Bottleneck analysis approach to accelerate newborn care services in two regions in Ghana: implications for national newborn care.

OBJECTIVE: The aim of this work is to describe application of a data-driven approach (bottleneck analysis [BNA] approach process) to accelerate newborn care services in two regions and what effect it had on national-level newborn care interventions in Ghana. STUDY DESIGN: A mixed-method approach was used for the study. The BNA tool generated quantitative data and group discussions provided phenomenological explanations to identified service gaps. METHODS: Regional newborn care health service assessments were conducted in November 2013 through desk reviews, field and health facility visits and coaching/mentorship. The BNA tool (an excel-based tool) directly utilized service coverage data and programme monitoring and review reports in Ghana. Outputs were generated based on service coverage indicators: supply side/health system factors (commodities, human resource and access), demand side (service utilization) and quality/effective coverage. National targets were used as benchmarks to assess gaps in coverage indicators. RESULTS: Key health system bottlenecks included absence/stock-out of essential newborn care commodities/resuscitation kits and absence of updated policies at services delivery points. In both regions, less than 55% of health facilities had at least 80% of midwives trained to provide essential obstetric and newborn care, management of preterm babies, resuscitation and inpatient paediatric care. In addition, less than 35% of pregnant women were assisted by a skilled birth attendant (midwife) and monitored with a partograph in the two regions. Demand-side bottlenecks included cultural preference for home deliveries, limited knowledge on importance of postnatal care and poor community involvement.The BNA approach in the two regions resulted in the development of national and other regional operational plans and monitoring and evaluation framework for newborn care services in Ghana over the period 2012-2016, and a relative improvement in neonatal mortality at the regional and national level. CONCLUSION: The BNA tool and approach provided data-driven planning for newborn care service delivery in a low-income setting. It identified gaps in service coverage based on empirical data at lower levels of the health system and garnered strategies in addressing bottlenecks to newborn care services at the national level.

Regional disparities in immunization services in Ghana through a bottleneck analysis approach: implications for sustaining national gains in immunization.

BACKGROUND: Immunization is considered one of the most cost effective public health interventions for reducing child morbidity, mortality and disability. The aim of this work is to describe the application of the Bottleneck analysis (BNA) process to assess gaps in immunization services in Ghana and implications for sustaining the gains in Immunization coverage. METHODS: A national assessment was conducted in May 2015, through use of desk reviews, field visits and key informant interviews. Quantitative data were analysed with the BNA Tool (an excel-based tool) based directly on service coverage data and programme monitoring and review reports in Ghana. Outputs were generated based on service coverage indicators; supply side/health system factors (commodities, human resource and access), demand side (service utilisation) and quality/effective coverage. National targets were used as benchmarks to assess gaps in coverage indicators. RESULTS: In all, only 50% of regions and districts had health facilities with at least 80% of health care workers training provided in-service training on routine immunization; only 40% of district had communities with functional fixed or outreach EPI service delivery point and over 70% of regions and districts had challenges with effective coverage of infants aged 0-11 months fully immunized during the past year. Other key health system bottlenecks included, limited number of fixed and outreach sites, difficult to reach island communities along the Volta Basin, inadequate storage facilities for vaccines at lower levels, stock out of vaccines and auto destruct syringes and absence of updated policies/field guides at services delivery points/facilities. In addition, inadequate in-service training in routine Immunization and absence of good quality data were major challenges. Demand side bottlenecks included fear of mothers on the safety of multiple vaccines and limited active involvement of communities in Immunization service delivery. CONCLUSION: The BNA tool and approach provided data driven planning of health service in Ghana. This resulted in the development of regional and national operational plans for immunization and will be the baseline for evaluating the national programme in three years.

Distribution of human Oesophagostomum bifurcum, hookworm and Strongyloides stercoralis infections in northern Ghana.

A cross-sectional study was carried out in 216 randomly selected, representative rural villages in the northeastern part of Ghana from March 1995 to May 1998. Inhabitants of randomly selected households, stratified by age and gender, were included. The geographical position of villages was recorded with a global positioning system (GPS). The prevalence of Oesophagostomum, hookworm and Strongyloides stercoralis infections in a study population of 20250 people was determined by microscopic examination of larvae in stool cultures. The overall prevalence was 10.2, 50.6 and 11.6% for the three nematodes, respectively. Hookworm infections were seen in all but one (99.5%) and S. stercoralis in 88.4% of the 216 villages, while Oesophagostomum infections were found to be common in a limited area with prevalences varying from 0 to 75%. An association was found between Oesophagostomum and hookworm infection, both at the individual and at the village level. Spatial analysis of the prevalence data indicated that the endemic area is relatively clearly demarcated to the south of the study area.

Intraobserver and interobserver variation of ultrasound diagnosis of Oesophagostomum bifurcum colon lesions.

Infection by the nematode Oesophagostomum bifurcum is focally distributed in Africa and causes a syndrome of abdominal pain, obstruction, or abdominal mass because of its predilection for invasion of colonic mucosa. To determine the reliability of ultrasound for the detection of colon pathology induced by this parasite, three studies to assess the intraobserver and interobserver variation of the technique were performed. In an area of northern Ghana endemic for O. bifurcum, 181 people from a low-prevalence village and 62 people from a high-prevalence village were examined twice by the same observer, and 111 people were independently examined by two observers in a moderately endemic village. The kappa statistics for the prevalence observations in the three studies were 0.82, 0.87, and 0.81, respectively, and kappa values for the intensity observations were 0.66, 0.63, and 0.71, respectively. The upper 95% confidence intervals of the average absolute difference in nodule size measurements in Study 1 and Study 3 were 3.6 and 4.5 mm, respectively. Therefore, ultrasound is useful in the diagnosis and management of O. bifurcum colon infection.

Distribution and clustering of Oesophagostomum bifurcum and hookworm infections in northern Ghana.

Human Oesophagostomum infections are locally common in northern Ghana. The present study describes the results of a cross-sectional survey involving 1011 subjects, selected by a compound-based random sampling method from 1227 compounds in 24 villages. Selected persons were examined by both Kato and coproculture methods. Hookworm-like eggs, representing ova of Oesophagostomum bifurcum and hookworm were detected in 87.5% of the Kato smears. The geometric mean egg count of the infected subjects was 1018. Upon coproculture, third-stage larvae of O. bifurcum and hookworm were detected in 53.0% and 86.9% of subjects respectively. Oesophagostomum infections were clustered but no clear explanation for aggregation of infections could be found as yet. Subjects infected with hookworm had a 5-fold higher risk of being infected with O. bifurcum. Infection rates in adult women were higher than in adult men. No association was found with family size, level of hygiene or with the presence of animals in the compounds. Representatives of the Bimoba-tribe were significantly more infected than those of the other tribes. It appears, however, that this tribal association is a geographical phenomenon: Bimoba are mostly living in villages with the highest infection rates.