Selection and behavioral responses of health insurance subsidies in the long run: Evidence from a field experiment in Ghana.

We study the effects of a health insurance subsidy in Ghana, where mandates are not enforceable. We randomly provide different levels of subsidy (1/3, 2/3, and full) and evaluate the impact at 7 months and 3 years after the intervention. We find that a one-time subsidy increased insurance enrollment for all groups in both the short and long runs, but health care utilization in the long run increased only for the partial subsidy group. We find supportive evidence that ex-post behavioral responses rather than ex-ante selective enrollment explain the long-run health care utilization results.

Impact of health system strengthening interventions on child survival in sub-Saharan Africa: a systematic review protocol.

BACKGROUND: Strengthening healthcare systems is a practical approach to enhance healthcare delivery and services. Although there has been a rise in the number of health systems strengthening (HSS) interventions in sub-Saharan Africa (SSA), there is limited evidence on the causal effect of these activities on child survival. Furthermore, the findings reported so far have been varied, and how they relate to each other remains unclear. This systematic review study aims to assess all available evidence to understand the impact of HSS activities on child survival in SSA. METHODS: We developed a search strategy to retrieve all relevant studies from electronic databases such as PubMed/MEDLINE, Web of Science, and African Journals Online. We will use a combination of search terms such as "under-five mortality," "child mortality," "infant mortality," "neonatal mortality," "child survival," and "health systems strengthening." The review will include studies that establish a causal relationship between HSS interventions and child survival. This will include studies with designs such as randomized controlled trials and quasi-experimental and methods like difference-in-difference. Two reviewers will independently screen all citations, abstracts, and full-text data and a third reviewer will act as a tiebreaker in case of disagreements. The primary outcome of interest is the impact of HSS activities on under-five survival. We will evaluate the quality of each study using the Bradford Hill criteria for causation. DISCUSSION: Our systematic review will identify and evaluate all relevant evidence that establishes a causal relationship between HSS activities and the survival of children under five years in SSA. The review's findings regarding the impact of HSS activities on child survival could be of significant interest to the donor community and policy actors in the region. We also anticipate that the review's conclusions could serve as a valuable guide for the development of future health system interventions and strategies in SSA. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022333913.

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.

How different incentives influence reported motivation and perceptions of performance in Ghanaian community-based health planning and services zones.

BACKGROUND: Maternal mortality is still a burden worldwide, and Ghana's maternal and child mortalities are still high. Incentive schemes have been effective in improving health workers' performance thereby reducing maternal and child deaths. The efficiency of public health services in most developing countries has been linked to the provision of incentives. Thus, financial packages for Community Health Volunteers (CHVs) serve as enablers for them to be focused and committed to their work. However, the poor performance of CHVs is still a challenge in health service delivery in many developing countries. Although the reasons for these persistent problems are understood, we need to find out how to implement what works in the face of political will and financial constraints. This study assesses how different incentives influence reported motivation and perceptions of performance in Community-based Health Planning and Services Program (CHPS) zones in the Upper East region. METHODS: A quasi-experimental study design with post-intervention measurement was used. Performance-based interventions were implemented for 1 year in the Upper East region. The different interventions were rolled out in 55 of 120 CHPS zones. The 55 CHPS zones were randomly assigned to four groups: three groups of 14 CHPS zones with the last group containing 13 CHPS zones. Several alternative types of financial and non-financial incentives as well as their sustainability were explored. The financial incentive was a small monthly performance-based Stipend. The non-financial incentives were: Community recognition; paying for National Health Insurance Scheme (NHIS) premiums and fees for CHV, one spouse, and up to two children below 18 years, and; quarterly performance-based Awards for best-performing CHVs. The four groups represent the four different incentive schemes. We conducted 31 In-depth interviews (IDIs) and 31 Focus Group Discussions (FGDs) with health professionals and community members. RESULTS: Community members and the CHVs wanted the stipend as the first incentive but requested that it be increased from the current level. The Community Health Officers (CHOs) prioritized the Awards over the Stipend because they felt it was too small to generate the required motivation in the CHVs. The second incentive was the National Health Insurance Scheme (NHIS) registration. Community recognition was also considered by health professionals as effective in motiving CHVs and work support inputs and CHVs training helped in improving output. The various incentives have helped increase health education and facilitated the work of the volunteers leading to increased outputs: Household visits and Antenatal Care and Postnatal Care coverage improved. The incentives have also influenced the initiative of volunteers. Work support inputs were also regarded as motivators by CHVs, but the challenges with the incentives included the size of the stipend and delays in disbursement. CONCLUSION: Incentives are effective in motivating CHVs to improve their performance, thereby improving access to and use of health services by community members. The Stipend, NHIS, Community recognition and Awards, and the work support inputs all appeared to be effective in improving CHVs' performance and outcomes. Therefore, if health professionals implement these financial and non-financial incentives, it could bring a positive impact on health service delivery and use. Also, building the capacities of CHVs and providing them with the necessary inputs could improve output.

Postpartum contraceptive initiation and use: Evidence from Accra, Ghana.

BACKGROUND: Postpartum contraceptive use reduces unintended pregnancies and results in better health outcomes for children and women. However, there is a dearth of knowledge on postpartum contraceptive use in Ghana, particularly among women in low-income urban settings. To shed light on strategies that might enhance access to postpartum family planning services in low-income urban settings, we examined contraceptive use among postpartum women in Accra, Ghana, at 1, 3, 6, and 12 months following the birth and the methods used. The predictors of modern contraceptive use in the 12-month postpartum period were also examined. METHODS: Data come from a cross-sectional survey conducted in 2018 among 624 women aged 16-44 years who reported giving birth in the past 13-31 months prior to the interview. We generated descriptive statistics to examine the prevalence of contraceptive use among postpartum women at 1, 3, 6, and 12 months after birth. We further estimated a binary logistic regression to examine the predictors of modern contraceptive use at 12 months postpartum. RESULTS: Forty percent of postpartum women never used any contraceptive method during 1 year after birth and of those who used a method, 40% relied on traditional methods. Moreover, 29% of women started using a method the immediate 1 month post-birth. Results further show that postpartum modern contraceptive uptake was positively associated with higher education, having more live births, and being currently in a union. CONCLUSIONS: Findings highlight that there may be opportunities to improve the quality of counseling during antenatal and postnatal care visits by clients to ensure fully informed choices regarding postpartum contraception. Community outreach by health providers/promoters or similar models should be promoted in low-income population settings to educate postpartum women on modern contraceptive use. Women who plan to use traditional methods should be provided with information on the consistent and correct use of these methods.

The impact of a health systems strengthening initiative on child morbidity: The case of the Ghana Essential Health Interventions Program in rural northern Ghana.

BACKGROUND: Improving child and maternal health remains a core objective of global health priorities, extending from the millennium development goal (MDG) era to the current focus on the Sustainable Development Goals (SGDs). This paper analyses the childhood morbidity effects of the Ghana Essential Heath Interventions Program (GEHIP), a community-based health systems strengthening in rural northern Ghana. GEHIP was a five-year embedded implementation science plausibility trial that implemented a set of health systems strengthening strategies and tested the proposition that their combined effect at the district, subdistrict and community levels could foster effective community engagement and thereby improve maternal and child health outcomes. METHODS: A two stage random sample survey of reproductive-aged women residing in treatment and comparison districts at the GEHIP baseline and end line was used for Heckman Difference-in-differences (DiD) regression models for estimating the incremental effect of GEHIP exposure on three child morbidity conditions (diarrhea, fever and cough), as recalled by maternal respondents in the course of survey interviews. RESULTS: After controlling for child age and gender, maternal age, education, marital status, health insurance status, religion, ethnicity, occupation and household wealth index, regression results show that GEHIP had a statistically significant 45% reduction in fever (OR = 0.55, CI = 0.31-0.98) and 47% reduction in cough (OR = 0.53, CI = 0.30-0.94), over and above temporal reductions that prevailed in study districts. Although not significant, GEHIP also had 38% reduction in the incidence of diarrhea. CONCLUSION: Previous research has shown that GEHIP had a pronounced positive effect with a reduction in mortality. Our results show that household location in GEHIP districts also led to a significant reduction in morbidity due to cough and fever among under-five children. This association is a likely outcome of GEHIP's impact on the accessibility of primary health care services. Results lend further support to the growing body of evidence that strengthening health systems in rural Africa through the provision of community-based strategies enhances prospects for achieving the United Nations child health SDGs.

Partner support and women's contraceptive use: insight from urban poor communities in Accra, Ghana.

BACKGROUND: Despite the benefits associated with contraceptive use, there is a low prevalence of contraceptive use in sub-Saharan Africa and Ghana. Previous studies have partly and consistently attributed the low prevalence of contraceptive use to partner opposition. However, little is known about the influence of men in contraceptive related choices of their partners, particularly within the context of urban poverty. This study examines the influences of partners on women's contraceptive choices. METHODS: The study utilized a cross-sectional household survey data of 1578 currently married women and women in a union of reproductive ages 16-44 years. Women who were pregnant and those trying to be pregnant were excluded from the analysis. The dependent variables for the study were current use of any contraceptive method, types of contraceptive methods and types of modern contraceptive methods. The independent variable for the study was a woman's report of partner support in contraceptive related choices. A binary logistic regression model was used to examine the associations between partner support in contraceptive related choices and contraceptive use of women. RESULTS: The results of the study show that partner support of contraceptive related choices has a significant influence on contraceptive use of women. Women who indicated support from their partners were more likely to be current users of any contraceptive method, yet were less likely to use modern contraceptive methods. CONCLUSION: The study highlights the need to involve men in family planning programs and research, as well as educating them on the various contraceptive modern methods and the side effects.

Impact of Covid-19 on Maternal Health Seeking in Ghana.

The Covid-19 pandemic is widely speculated to have disrupted the delivery of primary health care in low-income countries. Yet, there is little rigorous empirical research identifying this effect. This paper estimates the impact of Covid-19 on facility and skilled delivery and utilisation of antenatal care (ANC) services by comparing these outcomes for women who were pregnant/delivered before and during the Covid-19 period. The results show that Covid-19 led to 23% and 25% reductions, respectively, in the likelihood of facility delivery and four or more ANC visits during pregnancy. These findings highlight the need to build more resilient health systems in low-income settings.

Methods women use for induced abortion and sources of services: insights from poor urban settlements of Accra, Ghana.

BACKGROUND: Increasing access to safe abortion methods is crucial for improving women's health. Understanding patterns of service use is important for identifying areas for improvement. Limited evidence is available in Ghana on factors associated with the type of method used to induce abortion. This paper examined the methods and sources of services used for abortion by women living in poor urban settings of Accra. METHODS: Data are from a survey that was conducted in 2018 among 1233 women aged 16-44 years who reported ever having had an induced abortion. We estimated a multinomial logistic regression model to examine factors associated with the type of abortion methods women used. We further generated descriptive statistics for the source of abortion services. RESULTS: About 50% women used surgical procedures for their last abortion, 28% used medication abortion (MA), 12% used other pills, 3% used injection, and 7% used non-medical methods. However, nearly half (46%) of the women who terminated a pregnancy within the year preceding the survey used medication abortion (MA), 32% used surgical procedures, while 5% used non-medical methods. Women who terminated a pregnancy within three years preceding the survey had a 60% lower chance of using surgical procedures if they did not use MA compared to those who terminated a pregnancy more than 3 years before the survey (Relative Risk Ratio [RRR] 0.4; 95% CI 0.3-0.5). The vast majority (74%) of women who used MA obtained services from pharmacies. CONCLUSIONS: The use of MA pills to terminate pregnancies has increased in recent years in Ghana and these pills are mostly accessed from pharmacies. This suggests a need for a review of the national guidelines to include pharmacists and chemists in the provision of MA services.

Dynamics of Emergency Contraceptive Use in Accra, Ghana.

Recent data suggest increasing rates of emergency contraception (EC) use in Ghana, particularly in urban areas. In 2018, we collected survey data from 3,703 sexually experienced women aged 16-44 years living in low-income settlements of Accra. We estimated the prevalence of lifetime and current EC use. Multivariate logistic regression was used to assess factors associated with current use of EC. Retrospective monthly calendar data on contraceptive use were analyzed to identify patterns of EC use, including repeat and continuous use, and uptake of other contraceptive methods in the months following EC use. Nearly 15 percent of women had ever used EC. About half of recent EC users (52 percent) used EC for at least four months cumulatively within a 12-month window. There was no evidence of adoption of other modern methods in the months after using EC. Our results suggest that EC is a common method for pregnancy prevention in Accra, particularly among young, unmarried, highly educated women. Counseling on effective EC use and strategies that promote equitable access should be prioritized.

Contraceptive method use, discontinuation and failure rates among women aged 15-49 years: evidence from selected low income settings in Kumasi, Ghana.

BACKGROUND: This paper provides estimates of contraceptive discontinuation and failure rates in a poor urban setting in Ghana. Contraceptive use is for the purposes of preventing unintended or mistimed pregnancies. Unfortunately, evidence abounds in many parts of the world where there is considerable levels of contraceptive failure and high levels of discontinuation resulting in unintended pregnancies. METHODS: We estimated discontinuation rates during a 12-month period since starting use by applying single and multiple decrement life table methods to the contraceptive calendar data collected in a survey of women in reproductive age of 15-49 years. RESULTS: Modern contraceptive method use was estimated to be 13.7% at the time of the survey. The results show that contraceptive method discontinuation vary markedly by type of contraceptive method but are high for almost all methods, except for implants (23.7%). Discontinuation rate for emergency contraception was estimated at 88.5%, withdrawal 87.6%, and male condom use 80.9%. However, discontinuation rates were moderately high for rhythm (63.6%), pills (65.6%) and injectables (56%). In terms of failure rates, overall contraceptive failure for all methods was estimated at 7.9%. The factors significantly associated with method failure include being within age bracket 40-44 years (OR = 0.3, p < 0.05), having secondary/higher education (OR = 0.4, p < 0.01), belonging to the richest household wealth scale (OR = 3.3, p < 0.01), currently in union with a partner (OR = 2.2, p < 0.01), and using contraceptive methods such as rhythm (OR = 5.6, p < 0.01) and withdrawal (OR = 3.7, p < 0.01). On the flip side, the odds for method discontinuation were significantly higher for women in their 20s and mid 30s, formerly in union (OR = 1.9, p < 0.05) and use of withdrawal method (OR = 1.4, p < 0.05) and lower for women formerly in union (OR = 0.4, p < 0.01) and use of implants (OR = 0.2, p < 0.01) and injectables (OR = 0.6, p < 0.01). CONCLUSION: While contraceptives use is low, both discontinuation and failure rates are high and variable among different methods. Failure and discontinuation rates are lowest for long-acting methods such as implants while higher failure rates are more prevalent among women who rely on withdrawal and the rhythm methods.

Contraception before and after induced abortion: Trajectories of women in selected urban-poor settlements of Accra, Ghana.

This paper examined women's pre- and post-induced abortion contraceptive use and predictors of post-abortion modern contraceptive uptake in selected poor settlements of Accra, Ghana. Data from a cross-sectional study of 251 women aged 16-44 years were used. Patterns of contraceptive use were analysed descriptively while the predictors of modern contraceptive use in the month following induced abortion were examined using a binary logistic regression model. Majority of women (60%) were not using any method of contraception when they became pregnant before their abortion. Just over 30% of these women switched to using any method in the month immediately after abortion (22% modern and 9% traditional). Women who had became pregnant while using a modern method before their abortion had higher odds of using a modern method post-abortion than women who had not been using any method of contraception when they became pregnant. Following induced abortion, many women remained at potential risk of future unintended pregnancy. Our findings suggest the need for improved contraceptive counselling for women who seek abortion services, both during post-abortion care for facility-based abortions or at the time of obtaining medication abortion pills for those who are self-managing their abortion.

The impact of a personalized, community-based counselling and referral programme on modern contraceptive use in urban Ghana: a retrospective evaluation.

Community-based demand-generation family planning programmes have been associated with increased contraceptive use in rural areas of Ghana. However, rigorous evaluations of such programmes in urban contexts are lacking. We used a retrospective, cross-sectional with comparison group design to estimate the immediate and sustained impact of the Willows intervention on modern contraceptive use in Kumasi, Ghana. The Willows intervention is a home-based counselling and referral programme for women in low-income urban settlements. We analysed data from a cross-sectional representative survey of 1205 women of reproductive age in the intervention area and 1108 women in a matched comparison site. The main outcome was women's reported contraceptive use at: (1) baseline (January 2013); (2) programme close (December 2016); and (3) follow-up (August to October 2018). We estimated the programme effect at the community level and for women who reported receiving a family planning counselling visit. We used coarsened exact matching to assess the impact of the intervention relative to outcomes for matched comparison women. Comparing those who reported a family planning visit in the intervention area with matched comparison area women who reported no visit, we estimated a 10.5 percentage point increase in use of modern contraceptives from baseline to close (95%CI : 6.2, 14.8; P < 0.001) and a 7.6 percentage point increase from baseline to follow-up (95%CI : 3.3, 11.9; P < 0.001). However, only 20.2% of women in the Willows intervention area reported a visit. The Willows intervention, therefore, did not achieve its aim to reach all reproductive-aged women in the community. At the community level, we found no significant effect of the intervention at either programme close or 2 years later. We recommend that similar community-based interventions strive for greater outreach and simultaneously launch robust prospective impact evaluations.

Evaluating health service coverage in Ghana's Volta Region using a modified Tanahashi model.

Background: The United Nations 2030 Sustainable Development Goals have reaffirmed the international community's commitment to maternal, newborn, and child health, with further investments in achieving quality essential service coverage and financial protection for all.Objective: Using a modified version of the 1978 Tanahashi model as an analytical framework for measuring and assessing health service coverage, this paper aims to examine the system of care at the community level in Ghana's Volta Region to highlight the continued reforms needed to achieve Universal Health Coverage.Methods: The Tanahashi model evaluates health system coverage through five key measures that reflect different stages along the service provision continuum: availability of services; accessibility; initial contact with the health system; continued utilization; and quality coverage. Data from cross-sectional household and health facility surveys were used in this study. Immunization and antenatal care services were selected as tracer interventions to serve as proxies to assess systems bottlenecks.Results: Financial access and quality coverage were identified as the biggest bottlenecks for both tracer indicators. Financial accessibility, measured by enrollment in Ghana's National Health Insurance Scheme was poor with 16.94% presenting valid membership cards. Childhood immunization was high but dropped modestly from 93.8% at initial contact to 76.7% quality coverage. For antenatal care, estimates ranged from 65.9% at initial visit to 25.1% quality coverage.Conclusion: Results highlight the difficulty in achieving high levels of quality service coverage and the large variations that exist within services provided at the primary care level. While vertical investments have been prioritized to benefit specific health services, a comprehensive systems approach to primary health care needs to be further strengthened to reach Ghana's Universal Health Coverage objectives.

Perceptions and trends in the use of community pharmacies in Ghana.

OBJECTIVE: To examine the patterns in utilization of community pharmacies and perceptions of the general public towards community pharmacists' role in health services delivery. METHOD: A cross-sectional household survey was conducted in Ga West district. A total of 497 adults (18 years and above) were chosen using a three-stage cluster random sampling technique. information on respondents' contact with community pharmacies (i.e. 12 months prior to the study), reasons for visiting the pharmacies, factors influencing the choice of a particular pharmacy and perception towards community pharmacists' roles were collected. Data collected were analyzed using stata version 14. KEY FINDINGS: Out of the 497 respondents, 415 indicated that they had used pharmacies within the last 12 months prior to the study, while 82 indicated that they had not used the facilities within the same time frame. majority of the pharmacy users (33.7%) visited community pharmacies once a month. Approximately 84% of the pharmacy users frequently visited community pharmacies to get treatment for minor ailments. most users (about 75%) chose to visit a particular pharmacy as it was close to their home/workplace/hospital/clinic. More than half of the pharmacy users identified the pharmacist as the first point of contact in case of any drug-related problem. Less than half of the respondents (44.9%) perceived community pharmacists as health professionals with a good balance between health and business matters. CONCLUSION: The findings of the study suggest that beside the fact that majority of the respondents believe that community pharmacists are responsive, friendlier and have the capacity to handle minor ailments, they are indeed using community pharmacies for the treatment of minor ailments. It will therefore be important to develop appropriate policy and regulations that enables community pharmacies to adequately participate in the delivery of primary care and thereby improve population health.

Out-of-pocket payment for primary healthcare in the era of national health insurance: Evidence from northern Ghana.

BACKGROUND: Ghana introduced a national health insurance program in 2005 with the goal of removing user fees, popularly called "cash and carry", along with their associated catastrophic and impoverishment effects on the population and ensuring access to equitable health care. However, after a decade of implementation, the impact of this program on user fees and out-of-pocket payment (OOP) is not properly documented. This paper contributes to understanding the impact of Ghana's health insurance program on out-of-pocket healthcare payments and the factors associated with the level of out-of-pocket payments for primary healthcare in a predominantly rural region of Ghana. METHODS: Using a five-year panel data of revenues accruing to public primary health facilities in seven districts, We employed mean comparison tests (t-test) to examine the trend in revenues accruing from out-of-pocket payments vis-à-vis health insurance claims for health services, medication, and obstetric care. Furthermore, generalized estimation equation regression models were used to assess the relationship between explanatory variables and the level of out-of-pocket payments and health insurance claims. RESULTS: Out-of-pocket payment for health services and medications declined by 63% and 62% respectively between 2010 and 2014. Insurance claims however increased by 16% within the same period. There was statistically a significant mean reduction in out-of-pocket payment over the period. Factors significantly associated with out-of-pocket payments in a given district are the number of community health facilities, availability of a district hospital and the year of observation. CONCLUSION: The study provides evidence that Ghana's national health insurance program is significantly contributing to a reduction in out-of-pocket payment for primary healthcare in public health facilities. Efforts should therefore be put in place to ensure the sustainability of this policy as a major pathway for achieving universal health coverage in Ghana.

The child survival impact of the Ghana Essential Health Interventions Program: A health systems strengthening plausibility trial in Northern Ghana.

BACKGROUND: The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. METHODS: Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. RESULTS: The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55-1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. CONCLUSION: GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up.

Contraceptive use intentions and unmet need for family planning among reproductive-aged women in the Upper East Region of Ghana.

BACKGROUND: Motivations for use of contraceptives vary across populations. While some women use contraceptives for birth spacing, others adopt contraception for stopping childbearing. As part of efforts to guide the policy framework to promote contraceptive utilization among women in Ghana, this paper examines the intentions for contraceptive use among reproductive-aged women in one of the most impoverished regions of Ghana. METHODS: This paper utilizes data collected in 2011 from seven districts in the Upper East Region of northern Ghana to examine whether women who reported the use of contraceptives did so for the purposes of stopping or spacing childbirth. A total of 5511 women were interviewed on various health and reproductive health related issues, including fertility and family planning behavior. Women were asked if they would like to have any more children (for those who already had children or those who were pregnant at the time of the survey). RESULTS: The prevalence of contraceptive use was low at 13%, while unmet need is highly pervasive and demand for family planning is predominantly for spacing future childbearing rather than for the purpose of stopping. Overall, about 31.7%of women not using contraceptives reported a need for spacing while 17.6% expressed a need for limiting. Thus, the latent demand for family planning is dominated by preferences for space rather than limiting childbearing. CONCLUSION: Results show that there is latent demand for family planning and therefore if family planning programs are appropriately implemented they can yield the desired impact.

Cost of implementing a community-based primary health care strengthening program: The case of the Ghana Essential Health Interventions Program in northern Ghana.

BACKGROUND: The absence of implementation cost data constrains deliberations on consigning resources to community-based health programs. This paper analyses the cost of implementing strategies for accelerating the expansion of a community-based primary health care program in northern Ghana. Known as the Ghana Essential Health Intervention Program (GEHIP), the project was an embedded implementation science program implemented to provide practical guidance for accelerating the expansion of community-based primary health care and introducing improvements in the range of services community workers can provide. METHODS: Cost data were systematically collected from intervention and non-intervention districts throughout the implementation period (2012-2014) from a provider perspective. The step-down allocation approach to costing was used while WHO health system blocks were adopted as cost centers. We computed cost without annualizing capital cost to represent financial cost and cost with annualizing capital cost to represent economic cost. RESULTS: The per capita financial cost and economic cost of implementing GEHIP over a three-year period was $1.79, and $1.07 respectively. GEHIP comprised only 3.1% of total primary health care cost. Health service delivery comprised the largest component of cost (37.6%), human resources was 28.6%, medicines was 13.6%, leadership/governance was 12.8%, while health information comprised 7.5% of the economic cost of implementing GEHIP. CONCLUSION: The per capita cost of implementing the GEHIP program was low. GEHIP project investments had a catalytic effect that improved community-based health planning and services (CHPS) coverage and enhanced the efficient use of routine health system resources rather than expanding overall primary health care costs.