How many years of life could be saved if malaria were eliminated from a hyperendemic area of northern Ghana?

For some time, Chinese government policies have treated rural and urban areas very differently, and a by-product of China’s rapid development seems to be an even greater differentiation between urban and rural social and economic life. Over the next several decades, in part because of rapid fertility declines and in part as a result of mortality declines at older ages, China and other developing countries will experience enormous increases in the proportion of older adults and the proportion of the “oldest-old.” It is reasonable to expect that these age structure changes will alter the provision of health care, making an understanding of the determinants of health at older ages critical for the development and implementation of policy. The analysis in this Population Council working paper describes differences in mortality and examines the extent to which variations are accounted for by socioeconomic and health-access and health-availability characteristics that are measured at individual and community levels. On the individual level, cadre status is influential and at the community level, the important measure is the number of amenities available to residents

Accelerating reproductive and child health program development: The Navrongo initiative in Ghana

Successive global health and development agendas have been embraced by African governments—Alma Ata in 1978, the Bamako Initiative in 1987, the 1994 Cairo International Conference on Population and Development, and more recently the Millennium Development Goals (MDGs)—only to be followed by widespread implementation failure. This paper presents an approach to program development in Ghana that is using research to accelerate policy implementation. Originally launched in 1994 as a participatory pilot project of the Navrongo Health Research Centre, a controlled experimental study was initiated in 1996 to assess the fertility and child-survival impact of alternative community health and family planning service strategies. Posting nurses to communities reduced childhood mortality rates by half, accelerating attainment of the childhood-survival MDG within five years. Adding community-mobilization strategies and volunteer outreach to this approach led to a 15-percent reduction in fertility. When a replication project in the Volta Region demonstrated that the Navrongo service model could be transferred to a nonresearch setting, the Government of Ghana adopted the Navrongo approach as the health component of its national poverty-reduction strategy. In 2000, the Community-based Health Planning and Services (CHPS) initiative was launched to accelerate implementation of this policy. By mid-2005, CHPS was fully operational in 20 districts and under development in nearly every other district of Ghana. Analysis of successive phases of the Ghana program-development process demonstrates feasible means of improving national access to reproductive and child health services

Does the contribution of women to household expenditure explain contraceptive use? An assessment of the relevance of bargaining theory to Africa

This paper draws on the concept of bargaining theory to interpret contraceptive decision-making among women who express a desire to limit or space children. Bargaining theory assumes conflict in decision making within households and posits that such conflict is resolved through bargaining. Women’s bargaining power is said to increase with more control of resources. The underlying assumption is that household decisions are governed by economics. This paper acknowledges that economics may influence reproductive decisions, but posits that African social norms and institutions are more important in defining conjugal roles than spousal relative economic contribution to family expenditure. Findings from seven African countries show that women who contribute more income to household expenditure are no more likely to adopt family planning as predicted by bargaining theory. These results bring into question theoretical perspectives that are sometimes promoted as generic explanatory models without validation in specific cultural settings

Monitoring the millennium development goals: the potential role of the INDEPTH Network

The Millennium Declaration, adopted by the United Nations (UN) in 2000, set a series of Millennium Development Goals (MDGs) as priorities for UN member countries, committing governments to realising eight major MDGs and 18 associated targets by 2015. Progress towards these goals is being assessed by tracking a series of 48 technical indicators that have since been unanimously adopted by experts. This concept paper outlines the role member Health and Demographic Surveillance Systems (HDSSs) of the INDEPTH Network could play in monitoring progress towards achieving the MDGs. The unique qualities of the data generated by HDSSs lie in the fact that they provide an opportunity to measure or evaluate interventions longitudinally, through the long-term follow-up of defined populations

The impact of immunization on the association between poverty and child survival: Evidence from Kassena-Nankana District of northern Ghana

Research conducted in Africa has demonstrated consistently that parental poverty and low educational attainment adversely affect child survival. Relative poverty has a pronounced effect on the survival of children, even in a setting where nearly all families are poor. Results from the research presented in the working paper lend strong support to the United Nations’ goal of reducing excess childhood mortality among the poor by directing a particular focus on immunization. Findings in this working paper show that the adverse effects of poverty disappear and that the effects of educational attainment are reduced in survival models that control for immunization status. This finding lends empirical support to policies that promote immunization as a strategic component of poverty-reduction programs

Research capacity building integrated into PHIT projects: leveraging research and research funding to build national capacity

Background Inadequate research capacity impedes the development of evidence-based health programming in sub-Saharan Africa. However, funding for research capacity building (RCB) is often insufficient and restricted, limiting institutions’ ability to address current RCB needs. The Doris Duke Charitable Foundation’s African Health Initiative (AHI) funded Population Health Implementation and Training (PHIT) partnership projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia) to implement health systems strengthening initiatives inclusive of RCB. Methods Using Cooke’s framework for RCB, RCB activity leaders from each country reported on RCB priorities, activities, program metrics, ongoing challenges and solutions. These were synthesized by the authorship team, identifying common challenges and lessons learned. Results For most countries, each of the RCB domains from Cooke’s framework was a high priority. In about half of the countries, domain specific activities happened prior to PHIT. During PHIT, specific RCB activities varied across countries. However, all five countries used AHI funding to improve research administrative support and infrastructure, implement research trainings and support mentorship activities and research dissemination. While outcomes data were not systematically collected, countries reported holding 54 research trainings, forming 56 mentor-mentee relationships, training 201 individuals and awarding 22 PhD and Masters-level scholarships. Over the 5 years, 116 manuscripts were developed. Of the 59 manuscripts published in peer-reviewed journals, 29 had national first authors and 18 had national senior authors. Trainees participated in 99 conferences and projects held 37 forums with policy makers to facilitate research translation into policy. Conclusion All five PHIT projects strongly reported an increase in RCB activities and commended the Doris Duke Charitable Foundation for prioritizing RCB, funding RCB at adequate levels and time frames and for allowing flexibility in funding so that each project could implement activities according to their trainees’ needs. As a result, many common challenges for RCB, such as adequate resources and local and international institutional support, were not identified as major challenges for these projects. Overall recommendations are for funders to provide adequate and flexible funding for RCB activities and for institutions to offer a spectrum of RCB activities to enable continued growth, provide adequate mentorship for trainees and systematically monitor RCB activities

Measuring health systems strength and its impact: experiences from the African Health Initiative.

BACKGROUND: Health systems are essential platforms for accessible, quality health services, and population health improvements. Global health initiatives have dramatically increased health resources; however, funding to strengthen health systems has not increased commensurately, partially due to concerns about health system complexity and evidence gaps demonstrating health outcome improvements. In 2009, the African Health Initiative of the Doris Duke Charitable Foundation began supporting Population Health Implementation and Training Partnership projects in five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) to catalyze significant advances in strengthening health systems. This manuscript reflects on the experience of establishing an evaluation framework to measure health systems strength, and associate measures with health outcomes, as part of this Initiative. METHODS: Using the World Health Organization's health systems building block framework, the Partnerships present novel approaches to measure health systems building blocks and summarize data across and within building blocks to facilitate analytic procedures. Three Partnerships developed summary measures spanning the building blocks using principal component analysis (Ghana and Tanzania) or the balanced scorecard (Zambia). Other Partnerships developed summary measures to simplify multiple indicators within individual building blocks, including health information systems (Mozambique), and service delivery (Rwanda). At the end of the project intervention period, one to two key informants from each Partnership's leadership team were asked to list - in rank order - the importance of the six building blocks in relation to their intervention. RESULTS: Though there were differences across Partnerships, service delivery and information systems were reported to be the most common focus of interventions, followed by health workforce and leadership and governance. Medical products, vaccines and technologies, and health financing, were the building blocks reported to be of lower focus. CONCLUSION: The African Health Initiative experience furthers the science of evaluation for health systems strengthening, highlighting areas for further methodological development - including the development of valid, feasible measures sensitive to interventions in multiple contexts (particularly in leadership and governance) and describing interactions across building blocks; in developing summary statistics to facilitate testing intervention effects on health systems and associations with health status; and designing appropriate analytic models for complex, multi-level open health systems

Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries.

BACKGROUND: Achieving the United Nations Sustainable Development Goals in sub-Saharan Africa will require substantial improvements in the coverage and performance of primary health care delivery systems. Projects supported by the Doris Duke Charitable Foundation's (DDCF) African Health Initiative (AHI) created public-private-academic and community partnerships in five African countries to implement and evaluate district-level health system strengthening interventions. In this study, we captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions. METHODS: We used qualitative data from key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through AHI in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. RESULTS: Four major overarching lessons were highlighted. First, variety and inclusiveness of concerned key players (public, academic and private) are necessary to address complex health system issues at all levels. Second, a learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Third, inclusion of strong implementation science tools and strategies allowed informed and measured learning processes and efficient dissemination of best practices. Fourth, five to seven years was the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the PHIT partnership projects. CONCLUSION: The AHI experience has raised remaining, if not overlooked, challenges and potential solutions to address complex health systems strengthening intervention designs and implementation issues, while aiming to measurably accomplish sustainable positive change in dynamic, learning, and varied contexts

Deliberation for Development: Ghana’s First Deliberative Poll

This article poses the problem of public consultation in developing countries and applies a solution in Ghana as a test case. It describes the theoretical rationale for deliberative consultation with random samples, describes specific criteria for success, and then assesses an application under the challenging conditions of a developing country. It builds on notions of “deliberative democracy,” and shows how they can be practically realized in an African context through “Deliberative Polling” (DP). The challenge is that the context is one of the poorest parts of one of the poorest countries in Africa. Rather than consulting just stakeholders, or self-selected populations, or using conventional surveys, DP’s have the advantage of consulting random samples with deliberation in depth in confidential surveys so that the opinion changes can be evaluated at the individual level, free of social pressures for consensus. Is this practical in this context? A DP was conducted in Tamale, Ghana on issues of water, sanitation, hygiene and food security. Criteria for success for DPs that have been applied in highly developed countries are discussed and then applied in Ghana under challenging conditions

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