Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana

Background: The Government of Ghana’s fee exemption policy for delivery care introduced in September 2003, aimed at reducing financial barriers to using maternal services. This policy also aimed to increase the rate of skilled attendance at delivery, reduce maternal and perinatal mortality rates and contribute to reducing poverty. Objective: To evaluate the economic outcomes of the policy on households in Ghana. Methods: Central and Volta regions were selected for the study. In each region, six districts were selected. A two stage sampling approach was used to identify women for a household cost survey. A sample of 1500 women in Volta region (made up of 750 women each before and after the exemption policy) and 750 women after the policy was introduced in Central region. Outcome Measures: Household out-of-pocket payment for maternal delivery and catastrophic out-of-pocket health payments. Results: There was a statistically significant decrease in the mean out-of-pocket payments for caesarean section (CS) and normal delivery at health facilities after the introduction of the policy. The percentage decrease was highest for CS at 28.40% followed by normal delivery at 25.80%. The incidence of catastrophic out-of-pocket payments also fell. At lower thresholds, the incidence of catastrophic delivery payment was concentrated more amongst the poor. For the poorest group (1st quintile) household out-of-pocket payments in excess of 2.5% of their pre-payment income dropped from 54.54% of the households to 46.38% after the exemption policy. The policy had a more positive impact on the extreme poor than the poor. The richest households (5th quintile) had a decline in out-of-pocket payments of 21.51% while the poor households (1st quintile) had a 13.18% decline. Conclusions: The policy was beneficial to users of the service. However, the rich benefited more than the poor. There is need for proper targeting to identify the poorest of the poor before policies are implemented to ensure maximum benefit by the target group.This work was undertaken as part of an international research programme . Immpact (Initiative for Maternal Mortality Programme Assessment), funded by the Bill & Melinda Gates Foundation, the Department for International Development, the European Commission and USAID

Women Becoming Bosses: Changing Gender Roles and Decision Making in Dangme West District of Ghana

Using both quantitative and qualitative data from the Dangme West district of Ghana, this study shows how the changing socio-economic status of women, as a result of governmental and non-governmental interventions, has influenced women to economically contribute more in their homes, become less vulnerable and subsequently improve their decision-making roles. The study also revealed that other factors such as unemployment and out-migration of men are creating more space for women to assume 'headship' positions and act as major decision-makers in the home. This 'new' gender role and position of women is, however, creating gender antagonism at the household level. The study recommends that NGOs and government agencies must strategically tackle the complexities of decisionmaking and bmgaining power in interpersonal relationships. Moreover, sensitive issues concerning sexual behaviour must be addressed as the first step towards any intervention. Key words: Ghana, Dangme West, decision making, gender, gender role

INVESTIGATION OF HORIZONTAL AND VERTICAL CONTROLS ON KNUST CAMPUS

Controls are coordinated horizontal or vertical positional data for land and geographic information systems forming a framework to which surveys are started, referenced and adjusted. Controls on KNUST campus were established over three decades ago with new ones being added as and when t h e y a r e required. Conventional survey methods like trilateration, triangulation and traversing were used and are still being used for densification of controls. These approaches involve the use of low precision instruments such as analogue/optical theodolites and leveling equipment. Since the establishment of these controls, t h e y have not been investigated but t h e y are being used for p r o j e c t development. A modern method that uses satellite positioning techniques such as GPS is currently in operation and has numerous advantages in the establishmentof control networks. GPS control surveys were carried-out on seven controls and ellipsoidal coordinates were obtained in the World Geodetic System 84 reference frame. The Cartesian coordinates were projected onto the Universal Transverse Mercator frame. A two dimensional conformal transformation was done using existing KNUST boundary coordinatesto Ghana National coordinates based on the War Office ellipsoid. Precise Level routines were carried out on the seven controls for the computations of orthometric heights. The method of least squares adjustment, root mean square errors (RMSE), standard errors (SE) and residuals derived were used to analyse the differences in horizontal positions and heights of the controls.The linear displacement between the computed and the existing coordinates were within the range of 0.015m to 0.014m. The RMSE were 0.048 and 0.106, whiles the SE were also 0.057 and 0.125 for the northings and eastings respectively. The computed and existing heights differed between -0.075m and -0.004m with a mean downward movement of 0.011m.Keywords: Surveying; coordinates; control points; GPS; precise leve

Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana

Background: The Government of Ghana’s fee exemption policy for delivery care introduced in September 2003, aimed at reducing financial barriers to using maternal services. This policy alsoaimed to increase the rate of skilled attendance at delivery, reduce maternal and perinatal mortality rates and contribute to reducing poverty. Objective: To evaluate the economic outcomes of the policy on households in Ghana. Methods: Central and Volta regions were selectedfor the study. In each region, six districts were selected. A two stage sampling approach was used to identify women for a household cost survey. A sample of 1500 women in Volta region (made up of 750 women each before and after the exemption policy) and 750 women after the policy was introduced in Central region. Outcome Measures: Household out-of-pocket payment for maternal delivery and catastrophic out-of-pocket health payments. Results: There was a statistically significant decrease in the mean out-of-pocket payments for caesarean section (CS) and normal delivery at health facilities after the introduction of the policy. The percentage decrease was highest for CS at 28.40% followed by normal delivery at 25.80%. The incidence of catastrophic out-of-pocket payments also fell. At lower thresholds, the incidence of catastrophic delivery payment was concentratedmore amongst the poor. For the poorest group (1st quintile) household out-of-pocket payments in excess of 2.5% of their pre-payment incomedropped from 54.54% of the households to 46.38% after the exemption policy. The policy had a more positive impact on the extreme poor than the poor. The richest households (5th quintile) had a declinein out-of-pocket payments of 21.51% while the poor households (1st quintile) had a 13.18% decline. Conclusions: The policy was beneficial to users of the service. However, the rich benefited more thanthe poor. There is need for proper targeting to identify the poorest of the poor before policies are implemented to ensure maximum benefit by thetarget group

Effect of Gamma Irradiation on Chlorophyll Content in the Cowpea (Vigna unguiculata (L.) Walp)

The experiment was conducted to study the mutagenic effect of gamma rays on chlorophyll content at three different physiological stages in the cowpea: pre-flowering, flowering and post-flowering. Five sets of cowpea seeds were subjected to individual doses of gamma rays: 400 Gy, 450 Gy, 500 Gy, 600 Gy and 0 Gy. The seeds were sown to raise the M1 generation. The M1 generation seeds were collected and sown in the next season to raise the M2 generation. Leaf chlorophyll content was measured for M2 generation plants. Mean chlorophyll content for pre-flowering stage ranged between 38.9 ± 8.17 (control) and 64.2 ± 6.16 (400 Gy). Flowering stage mean chlorophyll content ranged from 48.3 ± 14.4 (600 Gy) to 99.4 ± 6.22 (450 Gy). Post-harvest chlorophyll mean content ranged between 13.1 ±0.98 (600 Gy) and 38.0 ±1.90 (400 Gy). There were significant differences in treatment effects for pre-flowering (P = 0.021), flowering (P = 0.005) and harvest (P = 0.000). At pre-flowering treatment, treatment 400 Gy scored a significant increase of 64 percent (P = 0.02) above the control. The optimum dose for useful induced mutation for increases in chlorophyll concentration in the cowpea was 400 Gy

Formalin-induced behavioural hypersensitivity and neuronal hyperexcitability are mediated by rapid protein synthesis at the spinal level

Background: The mammalian target of rapamycin ( mTOR) is a key regulator of mRNA translation whose action can be inhibited by the drug rapamycin. Forms of long-term plasticity require protein synthesis and evidence indicates that mRNA in dendrites, axon terminals and cell bodies is essential for long-term synaptic plasticity. Specific to pain, shifts in pain thresholds and responsiveness are an expression of neuronal plasticity and this likely contributes to persistent pain. We investigated this by inhibiting the activity of mTOR with rapamycin at the spinal level, of rats that were subjected to the formalin test, using both behavioural and electrophysiological techniques.Results: For in vivo electrophysiology, Sprague Dawley rats were fully anaesthetised and single-unit extracellular recordings were obtained from lamina V wide dynamic range (WDR) dorsal horn spinal neurones at the region where input is received from the hind paw. Neuronal responses from naive rats showed that rapamycin-sensitive pathways were important in nociceptive-specific C-fibre mediated transmission onto WDR neurones as well mechanically-evoked responses since rapamycin was effective in attenuating these measures. Formalin solution was injected into the hind paw prior to which, rapamycin or vehicle was applied directly onto the exposed spinal cord. When rapamycin was applied to the spinal cord prior to hind paw formalin injection, there was a significant attenuation of the prolonged second phase of the formalin test, which comprises continuing afferent input to the spinal cord, neuronal hyperexcitability and an activated descending facilitatory drive from the brainstem acting on spinal neurones. In accordance with electrophysiological data, behavioural studies showed that rapamycin attenuated behavioural hypersensitivity elicited by formalin injection into the hind paw.Conclusion: We conclude that mTOR has a role in maintaining persistent pain states via mRNA translation and thus protein synthesis. We hypothesise that mTOR may be activated by excitatory neurotransmitter release acting on sensory afferent terminals as well as dorsal horn spinal neurones, which may be further amplified by descending facilitatory systems originating from higher centres in the brain

Efficacy of RTS,S malaria vaccines: individual-participant pooled analysis of phase 2 data.

BACKGROUND: The efficacy of RTS,S/AS01 as a vaccine for malaria is being tested in a phase 3 clinical trial. Early results show significant, albeit partial, protection against clinical malaria and severe malaria. To ascertain variations in vaccine efficacy according to covariates such as transmission intensity, choice of adjuvant, age at vaccination, and bednet use, we did an individual-participant pooled analysis of phase 2 clinical data. METHODS: We analysed data from 11 different sites in Africa, including 4453 participants. We measured heterogeneity in vaccine efficacy by estimating the interactions between covariates and vaccination in pooled multivariable Cox regression and Poisson regression analyses. Endpoints for measurement of vaccine efficacy were infection, clinical malaria, severe malaria, and death. We defined transmission intensity levels according to the estimated local parasite prevalence in children aged 2-10 years (PrP₂₋₁₀), ranging from 5% to 80%. Choice of adjuvant was either AS01 or AS02. FINDINGS: Vaccine efficacy against all episodes of clinical malaria varied by transmission intensity (p=0·001). At low transmission (PrP₂₋₁₀ 10%) vaccine efficacy was 60% (95% CI 54 to 67), at moderate transmission (PrP₂₋₁₀ 20%) it was 41% (21 to 57), and at high transmission (PrP₂₋₁₀ 70%) the efficacy was 4% (-10 to 22). Vaccine efficacy also varied by adjuvant choice (p<0·0001)--eg, at low transmission (PrP₂₋₁₀ 10%), efficacy varied from 60% (95% CI 54 to 67) for AS01 to 47% (14 to 75) for AS02. Variations in efficacy by age at vaccination were of borderline significance (p=0·038), and bednet use and sex were not significant covariates. Vaccine efficacy (pooled across adjuvant choice and transmission intensity) varied significantly (p<0·0001) according to time since vaccination, from 36% efficacy (95% CI 24 to 45) at time of vaccination to 0% (-38 to 38) after 3 years. INTERPRETATION: Vaccine efficacy against clinical disease was of limited duration and was not detectable 3 years after vaccination. Furthermore, efficacy fell with increasing transmission intensity. Outcomes after vaccination cannot be gauged accurately on the basis of one pooled efficacy figure. However, predictions of public-health outcomes of vaccination will need to take account of variations in efficacy by transmission intensity and by time since vaccination. FUNDING: Medical Research Council (UK); Bill & Melinda Gates Foundation Vaccine Modelling Initiative; Wellcome Trust

A comparison of outcomes between finger and pulp replantation/revascularization in a single centre

Background: Supermicrosurgery has allowed the replantation/revascularization of the pulp, but how does this currently compare with more proximal digit replantation/revascularization? Methods: In a retrospective case study over a 5-year period at our institute, a total of 21 patients (n = 21) had either finger or pulp replantation-revascularization posttrauma. All pulp replants had a single-vessel anastomosis viz., “artery-to-artery” or “artery-to-vein” only, with venous outflow dependent on the skin-shave technique, while more proximal replants had both arterial and venous anastomoses. Age, sex, ischemic time, handedness, smoker status, and injury-replant interval were compared between the two groups, with all procedures performed by a single surgeon. The outcome parameters studied were length of hospital stay, timeline for wound healing, viability, and functional outcomes. Results: Our patients consisted of 18 men and three women, of which 14.3% were smokers and 85.7% were right-handed. There were 11 finger replantation/revascularizations (n = 11) versus 10 pulp replantation/revascularizations (n = 10). The average age of digit replantation/revascularization patients was 44.8 years compared with 26.4 years in pulp replantation/revascularization patients (Student t test, P = 0.04). Mean ischemia time in digital replants was 67 minutes versus 32.3 minutes in pulp replantation/revascularization (Student t test, P = 0.056). Digital replantation/revascularization was viable in 72% of cases versus a 90% viability in the pulp subcohort. Conclusions: In our patient cohort, pulp replantation/revascularizations produced better postoperative viability. Where supermicrosurgery expertise is available, pulp replantation/revascularization should be considered a worthwhile option when compared with digital replantation/revascularization