Costs of routine immunization and the introduction of new and underutilized vaccines in Ghana.

BACKGROUND: Limited knowledge exists on the full cost of routine immunization in Africa. Ghana was the first African country to simultaneously introduce rotavirus, pneumococcal and measles second-dose vaccines. Given their high price, it would be beneficial to Ghanaian health authorities to know the true cost of their introduction. METHODS: The economic costs of routine immunization for 2011 and the incremental costs of new vaccines were assessed as part of a multi-country study on costing and financing of routine immunization known as the Expanded Program on Immunization Costing (EPIC). Immunization delivery costs were evaluated at the local facility, district, regional, and central levels. Stratified random sampling was used for district and facility selection. We calculated the allocation of nationwide costs to the four health-system levels. RESULTS: The total aggregated national costs for routine immunization - including vaccine costs - equaled US$ 53.5 million during 2011 (including central, regional, and district costs); this equated to US$ 60.3 per fully immunized child (FIC) when counting vaccine costs, or US$ 48.1 without. National immunization program delivery costs were allocated as follows: local facility level, 85% of total national cost; district, 11%; central, 2% and regional, 2%. Salaried labor represented 61% of total costs, and vaccines represented 17%. For new vaccine introduction, programmatic start-up costs amounted to US$ 3.9 million, primarily due to salaried labor (66%). The mean facility-level cost per vaccine dose administered in a routine immunization program was US$ 5.1 (with a range of US$ 2.4-7.8 depending on facility characteristics) and US$ 3.7 for delivery costs. DISCUSSION: We identified a high cost per fully immunized child, mostly due to non-vaccine costs at the facility level, which indicates that immunization program financing - whether national or donor-driven - must take a broad viewpoint. This substantial variation in overall costs emphasizes the additional effort associated with reaching children in various settings.

The Ghana essential health interventions program: a plausibility trial of the impact of health systems strengthening on maternal & child survival.

BACKGROUND: During the 1990s, researchers at the Navrongo Health Research Centre in northern Ghana developed a highly successful community health program. The keystone of the Navrongo approach was the deployment of nurses termed community health officers to village locations. A trial showed that, compared to areas relying on existing services alone, the approach reduced child mortality by half, maternal mortality by 40%, and fertility by nearly a birth - from a total fertility rate of 5.5 in only five years. In 2000, the government of Ghana launched a national program called Community-based Health Planning and Services (CHPS) to scale up the Navrongo model. However, CHPS scale-up has been slow in districts located outside of the Upper East Region, where the "Navrongo Experiment" was first carried out. This paper describes the Ghana Essential Health Intervention Project (GEHIP), a plausibility trial of strategies for strengthening CHPS, especially in the areas of maternal and newborn health, and generating the political will to scale up the program with strategies that are faithful to the original design. DESCRIPTION OF THE INTERVENTION: GEHIP improves the CHPS model by 1) extending the range and quality of services for newborns; 2) training community volunteers to conduct the World Health Organization service regimen known as integrated management of childhood illness (IMCI); 3) simplifying the collection of health management information and ensuring its use for decision making; 4) enabling community health nurses to manage emergencies, particularly obstetric complications and refer cases without delay; 5) adding $0.85 per capita annually to district budgets and marshalling grassroots political commitment to financing CHPS implementation; and 6) strengthening CHPS leadership at all levels of the system. EVALUATION DESIGN: GEHIP impact is assessed by conducting baseline and endline survey research and computing the Heckman "difference in difference" test for under-5 mortality in three intervention districts relative to four comparison districts for core indicators of health status and survival rates. To elucidate results, hierarchical child survival hazard models will be estimated that incorporate measures of health system strength as survival determinants, adjusting for the potentially confounding effects of parental and household characteristics. Qualitative systems appraisal procedures will be used to monitor and explain GEHIP implementation innovations, constraints, and progress. DISCUSSION: By demonstrating practical means of strengthening a real-world health system while monitoring costs and assessing maternal and child survival impact, GEHIP is expected to contribute to national health policy, planning, and resource allocation that will be needed to accelerate progress with the Millennium Development Goals.

The Ghana community-based health planning and services initiative for scaling up service delivery innovation.

Research projects demonstrating ways to improve health services often fail to have an impact on what national health programmes actually do. An approach to evidence-based policy development has been launched in Ghana which bridges the gap between research and programme implementation. After nearly two decades of national debate and investigation into appropriate strategies for service delivery at the periphery, the Community-based Health Planning and Services (CHPS) Initiative has employed strategies tested in the successful Navrongo experiment to guide national health reforms that mobilize volunteerism, resources and cultural institutions for supporting community-based primary health care. Over a 2-year period, 104 out of the 110 districts in Ghana started CHPS. This paper reviews the development of the CHPS initiative, describes the processes of implementation and relates the initiative to the principles of scaling up organizational change which it embraces. Evidence from the national monitoring and evaluation programme provides insights into CHPS' success and identifies constraints on future progress.

Bridging the gap between evidence-based innovation and national health-sector reform in Ghana.

Although experimental trials often identify optimal strategies for improving community health, transferring operational innovation from well-funded research programs to resource-constrained settings often languishes. Because research initiatives are based in institutions equipped with unique resources and staff capabilities, results are often dismissed by decisionmakers as irrelevant to large-scale operations and national health policy. This article describes an initiative undertaken in Nkwanta District, Ghana, focusing on this problem. The Nkwanta District initiative is a critical link between the experimental study conducted in Navrongo, Ghana, and a national effort to scale up the innovations developed in that study. A 2002 Nkwanta district-level survey provides the basis for assessing the likelihood that the Navrongo model is replicable elsewhere in Ghana. The effect of community-based health planning and services exposure on family planning and safe-motherhood indicators supports the hypothesis that Navrongo effects are transferable to impoverished rural settings elsewhere, confirming the need for strategies to bridge the gap between Navrongo evidence-based innovation and national health-sector reform.