Barriers and facilitators to the implementation of the collaborative framework for the care and control of tuberculosis and diabetes in Ghana.

Abstract

Background: The rising tuberculosis -diabetes mellitus co-epidemic is threatening the advances made by global policy to reduce tuberculosis and diabetes mellitus prevalence. In 2011, the World Health Organization (WHO) and International Union Against Lung Disease (Union) launched the Collaborative Framework for Care and Control of Tuberculosis and Diabetes. The recommendations provided by the framework have been adopted by many countries, globally. The overall aim of this research was to explore the barriers and facilitators to the implementation of the WHO-Union collaborative framework in Ghana, from the perspectives of the policymakers, program managers, health facility managers, and front-line implementers (healthcare workers). Methods: Using an explorative qualitative study design, data was generated by employing a scoping review, documents review, in-depth interviews, and non-participant observation. In-depth interviews were conducted with 27 participants from Accra and Tamale in Ghana. All interviews were audio recorded (with participants’ permission) and transcribed verbatim, except for two interviews, whereby participants requested the interview not to be audio-recorded. Non-participant observation was guided by a checklist of sensitising concepts. Analysis was guided by the grounded theory to identify recurrent ideas which were coded and further grouped to develop themes. Results: This thesis presents key findings from research on the implementation of the framework in Ghana. The major outputs of this study included: 1) a scoping review to map evidence on the implementation of the framework, globally. 2) paper one examines the systems and structures in place for implementing the collaboration of TB-DM management in the selected health facilities. 3) paper two explores the mechanisms of collaboration between the National Tuberculosis Control Program and the Non-Communicable Disease Control Program at the national, regional, and local (health facility) levels of the health care system. 4) paper three addresses the experiences of frontline healthcare workers through the lens of Lipsky’s theoretical framework of street-level bureaucracy. Conclusion: The findings of this research support the implementation of the framework in Ghana. This has been enhanced by the increased staff capacity and institutionalization of screening. However, gaps still exist which require increased awareness about TB-DM comorbidity, and increased support for inservice training to curb the rising TB-DM comorbidity.