Ghana, like most of sub-Saharan Africa (SSA), faces a double burden of disease. 1 While infectious diseases like malaria have always been of prime importance, with the epidemiological transition in SSA, non-communicable diseases (NCDs) have increasingly become leading causes of mortality and morbidity. 2 It has been projected that by 2030, NCDs will be the foremost cause of death in the region exceeding deaths from communicable, maternal, perinatal and nutritional diseases. 3 In 2015, NCDs accounted for a productivity loss of over Int$1.1 trillion in Africa, the highest for any disease group measured.45 Cardiovascular diseases (CVDs) such as coronary heart disease and stroke account for the majority of NCD-related deaths. 6 The leading modifiable risk factor for these CVDs is hypertension which has its highest prevalence in African countries. 7–9 In Ghana, for instance, a meta-analysis by Atibila et al. 10 reported the prevalence of hypertension in the general population to be 30%, rising to approximately 44% in the adult population. Additionally, hypertension has been recognised as the leading cause of disability among Ghanaian adults. 11
This double burden of disease has not only put a huge strain on the limited healthcare resources in Ghana but, given the historical epidemiological dominance of infectious diseases, the allocation of healthcare resources in the region has been and continues to be disproportionate with less focus being placed on hypertension and other NCDs despite their increasing relevance.2 That is to say, healthcare resource allocation in the country has failed to correspondingly evolve with the epidemiology. Data from the Ghana national health accounts published in 2017 showed that of the over GH₵8 billion spent on healthcare in 2015, only 12.6% was spent on NCDs compared to approximately 40.8% on infectious diseases.12 The same trend was reported over the previous 2 years.12 Consequently, access to healthcare for NCDs has been inadequate. Kushitor et al.13 reported from their study that only 35% of healthcare facilities in Ghana had essential drugs for diabetes and hypertension.
It was against this backdrop that Ghana was hit by the COVID-19 pandemic. The WHO reported that the pandemic and its associated measures resulted in the disruption, and in some cases, collapse, of essential health services in almost all countries (about 90%); however, these disruptions were more severe in low- and middle-income countries (LMICs).14 African countries were some of the most affected with the disruption of a median of 60% (up to 90% in some African countries) of all essential health services including those for infectious diseases; maternal, reproductive and child health; emergency care; as well as those for non-communicable diseases.14 The disruption of health services is particularly important in the case of NCDs as these diseases not only require long-term care but can progress into advanced stages and result in severe complications without showing significant symptoms.15,16 In some cases, such complications may be the first manifestation of the disease.15,16 For hypertension, also referred to as the “silent killer”, some patients may first present with major cardiovascular events such as strokes or myocardial infarctions. Even for those diagnosed, poor management may still result in these cardiovascular complications and others such as kidney failure.17,18 Disruption of healthcare for hypertension leads to delayed or forgone care which results in a significant increase in mortality and morbidity and, resultingly, an extortionate social and economic toll. It has been globally acknowledged that these pandemic-related health service disruptions would have long-term effects on health systems and population health, necessitating research to quantify and understand the impact of these disruptions, particularly in LMICs where systems were already fragile.14
Research has been underway in Ghana to explore the impact of COVID-19 and its associated measures on various dimensions of life and well-being. During the peak of the pandemic, lockdown policies which impacted accessibility to health facilities, the closure of health facilities as a consequence of health workers having to be quarantined or isolated, and the continuous prioritization of COVID-19 over other health conditions have left lingering effects.19,20 Aberese-Ako et al.21 from their study on the socioeconomic and health effects of COVID-19 among rural and urban slum dwellers found a significant change in health-seeking behaviours during the pandemic with over 65% of participants from their study reporting anxiety and fear to seek healthcare even when they were unwell. Kawakatsu et al.22 also examined the effect of COVID-19 on essential health service utilisation (comprising maternal care, child health and general outpatient care) across the country and reported a loss of 3,480,292 (95% CI: −3,510,820 to − 3,449,676) outpatient visits by November 2020. Limited research has, however, focused on the impact of COVID-19 on NCDs such as hypertension in Ghana. Studies such as that by Mustapha et al.23 which highlighted a 64% increase in the adjusted prevalence ratio of poor glycaemic control in diabetes management during the pandemic, have investigated the impact of COVID-19 on NCDs but from a more epidemiological stance. There is a dearth of studies that have investigated and quantified the impact of COVID-19 and its associated measures on NCDs focusing on health service utilisation.
Given the economic and disease burden of hypertension in Ghana, especially those likely to result from complications due to disruptions in care, it is necessary to quantify the impact of COVID-19 on the management of hypertension to inform policymakers and other relevant stakeholders. Using claims data from the Ghana National Health Insurance Authority (NHIA), this study investigates the impact of the pandemic on the management of hypertension by identifying the changes in disease severity, in use patterns and the resulting changes in expenditures for the condition.