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Introduction: Achieving effective community‐based primary health care requires evidence for guiding strategic decisions that must be made. However, research processes often limit data collection to particular organizational levels or disseminate results to specific audiences. Decision‐making that emerges can fail to account for the contrasting perspectives and needs of managers at each organizational level. The Ghana Health Service (GHS) addressed this problem with a multilevel and sequential research and action approach that has provided two decades of implementation learning for guiding community‐based primary health care development. Method: The GHS implementation research initiatives progressed from (i) a participatory pilot investigation to (ii) an experimental trial of strategies that emerged to (iii) replication research for testing scale‐up, culminating in (iv) evidence‐based scale‐up of a national community‐based primary health care program. A reform process subsequently repeated this sequence in a manner that involved stakeholders at the community, sub‐district, district, and regional levels of the system. The conduct, interpretation, and dissemination of results that emerged comprised a strategy for achieving systems learning by conducting investigations in phases in conjunction with bottom‐up knowledge capture, lateral exchanges for fostering peer learning at each system level, and top‐down processes for communicating results as policy. Continuous accumulation of qualitative data on stakeholder reactions to operations at each organizational level was conducted in conjunction with quantitative monitoring of field operations. Results: Implementation policies were enhanced by results associated with each phase. A quasi‐experiment for testing the reform process showed that scale‐up of community‐based primary health care was accelerated, leading to improvements in childhood survival and reduced fertility. Conclusion: Challenges to system learning were overcome despite severe resource constraints. The integration of knowledge generation with ongoing management processes institutionalized learning for achieving evidence‐driven program action. [ABSTRACT FROM AUTHOR]

The Tigray crisis in Ethiopia is a grave humanitarian catastrophe with causes and consequences that resemble the Nigerian Civil War that ended with the defeat of secessionist Biafra five decades ago. As in the Biafra example, an ethnically distinct and embattled enclave is surrounded by hostile forces and cut off from commerce of any kind, producing starvation, forced migrant encampments, and pervasive dependence on externally provided food relief. Relief action strategies developed during the Nigerian Civil War were comprised of operational components that were often insufficiently integrated into a unified system for nutritional screening, referral, acute care, nutritional rehabilitation, and team deployment. This lack of strategic integration for post-conflict relief actions merits review for possible lessons that could avert its recurrence in Tigray. If evidence-based systems for relief organization had been comprehensively applied in Biafra, the pace of post-conflict nutritional recovery could have been accelerated. Although component strategies of the Biafra-Nigeria Relief Action are being replicated by various agencies that are providing humanitarian assistance in Tigray, their collective impact could be enhanced if these strategies were integrated into a unified, evidence-driven systems response to the emergency. The elements of such a systems approach for assisting Tigray are reviewed. [ABSTRACT FROM AUTHOR]

Objective: Improving equity in the use of maternal health services in rural and remote communities is critical to meeting the Sustainable Development Goals targets on maternal and child health. This study examines the effect of a community‐based primary healthcare strengthening programme on improving the utilisation of antenatal care (ANC4+), skilled delivery and health facility delivery. Methods: Baseline and endline survey data of women of reproductive age for intervention and comparison districts were used to examine the equity impact of the Ghana Essential Health Interventions Programme (GEHIP) on antenatal care visits, skilled delivery and health facility delivery. The Wagstaff extension of the concentration index and regression models are used to assess equity effects of the programme on the utilisation of these services by wealth index and educational attainment. Results: Coverage rates increased for both intervention and comparison districts, but were generally higher in intervention districts than comparison districts at endline (90% vs. 88% for ANC4+, 88% vs. 84% for skilled delivery and 93% vs. 88% for health facility delivery). Only ANC4+ showed a statistically significant positive treatment effect of the intervention (Dif‐in‐Dif = 0.071, p‐value = 0.010). Equity analysis showed a mixed picture with intervention districts achieving significant equity improvement for skilled delivery for both wealth index and maternal education but only education equity for health facility delivery, while comparison districts achieved both wealth and education equity improvements for two indicators (health facility delivery and skilled delivery). No significant equity/inequity effects were found for ANC4+. Conclusion: Efforts to improve community‐based healthcare access have been associated with improved coverage of maternal health services; however, the effect on improving equity in service coverage is mixed. Results indicate a need to extend community‐based primary health care development beyond general improvements in access to ensure equity in the coverage of maternal and child health services that such programmes provide. [ABSTRACT FROM AUTHOR]

The article discusses emergency public health and humanitarian efforts during a civil war between Nigeria and the Republica of Biafra. Topics include the French Red Cross' role in the Biafra relief effort, the United States' supply of personnel, aircraft, financial support and medical supplies in the relief effort, and the need for public health practitioners to plan for the end of conflict in order to avoid situations such as Biafra's collapse resulting from nutritional adversity and famine.

This study assesses the long-term fertility impact of the Community Health and Family Planning Project of the Navrongo Health Research Centre in Ghana and addresses policy debates concerning the role of family planning programs in rural Africa. Conducted in a remote traditional area on Ghana's northern border, the study tests the hypothesis that convenient family planning service delivery can induce and sustain reproductive change in a societal context that would not be expected to foster demographic transition. By 1999, results indicated that significant fertility decline arose in the early years of the project, associated with the combination of services provided by community nurses and social mobilization activities focused on men. When project strategies were scaled up, social mobilization components were neglected. As a consequence, the long-term impact of scaled-up operations was negligible. Results suggest that initial effects met the need for child spacing without introducing a sustained demographic transition. [ABSTRACT FROM AUTHOR]

Religious affiliation is undergoing major changes in rural Sahelian Africa, with profound consequences for customs that are grounded in traditional belief systems. This study examines the influence of women's religious affiliation on contraceptive use and fertility among the Kassena-Nankana of northern Ghana. Analysis of longitudinal data for women in 1995 and 2003 shows that 61 percent of women changed their religion, with shifts from traditional beliefs to Christianity being dominant. Moreover, women were more likely than men to make such a change. Regression results show that, compared with those who did not change, switching from traditional religion to Christianity or Islam is associated with increased contraceptive use and decreased fertility. The more rapid change in religious affiliation among women than men may have social consequences for the status of women, signaling a trend toward greater autonomy in the family and new aspirations, values, and behavior as evidenced by the proportion of people adopting contraceptives. [ABSTRACT FROM AUTHOR]

Abstract: Vietnam''s sustained investment in primary healthcare since the onset of socialism has lowered infant and childhood mortality rates and improved life expectancy, exceeding progress achieved in other poor countries with comparable levels of income per capita. The recent introduction of user fees for primary healthcare services has generated concern that economic policies may have adversely affected health-seeking behavior and health outcomes of the poor, particularly among impoverished families who are members of socially marginalized minority groups. This paper examines this debate by analyzing parental recall of illness and care-seeking for sick children under the age of 5 years recorded by the 2001–2002 Vietnam National Health Survey. We estimate statistical models of the determinants of parental recall of incidence and response to illness among their children. Ethnic minority parents less frequently reported their children to have been sick than Kinh and Chinese parents. When they recognize an illness episode, minority parents are less likely to seek care—whether professional consultation or self-prescribed care—than non-minority parents. Ethnic differentials are evident in all geographic and income levels, although adverse effects of minority status are most pronounced among poor households in remote areas. Regression estimates of the effects of ethnicity and maternal education on health decisions are pronounced even when poverty effects are controlled, suggesting that social equity may have been under-emphasized in Vietnam''s early health policy deliberations. Policies extending free healthcare to poor communes affect parental decisions to seek professional care or self-prescribed care among better-off parents without affecting parental decision making among the poor. Early health initiatives for the poor may therefore have failed to offset equity problems confronting impoverished ethnic minority families. [Copyright &y& Elsevier]

In this article, we examine the relationship between child mortality and subsequent fertility using prospective longitudinal data on births and childhood deaths occurring to nearly 8000 Bangladeshi mothers observed over the 1982-1993 period, a time of rapid fertility decline. Generalized hazard-regression analyses are employed to assess the effect of infant and child mortality on the hazard of conception, with controls for birth order and maternal age and educational attainment. Results show that childhood mortality reduces the time to subsequent conception if the death occurs within a given interval, representing the combined effect of biological and volitional replacement. The time to conception is also reduced if a childhood death occurs during a prior birth interval, a finding that signifies an effect of volitional replacement of the child that died. Moreover, mortality effects in prior birth intervals are consistent with hypothesized insurance (or hoarding) effects. Interaction of replacement with elapsed time suggests that the volitional impact of child mortality increases as the demographic transition progresses. This volitional effect interacts with sex of index child. Investigation of higher-order interactions suggests that this gender-replacement effect has not changed over time. [ABSTRACT FROM AUTHOR]

Objective To determine the demographic and health impact of deploying health service nurses and volunteers to village locations with a view to scaling up results. Methods A four-celled plausibility trial was used for testing the impact of aligning community health services with the traditional social institutions that organize village life. Data from the Navrongo Demographic Surveillance System that tracks fertility and mortality events over time were used to estimate impact on fertility and mortality. Results Assigning nurses to community locations reduced childhood mortality rates by over half in 3 years and accelerated the time taken for attainment of the child survival Millennium Development Goal (MDG) in the study areas to 8 years. Fertility was also reduced by 15%, representing a decline of one birth in the total fertility rate. Programme costs added US$ 1.92 per capita to the US$ 6.80 per capita primary health care budget. Conclusion Assigning nurses to community locations where they provide basic curative and preventive care substantially reduces childhood mortality and accelerates progress towards attainment of the child survival MDG. Approaches using community volunteers, however, have no impact on mortality. The results also demonstrate that increasing access to contraceptive supplies alone fails to address the social costs of fertility regulation. Effective deployment of volunteers and community mobilization strategies offsets the social constraints on the adoption of contraception. The research in Navrongo thus demonstrates that affordable and sustainable means of combining nurse services with volunteer action can accelerate attainment of both the International Conference on Population and Development agenda and the MDGs. [ABSTRACT FROM AUTHOR]

Assesses the effect of household delivery of planning services on changes in Bangladeshi rural women's ability to regulate their fertility rather than to the home visits themselves. Decision of the Bangladesh Ministry of Health and Family Welfare to resume household family planning services; Gender benefits to female clients served by the program.

The Navrongo Community Health and Family Planning Project is a quasi-experimental study designed to test the hypothesis that introducing health and family planning services in a traditional African societal setting will introduce reproductive change. This article presents the impact of the initial three years of project exposure on contraceptive knowledge, awareness of supply sources, reproductive preferences, contraceptive use, and fertility. Findings show that knowledge of methods and supply sources increased as a result of exposure to project activities and that deployment of nurses to communities was associated with the emergence of preferences to limit childbearing. Fertility impact is evident in all treatment cells, most prominently in areas where nurse-outreach activities are combined with strategies for involving traditional leaders and male volunteers in promoting the program. In this combined cell, the initial three years of project exposure reduced the total fertility rate by one birth, comprising a 15 percent fertility decline relative to fertility levels in comparison communities. [ABSTRACT FROM AUTHOR]

Investigates the impact of soothsaying on responses of lineage heads to the introduction on family planning services. Role of traditional religion in fertility regulation; Reference to the launch of the Community Health and Family Planning Project in 1994; Observation that fertility and mortality have stable high rates; How religion impacts on fertility.

Investigates the long-term role of active outreach community programs on household family planning in Bangladesh. Deployment of paid outreach workers; Use of contraceptives; Decline in fertility; Normative change in reproductive preferences.

Assesses the effect of the household visitation program on the continuity of contraceptive use in Bangladesh. What the visitation programs composes of; Effect household outreach programs has on the continuity of contraceptive; Results of a `Contraceptive Prevalence Survey' conducted on Bangladeshi women in 1991; Controversy of programs; Method employed in study of programs; What results from study shows.

Assesses the impact of household visits from family planning workers on contraceptive use in rural Bangladesh. Role of the Community-Based Distribution (CBD); Demand fulfillment vs. demand generation; Implications of the family planning program of Bangladesh in 1976; Analysis of the determinants of contraception; Effects of client-worker relationship on contraception.

Describes the findings, developments and trends with respect to behavioral training and management of educational staff in classroom sand related settings. Intervention effectiveness and efficiency; Effects on student performance; Durability, acceptability, generalization and comprehensiveness of the organizational behavioral management in schools.

Presents a study on the availability of contraceptives pills (family planning pills) and cultural factors, among a group of women in Northern Ghana, called the Kassena-Nankana. Details on the setting and study design; Information on marriage, spousal relations, and gender roles among the Kassena-Nankana; Information on the fertility implications of the lineage system among the group; Indepth look at the Kassena-Nankana.

Family planning knowledge, attitude and practice surveys typically assess respondents' reproductive attitudes and intentions to use contraception. Longitudinal observation of individual respondents nevertheless shows that such questions are not strongly predictive of subsequent behaviour. This study examines 3 years' data which show that a set of such responses to questions are nevertheless substantially superior in predicting behaviour than any single indicator. Thus statistical techniques which bring into account the apparent multidimensionality of contraceptive motivation can greatly improve upon the estimation of future practice of family planning in a population. [ABSTRACT FROM PUBLISHER]

Because of the importance of contraceptive behaviour in most societies today a better understanding is needed of the social and behavioural factors affecting contraceptive decisions and choices of individuals and couples. This paper examines the need for longitudinal, theoretically-based studies of contraceptive use dynamics, including the timing, duration and interaction of reproductive events which may be more important than contraceptive technology in the social, cultural and economic context of fertility control. New research methods and appropriate analysis of data are relevant. Consideration of the social context is essential for the formulation and implementation of effective policies relating to the provision of contraceptive services. [ABSTRACT FROM AUTHOR]

The levels of fertility of two rural areas, Matlab and Teknaf, of different environmental and cultural settings of Balgladesh are markedly different. The proximate fertility determinants that may explain this difference are identified and their possible effect is examined.Most of the variation of natural fertility is explained by the difference in breast-feeding practices of the two populations, median duration 30 months for Matlab and 22 months for Teknaf. This difference suggests that prolonged breast-feeding is as important a factor contributing to the relatively low fertility in Matlab as contraception. While the increase of contraceptive use in Matlab has greatly affected fertility, the concomitant contribution of prolonged lactational amenorrhoea is also important. [ABSTRACT FROM PUBLISHER]

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: Ghana introduced a national health insurance program in 2005 with the goal of removing user fees, popularly called "cash and carry", along with their associated catastrophic and impoverishment effects on the population and ensuring access to equitable health care. However, after a decade of implementation, the impact of this program on user fees and out-of-pocket payment (OOP) is not properly documented. This paper contributes to understanding the impact of Ghana's health insurance program on out-of-pocket healthcare payments and the factors associated with the level of out-of-pocket payments for primary healthcare in a predominantly rural region of Ghana. Methods: Using a five-year panel data of revenues accruing to public primary health facilities in seven districts, We employed mean comparison tests (t-test) to examine the trend in revenues accruing from out-of-pocket payments vis-à-vis health insurance claims for health services, medication, and obstetric care. Furthermore, generalized estimation equation regression models were used to assess the relationship between explanatory variables and the level of out-of-pocket payments and health insurance claims. Results: Out-of-pocket payment for health services and medications declined by 63% and 62% respectively between 2010 and 2014. Insurance claims however increased by 16% within the same period. There was statistically a significant mean reduction in out-of-pocket payment over the period. Factors significantly associated with out-of-pocket payments in a given district are the number of community health facilities, availability of a district hospital and the year of observation. Conclusion: The study provides evidence that Ghana's national health insurance program is significantly contributing to a reduction in out-of-pocket payment for primary healthcare in public health facilities. Efforts should therefore be put in place to ensure the sustainability of this policy as a major pathway for achieving universal health coverage in Ghana. [ABSTRACT FROM AUTHOR]

Acute respiratory infection (ARI) is a major cause of mortality among children under the age of five in developing countries. This paper examines Demographic and Health Survey (DHS) data on maternal recall of episodes of ARI in the contrasting settings of Bangladesh and Nigeria, where about 11.1% and 3.3% of under-5 children, respectively, are reported to have symptoms of ARI. The surveys found that about 25.6% of married Bangladeshi women and 15.4% of married Nigerian women reported experiencing spousal violence in the past year. To test the proposition that women's experience of intimate partner violence (IPV) is associated with adversity in their children, the study examined the relationship between spousal violence in the past year and childhood ARI in the past 2 weeks among children under the age of five in Bangladesh and Nigeria. Data were taken from a nationally representative sample of mothers aged 15-49 years obtained from the 2007 Bangladesh DHS and 2008 Nigeria DHS. Random-effects multiple logistic regression models were estimated to assess the association of maternal exposure to IPV with the incidence of ARI in the past 2 weeks among under-5 children after controlling for the potentially confounding effects of maternal social and demographic characteristics. Results from Nigeria suggest that the odds of ARI incidence among children of mothers who were IPV victims were almost two times higher than among their counterparts whose mothers had not experienced IPV (OR = 1.78; 95% CI: 1.45-2.19; p <0.001). Similarly, the odds for the children of Bangladeshi IPV victims were elevated one and half times (OR = 1.61; 95% CI: 1.21-2.14; p <0.001). The findings suggest that under-5 children suffer indirect health consequences of gender-based violence. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: This paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training. Methods: A mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus–post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process. Results: After intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI). Conclusions: A pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance. [ABSTRACT FROM AUTHOR]

Background: Rapid urban population growth is of global concern as it is accompanied with several new health challenges. The urban poor who reside in informal settlements are more vulnerable to these health challenges. Lack of formal government public health facilities for the provision of health care is also a common phenomenon among communities inhabited by the urban poor. To help ameliorate this situation, an innovative urban primary health system was introduced in urban Ghana, based on the milestones model developed with the rural Community-Based Health Planning and Services (CHPS) system. This paper provides an overview of innovative experiences adapted while addressing these urban health issues, including the process of deriving constructive lessons needed to inform discourse on the design and implementation of the sustainable Community-Based Health Planning and Services (CHPS) model as a response to urban health challenges in Southern Ghana.Methods: This research was conducted during the six-month pilot of the urban CHPS programme in two selected areas acting as the intervention and control arms of the design. Daily routine data were collected based on milestones initially delineated for the rural CHPS model in the control communities whilst in the intervention communities, some modifications were made to the rural milestones.Results: The findings from the implementation activities revealed that many of the best practices derived from the rural CHPS experiment could not be transplanted to poor urban settlements due to the unique organizational structures and epidemiological characteristics found in the urban context. For example, constructing Community Health Compounds and residential facilities within zones, a central component to the rural CHPS strategy, proved inappropriate for the urban sector. Night and weekend home visit schedules were initiated to better accommodate urban residents and increase coverage. The breadth of the disease burden of the urban residents also requires a broader expertise and training of the CHOs.Conclusions: Access to improved urban health services remains a challenge. However, current policy guidelines for the implementation of a primary health model based on rural experiences and experimental design requires careful review and modifications to meet the needs of the urban settings. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease (CVD) prevalence is high in Ghana—but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors. Methods: We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes. Results: CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital. Conclusions: CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors–in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD–including its behavioral and mental health causes–in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise. [ABSTRACT FROM AUTHOR]

Background: Improving child and maternal health remains a core objective of global health priorities, extending from the millennium development goal (MDG) era to the current focus on the Sustainable Development Goals (SGDs). This paper analyses the childhood morbidity effects of the Ghana Essential Heath Interventions Program (GEHIP), a community-based health systems strengthening in rural northern Ghana. GEHIP was a five-year embedded implementation science plausibility trial that implemented a set of health systems strengthening strategies and tested the proposition that their combined effect at the district, subdistrict and community levels could foster effective community engagement and thereby improve maternal and child health outcomes. Methods: A two stage random sample survey of reproductive-aged women residing in treatment and comparison districts at the GEHIP baseline and end line was used for Heckman Difference-in-differences (DiD) regression models for estimating the incremental effect of GEHIP exposure on three child morbidity conditions (diarrhea, fever and cough), as recalled by maternal respondents in the course of survey interviews. Results: After controlling for child age and gender, maternal age, education, marital status, health insurance status, religion, ethnicity, occupation and household wealth index, regression results show that GEHIP had a statistically significant 45% reduction in fever (OR = 0.55, CI = 0.31–0.98) and 47% reduction in cough (OR = 0.53, CI = 0.30–0.94), over and above temporal reductions that prevailed in study districts. Although not significant, GEHIP also had 38% reduction in the incidence of diarrhea. Conclusion: Previous research has shown that GEHIP had a pronounced positive effect with a reduction in mortality. Our results show that household location in GEHIP districts also led to a significant reduction in morbidity due to cough and fever among under-five children. This association is a likely outcome of GEHIP's impact on the accessibility of primary health care services. Results lend further support to the growing body of evidence that strengthening health systems in rural Africa through the provision of community-based strategies enhances prospects for achieving the United Nations child health SDGs. [ABSTRACT FROM AUTHOR]

Background: The burden of cardiovascular disease (CVD) in Ghana is rising, but details on its epidemiology are scarce. We sought to quantify mortality due to CVD in two districts in rural Ghana using verbal post-mortem (VPM) data.Methods: We conducted a proportional sub-hazards analysis of 10 232 deaths in the Kassena-Nankana East and West districts from 2005 to 2012, to determine adult mortality attributed to CVD over time. We stratified results by age, gender and socio-economic status (SES), and compared CVD mortality among SES and gender strata over time. A competing risk model estimated the cumulative effect of eliminating CVD from the area.Results: From 2005 to 2012, CVD mortality more than doubled overall, from 0.51 deaths for every 1000 person-years in 2005 to 1.08 per 1000 person-years in 2012. Mortality peaked in 2008 at 1.23 deaths per 1000 person-years. Increases were comparable in men (2.0) and women (2.3), but greater among the poorest residents (3.3) than the richest (1.3), and among persons aged 55-69 years (2.1) than those aged ≥70 years (1.8). By 2012, male and female CVD mortality was highest in middle-SES persons. We project that eliminating CVD would increase the number of individuals reaching age 73 years from 35% to 40%, adding 1.6 years of life expectancy.Conclusions: The burden of CVD on overall mortality in the Upper East Region is substantial and markedly increasing. CVD mortality has especially increased in lower-income persons and persons in middle age. Further initiatives for the surveillance and control of CVD in these vulnerable populations are needed. [ABSTRACT FROM AUTHOR]

Background Male involvement in contraceptive use is increasingly becoming a global reproductive health issue. Vasectomy is one of the two male modern contraceptive methods espoused by the National Family Planning Policy in Ghana. Despite these advocacies, there are reports of low patronage of this method in Ghana. This study therefore explored the social and cultural factors that may be affecting the low vasectomy uptake in Southern Ghana. Methods The study was conducted in Sefwi Bibiani-Ahwiaso Bekwai (SBAB) District and KomendaEdina-Eguafo-Abrem (KEEA) Municipal area in the Western and Central regions of Ghana respectively. Twelve Focus Group Discussions were held with both male and female community members. In-depth interviews were also carried out with Community Health Officers (CHOs), Community Health Volunteers (CHVs) and health managers at both the district and regional levels. The discussions and interviews were recorded, transcribed verbatim and analysed using Nvivo 10. Results The study revealed that vasectomy was perceived as an act against God, which was punishable either by death or answerable on judgement day. Vasectomy was also perceived to be a form of castration, which can make men weak and incapable, thereby unable to satisfy their wives sexually, leading to marital conflicts. Women were more concerned about the negative effects of vasectomy on men. Cafalgin and panacin which are locally manufactured analgesics were perceived to have contraceptive abilities and therefore used by men as an alternative to modern contraceptive methods. Conclusions Stigma and the misconceptions in the community may be accounting for the low vasectomy uptake in Ghana despite several advocacy strategies. Women were highly influential in a man's decision on vasectomy. This calls for the need to increase health education to demystify the misconceptions about vasectomy. Vasectomy-related campaign messages should target both men and women. [ABSTRACT FROM AUTHOR]

Background: Reproductive health and Family Planning (FP) services have been of global concern especially in developing countries where fertility rates are high. Traditionally FP services had always targeted females with little or no attention given to males. To ensure equitable distribution of health services, Ministry of Health (MOH), Ghana adopted the Community-Based Health Planning and Services (CHPS) as a nationwide health policy with the aim of reducing obstacles to physical and geographical access to health care delivery including FP services. However, not much is known about the extent to which this policy has contributed to male involvement in FP services. This qualitative descriptive study was therefore designed to explore male involvement in FP services in communities with well functioning CHPS and those with less or no functioning CHPS structures. The study further solicited views of the community on the health status of children. Methods: This was a qualitative descriptive study and adapted the design of an ongoing study to assess the impact of male involvement in FP referred to as the Navrongo experiment in Northern Ghana. Twelve focus group discussions were held with both male and female community members, six in communities with functional CHPS and six for communities with less/no-functional CHPS. In addition, fifty- nine (59) in-depth interviews were held with Community Health Officers (CHOs), Community Health Volunteers (CHVs) and Health Managers at both the districts and regional levels. The interviews and discussions were tape recorded digitally, transcribed and entered into QSR Nvivo 10© for analysis. Results: The results revealed a general high perception of an improved health status of children in the last ten years in the communities. These improvements were attributed to immunization of children, exclusive breastfeeding, health education given to mothers on childcare, growth monitoring of children and accessible health care. Despite these achievements in the health of children, participants reported that malnutrition was still rife in the community. The results also revealed that spousal approval was still relevant for women in the use of contraceptives; however, the matrilineal system appears to give more autonomy to women in decision-making. The CHPS strategy was perceived as very helpful with full community participation at all levels of the implementation process. Males were more involved in FP services in communities with functioning CHPS than those without functioning CHPS. Conclusion: The CHPS strategy has increased access to FP services but spousal consent was very important in the use of FP services. Involving males in reproductive health issues including FP is important to attain reproductive health targets. [ABSTRACT FROM AUTHOR]

Background: Despite effective treatments and preventive measures for the major causes of child illness and death in less wealthy nations, child mortality remains high in resource-poor settings due in part to ineffective health service delivery models. Methods: The Navrongo Community Health and Family Planning Project is a longitudinal community trial of alternative organizational strategies for health service delivery in a rural, impoverished area of Ghana. In one area, nurses are placed in communities with doorstep visitation and service responsibilities. A second area includes training of a local health volunteer and community involvement in health delivery. A third area combines both strategies. Under-five mortality rates were calculated and Poisson regression was used to adjust for potential confounding characteristics. Results: In areas with village-based community nurse services, under-five child mortality fell by 14% during five years of program implementation compared with before the intervention, with reductions in infant (5%), early child (18%), and late child (39%) mortality. The volunteer intervention was associated with a 14% increase in mortality, primarily driven by a 135% increase in early child mortality. Areas with both nurses and volunteers saw an 8% increase, with small increases in all age groups. Mortality in a comparison area with standard Ministry of Health services fell by 4% during the same time period. Conclusions: These results suggest that convenient, accessible professional nursing care can reduce child mortality in impoverished African settings. However, they do not demonstrate a beneficial effect of community volunteers and suggest a possible negative impact on children's survival. [ABSTRACT FROM AUTHOR]

Objective To determine the impact of deploying nurses and volunteers to village locations on demographic and health outcomes. Method We implemented an experimental design that emphasizes the value of aligning community health services with traditional social institutions that organize village life. Data for this analysis come from the Navrongo demographic surveillance system, a longitudinal database that tracks fertility, mortality, and migration events over time. The experiment uses conventional demographic methods for estimating mortality rates from longitudinal demographic surveillance registers. Results Posting nurses to community locations reduced childhood mortality rates by over half in 3 years and accelerated attainment of the childhood-survival millennium development goal (MDG) in the study areas relative to trends observed in comparison areas. Conclusion Results from the Navrongo experiment demonstrate that community health and family planning programmes can have an impact on childhood mortality. Posting nurses to communities can dramatically accelerate the pace of progress in achieving the childhood-survival MDGs. Community-volunteer approaches, however, have no additional impact, a finding that challenges the child survival value of international investment in volunteer-based health programmes. The total cost of the intensive arm of the project is less than $10 per capita per year. Navrongo research thus demonstrates affordable means of attaining the child survival MDG agenda with existing technologies. [ABSTRACT FROM AUTHOR]

The 1994 Cairo Conference on Population and Development consensus called for actions that will make family planning programmes oriented to the needs and concerns of women that are served. This paper, based on data from Bangladesh, presents an illustrative analysis of how an outreach programme can be evaluated by this criterion. A scale for perceived service quality is developed from five indicators of desirable characteristics of services. Regression methods are used to assess the impact of outreach service encounters on the perceived quality scale. Econometric methods are used to adjust for endogeneity that arises from the selectivity of outreach encounters and the selective service exposure of contraceptive users. Results show that increasing contact with outreach workers increases client satisfaction with the overall quality of the Bangladesh family planning programme. [ABSTRACT FROM AUTHOR]

National family planning programs have been an important instrument in accelerating global fertility decline and in restricting ultimate world population to a level probably below ten billion. They began to come into being after 1950 and will probably go out of existence in most of the world's regions by 2050. The archetypal programs were instituted in Asia and North Africa. The end of the twentieth century is an appropriate half-way mark at which to evaluate the twentieth-century programs and to assess what changes in them will be needed for the twenty-first century. Some changes are necessary because dramatic events have occurred: (1) long-term replacement-level fertility has been attained in most of East Asia and some of Southeast Asia, and accordingly, some programs there are being phased out; (2) mainland South Asian fertility has been slower to decline; (3) international donor funding is diminishing and may not be significant during much of the twenty-first century; (4) the 1994 International Conference on Population and Development held in Cairo called for a radical change in programs away from demographic aims and toward reproductive health and the improvement of the situation of women; and (5) the future family planning frontier will be sub-Saharan Africa, for which radically new types of programs may have to be developed. These issues were discussed in January 2000 at a conference held in Dhaka, Bangladesh. A selection of contributions to the conference is published here. This article provides an overview of the issues based partly on this selection and partly on the discussions that took place at the conference. [ABSTRACT FROM AUTHOR]

Introduction: The practice of female genital mutilation (FGM/C) in traditional African societies is grounded in traditions of patriarchy that subjugate women. It is widely assumed that approaches to eradicating the practice must therefore focus on women's empowerment and changing gender roles. Methods: This paper presents findings from a qualitative study of the FGM/C beliefs and opinions of men and women in Kassena-Nankana District of northern Ghana. Data are analyzed from 22 focus group panels of young women, young men, reproductive age women, and male social leaders. Results: The social systemic influences on FGM/C decision-making are complex. Men represent exogenous sources of social influence on FGM/C decisions through their gender roles in the patriarchal system. As such, their FGM/C decision influence is more prominent for uncircumcised brides at the time of marriage than for FGM/C decisions concerning unmarried adolescents. Women in extended family compounds are relatively prominent as immediate sources of influence on FGM/C decision-making for both brides and adolescents. Circumcised women are the main source of social support for the practice, which they exercise through peer pressure in concert with co-wives. Junior wives entering a polygynous marriage or a large extended family are particularly vulnerable to this pressure. Men are less influential and more open to suggestions of eliminating the practice of FGM/C than women. Conclusion: Findings attest to the need for social research on ways to involve men in the promotion of FGM/C abandonment, building on their apparent openness to social change. Investigation is also needed on ways to marshal women's social networks for offsetting their extended family familial roles in sustaining FGM/C practices. [ABSTRACT FROM AUTHOR]

A helpful component for comprehensive residential services for develop-mentally disabled persons is volunteer assistance. This investigation involved the evaluation of a program developed to increase the amount of volunteer assistance provided to a public residential facility. The program consisted of three types of related procedures: systematic volunteer recruitment steps, specific volunteer activities at the facility, and consequence/recognition for the volunteer assistance. The program was successively implemented to involve students as volunteers from two local universities, and resulted in an increase in new students volunteering from both universities. Additionally, the frequency with which the students volunteered at the residential facility increased substantially from both universities relative to control periods during which the volunteer program was not in effect. Results are discussed in terms of the benefits of volunteers and continued research to increase involvement of other prospective groups of volunteers. [ABSTRACT FROM AUTHOR]

Reducing neonatal mortality rates (NMR) in developing countries is a key global health goal, but weak registration systems in the region stifle public health efforts. To calculate NMRs, investigate modifiable risk factors, and explore neonatal deaths by place of birth and death, and cause of death in two administrative areas in Ghana. Data on livebirths were extracted from the health and demographic surveillance systems in Navrongo (2004–2012) and Kintampo (2005–2010). Cause of death was determined from neonatal verbal autopsy forms. Univariable and multivariable logistic regression were used to analyse factors associated with neonatal death. Multiple imputations were used to address missing data. The overall NMR was 18.8 in Navrongo (17,016 live births, 320 deaths) and 12.5 in Kintampo (11,207 live births, 140 deaths). The annual NMR declined in both areas. 54.7% of the births occurred in health facilities. 70.9% of deaths occurred in the first week. The main causes of death were infection (NMR 4.3), asphyxia (NMR 3.7) and prematurity (NMR 2.2). The risk of death was higher among hospital births than home births: Navrongo (adjusted OR 1.14, 95% CI: 1.03–1.25, p = 0.01); Kintampo (adjusted OR 1.76, 95% CI: 1.55–2.00, p < 0.01). However, a majority of deaths occurred at home (Navrongo 61.3%; Kintampo 50.7%). Among hospital births dying in hospital, the leading cause of death was asphyxia; among hospital and home births dying at home, it was infection. The NMR in these two areas of Ghana reduced over time. Preventing deaths by asphyxia and infection should be prioritised, centred respectively on improving post-delivery care in health facilities and subsequent post-natal care at home. [ABSTRACT FROM AUTHOR]

Background: To strengthen the implementation of the Community-based Health Planning and Services (CHPS) programme which is Ghana's key primary health care delivery strategy, the CHPS+ Project was initiated in 2017. We examined community utilisation and satisfaction with CHPS services in two System Learning Districts (SLDs) of the project.Methods: This community-based descriptive study was conducted in the Nkwanta South Municipality and Central Tongu District of Ghana. Data were collected from 1008 adults and analysed using frequency, percentage, chi-square, and logistic regression models.Results: While the level of utilisation of CHPS services was 65.2%, satisfaction was 46.1%. Utilisation was 76.7% in Nkwanta South and 53.8% in Central Tongu. Satisfaction was also 55.2% in Nkwanta South and 37.1% in Central Tongu. Community members in Nkwanta South were more likely to utilise (AOR = 3.17, 95%CI = 3.98-9.76) and be satisfied (AOR = 2.77, 95%CI = 1.56-4.90) with CHPS services than those in Central Tongu. Females were more likely to utilise (AOR = 1.75, 95%CI = 1.27-2.39) but less likely to be satisfied [AOR = 0.47, 95%CI = 0.25-0.90] with CHPS services than males. Even though subscription to the National Health Insurance Scheme (NHIS) was just 46.3%, NHIS subscribers were more likely to utilise (AOR = 1.51, 95%CI = 1.22-2.03) and be satisfied (AOR = 1.45, 95%CI = 0.53-1.68) with CHPS services than non-subscribers.Conclusion: Ghana may not be able to achieve the goal of universal health coverage (UHC) by the year 2030 if current levels of utilisation and satisfaction with CHPS services persist. To accelerate progress towards the achievement of UHC with CHPS as the vehicle through which primary health care is delivered, there should be increased public education by the Ghana Health Service (GHS) on the CHPS concept to increase utilisation. Service quality should also be improved by the GHS and other stakeholders in Ghana's health industry to increase satisfaction with CHPS services. The GHS and the National Health Insurance Authority (NHIA) should also institute innovative strategies to increase subscription to the NHIS since it has implications for CHPS service utilisation and satisfaction. [ABSTRACT FROM AUTHOR]

Background: Community volunteerism is essential in the implementation of the Community-based Health Planning and Services (CHPS) in Ghana. We explored the responsibilities, motivations and challenges of community health management committees (CHMCs) in two CHPS+ Project districts in Ghana.Methods: We used a qualitative approach to collect data through 4 focus group discussions among a purposive sample of community health volunteers in December 2018 and analysed them thematically.Results: Community health management committees (CHMCs) were found to provide support in running the CHPS programme through resource mobilisation, monitoring of logistics, assisting the Community Health Officers (CHO) in the planning of CHPS activities, and the resolution of conflicts between CHOs and community members. The value, understanding and protective functions were the key motivations for serving on CHMCs. Financial, logistical and telecommunication challenges, lack of recognition and cooperation from community members, lack of motivation and lack of regular skill development training programmes for CHMC members who serve as traditional birth attendants (TBAs) were major challenges in CHMC volunteerism.Conclusion: Community health volunteerism needs to be prioritised by the Ghana Health Service and other health sector stakeholders to make it attractive for members to give off their best in the discharge of their responsibilities. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular Disease (CVD) is a growing cause of morbidity and mortality in Ghana, where rural primary health care is provided mainly by the Community-based Health Planning and Services (CHPS) initiative. CHPS locates nurses in community-level clinics for basic curative and preventive health services and provides home and outreach services. But CHPS currently lacks capacity to screen for or treat CVD and its risk factors.Methods: In two rural districts, we conducted in-depth interviews with 21 nurses and 10 nurse supervisors to identify factors constraining or facilitating CVD screening and treatment. Audio recordings were transcribed, coded for content, and analyzed for key themes.Results: Respondents emphasized three themes: community demand for CVD care; community access to CVD care; and provider capacity to render CVD care. Nurses and supervisors noted that community members were often unaware of CVD, despite high reported prevalence of risk factors. Community members were unable to travel for care or afford treatment once diagnosed. Nurses lacked relevant training and medications for treating conditions such as hypertension. Respondents recognized the importance of CVD care, expressed interest in acquiring further training, and emphasized the need to improve ancillary support for primary care operations.Conclusions: CHPS staff expressed multiple constraints to CVD care, but also cited actions to address them: CVD-focused training, provision of essential equipment and pharmaceuticals, community education campaigns, and referral and outreach transportation equipment. Results attest to the need for trial of these interventions to assess their impact on CVD risk factors such as hypertension, depression, and alcohol abuse. [ABSTRACT FROM AUTHOR]

Background: In 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017. Methods: This exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed. Results: Negative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns. Conclusion: Health-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme. [ABSTRACT FROM AUTHOR]

Background: The United Nations 2030 Sustainable Development Goals have reaffirmed the international community’s commitment to maternal, newborn, and child health, with further investments in achieving quality essential service coverage and financial protection for all. Objective: Using a modified version of the 1978 Tanahashi model as an analytical framework for measuring and assessing health service coverage, this paper aims to examine the system of care at the community level in Ghana’s Volta Region to highlight the continued reforms needed to achieve Universal Health Coverage. Methods: The Tanahashi model evaluates health system coverage through five key measures that reflect different stages along the service provision continuum: availability of services; accessibility; initial contact with the health system; continued utilization; and quality coverage. Data from cross-sectional household and health facility surveys were used in this study. Immunization and antenatal care services were selected as tracer interventions to serve as proxies to assess systems bottlenecks. Results: Financial access and quality coverage were identified as the biggest bottlenecks for both tracer indicators. Financial accessibility, measured by enrollment in Ghana’s National Health Insurance Scheme was poor with 16.94% presenting valid membership cards. Childhood immunization was high but dropped modestly from 93.8% at initial contact to 76.7% quality coverage. For antenatal care, estimates ranged from 65.9% at initial visit to 25.1% quality coverage. Conclusion: Results highlight the difficulty in achieving high levels of quality service coverage and the large variations that exist within services provided at the primary care level. While vertical investments have been prioritized to benefit specific health services, a comprehensive systems approach to primary health care needs to be further strengthened to reach Ghana’s Universal Health Coverage objectives. [ABSTRACT FROM AUTHOR]

Background: Ever since Ghana embraced the 1978 Alma-Ata Declaration, it has consigned priority to achieving ‘Health for All.’ The Community-based Health Planning and Services (CHPS) Initiative was established to close gaps in geographic access to services and health equity. CHPS is Ghana’s flagship Universal Health Coverage (UHC) Initiative and will soon completely cover the country with community-located services. Objectives: This paper aims to identify community perceptions of gaps in CHPS maternal and child health services that detract from its UHC goals and to elicit advice on how the contribution of CHPS to UHC can be improved. Method: Three dimensions of access to CHPS care were investigated: geographic, social, and financial. Focus group data were collected in 40 sessions conducted in eight communities located in two districts each of the Northern and Volta Regions. Groups were comprised of 327 participants representing four types of potential clientele: mothers and fathers of children under 5, young men and young women ages 15–24. Results: Posting trained primary health-care nurses to community locations as a means of improving primary health-care access is emphatically supported by focus group participants, even in localities where CHPS is not yet functioning. Despite this consensus, comments on CHPS activities suggest that CHPS services are often compromised by cultural, financial, and familial constraints to women’s health-seeking autonomy and by programmatic lapses constrain implementation of key components of care. Respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services. Conclusion: Improving geographic and financial access to CHPS facilities is essential to UHC, but responding to community need for improved outreach, and service quality is equivalently critical to achieving this goal. [ABSTRACT FROM AUTHOR]

Background: The United Nations 2030 Sustainable Development Goals have reaffirmed the international community's commitment to maternal, newborn, and child health, with further investments in achieving quality essential service coverage and financial protection for all. Objective: Using a modified version of the 1978 Tanahashi model as an analytical framework for measuring and assessing health service coverage, this paper aims to examine the system of care at the community level in Ghana's Volta Region to highlight the continued reforms needed to achieve Universal Health Coverage. Methods: The Tanahashi model evaluates health system coverage through five key measures that reflect different stages along the service provision continuum: availability of services; accessibility; initial contact with the health system; continued utilization; and quality coverage. Data from cross-sectional household and health facility surveys were used in this study. Immunization and antenatal care services were selected as tracer interventions to serve as proxies to assess systems bottlenecks. Results: Financial access and quality coverage were identified as the biggest bottlenecks for both tracer indicators. Financial accessibility, measured by enrollment in Ghana's National Health Insurance Scheme was poor with 16.94% presenting valid membership cards. Childhood immunization was high but dropped modestly from 93.8% at initial contact to 76.7% quality coverage. For antenatal care, estimates ranged from 65.9% at initial visit to 25.1% quality coverage. Conclusion: Results highlight the difficulty in achieving high levels of quality service coverage and the large variations that exist within services provided at the primary care level. While vertical investments have been prioritized to benefit specific health services, a comprehensive systems approach to primary health care needs to be further strengthened to reach Ghana's Universal Health Coverage objectives. [ABSTRACT FROM AUTHOR]

Background: Ever since Ghana embraced the 1978 Alma-Ata Declaration, it has consigned priority to achieving 'Health for All.' The Community-based Health Planning and Services (CHPS) Initiative was established to close gaps in geographic access to services and health equity. CHPS is Ghana's flagship Universal Health Coverage (UHC) Initiative and will soon completely cover the country with community-located services. Objectives: This paper aims to identify community perceptions of gaps in CHPS maternal and child health services that detract from its UHC goals and to elicit advice on how the contribution of CHPS to UHC can be improved. Method: Three dimensions of access to CHPS care were investigated: geographic, social, and financial. Focus group data were collected in 40 sessions conducted in eight communities located in two districts each of the Northern and Volta Regions. Groups were comprised of 327 participants representing four types of potential clientele: mothers and fathers of children under 5, young men and young women ages 15–24. Results: Posting trained primary health-care nurses to community locations as a means of improving primary health-care access is emphatically supported by focus group participants, even in localities where CHPS is not yet functioning. Despite this consensus, comments on CHPS activities suggest that CHPS services are often compromised by cultural, financial, and familial constraints to women's health-seeking autonomy and by programmatic lapses constrain implementation of key components of care. Respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services. Conclusion: Improving geographic and financial access to CHPS facilities is essential to UHC, but responding to community need for improved outreach, and service quality is equivalently critical to achieving this goal. [ABSTRACT FROM AUTHOR]