Does the provision of community health services offset the effects of poverty and low maternal educational attainment on childhood mortality? An analysis of the equity effect of the Navrongo experiment in Northern Ghana.

The Government of Ghana has instituted a National Poverty Reduction Program with an initiative known as the Community-based Health Planning and Services (CHPS) as its core health development strategy. CHPS was derived from a plausibility trial of the Navrongo Health Research Centre testing four contrasting primary health care strategies: i) Training unpaid volunteers to promote health in communities, ii) placing nurses in communities with training and supplies for treating childhood illnesses, iii) combining the nurse and volunteer approaches, and iv) sustaining a comparison condition whereby clinic services were provided without community resident workers. This paper presents an age-conditional proportional hazard analysis of the long term impact of community health worker exposure among 94,599 children who were ever under age five over the January 1, 1995 to December 2010 period, adjusting for age conditional effects of shifts in exposure type as CHPS was scaled up in Navrongo project area over the 1995-2000 period. Results show that children whose parents are uneducated and relatively poor experience significantly higher mortality risks than children of the educated and less poor. Conditional hazard regression models assess the impact of CHPS on health equity by estimating the interaction of equity indicators with household exposure to CHPS service operations, adjusting for age conditional exposure to original Community Health and Family Planning Project (CHFP) service strategies as scale-up progressed. The association of mortality risk among children with uneducated and relatively impoverished mothers is offset by exposure to community health nursing services. If exposure is limited to volunteer-provided services alone, survival benefits arise only among children of relatively advantaged households. Findings lend support to policies that promote the CHPS nurse approach to community-based services as a core health component of poverty reduction programs.

What Governs District Manager Decision Making? A Case Study of Complex Leadership in Dangme West District, Ghana.

Abstract-Management and leadership in complex health systems have been little addressed as contributors toward improving maternal and newborn health. Widespread perceptions of weak district-level management and leadership have encouraged capacity strengthening interventions with a predominant focus on individual rather than systemic capacities. However, both types of capacities matter. Greater understanding is required about how managerial decision making and policy implementation are influenced by the systems in which managers operate. This article presents an exploratory case study to understand the balance of top-down and bottom-up dynamics influencing district manager decision making in one district in the Ghanaian health system. Our study was theory driven, drawing on concepts of decision space, power, and trust from the literature. Data collection methods included document review, participant observation, and semistructured interviews. Using analysis that drew upon complex leadership theory, we found that contexts of hierarchical authority and resource uncertainty constrained district manager decision space. These constraints also gave rise to a leadership type oriented toward serving the bureaucratic functions of the health system (more top-down than bottom-up). The analysis of this case study showed that, as a result, district-level management and leadership were less responsive to maternal and newborn health service delivery challenges.