Ten2Twenty-Ghana: a randomised controlled trial on the efficacy of multiple micronutrient-fortified biscuits on the micronutrient status of adolescent girls.

Adolescent girls are an important target group for micronutrient interventions particularly in Sub-Saharan Africa where adolescent pregnancy and micronutrient deficiencies are common. When consumed in sufficient amounts and at levels appropriate for the population, fortified foods may be a useful strategy for this group, but little is known about their effectiveness and timing (regarding menarche), particularly in resource-poor environments. We evaluated the effect of consuming multiple micronutrient-fortified biscuits (MMB), sold in the Ghanaian market, 5 d/week for 26 weeks compared with unfortified biscuits (UB) on the micronutrient status of female adolescents. We also explored to what extent the intervention effect varied before or after menarche. Ten2Twenty-Ghana was a 26-week double-blind, randomised controlled trial among adolescent girls aged 10-17 years (n 621) in the Mion District, Ghana. Biomarkers of micronutrient status included concentrations of Hb, plasma ferritin (PF), soluble transferrin receptor (TfR) and retinol-binding protein (RBP), including body-iron stores. Intention-to-treat analysis was supplemented by protocol-specific analysis. We found no effect of the intervention on PF, TfR and RBP. MMB consumption did not affect anaemia and micronutrient deficiencies at the population level. MMB consumption increased the prevalence of vitamin A deficiency by 6·2 % (95 % CI (0·7, 11·6)) among pre-menarche girls when adjusted for baseline micronutrient status, age and height-for-age Z-score, but it decreased the prevalence of deficient/low vitamin A status by -9·6 % (95 % CI (-18·9, -0·3)) among post-menarche girls. Consuming MMB available in the market did not increase iron status in our study, but reduced the prevalence of deficient/low vitamin A status in post-menarcheal girls.

Effectiveness of a culturally tailored text messaging program for promoting cervical cancer screening in accra, Ghana: a quasi-experimental trial.

INTRODUCTION: Despite breakthroughs in cervical cancer detection, resource-constrained countries continue to have a disproportionately high incidence and death rate. Mhealth has been identified as an important tool for increasing cervical cancer screening rates in Sub-Saharan Africa. We determined whether sending Ghanaian women culturally tailored one-way mobile phone SMS text messages about cervical cancer would encourage the uptake of the human papillomavirus (HPV) test. METHODS: From August to November 2016, 88 women aged 18 to 39 living or working in an urban community (Accra, Ghana) participated in a quasi-experimental study. For 8 weeks, 32 SMS messages regarding cervical cancer were developed and sent to the personal phones of intervention arm participants (n = 42). Women in the control group (n = 46) received SMS texts with general health and lifestyle advice. Fischer's exact tests were performed to assess cervical cancer screening uptake and associated reasons for non-uptake between the intervention and control groups (p < 0.05). RESULTS: At the baseline, women differed in terms of ethnicity and wealth. After the intervention, participants' self-reported risk factors for cervical cancer, such as early menarche, usual source of medical treatment, family history of cancer, smoking, and alcohol history, changed. None of the women in the intervention group sought cervical cancer screening after the intervention, but only one (2.2%) of the control arm participants did. Almost all the women (> 95%) agreed that an HPV test was essential and that regular healthcare check-ups could help prevent cervical cancer. Some women believed that avoiding particular foods could help prevent cervical cancer (23.8% intervention vs. 58.7% control, p < 0.001). Time constraints and out-of-pocket expenses were significant barriers to cervical cancer screening. CONCLUSION: A one-way SMS delivered to urban women did not increase cervical cancer screening attendance. The time spent in screening facilities and the lack of coverage by the National Health Insurance Scheme limited screening uptake. We urge for the establishment of screening centers in all healthcare facilities, as well as the inclusion of cervical cancer screening in healthcare programs through cost-sharing.

Unsung heroes in Ghana's healthcare system: the case of community health volunteers and community health management committee.

BACKGROUND: In Ghana, the community-based health planning and services (CHPS) policy highlights the significance of both community health management committees (CHMCs) and community health volunteers (CHVs) in the Ghanaian health system. However, research into their specific effects on health system improvement is scarce. Some research has focussed on the roles of the CHMCs/CHVs in implementing specific targeted health interventions but not on improving the overall health system. Therefore, this research aims to examine the role of the CHMCs and CHVs in improving the Ghanaian health system. METHODS: The study was conducted in three districts in the Ashanti region of Ghana. A total of 35 participants, mainly health service users and health professionals, participated in the study. Data were collected using semi-structured individual in-depth interviews. Participants were selected according to their patient-public engagement or community health activity roles. Data were transcribed and analysed descriptively using NVIVO 12 Plus. RESULTS: We found that the effectiveness of CHMCs and CHVs in health systems improvement depends largely on how members are selected. Additionally, working through CHMC and CHVs improves resource availability for community health services, and using them in frontline community health activities improves health outcomes. CONCLUSIONS: Overall, we recommend that, for countries with limited healthcare resources such as Ghana, leveraging the significant role of the CHMCs and CHVs is key in complementing government's efforts to improve resource availability for healthcare services. Community health management committees and CHVs are key in providing basic support to communities with limited healthcare personnel. Thus, there is a need to strengthen their capacities to improve the overall health system.

Actor Perceptions of the Governance Framework and Non-Carbon Benefits from the Ghana Cocoa Forest REDD+ Program: An Extended Q-Study of the Juabuso-Bia Hotspot Intervention Area.

The expansion of cocoa farms is a major driver of deforestation and emissions in Ghana's high forest zone. The Ghana Cocoa Forest Reducing Emissions from Deforestation and Forest Degradation Program (REDD+) was launched as the world's first commodity-based initiative to address emissions from deforestation caused by cocoa production and generate non-carbon benefits. Hotspot Intervention Areas were established to implement the Ghana Cocoa REDD+ program. This study combines Q-methodology with focus group discussions and interviews to assess stakeholder perceptions in the Juabuso-Bia cocoa landscape regarding the capacity of the Hotspot Intervention Area to facilitate the generation of governance and economic non-carbon benefits to sustain emission reductions. We found that introducing the Hotspot Intervention Area has re-centralized landscape governance, which, coupled with weak collaboration among stakeholders, has led to poor generation of non-carbon benefits. Furthermore, efforts to include women in the leadership structure of the Hotspot Intervention Area can be described as tokenism, and little has been done to improve land and tree tenure for vulnerable groups. This, combined with the low adoption of climate-smart cocoa practices, is likely to negatively affect the generation of economic non-carbon benefits. To overcome these challenges, we recommend reforming the Hotspot Intervention Area, bolstering community-level sensitization, improving access to decision-making spaces that will enhance the participation of women and minority groups in landscape governance, and improving farmers' tenure security through a registration scheme for land and trees. These recommendations can ensure the efficient generation of non-carbon benefits, which are key to the success of REDD+.

Successful implementation of ITN distribution through health facilities in Ghana.

BACKGROUND: Global efforts to reduce malaria burden include distribution of insecticide-treated mosquito nets through mass campaigns and routine channels. Ghana's National Malaria Elimination Programme (NMEP) distributes insecticide-treated bed nets (ITNs) through various channels, including to pregnant women at antenatal care (ANC) visits and children at vaccination visits through child welfare clinics (CWC). This study assessed historical ITN distribution throughout ANCs and CWCs across Ghana and the characteristics of high performing facilities. METHODS: Monthly data on routine ITN distribution was provided from Ghana's national health information management system for the years 2016-2021. Analyses were conducted to assess the performance of ITN distribution at ANC and CWC across time, ecological zone, regions, districts, facility ownership, and facility type. Univariate and multivariate logistic regressions were performed to predict the odds of ANC and CWC issuing rates greater or equal to 80% for a given facility type or ownership. RESULTS: In 2021, 93% of women who attended their first antenatal care visit and 92% of children under five who received their second dose of the measles-rubella vaccine (MR2) had received an ITN. At the regional level, 94% of regions (n = 15/16) maintained the NSP target issuing rate of 80% throughout 2020 and 2021. While there were no clear differences in issuing rates between ecological zones, district-level differences were present across the six years. All health facility types performed at or above 80% in 2021 for both ANC and CWC. Odds ratios demonstrated differences in the likelihood of meeting the 80% issuing rate goal among different facility types as well as private versus public ownership when comparing ANC and CWC. CONCLUSION: By 2021, Ghana had improved its ITN issuing rates since the initial year of analysis, surpassing the 80% target by issuing nets to over 90% of pregnant women and young children attending ANC and CWC. Future work can explore the reasons for national and subnational differences in issuing rates as well as help understand additional characteristics of high performing facilities. Additionally, it is necessary to identify and expand on the drivers for improved performance over the time period.

A critical review and analysis of the context, current burden, and application of policy to improve cancer equity in Ghana.

BACKGROUND: Cancer causes a major disease burden worldwide. This is increasingly being realised in low and middle-income countries, which account disproportionately for preventable cancer deaths. Despite the World Health Organization calling for governments to develop policies to address this and alleviate cancer inequality, numerous challenges in executing effective cancer policies remain, which require consideration of the country-specific context. As this has not yet been considered in Ghana, the aim of this review was to bring together and critique the social-environmental, health policy and system factors to identifying opportunities for future health policies to reduce cancer burden in the Ghanian context. A critical policy-focused review was conducted to bring together and critique the current health systems context relating to cancer in Ghana, considering the unmet policy need, health system and social factors contributing to the burden and policy advances related to cancer. CONCLUSION: The findings highlight the changing burden of cancer in Ghana and the contextual factors within the socio-ecosystem that contribute to this. Policies around expanding access to and coverage of services, as well as the harmonization with medical pluralism have potential to improve outcomes and increase equity but their implementation and robust data to monitor their impact pose significant barriers.

Hot fomentation of newborn fontanelles as an indigenous practice in Ghana: implications for policy and integrated community-based health care in Covid-19 pandemic and beyond.

OBJECTIVE: African newborns undergo numerous traditional and religious practices ranging from fontanelle fomentation to total head shaving, scalp molding, skin scarification and ano-genital irrigation which can negatively impact the health of neonates. Hot fomentation of fontanelles has been a predominant indigenous home-based postnatal practice in Ghana and among Africans in the diaspora. Mobility restrictions during the Covid-19 pandemic has impacted direct access to facility-based care as well as home care. The flourishing of newborn traditional practices among African populations during this Covid-19 pandemic offers opportunities to rethink the provision of family healthcare support for newborns during the ongoing pandemic and beyond. Hence, the aim of this critical review was to examine and describe a common indigenous practice-hot fontanelle fomentation to inform home birth support, discharge planning, and the delivery of optimal home-based care support. STUDY DESIGN: This study is a review of literature on hot fomentation of newborn fontanelles. METHODS: Literature search in CINAHL, PubMed, African Index Medicus and Scopus, was conducted and evidence synthesised from articles ranging from 1983-2022. Sixty articles were reviewed; however, 10 manuscripts were excluded prior to screening. The other 19 were exempted because they were either below 1983 or were not the best fit for the study purpose. In all, 31 studies were included in the study. The study was guided by Madeleine Leininger's Culture Care Diversity and Universality care theory. RESULTS: The current study identifies hot fomentation of newborn fontanelles practices in Ghana, the description of hot fomentation practices and the dangers associated with it. The findings and suggested ways to help overcome this challenge. CONCLUSION: There are several neonatal indigenous practices including fontanelle fomentation which pose threat to the health of the neonate as discussed in this study. Future research needs to investigate innovative ways of fontanelle fomentation where necessary instead of the use of hot water by mothers, especially in this Covid-19 pandemic where health and mobility restrictions impact physical access to timely health care. This research will help educate mothers about the dangers of fontanel fomentation and reduce the practice, especially in rural areas of developing countries. This could help reduce neonatal mortality and unnecessary healthcare costs.

Health needs of migrant female head porters in Ghana: evidence from the Greater Accra and Greater Kumasi Metropolitan areas.

BACKGROUND: In low-and middle-income countries, migrants are confronted with health needs which affect the promotion of their well-being and healthy lives. However, not much is known about the health needs of migrant female head porters (Kayayei) in Ghana. This study assesses the health needs of migrant female head porters in the Greater Kumasi Metropolitan Area (GKMA) and Greater Accra Metropolitan Area (GAMA). METHODS: The study adopted a convergent mixed methods design where both qualitative and quantitative data were used. A representative sample size of 470 migrant female head porters was used for the study. RESULTS: The study revealed that ante-natal care, post-natal care, treatment of malaria, treatment of diarrhoea diseases, mental health, sexual health, and cervical cancer were health needs of migrant female head porters. The findings showed that participants from the GAMA significantly have greater cervical cancer needs (71.6% vrs 67.1%, p = 0.001) compared to those from the GKMA. Kayeyei from the GKMA significantly have greater mental health needs than those from the GAMA (84.6% vrs 79.2%, p = 0.031). Also, Kayeyei from the GKMA significantly have higher attendance of post-natal care compared to those from the GAMA (99.4% vrs 96.2%, p = 0.013). CONCLUSION: The findings underscore differential health needs across geographical localities. Based on the findings of the study, specific health needs such as ante-natal care and post-natal care should be included in any health programmes and policies that aim at addressing health needs of migrant female head porters in the two metropolitan areas of Ghana.

Factors influencing the free maternal health care policy under the national health insurance scheme's provision for skilled delivery services in Ghana: a narrative literature review.

BACKGROUND: Skilled Birth Attendance (SBA) is important in achieving the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1. Ghana has made steady progress in SBA, yet, unsupervised deliveries still occur. The introduction of the Free Maternal Health Care Policy under the National Health Insurance Scheme (FMHCP under the NHIS) has improved the uptake of SBA but with some implementation challenges. This narrative review sought to explore the factors influencing the FMHCP under the NHIS provision for skilled delivery services in Ghana. METHODS: Electronic searches were conducted of databases including PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 2003 and 2021 on factors influencing FMHCP/NHIS provision for skilled delivery services in Ghana. Keywords used in the literature search were in various combinations for the different databases. The articles were screened to determine the inclusion and exclusion criteria and quality was assessed using a published critical appraisal checklist. A total of 516 articles were retrieved for initial screening based on their titles, of which 61 of them, were further screened by reading their abstracts and full text. Of this number, 22 peer-reviewed and 4 grey articles were selected for the final review based on their relevance. RESULTS: The study revealed that the FMHCP under the NHIS does not cover the full costs associated with skilled delivery and low socioeconomic status of households affects SBA. Also, funding and sustainability, hinders the quality-of-service delivery offered by the policy. CONCLUSION: For Ghana to achieve the SDGs above and further improve SBA, the cost associated with skilled delivery should be fully covered by the NHIS. Also, the government and the key stakeholders involved in the policy implementation, must put in place measures that will enhance the operation and the financial sustainability of the policy.

Impact of community health interventions on maternal and child health indicators in the upper east region of Ghana.

BACKGROUND: This paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training. METHODS: A mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus-post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process. RESULTS: After intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI). CONCLUSIONS: A pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance.

Individual risk preference as a predictor of health behaviour: evidence from the use of condoms against HIV/AIDS in Ghana.

BACKGROUND: It is evident that public health education interventions to promote the use of condoms against HIV infections in Ghana have yielded modest results. However, existing studies in the field of sexual and reproductive health in Ghana have failed to account for differences in risk preferences of individuals. This study fills the gap by investigating how individuals' risk preferences predict their behaviour toward using condoms against HIV in Ghana. METHOD: Conceptually, the study followed the Grossman health capital theoretical model for risk preference and health behaviour nexus. Data were obtained from the most recent Ghana Living Standards Survey Round 7 (GLSS 7), conducted in 2017. Using data from GLSS 7, a probit regression model was estimated to show how the risk preferences of individuals that did not abstain from sex predicted their use of condoms against HIV. To ensure robustness, two scenarios of declared risk preferences were used to predict the use of condom behaviour against HIV. RESULTS: Probit regression estimation shows that the risk preferences of individuals that did not abstain from sex significantly predicted their use of condoms against HIV in Ghana. Even though the study found that the predicted probability of using a condom reduces among risk-averse individuals that do not abstain from sex, not using a condom against HIV was found to be worse among risk lovers. CONCLUSION: The study provides empirical evidence that public health education against HIV/AIDS in Ghana cannot continue to ignore the risk preference of individuals. The results of this study have immediate implications, first for a comprehensive and continuous measurement of risk preferences among Ghanaians in major household surveys going forward. At the moment, the latest round of the GLSS is just about the only household survey in Ghana that has attempted to collect some data on individual time and risk preferences using only hypothetical monetary rewards. Second is the immediate consideration of individual risk preferences in public health education campaigns against HIV/AIDS in Ghana.

Coverage of preventive measures and surveillance for neglected tropical diseases in hard-to-reach communities in Ghana.

BACKGROUND: Neglected tropical diseases (NTDs) are a major public health burden which mainly affects poor populations living in tropical environments and hard-to-reach areas. The study sought to examine coverage of preventive efforts, and case surveillance for NTDs in hard-to-reach communities in Ghana. METHODS: The study investigated treatment efforts for lymphatic filariasis (LF), and onchocerciasis and schistosomiasis/soil transmitted helminths (SCH/STH) at household level, in difficult-to-access communities in Ghana. A total of 621 households were sampled from 6 communities in the Western, Oti and Greater Accra regions. RESULTS: Over 95% of the households surveyed were covered under mass drug administration (MDA) campaigns for lymphatic filariasis (LF) and onchocerciasis. More than 80% of households had received at least two visits by community drug distributors under the MDA campaigns in the last two years preceding the study. In addition, over 90% of households in the LF and onchocerciasis endemic communities had at least one member using anthelminthic medications under the MDA campaigns in the 12 months preceding the study. However, households where no member had taken anthelminthic medications in 12 months preceding the study were over 6 times likely to have someone in the household with LF. CONCLUSIONS: This study determined that SCH/STH, LF and onchocerciasis are of serious public health concern in some communities in Ghana. There is an urgent need for holistic practical disease control plan involving both financial and community support to ensure total control of NTDs in difficult-to-access communities is achieved.

Policymakers' and healthcare providers' perspectives on the introduction of oral pre-exposure prophylaxis for key populations in Ghana.

BACKGROUND: Key populations (KPs) such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID), and their partners contribute more than a quarter (27.5%) of new HIV infection in Ghana. Oral pre-exposure prophylaxis (PrEP) can substantially reduce HIV acquisition among this group. While the available research indicates KPs willingness to take PrEP in Ghana, little is known about the position of policymakers and healthcare providers on the introduction of PrEP for KPs. METHODS: Qualitative data were collected from September to October 2017 in the Greater Accra (GA) and Brong-Ahafo (BA) regions of Ghana. Key informant interviews were conducted with 20 regional and national policymakers and supplemented with In-depth Interviews with 23 healthcare providers to explore their level of support for PrEP and their perspectives on challenges and issues to consider for oral PrEP implementation in Ghana. Thematic content analysis was used to unearth the issues emerging from the interviews. RESULTS: Policymakers and healthcare providers in both regions expressed strong support for introducing PrEP for KPs. Key concerns regarding oral PrEP introduction included potential for behavioral disinhibition, non-adherence and side effects of medication, cost and long-term financial implications, and stigma related to HIV and key populations. Participants stressed the need to integrate PrEP into existing services and the provision of PrEP should start with high risk groups like sero-discordant couples, FSWs and MSM. CONCLUSIONS: Policymakers and providers recognize the value of PrEP in cubing new HIV infections but have concerns about disinhibition, non-adherence, and cost. Therefore, the Ghana health service should roll-out a range of strategies to address their concerns including: sensitization with providers to mitigate underlying stigma towards KPs, particularly MSM, integration of PrEP into existing services, and innovative strategies to improve continued use of PrEP.

Danger and sexuality: exploring negotiations in romantic and sexual relationships among university students in Ghana.

Gender inequalities and social mores normalise gender-based violence in many settings. The goal of this study was to gain a more in-depth understanding of romantic and sexual relationships, consent, and gender-based violence among university students in Ghana. We used focus group discussions to explore individual factors influencing romantic and sexual relationships among students enrolled at a university in the Central Region of the country to inform the development and tailoring of future interventions. During a series of four focus group discussions comprising students recruited via convenience and snowball sampling, participants were asked to reflect on the nature of their romantic and sexual relationships. Demographic data and experiences of gender-based violence were also collected. The focus groups discussions were recorded and transcribed verbatim and analysed thematically. Five themes were developed from the data: (1) traditional gender roles; (2) self-control; (3) relationship-based consent; (4) cheating; and (5) non-verbal communication. This study suggests negative health and social ramifications of violence will continue until there is a resolution of conflicting social norms that result in different expectations about how men and women can address their sexual needs. Future programming and interventions for gender-based violence prevention should reflect on their impact across all ecological levels.

How do we improve maternal and child health outcomes in Ghana?

Maternal and infant mortality includes a number of health challenges in Ghana, with outcomes among the worst in the subregion and the world. Our aim here was to provide insights into how Ghana has approached these challenges, with a view to making suggestions for the future. Ghana has made significant gains in reducing infant and maternal deaths in the past decade through initiatives like the Free Maternal Care Policy, the Community-based Health Planning Services, and the National Health Insurance Policy. These policies have improved financial access to maternal and obstetric health services, facility-based delivery, and antenatal care services in particular. However, a number of challenges still hinder access to maternal and child health outcomes. Poor infrastructure, human resource challenges, poor access to essential medicines, poor quality of care, and superstitious and cultural beliefs have been noted in the literature. We suggest that while providing the necessary human and financial resources, other initiatives including the promotion of maternal health education, supervised home delivery, and zero maternal death interventions should be encouraged to help improve maternal and child health outcomes in Ghana.

Impact evaluation of long-lasting insecticidal nets distribution campaign on malaria cases reported at outpatient departments across all the regions in Ghana.

BACKGROUND: Malaria remains the biggest public health challenge globally, and Ghana is among the 15 highest burden malaria countries in the world, with 2% of global malaria cases and 3% deaths in 2019. This study sought to assess the impact of mass LLIN distribution campaign on malaria morbidity using all health facilities outpatient data across 15 regions of Ghana. METHODS: Data for this study was obtained from the DHIMS2 for health facilities providing OPD and malaria services in Ghana. This was an ecological study that employed the difference-in-difference approach to assess the change in proportion of uncomplicated confirmed malaria cases among OPDs in all types of health facilities in Ghana between 2015 and 2019 following the mass distribution campaign of LLINs in 2018. Malaria cases at the OPDs before and after the free LLIN mass distribution exercise were evaluated. RESULTS: The trend of the proportion of OPD cases that were confirmed uncomplicated malaria cases increased from 14.8% in 2015 to 18.9% in 2019 at the national level. The average proportion of malaria cases among OPDs in Ghana in 2019 reduced against the expected by - 3.76% (95% CI - 4.69 to - 2.84], p<0.001) among all cases, - 4.52% (95% CI [- 5.70 to - 3.34], p<0.001) among children under-fives years, - 4.10% (95% CI - 5.3 to 2.9], p<0.001) among female children under-five and - 5.18% (95% CI [- 6.33 to - 4.02], p<0.001) among male children under-five. The reduction on the average proportion of malaria cases among OPDs varied significantly across regions and the type of health facilities. CONCLUSION: The mass distribution of LLINs across Ghana in 2018 can be associated with reduction in the proportion of malaria cases among OPDs across health facilities in Ghana. The study recommends the biannual mass distribution campaigns especially in the high-density regions.

Inequalities in the use of insecticide-treated nets by pregnant women in Ghana, 2011 and 2017.

BACKGROUND: Pregnant women and children are the most vulnerable group of people usually affected by malaria. The use of insecticide-treated nets is one of the proven interventions for mitigating malaria and its associated deaths in endemic regions, including Ghana. Meanwhile, there is limited evidence on the extent of inequality in insecticide-treated nets use by pregnant women in Ghana. This study assessed the inequalities in insecticide-treated nets use by pregnant women in Ghana. METHODS: Data from the 2011 and 2017 versions of the Ghana Multiple Indicator Cluster Surveys were used. The 2019 updated World Health Organization (WHO) HEAT software (version 3.1) was used for all analyses. Four equity stratifiers were employed to disaggregate insecticide-treated nets use by pregnant women in Ghana. These are economic status, level of education, place of residence, and sub-national region. Four measures were used to compute inequality namely Difference (D), Population Attributable risk (PAR), Population Attributable Fraction (PAF) and Ratio (R). RESULTS: The analyses indicated a rise in pregnant women's insecticide-treated nets use from 32.6% in 2011 to 49.7% in 2017. Except sub-national region, all the factors showed mild inequality in insecticide-treated nets use. For instance, with respect to the economic status of pregnant women, only a slight inequality was exhibited by one of the simple measures in both 2011 (R = 0.3; 95% UI = 0.2-0.6) and 2017 (R = 0.5; 95% UI = 0.3-0.7). Marginal inequality in insecticide-treated nets use was noted in 2011 (R = 0.6; 95% UI = 0.5-0.9) and 2017 (R = 0.8; 95% UI = 0.6-0.9) for level of education. In the same vein, slight inequality was realized with respect to place of residence in 2011 (R = 0.4; 95% UI = 0.3-0.6) and 2017 (R = 0.6; 95% UI = 0.5-0.7). For sub-national region, both simple (D = 50.5; 95% UI = 30.7-70.4) and complex (PAF = 91.3; 95% UI = 72.3-110.3) measures demonstrated substantial inequality in 2011. In the case of 2017, considerable inequality in insecticide-treated nets use occurred (D = 58; 95% UI = 42.2-73.8, PAF = 51.9; 95% UI = 36.2-67.6). CONCLUSION: In conclusion, insecticide-treated nets utilization by pregnant Ghanaian women increased between 2011 and 2017. The findings show that Ghana's Ministry of Health in collaboration with anti-malarial non-governmental organizations must review patterns of insecticide-treated nets distribution and intensify advocacy among educated pregnant women, those in urban settings and the rich, to assuage the magnitude of inequality.

Estimating the costs for implementing a maternity leave cash transfer program for women employed in the informal sector in Brazil and Ghana.

BACKGROUND: Maternity leave policies are designed to protect gender equality and the health of mothers in the workforce and their children. However, maternity leave schemes are often linked to jobs in the formal sector economy. In low- and middle-income countries a large share of women work in the informal sector, and are not eligible to such benefit. This is worrisome from a social justice and a policy perspective and suggests the need for intervening. Costing the implementation of potential interventions is needed for facilitating informed decisions by policy makers. METHODS: We developed and applied a costing methodology to assess the cost of a maternity leave cash transfer to be operated in the informal sector of the economy in Brazil and Ghana, two countries with very different employment structures and socioeconomic contexts. We conducted sensitivity analysis by modeling different numbers of weeks covered. RESULTS: In Brazil, the cost of the maternity cash transfer would be between 0.004% and 0.02% of the GDP, while in Ghana it would range between 0.076% and 0.28% of the GDP. The relative cost of rolling out a maternity intervention in Brazil is between 2.2 to 3.2 times the cost in Ghana depending on the benchmark used to assess the welfare measure. The differences in costs between countries was related to differences in labor market structure as well as demographic characteristics. CONCLUSIONS: Findings show how a standard methodology that relies on routinely available information is feasible and could assist policymakers in estimating the costs of supporting a maternity cash transfer for women employed in the informal sector, such intervention is expected to contribute to social justice, gender equity, and health trajectories.

Supporting a review of the benefits package of the National Health Insurance Scheme in Ghana.

BACKGROUND: Although Ghana is lauded for its National Health Insurance Scheme (NHIS), concerns exist about the scheme's functioning and sustainability. An often-cited issue-contributing to the scheme's decreasing membership, long-standing financial deficit, and frequent out-of-pocket payments among members-is the large benefits package (BP). While, on paper, the BP covers over 95% of the conditions occurring in Ghana, its design was not informed by any budget analysis, nor any systematic prioritization of interventions. This paper aims to provide evidence-based input into ongoing discussions regarding a review of the NHIS benefits package. METHODS: An existing analytic framework is used to calculate net health benefit (NHB) for a range of interventions in order to assess their cost-effectiveness and enable the prioritization of 'best buys'. The framework is expanded upon by incorporating concerns for financial protection, and practical feasibility, as well as the political economy challenges of disinvesting in currently funded activities. Five different options for the benefits package, each based on policy discourse in Ghana's health sector, are presented and evaluated. RESULTS: Implementing all interventions for which data was available to 100% of the population in need was estimated to cost GH₵4323 million (US$994 million), while the available NHIS budget was only GH₵970 million (US$223 million). Options for the benefits package that focussed on cost-effectiveness and primary care provision achieved the best health outcomes, while options reflecting the status quo and allowing for co-payments included a higher number of healthcare interventions. Apart from the package option focussing on primary care, all packages were faced with physician shortages. CONCLUSIONS: Current funding to the NHIS is insufficient to provide the historical benefits package, which promises to cover over 95% of disease conditions occurring in Ghana, to the total population. Shifting the NHIS focus from intervention coverage to population coverage is likely to lead to better health outcomes. A primary care package may be most feasible in the short-term, though additional physicians should be trained to provide higher-level care that is highly cost-effective, such as emergency neonatal care.

The effect of community engagement on healthcare utilization and health insurance enrollment in Ghana: Results from a randomized experiment.

Health insurance enrollment in many Sub-Saharan African countries is low, even with highly subsidized premiums and exemptions for vulnerable populations. One possible explanation is low service quality, which results in a low valuation of health insurance. Using a randomized control trial in 64 primary health care facilities in Ghana, this study assesses the impact of a community engagement intervention designed to improve the quality of healthcare and health insurance services on households living nearby the facilities. Although the intervention improved the medical-technical quality of health services, our results show that households' subjective perceptions of the quality of healthcare and insurance services did not increase. Nevertheless, the likelihood of illness and concomitant healthcare utilization reduced, and especially households who were not insured at baseline were more likely to enroll in health insurance. The results show that solely increasing the technical quality of care is not sufficient to increase households' subjective assessments of healthcare quality. Still, improving technical quality can directly contribute to health outcomes and further increase health insurance coverage, especially among the previously uninsured.