Start-stop funding, its causes and consequences : a case study of the delivery exemptions policy in Ghana

This article looks at the issue of sustaining funding for a public programme through the case study of the delivery exemptions policy in Ghana. The Government of Ghana introduced the policy of exempting users from delivery fees in September 2003 in the four most deprived regions of the country, and in April 2005 it was extended to the remaining six regions in Ghana. The aim of the policy of free delivery care was to reduce financial barriers to using maternity services. Using materials from key informant interviews at national and local levels in 2005, the article examines how the policy has been implemented and what the main constraints have been, as perceived by different actors in the health system. The interviews show that despite being a high-profile public policy and achieving positive results, the delivery exemptions policy quickly ran into implementation problems caused by inadequate funding. They suggest that facility and district managers bear the brunt of the damage that is caused when benefits that have been promised to the public cannot be delivered. There can be knock-on effects on other public programmes too. Despite these problems, start-stop funding and under-funding of public programmes is more the norm than the exception. Some of the factors causing erratic funding—such as party politics and intersectoral haggling over resources—are unavoidable, but others, such as communication and management failures can and should be addressed.This work was undertaken as part of an international research programme— Initiative for Maternal Mortality Programme Assessment (IMMPACT), funded by the Bill & Melinda Gates Foundation, the Department for International Development, the European Commission and USAID

When ‘solutions of yesterday become problems of today': crisis-ridden decision making in a complex adaptive system (CAS)—the Additional Duty Hours Allowance in Ghana

Implementation of policies (decisions) in the health sector is sometimes defeated by the system's response to the policy itself. This can lead to counter-intuitive, unanticipated, or more modest effects than expected by those who designed the policy. The health sector fits the characteristics of complex adaptive systems (CAS) and complexity is at the heart of this phenomenon. Anticipating both positive and negative effects of policy decisions, understanding the interests, power and interaction between multiple actors; and planning for the delayed and distal impact of policy decisions are essential for effective decision making in CAS. Failure to appreciate these elements often leads to a series of reductionist approach interventions or ‘fixes'. This in turn can initiate a series of negative feedback loops that further complicates the situation over time. In this paper we use a case study of the Additional Duty Hours Allowance (ADHA) policy in Ghana to illustrate these points. Using causal loop diagrams, we unpack the intended and unintended effects of the policy and how these effects evolved over time. The overall goal is to advance our understanding of decision making in complex adaptive systems; and through this process identify some essential elements in formulating, updating and implementing health policy that can help to improve attainment of desired outcomes and minimize negative unintended effect

Evaluation of Insecticides for the Management of Insect Pests of Tomato, Solanum Lycopersicon L.

Field studies were undertaken in Kumasi, Ghana in 2012 and 2013 to evaluate the efficacy of two insecticides i.e. Lambda Super 2.5 EC (a.i- lambda cyhalothrion) and Cymethoate Super EC (a. i.-cypermethrin and cymethoate) for the management of insect pests on tomato, Solanum lycopersicum L. Lambda Super was applied at 1.5 ml/0.5 L of water whilst Cymethoate Super was applied at 0.25 ml/0.5 L of water. A control plot (water application only) was also maintained. Whiteflies, Bemisia tabaci (Gennadius), thrips, Thrips tabaci Lindeman, aphids, Aphis gossypii (Glover), leaf miners, Liriomyza sp. and the tomato fruit worm, Helicoverpa armigera (Hubner) were the most important insect pests collected on tomato in the area. In 2012, there were no significant differences among the insecticide-treated plots and the control with respect to the densities of B. tabaci, A. gossypii, Liriomyza sp. and H. armigera. Cymethoate Super treated plots recorded significantly lower number of T. tabaci than the control plots. However, in 2013, the control plots recorded significantly more aggregations of B. tabaci, H. armigera and A. gossypii than the Lambda Super and Cymethoate Super treated plots. No significant differences were obtained in the numbers of Liriomyza sp. and T. tabaci among the treatments. In 2012, the insecticide-treated plots recorded significantly higher fruit yield than the control but there were no significant differences among the treatments with respect to percent damaged fruits and mean shoot dry weight in 2013. Lambda Super and Cymethoate Super can be used to manage insect pests on tomato for increased yield. Keywords: Insecticides, efficacy, tomato pests, population densities, yiel

Understanding the relationship dynamics between female sex workers and their intimate partners in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report presents findings from a qualitative study examining vulnerability to HIV and the prevention needs of men involved in intimate relationships with female sex workers (FSW) in Kumasi, Ghana. The study was conducted by a collaborative team of researchers from Boston University’s Center for Global and Health and Development (CGHD), Kwame Nkrumah University of Science and Technology (KNUST), and FHI 360. It is the last of nine small qualitative studies conducted under the Operations Research among Key Populations in Ghana project designed to gather in-depth, personal information from members of key populations about their vulnerability to HIV and other threats to their health and well-being. This project was funded by the United States Agency for International Development Ghana in collaboration with the Ghana AIDS Commission (GAC). The findings will be used to strengthen harm reduction interventions for sex workers and their intimate partners. Intimate partners of FSW are a population of growing interest in Ghana, where interventions focused on sex workers and both their paying and non-paying partners are being implemented by FHI 360 and other local organizations with support from the GAC and USAID. In 2012 Boston University and KNUST conducted a qualitative study looking at the backgrounds, living conditions, vulnerabilities, and HIV prevention needs of young female sex workers in Kumasi. Most (22/24) of the young women participating in in-depth interviews reported having a boyfriend or intimate partner, and half reported either never or only sometimes using condoms with these partners (1). In addition, quantitative data from two previous integrated bio-behavioral surveillance studies (IBBSS) conducted in 2009 and 2011 provide critical data showing the degree to which these men and their female partners (both those involved in sex work and others) are highly vulnerable to HIV and other sexually transmitted infections. The specific objectives were to: explore the emotional, financial and other power dynamics within these relationships; describe the sexual behaviors and HIV knowledge and vulnerabilities of both partners; and document the perceived availability and accessibility of social support and health services.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

A Call for Responsible Estimation of Global Health

Peer reviewedPublisher PD

Ectopic pregnancies in low resource setting: a retrospective review of cases in Kumasi, Ghana

Background: Ectopic pregnancy remains a public health threat for women in reproductive age, and a major cause of maternal mortalities in the first trimester of pregnancy. Past studies in Ghana on the burden of Ectopic Pregnancy (EP) have focused on major referral health facilities with little consideration of primary health facilities. This study was set out to determine the prevalence of Ectopic Pregnancy, demographic characteristics involved and the various types of Ectopic Pregnancy seen in primary health settings in Kumasi, Ghana.Methods: A retrospective descriptive cross-sectional study was conducted at the Suntreso Government and Tafo Government Hospitals in the Kumasi metropolitan area from 2007 to 2017. A review of 28,600 obstetric cases recorded in registers of the two facilities was done using electronic data extraction form. The data were exported into STATA/IC 14.0 for statistical analysis.Results: A prevalence of 0.76% EP was recorded over the study period of 10 years. 61.75% of the women diagnosed with EP were between the ages of 21-30 years with a mean age and standard deviation of 27.61 and 5.91 respectively. Tubal (fallopian tubes) EP was seen in 76.96% of the women diagnosed with EP. 10.18% and 7.19% of the tubal EP occurred in the cornual and fimbriae respectively. Ruptured EP was seen in 58.99% of the cases.Conclusions: The study reported EP in about one in a hundred cases. The commonest EP that emerged from this study was tubal (fallopian tube) EP. Among the tubal EP, cornual and fimbria were the commonest EP that occurred in the fallopian tube. Although cases of tubo-ovarian and ovarian EP are rare, a significant percentage were observed in this study. Early reporting and diagnosis of EP should be of great importance to prevent ruptured EP and any associated complications

Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana

Background: There is a growing movement, globally and in the Africa region, to reduce financial barriers to health care generally, but with particular emphasis on high priority services and vulnerable groups. Objective: This article reports on the experience of implementing a national policy to exempt women from paying for delivery care in public, mission and private health facilities in Ghana. Design: Using data from a complex evaluation which was carried out in 2005-2006, lessons are drawn which can inform other countries starting or planning to implement similar service-based exemption policies. Results: On the positive side, the experience of Ghana suggests that delivery exemptions can be effective and cost-effective, and that despite being universal in application, they can benefit the poor. However, certain ‘negative’ lessons are also drawn from the Ghana case study, particularly on the need for adequate funding, and for strong institutional ownership. It is also important to monitor the financial transfers which reach households, to ensure that providers are passing on benefits in full, while being adequately reimbursed themselves for their loss of revenue. Careful consideration should also be given to staff motivation and the role of different providers, as well as quality of care constraints, when designing the exemptions policy. All of this should be supported by a proactive approach to monitoring and evaluation. Conclusion: The recent movement towards making delivery care free to all women is a bold and timely action which is supported by evidence from within and beyond Ghana. However, the potential for this to translate into reduced mortality for mothers and babies fundamentally depends on the effectiveness of its implementation

Impact of vitamin A with zinc supplementation on malaria morbidity in Ghana.

BACKGROUND: Malaria is a leading cause of morbidity and mortality among young children and is estimated to cause at least 1 million deaths each year especially among pregnant women and young children under the age of five years. Vitamin A supplementation is known to reduce morbidity and mortality in young children. Zinc is required for growth and immunity and we sought to replicate the study by Zeba et al. which showed 30% lower cases of clinical malaria in children on a combination of zinc and a large dose of vitamin A compared with children on vitamin A alone based on the hypothesis that combined vitamin A and zinc reduced symptomatic malaria compared to vitamin A alone. OBJECTIVES: The primary objective was to determine the effect of vitamin A alone vs. vitamin A and zinc supplements on the incidence of clinical malaria and other anthropometric indices. It also sought to assess the effects on the incidence of anaemia, diarrhoea and pneumonia. METHODS: The study was community-based and 200 children between the ages of 6-24 months were randomised to receive either vitamin A (100,000 IU for infants less than 12 months & 200,000 IU for children greater than 12 months and 10 mg daily zinc in the intervention group or vitamin A and zinc placebo for 6 months in the control group. RESULTS: The number of children who were diagnosed with uncomplicated malaria in the intervention group was 27% significantly lower compared with the children in the control group (p = 0.03). There were, however, no effects on severe malaria, pneumonia, anaemia and diarrhea. CONCLUSIONS: Our study confirms a significant role of vitamin A and zinc in reducing malaria morbidity

Vitamin A status and body pool size of infants before and after consuming fortified home-based complementary foods.

BACKGROUND: Home fortification using sachets of micronutrient powder (e.g. "Sprinkles") is a food-based approach offering an alternative to high dose vitamin A (VA) supplements for infants. The primary objective was to investigate the impact of VA-home fortification on infant VA pool size. The secondary objective was to compare VA status of infants assessed by the modified relative dose response (MRDR) test before and the (13)C-retinol isotope dilution ((13)C-RID) test in the same infants after vitamin A supplementation. METHODS: A randomized-controlled trial was conducted in 7-9 month old infants in Ghana. Eligible children were randomly allocated to receive a daily sachet of "Sprinkles" with or without VA for 5 months added to complementary foods. The MRDR test indirectly determined VA liver reserves at baseline and the (13)C-RID determined VA body pool at follow-up in the same cohort of children. RESULTS: At baseline, the MRDR values (95 % CI) for infants were comparable in the intervention and control groups: normal at 0·032 (SD 0·018) (0·025-0·038) and 0·031 (SD 0·018) (0·024-0·038), respectively. After intervention, total body stores (TBS) and liver retinol concentrations did not differ between intervention and control groups; TBS were 436 (SD 303) and 434 (SD 186) μmol, respectively, and estimated liver concentrations were 0·82 (SD 0·53) and 0·79 (SD 0·36) μmol/g liver, indicating adequate reserves in all children. CONCLUSIONS: Both the MRDR and (3)C-RID tests confirmed that the infants had adequate VA status before and after home fortification of their complementary foods. These tests offered more information than serum retinol concentrations alone, which predicted VA deficiency using current suggested cutoffs not corrected for inflammation status