Effect, equity and costs of an integrated and decentralised intervention to improve access to primary care for skin diseases: a prospective before-and-after study in south-west Ghana

A prospective before-and-after study in south-west Ghana demonstrates that integrating skin disease care into routine primary health services significantly increased service uptake, particularly in rural areas and among school-age children, yet revealed persistent gaps in access for high-risk groups like males and preschoolers alongside residual catastrophic costs driven by pre-facility expenses.

The Gist

Imagine your local health system as a giant, complex machine. For a long time, this machine had a specific, broken gear: skin diseases. Whether it was a simple rash, a deep wound, or a neglected tropical disease, people often had to travel far, pay extra money, or wait in line at specialized clinics just to get help. Many people, especially children and men, simply gave up and suffered in silence.

This study is like a mechanic's experiment in a rural district of Ghana called Atwima Mponua. The researchers asked: "What if we didn't build a new, separate machine for skin problems, but instead fixed the main machine (the primary health clinics) so it could handle skin issues right alongside everything else?"

Here is the story of what they did, what happened, and what they learned, explained simply.

The Plan: Turning Every Clinic into a "Skin Station"

Instead of sending patients to a distant specialist, the researchers launched a 11-month "fix-it" campaign across all 17 public health facilities in the district.

Think of it like upgrading every local grocery store to also sell fresh, high-quality produce, rather than forcing everyone to drive to a distant supermarket. They did three main things:

1. Training: They taught the local nurses and doctors (the "grocery clerks") how to spot and treat skin problems, from fungal infections to complex wounds.
2. Stocking: They made sure the shelves were always full of the right medicines and bandages, so patients didn't have to run to private shops to buy them.
3. Community Chatter: They sent volunteers into schools and villages to tell people, "Hey, you don't need to travel far. Your local clinic can fix that rash."

The Results: The "Double" Effect

When they turned the lights on and opened the doors, the results were like a floodgate opening.

• More People Showed Up: The number of people seeking care for skin problems doubled. It was as if the local clinic suddenly became the go-to place for everyone.
• The Biggest Winners: The biggest jump in visitors came from school-age children and people living in the most remote, rural villages. It was as if the "remote villages" finally got a bridge built to the health system.

The Catch: The "Invisible" Groups

However, the story isn't a perfect fairy tale. Even with the floodgates open, some people were still missing from the crowd.

• The "Missing" Males and Kids: While the number of kids going to the clinic went up, it didn't go up enough to match how many kids actually had skin problems in the community. Similarly, men were still underrepresented. It's like a party where the music is great and the door is open, but the men and the kids are still sitting on the porch, too shy or too busy to come in.
• The Rural Gap: Even though rural people visited more, they were still less likely to show up than people living near towns.

The Cost: The "Hidden Fee" Problem

The researchers also looked at the wallet impact.

• Good News: Once you got to the new integrated clinic, treatment was cheap. The government insurance covered most of it.
• Bad News: Before people finally made it to the right clinic, they often spent a lot of money on the wrong path. They paid private drug sellers, traditional healers, or traveled to other districts first.
  • The Analogy: Imagine you need a specific tool. You go to the wrong hardware store, buy the wrong tool, and pay for it. Then you realize you need the right one, so you go to the right store. The study found that 80% of the money people spent was wasted on the wrong stops before they finally reached the right clinic.
• Catastrophic Costs: About 4% of people with serious wounds still ended up spending so much money that it broke their household budget.

The Big Lesson

This study teaches us a powerful lesson about fixing broken systems:

Integration is a powerful engine, but it needs a steering wheel.

Simply putting skin care into regular clinics is like putting a Ferrari engine in a bus—it goes much faster and carries more people. But if you don't also build ramps for the wheelchair users (men, kids, and the very poor) and fix the potholes on the road (the hidden costs of going to the wrong place first), some people will still be left behind.

In short: The experiment proved that bringing skin care to the local clinic works wonders to get more people help. But to make it truly fair, we need to be extra careful to chase down the groups that are still hiding in the shadows and make sure the path to the clinic is free of hidden fees.

Technical Summary

1. Problem Statement

Skin diseases are a major global contributor to morbidity, stigma, and economic hardship, yet they have historically received limited policy attention. While the World Health Organization (WHO) and the World Health Assembly have recently called for the integration of skin disease services (including neglected tropical diseases or NTDs) into routine primary health care (PHC), robust evidence on how to operationalize this effectively, equitably, and affordably is scarce.

In low- and middle-income countries (LMICs), barriers to care include:

• Limited provider training and capacity.
• Inconsistent availability of essential medicines and diagnostics.
• Fragmented care pathways.
• High out-of-pocket (OOP) costs that deter care-seeking.

The study aimed to evaluate a comprehensive, district-wide intervention in Ghana designed to decentralize and integrate skin disease care into routine PHC, assessing its impact on uptake, equity relative to disease burden, and treatment costs.

2. Methodology

Study Design & Setting:

• Design: Prospective before-and-after (pre-post) intervention study.
• Location: Atwima Mponua district, a rural district in southwest Ghana (population ~155,254).
• Facilities: All 17 public health facilities (6 Community Health Planning and Services [CHPS] compounds, 10 health centres, 1 district hospital).
• Timeline:
  • Pre-intervention period: January – October 2023.
  • Intervention period: November 2023 – September 2024.

The Intervention:
A co-created, context-driven strategy involving three core activities:

1. Capacity Building: Training for primary healthcare workers on diagnosing and managing a broad spectrum of skin conditions (skin NTDs, complex wounds, inflammatory dermatoses, fungal infections).
2. Supply Chain Strengthening: Provision of essential medicines, diagnostics, and dressing materials to all facilities, ensuring availability regardless of National Health Insurance Scheme (NHIS) enrollment.
3. Community Engagement: Training community surveillance volunteers and school health officers to promote awareness and referral.

Data Sources & Analysis:

• Health Facility Records: Routine outpatient data extracted to calculate incidence rates (cases per person-time at risk) pre- and post-intervention.
• Cross-Sectional Survey: A two-stage screen-and-verify community survey (August–September 2024) covering 101 clusters and 42,801 individuals to estimate true disease prevalence.
• Patient Questionnaires: Post-care surveys for patients with skin NTDs and complex wounds to assess financial and productivity costs.
• Provider Surveys: Assessment of resource use and costs for the intervention.
• Statistical Analysis: Poisson regression for incidence rate ratios (IRR); mixed-effects logistic regression for prevalence odds ratios (OR); multiple linear regression for cost drivers.

3. Key Contributions

• Holistic Scope: Unlike previous studies focusing narrowly on specific NTDs (e.g., Buruli ulcer or leprosy), this intervention addressed the entire spectrum of skin diseases, including common conditions like scabies, dermatophytosis, and wounds.
• Equity Assessment: The study uniquely compared facility-based uptake against community-based prevalence to identify "missed" populations (disparities between those who seek care and those who actually have the disease).
• Cost Analysis: It provided a dual perspective on costs:
  • Patient costs: Including OOP payments and productivity losses.
  • Provider costs: Including training, supplies, and clinical care.
• Real-World Implementation: The intervention was implemented across an entire district's routine health system rather than as a parallel vertical program, offering high external validity for scale-up.

4. Key Results

A. Uptake of Care (Incidence)

• Overall Increase: The incidence of skin disease cases recorded in health facilities doubled during the intervention period (Adjusted Incidence Rate Ratio [aIRR] = 2.0; 95% CI 1.92–2.09).
• Specific Conditions:
  • Scabies saw the most dramatic increase (aIRR = 83.2).
  • Dermatophytosis and complex wounds also increased significantly.
  • Inflammatory dermatoses decreased (likely due to improved coding or shifting diagnostic patterns).
• Demographic Shifts: The greatest relative increases in care-seeking occurred among school-age children (aIRR = 2.78) and residents of very rural communities (aIRR = 2.76).

B. Disease Burden & Equity (Prevalence vs. Uptake)

• Community Prevalence: The cross-sectional survey found a skin disease prevalence of 55.9 per 1,000 persons (95% CI 53.8–58.1).
• Risk Factors: Prevalence was significantly higher in males (aOR = 1.27), pre-school children (aOR = 1.72), and very rural communities (aOR = 1.71).
• Persistent Inequities: Despite the overall increase in care, significant disparities remained:
  • Males were under-represented in facility records compared to survey findings (-5.3% difference).
  • School-age children were severely under-represented (-24.0% difference).
  • Very rural residents showed a trend toward under-representation.
  • Only ~30% of survey participants with skin disease had visited a health facility.

C. Economic Impact

• Patient Costs:
  • Median financial cost for NTD/complex wound patients was GHS 90 (USD 6.5).
  • Critical Finding: 79% of total costs were incurred before the patient visited the intervention facility (e.g., at private providers, traditional healers, or outside the district).
  • Catastrophic expenditure (>10% of household spending) affected 4% of patients with serious skin conditions.
• Provider Costs:
  • Total intervention cost: GHS 1.54 million (USD 107,670).
  • Mean cost per patient treated: GHS 183 (USD 12.80).
  • Major cost drivers: Clinical care (42%) and Training (31%).

5. Significance and Conclusions

Significance:

• Proof of Concept: The study demonstrates that integrating skin disease services into routine PHC can substantially increase service uptake at a district scale.
• Supply Chain is Critical: The intervention succeeded largely because it ensured the physical availability of medicines and diagnostics, bridging the gap between insurance coverage and actual access.
• Limitations of Integration Alone: While integration improved access, it did not fully resolve equity gaps. High-risk groups (males, children, rural poor) remained under-served, suggesting that facility-based integration must be complemented by targeted outreach (e.g., school-based services).

Conclusions:
The authors conclude that while integrating skin health into primary care is an effective strategy to expand access, it is insufficient on its own to ensure equitable care. To achieve universal health coverage for skin diseases, future strategies must:

1. Maintain resilient supply chains for essential medicines.
2. Implement deliberate, targeted strategies to reach underserved populations (e.g., men and children) who face structural or cultural barriers to facility-based care.
3. Address the "pre-facility" costs that drive catastrophic expenditure, potentially by reducing reliance on informal providers.

This study provides a scalable model for other LMICs aiming to operationalize WHO guidelines on skin disease integration while highlighting the specific challenges of achieving equity in decentralized health systems.