Four dimensions of structural responses have been identified in the global literature: policy, fiscal, engagement with industry and with international partners. Ghanaian responses have focused on policy and, to a lesser extent, engagement with industry (see next section).
Attempts were made to establish an NCD Control Programme in Ghana in the 1970s . This followed the establishment of a Burkitt's lymphoma centre at KBTH in the mid-1960s and the development of a national cancer registry in the early 1970s. These early attempts faced operational, professional and political challenges. Formal discussion of Ghana's chronic disease burden resumed in the 1990s. Some conditions such as hypertension and diabetes were placed on the priority health intervention list of the Ministry of Health (MOH) [42, 43]. A Non-communicable Disease Control Programme (NCDCP) was established in 1992, with an extensive remit for improving knowledge and advocacy for CVDs, diabetes, chronic respiratory diseases, cancers and sickle cell disease. In the last five years the NCDCP has convened national workshops on chronic diseases, advocated on radio, engaged in media training, advocated for tobacco control and participated in consultations towards alcohol policy development . Despite these activities there is no policy or plan for chronic disease prevention. Local experts believe that chronic diseases are "neglected, constitute low policy priority and receive low interest from development partners" . For instance, while the NCDCP is expected to play a public health role, it is poorly resourced and staffed entirely by medical professionals. However there have been other responses by the MOH to Ghana's health burden that are relevant to chronic disease prevention.
In 2006, the MOH implemented a National Health Insurance Scheme (NHIS), which includes medicines for hypertension, diabetes and some cancers on its exemption list. It is useful to note that the inclusion of some chronic disease medications have occurred as a result of lobbying by patient organisations (e.g. breast cancer) and research groups (e.g. sickle cell disease). Chronic disease care in Ghana is expensive. The monthly cost of treating conditions like diabetes exceeds the average salary . For example, in 2007, the monthly cost of treating diabetes ranged between $106 and $638; the monthly cost for treating complications of diabetes (e.g dialysis for end-stage renal failure) was $1383 . The minimum daily wage in 2007 was $2; the average monthly salary for a civil servant was $213 . The financial burden of living with chronic disease exacerbates the psychosocial burden, for example it leads to family disruption and diminished family support. Studies suggest that the NHIS eases the financial burden of chronic disease for individuals able to afford the premium payments [28, 30]. A Disability Bill was also introduced by the government in 2006. The Bill stipulates free access to general and specialist medical care for the disabled. Its significance for individuals disabled by chronic diseases (e.g impaired vision and limb amputations due to diabetic complications) has not been fully explored by interest groups.
Chronic disease prevention at community level should ideally encompass activities of the following key actors: primary health care services, voluntary organizations, the food industry and supermarkets, work sites, schools and the local media. In Ghana, the majority of these groups of actors have been involved in chronic disease prevention. We begin by documenting community level activities relevant to primary prevention and then focus on those relevant to secondary prevention.
Sedentary lifestyles have been strongly implicated in Ghana's chronic disease burden . However there is also an emerging keep-fit culture in urban and rural areas. In the capital Accra and other major cities, a growing number of fitness centres offer physical fitness and general health services (e.g medical screening) . Keep fit and football clubs are also common across the country; these clubs are usually run by, and dominated by, young men. The role of these organizations in promoting public health is important. However they cater to limited segments of society, such as the middle to high income urban middle class (for fitness centres) and to young men (for the keep fit clubs).
Churches, mosques and other faith-based institutions play an important role in health promotion. Churches have been visible facilitators of mass health walks, screening and health expert talks on public health problems. An estimated 65% of Ghana's population is Christian. Church members form strong civic ties within subgroups, such as the women's and men's fellowships or choirs. Research suggests that the church is an important source of information for lay people ; similarly people with chronic diseases rely on their churches for information and psychosocial support . On the other hand religious institutions offer chronic disease treatment through their faith healing prayer camps or through Islamic divination. The impact of these practices is mixed. Research suggests that faith healing practices can cause disease complications for people with diabetes .
The mass media is a key site for disseminating information on chronic diseases in Ghana. Newspaper articles on cancer, sickle-cell disease, leukaemia, diabetes, hypertension and stroke appear in national publications such as the Daily Graphic and the Mirror, as well as their online versions. The local radio stations also tackle chronic diseases on their health programmes and present selected information on their websites (see for e.g. http://www.myjoyonline.com/radio/). Media information is either culled from international media sources or produced by local medical experts. Some experts write their own newspaper columns or host TV and radio shows. There is a growing trend of influential herbalists providing incorrect (chronic) disease information on radio and television as part of their advertising strategy.
Generally national newspaper coverage is low and few people read . While radio has wider national coverage there is little knowledge of what is broadcast on rural radio. To address some of the challenges in media reportage the NCDP organised a training workshop for media representatives to increase media awareness, knowledge and reporting of chronic diseases . The impact of this project is yet to be evaluated.
In 2005 the MOH established the Regenerative Health and Nutrition Programme (RHNP) which aimed to promote a preventative model of public health, rather than the dominant curative model . The RHNP was not explicitly concerned with chronic disease, but its health enabling focus encompassed activities that reduce chronic disease risks, for instance eating more fruits and vegetables, reducing consumption of fatty foods and alcohol and taking up exercise. The programme was piloted in communities in eight regions through participatory education workshops. No baseline data was gathered on health knowledge or status prior to the programme, so it is difficult to evaluate the impact of the programme along these lines. However an independent review of the pilot programme  produced a number of insights: (1) the majority of programme recipients remembered key aspects of the nutrition and healthy lifestyles messages; (2) the easiest lifestyles to adopt were drinking more water and eating more fruits and vegetables, a challenging lifestyle was increasing physical activity, the most difficult was to reduce meat intake; (3) the high cost of fruit and vegetables in some regions and widespread perceptions of the toxicity of staple foods were barriers to adopting healthy lifestyles; (4) a minority of individuals had become advocates of the regenerative lifestyles; churches, mosques, the workplace and school were important spaces for advocacy. The pilot programme has not been replicated or scaled up. It has been commended as an important initiative for chronic disease prevention, but criticised for working in isolation from health services provided by the Ghana Health Service . However, the RHNP is included in the MOH's current programme of work and it has entered a phase of engagement with industry and businesses through annual health fairs and public education via the mass media. A nutrition manual for schools and a strategic plan have been developed. These new developments are yet to be evaluated.
A number of patient advocacy groups exist for asthma, cancers (breast, leukaemia, prostate), diabetes, heart disease, hypertension and cardiovascular disease, epilepsy and kidney disease. Each organisation has different structures and modes of operation. The Korle-Bu Breast Cancer Clinic, Reach for Recovery, Mammocare and DWIB Leukemia Trust, provide support and advocacy services for individuals living with cancer. The Ghana Heart Foundation raises awareness on heart disease and provides clinical and surgical services for needy individuals with serious heart conditions. Basic Needs, an international mental health NGO provides education, psychosocial support and opportunities for enhancing livelihoods for people living with epilepsy http://www.basicneeds.org/ghana/. The Ghana Diabetes Association provides information and education on diabetes especially through World Diabetes Day events. Research suggests that advocacy groups help members to cope better with their conditions [13, 28, 30].
There are three major challenges in this area. The majority of advocacy services are located in the urban South and chiefly the capital Accra. This excludes a growing number of individuals living with chronic diseases in other parts of the country from accessing psychosocial support. The establishment of self-help groups in rural areas in the Brong Ahafo, Ashanti and Northern regions for example point to a need for national expansion of advocacy services (; J. Adomako, pers communication, 2008). Second, with few exceptions, these services are run by healthcare professionals. Finally, while membership improves coping, there is no systematic information on how group membership and/or better coping improves self-care, management and health outcomes. There is growing evidence to suggest that patient-led self-help and advocacy groups have greater longevity and achieve more comprehensive sustainable goals (education, psychosocial support, advocacy) for their members [50, 51]. Furthermore, research on sickle cell disease and chronic pain shows that skilled self-help groups can improve treatment and quality of life outcomes [51–53].
At the individual level we focus on health service provision and individual pharmacological interventions. Medical facilities in Ghana are poorly equipped to treat chronic diseases: asthma, diabetes and sickle-cell disease are particularly affected by poor health services [13, 28, 30, 39]. Challenges include poor infrastructure (both basic and sophisticated), inadequate training of healthcare providers (especially in terms of acquiring specialist knowledge of chronic conditions and of communicating knowledge to lay people and patients), and high cost of care. The challenges experienced by biomedical services are compounded by competing services provided by ethnomedical professionals and faith healers, which are unregulated, pharmacologically unsafe and are often implicated in avoidable complications . There are few specialist chronic disease centres in the country. The country has only two specialist diabetes centres, situated in the two teaching hospitals in Accra and Kumasi, both southern urban cities. While general practitioners often run diabetes clinics in regional and district hospitals, they may lack the clinical depth of the specialist clinics.
Despite challenges to chronic disease treatment and management in Ghana, there is evidence of innovative care. The Korle-Bu Teaching Hospital's breast cancer clinic operates with a multidisciplinary team including surgeons, radiation oncologists, a clinical pharmacist and a clinical psychologist. This team works alongside cancer survivors (as peer supporters and counsellors) and a cancer advocacy group (Reach for Recovery). The clinic's approach has led to increased trust and improved communication between patients and health professionals  and created an important space for group education and psychosocial support .