Predictors of caesarean section in Northern Ghana: a case-control study

Introduction: Caesarean section rates have become a global public health. This study investigated obstetric and socio-demographic factors associated with caesarean section in northern Ghana. Methods: This was a case-control study comparing 150 women who had caesarean section (cases) and 300 women who had vaginal delivery (controls). Data were collected retrospectively from delivery registers, postpartum and postnatal registers in the Bolgatanga Regional Hospital. Univariate and multivariate analysis of data were done using SPSS 22. Results: The study revealed that women who had higher odds of having a caesarean section were women who; attended Antenatal care (ANC) ≥ 4 times (Adjusted OR= 2.99, 95% CI1.762-5.065), were referred from other health facilities (Adjusted OR = 1.19, 95% CI 1.108-1.337) and had a foetal weight of ≥ 4000 grams (Adjusted OR = 1.21, 95% CI 1.064-1.657). There was a slight increase in odds of having a caesarean section among women who had a gestational age > 40 weeks (Adjusted OR = 1.09, 95% CI 1.029-1.281). Women who had secondary/higher education (Adjusted OR = 0.55, 95% CI 0.320-0.941), gestational age < 37 weeks (Adjusted OR = 0.20, 95% CI: 0.100-0.412) and women who had a foetal weight of 1500 grams to 2499 grams (Adjusted OR = 0.17, 95% CI 0.086-0.339) were associated with a lower odds of having a caesarean section. Conclusion: There was an increase in odds of having a caesarean section among pregnant women who had a foetal weight of ≥ 4000 grams and women who attended ANC ≥ 4 times. Pregnant women who were referred also had increase odds of having a caesarean section

Implementation research for integrated health system strengthening in Ghana : towards tipping point for improved health systems performance and population health

Recent decades have witnessed the proliferation of large-scale initiatives for improving health systems. Strategies such as the Bamako Initiative, the Sector-Wide Approach, Child Survival+ and many others were instituted with compelling rationales for improving the provision of essential health services. Yet, large-scale investments in untested health system initiatives have often been associated with disappointing results, or with little formal evidence that investments in organizational strategies have actually improved health. Interestingly, no prior study has tested the proposition that the six WHO health system building block subsystems (integrated health service delivery, health workforce, information for decision making, essential drug supplies and logistics, health financing and resources allocation and leadership and governance) can be strengthened with an integrated package of systems interventions in ways that can accelerate the pace of improvements in child health and survival. If such incremental effects can be demonstrated, prospects for expanding international and national commitment to health systems strengthening will be greatly enhanced and specific lessons from implementation research and operational experience of this nature will be invaluable to health planners. Health services delivery in Ghana is decentralized and in discharging its constitutional mandate to expand access to healthcare, the Government of Ghana has implemented policies that mandate a system of services, referral operations and supervisory roles for health care services that is provided in hospitals, sub-district health centres and community-based facilities. Health service innovations are provided at the community level through a policy known as the Community-based Health Planning and Services (CHPS) Initiative that aims to mobilize community leadership, decision-making systems and resources in poor rural areas; relocate facility-based nurses to community service points called “CHPS zones” and orient these workers to the active provision of community-based outreach and doorstep healthcare. CHPS also supports nurses with logistics and community volunteer systems to provide services according to the principles of primary healthcare including integrated management of childhood illnesses, comprehensive immunization services and basic safe motherhood care. Despite efforts to implement this community-based health system, a number of challenges have emerged that limit access to service delivery using the six WHO health systems building block subsystems. Critically identified are the following challenges: 1. Governance: Leadership and governance systems are poorly understood and inadequately marshalled for health development at the local and community level. 2. Financing: Budgets and financial plans are largely determined by past budgets or external vertical programmes rather than resource allocation that is based on the configuration of need. 3. Information: Health information capability to support decentralized healthcare system has instead been a time consuming data extraction process for the health insurance and central health bureaucracy rather than a system for community-based healthcare workers that contributes to their work, decision-making, or supervisory support needs. 4. Logistics: Even though there is deemed to be a decentralized management of health services, there is still a centralized medical stores system, resulting in episodes of catastrophic breakdown in supply chains, with stock-outs that are exacerbated when district health service operations increase. 5. Human resources: Shortages in the district health management, midwifery, and nursing workforce arise, either because of their inappropriate posting location or inadequate numbers as well as poor leadership that seriously undermines efforts to strengthen the health systems. This work reviews the Ghana Essential Health Interventions Project (GEHIP), implemented in the Upper East Region of Ghana to contribute to the health systems strengthening policy by testing the health and survival impact of strengthening the primary health care system. GEHIP tested the hypothesis that integrated system initiatives cutting across the WHO “pillars” of health system strengthening can improve system performance to the point of having an impact on population and health outcomes and ensure that essential health interventions reach under-served populations and progress towards Millennium Development Goal (MDG) 4 can be achieved. The project essentially focused on strengthening district-level capacity to plan and set priorities using locally obtained burden of disease and cost-effectiveness data in order to increase the effectiveness of Ghana’s Community-based Health Planning and Services (CHPS) programme, with the goal of accelerating the expansion of CHPS coverage and improving the quality of CHPS provided care. A mixed methodology was used to gauge the impact of the health system functioning according to a framework of interventions spanning the six WHO health systems building block subsystems. Aggregate impact of GEHIP on child survival was tested with the Heckman “difference of differences” procedure using results from a baseline survey that was conducted in 2010 and an endline survey conducted in 2015 in four treatment and seven comparison districts. Qualitative Systems Appraisal (QSA) in the form of in-depth interviews and focus group investigations of community stakeholders, frontline workers, supervisors, and district health managers was employed to gauge reactions to the GEHIP system, clarify inputs by the health subsystem, reactions to these inputs and recommendations for systems change. Regression methods were used to refine the Heckman procedure, adjusting for potential confounders and estimating net effects of household exposure to GEHIP improved care on the survival of children. GEHIP is a quasi-experimental study of a project designed to accelerate the scale up of one of the most effective health development experiments ever conducted in Africa –The “Navrongo Experiment”. It supplements the provision of effective primary healthcare strategies with leadership training, field demonstration, improved budgeting and resource mobilization. By means of these interventions, GEHIP sought to enhance health equity, mitigate social and monetary health care costs, foster parental health seeking behaviour and improve maternal and child survival. Training was designed to expand access to life saving technology that reduces neonatal, infant, and childhood mortality. Additional components for improving referral, neonatal survival, and maternal health rekindled Ghana’s legacy of generating evidence-based means of achieving affordable and accessible primary health care throughout Ghana. Findings from this work have shown that the combined effects of leadership training, catalytic investment, political engagement, and evidence-based budgeting are capable of solving CHPS start-up problem and accelerate scale up. At baseline, neonatal and maternal mortality rates were unacceptably high, but the rapid training of frontline workers proved to be inexpensive, operationally feasible, and potentially effective in reducing maternal and neonatal mortality. Moreover, an innovative pilot referral system utilizing locally appropriate tri-car ambulances has been implemented and information systems have been reformed through the adoption of a simplified register system with impressive results. Accelerating CHPS scale-up is crucial to health development in Ghana where the expansion of CHPS has languished because district health systems strengthening requirements were unanticipated by national policies. Research results showed that the interventions had their intended impact on the pace of CHPS scale-up. This success translated into an impact on child mortality resulting in GEHIP providing a critically needed focus for national efforts to develop primary health care, and lessons for global healt

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

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.; 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.; 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.; 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

Evaluation of the reporting completeness and timeliness of the integrated disease surveillance and response system in northern Ghana

Objectives: The integrated disease surveillance and response (IDSR) and district health information management system II (DHIMS2) strategies were implemented in 2002 and 2012 respectively to improve surveillance data reporting and quality. The objective of this study was to evaluate the reporting completeness and timeliness of the IDSR system at the sub-national level in northern Ghana.Methods: This was an observational study in Upper East Region (UER). Weekly and monthly disease surveillance reports on completeness and timeliness were downloaded and analysed for 2012 and 2013 from the DHIMS2 in UER, the two Kassena-Nankana districts and their nine health facilities representing public, private and mission providers. Comparison of paper-based and DHIMS2 reporting from the periphery health facilities were assessed.Results: IDSR monthly reporting completeness and timeliness in UER increased by 9% and 37% respectively in 2013 compared to 2012 and weekly completeness and timeliness improved by 79% and 24% respectively in 2013. Similar reporting increases were seen in the districts and health facilities over the same period, except the Kassena-Nankana Municipal which showed decrease of 2% in monthly completeness for 2013. At the health facilities, the paper-based reporting completeness was 96% and timeliness 45% while DHIMS2 completeness was 83% and timeliness 18% in 2012. However, DHIMS2 reporting completeness and timeliness improved in 2013 reaching 100% and 61% respectively.Conclusions: Disease surveillance reporting through DHIMS2 became more complete over time, but there remain problems with timeliness. Surveillance data need to be timely to enable rapid responses to disease outbreaks.Keywords: disease surveillance, completeness, timeliness, health information system, Ghan

The Ghana Community-based Health Planning and Services Initiative: Fostering evidence-based organizational change and development in a resource-constrained setting

Research projects demonstrating ways to improve health services often fail to have an impact on what national health programs actually do. An approach to evidence-based policy development has been launched in Ghana that bridges the gap between research and program implementation. The Community-based Health Planning and Services (CHPS) initiative employs strategies tested in the successful Navrongo experiment to guide national health reforms that mobilize volunteers, resources, and cultural institutions to support community-based primary health care. Over the 1999 to 2002 period, 100 out of the 110 districts in Ghana adopted a CHPS initiative. This paper reviews features of the initiative that explain its success and constrain future progress

The Application of Geographic Information Systems (GIS) to Improving Health Systems in the Upper East Region of Ghana

Despite the increased use of Geographic Information System (GIS) for health research, the technology is least used in settings where evidence based decision-making is needed most: High mortality settings of Africa where resource constraints impede the provision of essential care. This paper reports on a case study of GIS application in the Upper East Region (UER), one of the poorest regions in Ghana. Methods: Ghana Health Service (GHS) workers were trained to use GPS handheld devices to gather waypoints (coordinates) of all health care facilities and amenities throughout the UER. The waypoints data were then exported to Excel spreadsheets and cleaned of all inconsistencies. The final data was imported into ArcMap 10.2.2 software for data manipulation, display, and analysis. Results: Preventive health issues portrayed by GIS visualization included a substandard access to potable water in one community and health facility deficiencies in the Binduri district. As examples of GIS morbidity surveillance, we map the temporal incidence of cholera in two districts, and evidence of a pattern in the seasonal outbreaks of cerebral spinal meningitis (CSM). Conclusion: Results attest to the feasibility of using GIS to clarify health issues in a severely health service deprived setting, enabling public health authorities to optimize system responses where mostly needed. GIS technology has enabled health officials in the region to visualize the geographic pattern of disease outbreaks in ways that permit the imposition of efficient containment strategies

Best practices in scaling digital health in low and middle income countries.

Healthcare challenges in low and middle income countries (LMICs) have been the focus of many digital initiatives that have aimed to improve both access to healthcare and the quality of healthcare delivery. Moving beyond the initial phase of piloting and experimentation, these initiatives are now more clearly focused on the need for effective scaling and integration to provide sustainable benefit to healthcare systems.Based on real-life case studies of scaling digital health in LMICs, five key focus areas have been identified as being critical for success. Firstly, the intrinsic characteristics of the programme or initiative must offer tangible benefits to address an unmet need, with end-user input from the outset. Secondly, all stakeholders must be engaged, trained and motivated to implement a new initiative, and thirdly, the technical profile of the initiative should be driven by simplicity, interoperability and adaptability. The fourth focus area is the policy environment in which the digital healthcare initiative is intended to function, where alignment with broader healthcare policy is essential, as is sustainable funding that will support long-term growth, including private sector funding where appropriate. Finally, the extrinsic ecosystem should be considered, including the presence of the appropriate infrastructure to support the use of digital initiatives at scale.At the global level, collaborative efforts towards a less-siloed approach to scaling and integrating digital health may provide the necessary leadership to enable innovative solutions to reach healthcare workers and patients in LMICs. This review provides insights into best practice for scaling digital health initiatives in LMICs derived from practical experience in real-life case studies, discussing how these may influence the development and implementation of health programmes in the future

Socio-economic and demographic disparities in ownership and use of insecticide-treated bed nets for preventing malaria among rural reproductive-aged women in northern Ghana

Background Malaria continues to be a leading cause of morbidity and mortality in most countries in Sub-Saharan Africa. Insecticide-treated bed nets (ITNs) is one of the cost-effective interventions for preventing malaria in endemic settings. Ghana has made tremendous efforts to ensure widespread ownership and use of ITNs. However, national coverage statistics can mask important inequities that demand targeted attention. This study assesses the disparities in ownership and utilization of ITNs among reproductive-aged women in a rural impoverished setting of Ghana. Methods Population-based cross-sectional data of 3,993 women between the age of 15 and 49 years were collected in seven districts of the Upper East region of Ghana using a two-stage cluster sampling approach. Bivariate and multivariate regression models were used to assess the social, economic and demographic disparities in ownership and utilization of ITN and to compare utilization rates among women in households owning at least one ITN. Results As high as 79% of respondents were found to own ITN while 62% of ITN owners used them the night preceding the survey. We identified disparities in both ownership and utilization of ITNs in wealth index, occupational status, religion, and district of residence. Respondents in the relative richest wealth quintile were 74% more likely to own ITNs compared to those in the poorest quintile (p-value< 0.001, CI = 1.29–2.34) however, they were 33% less likely to use ITNs compared to the poorest (p-value = 0.01, CI = 0.50–0.91). Conclusion Interventions aimed at preventing and controlling malaria through the use of bed nets in rural Ghana and other similar settings should give more attention to disadvantage populations such as the poor and unemployed. Tailored massages and educational campaigns are required to ensure consistent use of treated bed nets