Implementation of a referral and expert advice call Center for Maternal and Newborn Care in the resource constrained health system context of the Greater Accra region of Ghana

Background: Referral and clinical decision-making support are important for reducing delays in reaching and receiving appropriate and quality care. This paper presents analysis of the use of a pilot referral and decision making support call center for mothers and newborns in the Greater Accra region of Ghana, and challenges encountered in implementing such an intervention. Methods: We analyzed longitudinal time series data from routine records of the call center over the first 33 months of its operation in Excel. Results: During the first seventeen months of operation, the Information Communication Technology (ICT) platform was provided by the private telecommunication network MTN. The focus of the referral system was on maternal and newborn care. In this first phase, a total of 372 calls were handled by the center. 93% of the calls were requests for referral assistance (87% obstetric and 6% neonatal). The most frequent clinical reasons for maternal referral were prolonged labor (25%), hypertensive diseases in pregnancy (17%) and post-partum hemorrhage (7%). Birth asphyxia (58%) was the most common reason for neonatal referral. Inadequate bed space in referral facilities resulted in only 81% of referrals securing beds. The national ambulance service was able to handle only 61% of the requests for assistance with transportation because of its resource challenges. Resources could only be mobilized for the recurrent cost of running the center for 12 h (8.00 pm – 8.00 am) daily. During the second phase of the intervention we switched the use of the ICT platform to a free government platform operated by the National Security. In the next sixteen-month period when the focus was expanded to include all clinical cases, 390 calls were received with 51% being for medical emergency referrals and 30% for obstetrics and gynaecology emergencies. Request for bed space was honoured in 69% of cases. Conclusions: The call center is a potentially useful and viable M-Health intervention to support referral and clinical decision making in the LMIC context of this study. However, health systems challenges such inadequacy of human resources, unavailability of referral beds, poor health infrastructure, lack of recurrent financing and emergency transportation need to be addressed for optimal functioning. The call center was established with local resources contributed by the hospitals and clinics in the region from their internally generated funds (IGF). IGF comprises client out of pocket payments and National Health Insurance scheme reimbursements. Health facilities within the Ghana Health Service in the Greater Accra region agreed to contributed a portion of their IGF, based on the size of the facility. The hospitals and clinics had been part of the design of the intervention; and saw it as a response to a felt need. The fact that the agenda setting was led by and the implementation of the formative research and design of the intervention were done as a close collaborative effort with the Ghana Health Service regional, district and hospital managers as well as frontline workers in the region enabled this strong sense of ownership. The amounts were agreed on by consensus taking into account their IGF income and were the Ghana cedi equivalent of USD 600 for hospitals, USD460 for polyclinics. The smaller facilities (health centres) and small clinics with less revenue did not contribute. Ten (10) hospitals and six (6) polyclinics contributed approximately USD 15,000. This was many times less than the budget estimates that were made calculated as needed to run the intervention full scale 24 h daily and conduct formative as well as summative evaluation. The IGF contributions were paid into a pooled fund coordinated by the Greater Accra Regional Health Directorate (RHD). Space for the housing of the center, and the costs of shared overheads such as electricity and water was provided by the Ridge Regional Hospital Out-Patients Department (OPD), Adabraka (now Adabraka Polyclinic). The Free University of Amsterdam Athena Center, as part of a research collaboration contributed through the University of Ghana’s School of Public Health, an amount of Nine thousand nine hundred and fifty Euro (€9950.00) to support the initial monitoring and documentation of the center and its effects and outputs. Beyond this there was no dedicated funding for the establishment and recurrent costs of the intervention or its monitoring and evaluation. The need to manage within these severe resource constraints was an important factor affecting how and why the intervention was implemented. A series of stakeholder meetings were held with heads of referring (smaller hospitals and polyclinics) and receiving (larger hospitals, including secondary and tertiary) facilities to discuss and refine the modalities for the setup and functioning of the center and make sure they were responsive to the felt needs of the providers. MTN Ghana, a private telecom operator, set up the equipment to provide the Telecommunication backbone for the center between February and March 2015. The call center started full operations on 12th April 2015. The service was advertised only to the frontline health workers who refer and the receiving hospitals who take the referrals through these stakeholder engagements with facilities and their managers. These staff were regarded as the direct potential population being served by the call center or the primary users. All frontline health workers within the various health facilities within Greater Accra region (over 11 hospital, 11 polyclinics, 16 health centers, over 30 private hospitals etc.) were all part of the target population for this intervention as well as the referral hospitals receiving patients from all lower level hospitals within the region. The clients who were referred or received referral services through the center were regarded as the indirect potential population to be served by the center. This is because these clients themselves were not the ones who took the decision to use the center or who contacted the call center for service once the decision was taken. No specific advertising was targeted at clients therefore. However, our ultimate goal was to improve the health and wellbeing of the clients. The Regional Call Center at inception was staffed by 8 officers who worked on a shift system. They were assisted by an administrative assistant, and supervised by a coordinator. The 8 officers comprised 3 midwives, 3 general nurses and 2 national service persons. They were trained on how to operate the center using the Ghana Safe Motherhood protocols over a two-day period in March 2015 by the Chief Nursing Office, the Deputy Director of Nursing in charge of Clinical Care and Emergencies, the Call Center Coordinator, staff of the Institutional Care Division of the Ghana Health Service and the National Ambulance Service. These officers were responsible for carrying out the technical functions of the call center i.e. coordinating access to expert support and referral coordination. The center operated under the office of the Regional Director of Health Services. The coordinator had oversight responsibility for the day-to-day running of the facility. The center primarily supported maternal and neonatal units of all health facilities within the region for two main functions of the coordination of expert advice and referrals. To coordinate expert advice, the center worked with an expert panel of senior practitioners to aid frontline maternal and newborn health (MNH) service providers at all levels of care in the region. Frontline service providers were able to reach the experts by a phone call routed through the center. The expert panel had a membership of three obstetricians, two paediatricians, the regional pharmacist and an anaesthetist. These officers were employees of the Ghana Health Service and did not receive any special remmuneration for providing advice. It was treated as part of their normal work. The center officers received calls for help directly from frontline health service providers, and immediately transfered the call to the appropriate expert panel member based on the nature of the request. Follow up officers were as part of the standard operating procedure (SOP) required to call health facilities back within 15 min of transferring their calls to the expert panel members for feedback. Where a referral was required, either by information from the expert panel or feedback from the health facility, the follow-up officers proceeded to arrange for the referral. This mechanism is illustrated in Fig. 1. Flow chart showing the direction of communication between the call center, lower level facilities requesting expert advice and the expert panel The call center coordinated referrals between health facilities, based on bed availability and the availability of personnel to manage the patient’s condition. Staff of the Call Center worked closely with the National Ambulance Service (NAS) and the major referral hospitals in Accra (Ridge Regional Hospital, Tema General Hospital, LEKMA Hospital, La General Hospital, Achimota Hospital, Pentecost Hospital, Korle-Bu Teaching Hospital and 37 Military Hospital) to ensure that referrals were handled efficiently. When a frontline worker needed to refer an emergency, a call was placed by the frontline worker to the call center. The officer at the center answered the call and conducted a brief telephone interview of the caller to document the details of the call on the Call Center Documentation form, and then transferred the call to the follow-up officer. It was the responsibility of the follow-up officer to ensure that a bed was secured in a health facility and an ambulance was dispatched where possible to transport the patient to the receiving facility (Fig. 2). This was to ensure that effective inter-facility referral communications were made before referrals with the main aim of ensuring that receiving facilities were pre-informed and were ready to receive the patients. Flow chart showing the direction of communication between the call center, referring facilities, receiving facilities and the national ambulance service In all cases, it was Standard Operating Procedure (SOP) for any missed phone call to be returned within 15 min. Call logs on the phones were routinely checked to verify this. It is however possible that a few calls may have been missed and therefore, not documented. Phases of operation of the call center can be split into the first 17 months (phase 1) when a private telecommunications company, MTN, providing the ICT platform (April 2015 to August 2016) and the period after the exit of MTN (phase 2) when the platform relied on the limited but free Gota phone system provided by National Security. The center operated with a backbone support for the Information Communication Technology (ICT) equipment provided by MTN Ghana. Operations started with 6 triage officers (3 midwives, 3 general nurses) and two national service personnel. The staff operated from 8 pm to 8 am i.e. run 12-h night shifts, with at least one midwife and one general nurse on duty per shift. Calls expected to be received at the center were to be for either expert advice or referral purposes. The running of 24-h services in phase 1 was constrained by inadequate resources for the recurrent operational costs. The original concept and design was for 24 h but faced with these resource constraints, priority was given to operating the center between 8 pm to 8 am, when the need for expert or specialist support for frontline health workers was greatest. The extra resources that were not immediately available to make a 24-h service possible were mainly for recurrent costs such as phone bills, stationery, additional staff, staff training etc. The challenge occurred because health facilities that had initially pledged to make financial contributions to support the center reneged on their pledges as they themselves struggled with inadequate financing. Ghana has moved to lower middle-income status and many development partners that supported the health sector are transitioning out. Unfortunately, resources available for service delivery at the frontline from government taxes are also declining. Apart from the startup costs already described, health facilities had agreed and were required to make recurrent monthly contributions to the regional health directorate to help pay for the cost of maintaining the contract with MTN Ghana. As these payments continued not to be made as agreed, the service provide MTN Ghana could not be paid and they eventually disconnected the phone lines of the center on 31st August 2016. This challenge was addressed when the National level took an interest in the center’s activities, and provided GOTA phones and additional staffing to man the center in September 2016. With the discontinuation by MTN of its support to the center because it was unable to meet the recurrent cost, the center from September 2016 operated with GOTA phones which are dedicated security phones donated by the National Security Service through the Ghana Health Service. Cordless and mobile GOTA phones were also distributed across most health facilities. In all, twelve facilities received cordless referral Gota phones. This was made up of nine (9) Ghana Health facilities, two (2) quasi-government hospitals and one (1) teaching hospital. A phone was also given to the National Ambulance Service. All health facilities who received Gota phones were referral level hospitals i.e. received emergencies from lower level health facilities. These advantage of these phones and the service was that they were provided free by government. The disadvantage was that the scope of service available under this system was less than under the commercial system run by MTN and they could not be used for conference calling, call transfers and expert advice. Hence, the role of the call center in providing expert advice was curtailed. The center could now only support referrals between facilities. The introduction of the Gota phones, and provision of extra staff for the call center by government through the Regional Health Directorate allowed a decision to run the center for 24 h instead of 12 h, and to open the center to receive calls for all clinical emergencies, not just maternal and newborn care. Additional personnel were trained and brought on board, making a total of 10 officers (5 clinical staff and 5 non-clinical staff, with the sixth clinical staff taking up other duties in another unit). These officers run 12 h shifts i.e. day and night duties; with at least two on duty in a given shift. The call center has continued to operate after this 33-month pilot period, and has been upgraded to a teleconsultation center by the Ghana Health Service. The study design was a longitudinal time series routine data analysis of process indicators of the immediate outcomes of call center functioning over a 33-month period starting from April 2015 when the centre commenced operation. This covers the 17 months of phase 1 and an almost equivalent period of 16 months of phase 2. At inception of the operation of the center, a simple form (Supplementary 1) was designed for the call center staff to manually fill as they responded to calls. The staff documented on this form, each call, made to the call center, the source clinic or hospital (including caller and phone number), referral diagnoses, cases received at first attempt, those received at subsequent attempts, outcomes of referrals and expert advice. The advice algorithm used by the staff at the call centre to guide their decision making on each call is attached as Tables 1 & 2. Maternal protocol for call center Newborn protocol for call center Some receiving facilities failed to respond when their emergency lines were called on some days, or had their phones off, making it difficult for the call center to reach them. Some staff members were delegated as focal persons for the call center in their health facilities. Their role was to coordinate activities of the call center within their facilities, providing regular updates on the bed states of their facilities and serving as a point of contact if the call center is facing difficulties accessing a bed. However, follow-up officers were not able to perform this task as no phones were provided for them specifically for this role due to the financial constraints under which the intervention was implemented. The data generated was regularly checked for completeness and consistency and then entered into Excel. We analyzed this data in Excel for frequencies and trends.