This paper moved away from the most frequently reported social science studies on BU with emphasis on socio-cultural aspects of the disease including perceptions, attitudes toward treatment and economic burden of disease to patients and their families
[6–8, 10, 12, 13] to focus on how to increase access to early case detection, diagnosis and treatment as well as how to reduce treatment default and dropout during the course of 56 days antibiotic treatment. Building on the BUPaT project
; the social intervention was to remove socio-economic challenges to accessing treatment once diagnosis was made. However, this project was different from BUPaT in many ways as treatment/management was organized on an outpatient basis with no hospital admission; also daily breakfast and transportation were provided for each patient. Results reported in this paper showed that when various interventions are implemented together, they could enhance effective early case detection; diagnosis and treatment with little default and drop out. Whereas, the BUPat project has reported challenges with lack of hospital ward space
, this was not the case in the current intervention as patients were supported to come from home to the clinic on daily basis. While in the BUPat project caretakers accompanied patients to the hospital and stay with them as long as the patient remained on admission, thus raising the issue of space at the wards for patients and accommodation for caretakers
. This also took caretakers away from their daily subsistence work. The current study did not subject caretakers to such activities nor were they taken away from their daily works, thus caretakers were not on ‘admission’ together with the patients and therefore able to take care of other pressing needs while the patient receive treatment at the hospital on an outpatient basis.
The provision of breakfast and transportation means that school children could receive daily treatment on time, have breakfast and be conveyed back to school on time in order not to miss any lesson and thereby removing the incentive of dropping out of school.
The relevance of the five dimensions of access to health care  cannot be overemphasized. Availability issues were addressed in this intervention by ensuring that the intervention health facility at Obom was ready to deal with the health needs of BU patients when referred there. To achieve this, training was organized for the staff on BU management including sample taking and wound dressing. Also, some basic supplies were made available to the health centre from time to time to ensure that they do not run out of stock necessary to meet the needs of BU patients effectively. In terms of accessibility, the project ensures that BU management services are provided at a location acceptable to patients. However, the challenge of accessibility was addressed by the provision of free transport to carry patients to and from the clinic on daily basis. Affordability, which deals with the ability of patients to pay for the cost of the health care service being provided with very little or no difficulty, was removed completely because BU treatment is generally free in Ghana and all other associated cost including transportation were taken care of by the Stop-Buruli project. The issue of adequacy was addressed by making sure that whatever services that are being provided meet the needs and expectations of BU patients. To make the service acceptable, providers were encouraged and motivated to develop attitudes and atmospheres that make BU patients feel at home and willing to come to the clinic on daily basis for 56 days or more.
The number of cases referred by community-based volunteers had increased significantly during the implementation of the intervention. This increase could be attributed to the incentive schemes put in place to reward hardworking volunteers. Besides the token given for each case referred, the provision of bicycles to them for easy movement within the community had also contributed to the surge in cases being referred. This has confirmed the fact that for volunteers to work effectively, a reward system is required to reward hardworking ones among them. These incentives do not have to be anything too big but the mere fact of knowing that one’s work is being recognized and appreciated is enough incentive to most community based volunteers.
Traditional healers did not contribute much to case referrals but it was symbolic to collaborate with them as this could influence what they do and how long they may keep patients before referring them to the clinic. In the light of this, the three cases referred by them should be seen symbolically as a good starting point taking into account the fact that they were not referring any case prior to the implementation of the intervention.
It has been demonstrated from this study that it was not only possible to increase BU early case detection and diagnosis but also to effectively treat BU patients on outpatient basis at health centres to significantly reduce in-patient pressure on the health facilities in terms of space for admission. Hospital admission do not only put pressure on the health facility but also on the family caretakers who have to stay on ‘admission’ with the patients for as long as it takes to get the patient discharge from the hospital
. In this study, caretakers were not even accompanying patients to the health centre and this made it possible for them to go about their normal daily works while patients receive effective treatment from the health centre.
For programme implementers, the need for retaining community based volunteers, the formation of former patients clubs, organization of community outreaches education and screening are recommended to enhance early case detection and treatments. However, in order to encourage patients from poor communities to start and complete treatments, the provision of transportation to and from clinic as well as breakfast after drug administration could enhance attendance to reduce treatment dropout and default significantly.
In implementing interventions such as reported here involves some cost but the cost of this intervention should not be over exaggerated because in the long run it may be cheaper to implement these activities to diagnose and treat patients early as outpatient than to receive them late and keep them on admission, which may require surgical interventions in some cases. Given that only about 2000 cases are reported annually in Ghana and assuming that this number will go up to about 2500 annually due to improved active case searching, it should be possible for the Government, through the district assemblies and in collaboration with the Ghana health service, to raise sufficient funds to support this important intervention in poor communities. Early case detection will prevent surgery in the future and this will save a lot of money for the health system as most of the cases will get healed with antibiotic treatment and adequate wound care”. BU affects mostly the poorest of the poor and this should be enough motivation for implementing interventions to reduce the disease burden on this vulnerable population. However, there is a need to do cost effectiveness analysis to determine the cost benefits of the interventions reported in this study.
For interventions such as reported in this paper to be successfully implemented, there is a need to involve stakeholders, especially community groups and health care workers at the periphery facilities who will attend to the patients when referred. Involving the local people will help us to know their needs instead of assuming that money is their problem. In fact, doing so, we realized that the patients do not need money but a means of transport and readily available breakfast to take after drug administration, hence the introduction of these two social interventions. Health facilities could easily be overwhelmed by the number of cases that they see on daily basis and if they are not involved in planning for these cases, could affect the quality of care that are given and this may work against the intended purpose of the intervention.
Weaknesses of the study
One major weakness of this study is that it was not a randomized control trial and therefore one could not tell the actual contribution of each intervention to the increased number of cases seen at the clinic as well as the near elimination of treatment default and dropout. Also, the study was purely qualitative besides the clinic records evaluated therefore results could not be generalized. However, we believe that this has been compensated for by the baseline data and the presentation of qualitative narratives to express the actual feelings of respondents.