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PROPOSAL TO STRENGTHEN GHANA’S CAPACITY TO ADDRESS GROWING BURDEN OF DIABETES MELLITUS

Proposal to Strengthen Ghana’s Capacity to Address Diabetes Mellitus

An mHealth application of the Human Development Framework

STIA-375 Global Health EthicsGeorgetown University

Kelly Song, Simone Wahnschafft, and John Campbell

FINAL PROJECT PROPOSAL


To: United States Agency for International Development (USAID), National Institute of Health

(NIH), The Clinton Foundation, Bill and Melinda Gates Foundation

From: Kelly Song, Simone Wahnschafft, and John Campbell

Re: Proposal to Strengthen Ghana’s Capacity to Address Diabetes Mellitus

Date: April 2016

Abstract: In this proposal, we apply the human development ethical framework as put forth by

Alex John London in his article, “Justice and the Human Development Approach to International

Research," towards improving access to sustainable health services to address diabetes in Ghana.

This particular ethical framework focuses not only on sustainably improving health outcomes, but

fundamentally ensuring that individuals are afforded the opportunity to develop their most basic

capabilities and achieve a higher quality of life. In order to improve individual and population

health status proactively and, in particular, to prevent diabetes before its onset, a combination of

government facilities, NGOs, and the community will manage a new and innovative mobile

primary care technology program (mHealth) that would encompass four main pillars:

1. Improve the process of providing adequate supplies of medicines and laboratory tests.

2. Capacity building of health infrastructure via technology to sustainably transform and

better coordinate prevention and care.

3. Proactive prevention and evidence-based detection, treatment and management of

diabetes.

4. Patient engagement and mHealth tools for better care, access, and equity.

FINAL PROJECT PROPOSAL 2


Project Rationale, Goal and Specific Objectives

In the past decade, Ghana has significantly increased its government expenditure on

healthcare, demonstrating a marked shift towards prioritizing public health at the national level

(1). However, the country's healthcare infrastructure is still sparse and inadequate. Even within

cities, hospitals and emergency services struggle to keep up with growing need, especially as

non-communicable diseases (NCDs) become the country's next chronic health issue. Diabetes

mellitus, in particular, presents an increasingly growing burden, as diabetes prevalence continues

to increase with each passing year (2). Accessibility to healthcare institutions and workers is even

more limited outside of urban settings, where many patients in rural areas instead rely on African

traditional medicine because they cannot afford to travel long distances for healthcare. In many

developing countries such as Ghana, Western models of health care tend to emphasize improving

hospitals and curative care rather than addressing local health needs and the particular social and

economic context that determine them.

In this proposal, we apply the human development ethical framework as put forth by

Alex John London in his article, “Justice and the Human Development Approach to International

Research," towards improving access to sustainable health services to address diabetes in Ghana

(3). We have chosen the human development framework in particular because it recognizes and

emphasizes the role of social structure in influencing the health outcomes of a population and is

structured to justly distribute scarce resources to improve social fabric itself. In this sense, the

human development framework focuses not only on sustainably improving health outcomes, but

fundamentally ensuring that individuals are afforded the opportunity to develop their most basic

capabilities and achieve a higher quality of life. We believe a thorough consideration of the social

determinants of health, as afforded by the human development framework, is of utmost

importance for any strategy aimed to address NCDs such as diabetes in Ghana, since the rise of

non-communicable diseases is entwined in a broader social context of modernization,

development, and changing lifestyles.

The goal of this proposal is to improve individual and population health status

proactively and, in particular, to prevent diabetes before its onset, rather than treat the disease

reactively after the person's health has already been compromised. The program put forth in this

proposal will function to deliver diabetes prevention information and care in line with

international best practices by promoting changes in health behavior, providing outreach to

patients in their homes, and providing effective health services throughout the continuum of care

from prevention to follow-up. The intent is to incorporate the principle of distributive justice into



health systems planning to strengthen the institutional capacity of the public sector in Ghana and

increase both accessibility and sustainability of proper healthcare services. In doing so, the

program seeks to fill the gaps between the community's health needs and the capability of its

social institutions to meet those needs. Instead of allocating enormous amounts of time and

resources to completely breaking down and rebuilding the existing health structure in Ghana, this

proposal seeks to build on the current system effectively in the context of Ghana's healthcare

infrastructure and available resources. At the heart of this proposal is the definition of health put

forth by the WHO: “health is a state of complete physical, mental and social well-being and not

merely the absence of disease or infirmity" (4). For both short-term and long-term strengthening

measures, this proposal addresses diabetes in the context of the human development framework

with the intent of improving not only physical but social well-being and ultimately, quality of life

for diabetic patients.

Background and Significance

A few decades ago, diabetes was considered a disease of affluent societies; however, with

each passing year, the percentage of the global diabetic population residing in developing nations

continues to increase, as current predictions hold that by the year 2025, over 75% of people with

diabetes will be residing in developing countries (5, 6). In absolute numbers, most of these people

live in China and India (6). However, the burden of diabetes in sub-Saharan Africa (SSA) is

already substantial and continues to increase at a very rapid rate: current predictions estimate that

the number of people living with diabetes on the continent will almost double by the year 2030,

reaching approximately 18.6 million people (7). Ghana is no exception to this rapidly increasing

burden of diabetes. Though research into diabetes prevalence in Ghana is few and far between,

studies have demonstrated an increase in national diabetes prevalence from 0.2% in the late 1950s

to 6.0% in 2009 (8). In order to apply the human development ethical framework to this growing

issue of diabetes prevalence in Ghana, we must first understand the broader social, political and

economic context surrounding diabetes in both Ghana and Sub-Saharan Africa as a whole. In

accordance with the human development framework, our proposal ultimately aims to mitigate

existing weaknesses and build on existing strengths of Ghana’s available resources. This section

illuminates both the obstacles and opportunities that surround modern diabetes care in Sub-

Saharan Africa and Ghana.

Diabetes in Sub-Saharan Africa

Sub-Saharan Africa (SSA) has experienced remarkable economic growth in recent years,

leading to an improvement in the living conditions of its inhabitants (9). Modernization and



economic development have resulted in profound changes in African societies, which have

adopted Western lifestyles, especially in urban areas. A direct consequence of Westernization in

Africa is the increased prevalence of risk factors associated with non-communicable diseases

(NCDs) such as tobacco use, physical inactivity, harmful use of alcohol and an unhealthy diet.

All of these factors contributing to NCDs in SSA directly influence the growing diabetes

epidemic in particular. Moreover, Africa is currently undergoing an epidemiological transition

that is different from that of most western countries: the transition in Africa is following a

delayed model characterized by high fertility and high but reducing mortality, resulting in a

double demographic disease pattern (10). This means that the low-income economies of most

African countries and their strained healthcare systems have to grapple with the burden of

infections and chronic malnutrition in children, and obesity and cardiovascular diseases in adults.

Despite worrying figures, diabetes has only recently become a priority on the international

development agenda as a part of the Sustainable Development Goals (11). Consequently, the

support of donors and international organizations has lagged severely behind, given the rapidly

increasing severity of the diabetes epidemic.

Problems Confronting Diabetes Patients in Sub-Saharan Africa

Myriad factors act in concert to confound the impact of diabetes in SSA. Diabetes in the

region is associated with higher complication rates compared to developed countries. Because of

limited economic resources and poor healthcare systems, most diabetic patients are diagnosed at

advanced stages of disease progression when diabetes-related infections or complications, such as

retinopathy, nephropathy, foot ulceration, myocardial infarction, and stroke, already exist (12).

These complications have detrimental consequences for the patient, his/her family and,

consequently, society as a whole. Diabetic nephropathy is a major concern, given the fact that

once a patient reaches this stage of renal failure, therapeutic options are limited. Dialysis and

kidney transplantation are almost entirely inaccessible to the majority of patients in SSA (12).

Diabetic retinopathy is a leading cause of adult blindness, and diabetic neuropathy may lead to

lower extremity amputation. Moreover, foot complications are the leading cause of prolonged

hospital stays for people with diabetes in SSA and are in turn associated with high mortality (12).

Furthermore, essential insulin and other medications remain widely out of reach, due

either to their excessive cost or the unreliable and insecure supply chains that make these life-

saving supplies unobtainable. These previously mentioned burdens are related to health system

costs incurred by society in managing diabetes, the indirect costs resulting from productivity

losses due to absenteeism, patient disability and premature mortality, time spent by family



members accompanying patients when seeking care, and intangible costs like psychological pain

to the family and loved ones (13). Diabetes is an expensive disease, especially when the cost of

complications is considered, including the many diseases associated with diabetes that were

mentioned earlier. The International Diabetes Federation has estimated that, in 2010, national

funding for the health care of patients with diabetes mellitus in Africa was US$ 111 per person,

which already amounts to 7% of national healthcare expenditure (14).

On the African continent, the economic cost of diabetes and its accompanying

complications are unaffordable for most individual patients and their families. Often, national

funding is limited, and government subsidies are insufficient. Consequently, patients and their

families may have to spend significant proportions of their income on treatment for diabetes, a

level of expenditure that may not be affordable nor sustainable. In countries with an average

yearly income of about US$300, the care of a person with diabetes mellitus can cost as much as

half or two-thirds that sum, about half of which is the cost of insulin (15). Furthermore, diabetes

mostly affects people of working age. Therefore, a reduction in the economic activity of this

group and consequent loss of productivity can be anticipated with an impact on both household

and national economies (15).

Despite the high cost of managing diabetes, health care professionals are often more

focused on medical care than prevention, and the systems often suffer from inadequate health

policies and guidelines, a lack of human resources and medicines, and insufficient coverage of

service delivery. They are often poorly accessible, acceptable, affordable, or adequate, resulting

in the poor prevention and management of diabetes. The rapid development of short-term

complications (ketoacidosis, severe hypoglycemia – leading to coma and, if untreated, premature

death) constitutes a common threat to the majority of people with diabetes in sub-Saharan Africa.

Most of those affected by the dramatic increase in NCD prevalence are of working age,

provoking a significant loss of productive capacity. The impact of these indirect costs, added to

the direct treatment costs to individuals and healthcare systems, threaten to undermine already

fragile economies and choke development throughout the region.

Diabetes in Ghana’s Healthcare System

Ghana's healthcare system is no exception to the structural issues that hinder diabetes

care. The Ghanaian health care system is organized into three levels: tertiary (teaching hospitals),

secondary (regional and sub-regional hospitals), and primary (health centers and health posts)

(16). Ghana has no diabetes advisory board and no guidelines for diabetes care at any of these

health care levels (16,17). Data on diabetes mortality, morbidity, and disability trends are largely



unavailable though current estimates hold that there were approximately 450,000 cases of

diabetes in 2014 (18). Well-structured and appropriate diabetes education is lacking, and poor

understanding of the clinical complexity of the disease is a key cause of diabetic patients turning

to traditional medicine (19). Community prevalence surveys have demonstrated that a significant

proportion of Ghanaians with diabetes is not even aware of their condition (20). Furthermore,

management and self-care for the disease are extremely poor (21). A common practice amongst

people with diabetes in Ghana is healer shopping, where diabetic patients “shop" for healing

amongst different treatment services, including biomedical services, ethnomedical services, faith

healers and non-African complementary therapies (8,19). Though healer shopping is linked with

causal spiritual beliefs surrounding diabetes, the primary cause for healer shopping has been

attributed to be the high cost of biomedical care for diabetes (19). Ultimately, although steps have

been taken to mitigate issues of accessibility, such as the recent implementation of a national

health insurance scheme covering chronic conditions such as diabetes, the lack of accessibility to

existing resources and a lack of understanding surrounding the disease are critical issues of

Ghana's healthcare system that must be addressed. Therefore, developing and expanding the

reach of health systems down to the community level is a crucial approach to tackling the

diabetes epidemic in Ghana.

Population-wide strategies have recently been implemented to tackle the rising

prevalence of pre-obesity and obesity, through the government's National Diabetes Program,

which promotes collaboration between all government agencies (mainly the Health and Education

Ministries) and a series of multi-sector interventions aimed at improving the population's diet and

incentivizing physical activity (22). Ghana has also advanced in extending universal health

coverage through its national universal medical insurance system, the National Health Insurance

Scheme (NHIS), which has granted nominal coverage to previously uninsured populations,

funding all primary health-care interventions, 95% of second-level care and implementing a

reimbursement fund to cover the most important tertiary healthcare interventions (23). However,

NHIS does not guarantee full access to effective health care, due to inefficiencies in health care

infrastructure such as the insufficient and irregular supply of medicines, lack of access to

laboratory tests, and inadequate coverage of health services.

Proliferation of Mobile Technologies in Ghana

In just a few years, the proliferation of mobile phone networks has allowed Africans to

leapfrog the landline stage of development and jump to a point where cell phone use pervades

society. Amazingly, according to the Pew Research Center Spring 2014 Global Attitudes survey,



83% of adults in Ghana own a cell phone, just behind the 89% of adults who own a cell phone in

the U.S. (28). Currently, the sixth most common use of mobile phones in Africa is to get health

information (28). Although only 14% of cell phone owners in Ghana own a smartphone, the

numbers are growing rapidly, especially in urban areas (28). While it may be a challenge to

distribute smartphones to the majority of Ghanaian patients, doing so would be much more

efficient and effective than completely renovating Ghana's health infrastructure and, in line with

the human development approach, focuses on an effective allocation of existing resources in the

Ghanaian health care system. While Ghana's healthcare system improves at its own pace, our

project will focus on Ghana’s strength in mobile technologies, specifically on its mobile phone

networks.

Project Design and Methods

Human Development Framework Applied

The human development approach presents a nuanced model for ethical considerations

surrounding diabetes care in Ghana. As highlighted in the background discussion, the situation

for diabetic patients in Sub-Saharan Africa is characterized by fundamental issues of distributive

justice, as existing biomedical services are largely inaccessible to the majority of the population

due to high costs as well as a lack of education surrounding the disease. One of the central tenets

of the human development framework is the idea that social structure, primarily the governmental

and health institutions for a given community must provide each person the “opportunity to

cultivate their basic intellectual, affective and social capabilities to pursue a meaningful life plan"

(3). It is when this fundamental condition is not met that poor health outcomes arise, and

obligations exist to allocate resources towards sustainable improvement of these social structures

to foster human development. In Ghana, fundamental issues of health education, availability and

accessibility of services, and health service delivery have resulted in very poor support at the

institutional level for people suffering from diabetes. From a fundamentally ethical point of view,

an obligation exists to strengthen the capacity of the Ghanaian health care system to address these

issues of accessibility so that diabetic Ghanaian citizens are afforded the opportunity to take

control of their own health. An effective solution for addressing diabetes in Ghana, therefore,

must be aimed towards fostering the capabilities of diabetes patients to better access healthcare

systems and manage their disease within the context of Ghana's current healthcare system. Thus,

rather than focusing on improving direct medical services for diabetes in Ghana, this proposal



turns rather to an innovative solution to help diabetic patients more efficiently access existing

resources in Ghana's healthcare system.

Assessing Local Health Needs

We have chosen three communities outside the capital city of Accra to establish active

research field sites in: Jamestown, Ussher Town, and Agbobloshie. These urban poor

communities, with high rates of diabetes, were chosen as locations that are within reasonable

distance of existing healthcare services for diabetes, but who lack accessibility to these services.

We believe that we can begin the project in these communities in order to assess if and how we

will be able to expand the project to more rural communities throughout Ghana going forward.

The human development framework situates the health needs of a population within the social

determinants of health to determine the allocation of resources best suited to sustainably targeting

the heart of these health needs. However, due to a dearth of the overall investigation into the

specific needs of Ghanaian communities that are struggling with diabetes, the first goal of this

project is to identify the particular needs of these communities in which we intend to launch this

project. To do this, we will gather available epidemiological information from national, regional,

and local sources to confirm or learn more about diabetes in Ghana. This will give us information

about the use of local health services and build a picture of the health needs of the local

populations. For example, hospital inpatient records can be obtained to study numbers of

admissions, the cause of admission, and length of stay and outpatient consultations can be

explored for patient diagnoses and volume. Since many patients may not have checked into a

hospital, workplaces can also provide data for absences due to sickness and available

employment health checks (24). We will supplement this general patient health information with

community appraisals to involve the local people, giving them the opportunity to participate in

health planning, while allowing us to perceive better strengths and weaknesses of diabetes

services. We will identify a group of 15 to 20 individuals in each community who are considered

to be community leaders representing the interests of their community across various sectors like

health, education, business, agriculture, faith and ethics at the national level. This group will

include people with expertise in public health as well as members or representatives of the

medically underserved, low-income, minorities, and populations with existing diabetes needs. We

would involve all of these actors in an active consideration of the principle of distributive justice

in relation to both this project and diabetes care in general. We will organize a meeting to explain

to them our goal for diabetes prevention and better health, then ask them to elaborate on the

following:



1. Describe all of the local health services you are aware of.

2. Please locate these available health services.

3. Explain the hospital’s services, facilities, and community benefits.

4. What are the symptoms of diabetes?

5. What do you or others do if you suspect you have diabetes?

6. Are healthcare workers and treatment accessible?

These discussions will further inform us on the strengths and weaknesses of local health

systems in Ghana and how our project can best approach our goal of building on existing

strengths of Ghana’s available resources to strengthen distributive justice in the context of a

diabetes strategy.

Overview of Project

Ghana is currently facing a dramatic increase in the number of adults suffering from non-

communicable diseases (NCDs) such as diabetes, cardiovascular disease (CVD) and chronic

kidney disease (CKD), which all require prolonged, continuous care. This epidemiological shift

has created new challenges for healthcare systems. Both the World Health Organization (WHO)

and the United Nations (UN) have recognized the growing human and economic costs of NCDs

and outlined an action plan, recognizing that NCDs are preventable, often with common

preventable risk factors linked to risky health behaviors. In line with international best practices,

Ghana has attempted to address a number of approaches to tackle these diseases. However,

challenges remain for the Ghanaian healthcare system, and in planning a strategy for combating

and preventing NCDs, it must consider how best to integrate these strategies with existing

healthcare infrastructures. Shifting the paradigm of care in Ghana from a curative, passive

approach to a preventive, proactive model will require an innovative and replicable system that

guarantees availability of medicines and services, strengthens human capital through

ongoing professional education and capacity building, expands early and continuous access to

care through proactive prevention strategies, and incorporates technological innovations in order

to do so. Here, we propose Mobile Technology for Prevention of Diabetes (MoPD): an innovative

model in healthcare that leverages international best practices and uses innovative technology to

deliver type 2 diabetes care, control, and prevention.

Applying the human development ethical framework to the issue of care for diabetes

patients in Ghana, there is a need to expand the capacity of basic social structures to meet



distinctive health priorities of the Ghanaian community's members, or otherwise meet their basic

health needs given the biomedical resources available in Ghana's healthcare system for diabetes.

A combination of government facilities, NGOs, and the community will manage this program,

maximizing participatory decision-making and, therefore, strengthening capacity for ethical

decision-making and improving access. This innovative mobile primary care technology would

encompass four main pillars:

1. Improve the process of providing adequate supplies of medicines and laboratory tests.

2. Capacity building of health infrastructure via technology to sustainably transform and

better coordinate prevention and care.

3. Proactive prevention and evidence-based detection, treatment and management of

diabetes.

4. Patient engagement and mHealth tools for better care, access, and equity.

To address the first component of our innovative mobile primary care technology,

providing adequate supplies of medicines and laboratory tests, the mHealth app will incorporate

daily tracking of mobile health units that carry health workers and medication to and from urban

and rural areas (26). This part of the app will follow the model of NextGUTS, Georgetown

University's app to track GUTS buses in real time (27). This would expand access to care for

diabetes patients in rural areas who are unable to access health facilities otherwise. By devising

consistent daily routes for the vans to travel throughout different communities and allowing

patients to see on their mobile phones when and where these vans will stop, we are seeking to

bring the necessary care from hospitals and clinics to individuals who need it.

Regarding the second and third components to strengthen human capital through ongoing

professional and practical education and to incorporate proactive prevention strategies that would

reach individual households and entire communities, we propose iMED: an Integrated

Measurement for Early Detection. iMED, the core innovation for this model, aims to move away

from the traditional dual approach of classifying individuals as sick or healthy and instead applies

systematic risk assessment to patient screening, identifying people as healthy, at risk (or pre-

disease) or sick. Identifying individuals at a pre-disease stage is a recommended practice to

reduce significantly the burden of disease (25). iMED assessment is available in two formats: the

first is provided by nurses in primary health care settings and urban centers using an iMED

Mobile Module; the second is designed for nurses to administer in patients' homes, using Portable

iMED.



Clinics and public places: iMED Mobile Module

Health professionals can assess NCDs either at a clinic or in public

places, including supermarkets, community centers, and outside schools. It

also includes personalized handouts to provide recommendations and

treatment options according to the level of risk detected for each disease.

Household and community outreach: Portable iMED

Community healthcare practitioners (HCPs) can assess diabetes,

hypertension, and their preceding conditions in the community or household

using Portable iMED, an all-in-one system with a blood pressure meter and

glucometer connected to a mobile phone via Bluetooth. Personalized

recommendations, aimed at preventing NCDs, are given depending on the

patient's level of risk. HCPs can refer any patients found to have an NCD to a

clinic to confirm the diagnosis and start treatment immediately.

For both iMED Mobile Module and Portable iMED, measurements of weight, height,

blood pressure and blood glucose are transmitted wirelessly via Bluetooth to a laptop or a mobile

phone, where the iMED information system sends the data to a cloud storage provider and

performs analysis to provide HCPs with up-to-date information to support them in evidence-

based decision-making.

iMED directly applies to the human development framework by allowing for mass

screening, thereby increasing education and early access to primary healthcare services. A central

tenet of the framework emphasizes the role of social structure, particularly health institutions for

a community to provide each person with the capabilities to pursue how they want to live.

Without access to health education or health care services, poor health outcomes arise and this

fundamental condition is not met. Therefore, iMED seeks to meet the obligation to allocate

resources towards sustainable improvement of these social structures to foster human

development. In Ghana, issues with health education, availability and accessibility of services,

and health service delivery have resulted in very poor support at the institutional level for people

suffering from diabetes. Treatment through a personalized set of recommendations encourages

informed decision-making and patient responsibility for their own health.

The human development framework focuses not only on sustainably improving health

outcomes in the long run, but also on fundamentally ensuring that individuals are afforded the



opportunity to develop their most basic capabilities and achieve a higher quality of life. For

iMED to effectively achieve its fourth component of expanding early access to health care

through the strategic use of a mobile app and its complementary technologies, patients will need

tools to support them in taking responsibility for their own health, post-screening. For this, we

will implement an innovative solution via mobile phone and the Internet: The Sweet Life: A

Diabetic’s Diary—an application for people living with diabetes.

The fourth and final pillar of this project is encompassed in The Sweet Life: A Diabetic’s

Diary. This is a mobile application that focuses on the empowerment of patients already

diagnosed and living with diabetes. Its main objective is to improve their compliance with

treatment, thereby helping them achieve effective control of the disease, averting complications

and improving quality of life significantly.

The application gives diabetic patients the ability to access personalized monitoring

protocols, including reminders for taking medicines or attending doctors’ appointments, an

educational platform to learn more about the disease, and an application to self-assess risk and

health status. Additionally, individuals can register their glucose, blood pressure, weight and

various laboratory tests, and the application will immediately provide feedback based on the

results. Information on health indicators is stored securely and can be monitored by the individual

through a web page indicating their level of risk and giving recommendations on when to seek

medical attention.

Using a structured process to deploy these four components, our innovative mHealth

technology would ideally enhance healthcare delivery, increase the capacity of services, and

improve both the efficiency and quality of care for diabetes patients in Ghana. These are all in

line with the human development framework, under which we seek to fulfill our ethical

obligation to strengthen the capacity of the Ghanaian health care system to address its issues of

accessibility so that diabetic Ghanaian citizens are afforded the opportunity to take control of

their own health. A focal point of this proposal is the distribution of smartphones to patients who

would then download and use our MoPD technologies for diabetes. While Ghana's healthcare

system improves at its own pace, we can distribute smartphones with the mHealth app

downloaded, along with simple instructions for using the app to Ghanaian clinicians and local

health workers to then pass on to their diabetes patients to use. For those patients in rural settings

who lack access to healthcare and are most in need of this app, we will have Ghanaian health

workers and volunteers travel by vans we provide to distribute smartphones with the app and app

instructions.



The iMED and The Sweet Life applications would give diabetes patients control of their

own health by helping them record blood pressure, track dietary and exercise habits, as well as

providing them with information to improve education surrounding the disease. With every input

of blood sugar level, the app will notify the patient if it is approximately high, low, or normal

range, based on standard thresholds. Also, the patient can use the app to set reminders for when to

take insulin. This application would be developed alongside doctors from the U.S. and Ghana,

allowing for accurate professional and practical education on diabetes to be immediately

accessible via smartphone for anyone who downloads the app. The use of this app would promote

a healthy lifestyle that could prevent diabetes for at-risk individuals and encourage consistent

treatment for those already living with the disease.

Accessibility and usability of our MoPD technologies depend heavily on the literacy of

the patient in the languages offered by our applications. The official language of Ghana is

English, so that will be the primary language used in our technologies (29). However, we

acknowledge that there are also nine other very diverse government-sponsored languages: Akan,

Ewe, Dagbani, Dangme, Dagaare, Ga, Nzemaa, Kasem, and Gonja (29). In an effort to make

MoPD accessible to as many Ghanaian patients as possible, we will conduct a pilot program to

offer our technologies in three additional local languages other than English. These will include

Akan, the most widely-spoken language in Ghana, Ga, the language spoken most in and around

Accra in the southern region, and Gonja, which is widespread in Ghana’s northern region (30).

As our MoPD technologies begin to improve healthcare for Ghanaian patients, added language

versions will allow for even greater accessibility for those who are less comfortable with English.

Organization & Funding

This operation would be financed by a group of established, international health institutes

from U.S. universities like Georgetown, and/or foundations like USAID, NIH, the Clinton

Foundation, or the Bill and Melinda Gates Foundation. We would submit our proposal to access

their resources and assistance to pay for development of our mobile app, supply of smartphones,

and training of healthcare workers. After reaching out to established health institutes, we would

take an approach of public-private partnership with local NGOs in the Ghanaian communities we

are looking to implement this project in. We would also partner with both the Ghanaian Ministry

of Health and the Ghana Health Service to identify local NGOs that have strong relationships

with the national government. We believe that this sort of partnership would present the most

effective and sustainable approach to the implementation of this project. We fundamentally want



to ensure that Ghanaian health priorities remain at the heart of this project and thus, private-

public partnership is key to the ethical implementation of this innovative technology.

Prevalence, morbidity, and mortality of type 2 diabetes is rising rapidly in Ghana and

represent a crisis that must urgently be tackled. Both the Ghanaian government and Ministry of

Health have acknowledged that a radical change of health-care paradigm is required to reflect this

epidemiological shift; health care must now move towards a proactive, preventive model

incorporating community outreach rather than the traditional passive, therapeutic, hospital-

centered approach. Fundamentally, MoPD offers a comprehensive, integrated, sustainable and

innovative health-care model to ensure effective access to continuous health care and to combat

NCDs like type 2 diabetes. Through the initiatives described here, MoPD delivers solutions to the

type 2 diabetes crisis facing Ghana, along with the rest of Sub-Saharan Africa, based on its four

key design principles and aims to optimize the existing health care system and sustainably change

the healthcare paradigm, providing hope for combating Ghana's current NCD epidemic.

Evaluation

This project will be evaluated based on how well it fills the gaps between the Ghanaian

community's health needs and the capability of its social institutions to meet those needs. One of

the fundamental goals of this initiative is to empower diabetic patients in Ghana to take active

control of their health by increasing their access to existing healthcare services through our

mobile app. The success of this goal will be evaluated via tracking of the number of people who

activate the application on their mobile phones and continue to use it consistently every week.

The app will allow us to measure the number of users and track usage through phone data and app

support. This information will be compiled into monthly progress reports that will be reviewed by

our team at Georgetown and distributed to donor foundations of the project for further review.

Furthermore, health providers will be able to track this app usage every month, through internet

software created by the app developer.

Another goal of this project is to improve the access to adequate supplies of medicines

and laboratory tests via real-time tracking of mobile health units. The success of this objective

will be evaluated based on feedback forms and records that health workers traveling in the vans

will keep. This information will include a number of patients, distribution of medication, and

health status of individuals in communities, as well as qualitative feedback from patients

regarding their perception of the effectiveness of the app in helping them meet their daily needs.

These forms will be incorporated into the aforementioned progress reports to ensure that the

effectiveness of this initiative is actively assessed. A third specific objective of this project is to



improve the general education of both health providers and patients surrounding diabetes. This

will be evaluated primarily through periodic surveys sent via our app, which will be completed

anonymously via recipient mobile phones and compiled as another important facet of monthly

progress reports. Data from compiled reports will be discussed in bi-monthly meetings with

healthcare providers and NGOs in Ghana and America via teleconference to actively incorporate

feedback into the sustainable improvement of this project to effectively cater to the health needs

of diabetic patients in Ghana.

Ultimately, the goal of this project is to proactively foster human development by

increasing the capacity of the Ghanaian healthcare system and incorporate the principle of

distributive justice to improve accessibility to health care for Ghana’s rapidly growing diabetic

population. Though this initiative is only one of many steps that must be taken in order to control

the diabetes epidemic in Ghana, this project sets an ethical precedent for future projects to

address diabetes in an effective, sustainable and holistic manner to promote health as not merely

the absence of disease, but a state of physical, social and mental well-being.



References

1. The World Bank, “Health expenditure, total (% of GDP).” 2015.2. The World Bank Cross Country Data, “Ghana: Diabetes prevalence (% of population ages 20 to 79).” 31 July 2015.3. John London, Alex. “Justice and the Human Development Approach to International Research.” Carnegie Mellon University. January 2005.4. World Health Organization, “WHO Definition of Health.” 7 April 1948.5. Kirigia, J.M., et al., “Economic burden of diabetes mellitus in the WHO African region.” BMC International Health and Human Rights, 9(6). 31 March 2009.6. International Diabetes Federation, “IDF Diabetes Atlas: Sixth Edition.” 2013.7. Azevedo, M. and Alla, S., “Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia.” International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108. 2008.8. de-Graft Aikins, A. et al., “Diabetes in Ghana: A Review of Research on Prevalence, Experiences and Healthcare.” University of Ghana, Balme Library. 2012.9. International Monetary Fund, “Sub-Saharan Africa: Navigating Headwinds.” World Economic and Financial Surveys. 15 Apr. 2015.10. Agyei-Mensah, S. and de-Graft Aikins, Ama., “Epidemiological Transition and the Double Burden of Disease in Accra, Ghana.” Journal of Urban Health. 87(5): pp.879-897. Sep 2010.11. United Nations Development Programme, “Sustainable Development Goals (SDGs).” 25 Sep. 2015. 12. Mbanya, J.C.N., et al., “Diabetes in Sub-Saharan Africa.” The Lancet, 375, pp. 2254-66. 2010.13. Hossain, P. et al.,”Obesity and diabetes in the developing world – a growing challenge.” New England Journal of Medicine, 356(3), pp. 213-215. 2010.14. International Diabetes Federation, “Diabetes Atlas, IDF: Fourth Edition.” Economic Impact of Diabetes. 2009.15. Hall, V., et al., “Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review.” BMC Public Health, 11(564). 2011.16. Amoah, A.G.B. et al., “A National Diabetes Care and Education Programme: The Ghana Model.” Diabetes Research and Clinical Practice. 49(2-3): pp. 149-157. Aug. 2000.17. de-Graft Aikins, A. et al., “Lay Representations of Chronic Diseases in Ghana: Implications for Primary Prevention.” Ghana Medical Journal. 46(2): pp. 59-68. Jun. 2012.18. International Diabetes Federation Africa, “Diabetes in Ghana.” 2014.19. de-Graft Aikins, A. et al., “Healer Shopping in Africa: New Evidence From Rural-Urban Qualitative Study of Ghanaian Diabetes Experiences.” British Medical Journal. 331(7519): pp. 737. 2005.20. Addo J. et al., “Prevalence, detection, management, and control of hypertension in Ghanaian civil servants.” Ethnicity and Disease.18: pp. 505–511. 2008.21. Ofei F. et al., “A preliminary study of self-care behaviour among Ghanaians with diabetes mellitus.” Global Medical Journal. 36(2): pp. 54–59. 2002.22. World Diabetes Foundation, “National Diabetes Programme WDF08-403.” 2015.23. Center for Health Market Innovations, “Ghana: National Health Insurance Scheme.” 2015.24. Vaughan J.P et al., “Manual of epidemiology for district health management.” World Health Organization. 1989.25. Center for Disease Control and Prevention, “The Power of Prevention: Chronic Disease – The Public Health Challenge of the 21st Century.” 2009.26. “Mobile Clinics for Specialist Patient Outreach Services Received by Ghana Ministry of Health.” Odulair: Healthcare Where You Need It. 19 May 2013.



27. Georgetown University, “New Mobile App Allows Users to Track GUTs Buses.” 15 Apr. 2013. 28. “Cell Phones in Africa: Communication Lifeline.” Pew Research Center. 15 Apr. 2015. 29. "The Bureau Of Ghana Languages-BGL". National Commission on Culture. 2006. Retrieved 11 November 2013.30. "Introduction To The Verbal and Multi-Verbalsystem of Akan" (PDF). ling.hf.ntnu.no. 2013. Retrieved16 November 2013.


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