Ghana has seen a steady increase in COVID-19 cases following the detection of the first two COVID-19 cases on March 12, 2020. According to the Ghana Health Service (GHS) COVID-19 situation update, as of April 5, 2021, Ghana had 1386 active cases among 91,109 cumulative confirmed cases and 752 cumulative deaths 123 (Figure 1a & 1b)

Globally, various precautionary measures have been put in place to help reduce the spread of the infection. These include frequent hand hygiene practices, social or physical distancing, the use of a nose mask, and social etiquettes such as avoiding handshakes and unnecessary touching of surfaces 4. Ghana implemented additional measures such as partial lockdown of some regions in the country (March 2020), closure of borders (air, land, and seaports), halting of public gatherings (i.e., religious activities, funerals, weddings, sporting events, restaurants, night clubs, and beaches). Also, fumigation of public places (such as community/farmers markets and public transit areas). Other measures included mass testing through contact tracing of targeted groups (in April 2020), quarantine, and isolation of suspected exposure and confirmed cases. In its quest to manage COVID-19, the Government of Ghana delivered six hundred thousand (600,000) doses of the AstraZeneca vaccine, the first consignment of many more to come, to vaccinate the populace.

The major challenge in this situation is appropriately managing the health facilities so that they do not become sources of infection or re-infection of COVID-19. Suppose the infection prevention and control system of the facilities are not robust enough. In that case, surfaces and materials in the health facilities may be contaminated, presenting a risk of infecting people who may contact these surfaces and materials within the health facilities 5 Hospital-based infections acquired during health delivery could be transmitted from the health worker to patients through contaminated equipment, surfaces, bed liners, and air droplets. Covid-19 has a varying lifespan ranging from 4 hours on copper surfaces, 24 hours on cardboards, 2-3 days on stainless steel materials, three days on plastics and sewage, and three to four days on fecal waste 678 Implementing a robust infection prevention and control system is essential as part of the nationwide fight against COVID-19 to prevent further infections in Ghana and safeguard people's lives and the environment.

Ghana has a national policy and guidelines for infection prevention and control in a health care setting 910 The IPC policy aims to direct healthcare workers and clients on the prevention and control of hospital-acquired infection to protect health workers while ensuring the safety of patients. The policy outlines that blood, body fluids, secretions, excretion, non-intact skin, and mucous membranes may contain transmissible infectious agents. The policy proposes preventive measures such as hand washing and appropriate PPEs to reduce exposure to microorganisms and manage sharps as effective ways of infection control.

Several researchers have reported on the impact of Covid 19 on infection prevention and control 12 water, sanitation, and hygiene (WASH) 1314 and medical waste management 15161718 While most of these researches were conducted in advanced economies, only limited studies 192021 have assessed medical waste management during Covid 19 in sub-Sahara Africa. In Ghana, limited studies have reported Covid-19 and WASH, IPC, and healthcare waste management 22232425.

In the era of this pandemic, health facilities are the central point of seeking health care, thus making this sector a potential epicenter for the spread of the Covid-19 virus if stringent measures, based on accurate data, are not implemented and enforced. Yet, the data needed to clarify the extent to which organizational systems (governance/leadership) affect IPC and healthcare waste management in the era of Covid-19 is challenging to access in Ghana at the moment. The above observation is due to insufficient publication data on findings after monitoring and data collection from health facilities by researchers and organizations.

Therefore, this paper seeks to fill the information gap by assessing the Governance and IPC from healthcare facilities in the Greater Accra and Ashanti Regions of Ghana in the COVID-19 era. These two regions are the epicenters of the pandemic in Ghana, with the Greater Accra Region recording 56,224 cumulative cases. At the same time, the Ashanti region has also recorded 18,195 patients so far as of July 27, 2021 2 as shown in Figure 1a and 1b. (Figures)

The characteristics of health facilities in the study were described using percentages and frequencies. The bar chart was used to describe the percentages of health facilities based on their scorings from the individual items under IPC, the overall assessment levels of the IPC, the Organizational system, Infrastructure, Safety, Assets, and Signage assessment levels. The Pearson's chi-square test was used to assess the association between health facility characteristics and IPC systems. The Pearson's chi-square test was also used to determine the association between organizational systems, infrastructure, safety, assets, signage assessment levels, IPC systems.

The three IPC assessment levels were then dichotomized such that good and moderate assessment levels were combined against poor assessment levels. The crude and adjusted odds ratio of poor IPC assessment levels were then estimated using the binary logistic regression models. The 95% confidence interval and the corresponding p-values of all odds ratios were also calculated. All statistical analyses were considered significant at a p-value less than 0.05 

The facilities assessed included hospitals (32.1%), health centres and clinics (36.2%), medical centres (14.4%), maternity homes (6.4%), diagnostic/ laboratories (4.1%), specialist clinic (3.1%), polyclinics (2.5%) and CHPS compound (1.2%). The majority of the 486 health facilities assessed scored high for sterilization system (66.4%), knowledge on decontamination of instruments (60.5%), availability and use of handwashing basin/Veronica bucket with elbow tap (58.4%), PPE availability and use (55.0%) and disinfection practices (52.4%). 92.4% of the facilities had an adequate, fair distribution of sinks and veronica buckets with running water in the IPC equipment assessment domain. Findings from Oppong et al. (2020) study on IPC and associated determinants in 56 acute healthcare facilities in Ghana indicated that the majority of the facilities did not have a significant supply of IPC materials like detergents (66.1%), running water (57.1%) and PPEs availability and use (66.1%). In our study, only 25.7% of the health facilities scored poorly for displaying appropriate handwashing technique materials, 21.6% for handwashing protocol, 37.0% for guidelines or policy for infection control, and 27.6% for infection control IPC/ WASH focal person. This means that the poorly scored facilities have not prioritized providing information to remind staff and posters to support their adherence to standard practices. The implication is that healthcare workers may be limited in responding to emergencies to prevent infection or reinforce standard procedures for infection prevention in case of an outbreak such as COVID-19. 3 required that as part of SOPs for COVID-19 prevention in health facilities, information materials should be displayed at all healthcare facilities' entrances and vantage areas to educate and minimize the risk of transmission (droplet/ contact) of COVID-19. This is a potential non-adherence to the National IPC policy requiring facilities to develop training and learning materials such as flyers, brochures, and posters on IPC for all health workers (Ministry of Health, 2015). 

In this study, the overall assessment level of health facilities on infection prevention and control determined as good/moderate IPC system is 80.8%. However, this finding is similar to Oppong et al. (2020), where 87.5% of facilities scored 'adequate' on IPC preparedness. Moreover, our result of 19.2% of facilities with poor IPC is consistent with Oppong et al., (2020) finding of 12.5% with inadequate IPC. This means that facilities with poor IPC systems are likely to expose employees, patients, and visitors to nosocomial infections and risk further COVID-19 infection. Such facilities are not adequately equipped to manage COVID-19 patients.

This study reported the overall assessment of health facilities as good/moderate (82.3%) concerning the Governance and Leadership metric. The facilities with good/moderate Governance and leadership scored higher on the IPC assessment metric (over 67%). The implication is that most facilities with good/moderate Governance and leadership systems support efficient operations and compliance with regulatory requirements. The effect of poor leadership and governance system can affect how the facilities manage infectious disease crises (example, COVID-19), create role conflicts and gaps that can contribute to a possible escalation of nosocomial infections 27 The finding assures that strengthening Governance and leadership at health facilities promotes adherence to IPC policy and guidelines, which will mitigate the risk of spread of infections and promote hygiene. The overall assessment of health facilities, management was good/moderate. Poor management of health facilities negatively affects the quality of health care, patient health outcomes, infection prevention and control, and the image of the health facility 28 . 

For the Quality Assurance system, 42.8% were assessed as good, 24.5% moderate, and 32.7% were poor. Further analysis showed that the facilities with good/moderate Quality Assurance (67.3%) also scored higher on the IPC assessment metric (over 69%). Poor Quality Assurance score indicates a flawed health care delivery system and antecedent lack of readiness to prevent and control an outbreak of infection through a standardized approach, with low client interest and satisfaction and high mortality 29. Again, the above further underscores the importance of investment in Quality Assurance systems to improve adherence to IPC policy and guidelines significantly. 

For Human Resource assessment, 88.1% were good, 6.6% were moderate, and 5.3% were poor. Most facilities in these regions have access to qualified health workers with a high doctor and nurse-to-patient ratios 30

With respect to the IPC assessment metric, the proportion of facilities from the Greater Accra region with poor assessment (23.3%) was significantly higher when compared to the facility with poor assessment in the Ashanti Region (9.9%). This means that majority of the health facilities in the Ashanti region are not complying with the IPC policy of the country, and therefore have poor IPC systems in place. The ability of such facilities to prevent and control the spread of infection within their operational areas cannot be assured. Therefore, workers and care seekers (patients) may be vulnerable to nosocomial infections.

This study used primary data collected from selected health facilities in Ghana's Greater Accra and Ashanti regions with a high participation rate. Hence, selection bias is minimized. The study population was relatively homogeneous with regard to background factors. Hence, the potential effect of unmeasured confounders was minimized. Additionally, findings from this study can be generalized considering the homogeneity of the facilities at various levels in the country, from CHPS compound to regional referral hospitals, inclusive of private and public facilities. No tertiary hospitals were included.

This study used a cross-sectional design; hence, causality cannot be established, and therefore, this study could only report on associations and not cause and effects. There is the possibility of information biases as a selection of variables and self-reported information on Governance and IPC were not controlled by the researchers.

The monitoring has revealed that the majority of the health facilities in the two regions (Greater Accra and Ashanti) have a good system to ensure effective infection prevention and control and have been adhering to the regulatory requirements of the Health Facilities Regulatory Agency. These areas of compliance with adequate performance include Water supply, Human Resources, Governance, Management, IPC Equipment, Quality Assurance, and Assets of the facilities. However, signage was a significant challenge in many facilities, which is likely to affect communication within the facilities on IPC-related actions. The leadership and Governance system of the health facilities influenced compliance to IPC requirements, good assets available in the facility positively influenced the IPC system, and a good water supply system contributed to an enhanced IPC system. IPC assessment was poor in the Greater Accra region. 

Not applicable

Not applicable

Available on request from PAB

The study received significant funding from United Nations Development Program ^UNDP and Ghana Ministry of Health. 

PAB developed the research strategy and concept. BAK, MA, JA, F.O., L.O., and AY supervised the data collection and conceptualized the data analysis. E.A., MA, S.T., RMO, and D.D. drafted the first version of the manuscript. PAB, E.A., MA, R.Q., RMO, and Y.A. conceptualized the research questions and interpreted the final version of the manuscript. All authors read and approved the manuscript.

We acknowledge the support from HeFRA and management and owners of all health facilities in the Greater Accra and Kumasi Regions.