Effect, equity and costs of an integrated and decentralised intervention to improve access to primary care for skin diseases: a prospective before-and-after study in south-west Ghana

Background: Global guidelines recommend strengthening and integrating health services for skin diseases, yet evidence for strategies remains scarce. We evaluated a decentralised approach to the care of skin disease through integration within routine primary care, by assessing uptake, equity, alignment with skin disease burden and associated treatment costs. Methods and findings: A before-and-after intervention study was conducted across all 17 public health facilities in Atwima Mponua district, Ghana from November 2023 to September 2024 (intervention period). We analysed routine health facility records to compare uptake of primary care for skin diseases pre-intervention (January to October 2023) and during the intervention. We assessed the burden of skin disease through a community-based two-stage cross-sectional dermatological survey, and estimated patient and provider costs for skin disease through post-care questionnaires and health facility surveys. We compared uptake to disease burden and assessed catastrophic expenditure and factors associated with higher treatment costs. Uptake of primary care for skin disease doubled during the intervention period relative to the pre-intervention period (adjusted incidence rate ratio (aIRR) 2.0, 95% CI 1.92-2.09), with greatest increases amongst school-age children (aIRR 2.70, 2.46-2.97) and individuals residing within very rural communities (aIRR 2.79, 2.47-3.15). Amongst 42,801 individuals surveyed, odds of any skin disease were greater amongst males (adjusted odds ratio (aOR) 1.25; 1.13-1.38), pre-school age children (aOR=1.80, 1.61-2.80), and residents of very rural communities (aOR=1.68, 1.09-2.61). Males and school-age children remained underrepresented amongst those who sought care during the intervention period relative to those diagnosed during the survey. Amongst patients seeking care for skin NTDs and complex wounds, 4% experienced catastrophic expenditure, driven largely by costs prior to visiting an intervention health facility. Conclusions: Greater integration within primary care substantially increased uptake of care for skin disease, but populations at greatest risk remained underrepresented amongst those accessing care. These findings highlight the need for deliberate strategies to address persistent barriers to care, with lessons for integration efforts across primary health systems.