A comparative study on the availability of modern contraceptives in public and private health facilities in a peri-urban community in Ghana.

BACKGROUND: Sub-Saharan Africa reports low use of family planning methods and high unmet need. Availability of these methods is one of the major barriers to contraceptive use in the region. This study determined the availability of modern contraceptives and perceived factors affecting this in health facilities in the Ga East municipality of Ghana. METHODS: This was a cross-sectional study involving quantitative and qualitative techniques. Data was obtained from 51 randomly selected health facilities using a checklist. Relationships between certain attributes of the facilities and availability of each category of contraceptive identified was tested using univariate and and multiple logistic regression techniques. The qualitative data was obtained by conducting in-depth interviews with the managers of the facilities and then analysed according to emerging themes. RESULTS: The study gave an indication that there was a low availability of long acting reversible contraceptives (LARC) such as implants (14%) and IUDs (14%) in the health facilities. Male condoms (78%) and combined oral contraceptives (82%) were the most available At the bivariate level, emergency contraceptives were less likely to be found in public health facilities (OR = 0.11, p = 0.05). Facility managers cited 'profit' and 'preference' as some of the reasons for availability of their contraceptives. CONCLUSION: Availability of modern contraceptives differ according to the type and brand of contraceptive. There is however a low availability of LARC methods in all the health facilities. Factors such as 'profit' accounted for the low availability of this method.

Integration of control of neglected tropical diseases into health-care systems: challenges and opportunities.

Although progress has been made in the fight against neglected tropical diseases, current financial resources and global political commitments are insufficient to reach the World Health Assembly's ambitious goals. Increased efforts are needed to expand global coverage. These efforts will involve national and international harmonisation and coordination of the activities of partnerships devoted to control or elimination of these diseases. Rational planning and integration into regular health systems is essential to scale up these interventions to achieve complete eradication of these diseases. Programmes with similar delivery strategies and interventions-such as those for onchocerciasis, lymphatic filariasis, and soil-transmitted helminthiasis-could be managed on the same platform and together. Furthermore, better-resourced programmes-such as those for malaria, HIV/AIDS, and tuberculosis-could work closely with those for neglected tropical diseases to their mutual benefit and the benefit of the entire health system.

Paenibacillus polymyxa JB05-01-1 and its perspectives for food conservation and medical applications.

The aim of this study was to isolate a novel bacterial strain with strong and broad spectrum antibacterial activity from a livestock feed prebiotic supplement. A novel strain, termed Paenibacillus polymyxa JB05-01-1, was isolated using traditional microbiological methods and identified on the basis of its phenotypic and biochemical properties as well as its 16S rRNA gene sequence. This strain was able to inhibit growth of gram-negative bacteria including Escherichia coli RR1, Pseudomonas fluorescens R73, Pantoea agglomerans BC1, Butyrivibrio fibrisolvens OR85, and Fibrobacter succinogenes. The above antagonism against the aforementioned bacteria was attributed to production of an antimicrobial substance(s) termed "JB05-01-1." Its production was optimal during the stationary phase. JB05-01-1 has a molecular weight of 2.5 KDa, its mode of action is bactericidal, and the divalent cations, Ca(2+) and Mn(2+), reduced its lethality. The antibacterial activity was heat-stable and was effective at a pH range of 2-9. Enzymes like trypsin, α-chymotrypsin, and proteinase K have abolished the antibacterial activity of JB05-01-1 indicating a proteinaceous motif. This type of naturally occurring bacteria and inhibitory substance(s) could represent an additional value in livestock feed supplements. The natural presence of antibacterial activity indicates an opportunity to decrease the addition of antibiotics.

From data to policy: good practices and cautionary tales.

Sound statistics are a key component of evidence. However, many institutional, political, and practical barriers impede effective use of data to inform policy. In the fourth paper in this Series on health statistics, we look at the relation between health statistics and policymaking at country and global levels. We propose a fourfold framework to help the transition from data to policy. Good practices include: (1) reconciling statistics from different sources; (2) fostering communication and transparency, including reaching out to the media for dissemination; (3) promoting country ownership of data and statistical analyses; and (4) addressing conflicts of interest, including those arising when workers responsible for attainment of health goals are also charged with measurement and monitoring of progress. Further investments are needed not only in primary data collection across a full range of sources but also in building capacity in countries to analyse, interpret, and present statistics effectively in ways that are meaningful and useful for policymaking.

Balancing equity and efficiency in health priorities in Ghana: the use of multicriteria decision analysis.

OBJECTIVES: To guide the Ministry of Health in Ghana in the priority setting of interventions by quantifying the trade-off between equity, efficiency, and other societal concerns in health. METHODS: The study applied a multicriteria decision analytical framework. A focus group of seven policymakers identified the relevant criteria for priority setting and 63 policymakers participated in a discrete choice experiment to weigh their relative importance. Regression analysis was used to rank order a set of health interventions on the basis of these criteria and associated weights. RESULTS: Policymakers in Ghana consider targeting of vulnerable populations and cost-effectiveness as the most important criteria for priority setting of interventions, followed by severity of disease, number of beneficiaries, and diseases of the poor. This translates into a general preference for interventions in child health, reproductive health, and communicable diseases. CONCLUSION: Study results correspond with the overall vision of the Ministry of Health in Ghana, and are instrumental in the assessment of present and future investments in health. Multicriteria decision analysis contributes to transparency and accountability in policymaking.

Going to scale with professional skilled care.

Because most women prefer professionally provided maternity care when they have access to it, and since the needed clinical interventions are well known, we discuss in their paper what is needed to move forward from apparent global stagnation in provision and use of maternal health care where maternal mortality is high. The main obstacles to the expansion of care are the dire scarcity of skilled providers and health-system infrastructure, substandard quality of care, and women's reluctance to use maternity care where there are high costs and poorly attuned services. To increase the supply of professional skilled birthing care, strategic decisions must be made in three areas: training, deployment, and retention of health workers. Based on results from simulations, teams of midwives and midwife assistants working in facilities could increase coverage of maternity care by up to 40% by 2015. Teams of providers are the efficient option, creating the possibility of scaling up as much as 10 times more quickly than would be the case with deployment of solo health workers in home deliveries with dedicated or multipurpose workers.

Safe motherhood in Ghana: still on the agenda?

OBJECTIVE: This paper is an exploration of health sector and programming issues that resulted from a description of safe motherhood activities in Ghana. METHODS: Descriptions of safe motherhood programmes were collected from various stakeholders through structured interviews. The characteristics of the programmes were compared to national safe motherhood aims and in the context of the reproductive health and sector-wide environment in Ghana. RESULTS: Thirteen safe motherhood programmes were described. Their goals were wide ranging and did not necessarily target pregnant and postpartum women only. Community based interventions were slightly less dominant than service provision activities. A broad funding base was identified, strongly represented by external donors. Many funding contributions were not part of the Ghana government's Sector-Wide Approach (SWAp) to health. CONCLUSIONS: Although reduction in maternal mortality ratio is a priority in Ghana's policy, many funding agencies supporting what are known as "safe motherhood" programmes are actually pursuing a somewhat broader reproductive health agenda. The evidence that this situation has actually led to a dilution of the maternal mortality reduction agenda is inconclusive, although our analysis has resulted in lessons which could be used to avert any risk to achieving this key millennium development goal. Government can use the SWAp to keep interests focused on the need for maternal mortality reduction, without detriment to other priorities. Strengthening partnerships will allow civil society and community focused interests to have a voice in influencing SWAp agendas. Good programme design with clear understanding of the link between programme components and objectives will help in making sure that maternal mortality targets are indeed achieved.

Strategies to improve adherence to recommended chloroquine treatment regimes: a quasi-experiment in the context of integrated primary health care delivery in Ghana.

This paper presents the results of an intervention study carried out as part of the activities of a District Health Management Team responsible for integrated primary health care delivery in a rural district in Ghana. The aim was to test the impact of a combination of improved information provision to patients and drug labeling on adherence to recommended anti-malarial treatment regimens focusing on oral chloroquine, for the outpatient management of acute uncomplicated malaria. The study had a quasi-experimental pre-test post-test control group design with partly random allocation by clinic. The results show that the intervention resulted in an improved flow of information to clients prescribed chloroquine, and better labeling of drugs for the home treatment of acute clinical episodes of malaria in the intervention area. Improvements in adherence occurred in all clinics. However, improvements in adherence were most marked in the clinic that was worst performing at the start of the intervention. Implications of the results for improving adherence to chloroquine therapy on an outpatient basis are discussed.

When 'solutions of yesterday become problems of today': crisis-ridden decision making in a complex adaptive system (CAS)--the Additional Duty Hours Allowance in Ghana.

Implementation of policies (decisions) in the health sector is sometimes defeated by the system's response to the policy itself. This can lead to counter-intuitive, unanticipated, or more modest effects than expected by those who designed the policy. The health sector fits the characteristics of complex adaptive systems (CAS) and complexity is at the heart of this phenomenon. Anticipating both positive and negative effects of policy decisions, understanding the interests, power and interaction between multiple actors; and planning for the delayed and distal impact of policy decisions are essential for effective decision making in CAS. Failure to appreciate these elements often leads to a series of reductionist approach interventions or 'fixes'. This in turn can initiate a series of negative feedback loops that further complicates the situation over time. In this paper we use a case study of the Additional Duty Hours Allowance (ADHA) policy in Ghana to illustrate these points. Using causal loop diagrams, we unpack the intended and unintended effects of the policy and how these effects evolved over time. The overall goal is to advance our understanding of decision making in complex adaptive systems; and through this process identify some essential elements in formulating, updating and implementing health policy that can help to improve attainment of desired outcomes and minimize negative unintended effects.

Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana.

BACKGROUND: There is a growing movement, globally and in the Africa region, to reduce financial barriers to health care generally, but with particular emphasis on high priority services and vulnerable groups. OBJECTIVE: This article reports on the experience of implementing a national policy to exempt women from paying for delivery care in public, mission and private health facilities in Ghana. DESIGN: Using data from a complex evaluation which was carried out in 2005-2006, lessons are drawn which can inform other countries starting or planning to implement similar service-based exemption policies. RESULTS: On the positive side, the experience of Ghana suggests that delivery exemptions can be effective and cost-effective, and that despite being universal in application, they can benefit the poor. However, certain 'negative' lessons are also drawn from the Ghana case study, particularly on the need for adequate funding, and for strong institutional ownership. It is also important to monitor the financial transfers which reach households, to ensure that providers are passing on benefits in full, while being adequately reimbursed themselves for their loss of revenue. Careful consideration should also be given to staff motivation and the role of different providers, as well as quality of care constraints, when designing the exemptions policy. All of this should be supported by a proactive approach to monitoring and evaluation. CONCLUSION: The recent movement towards making delivery care free to all women is a bold and timely action which is supported by evidence from within and beyond Ghana. However, the potential for this to translate into reduced mortality for mothers and babies fundamentally depends on the effectiveness of its implementation.

Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme.

The public social policy and programme decisions that are made in low-income countries have critical effects on human social and development outcomes. Unfortunately, it would appear that inadequate attention is paid to analysing, understanding and factoring into attempts to reshape or change policy, the complex historical, social, cultural, economic, political, organizational and institutional context; actor interests, experiences, positions and agendas; and policy development processes that influence policy and programme choices. Yet these can be just as critical as the availability of research or other evidence in influencing decision making on policies and their accompanying programmes and the resulting degree of success or failure in achieving the original objectives. Ghana, a low-income developing country in sub-Saharan Africa, embarked on a national policy process of replacing out-of-pocket fees at point of service use with national health insurance in 2001. This paper uses a case study approach to describe and reflect on the complex interactions of context with actors and processes including political power play; and the effects on agenda setting, decision making and policy and programme content. This case study supports observations from the literature that although availability of evidence is critical, major public social policy and programme content can be heavily influenced by factors other than the availability or non-availability of evidence to inform content decision making. In the low-income developing country context there can be imbalances of policy decision-making power related to strong and dominant political actors combined with weak civil society engagement, accountability systems and technical analyst power and position. Efforts at major reform need to consider and address these issues alongside efforts to provide evidence for content decision-making. Without an analysis and understanding of the politics of reform and how to work within it, researchers and other technical actors may find their information to support reform is not applied effectively. Similarly, without an appreciation of the need for critical technical analysis to support decision making rather than an indiscriminate use of political approaches, political actors may find that even with the best of intentions, desired policy objectives may not be attained.

Start-stop funding, its causes and consequences: a case study of the delivery exemptions policy in Ghana.

This article looks at the issue of sustaining funding for a public programme through the case study of the delivery exemptions policy in Ghana. The Government of Ghana introduced the policy of exempting users from delivery fees in September 2003 in the four most deprived regions of the country, and in April 2005 it was extended to the remaining six regions in Ghana. The aim of the policy of free delivery care was to reduce financial barriers to using maternity services. Using materials from key informant interviews at national and local levels in 2005, the article examines how the policy has been implemented and what the main constraints have been, as perceived by different actors in the health system. The interviews show that despite being a high-profile public policy and achieving positive results, the delivery exemptions policy quickly ran into implementation problems caused by inadequate funding. They suggest that facility and district managers bear the brunt of the damage that is caused when benefits that have been promised to the public cannot be delivered. There can be knock-on effects on other public programmes too. Despite these problems, start-stop funding and under-funding of public programmes is more the norm than the exception. Some of the factors causing erratic funding--such as party politics and intersectoral haggling over resources--are unavoidable, but others, such as communication and management failures can and should be addressed.

Sexual and reproductive health: challenges for priority-setting in Ghana's health reforms.

Many countries are undertaking widespread structural change of their health sectors. There is mounting concern that priority-setting mechanisms used in planning the reforms are not suited to recognizing or taking account of the needs and priorities of sexual and reproductive health (SRH) services. The main aim of this research was to assess the sensitivity of the priority-setting tools and mechanisms used in the development of the health sector reforms in Ghana, to the needs and priorities of SRH services, and to consider how priority-setting mechanisms could be improved. We conclude that priority-setting tools in Ghana's reform process were rudimentary, and SRH donors and advocates were little involved. While it is tempting for a strong programme like Ghana's SRH programme to remain independent, we argue that closer involvement in system-wide reforms is a preferable long-term objective. Clearly, SRH priorities need safeguarding within a systems approach and we suggest a number of ways in which this can be achieved. Most importantly, the SRH community, in collaboration with the wider development community, needs to challenge current priority-setting mechanisms and the long-held view that traditional disease-ranking and cost-effectiveness measures are necessarily the best, most accurate way to measure health priorities. Traditional priority-setting tools do not adequately reflect the long-term benefits of preventive interventions such as family planning, and are therefore not an adequate reflection of holistic health sector planning needs. In response to this, there needs to be greater commitment from the international development and research communities to: (1) support collaboration between economists and reproductive health specialists to develop better measures for the effectiveness and impact of SRH services; and (2) in the interim, accept proxies for priority-setting which may include small-scale, qualitative research data combined with priorities identified by SRH specialists. To achieve this, the priority-setting processes need to become more inclusive and SRH specialists need to be proactive in their engagement with health sector decision-makers.

Progress in the control of measles in Ghana, 1980-2000.

By review of available literature, routine surveillance data, coverage surveys, and hospital records, measles control in Ghana was assessed since vaccinations began in 1978. Nationally, measles vaccination coverage increased from 24% in 1980 to 84% in 2000. This achievement is attributed to health sector reforms that included a higher district share of the total recurrent health budget from 20% in 1996 to 42% in 1999. The budget reallocation resulted in improved access to immunization services, supply procurement, transport management, staff motivation, and information flow. On the client side, the age of the child, socioeconomic status of parents, and type of prenatal care were associated with vaccination coverage. Routine vaccination coverage of >80% has resulted in lower measles incidence, a longer interepidemic interval, and a shift in cases to older children. Ghana recently developed a strategic plan to reduce measles deaths to near zero.

The skilled attendance index: proposal for a new measure of skilled attendance at delivery.

Increasing the proportion of deliveries with skilled attendance is widely regarded as key to reducing maternal mortality and morbidity in developing countries. The percentage of deliveries with a health professional is commonly used to assess skilled attendance, but measures only the presence of an attendant, not the skills used or the enabling environment To supplement currently available information on the presence of an attendant at delivery, a method to measure the extent of skilled attendance at delivery through use of clinical records was devised. Data were collected from 416 delivery records in hospitals, government health centres and private non-hospital maternity facilities servicing Kintampo District, Ghana, using a case extraction form. Based on the defined criteria, summary measures of skilled attendance were calculated. Between 32.6% and 93.0% of the criteria for skilled attendance were met in the sample, with a mean of 65.5%. No delivery met all the criteria. A Skilled Attendance Index (SAI) was developed as a composite measure of delivery care. The SAI revealed that 26.9% of delivery records met at least three-quarters of the criteria for skilled attendance. Documentation of haemoglobin, current pregnancy complications, post-partum vital signs and completed partographs were amongst the criteria most poorly recorded. The purpose of applying these measures should be seen not as an end in itself but to advance improvements in delivery care.

Ill-health reported by schoolchildren during questionnaire surveys in Ghana, Mozambique and Tanzania.

BACKGROUND: Insufficient attention has been paid to the health problems of school-age children in sub-Saharan Africa. A questionnaire administered to schoolchildren about their ill-health has been developed to identify schools in which urinary schistosomiasis occurs. The data collected during the interviews can also be used to assess other common health problems. OBJECTIVES: To analyse data collected during health questionnaires in schools to assess how schoolchildren perceive their own health, and to compare the findings between three countries in sub-Saharan Africa. METHODS: Questionnaires asking about recent health problems were administered by teachers to schoolchildren in 120 primary schools in Mozambique, 52 primary schools in Tanzania and 298 primary schools in Ghana. A total of 67 002 children aged 8-15 years took part. RESULTS: Of the 10 health problems asked about in all questionnaires, the average number reported by each child was 3.9 in Ghana, 3.4 in Mozambique and 3.1 in Tanzania. The distributions of the prevalence of each condition among schools were similar and the prevalence of all conditions showed a similar ranking. For most conditions a greater percentage of girls than boys reported each health problem. CONCLUSIONS: Schoolchildren in Ghana, Mozambique and Tanzania do not perceive themselves to be healthy. The pattern of reported health problems was similar in each country. School health questionnaires are worthy of further study and validation.