Impact of community health interventions on maternal and child health indicators in the upper east region of Ghana.

BACKGROUND: This paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training. METHODS: A mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus-post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process. RESULTS: After intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI). CONCLUSIONS: A pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance.

Self-reported delays in care-seeking in West Africa during the first wave of the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic caused delays in care-seeking due to fears of infection and decreased healthcare access globally. These delays have been linked in some countries to COVID-19 perceptions, decreased income, and food insecurity, but little is known about patient-level factors for decreased care-seeking specifically at the beginning of COVID-19 in West Africa. Understanding these factors is important to identify those at highest risk and address healthcare-related barriers. METHODS: This study used self-reported data from telephone surveys in a population-based sample in Burkina Faso (n = 1352), Ghana (n = 1621), and Sierra Leone (n = 1301) in May-June 2020. Questions assessed delays in care-seeking, sociodemographic variables, COVID-19 beliefs, and food insecurity. Bivariate analyses using chi-square and multivariate analyses using logistic regression were used to explore associations between factors and delays in care-seeking by country. Independent variables were chosen based on prior research suggesting that financial insecurity, older age, female sex, rural location, and COVID-related concerns are associated with delays. RESULTS: Between March-June 2020, 9.9%, 10.6%, and 5.7% of participants in Burkina Faso, Ghana, and Sierra Leone, respectively, delayed care-seeking. Food insecurity was prevalent (21.8-46.1%) and in bivariate analyses was associated with delays in care-seeking in Burkina Faso and Ghana. Concern about risk of household contraction of COVID-19 was common (18.1-36.0%) and in Ghana and Sierra Leone was associated with delays in care-seeking in both bivariate and multivariate analyses. In bivariate analyses, females showed more delays in Burkina Faso, while age above 30 and urban location were associated with delays in Ghana. In multivariate analyses, food insecurity was associated with increased delayed care-seeking in Burkina Faso. CONCLUSIONS: Multiple factors were associated with delays in care-seeking early in the COVID-19 pandemic, with food insecurity and concerns about infection showing significant associations in multiple countries. These findings highlight the need to invest in clinic accessibility, community education, and financial assistance to address barriers in healthcare. While many delays have subsided since the initial phase of the COVID-19 pandemic, understanding factors associated with early disruptions of care-seeking at the patient and household level will inform strategies for maintaining healthcare access during future pandemics in West Africa.

Associations between the stringency of COVID-19 containment policies and health service disruptions in 10 countries.

BACKGROUND: Disruptions in essential health services during the COVID-19 pandemic have been reported in several countries. Yet, patterns in health service disruption according to country responses remain unclear. In this paper, we investigate associations between the stringency of COVID-19 containment policies and disruptions in 31 health services in 10 low- middle- and high-income countries in 2020. METHODS: Using routine health information systems and administrative data from 10 countries (Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, South Korea, and Thailand) we estimated health service disruptions for the period of April to December 2020 by dividing monthly service provision at national levels by the average service provision in the 15 months pre-COVID (January 2019-March 2020). We used the Oxford COVID-19 Government Response Tracker (OxCGRT) index and multi-level linear regression analyses to assess associations between the stringency of restrictions and health service disruptions over nine months. We extended the analysis by examining associations between 11 individual containment or closure policies and health service disruptions. Models were adjusted for COVID caseload, health service category and country GDP and included robust standard errors. FINDINGS: Chronic disease care was among the most affected services. Regression analyses revealed that a 10% increase in the mean stringency index was associated with a 3.3 percentage-point (95% CI -3.9, -2.7) reduction in relative service volumes. Among individual policies, curfews, and the presence of a state of emergency, had the largest coefficients and were associated with 14.1 (95% CI -19.6, 8.7) and 10.7 (95% CI -12.7, -8.7) percentage-point lower relative service volumes, respectively. In contrast, number of COVID-19 cases in 2020 was not associated with health service disruptions in any model. CONCLUSIONS: Although containment policies were crucial in reducing COVID-19 mortality in many contexts, it is important to consider the indirect effects of these restrictions. Strategies to improve the resilience of health systems should be designed to ensure that populations can continue accessing essential health care despite the presence of containment policies during future infectious disease outbreaks.

Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

Prevalence and correlates of maternal early stimulation behaviors during pregnancy in northern Ghana: a cross-sectional survey.

BACKGROUND: Per UNICEF's Nurturing Care Framework, early childhood development (ECD) begins during pregnancy and many lower-resource settings need data to inform their programs for optimal child development. The maternal-fetal relationship can be partly examined via a series of bonding activities called early stimulation behaviors (ESB). This study describes early stimulation behaviors and the associated correlates among pregnant women in Ghana. METHODS: This cross-sectional study used data from a cluster-randomized trial in two districts of Northern Ghana. A total of 374 pregnant women were enrolled at baseline and administered a pre-intervention survey. Communication-related early stimulation behaviors was the primary outcome which was evaluated using three maternal-fetal bonding activities; did the woman self-report touching and/or talking, singing, and/or talking about family to her belly. A generalized estimating equation modified Poisson model was used for the bivariate and multivariable analysis. RESULTS: About half of the participants reported performing communication-related ESB during pregnancy frequently or sometimes. Bivariate analysis revealed that negative life experiences including higher rates of emotional, physical and sexual intimate partner violence (IPV) and having moderate to severe depressive symptoms were associated with women performing early stimulation behaviors more often. In the multivariable model, physical intimate partner violence remained significantly associated with early stimulation behaviors. CONCLUSION: Research on early stimulation behaviors is still in a nascent phase. It is unclear why our results revealed an association between intimate partner violence and early stimulation behaviors; this could reflect a coping mechanism for the expectant mother. Further research is needed to better understand this association and explore potential long-term impacts of early stimulation behaviors during pregnancy on child development. TRIAL REGISTRATION: Clinical Trials # NCT03665246 , August 29, 2018.

The cost of health workforce gaps and inequitable distribution in the Ghana Health Service: an analysis towards evidence-based health workforce planning and management.

BACKGROUND: Despite tremendous health workforce efforts which have resulted in increases in the density of physicians, nurses and midwives from 1.07 per 1000 population in 2005 to 2.65 per 1000 population in 2017, Ghana continues to face shortages of health workforce alongside inefficient distribution. The Ministry of Health and its agencies in Ghana used the Workload Indicators of Staffing Needs (WISN) approach to develop staffing norms and standards for all health facilities, which is being used as an operational planning tool for equitable health workforce distribution. Using the nationally agreed staffing norms and standards, the aim of this paper is to quantify the inequitable distribution of health workforce and the associated cost implications. It also reports on how the findings are being used to shape health workforce policy, planning and management. METHODS: We conducted a health workforce gap analysis for all health facilities of the Ghana Health Service in 2018 in which we compared a nationally agreed evidence-based staffing standard with the prevailing staffing situation to identify need-based gaps and inequitable distribution. The cost of the prevailing staffing levels was also compared with the stipulated standard, and the staffing cost related to inequitable distribution was estimated. RESULTS: It was found that the Ghana Health Service needed 105,440 health workers to meet its minimum staffing requirements as at May 2018 vis-à-vis its prevailing staff at post of 61,756 thereby leaving unfilled vacancies of 47,758 (a vacancy rate of 41%) albeit significant variations across geographical regions, levels of service and occupational groups. Of note, the crude equity index showed that in aggregate, the best-staffed region was 2.17 times better off than the worst-staffed region. The estimated cost (comprising basic salaries, market premium and other allowances paid from central government) of meeting the minimum staffing requirements was estimated to be GH¢2,358,346,472 (US$521,758,069) while the current cost of staff at post was GH¢1,424,331,400 (US$315,117,566.37), resulting in a net budgetary deficit of 57% (~ US$295.4 million) to meet the minimum requirement of staffing for primary and secondary health services. Whilst the prevailing staffing expenditure was generally below the required levels, an average of 28% (range 14-50%) across the levels of primary and secondary healthcare was spent on staff deemed to have been inequitably distributed, thus providing scope for rationalisation. We estimate that the net budgetary deficit of meeting the minimum staffing requirement could be drastically reduced by some 30% just by redistributing the inequitably distributed staff. POLICY IMPLICATIONS: Efficiency gains could be made by redistributing the 14,142 staff deemed to be inequitably distributed, thereby narrowing the existing staffing gaps by 30% to 33,616, which could, in turn, be filled by leveraging synergistic strategy of task-sharing and/or new recruitments. The results of the analysis provided insights that have shaped and continue to influence important policy decisions in health workforce planning and management in the Ghana Health Service.

The impact of a maternal mental health intervention on intimate partner violence in Northern Ghana and the mediating roles of social support and couple communication: secondary analysis of a cluster randomized controlled trial.

BACKGROUNDS: Diverse intervention efforts are implemented to address intimate partner violence (IPV) against women. Via a syndemics theory lens and emerging empirical evidence, mental health interventions demonstrate promise to partially ameliorate IPV. However, the mechanisms of change underlying many IPV interventions are not well understood. These gaps impede our efforts to strengthen or integrate effective components into the current mental health resources, especially in low- and middle-income countries (LMICs). This study aims to examine the impact of a maternal mental health intervention called Integrated Mothers and Babies Course & Early Childhood Development (iMBC/ECD) on IPV and whether social support and/or couple communication mediates the intervention effects among women in rural, Northern Ghana. METHODS: The current study is a secondary data analysis of a cluster randomized controlled trial. IPV was measured at baseline and 8 months post-intervention (~ 19 months post-baseline). At baseline, 84.8% of the women enrolled in the study (n = 374) reported some type of IPV in the past 12 months. Logistic regression models and multiple mediation analyses were used to address the study aims. RESULTS: iMBC/ECD did not reduce IPV in the intervention group compared to the control group. Social support and couple communication did not mediate the intervention effects on IPV as indicated by the indirect effects of the multiple mediation models. However, increase in social support reduced women's odds of experiencing emotional violence by 7%, odds ratio (OR) = 0.93, p = 0.007; b = - 0.07, 95% confidence interval (CI) = (- 0.13, - 0.02), and improvement in couple communication demonstrated promise in reducing women's odds of experiencing controlling behaviors by 7%, OR = 0.93, p = 0.07; b = - 0.07, CI = (- 0.14, 0.005), though the improvements were not due to the intervention. CONCLUSION: This maternal mental health intervention did not reduce IPV; however, the findings extend our knowledge about the impact of such interventions on IPV and the potential mechanisms of change via social support and couple communication. Future research evaluating the impact of mental health interventions on IPV and mechanisms of change is essential for the development of effective interventions. Future programs addressing IPV in LMICs should consider risk factors beyond relationship level (e.g. poverty and gender inequity). TRIAL REGISTRATION: ClinicalTrials.gov # NCT03665246 , Registered on August 20th, 2018.

Community utilisation and satisfaction with the community-based health planning and services initiative in Ghana: a comparative study in two system learning districts of the CHPS+ project.

BACKGROUND: To strengthen the implementation of the Community-based Health Planning and Services (CHPS) programme which is Ghana's key primary health care delivery strategy, the CHPS+ Project was initiated in 2017. We examined community utilisation and satisfaction with CHPS services in two System Learning Districts (SLDs) of the project. METHODS: This community-based descriptive study was conducted in the Nkwanta South Municipality and Central Tongu District of Ghana. Data were collected from 1008 adults and analysed using frequency, percentage, chi-square, and logistic regression models. RESULTS: While the level of utilisation of CHPS services was 65.2%, satisfaction was 46.1%. Utilisation was 76.7% in Nkwanta South and 53.8% in Central Tongu. Satisfaction was also 55.2% in Nkwanta South and 37.1% in Central Tongu. Community members in Nkwanta South were more likely to utilise (AOR = 3.17, 95%CI = 3.98-9.76) and be satisfied (AOR = 2.77, 95%CI = 1.56-4.90) with CHPS services than those in Central Tongu. Females were more likely to utilise (AOR = 1.75, 95%CI = 1.27-2.39) but less likely to be satisfied [AOR = 0.47, 95%CI = 0.25-0.90] with CHPS services than males. Even though subscription to the National Health Insurance Scheme (NHIS) was just 46.3%, NHIS subscribers were more likely to utilise (AOR = 1.51, 95%CI = 1.22-2.03) and be satisfied (AOR = 1.45, 95%CI = 0.53-1.68) with CHPS services than non-subscribers. CONCLUSION: Ghana may not be able to achieve the goal of universal health coverage (UHC) by the year 2030 if current levels of utilisation and satisfaction with CHPS services persist. To accelerate progress towards the achievement of UHC with CHPS as the vehicle through which primary health care is delivered, there should be increased public education by the Ghana Health Service (GHS) on the CHPS concept to increase utilisation. Service quality should also be improved by the GHS and other stakeholders in Ghana's health industry to increase satisfaction with CHPS services. The GHS and the National Health Insurance Authority (NHIA) should also institute innovative strategies to increase subscription to the NHIS since it has implications for CHPS service utilisation and satisfaction.

Volunteer responsibilities, motivations and challenges in implementation of the community-based health planning and services (CHPS) initiative in Ghana: qualitative evidence from two systems learning districts of the CHPS+ project.

BACKGROUND: Community volunteerism is essential in the implementation of the Community-based Health Planning and Services (CHPS) in Ghana. We explored the responsibilities, motivations and challenges of community health management committees (CHMCs) in two CHPS+ Project districts in Ghana. METHODS: We used a qualitative approach to collect data through 4 focus group discussions among a purposive sample of community health volunteers in December 2018 and analysed them thematically. RESULTS: Community health management committees (CHMCs) were found to provide support in running the CHPS programme through resource mobilisation, monitoring of logistics, assisting the Community Health Officers (CHO) in the planning of CHPS activities, and the resolution of conflicts between CHOs and community members. The value, understanding and protective functions were the key motivations for serving on CHMCs. Financial, logistical and telecommunication challenges, lack of recognition and cooperation from community members, lack of motivation and lack of regular skill development training programmes for CHMC members who serve as traditional birth attendants (TBAs) were major challenges in CHMC volunteerism. CONCLUSION: Community health volunteerism needs to be prioritised by the Ghana Health Service and other health sector stakeholders to make it attractive for members to give off their best in the discharge of their responsibilities.

Evaluating the impact of community health volunteer home visits on child diarrhea and fever in the Volta Region, Ghana: A cluster-randomized controlled trial.

BACKGROUND: Although there is mounting evidence demonstrating beneficial effects of community health workers (CHWs), few studies have examined the impact of CHW programs focused on preventing infectious diseases in children through behavior changes. We assessed the preventive effects of community health volunteers (CHVs), who receive no financial incentive, on child diarrhea and fever prevalence in Ghana. METHODS AND FINDINGS: We conducted a cluster-randomized controlled trial in 40 communities in the Volta Region, Ghana. Twenty communities were randomly allocated to the intervention arm, and 20 to the control arm, using a computer-generated block randomization list. In the intervention arm, CHVs were deployed in their own community with the key task of conducting home visits for health education and community mobilization. The primary outcomes of the trial were diarrhea and fever prevalence at 6 and 12 months among under-5 children based on caregivers' recall. Secondary outcomes included oral rehydration treatment and rapid diagnostic testing for malaria among under-5 children, and family planning practices of caregivers. Generalized estimating equations (GEEs) with a log link and exchangeable correlation matrix were used to determine the relative risk (RR) and 95% confidence intervals (CIs) for diarrhea, fever, and secondary outcomes adjusted for clustering and stratification. Between April 18 and May 4, 2015, 1,956 children were recruited and followed up until September 20, 2016. At 6 and 12 months post-randomization, 1,660 (85%) and 1,609 (82%) participants, respectively, had outcomes assessed. CHVs' home visits had no statistically significant effect on diarrhea or fever prevalence at either time point. After a follow-up of 12 months, the prevalence of diarrhea and fever was 7.0% (55/784) and 18.4% (144/784), respectively, in the control communities and 4.5% (37/825) and 14.7% (121/825), respectively, in the intervention communities (12-month RR adjusted for clustering and stratification: diarrhea, RR 0.73, 95% CI 0.37-1.45, p = 0.37; fever, RR 0.76, 95% CI 0.51-1.14, p = 0.20). However, the following were observed: improved hand hygiene practices, increased utilization of insecticide-treated bed nets, and greater participation in community outreach programs (p-values < 0.05) in the intervention group. In a post hoc subgroup analysis, the prevalence of diarrhea and fever at 6 months was 3.2% (2/62) and 17.7% (11/62), respectively, in the intervention communities with ≥70% coverage and a ≥30-minute visit duration, and 14.4% (116/806) and 30.2% (243/806) in the control communities (RR adjusted for clustering, stratification, baseline prevalence, and covariates: diarrhea, RR 0.23, 95% CI 0.09-0.60, p = 0.003; fever, RR 0.69, 95% CI 0.52-0.92, p = 0.01). The main limitations were the following: We were unable to investigate the longer-term effects of CHVs; the trial may have been underpowered to detect small to moderate effects due to the large decline in diarrheal and fever prevalence in both the intervention and control group; and caregivers' practices were based on self-report, and the possibility of caregivers providing socially desirable responses cannot be excluded. CONCLUSIONS: We found no effect of CHVs' home visits on the prevalence of child diarrhea or fever. However, CHV programs with high community coverage and regular household contacts of effective duration may reduce childhood infectious disease prevalence. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Registry, ISRCTN49236178.

A qualitative appraisal of stakeholders' perspectives of a community-based primary health care program in rural Ghana.

BACKGROUND: The Ghana Community-based Health Planning and Services (CHPS) initiative is a national strategy for improving access to primary health care services for underserved communities. Following a successful trial in the North Eastern part of the country, CHPS was adopted as Ghana's flagship programme for achieving the Universal Health Coverage. Recent empirical evidence suggests, however, that scale-up of CHPS has not necessarily replicated the successes of the pilot study. This study examines the community's perspective of the performance of CHPS and how the scale up could potentially align with the original experimental study. METHOD: Applying a qualitative research methodology, this study analysed transcripts from 20 focus group discussions (FGDs) in four functional CHPS zones in separate districts of the Northern and Volta Regions of Ghana to understand the community's assessment of CHPS. The study employed the thematic analysis to explore the content of the CHPS service provision, delivery and how community members feel about the service. In addition, ordinary least regression model was applied in interpreting 126 scores consigned to CHPS by the study respondents. RESULTS: Two broad areas of consensus were observed: general favourable and general unfavourable thematic areas. Favourable themes were informed by approval, appreciation, hard work and recognition of excellent services. The unfavourable thematic area was informed by rudeness, extortion, inappropriate and unprofessional behaviour, lack of basic equipment and disappointments. The findings show that mothers of children under the age of five, adolescent girls without children, and community leaders generally expressed favourable perceptions of CHPS while fathers of children under the age of five and adolescent boys without children had unfavourable expressions about the CHPS program. A narrow focus on maternal and child health explains the demographic divide on the perception of CHPS. The study revealed wide disparities in actual CHPS deliverables and community expectations. CONCLUSIONS: A communication gap between health care providers and community members explains the high and unrealistic expectations of CHPS. Efforts to improve program acceptability and impact should address the need for more general outreach to social networks and men rather than a sole focus on facility-based maternal and child health care.

Preliminary validation of the PRImary care facility Management Evaluation tool (PRIME-Tool), a national facility management survey implemented in Ghana.

BACKGROUND: The management quality of healthcare facilities has consistently been linked to facility performance, but available tools to measure management are costly to implement, often hospital-specific, not designed for low- and middle-income countries (LMICs), nor widely deployed. We addressed this gap by developing the PRImary care facility Management Evaluation Tool (PRIME-Tool), a primary health care facility management survey for integration into routine national surveys in LMICs. We present an analysis of the tool's psychometric properties and suggest directions for future improvements. METHODS: The PRIME-Tool assesses performance in five core management domains: Target setting, Operations, Human resources, Monitoring, and Community engagement. We evaluated two versions of the PRIME-Tool. We surveyed 142 primary health care (PHC) facilities in Ghana in 2016 using the first version (27 items) and 148 facilities in 2017 using the second version (34 items). We calculated floor and ceiling effects for each item and conducted exploratory factor analyses to examine the factor structure for each year and version of the tool. We developed a revised management framework and PRIME-tool as informed by these exploratory results, further review of management theory literature, and co-author consensus. RESULTS: The majority (17 items in 2016, 23 items in 2017) of PRIME-Tool items exhibited ceiling effects, but only three (2 items in 2016, 3 items in 2017) showed floor effects. Solutions suggested by factor analyses did not fully fit our initial hypothesized management domains. We found five groupings of items that consistently loaded together across each analysis and named these revised domains as Supportive supervision and target setting, Active monitoring and review, Community engagement, Client feedback for improvement, and Operations and financing. CONCLUSION: The revised version of the PRIME-Tool captures a range of important and actionable information on the management of PHC facilities in LMIC contexts. We recommend its use by other investigators and practitioners to further validate its utility in PHC settings. We will continue to refine the PRIME-Tool to arrive at a parsimonious tool for tracking PHC facility management quality. Better understanding the functional components of PHC facility management can help policymakers and frontline managers drive evidence-based improvements in performance.

Contraceptive use intentions and unmet need for family planning among reproductive-aged women in the Upper East Region of Ghana.

BACKGROUND: Motivations for use of contraceptives vary across populations. While some women use contraceptives for birth spacing, others adopt contraception for stopping childbearing. As part of efforts to guide the policy framework to promote contraceptive utilization among women in Ghana, this paper examines the intentions for contraceptive use among reproductive-aged women in one of the most impoverished regions of Ghana. METHODS: This paper utilizes data collected in 2011 from seven districts in the Upper East Region of northern Ghana to examine whether women who reported the use of contraceptives did so for the purposes of stopping or spacing childbirth. A total of 5511 women were interviewed on various health and reproductive health related issues, including fertility and family planning behavior. Women were asked if they would like to have any more children (for those who already had children or those who were pregnant at the time of the survey). RESULTS: The prevalence of contraceptive use was low at 13%, while unmet need is highly pervasive and demand for family planning is predominantly for spacing future childbearing rather than for the purpose of stopping. Overall, about 31.7%of women not using contraceptives reported a need for spacing while 17.6% expressed a need for limiting. Thus, the latent demand for family planning is dominated by preferences for space rather than limiting childbearing. CONCLUSION: Results show that there is latent demand for family planning and therefore if family planning programs are appropriately implemented they can yield the desired impact.

Referral patterns through the lens of health facility readiness to manage obstetric complications: national facility-based results from Ghana.

INTRODUCTION: Countries with high maternal and newborn mortality can benefit from national facility level data that describe intra-facility emergency referral patterns for major obstetric complications. This paper assesses the relationship between referral and facilities' readiness to treat complications at each level of the health system in Ghana. We also investigate other facility characteristics associated with referral. METHODS: The National Emergency Obstetric and Newborn Care Assessment 2010 provided aggregated information from 977 health facilities. Readiness was defined in a 2-step process: availability of a health worker who could provide life-saving interventions and a minimum package of drugs, supplies, and equipment to perform the interventions. The second step mapped interventions to major obstetric complications. We used descriptive statistics and simple linear regression. RESULTS: Lower level facilities were likely to refer nearly all women with complications. District hospitals resolved almost two-thirds of all complicated cases, referring 9%. The most prevalent indications for referral were prolonged/obstructed labor and antepartum hemorrhage. Readiness to treat a complication was correlated with a reduction in referral for all complications except uterine rupture. Facility readiness was low: roughly 40% of hospitals and 10% of lower level facilities met the readiness threshold. Facilities referred fewer women when they had higher caseloads, more midwives, better infrastructure, and systems of communication and transport. DISCUSSION: Understanding how deliveries and obstetric complications are distributed across the health system helps policy makers contextualize decisions about the pathways to providing maternity services. Improving conditions for referral (by increasing access to communication and transport systems) and the management of obstetric complications (increasing readiness) will enhance quality of care and make referral more effective and efficient.

Review of emergency obstetric care interventions in health facilities in the Upper East Region of Ghana: a questionnaire survey.

BACKGROUND: Maternal morbidity and mortality is most prevalent in resource-poor settings such as sub-Saharan Africa and southern Asia. In sub-Saharan Africa, Ghana is one of the countries still facing particular challenges in reducing its maternal morbidity and mortality. Access to emergency obstetric care (EmOC) interventions has been identified as a means of improving maternal health outcomes. Assessing the range of interventions provided in health facilities is, therefore, important in determining capacity to treat obstetric emergencies. The aim of this study was to examine the availability of emergency obstetric care interventions in the Upper East Region of Ghana. METHODS: A cross-sectional survey of 120 health facilities was undertaken. Status of emergency obstetric care was assessed through an interviewer administered questionnaire to directors/in-charge officers of maternity care units in selected facilities. Data were analysed using descriptive statistics. RESULTS: Eighty per cent of health facilities did not meet the criteria for provision of emergency obstetric care. Comparatively, private health facilities generally provided EmOC interventions less frequently than public health facilities. Other challenges identified include inadequate skill mix of maternity health personnel, poor referral processes, a lack of reliable communication systems and poor emergency transport systems. CONCLUSION: Multiple factors combine to limit women's access to a range of essential maternal health services. The availability of EmOC interventions was found to be low across the region; however, EmOC facilities could be increased by nearly one-third through modest investments in some existing facilities. Also, the key challenges identified in this study can be improved by enhancing pre-existing health system structures such as Community-based Health Planning and Services (CHPS), training more midwifery personnel, strengthening in-service training and implementation of referral audits as part of health service monitoring. Gaps in availability of EmOC interventions, skilled personnel and referral processes must be tackled in order to improve obstetric outcomes.

An assessment of a performance-based management agreement initiative in Ghana's health service.

BACKGROUND: As part of its efforts to improve efficiency, accountability and overall performance, the Ghana Health Service (GHS) introduced annual Performance-based Management Agreements (PMAs) in the year 2013. However, no assessment of this initiative has since been made in order to inform policy and practice. This paper provides an assessment of this policy initiative from the perspective of managers at various levels of service implementation. METHODS: Mixed methods were employed. Questionnaires were administered to managers through an online survey (using Google forms). Descriptive and inferential statistical methods were used to analyze and present quantitative results while qualitative data was analyzed via thematic analysis. RESULTS: The content and objectives of the PMAs were observed to be comprehensive and directed at ensuring high performance of directorates. Targets of PMAs were found to be aligned with overall health sector objectives and priorities. The directors felt PMAs were useful for delegating task to subordinates. PMAs were also found to increase commitment and contributed to improving teamwork and prudent use of resources. However, PMAs were found to lack clear implementation strategies and were not backed by incentives and sanctions. Also, budgetary allocations did not reflect demands of PMAs. Furthermore, directors at lower levels were not adequately consulted in setting PMAs targets as such district specific challenges and priorities are not usually factored into the process. Insufficient training of staff and lack of requisite staff were key challenges confronting the implementation of PMAs in most directorates. Weak monitoring and evaluation was also observed to significantly affect the success of PMAs. CONCLUSION: There is the need to address the weaknesses and improve on the existing strengths identified by this assessment in order to enhance the effectiveness of PMAs utilization in the Ghana health service.

What do you do with success? The science of scaling up a health systems strengthening intervention in Ghana.

BACKGROUND: The completion of an implementation research project typically signals the end of research. In contrast, the Ghana Health Service has embraced a continuous process of evidence-based programming, wherein each research episode is followed by action and a new program of research that monitors and guides the utilization of lessons learned. This paper reviews the objectives and design of the most recent phase in this process, known as a National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+). METHODS: A mixed method evaluation strategy has been launched involving: i) baseline and endline randomized sample surveys with 247 clusters dispersed in 14 districts of the Northern and Volta Regions to assess the difference in difference effect of stepped wedge differential cluster exposure to CHPS+ activities on childhood survival, ii) a monitoring system to assess the association of changes in service system readiness with CHPS+ interventions, and iii) a program of qualitative systems appraisal to gauge stakeholder perceptions of systems problems, reactions to interventions, and perceptions of change. Integrated survey and monitoring data will permit multi-level longitudinal models of impact; longitudinal QSA data will provide data on the implementation process. DISCUSSION: A process of exchanges, team interaction, and catalytic financing has accelerated the expansion of community-based primary health care in Ghana's Upper East Region (UER). Using two Northern and two Volta Region districts, the UER systems learning concept will be transferred to counterpart districts where a program of team-based peer training will be instituted. A mixed method research system will be used to assess the impact of this transfer of innovation in collaboration with national and regional program management. This arrangement will generate embedded science that optimizes prospects that results will contribute to national CHPS reform policies and action.

Bridging the intervention-implementation gap in primary health care delivery: the critical role of integrated implementation research.

For national and local leaders to achieve universal health coverage, a new approach or technique to gathering evidence and understanding the contexts that influence the outcome of a study and goes beyond the quantitative results of clinical trials and pilot projects is important. The Doris Duke Charitable Foundation's African Health Initiative (AHI) was designed to produce this type of knowledge through embedding implementation research into Population Health Implementation and Training (PHIT) partnership projects in five countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) with the goal of improving primary health care and population health. In Ghana, this integration of research into implementation has contributed to the successful testing, adaptation and implementation of the Community-based Health Planning and Services (CHPS) model (The Navrongo Pilot Project), with results from the AHI-funded work informing national scale-up of effective practices. Further application of implementation science methods and frameworks to study cross-project lessons also produced the evidence needed by national and local decision makers on how and why different intervention components were successful and where and how local context drove implementation and adaptation. Cross-project research also identified effective approaches across diverse settings for building capacity for data-driven improvement, coaching and mentoring clinicians and researchers, developing locally appropriate interventions to reduce neonatal mortality, and integrating implementation research to inform local implementers and researchers in more effective strategies to strengthen health systems and improve health services and population health. Evidence has already shown the potential for this type of work to accelerate regional learning and spread of successful interventions to achieve targeted health goals more efficiently, better enabling countries to achieve the ambitious, but important, U.N. Sustainable Development Goals.

Mentorship and coaching to support strengthening healthcare systems: lessons learned across the five Population Health Implementation and Training partnership projects in sub-Saharan Africa.

BACKGROUND: Despite global efforts to increase health workforce capacity through training and guidelines, challenges remain in bridging the gap between knowledge and quality clinical practice and addressing health system deficiencies preventing health workers from providing high quality care. In many developing countries, supervision activities focus on data collection, auditing and report completion rather than catalyzing learning and supporting system quality improvement. To address this gap, mentorship and coaching interventions were implemented in projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) as components of health systems strengthening (HSS) strategies funded through the Doris Duke Charitable Foundation's African Health Initiative. We report on lessons learned from a cross-country evaluation. METHODS: The evaluation was designed based on a conceptual model derived from the project-specific interventions. Semi-structured interviews were administered to key informants to capture data in six categories: 1) mentorship and coaching goals, 2) selection and training of mentors and coaches, 3) integration with the existing systems, 4) monitoring and evaluation, 5) reported outcomes, and 6) challenges and successes. A review of project-published articles and technical reports from the individual projects supplemented interview information. RESULTS: Although there was heterogeneity in the approaches to mentorship and coaching and targeted areas of the country projects, all led to improvements in core health system areas, including quality of clinical care, data-driven decision making, leadership and accountability, and staff satisfaction. Adaptation of approaches to reflect local context encouraged their adoption and improved their effectiveness and sustainability. CONCLUSION: We found that incorporating mentorship and coaching activities into HSS strategies was associated with improvements in quality of care and health systems, and mentorship and coaching represents an important component of HSS activities designed to improve not just coverage, but even further effective coverage, in achieving Universal Health Care.

Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of Primary Health Care? Perspectives of key stakeholders in northern Ghana.

BACKGROUND: In 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana's health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC. METHODS: Using qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers. A stakeholders' workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from respondents for the achievement of the goals of UHC and PHC. RESULTS: The key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS; inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC. CONCLUSION: This study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC.