1. Background
District hospitals in Ghana serve as focal points for the deployment of the state’s clinical and public health machinery, thus, placing these hospitals at the epicenter of the national COVID-19 pandemic control agenda (1). The pandemic has been experienced differently in various institutions but the commonality is that no centre was truly prepared for what was about to hit the world in waves (2).
During the peak of the COVID-19 pandemic, the Agogo Presbyterian Hospital (APH), a secondary centre, took a number of steps to address the health concerns of both staff and patients. There were a series of management meetings to discuss measures to address the problems posed by the pandemic on the hospital’s services. These measures included a ‘no mask, no entry’ policy within the hospital premises and a temporary suspension of all face-to-face gatherings. To limit patient crowding at the out-patient clinic and the general wards, all elective surgeries were also suspended for three months. The clinical team of doctors, nurses and biomedical scientists instituted measures including restricting the number visitors per patient, and the wearing of protective gear during working hours. All other COVID-19 protocols for handwashing and hand sanitization with alcohol-based solutions were adhered to as well.
A special COVID-19 task force was constituted to spearhead the pandemic control effort in APH and their task included arranging the isolation, testing, quarantining and follow-up for staff and patients who had a suspected or confirmed diagnosis of COVID-19 infection. The implications of these measures taken needed to be strategically evaluated to identify key lessons that can further enhance the effectiveness of service delivery in the hospital (3) in the face of a diverse and an unpredictable future.
2. Objectives
This case study employs a Strength, Weakness, Opportunities and Threat (SWOT) analytical approach to examine a range of COVID-19-related events occurring in APH since March 2020. The SWOT analysis has the capacity to situate the entire crisis within a ‘corporate strategy’ context which when implemented successfully, could shape the future of the hospital by making it more competitive, efficient and effective (4, 5) while it takes concrete steps toward crisis-resilience, emergency preparedness and enhanced crisis responsiveness.
3. Methods
This is an analytical case study examining the events that transpired at the Agogo Presbyterian Hospital during the peak of the COVID-19 pandemic. The purpose of this design was to unearth the peculiar experiences, challenges and success stories relating to the battle against COVID-19 at APH and draw out lessons strategically beneficial to APH and other district hospitals.
3.1. Data Collection
With the consent of the Agogo Presbyterian Hospital, the data for this research was obtained from the decisions communicated and implemented by departments and agents of the hospital with regard to addressing the COVID-19 outbreak. During the peak period of the COVID-19 pandemic, the observed individual and collective human behaviours within the hospital, the problems that arose and decision implementation outcomes were profiled for examination and analysis.
3.2. Data Analysis
The Strength, Weakness, Opportunities and Threat (SWOT) analysis is a tool originally devised within the domain of strategic management but has now found productive usage in other fields such as healthcare administration. This tool serves to dissect the given situation with a balanced view of the contributory role of all factors while depicting how much stakeholders are also impacted by the situation. The data retrieved was subjected to a thematic analysis and then the emerging themes, subsequently subjected to a SWOT analysis. The resultant core themes arising were simplified into bullet points that had unique significance for this setting and other district hospitals.
4. Results and Discussion
4.1. Strengths
Despite the general panic and the shortage of appropriate protective garments, the COVID-19 task force that was constituted did well to coordinate the isolation, testing and care of suspected COVID-19 patients to the admiration of many.
It was noted that widespread solidarity, empathy and beneficence motivated APH staff to continue to deliver services during the peak of the COVID-19 pandemic. The value of such innate motivations should be viewed as strategic assets that can be leveraged for attaining larger organizational goals (6) going forward. It would be advisable for management also to explore innovative ways of nurturing and sustaining these innate motivations. These include rewarding exceptional staff efforts with sponsored career development opportunities. Other approaches include instituting an objective and supportive performance appraisal system that aims to get staff to own their results while constantly pushing the boundaries of excellence. This would be an instrumental addition to the existing organizational culture of commitment and diligence.
4.2. Increased Volumes of Surgeries
In the year 2020, there was an overall increase in the volume of surgical operations done in APH from 3881 in 2019 to 4022 in 2020 despite the three-month suspension of elective surgeries in 2020. The reasons for this observation are multiple, but it is tempting to attribute this observation in part to the increased number of inward referral of surgical emergencies because many peripheral hospitals were themselves operating at very low capacities during the pandemic peak. With only one tertiary hospital serving the middle belt of a rapidly growing Ghanaian population, this finding indicates that APH could strategically position itself to be a capable and reliable alternative for surgical care in the Ashanti region (7). In line with this idea, it implies the need for institutional investment in personnel training and procuring strategic equipment to sustain and ultimately diversify the surgical services offered in APH.
4.3. Weaknesses
4.3.1. Underdeveloped Virtual Meeting Culture Exposed
Important meetings such as clinical audits and continuous medical education forums had to be suspended with serious implications for quality improvement and professional development (8). Going forward, it would be in the interest of APH to take advantage of online meeting platforms available to advance care projects. Mortality audits are required to initiate real-time improvement steps but the pandemic-triggered suspension of this meeting for some four months in 2020, opened the door to the risk of repeating avoidable errors. Adopting online meeting platforms, even in the post-pandemic era, would be an added advantage for APH because the medium is affordable and accessible to all.
4.4. Opportunity
As the COVID-19 health crisis deepened in Ghana, hospitals including APH witnessed a steady influx of donations on a scale that was unprecedented. Opinion leaders, faith bodies, businesses and individuals came forward to register their goodwill with the hospital in those difficult times by donating medical consumables and money. The bigger question, however, is how to sustain such donor partnerships for accessing funding outside of a pandemic situation (9). To address this, the hospital can constitute a proactive marketing team to harness the funding potential of local and international networks while also maintaining an uncompromising stance on the hospital’s reputation for inflexible accountability for its expenditure. It is important to recognize that sustaining donor partnerships would be more likely to succeed if key donors and stakeholders are kept satisfied and well-informed. Such a strategy serves as a negotiating ‘currency’ for continued donor support (10). District-level hospitals should be encouraged by this finding to prioritize the enhancement of donor engagements.
4.5. Threats
The next threat identified is the hospital’s apparent over-reliance on a single revenue source, which is the fee-for-service rendered to patients. This is the main financing source for running the hospital and the problem is compounded when the claims from the national health insurance scheme delays. This style has often been labelled a ‘hand-to-mouth’ spending tactic – a realistic and, sometimes, an unavoidable method in many low-resource settings. The pandemic-triggered sharp drop in hospital attendance and the consequent income shortfall, coupled with the skyrocketing prices of medical consumables threatened to close down many of Ghana’s district hospitals. In view of this brewing threat, APH and other district hospitals need to promptly and seriously look at sustainably diversifying income generation. While maintaining regular healthcare delivery, a more strategic emphasis may need to be placed on innovative income generation products and services. These include the introduction of premium care such as specialized surgeries, operating special wards and specialist clinics which would be available to clients that are willing to pay a relatively higher price for these additional conveniences (11).
4.6. Conclusions
The SWOT analysis can and probably should be employed by all well-meaning health institutions to retrospectively evaluate their performance during the peak of the COVID-19 pandemic. Gathering from the application of this tool in evaluating the pandemic events in the Agogo Presbyterian Hospital, the SWOT analysis and the successful implementation of its findings could strategically transform district hospitals into pandemic-resilient and financially self-sustaining institutions. It would be helpful for hospitals to use the SWOT analysis process to clarify their core values, their organizational culture and identify their success stories – those that have emerged from their experiences during the COVID-19 pandemic. Such innovative inquiry would require committed healthcare leadership to succeed in these unpredictable times.
