Temporal trends in childhood mortality in Ghana: impacts and challenges of health policies and programs

Figures & data

Table 1 Neonatal, infant, and under-five deaths, 1988–2008 Ghana Demographic and Health Survey

	Total live births	Neonatal deaths	Infant deaths	Under-five deaths
GDHS	Number (n)	Number (rate)	Number (rate)	Number (rate)
GDHS 1988	4,136	198 (47.9)	299 (72.3)	446 (107.8)
GDHS 1993	2,204	94 (42.6)	130 (59.0)	148 (67.2)
GDHS 1998	3,298	109 (33.1)	192 (58.2)	272 (82.5)
GDHS 2003	3,844	166 (43.2)	235 (61.1)	314 (81.7)
GDHS 2008	2,992	106 (35.4)	157 (52.5)	198 (66.2)

Average rate of decline per year: neonatal mortality 0.6%, infant mortality 1.0%, and under-five mortality 2.1%. GDHS: Ghana Demographic and Health Survey.

Fig. 1 Trends in childhood mortality in Ghana from 1988 to 2008.

Table 2 Poisson regression analyses of the trend in neonatal, infant, and under-five mortality, 1988–2008 Ghana Demographic and Health Survey

	Neonatal death	Infant death	Under-five death
Year	IRR (95% CI)	IRR (95% CI)	IRR (95% CI)
1988 GDHS	1 (reference)	1 (reference)	1 (reference)
1993 GDHS	0.90 (0.60–1.35)	0.82 (0.58–1.15)	0.62 (0.46–0.84)**
1998 GDHS	0.69 (0.44–1.07)	0.81 (0.57–1.14)	0.76 (0.57–1.01)
2003 GDHS	0.90 (0.59–1.35)	0.85 (0.60–1.19)	0.76 (0.57–1.01)
2008 GDHS	0.73 (0.47–1.12)	0.72 (0.50–1.03)	0.61 (0.45–0.83)**

CI: confidence interval; GDHS: Ghana Demographic and Health Survey; IRR: incidence risk ratio; **p<0.01.

Fig. 2 Trends in proportion of infant and under-five mortality attributed to neonatal death.

Fig. 3 National and regional trends in neonatal mortality in Ghana.

Table 3 Overview of National Health Policies implemented to address childhood mortality in Ghana from 1988 to 2008

National Health policy	Activities	Time of assessment	Findings of studies assessing the effectiveness of national health policy programs
Safe Motherhood (6) Program (SMP)	Ghana SMP entails primary health care, antenatal care, essential obstetric care, clean/safe delivery, family planning and equity for women. (Launched in 1993 and scaled up in 2000.)	After scale-up	Okiwelu et al. showed that some donors were implementing other interventions outside the objectives of the SMP, and the authors concluded that such action might dilute the expected effect of the policy (35).
			Anderson et al. identified migration of care providers (medical doctors) out of Ghana as one of the main factors that hampered the SMP in Ghana (36).
			Maine et al. in his review on the SMP showed that the policy was not well-defined and most policy makers believed that most of the components of SMP were already implemented prior to the SMP (37).
Community-Based Health Planning and Services (9) (CHPS)	Community health officer (CHO) provides the following services: treatment of minor illness, health education, family planning, skilled delivery, and antenatal and postnatal care. Community volunteers are trained to carry out community mobilization. (First piloted in 1999, adopted nationwide in 2005.)	Prior to scale-up (experimental phase)	Prior to policy implementation at the national level, Phillips et al. showed that the CHPS program decreased childhood mortality and fertility rate (24).
		Prior to scale-up	Prior to policy implementation at the national level, Debpuur et al. showed that the CHPS program increased women's knowledge of contraception, willingness for birth spacing, and usage of contraception (38).
			Before the policy was adopted nationally, Pence et al. showed that the CHPS program decreased childhood mortality (39).
			Before the CHPS program was adopted, Binka et al. found that the program decreased childhood mortality and improved parental health-seeking behavior (40).
			Phillips et al. observed that CHPS improved contraceptive usage before the policy was adopted nationwide (41).
			Prior to the adoption of the policy, Awoonor-Williams et al. showed that CHPS increased usage of contraception, skilled antenatal delivery, and postnatal attendants (42).
		During scale up,	During the scale-up phase, Awoonor-Williams et al. observed the following challenges: inadequate funding, less preparedness of community health officer, inadequate community engagement, shortage of manpower and equipment and inadequate monitoring (31).
		After the adoption of the policy	Assessment of the CHPS initiative by Adongo et al. after its adoption showed that the program improved the acceptance of family planning (43).
			Following adoption of the CHPS, Adongo et al. observed that the implementation of the program in urban areas was difficult due to contextual differences between rural (where the CHPS was tested) and urban areas, suggesting further modification of the implementation strategies (44).
		Post-adoption of CHPS initiative	During post-adoption of CHPS, Nyonator et al. identified the following: inadequate community engagement, lack of funds made health managers to perceive CHPS as an administrative burden (9).
User Fees Exemption for Delivery Care (UFEDC) (10)	Exemption for pregnant women from paying delivery fees in order to increase skilled delivery. Public, private, and mission health care providers were receiving reimbursement for service rendered (Initiated in 2003, scaled up in 2005)	Prior to scale up	Before the policy was adopted, Asante et al. reported that the policy decreased catastrophic out-of-pocket payment (45). Before the policy was scaled up, Bosu et al. showed that the policy had no statistically significant effect on maternal mortality (25). Before the scaling up of the policy, Penfold et al. observed that the policy increased skilled delivery and reduced inequality in the utilization of maternal healthcare service (46). McKinnon et al. observed that facility-based delivery increased while neonatal mortality decreased (47).
		After scale up	Witter et al. reported that the stakeholders believed that the policy was a cost-effective initiative that can reduce inequality in the utilization of maternal healthcare service. Insufficient funding, inadequate management, irregular reimbursement, increased workload without any increase in staff strength subsequently hampered the quality of maternal healthcare (29).
			Witter et al. reported that the stakeholders believed that the policy was a good initiative to improve skilled delivery. The study showed improvement in early antenatal registrants but regions were not well consulted in terms of reimbursement. Consequently, reimbursement was erratic and insufficient (30).
			The study conducted by Witter et al. showed that the policy was well accepted as an effective strategy to improve safe delivery; contents of the policy were clear but insufficient; erratic funding delayed inadequate reimbursement; increased workload without incentive or any corresponding increase in the number of care providers militate against the sustainability of the policy (34).
			Meessen et al. observed 1) Agenda setting: It was not clear whether the policy was adopted as a result of pressure from donors or taking the advantage of the offer of being a “low resource setting”. 2) Policy formulation: Assessment of this policy based on good practices in policy formulation showed that the objectives of the policy were clear and the stakeholders welcomed the policy but its formulation was not free from donor's influence. Important policy formulation good practices such as situation analysis, assessment of different policy options, and stakeholders’ involvement were not observed. 3) Implementation stage: suffered from erratic and insufficient funding (27).
Focused Antenatal Care (FANC) (11)	Individualized care for pregnant women to improve efficiency and safe delivery.It involves early detection of complication, pre-existing morbidity, birth preparedness, health education, and health promotion. For a healthy woman, four antenatal visits at <16, 26, 32, and 36 weeks were recommended. (Implemented in 2002)	During policy implementation	Increased antenatal registrants, increased early antenatal registrants, improved patient–doctor interaction, reduced waiting time, improved quality of antenatal care, increased health facility delivery, reduced stillbirth, and increased postnatal care utilization were observed by Deganus et al. following the implementation of FANC (26). Nyarko et al. reported that both patients and healthcare providers accepted the policy. It improved the quality of antenatal care. However, there was no difference between the intervention facilities and the control facilities in terms of birth preparedness, complication readiness, and postnatal care. In addition, some intervention facilities were unable to implement some of the components of FANC due to lack of equipment (33).
National Health Insurance Scheme (12) (NHIS)	National health insurance for pregnant women: six antenatal visits, delivery (incl. obstetrics complications), two postnatal visits within 6 weeks post-delivery, neonatal care up to age 3 months. (Implemented in 2008)	Following the implementation of NHIS	Witter et al. showed that the policy makers did not learn from errors of free delivery policy; NHIS policy formulation was top-down, politically induced by donors, no well-prepared policy guidelines, no proper consultation, poor communication of the policy, no proper costing, no additional funds were made available, no long-time financial plan, erratic and insufficient reimbursement. Sub-optimal implementation, lack of adequate monitoring and evaluation, increased workload with a negative impact on healthcare quality. Despite these limitations implementation of the NHIS increased access to healthcare (32).
Integrated Management of Childhood Illness (8) (IMCI)	Aims to improve case management at primary level of care, management of childhood illnesses, and family and community childcare practices. It involves antenatal, delivery, and postnatal services; treatment and prevention of infectious diseases (pneumonia, diarrhea, malaria, measles, HIV/AIDS); improves nutrition (improves breastfeeding, reduces malnutrition), vaccination, and psychosocial development. (Started in 1998, by 2000 all districts started IMCI.)	Following the implementation of IMCI	Baiden et al. observed that many of the care providers were yet to receive training on IMCI. The study showed a significant level of non-compliance with the IMCI guidelines; all the 11 items in the IMCI checklist were observed in just 1% of the children. 95% of them received antimalarial treatment but only 11% underwent laboratory investigation (28).

Maine et al. provided assessment was a general assessment of the SMP.

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