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

Abstract

ABSTRACT Background Global guidelines recommend strengthening and integrating health services for skin diseases, yet evidence for strategies remains scarce. We evaluated a decentralised approach to the care of skin disease through integration within routine primary care, by assessing uptake, equity, alignment with skin disease burden and associated treatment costs. Methods and findings A before-and-after intervention study was conducted across all 17 public health facilities in Atwima Mponua district, Ghana from November 2023 to September 2024 (intervention period). We analysed routine health facility records to compare uptake of primary care for skin diseases pre-intervention (January to October 2023) and during the intervention. We assessed the burden of skin disease through a community-based two-stage cross-sectional dermatological survey, and estimated patient and provider costs for skin disease through post-care questionnaires and health facility surveys. We compared uptake to disease burden and assessed catastrophic expenditure and factors associated with higher treatment costs. Uptake of primary care for skin disease doubled during the intervention period relative to the pre-intervention period (adjusted incidence rate ratio (aIRR) 2.0, 95% CI 1.92–2.09), with greatest increases amongst school-age children (aIRR 2.70, 2.46–2.97) and individuals residing within very rural communities (aIRR 2.79, 2.47–3.15). Amongst 42,801 individuals surveyed, odds of any skin disease were greater amongst males (adjusted odds ratio (aOR) 1.25; 1.13–1.38), pre-school age children (aOR=1.80, 1.61–2.80), and residents of very rural communities (aOR=1.68, 1.09–2.61). Males and school-age children remained underrepresented amongst those who sought care during the intervention period relative to those diagnosed during the survey. Amongst patients seeking care for skin NTDs and complex wounds, 4% experienced catastrophic expenditure, driven largely by costs prior to visiting an intervention health facility. Conclusions Greater integration within primary care substantially increased uptake of care for skin disease, but populations at greatest risk remained underrepresented amongst those accessing care. These findings highlight the need for deliberate strategies to address persistent barriers to care, with lessons for integration efforts across primary health systems. AUTHOR SUMMARY Why was this study done? Skin diseases are a common and major cause of poor health, but have historically received limited policy attention and remained a low public-health priority. Global recommendations have recently called for strengthening and integration of care for skin diseases into routine health services, but evidence for what is effective, fair and affordable remains very limited. We tested a new, comprehensive intervention in which health services for skin diseases were integrated into public primary health care in Atwima Mponua district, Ghana for one year. What did the researchers do and find? We compared the number of individuals who had sought care and were diagnosed with a skin disease across all public health facilities during the intervention period, as compared to the year immediately before (pre-intervention period). We also conducted detailed questionnaires with patients who received care, and a large community-based survey of skin diseases at the end of the intervention period. We saw that the number of skin disease cases doubled during the intervention period, with the greatest relative increases amongst school-age children (relative to other age groups) and people living in very rural communities (relative to urban and rural communities). Despite this, some of those at greatest risk of skin disease, including school-age children and males, remained disproportionately under-represented amongst those who had sought care; and around one in twenty individuals with a serious skin disease still incurred catastrophic out-of-pocket costs. What do these findings mean? Integrating health services for skin diseases into routine primary health care can successfully and substantially increase access to care, providing an effective strategy to achieve this urgent global health policy objective. However, integration with primary health care alone was not sufficient to ensure fair and equitable access, as some members of society continued to experience barriers to care for skin diseases. Beyond skin diseases, these findings can inform how routine healthcare for other public-health priorities can be better integrated into primary health care; but also the importance of identifying and targeting groups who may remain underserved by such approaches.