Cost of inappropriate prescriptions for uncomplicated malaria in Ghana.

BACKGROUND: Malaria remains a common course of morbidity in many sub-Saharan African countries. While treatment options have improved in recent times, inappropriate prescription seems conventional among providers, increasing the burden on patients and society. This study examined the cost of inappropriate prescriptions for uncomplicated malaria treatment in Ghana. METHODS: This study used retrospective data collected from January to December 2016 in 27 selected facilities, under different ownership in three regions of the country, mainly Volta, Upper East and Brong Ahafo. Stratified random sampling technique was used to extract 1625 outpatient folders of patients diagnosed and treated for malaria. Two physicians independently reviewed patient folders according to the stated diagnoses. Malaria prescriptions were described as inappropriate when they do not adhere to the standard treatment guidelines. The economic cost was mainly treatment cost which was sourced as medication cost. Total and average costs for country were calculated using sample estimates and the total number of uncomplicated malaria cases that received inappropriate prescriptions. RESULTS: The study revealed that patients received an average of two prescriptions per malaria episode. Artemether-lumefantrine (AL) was the major malaria medication (79.5%) prescribed to patients. Other medications usually antibiotics and vitamins and minerals were included in the prescription. More than 50% of prescribers did not follow the guidelines for prescribing medications to clients. By facility type, inappropriate prescription was high in the CHPS compounds (59.1%) and by ownership, government (58.3%), private (57.5%) and mission facilities (50.7%). Thus, about 55% of malaria prescriptions were evaluated as inappropriate during the review period, which translates into economic cost of approximately US$4.52 million for the entire country in 2016. The total cost of inappropriate prescription within the study sample was estimated at US$1,088.42 while the average cost was US$1.20. CONCLUSION: Inappropriate prescription for malaria is a major threat to malaria management in Ghana. It presents a huge economic burden to the health system. Training and strict enforcement of prescribers' adherence to the standard treatment guideline is highly recommended.

The dose-response association between LEAP 1000 and birthweight - no clear mechanisms: a structural equation modeling approach.

BACKGROUND: Birthweight is an important indicator of maternal and fetal health globally. The multifactorial origins of birthweight suggest holistic programs that target biological and social risk factors have great potential to improve birthweight. In this study, we examine the dose-response association of exposure to an unconditional cash transfer program before delivery with birthweight and explore the potential mediators of the association. METHODS: Data for this study come from the Livelihood Empowerment Against Poverty (LEAP) 1000 impact evaluation conducted between 2015 and 2017 among a panel sample of 2,331 pregnant and lactating women living in rural households of Northern Ghana. The LEAP 1000 program provided bi-monthly cash transfers and premium fee waivers to enroll in the National Health Insurance Scheme (NHIS). We used adjusted and unadjusted linear and logistic regression models to estimate the associations of months of LEAP 1000 exposure before delivery with birthweight and low birthweight, respectively. We used covariate-adjusted structural equation models (SEM) to examine mediation of the LEAP 1000 dose-response association with birthweight by household food insecurity and maternal-level (agency, NHIS enrollment, and antenatal care) factors. RESULTS: Our study included a sample of 1,439 infants with complete information on birthweight and date of birth. Nine percent of infants (N = 129) were exposed to LEAP 1000 before delivery. A 1-month increase in exposure to LEAP 1000 before delivery was associated with a 9-gram increase in birthweight and 7% reduced odds of low birthweight, on average, in adjusted models. We found no mediation effect by household food insecurity, NHIS enrollment, women's agency, or antenatal care visits. CONCLUSIONS: LEAP 1000 cash transfer exposure before delivery was positively associated with birthweight, though we did not find any mediation by household- or maternal-level factors. The results of our mediation analyses may serve to inform program operations and improve targeting and programming to optimize health and well-being among this population. TRIAL REGISTRATION: The evaluation is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations (RIDIESTUDY- ID-55942496d53af) and in the Pan African Clinical Trial Registry (PACTR202110669615387).

Role and capacity needs of community based surveillance volunteers in the integrated management of skin neglected tropical diseases (skin NTDs): a qualitative study from central Ghana.

BACKGROUND: Community Based Surveillance Volunteers (CBSVs) have been instrumental in the management of Neglected Tropical Diseases (NTDs) but a concern that their services in scale up programmes may be affected due to high attrition rates has been widely acknowledged. We explored the roles and capacity needs of existing CBSVs to inform for a successful integrated NTD management programme in Ghana and similar contexts. METHODS: We conducted qualitative interviews with 50 CBSVs, 21 Community Nurses, 4 Disease control officers, 7 skin NTD researchers, 2 skin NTD patients and a Director of District Health Services in Central Ghana. Interviews were digitally recorded, transcribed and coded prior to translation and thematic analysis. RESULTS: The roles of CBSVs in NTD management were shown to have an impact on disease identification, surveillance, health seeking behaviours and status of CBSVs. Lack of motivation, inadequate structures for engagement of CBSVs within the health system and delayed management of reported cases were identified as gaps that hinder effective delivery of CBSV roles. Provision of incentives as recognition for the unpaid services rendered by CBSVs was seen as a major factor to reduce the rate of CBSV attrition in this scale up programme. Other factors included the formulation of policies by government to guide CBSV engagement, regular training of CBSV in NTD management as well as provision of resources and logistics. CONCLUSION: Measures including continuous training, institution of rewards and incentivization are important for ensuring the sustainability of CBSVs in the provision of skin NTD services in Ghana.

Health services availability and readiness moderate cash transfer impacts on health insurance enrolment: evidence from the LEAP 1000 cash transfer program in Ghana.

BACKGROUND: Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services. METHODS: We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness. RESULTS: We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points). CONCLUSIONS: We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors. TRIAL REGISTRATION: This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations ( RIDIE-STUDY-ID-55942496d53af ).

Leveraging COVID-19 pandemic response for improved health system financing: Lessons from Ghana.

The COVID-19 pandemic has exposed health system funding challenges across many developing countries. The needed infrastructure to effectively respond to the pandemic was absent in many developing countries. This has resulted in policymakers resorting to various strategies to mobilise sufficient resources in response to the pandemic, especially in the early stages. This paper reviewed Ghana's efforts to mobilise domestic and external resources for the health sector in response to the pandemic. The paper also assessed lessons from these strategies and highlights how these lessons could be leveraged to sustain financing for the health sector. Using evidence from desk reviews, we demonstrate the existence of fiscal space through external sources, partnership with non-state actors, and effective public financial management (budget space). We also show that the COVID-19 pandemic presents an important momentum to drive future investment in health infrastructure across developing countries.

Socioeconomic inequalities in maternal health care utilization in Ghana.

BACKGROUND: Improving maternal and child health remains a public health priority in Ghana. Despite efforts made towards universal coverage, there are still challenges with access to and utilization of maternal health care. This study examined socioeconomic inequalities in maternal health care utilization related to pregnancy and identified factors that account for these inequalities. METHODS: We used data from three rounds of the Ghana Demographic and Health Surveys (2003, 2008 and 2014). Two health care utilization measures were used; (i) four or more antenatal care (ANC) visits and (ii) delivery by trained attendants (DTA). We first constructed the concentration curve (CC) and estimated concentration indices (CI) to examine the trend in inequality. Secondly, the CI was decomposed to estimate the contribution of various factors to inequality in these outcomes. RESULTS: The CCs show that utilization of at least four ANC visits and DTA were concentrated among women from wealthier households. However, the trends show the levels of inequality decreased in 2014. The CI of at least four ANC visits was 0.30 in 2003 and 0.18 in 2014. Similarly, the CIs for DTA was 0.60 in 2003 and 0.42 in 2014. The decomposition results show that access to National Health Insurance Scheme (NHIS) and women's education levels were the most important contributors to the reduction in inequality in maternal health care utilization. CONCLUSIONS: The findings highlight the importance of the NHIS and formal education in bridging the socioeconomic gap in maternal health care utilization.

Childhood mortality, intra-household bargaining power and fertility preferences among women in Ghana.

BACKGROUND: Continuing population growth could be detrimental for social and economic wellbeing. Understanding the factors that influence family planning decisions will be important for policy. This paper examines the effect of childhood mortality and women's bargaining power on family planning decisions. METHODS: Data was from the 2014 Ghana Demographic and Health Survey (DHS). A sample of 3313 women in their reproductive age were included in this study. We created variables on women's exposure to and experience of child mortality risks. Three different indicators of women's bargaining power in the household were also used. Probit models were estimated in accordance with the nature of the dependent variable. RESULTS: Results from the probit models suggest that child mortality has a positive association with higher fertility preference. Also, child mortality risks and woman's bargaining power play important roles in a woman's fertility choices in Ghana. Women with higher bargaining power were likely to prefer fewer children in the face of child mortality risks, compared to women with lower bargaining power. CONCLUSION: In addition to public sensitization campaigns on the dangers of high fertility and use of contraceptives, the findings of this study emphasize the need to focus on reducing child mortality and improving women bargaining power in developing countries.

Improving primary health care facility performance in Ghana: efficiency analysis and fiscal space implications.

BACKGROUND: Health centers in Ghana play an important role in health care delivery especially in deprived communities. They usually serve as the first line of service and meet basic health care needs. Unfortunately, these facilities are faced with inadequate resources. While health policy makers seek to increase resources committed to primary healthcare, it is important to understand the nature of inefficiencies that exist in these facilities. Therefore, the objectives of this study are threefold; (i) estimate efficiency among primary health facilities (health centers), (ii) examine the potential fiscal space from improved efficiency and (iii) investigate the efficiency disparities in public and private facilities. METHODS: Data was from the 2015 Access Bottlenecks, Cost and Equity (ABCE) project conducted by the Institute for Health Metrics and Evaluation. The Stochastic Frontier Analysis (SFA) was used to estimate efficiency of health facilities. Efficiency scores were then used to compute potential savings from improved efficiency. Outpatient visits was used as output while number of personnel, hospital beds, expenditure on other capital items and administration were used as inputs. Disparities in efficiency between public and private facilities was estimated using the Nopo matching decomposition procedure. RESULTS: Average efficiency score across all health centers included in the sample was estimated to be 0.51. Also, average efficiency was estimated to be about 0.65 and 0.50 for private and public facilities, respectively. Significant disparities in efficiency were identified across the various administrative regions. With regards to potential fiscal space, we found that, on average, facilities could save about GH₵11,450.70 (US$7633.80) if efficiency was improved. We also found that fiscal space from efficiency gains varies across rural/urban as well as private/public facilities, if best practices are followed. The matching decomposition showed an efficiency gap of 0.29 between private and public facilities. CONCLUSION: There is need for primary health facility managers to improve productivity via effective and efficient resource use. Efforts to improve efficiency should focus on training health workers and improving facility environment alongside effective monitoring and evaluation exercises.

Determinants of modern family planning use among women of reproductive age in the Nkwanta district of Ghana: a case-control study.

BACKGROUND: Average contraceptive prevalence rate in the Nkwanta district of Ghana was estimated to be 6.2% relative to the national average at the time, of 19%. While several efforts had been made to improve family planning in the country, the district still had very low use of modern family planning methods. This study sought to determine the factors that influenced modern family planning use in general and specifically, the factors that determined the consistently low use of modern family planning methods in the district. METHODS: A case-control study was conducted in the Nkwanta district of Ghana to determine socio-economic, socio-cultural and service delivery factors influencing family planning usage. One hundred and thirty cases and 260 controls made up of women aged 15-49 years were interviewed using structured questionnaires. A logistic regression was fitted. RESULTS: Awareness and knowledge of modern family planning methods were high among cases and controls (over 90%). Lack of formal education among women, socio-cultural beliefs and spousal communication were found to influence modern family planning use. Furthermore, favourable opening hours of the facilities and distance to health facilities influenced the use of modern contraceptives. CONCLUSION: While modern family planning seemed to be common knowledge among these women, actual use of such contraceptives was limited. There is need to improve use of modern family planning methods in the district. In addition to providing health facilities and consolidating close-to-client service initiatives in the district, policies directed towards improving modern family planning method use need to consider the influence of formal education. Promoting basic education, especially among females, will be a crucial step as the district is faced with high levels of school dropout and illiteracy rates.

Economic inequalities in health insurance subscription renewal: Evidence from Ghana's National Health Insurance Scheme.

Ghana's national health insurance scheme (NHIS) is considered a major step towards achieving Universal Health Coverage (UHC) in the country. However, over the years the scheme has faced challenges, including subscription non-renewal, that threaten its sustenance. In this study, we estimate and analyse the nature of economic inequalities in NHIS subscription renewal and determine factors that contribute to the observed inequality. Data from the seventh round of the Ghana Living Standard Survey (GLSS) was used for the study. A sample of 40,170 ever insured individuals was included in the analysis comprising 18,066 males and 22,104 females. We computed concentration indices (CIs) and used linear regression techniques to decompose the CIs. The results show that NHIS renewal is pro-rich [CI = 0.126; P < 0.01] and favored males [CI = 0.110; P < 0.01] and urban dwellers [CI = 0.066; p < 0.01]. Major contributors to the observed inequality in subscription renewal include premium and processing fees payment, access to information, and economic wellbeing. The observed rural-urban and male-female differences in subscription renewal were explained by differences in premium and processing fee payments, education outcomes, employment status and access to information. The findings suggest that interventions that reduce cost barriers to NHIS subscription for the poor, improve physical access to healthcare and improve sensitization efforts should be encouraged.

Development of an integrated and decentralised skin health strategy to improve experiences of skin neglected tropical diseases and other skin conditions in Atwima Mponua District, Ghana.

Integrated strategies are recommended to tackle neglected tropical diseases of the skin (skin NTDs), which pose a substantial health and economic burden in many countries, including Ghana. We describe the development of an integrated and decentralised skin health strategy designed to improve experiences of skin NTDs in Atwima Mponua district in Ashanti Region. A multidisciplinary research team led an iterative process to develop an overall strategy and specific interventions, based on a theory of change informed by formative research conducted in Atwima Mponua district. The process involved preparatory work, four co-development workshops (August 2021 to November 2022), collaborative working groups to operationalise intervention components, and obtaining ethical approval. Stakeholders including affected individuals, caregivers, other community members and actors from different levels of the health system participated in co-development activities. We consulted these stakeholders at each stage of the research process, including discussion of study findings, development of our theory of change, identifying implementable solutions to identified challenges, and protocol development. Participants determined that the intervention should broadly address wounds and other skin conditions, rather than only skin NTDs, and should avoid reliance on non-governmental organisations and research teams to ensure sustainable implementation by district health teams and transferability elsewhere. The overall strategy was designed to focus on a decentralised model of care for skin conditions, while including other interventions to support a self-care delivery pathway, community engagement, and referral. Our theory of change describes the pathways through which these interventions are expected to achieve the strategy's aim, the assumptions, and problems addressed. This complex intervention strategy has been designed to respond to the local context, while maximising transferability to ensure wider relevance. Implementation is expected to begin in 2023.

Improving experiences of neglected tropical diseases of the skin: Mixed methods formative research for development of a complex intervention in Atwima Mponua District, Ghana.

Integrated approaches to managing co-endemic neglected tropical diseases (NTDs) of the skin within primary healthcare services are complex and require tailoring to local contexts. We describe formative research in Atwima Mponua District in Ghana's Ashanti Region designed to inform the development of a sustainable intervention to improve access to skin NTD care. We employed a convergent, parallel, mixed-methods design, collecting data from February 2021 to February 2022. We quantitatively assessed service readiness using a standardised checklist and reviewed outpatient department registers and condition-specific case records in all government health facilities in the district. Alongside a review of policy documents, we conducted 49 interviews and 7 focus group discussions with purposively selected affected persons, caregivers, community members, health workers, and policy-makers to understand skin NTD care-seeking practices and the policy landscape. Outside the district hospital, skin NTD reporting rates in the surveyed facilities were low; supply chains for skin NTD diagnostics, consumables, and medicines had gaps; and health worker knowledge of skin NTDs was limited. Affected people described fragmented care, provided mostly by hospitals (often outside the district) or traditional healers, resulting in challenges obtaining timely diagnosis and treatment and high care-seeking costs. Affected people experienced stigma, although the extent to which stigma influenced care-seeking behaviour was unclear. National actors were more optimistic than district-level actors about local resource availability for skin NTD care and were sceptical of including traditional healers in interventions. Our findings indicate that improvement of the care cascade for affected individuals to reduce the clinical, economic, and psychosocial impact of skin NTDs is likely to require a complementary set of interventions. These findings have informed the design of a strategy to support high-quality, integrated, decentralised care for skin NTDs in Atwima Mponua, which will be assessed through a multidisciplinary evaluation.

Billing the Insured: An Assessment of Out-of-Pocket Payment by Insured Patients in Ghana.

Background: The Ghana National Health Insurance Scheme was introduced in 2003 to provide financial protection to the population. While the Scheme has made strides in improving access to healthcare there have been a few challenges including out of pocket charges to insured patients with weak client power. The study investigated the catastrophic nature of the out-of-pocket charges, the factors affecting the charges and the client power. Methodology: We used primary data collected in 3 administrative regions: Greater Accra, Ashanti and the Northern regions, within the period April and June 2022 to compute catastrophic expenditure of the out-of-pocket healthcare expenditure on household expenditure on food and non-food. In addition, multivariate logistic regressions and a linear regression were run to examine the incidence of the practice and client power. Results: The results showed that on average the insured paid out-of-pocket charges with a probability of 66%. The probability was highest (80%) in the Greater Accra, followed by Ashanti region (66.6%) and (52.9%) in the Northern region. The out-of-pocket charges were found to be catastrophic with incidence rate between 48.2% and 26.1% for the 5% and 20% thresholds; the overshoots ranged between 34.1% and 26.9% for the thresholds; the poor were more disadvantaged than the rich. Patients reported the out-of-pocket charges to the NHIA with probability of 1.9%, but the NHIA did not respond to 81% of the reported cases. Knowledge of the benefit list is likely to motivate the insured to report out-of-pocket charges, while cordial relationship between the NHIA staff and the insured deters providers from charging out-of-pocket. Conclusion: The out-of-pocket charges occur extensively across health facilities and is impoverishing. A close collaboration between the NHIA and the insured is needed to reduce the incidence and hold providers accountable.

Assessing the efficiency of health systems in achieving the universal health coverage goal: evidence from Sub-Saharan Africa.

OBJECTIVE: Universal health coverage (UHC) is a major pathway to save many people from catastrophic and impoverishing healthcare spending and address the inequality in health and healthcare. The objective of this paper is to assess the efficiency with which health systems in sub-Saharan Africa (SSA) are utilizing healthcare resources to progress towards achieving the UHC goal by 2030. METHODS: The study followed the guidelines proposed by the World Health Organization (WHO) and World Bank joint UHC monitoring framework and the computational operationalization approach proposed by Wagstaff et al. (2015) to estimate the UHC index for each of the 30 selected SSA countries. The bootstrapping output-oriented data envelopment analysis (DEA) was used to estimate the bias-corrected technical efficiency scores and examine the environmental factors that influence health system efficiency. RESULTS: The estimated UHC levels ranged from a minimum of 52% to a maximum of 81% [Formula: see text] with a median coverage of 66%. The average bias-corrected efficiency score was 0.81 [Formula: see text]. The study found that education, governance quality, public health spending, external health funding, and prepayment arrangements that pool funds for health had a positive significant effect on health system efficiency in improving UHC, while out-of-pocket payment had a negative impact. CONCLUSION: The results show that health systems in SSA can potentially enhance UHC levels by at least 19% with existing healthcare resources if best practices are adopted. Policymakers should aim at improving education, good governance, and healthcare financing architecture to reduce out-of-pocket payments and over-reliance on donor funding for healthcare to achieve UHC.

Effects of healthcare financing policy tools on health system efficiency: Evidence from sub-Saharan Africa.

Background: Evidence shows high levels of catastrophic and impoverishing healthcare expenditure among households in sub-Saharan Africa (SSA). The way healthcare is financed has an impact on how well a health system performs its functions and achieves its objectives. This study aims to examine the effect of healthcare financing policy tools on health system efficiency. Method: The study classifies 46 sub-Saharan African (SSA) countries into four groups of health systems sharing similar healthcare financing strategies. A two-stage and one-stage stochastic frontier analysis (SFA) and Tobit regression techniques were employed to assess the impact of healthcare financing policy variables on health system efficiency. Data from the selected 46 SSA countries from 2000 to 2019 was investigated. Results: The results revealed that prepayment healthcare financing arrangements, social health insurance, mixed- and external-financing healthcare systems significantly enhance health system efficiency. Reliance on a single source for financing healthcare, particularly private out-of-pocket payment reduces health system efficiency. Conclusion: For policy-making purposes, health care systems financed through a mix of financing arrangements comprising social health insurance, private, and public funding improve health system efficiency in delivering better health outcomes as opposed to depending on one major source of financing, particularly, private out-of-pocket payments.

Ghana's Livelihood Empowerment Against Poverty (1000) Program Seasonally Impacts Birthweight: A Difference-in-Differences Analysis.

Objectives: Low birthweight (LBW) prevalence remains high in African countries and evidence of cash transfer impacts on birthweight, particularly by season of infant birth, is limited. This study examines overall and seasonal cash transfer impacts on LBW in rural Ghana. Methods: Data come from a longitudinal, quasi-experimental impact evaluation of the Livelihood Empowerment Against Poverty (LEAP) 1,000 unconditional cash transfer program for impoverished pregnant or lactating women in rural districts of Northern Ghana. LEAP1000 program impacts on average birthweight and LBW were estimated for a multiply imputed sample of 3,258 and a panel sample of 1,567 infants using differences-in-differences models and triple difference models to assess impacts by season. Results: LEAP1000 decreased LBW prevalence by 3.5 and 4.1 percentage points overall and in the dry season, respectively. LEAP1000 increased average birthweight by 94, 109, and 79 g overall, in the dry season, and in the rainy season, respectively. Conclusion: Our findings of positive LEAP1000 impacts on birthweight across seasons and on LBW in the dry season demonstrate the need to take seasonal vulnerabilities into account when designing and implementing programs for rural populations in Africa.

Donor aid mentioning newborns and stillbirths, 2002-19: an analysis of levels, trends, and equity.

BACKGROUND: Global aid for reproductive, maternal, newborn, and child health has stagnated in recent years, and aid mentioning newborns or stillbirths has previously represented a very small proportion of aid for reproductive, maternal, newborn, and child health. Neonatal survival targets have been set by 78 countries, and stillbirth prevention targets have been set by 30 countries, to address the 4·4 million newborn deaths and stillbirths globally. We aimed to generate novel estimates of current levels of, and trends in, aid mentioning newborns and stillbirths over 2002-19, and to assess whether the amount of aid disbursed aligns with the associated mortality burden. METHODS: For this analysis, we did a manual review and coding of the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System database from 2002 to 2019 using key search terms for aid mentioning newborns and stillbirths. We compared these findings with estimates of aid for reproductive, maternal, newborn, and child health for 2002-19 based on the Muskoka2 method. Findings are presented in 2019 US$ according to the OECD's Development Assistance Committee deflators, which account for variation in exchange rates and inflation in donor countries. FINDINGS: We identified 21 957 unique records in the 2002-19 period. Aid mentioning newborns and stillbirths comprised approximately 10% ($1·6 billion) of reproductive, maternal, newborn, and child health funding overall in 2019 ($15·9 billion), with a small decrease in value between 2015 and 2019. 1284 (6%) of 21 957 records and 3·4% ($535 million) of their total value mentioned aid focused only on newborn health. Ten donors contributed 87% ($13·7 billion) of the total value of aid mentioning newborns and stillbirths during 2002-19. Aid mentioning newborns and stillbirths was inequitably allocated in the least developed countries (as defined by the UN), ranging from $18 per death in Angola to $1389 per death in Timor-Leste. Stillbirths were not mentioned in any funding in 2002-09, and they were only mentioned in 46 of 21 957 records in 2010-19, comprising $44·4 million of aid disbursed during this period. INTERPRETATION: Aid mentioning newborns and stillbirths is poorly matched to their corresponding mortality burden (representing 10% of aid for reproductive, maternal, newborn, and child health overall, yet accounting for approximately 50% of mortality in children <5 years) and across recipient countries (with substantial variation in the amount of aid received per newborn death and stillbirth between countries with similar health and economic needs). Our findings indicate that aid needs to be better targeted to populations with the highest mortality burdens, creating greater potential for impact. FUNDING: John D and Catherine T MacArthur Foundation, Bill & Melinda Gates Foundation, ELMA Philanthropies, Children's Investment Fund Foundation UK, Lemelson Foundation, and Ting Tsung and Wei Fong Chao Foundation. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Efficiency of malaria service delivery in selected district-level hospitals in Ghana.

Malaria remains an important public health concern. Sub-Saharan African countries carry over 95% of the global burden. Unfortunately, there are also major resource constraints that have limited efforts to reduce the burden. Our study sought to estimate efficiency in the use of malaria resources and to identify potential determinants. We used primary data collected from district-level health facilities in three administrative regions in Ghana from 2014 to 2016. The Data Envelopment Analysis technique was used to estimate efficiency. The Malmquist productivity index was estimated and disaggregated to reflect the sources of productivity change. The findings show an average technical efficiency score of 0.61 with private facilities being more efficient. Productivity changes were driven by changes in technology/innovation advancements. Facility revenue mix and ownership type were important determinants of efficiency. The findings highlight the need to improve resource use in the delivery of specific services such as malaria.

Strategic Health Purchasing Progress Mapping: A Spotlight on Ghana's National Health Insurance Scheme.

Ghana is a lower-middle-income economy that has made significant efforts to improve its health system, in order to achieve universal health coverage. Ghana has adopted strategic health purchasing as an important tool for efficient utilization of resources. This paper focuses on Ghana's National Health Insurance Scheme (NHIS) analyzing its governance arrangements and purchasing functions; and providing recommendations for improvement. The study applied the Strategic Health Purchasing Progress Tracking Framework co-created by the Strategic Purchasing Africa Resource Center (SPARC) and its partners to collect data from secondary and primary sources between September 2019 and June 2020. A descriptive and narrative approach was used to synthesize information on the NHIS governance arrangements and purchasing functions based on the framework. Benchmarks were used to describe the NHIS on the continuum from passive to strategic purchasing and to identify steps to make purchasing more strategic. Strengths and weaknesses were found in governance and purchasing functions. Progress was seen in how the NHIS selects the services in the benefit package, regularly reviewing the package to respond to the health needs of the population, and in how it selectively contracts with providers, particularly private providers, to ensure that standards for quality of care are met. However, challenges remain in performance monitoring, due to claims being mostly processed manually, and provider payment, due to frequent unbundling and upcoding of services Ghana has made significant strides toward the achievement of universal health coverage, but there is room for improvement in provider payment and performance monitoring.

The impact of unconditional cash transfers on morbidity and health-seeking behaviour in Africa: evidence from Ghana, Malawi, Zambia and Zimbabwe.

Unconditional cash transfers have demonstrated widespread, positive impacts on consumption, food security, productive activities and schooling. However, the evidence to date on cash transfers and health-seeking behaviours and morbidity is not only mixed, but the evidence base is biased towards conditional programmes from Latin America and is more limited in the context of Africa. Given contextual and programmatic design differences between the regions, more evidence from Africa is warranted. We investigate the impact of unconditional cash transfers on morbidity and health-seeking behaviour using data from experimental and quasi-experimental study designs of five government cash transfer programs in Ghana, Malawi, Zambia and Zimbabwe. Programme impacts were estimated using difference-in-differences models with longitudinal data. The results indicate positive programme impacts on health seeking when ill and on health expenditures. Our findings suggest that while unconditional cash transfers can improve health seeking when ill, morbidity impacts were mixed. More research is needed on longer-term impacts, mechanisms of impact and moderating factors. Additionally, taken together with existing evidence, our findings suggest that when summarizing the impacts of cash transfers on health, findings from conditional and unconditional programmes should be disaggregated.