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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. [ABSTRACT FROM AUTHOR]

Background: Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers' ability to serve poorer patient populations with quality health services? Methods: In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials' experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically. Results: Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers' abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility. Conclusions: Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing. [ABSTRACT FROM AUTHOR]

Background: This paper provides an insightful quantitative ethnoecological analysis and affirms that agro-pastoralists have a multiplicity of criteria for valuating their natural forage resources. Rural households in West Africa are not only confronted with water resource scarcity but also have to cope with limited forage resources to feed livestock in both wet and dry seasons based on local knowledge. Local agro-pastoral social-ecological systems (SESs) in the study areas stem from the daily utilization of available forage resources by dominant domestic livestock (cattle, goats, and sheep) over the years. However, there is very little systematic knowledge documentation on forage-related valuation criteria in this part of the world. Hence, this study aimed at examining (1) forage resources used for different seasons and livestock types, (2) explicit forage-related valuation criteria and associated salience, and (3) effects of socio-demographic and climatic aridity on local valuation criteria. Methods: To address these aims, a total of 526 individual ethnoecological interviews (encompassing Dagbani, Gurunsi, and Mossi ethnic groups) were conducted in 16 villages coupled with vegetation sampling of 144 plots in Ghana and Burkina Faso. Rigorous model selection, generalized linear mixed-effects models, cognitive salience indices, and descriptive statistics were applied. Results: The results revealed that majority (73%) of the agro-pastoralists regarded herbaceous forage plants to be very palatable for livestock consumption in the rainy season and for cattle while woody vegetation and crop-related forage plants were rather perceived to be more important in the dry season and for goats and sheep. The findings also indicated that climatic aridity significantly influenced the number of forage-related valuation criteria cited by agro-pastoralists for different seasonal and livestock types (p < 0.001). It was also found out that agro-pastoralists did not only judge forage plants based on their availability but also on other criteria such as palatability, stimulation of milk production, and healthy growth of livestock. Conclusion: Local agro-pastoralists' knowledge on natural forage resources and their valuation criteria is geared towards sustainable domestic livestock production. This study is thus interesting and crucially important for fellow scientists, policy-makers, and other stakeholders in the agricultural production sector in local farming landscapes within West Africa and beyond. [ABSTRACT FROM AUTHOR]

Background: Genetic diversity in Plasmodium falciparum (P. falciparum) parasites is a major hurdle to the control of malaria. This study monitored changes in the genetic diversity and the multiplicity of P. falciparum parasite infection in asymptomatic children living in southern Ghana at 3 month intervals between April 2015 and January 2016.Methods: Filter paper blood spots (DBS) were collected quarterly from children living in Obom, a community with perennial malaria transmission and Abura, a community with seasonal malaria transmission. Genomic DNA was extracted from the DBS and used in polymerase chain reaction (PCR)-based genotyping of the merozoite surface protein 1 (msp 1) and merozoite surface protein 2 (msp 2) genes.Results: Out of a total of 787 samples that were collected from the two study sites, 59.2% (466/787) tested positive for P. falciparum. The msp 1 and msp 2 genes were successfully amplified from 73.8% (344/466) and 82.5% (385/466) of the P. falciparum positive samples respectively. The geometric mean MOI in Abura ranged between 1.17 (95% CI: 1.08-1.28) and 1.48 (95% CI: 1.36-1.60) and was significantly lower (p < 0.01, Dunn's multiple comparison test) than that determined in Obom, where the geometric mean MOI ranged between 1.82 (95% CI: 1.58-2.08) and 2.50 (95% CI: 2.33-2.678) over the study period. Whilst the msp 1 R033:MAD20:KI allelic family ratio was dynamic, the msp 2 3D7:FC27 allelic family ratio remained relatively stable across the changing seasons in both sites.Conclusions: This study shows that seasonal variations in parasite diversity in these communities can be better estimated by msp 1 rather than msp 2 due to the constantly changing relative intra allelic frequencies observed in msp 1 and the fact that the dominance of any msp 2 allele was dependent on the transmission setting but not on the season as opposed to the dominance of any msp 1 allele, which was dependent on both the season and the transmission setting. [ABSTRACT FROM AUTHOR]

Background: Violence against women and girls (VAWG) is an important public health issue. Framing studies indicate that how the news media cover public health issues is critical for designing effective health promotion interventions. Notwithstanding this, there is little research particularly in low-and middle-income country context examining how the news media frame VAWG. This paper examines news coverage of VAWG in Ghana, and the implications of this for health promotion.Methods: This study used frame analysis as the methodological framework in examining how VAWG in Ghana is represented by the media. Qualitative content analysis approach to frame analysis was performed on 48 news articles which constituted the unit of analysis.Results: The findings indicate that media framing of VAWG was episodic in nature as the acts of violence perpetrated against women and girls were presented as individual cases without reference to the wider social contexts within which they occurred. Similarly, victim blaming language was largely used in the news articles. In framing VAWG as an individual incident and women as helpless victims, the media fail to shape society's perception of VAWG as a social and public health issue.Conclusions: For the media in Ghana to contribute to the prevention of VAWG, there is the need for news coverage to focus on social construction of the issue, and also raise awareness about support services available to victims. [ABSTRACT FROM AUTHOR]

Background: Understanding decision-making processes that influence the fate of items on the health policy agenda at national level in low- and middle-income countries is important because of the implications for programmes and outcomes. This paper seeks to advance our understanding of these processes by asking how and why maternal health policy agenda items have fared in Ghana between 1963 and 2014.Methods: The study design was a single case study of maternal health agenda evolution once on a decision pathway in Ghana, with three different agenda items as sub-units of analysis (fee exemptions for maternal health, free family planning and primary maternal health as part of a per capita provider payment system). Data analysis involved chronologically reconstructing how maternal health policy items evolved over time.Results: The fate of national level maternal health policy items was heavily influenced by how stakeholders (bureaucrats, professional bodies, general public and developmental partners) exercised power to put forward and advocate for specific ideas through processes of issues framing within a changing political and socioeconomic context. The evolution and fate of an agenda item once on a decision pathway involved an iterative process of interacting drivers shaping decisions through cycles of 'active' and 'static' pathways. Items could move from 'active' to 'static' pathways, depending on changing context and actor positions. Items that pursued the 'static' pathway in a particular cycle fell into obscurity by a process that could be described as a form of 'no decision made' in that an explicit decision was not taken to drop the item, but neither was any policy content agreed. Low political interest was exhibited and attempts to bring the item back into active decision-making were made by actors mainly in the bureaucratic arena seeking and struggling (unsuccessfully) to obtain financial and institutional support. Policy items that pursued 'active' pathways showed opposite characteristics and generally moved beyond agenda into formulation and implementation.Conclusion: Policy change requires sustaining policy agenda items into formulation and implementation. To do this, change agents need to understand and work within the relevant context, stakeholder interests, power, ideas and framing of issues. [ABSTRACT FROM AUTHOR]

Background: The paper carries out a situational analysis to examine the production, dissemination and utilisation of reproductive and child health-related evidence to inform policy formulation in Ghana's health sector.Methods: The study used Wald's model of knowledge production, transfer and utilisation as a conceptual model to collect relevant data via interviews and administration of questionnaire to a network of persons who either previously or currently hold policy-relevant positions in Ghana's health sector. Additional data was also gathered through a scoping review of the knowledge transfer and research utilisation literature, existing reproductive and child health policies, protocols and guidelines and information available on the websites of relevant institutions in Ghana's health sector.Results: The findings of the study suggest that the health sector in Ghana has major strengths (strong knowledge production capacity, a positive environment for the promotion of evidence-informed policy) and opportunities (access to major donors who have the resources to fund good quality research and access to both local and international networks for collaborative research). What remains a challenge, however, is the absence of a robust institutional-wide mechanism for collating research needs and communicating these to researchers, communicating research findings in forms that are friendlier to policy-makers and the inability to incorporate funding for research into the budget of the health sector.Conclusion: The study concludes, admonishing the Ministry of Health and its agencies to leverage on the existing strengths and opportunities to address the identified challenges. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Following years of out-of-pocket payment for healthcare, some countries in Africa including Ghana, Kenya and Rwanda have instituted social health protection programs through health insurance to provide access to quality and affordable healthcare especially for the poor. This paper examines equity in coverage under Ghana's National Health Insurance Scheme (NHIS). Methods: Secondary data from the 2008 Ghana Demographic and Health Survey based on an analytical sample of 4821 females (15–49 years) and 4568 males (15–59 years) were analysed using descriptive, bivariate and multivariate methods. Concentration curves and indices were used to examine equity in coverage on the NHIS. Results: As at 2008, more than 60% of Ghanaians aged 15–59 years were not covered under the NHIS with slightly more females (38.9%) than males (29.7%) covered. Coverage was highest among the highly educated, professionals, those from households in the richest wealth quintile and urban residents. Lack of coverage was most concentrated among the poor. Conclusions: Universal coverage under the NHIS is far from being achieved with marked exclusion of the poor. There is the need for deliberate action to enrol the poor under the NHIS. [ABSTRACT FROM AUTHOR]

Background: Population ageing presents considerable challenges for the attainment of universal health coverage (UHC), especially in countries where such coverage is still in its infancy. Ghana presents an important case study on the effectiveness of policies aimed at achieving UHC in the context of population ageing in low and middle-income countries. It has witnessed a profound recent demographic transition, including a large increase in the number of older adults, which coincided with the development and implementation of a National Health Insurance Scheme (NHIS), designed to help achieve UHC. The objective of this paper is to examine the community, household and individual level determinants of NHIS enrolment among older adults aged 50-69 and 70 plus. The latter are exempt from NHIS premium payments.Methods: Using the Ghanaian Living Standards Survey from 2012 to 2013, determinants of NHIS enrolment for individuals aged 50-69 and 70 plus living in rural Ghana are examined through the application of multilevel regression analysis.Results: Previous studies have mainly focused on the enrolment of young and middle aged adults and considered mainly demographic and socio-economic factors. The novel inclusion of spatial barriers within this analysis demonstrates that levels of NHIS enrolment are determined in part by the community provision of healthcare facilities. In addition, the findings imply that insurance enrolment increases with household expenditure even for those aged 70 plus who are exempt from the NHIS premium payment.Conclusion: Adequate and appropriate infrastructure as well as health insurance is vital to ensure movement to UHC in low and middle income countries. Overall, the results confirm that there remain significant inequalities in enrolment by expenditure quintile that future policy reform will need to address. [ABSTRACT FROM AUTHOR]

Background: Ghana introduced capitation payment method in 2012 but was faced with resistance for its perceived poor quality of care. This paper assesses National Health Insurance Scheme subscribers and care providers’ perception of quality of care under the capitation payment method. Methods: This is a cross-sectional survey of subscribers and care providers perception of quality of care in three administrative regions of Ghana using a 5-point Likert scale for the assessment based on a set of quality of care measures. We performed descriptive analysis to determine average perception of quality of care scores for each of the measures used. Bivariate and multivariate analyses were also performed to examine relationships between respondent’s characteristics and their perception of quality of care. Results: In general, subscribers expressed positive perception about the quality of care though subscribers in Ashanti were less positive compared to those in the Central region. A chi-square analysis, however, showed significant differences in subscribers’ perception of quality of care by occupation (p = 0.002), region (p = 0.007) length of NHIS membership (p = 0.006), and age (p = 0.014). Multivariate logistic regression analysis also showed that different factors, other than region of residence, were significantly associated with perceived good quality of care. Analysis of health care providers’ responses also showed significant differences in their perception of quality of care by region (p = 0.001). Multivariate logistic model showed that health care providers in the Volta region (OR = 0.14, 95% CI: 0.03–0.58) were significantly less likely to perceive quality of care as good compared to those in the Ashanti region. Conclusion: Subscribers and care providers across the three regions have relatively good perception of the quality of health care in general though subscribers in Ashanti were less positive than those in the Central region. It is, therefore, plausible that capitation payment may have influenced the relatively low perception of quality of care in the Ashanti region. [ABSTRACT FROM AUTHOR]

Background: Increasing prevalence of non-communicable diseases (NCDs) has been observed in Ghana as in other developing countries. Past research focused on NCDs among adults. Recent researches, however, provide evidence on NCDs among children in many countries, including Ghana. Beliefs about the cause of NCDs among children may be determined by the socioeconomic status of parents and care givers. This paper examines the relationship between educational status of parents and/or care givers of children with NCDs on admission and their beliefs regarding NCDs among children.Methods: A total of 225 parents and/or care givers of children with NCDS hospitalized in seven hospitals in three regions (Greater Accra, Ashanti and Volta) were selected for the study. Statistical techniques, including the chi-square and multinomial logistic regression, were used for the data analysis.Results: Educational status is a predictor of care giver's belief about whether enemies can cause NCDs among children or not. This is the only belief with which all the educational categories have significant relationship. Also, post-secondary/polytechnic (p-value =0.029) and university (p-value = 0.009) levels of education are both predictors of care givers being undecided about the belief that NCDs among children can be caused by enemies, when background characteristics are controlled for. Significant relationship is found between only some educational categories regarding the other types of beliefs and NCDs among children. For example, those with Middle/Juniour Secondary School (JSS)/Juniour High School (JHS) education are significantly undecided about the belief that the sin of parents can cause NCDs among children.Conclusions: Education is more of a predictor of the belief that enemies can cause NCDs among children than the other types of beliefs. Some categories of ethnicity, residential status and age have significant relationship with the beliefs when background characteristics of the parents and/or care givers were controlled for. [ABSTRACT FROM AUTHOR]

Background: The paper argues that several Sub-Saharan African countries have recorded marked improvements in the use of reproductive health services. However, the literature has hardly highlighted such progress and the factors responsible for them. The current study uses Ghana as a case to examine progress in the consumption of reproductive health services over the last two decades and the factors responsible for such progress.Methods: The study uses two rounds (1998 and 2014) of Demographic and Health Survey data from Ghana. Standard frequencies, a logit model and decomposition of the coefficients of the logit model (i.e. Oaxaca-type decomposition) was employed to examine changes in the use of reproductive health services (4+ antenatal visits and skilled attendance at birth) at national and sub-national levels (i.e the four ecological zones of Ghana) between 1998 and 2014 as well as factors explaining observed spatial changes between the two periods.Results: Descriptive results suggest that the highest level of improvement occurred in resource-poor zones (i.e. northern belt followed by the southern belt) compared to the middle belt and Greater Accra, where access to resources and infrastructure is relatively better. Results from Oaxaca-type decomposition also suggest that women and partner's education, household wealth and availability and accessibility to health facilities are the key factors explaining spatial variation in reproductive health service consumption over the two periods. Most importantly, the marginal efficiency of investment in women and partner's education and access to health services were highest in the two resource poor zones.Conclusion: There is the need to target resource poor settings with existing or new pro-poor reproductive health interventions. Specifically, the northern and southern zones where the key drivers of education and availability of health facilities are the lowest, will be key to further improvements in the consumption of reproductive health services in Ghana. [ABSTRACT FROM AUTHOR]

Background: Child marriage is a human rights violation disproportionately affecting girls in lower- and middle-income countries and has serious public health implications. In Ghana, one in five girls marry before their 18th birthday and one in 20 girls is married before her 15th birthday. This paper uses a unique dataset from Northern Ghana to examine the association between child marriage and adverse outcomes for women among a uniquely vulnerable population.Methods: Baseline data from on ongoing impact evaluation of a government-run cash transfer programme was used. The sample consisted of 1349 ever-married women aged 20-29 years from 2497 households in the Northern and Upper East regions of Ghana. We estimated a series of ordinary least squares (OLS) and logistic regression models to examine associations of child marriage with health, fertility, contraception, child mortality, social support, stress and agency outcomes among women, controlling for individual characteristics and household-level factors.Results: Child marriage in this sample was associated with increased odds of poorer health, as measured by difficulties in daily activities (OR = 2.08; CI 1.28-3.38 among women 20-24 years and OR = 1.58; CI 1.19-2.12 among women 20-29 years), increased odds of child mortality among first-born children (OR = 2.03; CI 1.09-3.77 among women 20-24 years) and lower odds of believing that one's life is determined by their own actions (OR = 0.42; CI 0.25-0.72 among women 20-24 years and OR = 0.54; CI 0.39-0.75 among women 20-29 years). Conversely, child marriage was associated with lower levels of reported stress (regression coefficient = - 1.18; CI -1.84--0.51 among women 20-29 years).Conclusions: Child marriage is common in Northern Ghana and is associated with poor health, increased child mortality, and low agency among women in this sample of extremely poor households. While not much is known about effective measures to combat child marriage in the context of Ghana, programmes that address key drivers of early marriage such as economic insecurity and school enrolment at the secondary level, should be examined with respect to their effectiveness at reducing early marriage.Trial Registration: Registered in the Registry for International Development Impact Evaluations (RIDIE) on 01 July 2015, with number RIDIE-STUDY-ID- 55942496d53af . [ABSTRACT FROM AUTHOR]

Background: In tuberculosis (TB) control, early disclosure is recommended for the purposes of treatment as well as a means of reducing or preventing person-to-person transmission of the bacteria. However, disclosure maybe avoided as a means of escaping stigma, and possible discrimination. This study aimed at providing insights into factors associated with intentions of Ghanaians to keep positive TB diagnosis in their families' a secret.Methods: The paper was based on data from the 2014 Ghana Demographic and Health Survey. Descriptive statistics of proportions with Chi-square test and binary logistic regression were used to identify individual, household and community level factors that predicted the outcome variable (keeping TB secret).Results: Women were more inclined (33%) than men (25%) to keep TB in the family a secret. Views about keeping TB secret declined with age for both sexes. For women, higher education had a positive association with whether TB in the family would be kept a secret or not but the same was not observed for men. In a multivariable regression model, the strongest predictor of keeping TB secret was whether the respondent would keep HIV secret, and this was uniform among women (OR = 6.992, p < 0.001) and men (OR = 9.870, p < 0.001).Conclusion: Unwillingness towards disclosing TB status in Ghana is associated with varied socioeconomic and demographic characteristics, which may be driven by fears of stigma and discrimination. Addressing TB-related stigma and discrimination can enhance positive attitudes towards TB disclosure. For an infectious disease such as TB, openness towards status disclosure is important for public health. [ABSTRACT FROM AUTHOR]