management/quality/assurance/QualityCare_B.Def.pdf?ua=1
32. World Health Organization, Sustainable Development Goals. (2015). UN Sustainable Development Summit
2015 [Press release]. Retrieved October, 2016, from
http://www.who.int/mediacentre/events/meetings/2015/un-sustainable-development-summit/en/
33. WHO (2016). Sustainable Development Goal 3: Health. Retrieved November, 2016, from
http://www.who.int/topics/sustainable-development-goals/targets/en/
38
39
Chapter 1: Introduction
This document is the strategy implementation plan that accompanies the Ghana National
Healthcare Quality Strategy. The document is divided into three parts:
1. Description of the general considerations governing the implementation
2. Coordination action plan and implementation responsibilities of sector agencies
3. Financial management for interventions
Chapter 2: Coordination and Accountability

2.1 General Considerations
The Policy, Planning, Monitoring and Evaluation (PPME) division of the Ministry of Health
(MOH) will lead the change process, supported by the National Quality Strategy Steering
Committee (NQSSC) and the National Quality Manager/Quality Management Unit
(NQM/QMU). The MOH will depend largely on in-country technical support from experts in the
priority health intervention areas and experts in the discipline of quality management.
The Ministry of Health will be ultimately accountable for successful implementation of the
NHQS, but as a sector ministry, the MOH will focus on its role of deciding priorities and leading
policy, planning, regulation and coordination. Therefore, even when the ministry is identified as
being responsible for an activity, each agency, sub-sector and level will be accountable for
implementation within their respective mandates. Furthermore, this document provides an
indication of the source of funding to support the implementation of the National Quality
Strategy (NQS), but day-to-day implementation within the agencies and at the various levels and
within the teaching hospitals and the private sector will be funded by the respective agencies,
levels, facilities and sub-sectors.
During the implementation of the NHQS, only the Ministry of Health will have the authority to
amend the implementation plan, although recommendations can be made to the MOH by key
players, particularly the NQSSC, QMU and Regional Quality Management Units. It is anticipated
that implementation of the strategy will start in all regions of the country simultaneously.
Communication between the MOH and stakeholders will be chiefly through the Regional Quality
Management Units and heads of agencies and through in-person forums where necessary.
Comprehensive indicators to measure progress in the priority areas are outlined in the Ghana
National Health Care Quality Strategy chapter on Measuring Improvement.
39
2.2 Action Plan for Coordination
Table 11: Action Plan for Coordination
Strategy Activities Responsibility Resources Short Term Long Term Indicator/Target

(2017-2019) (2020-2021)
1. Establish structures at all 1A. Develop Terms of Reference for MOH PPME with X TORs developed for NQSSC,
levels of the health system to NQSSC, QMU, RQMUs, DQMUs, facility support of NQSSC QMU, RQMUs, DQMUs,
lead quality across planning, (Complete by
QMTs (Quality Management Teams) and facility QMTs
control/assurance and Q1/2017)
agency quality teams
improvement
1B. Appoint and inaugurate NQSSC, QMU, Hon Minister X NQSSC, QMU, 10 RQMUs,
RQMUs, agency quality teams supported by MOH 15 agency quality teams
(By Q1/2017)
PPME, MOH HRD inaugurated
1C. Appoint and inaugurate DQMUs RDHSs X 210 DQMUs inaugurated
(By Q1/2017)
1D. Support the establishment of facility DDHS/DQMUs with X Minimum of 2,500 QMTs
QMTs support from RQMUs established
(By Q2/2017)
1E. Train NQSSC, QMU, RQMUs, agency Hon Minister through X 15 agency quality teams, 10
quality teams on functions and quality MOH PPME, MOH RQMUs trained
(By Q2/2017)
management principles HRD
1F. Train DQMUs on their functions and RQMUs supported by X 210 DQMUs trained
quality management principles NQSSC, QMU
(By Q3/2017)
1G. Train facility QMTs on their functions DQMUs supported by X Minimum of 2,500 QMTs
and quality management principles RQMUs trained
(By Q4/2017)
1H. Train facility managers in basic MOH HRD thru X Minimum of 2,000 facility
managerial skills RHMTs/RQMUs, managers trained
(By Q3/2018)
DHMTs/DQMUs
1I. Develop indicators and monitor the QMU supported by X X 50% QMUs/QMTs meet
performance of quality management NQSSC. Lower levels: targets on all indicators by
(From Q2/2018)
units/teams (QMUs/QMTs) at all levels RQMUs, DQMUs 2021
40

Strategy Activities Responsibility Resources Indicator/Target
(2017-2019) (2020-2021)
2. Develop and implement a 2A. Develop national health data policy MOH PPME supported X Availability of national data
uniform national policy on data by QMU, NQSSC policy
(broad consultation) (Q4/2017)
reporting and data use by health
workers and health sector 2B. Disseminate and train data officers in MOH HRD, MOH X Minimum of 2,000 data
agencies facilities (public, private, teaching hospitals) PPME officers trained
and in other agencies in the health sector (Q1-Q4/2018)
through NQSSC,
QMU,
RHMTs/RQMUs,
DHMTs/DQMUs
2C. Monitor data policy implementation in NQSSC, QMU, MOH X X 50% of sector agencies and
sector agencies, districts and facilities (data PPME through facilities entering timely,
collection, entry/reporting, local use) (from Q1/2019) accurate data into national
RQMUs, DQMUs
system
2D. Determine sanctions to apply to Chief Director, MOH X Availability of guidelines on

agencies, districts and facilities for not HRD, MOH PPME sanctions
complying with data reporting responsibilities Q2/2019
through QMU, NQSSC
or reporting standards
2E. Apply agreed sanctions to agencies, Chief Director, MOH X X 1. 80% sanctions for non-
districts and facilities not complying with data HRD, MOH PPME reporting
reporting responsibilities or reporting (From Q3/2019)
supported by QMU, 2. 80% sanctions for reporting
standards (in line with health worker code of
NQSSC, RQMUs, false data
ethics)
DQMUs
3. 80% sanctions for undue
delay in reporting
41

(2017-2019) (2020-2021)
3. Improve patient safety, client 3A. Involve patients, the community and the NQSSCs, RQMUs, X X Patient and/or community
satisfaction, and participation of media in quality improvement through DQMUs, QMTs participation in NQSSC, 10
participation in health committees at all (from Q1/2017)
patients and the community in RQMUs; 210 DQMUs; 2,500
levels
quality governance structures at QMTs (or more)
all levels
3B. Adopt/adapt/develop client satisfaction MOH PPME through X Availability of client
survey guidelines and tools and also tools NQSSC, QMU satisfaction survey guidelines
for conducting staff and community (From Q1/2018)
and tools
satisfaction surveys
3C. Train quality management units/teams MOH PPME, MOH X Staff in 15 agencies, 10
of sector agencies, districts and facilities on HRD, through NQSSC, RQMUs, 210 DQMUs, 2,500
the use of client satisfaction guidelines and (Q1-Q2 2018)
QMU, RQMUs, QMTs or more trained
tools
DQMUs
3D. Involve patients in defining quality QMTs, DQMUs X X 50% facilities report client
through biannual client satisfaction surveys satisfaction indicators twice a
(from Q3/2018)
year
3E. Train untrained health workers in the MOH PPME, MOH X X Minimum of 10,000 health
public, private service delivery sites and HRD thru workers trained
teaching hospitals on the existing national (Q4/2018 to
patient safety policy NQSSC, QMU, Q1/2019)
RQMUs, DQMUs
3F. Provide basic tools to facilitate scale-up MOH Procurement, X X Improvement in 50% of
of the implementation of the existing national NQSSC, QMU, patient safety indicators
(Q4/2018 to
patient safety policy to all public and private provider organizations, nationwide between Q1/2019
Q1/2019)
service delivery sites and to all teaching with support of and Q4/2021
hospitals RQMUs, DQMUs
3G. Monitor patient and community NQSSC, QMU through X X See 2A, 2B, 2C above
participation; patient satisfaction; and patient RQMUs, DQMUs
(From Q2/2019)
safety
42

(2017-2019) (2020-2021)
4. Improve quality culture in 4A. Provide in-service training on quality MOH HRD, MOH X X 10,000 health workers trained
health workers through training improvement for health workforce (in-service PPME through in QI by Q4/2018; 40,000
provision sites and within sector agencies) NQSSC, QMU, (From Q4/2017)
in the requisite clinical skills and trained by Q4/2020
RQMUs, DQMUs
in quality improvement methods
4B. Develop curricula and build quality into Training institutions X Integrated Curriculum
and incorporation of quality-
health workers’ training and deliver the supported by NQSSC, developed for QI, client
related performance indicators training to health workers (From Q1/2020)
QMU communication, data use,
in their job descriptions
etc.; 70% training institutions
deliver training by Q4/2021
4C. Incorporate ethics, Patient Charter Provider organizations, X X 50% of facilities and districts
requirements and quality standards into the agency heads, appraise health staff on
job descriptions and appraisal system for (Q1/2018 to
RHMTs, DHMTs, quality
health workers and workers in other health Q4/2019)
facility heads
sector agencies
supported by MOH
PPME, NQSSC, QMU
4D. Apply sanctions for non-compliance with Facility heads, DDHSs, X No. of sanctions reduced by
ethics or breeches of the Patient Charter or RDHSs, agency heads 50% by Q4 2021 compared to
reporting false data, in accordance with the (From Q1/2020) Q1 2020 levels
Code of Ethics and Code of Discipline
4E. Appoint expert teams to review/develop Hon Minister of Health, X Availability of protocols for
protocols for the management of population Chief Director, PPME population health priorities
health priorities as well as guidelines for (Q1/2018, complete
through QMU
traditional medical practice protocols by
Q3/2018)
4F. Train relevant health workforce in the use MOH PPME, MOH X X 70% relevant health workers
of the protocols HRD, thru QMU, trained
(Q4/2018 to
RQMUs, DQMUs
Q1/2019)
4G. Monitor adherence to protocols HEFRA supported by X X 70% average adherence to

NQSSC QMU, identified protocol
(From Q2/2019)
RQMUs, DQMUs
4H. Train selected health workers in basic MOH PPME, MOH X Minimum of 1,000 health
sign language HRD, thru QMU, workers trained
(From Q4/2019)
RQMUs, DQMUs
supported by NGO for
the Deaf
43

(2017-2019) (2020-2021)
5. Create the “joy at work” 5A. Provide medicines and logistics for MOH Procurement; X X Maximum of 5% stock-out
environment to enable health service provision at all levels provider organizations rate for identified tracer drugs
(From Q1/2018)
workers to consistently deliver in all service delivery sites
safe and high-quality care
5B. Provide incentives, including rural MOH HRD supported X X Over 50% of staff are satisfied
through the provision of
incentives by provider with incentives provided
essential inputs, incentives, (From Q1/2018)
organizations
recognition and reward
5C. Develop criteria to use in awarding MOH PPME, NQSSC, X Availability of criteria
deserving staff QMU, provider
(Q2/2018)
organizations
5D. Apply agreed criteria to reward/award Chief Director through X X Four annual awards at
deserving staff at facility, district, regional NQSSC, QMU, national level; four in 100%
(From Q3/2018)
and national levels RQMUs, DQMUs, regions; four in 50% districts;
QMTs four in 30% facilities
6. Enhance transparency 6A. Agree quality metrics to use in ranking MOH PPME thru X Quality indicators available
through the ranking of like agencies and like facilities in league tables NQSSC, QMU, (see 6B below)
(From Q4/2017)
facilities and like agencies in RQMUs, DQMUs
league tables, with awards at
6B. Build quality-related indicators into the MOH PPME supported X X Quality indicators built into all
annual quality conferences that
performance contracts of health facilities and by NQSSC, QMU sector agencies and health
involve patients, communities sector agencies (From Q1/2018)
facilities (public, private,
and providers
teaching hospitals)
6C. Maintain league tables for like health MOH PPME through X X League tables available for
facilities and for other health sector agencies NQSSC, QMU, sector agencies, regions,
(From Q1/2018)
RQMUs, DQMUs districts, facilities,
communities
6D. Hold annual national quality conference MOH PPME through X X Minimum of four annual
to evaluate NQS implementation and to QMU, NQSSC, awards held between 2018
(From Q4/2018)
award deserving health facilities and RQMUs and 2021
deserving health workers
6E. Carve out specific time slot during the MOH, NQSSC, QMU X Key next steps for quality
Annual National Health Summit to share strategy implementation
(Q2/2017)
updates, successes and challenges on the captured in Aide Memoire
quality strategy implementation
44

(2017-2019) (2020-2021)
7. Improve supportive 7A. Adopt/adapt existing supportive MOH PPME, QMU, X Existing supportive
supervision and monitoring supervision guidelines and tools for use in all NQSSC, supported by supervision (SS) guidelines
(Q1/2018) and tools adopted/adapted
across all MOH directorates, MOH directorates, agencies and service provider organizations
sector agencies and all service delivery facilities and sites
delivery sites in the public,
7B. Train supervisors on the supportive MOH PPME, MOH X X Managers and technical
private sub-sectors and
supervision guidelines and tools HRD, NQSSC, QMU, experts in 50% agencies and
teaching hospitals (Q2/2018 to
through RQMUs, provider sites trained in SS
Q3/2018)
DQMUs, provider
organizations
7C. Monitor implementation of supportive MOH PPME, QMU, X X 100% MOH directorates 50%
supervision within the health sector NQSSC, through of agencies, 100% regions,
(From Q4/2018)
RQMU, DQMUs, 80% districts and 50% service
provider organizations delivery sites implement SS
7D. Adopt/adapt existing peer-review MOH PPME, thru X Existing peer-review

guidelines and tools for use among like QMU, NQSSC, guidelines and tools
(Q4/2018 to adopted/adapted
agencies and like providers RQMUs, provider
Q1/2019)
organizations
7E. Train relevant health workforce and MOH PPME, MOH X 50% agencies and facilities
agencies on peer-review guidelines and HRD, NQSSC, QMU trained
(Q2/2019 to
tools thru RQMUs, DQMUs
Q3/2019)
7F. Monitor implementation of peer review NQSSC, QMU through X X 50% like agencies and like
among agencies and facilities RQMUs, DQMUs facilities participate in peer
(From Q4/2019)
review
7G. Develop reporting format for MOH MOH PPME through X 1. Availability of reporting
directorates, sector agencies, facilities NQSSC, QMU format for MOH directorates,
(Q3/2017)
sector agencies
2. Availability of reporting
format for facilities
7H. Monitor reporting by MOH divisions, MOH PPME through X X 1. 50% sector agencies and
sector agencies and facilities quarterly QMU, NQSSC, MOH directorates report
(From Q4/2017)
every quarter to NQSSC
RQMUs, DQMUs
2. 80% health facilities
(public, private, teaching)
report every quarter to RQMU
45
7I. Assess performance and provide MOH PPME, QMU, X X 80% reporting agencies,
feedback to reporting facilities, agencies and NQSSC supported by directorates and facilities
(From Q4/2017)
divisions quarterly given feedback
RQMUs, DQMUs
7J. Undertake sector-wide reviews once a MOH PPME supported X X Annual sector-wide reviews
year by QMU, NQSSC, undertaken
(From Q4/2017)
regulators, RQMUs,
DQMUs
46
2.3 Stakeholder Roles
Table 12 below summarizes the roles of the various key stakeholders in the implementation of the strategy.
Table 12: Stakeholder Roles in Implementation
No. STAKEHOLDER ROLES REMARKS
1. Hon Minister of Health  Overall oversight for development, launch and implementation for National Health Care Quality Strategy
 Appoint and inaugurate National Quality Steering Committee (NQSSC)
 Establish national QMU and appoint NQM, regional QMUs in all 10 regions
2. Chief Director  Ultimately responsible for health care quality in Ghana

 Chair NQSSC
 Support agencies to establish agency quality teams
 Support the Director of Policy Planning Monitoring and Evaluation to exercise closer operational oversight over
the NQSSC
3. National Quality Steering  Guide the implementation of the national quality strategy, including patient safety policy and subsequent  Technical experts supported by
Committee (NQSSC) variations of these their respective agencies
 Determine national quality priorities, policies and high-level planning  Committee chaired by Chief
 Decide and apply indicators for monitoring the implementation of quality plans, policies and health outcomes Director
in the priority areas
 Define data requirements for the measurement of quality at the various levels of the health system
 Provide guidelines/policy for compliance to data quality and reporting
 Strengthen leadership and ownership among stakeholders in the health system on quality planning, quality
assurance and quality improvement at all levels, in all sub-sectors and in all sector agencies
 Provide a platform for inter-agency knowledge sharing and learning
 Develop Terms of Reference for RQMUs, DQMUs, Facility QMTs
 Support regions to establish DQMUs
 Support MOH PPME and MOH HRD to train RQMUs
 Monitor implementation of NQS in all agencies at all levels
 Establish criteria for identifying and celebrating teams and individuals improving health care and patient
outcomes
47
4. National Quality  Day-to-day oversight of quality across all agencies, sub-sectors and all levels on behalf of Chief Director  Located in the MOH PPME
Management Unit  Implement a certification mechanism for data and information systems employed in the delivery of health  Focal person is National Quality
(QMU)/National Quality care at all levels
Manager
Manager (NQM)  Conduct operational research/National quality surveys/Health systems research
 Reports to the Chief Director
 Publish an annual report on the state of health care quality in Ghana
 Support NQSSC to develop Terms of Reference for RQMUs, DQMUs, Facility QMTs
 Coordinate with NQSSC to support regions to establish DQMUs
 Lead the monitoring of NQS implementation
 Identify required policies, standards and protocols and initiate the development process
 Publish annual State of Health Care Quality in Ghana reports
5. MOH PPME Directorate  Lead the development of policies, standards and protocols identified by national QMU  Lead directorate in the ministry
 Lead training of QMUs and QMTs at all levels, with support of MOH HRD and NQSSC for quality
 Lead training of health workers in standards and protocols, with support of MOH HRD and NQSSC
 Host and support national QMU and NQSSC in their monitoring functions
6. MOH HR Directorate  Support MOH PPME to train QMUs and QMTs at all levels
 Train facility heads in basic managerial skills in collaboration with PPME
 Support other forms of training geared towards quality management/improvement
7. MOH Procurement  Supply quality, efficacious medicines and other medical commodities to facilities and community service  Liaise with RHMTs and DHMTs
Directorate delivery points on continuous basis
 Monitor availability of medical commodities at service delivery sites through the national health database and
through the RHMTs and DHMTs
8. Health Facilities  Accredit and license health facilities  Collaborate with RHMTs
Regulatory Agency  Support NQSSC and QMU to develop quality standards for health facilities and for other health sector agencies /RQMUs and DHMTs /DQMUs
(HEFRA)
 Monitor quality of care in all health facilities to implement HEFRA’s
 Sanction health facilities for deviation from ethical standards and for non-compliance with national health data monitoring function
policy
48
9. Regional Quality  Apply approved indicators for monitoring the implementation of quality plans, policies and health outcomes in  Regional Health Committee will
Management Units the priority areas in the region be the convener
(RQMUs)
 Facilitate the implementation in the region of the harmonized approaches and data systems determined by the  Reports to NQSSC
national NQSSC
 Strengthen collaboration among agencies in quality planning, quality assurance and quality improvement
initiatives originating both locally and internationally and operating in the region
 Strengthen leadership and ownership among stakeholders in the health system on quality planning, quality
assurance and quality improvement in the region
 Disseminate national standards to the districts and train staff of the districts
 Partner with HEFRA to monitor the implementation of policies and plans, and health outcomes in the districts
on behalf of the NQSSC
 Use national standards to assess institutions and determine underperforming agencies, for mentoring and
make recommendations for improvements, with reward systems
 Establish and train DQMUs in all districts and supervise districts training of facility QMTs
 Monitor the functioning and performance of DQMUs
10. District Quality  Strengthen leadership and ownership among stakeholders in the health system on quality planning, quality  District Health Committee, led
Management Units assurance and quality improvement in the district and sub-districts by the District Director of
(DQMUs)
 Lead quality planning in the district and sub-districts Health Services (DDHS) will be
 Disseminate national standards to the facilities and communities and train staff at the facility and community convener
levels (both public and private)  Reports to RQMU
 Monitor the implementation of policies and plans, and health outcomes in the facilities and communities
 Use national standards to assess institutions and determine underperforming institutions, for mentoring and
make recommendations for improvements, with reward systems
11. Facility Quality  Exhibit leadership, participation and accountability at the health facility level Quality Management Team will be
Management Teams  Facility head to be responsible for the implementation of National Quality Strategy in the facility headed by the head of the health
(QMTs) – teaching,
public, private  QMT to feedback to the DQMU (regional hospitals feedback to RQMUs) any implementation challenges or facility
any other interesting development
 Use national standards to assess departments of the facility and determine underperforming departments, for
mentoring and make recommendations for improvements, with reward systems
 Disseminate and continuously train staff on Quality Strategy and Guidelines
 Oversee implementation of quality improvement activities across the facility
 Inculcate quality culture into health workforce
49
12. Community level  Collaborate with other agencies, organisations and relevant stakeholders in integrative planning and  Composition: CHPS, CHO,
implementation of the National Quality Strategy and create modalities for peer learning Health Promotion Officer
 Use national and quality standards to plan and implement health programs  Supported by DHMT
 Establish Quality Improvement Teams/Committees at the community level
13. Patients and community  Participation in quality governance structures at all levels
groups  Participation in defining quality
 Participation in quality improvement
 Adherence to health advice and lifestyle modification
14. Civil Society  Advocacy for policy and practice
Organizations  Community mobilization for health
 Community education
15. Service Provider  Support the MOH, QMU, NQSSC in the development of policies, standards and protocols  Include GHS, CHAG,
Organizations  Establish and maintain an organizational Quality Management Unit Ahmadiyya, GAQHI
 Supervise, monitor and evaluate facilities in their jurisdiction to adhere to quality and ethical standards in
collaboration with RQMUs and DQMUs
16. Professional Bodies  Support MOH in the development of policies, standards and protocols  Include GMA, PSGH, GRMA,
 Establish professional Quality Management Units/Teams GRNA, Biomedical Scientists,
 Peer review professional colleagues towards the delivery of safe and quality care Traditional Medical Practice
Association
17. Regulatory Bodies  Support MOH in developing policies, standards and protocols  Include MDC, NMC, TMPC,
 Support continuing education through CPDs HEFRA, FDA, Pharmacy
 Monitor adherence to professional ethics and standards Council
 Monitor performance of health facilities (HEFRA)
18. Training Institutions  Support MOH in the development of policies, standards and protocols  Include schools of nursing,
 Develop and implement quality training curricula midwifery, medicine, dentistry,
 Provide training in technical disciplines, managerial skills and quality for health professionals public health, pharmacy,
colleges
19. NHIA  Provide financial access

 Incentivize the provision of quality and safe care by service providers
 Undertake credentialing of health facilities to ensure minimum standards are in place for the provision of quality
care to NHIA Clients
20. Development Partners  Support the ministry and its agencies to plan and implement programs to improve quality and safety
50
Chapter 3: Financial Management for

Interventions
3.1 Funding sources
A resource plan will be looked at in the short, medium and long term. In the short term, we will
use the costed implementation plan, dissemination strategy and monitoring and evaluation of
and use these as a business case. Champions will use the business case for resource procurement.
The strategy is to get a good buy-in and support from WHO, UNICEF, JICA, USAID, DFID,
KOICA and the World Bank, as the strategy aims to improve quality and safety for all, including
the poor.
In the long-term we shall explore internal resources in order to sustain the momentum. In this
regard health facilities and agencies will use their internally generated funds (IGF) to implement
the strategy.
3.2 Key cost elements
The key cost elements are as tabulated in the table below:
Table 13: Key Cost Elements
No. Process Outcome (Costing)

1. Policy development Cost of strategy development
2. Policy dissemination: Cost of dissemination
 Prepare dissemination/communication
strategy
 Use champions
 Direct/electronic mechanisms
 Dissemination meetings at all levels
3. Coordination and accountability framework Cost of coordination and accountability
processes
4. Monitoring and evaluation (M&E) Cost of M&E plan
5. Executive capacity building Cost of capacity building
 Training manual(s)
 Facilitation
 Training facilities and materials
 Daily subsistence allowance for
participants
3.3 Use of resources and accountability
Priority activities in the strategy will be identified for priority funding; for example,
dissemination of the strategy and stakeholder engagement will be definite priorities. There are
options for accountability, such as the UN approach whereby funds are released directly to the
government partner. Other options include a harmonized approach to cash transfer in which
reports are written indicating itemized cost elements with evidence of appropriate spending such
as invoices and receipts; performance based grants; and the cashless approach.
51
Ghana National Healthcare
Quality Strategy (2017-2021)
Appendices
Appendix 1: Stakeholders Targeted for

Interview and/or Interviewed
The following were targeted for interview (*stakeholders interviewed):
1. Chief Director, Ministry of Health*

2. Director PPME MOH*
3. Director Procurement, MOH*
4. Health Facilities Regulatory Authority (HEFRA)*
5. Medical and Dental Council (MDC)
6. Nursing and Midwifery Council*
7. Pharmacy Council*
8. Registrar, Allied Health Professional Council*
9. Traditional Medical Practice Council*
10. Mental Health Authority*
11. Food and Drugs Authority (FDA)*
12. Director General, Ghana Health Service*
13. Ghana Health Service directors at the national level*
14. Regional Directors of Health Services*
15. District Directors of Health Services*
16. Christian Health Association of Ghana (CHAG)*
17. Ghana Association of Quasi-Government Institutions (GAQHI)*
18. Ahmadiyya Muslim Mission (Health Services)*
19. Society of Private Medical and Dental Practitioners (SPMDP)*
20. Community Practice Pharmacists Association (CPPA)*
21. Teaching hospitals*
22. Primary hospitals (CHAG, quasi-government and private sectors)*
23. Ghana Medical Association*
24. Pharmaceutical Society of Ghana (PSGH)*
25. Ghana Registered Nurses and Midwives Association (GRNMA)
26. Association of Biomedical Scientists*
27. Traditional Medicine Practitioners Association
28. Association of Health Service Administrators of Ghana (AHSAG)
29. Medical schools
30. Dental school
31. School of Pharmacy*
32. Nurses Training College*
33. Midwifery Training Schools*
34. Biomedical training institutions
35. College of Physicians and Surgeons*
36. National Health Insurance Authority*
37. Private Health Insurance Agency*
38. The Trades Union Congress*
39. The Ghana Employers Association (GEA)*
40. Coalition of NGOs in Health*
41. Consumer Protection groups*
42. Patients*
43. Community*
44. The media*
45. Ministry of Women, Children and Social Protection (MWCSP)*
46. Ministry of Local Government
47. Ministry of Finance and Economic Planning (MOFEP)
48. National Development Planning Commission (NDPC)
49. Development partners*
52
Appendix 2: National Quality Strategy

Steering Committee Members
Table 14: Members of the National Quality Strategy Steering Committee
National Quality Strategy Steering Committee

# AGENCY COMMENTS
1. Chief Director, Ministry of Health General oversight over policy

actions and implementation within
the Ministry’s agencies
2. Director, Policy Planning, Monitoring & Evaluation Chair of NQSSC

3. Director of Procurement & Supply, MoH Supply chain management
4. Director, National Ambulance Service Emergency and referral services
5. Representative, Teaching Hospitals Four representatives, one from
each Teaching Hospital
6. Ghana Health Service:
i. Director General
ii. Director, PPME
iii. Director, ICD
iv. Director, FHD
v. Director, PH
7. Representative, Christian Health Association of Ghana Faith-based sector with experience
in large-scale improvement work
8. Representative of Society of Private Medical & Dental Private sector
Practitioners
9. Representative of Health Regulatory Authorities To represent all Regulatory
Agencies in Ghana and set up
mechanisms for disseminating
information to them and receiving
feedback
10. Representative, Health Training Institutions Pre-service education/training
11. Representative, National Blood Transfusion Services Reliable supply of safe blood
nationwide
12. Representative, Mental Health Authority Mental health
13. Representative, National Health Insurance Authority Health financing
14. Representative, Patient Groups Patient voice
15. Technical Support: Perspectives from Quality
i. Institute for Healthcare Improvement Improvement, Infection Prevention
ii. Ubora Institute Control, Patient Safety, Data
iii. WHO Analysis, etc.
iv. Systems for Health, USAID
v. UNICEF
53
Appendix 3: National Quality Strategy Core

Working Group (NQS-CWG) Members
Table 15: Members of the Core Working Group
NAME INSTITUTION/AGENCY
DR. ISAAC C.N.MORRISON SOCIETY OF PRIVATE MEDICAL & DENTAL PRACTITIONERS
DR. MEMUNA TANKO NATIONAL HEALTH INSURANCE AUTHORITY (NHIA)
DR. SAMUEL KABA GHANA HEALTH SERVICE (GHS)
CHRISTIANA AKUFFO
BENJAMIN NYAKUTSEY MINISTRY OF HEALTH (MOH)
JOSEPH DODOO
MARK BIGOOL
ELOM HILLARY OTCHI
BARNABAS YEBOAH
EMELYN LOVETT YORKE
AMINU ZULEIHA
KAFUI DANSU
DR. SIMPSON ANIM BOATENG HEALTH FACILITY REGULATORY AUTHORITY (HEFRA)
DR. NICHOLAS A. TWENEBOA INDEPENDENT CONSULTANT
SODZI SODZI-TETTEY INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI)
TRICIA BOLENDER
AMRITA DASGUPTA
LAUREN MACY
CLEOLA PAYNE
ERNEST KANYOKE UBORA INSTITUTE
PHILOMINA AMOFAH
JOLANDA STEENWIJK
ROSELINE DOE WORLD HEALTH ORGANISATION (WHO)
DR. HARI KRISHNA BANSKOTA UNICEF
DR. PETER BAFFOE
MARNI LAVERENTZ USAID SYSTEMS FOR HEALTH
DR. ERNEST OPOKU
ISAAC AMENGA-ETEGO
DR. WISDOM ATIWOTO QUEAUJI CONSULT
54
Appendix 4: Synopsis of Interview Guide

for National Quality Strategy
The objective of the interviews is to collect primary data to enrich the Current State Analysis
and inform NQS formulation.
1. Quality of health care
 What you understand by quality of health care in the Ghanaian context
 What elements of quality are most important to you and why
 Ways in which your organization influences quality

 The role of patients and the community in influencing quality of care
 What the current state of quality is
 What you see as the “ideal” situation of quality

 What the barriers to achieving quality of healthcare are
 How we can reach the “ideal” state
2. Leadership and governance
 How quality policies and plans are developed; how this might be improved
 How quality is regulated and implemented from the national to the local level; how
this might be improved
 What quality levers/spheres of influence/drivers of quality exist at the various levels
 How these levers might be used to improve quality processes at all levels, across
regions and across sub-sectors
 Degree of involvement of the private sector
 Existence or otherwise of accountability systems
 How coordination and collaboration can be achieved
3. Quality initiatives
 What quality initiatives you have been involved in (or are you aware of)
 How the initiatives were planned, implemented and monitored
 The ownership of the initiatives
 The results of the initiatives
 With whom and how learning was shared
 How the initiatives were related/harmonised with other initiatives
55
 How ownership, collaboration and harmonization of quality initiatives might be

improved
4. Data
 What indicators your organization uses to monitor quality

 Who collects the data
 Reliability of the data

 The movement of the data
 Provision of feedback
 Who uses the data

 Public sector compared with private sector
5. Health of the population
 Priority diseases/health conditions

 Existing initiatives to address them
 Who is involved in current initiatives (e.g., public vs. private; provider vs.
patient/community; policy makers vs. implementers)
 Effectiveness of current efforts
 How participation and outcomes can be improved
56
Appendix 5: The Juran Trilogy

The Juran Trilogy summarizes three organizational components of quality: Quality Planning,
Quality Assurance, and Quality Improvement.
Quality Planning (QP) entails determining the needs that a health care system must fulfill, and
establishing the goals and strategy to meet these needs. Quality Planning involves designing a
structure that delivers the right care to patients at the right time, every time. It rests largely on
key principles laid out by W. Edwards Deming:
 Systems produce results.
 Data, especially variation in performance, reveals how the system functions.

 The system must create, adapt to, and spread new knowledge.
 Humans ultimately carry out the work; the system must be designed around human
psychology.
Quality Assurance (QA), or Quality Control, is often the starting point for a country’s quality
journey. QA is typically a regulatory approach to ensuring that quality remains at or above
baseline expectations. QA could include accreditation, licensing, empanelment of facilities, etc.
Often these are key government or parastatal functions to ensure a certain level of quality with
a broad stroke. Viewed within the Juran Trilogy, it is clear that QA is a vital component of a
quality strategy, which must be tightly integrated with planning and improvement efforts.
Finally, Quality Improvement (QI) allows a system achieve a new level of performance beyond
what QA requires. QI is a continuous process whereby organizations iteratively test and
measure changes, achieve ambitious aims, and spread best practices.
Quality Planning
Policy, resources, coordination,
accountability, execution
QA CQI
Standards/Guidelines/protocols 1. Aims: what are the “gaps” in
performance and outcomes
Professional oversight
Improved 2. Measures: tools to measure and
Accreditation
Outcomes feedback processes and outcomes
Performance review
3. Changes: QI change activities for
leadership, admin, and frontline to
close the “gap”
Figure 3: The Juran Trilogy
57
Appendix 6: Health Sector Medium Term

Development Plan in Relation to the NQS
The NHQS is developed in the milieu of the Health Sector Medium Term Development Plan
2014-2017 (HSMTDP) crafted by the Ministry of Health. The HSMTDP states that “The goal of
the health sector is to have a healthy and productive population that reproduces itself safely”
(MOH, 2014).
The HSMTDP recognizes the key players in health service delivery as the Ghana Health Service
(GHS), the Christian Health Association of Ghana (CHAG) and the Teaching Hospitals,
acknowledging that the private sector provides significant health services. “The Ghana Health
Service provides public health and clinical services at primary and secondary levels. As part of
the effort to improve access to health services, the Community-Based Health Planning and
Service programme (CHPS) has also been designated as another level of health care delivery that
combines public health and basic clinical care activities” (MOH, 2014).
The document catalogues the top 10 causes of outpatient attendance as malaria, upper
respiratory tract infections, diarrhoeal diseases, skin diseases, rheumatism and other joint pains,
anaemia, hypertension, intestinal worms, acute eye infections and acute urinary tract infection.
Challenges mitigating against achieving desirable health outcomes identified in the HSMTDP
include limited geographical and financial access to health services; poor quality of the services
provided, both from technical and client perspectives; weak coordination of regulatory functions
within the health sector, leading to continuing influx of substandard goods and services; weak
integrated research, information and monitoring systems to support evidence-based decision
making and to track performance in priority areas; weak leadership capacity within the health
sector to coordinate and promote effective participation of civil society organizations and the
private sector in health; and sub-optimal staff mix coupled with inequitable distribution of
existing staff.
Health sector development issues prioritized in the HSMTDP are leadership, governance and
management; health research and information management; human resource development;
regulation; financing; and health service delivery.
Issues prioritized under health service delivery are meeting health-related MDGs with the
challenges of persistent high neonatal, infant and maternal mortality, morbidity and mortality
from malaria, persistence of HIV and TB; disease promotion and control, with a focus on
increasing morbidity and mortality from NCDs, high prevalence of communicable diseases
including epidemic-prone diseases and climate-related diseases; high morbidity and mortality
from neglected tropical diseases such as yaws, leprosy, buruli ulcer and filariasis; access to health
care services with huge gaps in geographical access; quality of care with a focus on public and
users; concerns about the quality of health care; and a huge unmet need for mental health
services. The HSMTDP envisages community- and facility-based interventions for childhood
illnesses, attention to immunization in the Expanded Program on Immunization (EPI) and
improved response to medical emergencies.
58
Appendix 7: Driver Diagram
VISION GOALS STRATEGIC OBJECTIVES
1.1 To improve the clinical skills of relevant health workers

to manage identified priority health interventions
1.0 Continuously
improve health
1.2 To promote a quality culture and accountability for
outcomes in the quality in all health workers and sector agencies
population health
priority areas
To create a 2.1 To create sustainable leadership and governance for

harmonized and quality planning, quality control, and quality improvement at
coordinated health all levels of the health care system
care quality system 2.0 Develop a
that places the coordinated health
client at the centre care quality system in 2.2 To strengthen coordination among all health sector
of health care and the areas of quality agencies
ensures planning, quality
continuously control, and quality
improved improvement – 2.3 To standardize collection of data and improve use and
measurable health including improved use analysis of data at all levels (including by providers at the
outcomes of data for evidence- frontline) for evidence-based decision making
based decision-making
2.4 To resource and strengthen regulatory agencies

(especially HEFRA) to roll out a nationwide accreditation
process with clear links to facility-based quality
management teams for ongoing improvement action
3.0 Improve client 3.1 To sustain patient safety at all levels of health care
experience by being delivery
responsive to the
health needs and
aspirations of the
3.2 To improve client satisfaction and participation in quality
patient and the
definition and quality improvement
community
3.3 To build a culture of “joy at work” (financing, logistics,

recognition and reward) that creates the context for health
providers to treat clients with dignity and respect, deliver
high-quality care and be motivated to continuously improve
quality
59
Appendix 8: Data Systems and Reporting

Feedback Flow
MOH/NATIONAL- CENTRE FOR HEALTH INFORMATION MANAGEMENT (CHIM)/PROGRAMMES
REGION: REGIONAL HEALTH DIRECTORATES
REPORTING ON ACTIVITIES/SERVICE
REVIEW AND ANALYSE DATA/FEEDBACK
DISTRICT: DISTRICT HEALTH DIRECTORATES
REPORTING ON ACTIVITIES/SERVICE AND COLLATE
REVIEW AND ANALYSE DATA
SUB-DISTRICT/FACILITY: PRIVATE/PUBLIC/CHAG
REPORTING ON ACTIVITIES/SERVICE AND
ANALYSE DATA
Manual Transmission
Electronic Transmission (DHIMS)
FEEDBACK
Figure 4: Data Systems Flow
Source: Standard Operating Procedures on Health Information, 2 nd Edition, Ghana Health Service, January 2014
60

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REPORT : Ghana National Healthcare Quality Strategy

Part 2: Coordination and Accountability Framework

HON. ALEXANDER P. SEGBEFIA

Minister for Health

1st December, 2016

 Epidemic-prone diseases: cerebrospinal meningitis, cholera

 Non-communicable diseases: hypertension, diabetes

To continuously improve the health and well-being of Ghanaians through the

The specific goals of this strategy are to:

Vision for Healthcare Quality in Ghana

Table 1: Ideal State of Quality in Ghana

Quality Planning Quality Control Quality Improvement

 Quality improvement and  Patient feedback through  Capability building

 Clear and cordial  Motivation for workforce

Key successes in health of the population include significant reduction in under-five

Table 2: Key Areas to Address in Leadership and Functionality

Leadership and Functionality

Table 3: Key Areas to Address in Quality Improvement Initiatives

Quality Improvement Initiatives

The ultimate goal of the National Healthcare Quality Strategy is:

To continuously improve the health and well-being of Ghanaians through the

The specific goals of this strategy are to:

 Non-communicable diseases: hypertension, diabetes

Making This Happen

A separate document (Part 2: Coordination and Accountability Framework) outlines an action

Ghana’s quality journey in brief

Rationale and impetus for developing NHQS

 “Where health systems – particularly in developing countries – need to optimize

1.2 The strategy development process

Core Working Group

Ministry of NHIS, Private

Regulators, 5. NHQS WRITE UP MOFEP, Dev.

7. NQS REVIEW, FINALIZATION

Figure 1: Ghana NHQS Development Framework

Chapter 2: Vision for Healthcare

“Health care quality is the degree to which health care

Commonalities in stakeholder views emerged around the Donabedian principles of “structure,

2.2 Ideal state of quality in Ghana

 Quality Planning: Policy, resources, accountability, coordination, execution

 Quality Improvement: Gap analysis, needs assessment, tools and methods to

Chapter 3: Situation Analysis

 Health of the population

 Leadership and functionality

 Data systems and quality metrics

3.1 Health of the population

Maternal and Child Health

3.2 Leadership and functionality

Driving Quality at the National Level

Driving Quality at the Regional & District Level

Driving Quality at the Facility & Community Level

3.3 Quality improvement initiatives

 Prioritization of critical gaps for intervention

 Coaching and mentoring follow-up visits

Table 6: Quality Initiatives Across the Ghanaian Health System

Quality Initiatives Level of the Health System

National Regional/District Facility Patient/Community

 Accreditation and renewal of licenses by facilities through HEFRA and by health

3.4 Data systems and quality metrics

Chapter 4: Prioritizing for Improvement