Evaluating the Implementation of a COVID-19 Test-to-Treat Program in Ghana Using the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework: A Secondary Analysis of a Plan-Do-Study-Act (PDSA) Monitoring Activity.

CONTEXT: The COVID-19 Test-to-Treat (T2T) initiative aimed for early identification and treatment of cases in high-risk populations by providing free rapid antigen testing and oral antivirals. Its goal was to prevent avoidable morbidity and mortality by integrating COVID-19 care into routine services.

OBJECTIVE

As part of the Monitoring and Evaluation plan for the T2T project, a Plan-Do-Study-Act (PDSA) methodology was used to evaluate the effectiveness of service integration in health facilities across Ghana.

DESIGN

An evaluation of the PDSA tool was conducted to assess the 12 implementation steps taken to conduct the T2T project. Guided by the Exploration, Preparation, Implementation, and Sustainment framework, a qualitative evaluation examined implementation experiences, barriers, and strategies to support sustainability and inform future implementation planning.

SETTING/

PARTICIPANTS

Doctors, program directors, department directors, and government representatives from 17 health facilities participated in the PDSA quality assurance activity.

OUTCOME MEASURES: Factors affecting T2T Program adherence and fidelity.

RESULTS

Although most facilities successfully achieved the core T2T steps, several contextual challenges emerged, including staff turnover, competing priorities, and limited training infrastructure, which contributed to inconsistent adherence to clinical protocols, missed testing opportunities, and inappropriate prescribing. Facilities that maintained ongoing leadership involvement and internal monitoring achieved stronger program adherence and continuity.

CONCLUSION

This experience highlights that integration of new clinical processes in low- and middle-income countries is possible and sustainability depends on continuous staff training, strong leadership engagement, and structured monitoring systems. Embedding recurrent training, feedback loops, and accountability mechanisms within existing health system workflows proved essential for maintaining program performance. These lessons offer a practical framework for integrating new initiatives into routine care and strengthening system resilience against future public health emergencies in low- and middle-income countries.