ACCELERATING CHILD SURVIVAL AND DEVELOPMENT (ACSD)
Final Report
The Retrospective Evaluation of ACSD:
Ghana
Submitted to UNICEF on 7 October 2008
Institute for International Programs
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD
Disclaimer:
This report was prepared by IIP-JHU under contract with UNICEF. All photos were taken by members of
the IIP-JHU evaluation team after requesting permission from those who were photographed. All text,
data, photos and graphs should be cited with permission from the authors and UNICEF.
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
Summary
Introduction
UNICEF implemented the Accelerated Child Survival and Development (ACSD) project between 2001
and 2005 in 11 countries in Africa with support from Canadian CIDA. The aim of ACSD was to reduce
mortality among children less than five years of age by working with governments and other partners to
increase coverage with a set of proven interventions. In the “high-impact” countries of Benin, Ghana, Mali
and Senegal, a total of 16 districts worked to deliver the full set of interventions grouped into three
packages: “EPI+” including vaccinations, vitamin A supplementation and the use of insecticide-treated
nets (ITNs) for the prevention of malaria; “IMCI+” including promotion of exclusive breastfeeding for six
months, timely complementary feeding, use of iodized salt and improved and integrated management at
the health facility and community levels of children suffering from pneumonia, malaria and diarrhea,
including home-based ORS use, treatment of malaria, and treatment of pneumonia with antibiotics; and
“ANC+” including intermittent preventive treatment of malaria with SP (Fansidar) for pregnant women
(IPTp), tetanus immunization during pregnancy to prevent maternal and neonatal tetanus and
supplementation with iron/folic acid during pregnancy and with vitamin A post-partum. An internal
evaluation by UNICEF estimated through modeling that the levels of coverage achieved through ACSD
were associated with about a 20 percent reduction in all-cause under-five mortality relative to comparison
districts in participating districts in four “high-impact” countries. This retrospective evaluation was
commissioned by UNICEF to confirm these findings and provide additional information that could be used
th
in planning effective programs to reduce child mortality and achieve the 4 Millennium Development Goal
(MDG-4) in poor countries in Africa.
The IIP evaluation team worked with ACSD managers at international and national levels to develop a
generic ACSD framework that defined the pathways through which ACSD activities were expected to lead
to reductions in child mortality and improvements in child nutritional status. The generic framework
served as the “backbone” of the evaluation design. The country-specific evaluations also addressed
equity across socioeconomic and ethnic groups, for urban-rural residence and for girl and boy children.
At the request of UNICEF, the evaluation does not include an economic evaluation or a full assessment of
the effects of ACSD on national policy.
Aim of the independent retrospective evaluation in Ghana
The aim of the evaluation was to provide valid and timely evidence to child health planners and policy
makers about the effectiveness of ACSD in reducing child mortality and improving child nutritional status
in Ghana, as a part of the larger retrospective evaluation designed to inform future programs intended to
reduce child mortality and accelerate progress toward MDG-4. Equity was also assessed.
Two questions served as a guide to the analysis and reporting of the evaluation findings:
a) Was ACSD implementation associated with improvements in coverage, nutrition and
mortality over time?
b) If so, was progress in the ACSD districts faster than that observed for the national
comparison area?
ACSD implementation in Ghana
UNICEF-Ghana received approximately $3.8 million from Canadian CIDA to support ACSD activities in
i
six “high-impact” districts (HIDs) with a combined population of about one million located in the Upper
East region, and two expansion regions (Upper West and Northern regions) between 2001 and 2004.
ACSD was implemented at the regional, district and sub-district levels in partnership with the Ghana
i
These six districts subdivided into eight districts in 2005 during redistricting.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
iii
Health Service (GHS) and other development partners. The GHS supported EPI+ and ANC+ activities
after 2004 by incorporating them into routine health services. After a hiatus of about one year, other
ACSD activities received continued support from UNICEF funds, DANIDA and the Government of the
Netherlands. ACSD inputs and activities in the Ghana HIDs, comprised of the entirety of the Upper East
region, focused on:
1) Providing essential drugs, supplies, equipment and other support for outreach and
campaign activities. ACSD-Ghana: a) provided an estimated 814 bicycles, 18 motorcycles and
one vehicle to the HIDs over the course of the project for outreach and supervision activities; b)
equipped health facilities with 553 refrigerator units for cold chain; c) supported local and national
campaigns for vaccination and vitamin A supplementation, as well as routine health-facility
outreach activities; and d) supplied commodities including vitamin A supplements, antihelminths,
ORS, antimalarials and ITNs and retreatment chemicals for the prevention of malaria.
2) Supporting distribution and retreatment of ITNs at various levels. Over 200,000 ITNs were
distributed in the HIDs between 2002 and 2005 through health centers, community outreach and
distribution systems and campaigns. ACSD supported retreatment efforts at the community and
facility levels, as well as through campaigns starting in 2004. All health workers and volunteers
involved in ITN distribution and retreatment received training.
3) Training and supervising of facility-based workers. Forty-eight clinicians and three regional
staff received standard 11-day IMCI training in 2005.
4) Training, equipping and supervising community health workers. ACSD-Ghana provided
support for the training and supervision of over 1900 community-based agents (CBAs) in 600
communities to deliver messages to promote infant feeding, careseeking and treatment of
childhood illness and ITNs, and immunization. The CBAs received health kits containing
chloroquine, ORS, and handwashing and educational materials. ASCD also provided training
and educational materials to community-based mothers’ groups for the promotion of infant
feeding practices.
5) Supporting facility and outreach activities for pregnant women. The ANC+ package of
ACSD included support for tetanus toxoid supplemental immunization activities, as well as facility
and community distribution of postnatal vitamin A. IPTp was introduced in 2004 and ACSD
supported its regional scale-up.
Important barriers to full implementation of the ACSD implementation plan, as reported by program staff
and reflected in project documentation, included: a) commodity insecurity, particularly stockouts of ITNs
from late 2005 to late 2006; b) changes in the first-line antimalarial policy and the delayed authorization to
distribute these drugs at the community level; and c) inadequate incentives and support and supervision
systems for community-based workers.
Evaluation design and methods
The IIP evaluation team worked with UNICEF-Ghana, the Government of Ghana and other partners to
adapt the generic ACSD evaluation design to ACSD as implemented in Ghana. The intervention area was
defined as the six HIDs located in the Upper East region. The comparison area was the remainder of
Ghana excluding the urban areas of Greater Accra and Ashanti regions (Accra and Kumasi).
The primary data sources for estimates of intervention coverage were DHS surveys conducted in 1998-99
and 2003 at baseline, and a national MICS survey carried out in 2006 supplemented by a special
extension of the MICS in the HIDs carried out in 2007. Information was collected and summarized in
order to document ACSD intervention activities and contextual factors through key informant interviews,
document reviews and field visits carried out as part of a mapping exercise by investigators at Kwame
Nkrumah University of Science and Technology (KNUST). All results and interpretations were reviewed
with representatives of the Government of Ghana and UNICEF-Ghana.
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
Results
In Ghana, coverage for most of the ACSD interventions improved over time in the HIDs and reached the
target coverage levels set by ACSD. Indicators showing positive trends over time in the HIDs included
vaccinations, vitamin A, ITNs, antibiotics for suspected pneumonia, timely initiation of breastfeeding,
exclusive breastfeeding, antenatal care, IPTp and the presence of a skilled attendant at delivery.
Indicators that were observed to stagnate or decline included case management of common childhood
illnesses, tetanus toxoid vaccination and postnatal vitamin A. Utilization of ITNs, antibiotics for
pneumonia, breastfeeding initiation, skilled delivery and IPTp for pregnant women increased significantly
more in the HIDs than in the comparison area. Appropriate management of childhood fever and diarrhea
decreased in the HIDs, while stagnating in the comparison area; the difference in trends was statistically
significant.
For coverage, the answers to the two primary evaluation questions are as follows:
(a) Coverage indicators related to vaccination, vitamin A, ITNs, feeding behaviors, antenatal care
and skilled delivery improved over time in the HIDs and most reached the target coverage levels
set by ACSD. Indicators of correct management of childhood illness declined over time.
(b) Comparison with the rest of the country showed mixed results. Coverage increased rapidly for a
greater number of interventions in the HIDs than in the comparison area. On the other hand,
coverage declined significantly more for interventions related to the case management of
childhood illness in the HIDs than in the comparison area.
For nutritional status:
(a) The HIDs showed a reduction between 1998-9 and 2007 in the prevalence of stunting and
underweight, but not in wasting. The largest decline in stunting occurred between 1998-9 and
2003, before sufficient time had elapsed for interventions supported by ACSD to have had an
impact on nutrition
(b) Relative to the national comparison area, stunting declined faster in the HIDs in the period from
1998-9 to 2006-7. Most of this drop occurred before 2003, before ACSD inputs and activities
could have contributed, but the decline was maintained and extended during the ACSD project
period from 2003 onwards. Wasting declined significantly in the comparison area while remaining
stable in the HIDs.
For mortality:
(a) There was a reduction of 20% in under-five mortality in the HIDs from before to after ACSD
implementation, close to the ACSD goal of 25%. This trend was ascertained through the full birth
history technique, and the reduction was close to reaching statistical significance (p=0.10).
(b) Data on under-five mortality trends in the comparison area were available from a different source
than those for the intervention area, with data points available through 2003. Other analyses
suggest that mortality levels remained stable at around 115 deaths per thousand live births.
Although these results must be interpreted with caution, they do suggest that the drop in underfive mortality was greater in the HIDs than in the national comparison area.
The assessment of equity in coverage was limited to the period after ACSD implementation, because of
limited sample sizes available from earlier periods. There were no inequalities in coverage based on the
sex of the child, and few differences between urban and rural households. Results by socioeconomic
level were mixed, with few inequalities for interventions delivered through campaign approaches (e.g.,
vaccinations, vitamin A supplementation and ITNs), moderate levels of inequality for diarrhea
management and antenatal care visits, and large differences favoring wealthier households for the
presence of a skilled attendant at delivery. Children in the poorest households were somewhat more
likely to be stunted and to die before the age of five years than children in the least poor households.
Ethnic diversity within and between the HIDs and comparison area precluded examination of inequities by
IIP-JHU | Retrospective evaluation of ACSD in Ghana
v
ethnic group membership. When HIDs were compared to the rest of the country, there was no evidence
of differences in patterns of health inequalities.
Discussion and interpretation
ACSD in Ghana focused available resources on filling gaps in EPI, distributing ITNs, expanding C-IMCI
through community health workers and promoting antenatal care interventions. The highest coverage
levels in the endline surveys in the HIDs were achieved for vaccinations, vitamin A supplementation to
children, antenatal interventions (including IPTp and TT) and ITNs, and most of these interventions
progressed faster in the HIDs than in the national comparison area. Exclusive breastfeeding also showed
rapid increases in both the HIDs and the comparison area during the ACSD project period. Coverage
levels for the correct case management of malaria and diarrhea were low and decreased in the HIDs from
before to after ACSD. Taken together, the interventions showing large gains in coverage are likely to
have had only limited impact on the main causes of death in Ghana (malaria, neonatal conditions,
pneumonia, diarrhea and undernutrition) and hence are consistent with the 20 percent reduction in underfive mortality observed in the HIDs.
Interpretation of these findings jointly by the IIP evaluation and Ghana team focused on the missed
opportunities for saving further child lives through ACSD, including the need for: 1) greater emphasis on
interventions to address child undernutrition; 2) more intensive efforts to change behaviors related to the
management of childhood illnesses, skilled delivery and child feeding; 3) greater support and training for
the community-based workers that were a key part of intervention delivery; and 4) increased commodity
security to ensure adequate and continuous supply of essential commodities. The team also believed
that stronger supervision and monitoring systems would have increased ACSD effectiveness.
These results must be considered in light of the many international, bilateral and Ghanaian agencies that
were active in the HIDs before and concurrent with the ACSD project. Special advantages and
contributions of the ACSD project in this complex environment were defined by the implementation team
as: 1) the program’s ability to concentrate on a package of effective interventions; 2) the provision of
additional resources for commodities, equipment and human resources; 3) clearly stated targets; 4) the
establishment of productive partnerships and synergies across institutions; and 5) achievement of strong
commitment from the Government of Ghana and other donors. An important methodological issue for
this and future evaluations is that the presence of other partners throughout Ghana makes it impossible to
attribute observed changes to ACSD alone, and limits the validity of results based on comparisons
between the HIDs and broader geographic areas.
In summary, the ACSD HIDs accelerated gains in coverage of several key interventions relative to gains
in the rest of the country, despite the fact that the HIDs were among the poorest in Ghana and
geographically remote. However, several key interventions for reducing the main causes of death in
Ghana, showed little change and even some decreases in coverage. While stunting prevalence declined
during the ACSD period, there was a similar decline in the remainder of the country from 2003 to 2006.
In total, the changes in intervention coverage are consistent with the 20 percent reduction in under-five
mortality observed in the HIDs, and compares with what appears to be little or no reduction in the rest of
the Ghana.
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
Table of Contents
1. The external retrospective evaluation of ACSD in four countries .....................
1
2. Evaluation methods ...........................................................................................
5
3. Characteristics of the “high-impact” districts and comparison area ..................
11
4. ACSD as implemented in Ghana ......................................................................
21
5. Coverage and family practices ..........................................................................
29
6. Nutrition ............................................................................................................
49
7. Mortality .............................................................................................................
55
8. Equity of coverage, nutrition and mortality ......................................................
61
9. Conclusions ......................................................................................................
67
References ...............................................................................................................
71
Appendices
A. Description of Ghana and “high-impact” districts
B. Methodology for documentation of implementation activities and contextual factors
C. Documentation of implementation
D. Definition of key indicators
E. Survey Questions
F. Methodologies of surveys in Ghana 1998-2007
G. Tables presenting priority coverage indicators over time for ACSD “high-impact” districts
H. Tables presenting comparisons of priority coverage indicators over time in ACSD “high-impact”
districts and the comparison area
I.
Tables presenting 2007 MICS results for key coverage indicators in the ACSD “high-impact” districts
by socio-demographic characteristics of the population
J. Additional tables for nutrition
K. Methodological challenges
L. References for the appendices
M. Mapping of partners’ activities in ACSD “high-impact” districts (Upper East region) and nationally
IIP-JHU | Retrospective evaluation of ACSD in Ghana
vii
Acknowledgements
This evaluation could not have been conducted without full participation of the representatives from the
Ministry of Health, the Ghana Health Services, the Ghana Statistical Service, UNICEF-Ghana and other
development partners. We thank them for their commitment to child survival, as reflected in their
willingness to share their time, as well as information and their personal opinions about the contributions
and limitations of the ACSD project. We specifically would like to thank Eddie Addai and George Amofah
from the Ministry of Health and Ghana Health Service who were strong supporters of the evaluation. Vida
Abaseka provided valuable information on ACSD implementation; we are grateful to her and the Ghana
Health Service team in Upper East region for their dedication and openness to our questions. The Ghana
Statistical Service carried out surveys integral to this evaluation; we especially thank Faustina Ainguah
and Rochester Appiah for their on-going efforts. Easmon Otupiri at KNUST Department of Community
Medicine carried out the program mapping activities, essential to understanding the context in the Upper
East region, as well as contributing to the data interpretation.
UNICEF-Ghana staff were responsible for working with governments and partners to implement the
ACSD project and collaborate in activities related to the independent retrospective evaluation and we
thank them for their commitment to child survival and to the evaluation process as a means of improving
program effectiveness. We would also like to express our appreciation to Dorothy Rozga, Yasmin Haque,
Mark Young, Tamar Schrofer, Victor Ankrah, Bo Pedersen, Elias Massesa, George Fom Ameh,
Augustine Botwe, Felicia Mahata and Joanne Greenfield. UNICEF-Ghana also provided financial support
for the supplemental survey and advanced technical assistance from Macro, International. This support
was essential, as without it there would have been few data to analyze. We would also like to thank
UNICEF staff at regional and global levels for their efforts to provide us with documentation about ACSD
and the values and conceptual frameworks that guided its implementation.
Additionally, we would like to thank the members of the IIP-JHU for their insights and help throughout the
evaluation, as well as Macro International and Trevor Croft for technical assistance. Lanie Morgan
provided valuable assistance in the documentation of ACSD implementation and contextual factors.
Finally, we thank the leadership of UNICEF and CIDA, for their continuing commitment to the importance
of independent evaluations and their efforts to see that this work was completed.
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
Acronyms
ACSD
Accelerated Child Survival & Development Project
ACT
Artemisinin combination therapy for use in treating fever/malaria.
ANC
Antenatal care
ANC+
One of the ACSD intervention packages, consisting of antenatal care and the
intermittent prevention of malaria during pregnancy (IPTp)
BASICS
Basic Support for Institutionalizing Child Survival, a project supported by the United
States Agency for International Development.
BFHI
Baby Friendly Health Initiative
CBA
Community Based Agent
CDC
US Centers for Disease Control and Prevention
CHW
Community health worker
CHO
Community Health Officer
CHPS
Community-based Health Planning and Services
CIDA
Canadian International Development Agency
C-IMCI
Community component of Integrated Management of Childhood Illness
DANIDA
Danish International Development Agency
DFID
Department for International Development, government of the United Kingdom
DHS
Demographic and Health Surveys (DHS), supported by USAID.
DPT
Diphtheria, Pertussis, Tetanus immunization
EPI
Expanded Programme on Immunization
EPI+
One of the ACSD intervention packages, consisting of the full EPI schedule as well as
the provision of vitamin A and deworming twice each year for children aged six to
59 months, and the provision of insecticide-treated nets for the prevention of
malaria.
F-IMCI
Facility component of Integrated Management of Childhood Illness, which includes
improving the skills of facility-based health workers as well as strengthening
aspects of the health system needed to provide appropriate care for children less
than five years of age.
GAVI
Global Alliance for Vaccines and Immunizations
GHS
Ghana Health Service
GoG
Government of Ghana
IIP-JHU | Retrospective evaluation of ACSD in Ghana
ix
GoN
Government of the Netherlands
GRCS
Ghana Red Cross Society
GSS
Ghana Statistical Service
Hib
Haemophilus influenzae type b immunization
HIDs
“High-impact” districts for ACSD implementation, defined as Bawku East, Bawku West,
Bolgatanga, Bongo, Builsa, and Kasena-Nankana in the Upper East region in
Ghana
IEC
Information, Education and Communication
IHNS
Integrated Health and Nutrition Survey in Northern, Upper East, and Upper West
Regions of Ghana, 2002
IIP
The Institute for International Programs at JHU
IMCI
Integrated Management of Childhood Illness
IPTi
Intermittent preventative treatment for malaria in infancy
IPTp
Intermittent preventative treatment for malaria in pregnancy
ITN
Insecticide-treated net
JHSPH
The Johns Hopkins University Bloomberg School of Public Health
JICA
Japan International Cooperation Agency
KNUST
Kwame Nkrumah University of Science and Technology
LLITN
Long-lasting insecticide-treated net
MBB
Managing Budgets for Bottlenecks, a tool developed by UNICEF and the World Bank
to support results-based planning for maternal, newborn and child survival in
developing countries.
MDG
Millennium Development Goal
MDG-4
The fourth millennium development goal, which aims to reduce mortality among
children less than five years of age by two-thirds from levels in 1990.
MICS
Multiple Indicator Cluster Survey designed by UNICEF
MOH
Ministry of Health
NGO
Non-governmental organization
NHIS
National Health Insurance Scheme
NIDs
National Immunization Days
ORS
Oral Rehydration Salts, usually pre-packaged in a sachet
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
ORT
Oral Rehydration Therapy, can be either pre-packaged in a sachet or prepared in the
home
pp
Percentage points
PMTCT
Prevention of mother-to-child transmission of HIV
RHMT
Regional Health management team
SP
A combination of two drugs, sulfadoxine and pyrimethamine. This drug combination is
commonly known as Fansidar.
SIA
Supplementary Immunization Activity
SWAp
Sector-Wide Approach: World Bank
TBAs
Traditional Birth Attendants
TT2
Two doses of Tetanus toxoid vaccine during pregnancy
UER
Upper East Region
UNICEF
United Nations Children’s Fund
USAID
United States Agency for International Development
VCT
Voluntary Counseling and Testing
WHO
World Health Organization
IIP-JHU | Retrospective evaluation of ACSD in Ghana
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
1.
The external retrospective evaluation of ACSD in four
countries
UNICEF implemented the Accelerated Child Survival and Development (ACSD) project between 2002
and 2005 in 11 countries in Africa with support from Canadian CIDA and other partners. The main
objective was to use results-based planning techniques to increase coverage with three packages of
high-impact interventions known to reduce child mortality (see Box 1). In Benin, Ghana, Mali and
Senegal, 16 “high-impact” districts worked to
Box 1:
deliver all three packages; in the remaining
ACSD High-Impact
countries, the focus was on the “EPI+” package
that included vaccination, Vitamin A and
Implementation Packages*
insecticide-treated nets (ITNs) for the
Immunization plus (EPI+)
prevention of malaria.
Internal UNICEF
evaluations in 2003 and 2004 showed
 Routine immunization and periodic measles
catch-up and mop-up
increases in coverage for the EPI+ package in
all countries; UNICEF modeled the associated
 Vitamin A supplementation bi-annually
reductions in mortality using the "Marginal
Budgeting for Bottlenecks " (MBB) tool and
 Distribution and promotion of Insecticide Treated
Nets for all children who are fully vaccinated as
estimated an overall mortality reduction of 20
well as pregnant women, and re-dipping of
percent in the “high-impact” districts in the four
1
bednets every six months
countries, relative to comparison districts.
UNICEF and the evaluation team recognized
the limitations of a retrospective evaluation,
including the difficulties associated with
reconstructing
project
assumptions
and
activities on a post hoc basis, and making the
best possible use of available data and
information
despite
their
shortcomings.
Readers are reminded to treat the results with
2
caution.
Improved management of pneumonia, malaria
and diarrhea (IMCI+)
 Promotion of exclusive breastfeeding for six
months, timely complementary feeding

Improved and integrated management (at the
health facility, community and family levels) of
children suffering from ARI, malaria and
diarrhea, including home-based ORS use,
treatment of malaria with anti-malarial blisters,
and treatment of ARI with antibiotic blisters
The aim of the evaluation is to provide valid
and timely evidence to child health planners
and policy makers about the effectiveness of
ACSD Phase I in reducing child mortality and
improving child nutritional status. The specific
objectives are:

Promotion of household consumption of iodized
salt
1.
To evaluate the impact of ACSD on
mortality and nutritional status among children
under five.
2.
To
document
the
process
and
intermediate outcomes of ACSD and resultsbased planning as a basis for improved
planning and implementation of child health
programs.
Antenatal Care (ANC+)

Intermittent preventive treatment (IPT) of
malaria with SP (Fansidar) for pregnant women

Tetanus immunization during pregnancy to
prevent maternal & neonatal tetanus

Supplementation with iron/folic acid during
pregnancy and with vitamin A post-partum.
______
*
UNICEF grouped these interventions into
paragraphs in different ways at various points
during the project; we have adopted the grouping
used in the final report from UNICEF to CIDA for
1
the ACSD project in 2005.
3.
To document the contextual factors
necessary for effective implementation of
efforts to reduce child mortality in order to be able to extrapolate evaluation findings to other settings.
4.
To assess the process, outcomes and impact of ACSD and results-based planning on socioeconomic, ethnic and gender inequities.
Achievement of these objectives should also expand regional and global capacity for large-scale
effectiveness evaluations of strategies, programs and interventions designed to improve child health
in low-income countries.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
1
1.1
Evaluation design
Geographic focus: The global retrospective evaluation covers the four countries within which UNICEF
defined districts as “high impact” for the ACSD project. Within each country, we focus on these “highimpact” districts (HIDs).
Development of a generic impact model for ACSD: The first step in any evaluation is to define what
those implementing the project expect to happen because of project activities. We developed an
impact model that specifies the pathways through which UNICEF and implementing countries
3
expected ACSD activities to result in reductions in child mortality. Figure 1 presents the generic
ACSD impact model in two parts. Figure 1A shows the “top” of the framework describing expected
ACSD inputs and processes from the point of introduction at national level in a country through the
definition of the three packages of interventions recommended for accelerated implementation (see
Box 1 for a description of the three packages). We derived the “top” of the framework from ACSD
e.g.4
and discussions with ACSD implementers at all levels. Figure 1B shows the “bottom”
documents
of the framework, defining the pathways through which each of the three packages was expected to
result in reductions in under-five mortality and improvements in the nutritional status of infants and
young children. ACSD documents did not describe the pathways in the “bottom” of the model in
detail, but made reference to other sources where the effects of the interventions are defined and
5,6
1
quantified. For the internal evaluation, UNICEF utilized the estimates of effectiveness published in
these sources and changes in intervention coverage as the basis for modeling the impact of ACSD on
child mortality.
A central tenet of the evaluation is that the coverage, family practices and impact reflected in the
“bottom” of the framework cannot be attributed to ACSD alone. UNICEF and country partners
designed ACSD to reinforce existing activities in child survival by the government of each country and
its partners. Therefore, increases or decreases in coverage and mortality must be understood as the
result of a combined implementation effort, tempered by contextual factors. A key challenge for the
current evaluation is to arrive at a qualitative assessment of ACSD’s role as a part of this overall
effort; quantified attribution of the results to ACSD alone is not warranted given the implementation
approach.
Definition of priority indicators for coverage and family practices. Priority coverage indicators address
the prevalence of key family practices and intervention coverage for each of the elements defined in
the “bottom” of the framework. Although some of these indicators reflect behaviors—such as
exclusive breastfeeding and complementary feeding—rather than intervention coverage, these will be
referred to as coverage indicators throughout the text. Appendix D defines the priority indicators of
coverage utilized in the evaluation. Whenever possible, the ACSD priority coverage indicators are
consistent with those supported by a consensus of United Nations (UN) agencies and multi- and bi7,8
Where no international consensus indicator
lateral partners for tracking progress toward MDG-4.
exists, we contacted technical experts in the topical area to obtain advice on selection of a valid
coverage indicator that could be calculated using the data available in Ghana.
Definition of priority indicators of impact (nutrition and mortality). The main objective of the ACSD
project was to reduce mortality among children less than five years of age. The primary impact
indicator in the evaluation is the under-five mortality rate, expressed as the probability of dying
between birth and exact age five years. Additional priority indicators include infant and child mortality.
Some ACSD project documents described expected improvements in child nutritional status,
9
reflecting the synergy between undernutrition and infectious disease. In Ghana, the regional
management team in the HIDs specified ACSD targets to reduce undernutrition by 15 percent in three
10
years and by 25 percent in five years, although specific indicators of undernutrition were not defined.
Priority impact indicators include prevalence of stunting, wasting and underweight. Appendix D
presents the detailed definitions of the priority indicators for mortality and nutritional status.
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
Figure 1B
ACSD impact model:
“Bottom” model showing interventions to impact
“Top” model showing inputs and processes
Antenatal
care +
Immunization +
DPT, Hib, measles
vaccines
Pneumonia
Vitamin A
supplementation
Insecticide treated
nets
IPT for malaria
Iron/folic
acid
Tetanus
toxoid
Post-partum
Vitamin A
High attendance at facilities/outreach sessions;
deployment at community level
High attendance at facilities/outreach sessions
Increased coverage
Increased coverage
Measles
Meningitis / sepsis Diarrhea
Preterm delivery Neural tube defects Neonatal tetanus
Malaria
?????
Spillover effect (co-morbidity)
IMCI +
Improved nutrition
Reduced mortality
Malaria treatment
ORT
Reduced mortality
? Improved nutrition?
Pneumonia
treatment
Breastfeeding
promotion
Deployment of interventions at community level
Increased coverage
Malaria
Diarrhea
Pneumonia
Other infections
Spillover effect (co-morbidity)
Reduced mortality
Improved nutrition
IIP-JHU | Retrospective evaluation of ACSD in Ghana
3
Equity. As part of the evaluation, we examine inequity in coverage and impact indicators, including
socio-economic status, sex of the child, place of residence (urban or rural) and ethnic groups.
Documenting contextual factors. Contextual factors are defined as variables that can confound the
association between the delivery of interventions and their health impact, or modify the effects of the
11
We documented contextual indicators in the HIDs and comparison area, including: (1)
approach.
indicators of implementation-related contextual factors such as characteristics of the health system
(e.g., utilization rates), child health policy, drug policy, and availability of drugs; and (2) indicators of
impact-related contextual factors including baseline levels and patterns of child morbidity and mortality
11
that can affect the potential magnitude of program impact.
Economic evaluation.
component.
4
At the request of UNICEF, the evaluation does not include an economic
IIP-JHU | Retrospective evaluation of ACSD in Ghana
2.
Evaluation Methods
2.1
Evaluation design
Overall design.
The overall evaluation design was retrospective, drawing on existing population-based surveys with
over-sampling of the MICS in the Upper East region, commissioned for the purpose of this evaluation.
We re-analyzed pre-existing data sets whenever possible to ensure that the indicator definitions were
correct and consistent. Preliminary results were reviewed in meetings of the evaluation team with
representatives of the Ghana Health Service (GHS), the Ghana Ministry of Health (MOH), the Ghana
statistical service (GSS) and the UNICEF country office in Accra, Ghana in July 2008.
Coverage and family practice indicators.
We reanalyzed existing household survey data to calculate the ACSD priority coverage and family
practice indicators.
As described above, these indicators are consistent with those used
7,8
internationally for monitoring progress toward the Millennium Development Goals and are presented
in appendix D. Appendix E provides the specific survey questions used for the indicator calculations.
Nutrition and mortality indicators.
We reanalyzed existing household surveys to calculate the priority nutrition indicators using the 2006
12
Appendix J and section 6 present more details on these methods. For
WHO Growth Standards.
calculation of priority mortality indicators, the evaluation team analyzed mortality retrospectively, using
direct under-five mortality estimates based on full birth histories collected in the 2007 MICS
supplemental survey in the HIDs. Estimates of under-five mortality in the comparison area were
based on available direct and indirect estimates.
Intervention area.
The intervention area included the Upper East region (UER), selected for ACSD “high-impact”
implementation. When ACSD was first implemented, the Upper East region comprised six districts:
Bawku East, Bawku West, Bolgatanga, Bongo, Builsa, and Kasena-Nankana. In 2005, new health
districts and boundaries were defined, these eight districts in Upper East region are: Bawku
Municipality, Bolgatanga Municipality, Bongo, Builsa, Bawku West, Kasena-Nankana, Guru Tempane
and Talensi Nabdam (Figure 3). Throughout the body of this report and appendices, we refer to the
six “high-impact” districts (HIDs) defined at the inception of ACSD, unless otherwise noted.
Comparison area.
The main comparison area is the remainder of Ghana excluding the urban areas of Greater Accra and
Ashanti regions (Accra and Kumasi). We have excluded Accra and Kumasi because access to
services and living conditions in these areas differ considerably from the predominantly rural HIDs.
Intervention activities.
We documented the timing and scale of intervention activities using information collected from field
visits to the HIDs, key informant interviews and document review, such as administrative and
supervision reports and monitoring data.
Equity.
To examine inequities, we performed analyses of selected intervention coverage and impact
measures stratified by sub-groups of the population, including household assets (expressed in
quintiles), sex of the child, place of residence (urban/rural) and ethnic group.
Contextual factors.
We collected standard information on contextual factors, defined above, in order to assist in
interpretation of the results and the potential contributions of ACSD. Certain elements, such as
economic status, ethnicity and access to clean water were re-analyzed for HIDs and comparison
areas using existing household survey data. Field visits to the HIDs, key informant interviews and
IIP-JHU | Retrospective evaluation of ACSD in Ghana
5
document review provided contextual information not available in existing surveys. A program
mapping exercise, carried out by investigators at Kwame Nkrumah University of Science and
Technology (KNUST), documented health and development activities in the HIDs and nationally
between 1999 and 2007. Appendix B and M provide further details on the methods used to collect
contextual factors.
2.2
Data sources and methods
Tables 1a and 1b summarize the different types of information used in the evaluation. The 1998-9
and 2003 Demographic Health Surveys (DHS) and the 2006 Multiple Indicator Cluster Survey (MICS)
with a supplemental survey in the Upper East region (HIDs) conducted in 2007 served as the primary
data sources for estimates of intervention coverage and nutrition in the HIDs and comparison area.
For estimation of the endline coverage and nutrition results in the HIDs, we utilized the Supplemental
MICS 2007; the 2006 national MICS was utilized to provide endline estimates in the comparison area,
excluding the HIDs and urban areas of Greater Accra and Ashanti regions. We did not merge the
MICS 2006 data for the HIDs with the supplemental MICS 2007 data due to incompatible sampling
strategies and the small sample size of the data in the HIDs (Upper East region) in the 2006 MICS.
The 2007 supplemental MICS included a full-birth history module used to estimate child mortality both
before and after ACSD implementation. The full-birth history method allows the calculation of period
estimates of mortality ranging from the previous 12 months to 10 or more years in the past. No
comparable data was available for the comparison area. Estimation of under-five mortality in the
comparison area was based on indirect child mortality estimation as measured in the DHS 2003 and
MICS 2006, and direct estimates from DHS 2003. Section 7 describes the mortality analysis methods
in more detail.
Other survey data were available, but given lesser prominence in the analyses because they did not
fully meet the quality criteria established for the evaluation. These criteria were: 1) full data sets and
documentation, including sampling weights, available to the evaluation team so that the data could be
reanalyzed using the standard definitions for priority indicators; and 2) no more than 5 percent missing
values on key socio-demographic variables (e.g., child age) or the variables needed to construct the
priority indicators. We did not use data from the Integrated Health and Nutrition Survey (IHNS) 2002
and the CDC-ACSD 2003 survey in the primary analyses because they did not fulfill these criteria.
However, we use these data to explore time trends between 1998-9 and 2006-7. Descriptions of the
methodology and conduct of surveys used in the evaluation are presented in appendix F and full
documentation of 2003 ACSD-CDC survey data quality issues is available upon request from IIP-JHU
evaluation team.
Table 1b presents sources of information used in the documentation of intervention activities and
contextual factors. We collected information through: 1) review of documents, including administrative
and monitoring reports; 2) key informant interviews; and 3) searches and review of published and grey
literature. Technical staff at UNICEF-Ghana provided input and revisions throughout the process of
documentation.
Due to the retrospective nature of the evaluation, it was difficult to collect complete and standardized
information on ACSD implementation activities and other health activities in the Upper East region.
The collaborative nature of ACSD makes it difficult to distinguish which activities were: 1) carried out
as part of the ACSD program, 2) carried out with only partial technical and/or financial support from
the ACSD program, or 3) carried out by ACSD partners, but independent of the ACSD program. In
some cases, the information presented in administrative reports was inconsistent; for example, annual
reporting of the number of bednets treated varied slightly. Appendix C notes observed discrepancies
in implementation reports.
6
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Table 1a: Data sources for independent retrospective evaluation of ACSD in Ghana, populationbased surveys.
TYPE OF DATA
DESCRIPTION
USE IN EVALUATION
Populationbased surveys
that met
inclusion
criteria
DHS 1998/1999: Nationally representative
household survey conducted from November
to February 1999.
Used to establish baseline
levels of priority coverage
and nutrition indicators in
HIDs and comparison area.
DHS 2003: Nationally representative
household survey conducted from July to
October 2003.
Used to estimate interim
coverage and nutrition
indicators in HIDs and
comparison area.
MICS 2006: Nationally representative
household survey conducted from August to
November 2006.
Used to estimate priority
coverage and nutrition
indicators in HIDs and
comparison area.
MICS supplemental 2007: Household survey
in Northern, Upper West and Upper East
region conducted from September to
December 2007 with additional EA’s collected
in February 2008.
Used to estimate endline
coverage and nutrition
indicators in HIDs. Used for
retrospective estimation of
mortality in HIDs.
IHNS 2002: The Integrated Health and
Nutrition Survey in Northern, Upper East, and
Upper West regions conducted from February
to March 2002.
Reported in appendices, but
given limited weight in
analysis due to availability of
a usable datafile.
CDC-ACSD 2003: Household survey of 2341
households in the Upper East region carried
out from July to September 2003.
Reported, but given limited
weight in analysis due to
concerns about data quality.
Other
populationbased surveys
IIP-JHU | Retrospective evaluation of ACSD in Ghana
7
Table 1b: Data sources for independent retrospective evaluation of ACSD in Ghana, routine data,
administrative reports and key informant interviews.
TYPE OF DATA
DESCRIPTION OF KEY DOCUMENTS
USE IN EVALUATION
Routine health
information
system data
Routine data collected through health facilities
pertaining to intervention coverage, compiled at
the local, regional and national levels.
Documentation of MOH
and ACSD activities.
Administrative
reports
Annual UNICEF reports: Three administrative
reports from 2003 – 2005 detailing
implementation and inputs;
ACSD annual reports and presentations – Upper
East region: Eight reports/presentations on ACSD
progress 2004 - 2006, one EPI+ report 2004;
Ghana Health Service: Upper East region Health
Sector Annual Reviews: 2000 – 2006;
Documentation of
ACSD and partners’
activities.
Bawku West annual reports: five health sector
update reports: 2004 – 2006;
IMCI training/monitoring reports: Nine documents
prepared by the regional offices and KNUST.
8
Job aids and
tools
Job aids and tools, such as visual aids and
register books, used in the implementation of
ACSD were collected and reviewed where
possible.
Summary
report
UNICEF Assessment of ACSD, 2004.
Program
mapping of
development
activities in
UER and
nationally
KNUST contracted to perform sub-study on
partner activities in UER and nationally;
(Appendix M presents the full methods and
sources list).
Key informant
interviews
Approximately 24 interviews at the national,
regional and district level: see appendix B for
summary.
Documentation of
ACSD activities and
contextual factors.
Working
discussions
Field visit and discussions: November 2006;
Review of preliminary results: July 2008.
Discussion and
documentation of
ACSD activities and
contextual factors.
Documentation of
ACSD and partners’
activities.
Documentation of
ACSD activities.
Documentation of
contextual factors.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
2.3
Analysis
13
We employed the Habicht et al framework for real-life evaluations. Starting with an adequacy
evaluation, we assessed whether trends in coverage indicators were moving in the expected direction,
and whether goals were met. Next, we carried out a plausibility evaluation, defined as a controlled,
non-randomized study that assesses whether observed impact can be attributed to program
implementation. ACSD in Ghana was a combination of separate interventions – vaccines, mosquito
nets, vitamin A supplementation, etc – that are highly efficacious if delivered at optimal coverage. The
evaluation did not assess the efficacy of these interventions, but instead focused on their impact when
delivered under routine conditions. We carried out the analysis of coverage and nutrition in four
steps, explained below. Section 7 describes the analysis of under-five mortality.
Step 1: Generating indicator levels for each survey in the analysis
Objective: To describe levels of priority indicators for coverage and nutrition in all surveys included in
the analysis, overall and for specific subsets of children defined by age, sex, geographic location of
the household, mothers’ education and socioeconomic status, where sample sizes permit. We
applied standard indicator definitions to the reanalysis of all datasets to ensure the comparability of
indicators over different surveys. For each indicator, only data for women and children with known
responses for that indicator were included in the analyses; cases with missing or unknown data were
excluded. The point estimates of indicators presented here may therefore differ slightly from those
calculated using standard DHS and MICS tabulation programs, which do not exclude missing records
from the analyses.
Step 2: Comparing rates of change over time within each ACSD district (“time trends”).
Objective: To determine whether there are statistically significant differences in indicator levels within
HIDs from before ACSD was implemented to after ACSD was implemented in ACSD areas, with a
mid-point during the process of implementation where adequate data are available, overall and for
specific subsets of children. This step refers to the adequacy evaluation.
Step 3: Comparing rates of change between ACSD and non-ACSD districts within each
country (“time trend with comparison”).
Objective: To determine whether there are statistically significant differences in the rates of change for
indicator levels between the HIDs and comparison area where ACSD was not implemented (the
comparison area is comprised of the rest of Ghana, excluding Accra, Kumasi and the HIDs), overall
and for specific subsets of children.
Step 4: Attributing improvements to ACSD and related child survival activities at country
level.
Objective: To determine whether any statistically significant changes in indicator levels can be
attributed to ACSD activities, including activities implemented by others in collaboration with ACSD
and the national child survival plan, overall and for specific subsets of children. Steps 3 and 4 refer to
the plausibility evaluation, assessing whether progress was greater in the ACSD than in the
comparison area, and whether or not external factors can account for these differences.
For all comparisons across time and geography, we initially calculated a simple chi-square statistic of
difference. The simple chi-square statistic does not take into account the design effect of the survey,
thus it under-estimates the variance. If no statistical differences were observed using the simple chisquare statistic, we assumed that none would be observed after the design effect was taken into
consideration (adding to the variance) and that the groups were therefore not statistically different
from one another. For comparisons with a significant chi-square, we calculated standard errors and
95 percent confidence intervals that take into account the survey design effect, using the Taylor
Linearized Variance method. We used a “difference-in-differences” approach to compare whether the
change in each indicator over time differed significantly between the HIDs and comparison area.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
9
10
IIP-JHU | Retrospective evaluation of ACSD in Ghana
3. Characteristics of the “high-impact” districts and comparison
area
This section presents pertinent characteristics of Ghana as a whole
and the HIDs and the comparison area. We emphasize differences
between the HIDs and comparison area, as well as factors that have
changed over the evaluation period to help guide the interpretation of
evaluation results. Some of the quantitative results (table 2) presented
here are based on our reanalyses of available survey data, because
these provide the most recent information disaggregated by the HID and
comparison area. Appendices A and M present additional information
on the geographic, socio-demographic, economic, health and health
service factors in Ghana and the UER.
3.1
Figure 2: Map of Ghana and
its neighbors
The Ghana context
Ghana, located in West Africa, maintains three international boarders
and a coast off the Gulf of Guinea (Figure 2). Togo is situated to the East, Cote d’Ivoire to the West,
and Burkina Faso to the North and Northwest. Great Britain established a colony in 1874 known as
the Gold Coast, and Ghana declared independence in 1957. The first president of Ghana, Dr. Kwame
17
Nkrumah was overthrown in a military coup in 1966. A cession of military leaders ruled Ghana until
Jerry Rawlings seized power in 1981 and gradually restored civilian rule, with the first free elections in
17
1992. The current president John Agyekum Kufor holds office in his second and final term ending in
December 2008.
18
The
Of Ghana’s estimated 23 million population, 38 percent are younger than 15 years old.
estimated growth rate is currently 1.9
percent with a total fertility rate of 3.8
19
births per woman. In 2000, 41 percent
Box 2:
19
Wellof the population was urban.
Overview of child health in Ghana
endowed
with natural
resources,
Ghana’s per capita output is twice that
Causes of under-five deaths in Ghana*
of neighboring West African countries.
Despite prosperity relative to its
Pneumonia
Malaria
15%
27%
neighbors, Ghana maintains a 5.7 billion
33%
(US$) debt, 26 percent of the Gross
Injuries
3%
National Income. According to a new
Ghana
Living
Standards
Survey
reported by the World Bank, poverty
levels have dropped from 52 to 29
HIV/AIDS
6%
percent between 1992 and 2005.
3.2
Measles
3%
Child health in Ghana
Diarrhea
12%
Neonatal
29%
1990
2006
Mortality rates (per 1000 live births)**
Under-five
120
Infant
120
76
Prevalence of undernutrition***
Stunting (% mod + severe)
28
Underweight (% mod + severe)
13
14
15
16
Sources: *WHO, 2006 ; **SOWC ; ***MICS 2006
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Ghana had an estimated population of
3.2 million children under age five in
2006. The under-five mortality rate has
stagnated at 120 per 1000 live births
between 1990 and 2006, falling short of
progress needed to achieve the twothirds reduction from 1990 levels defined
by the fourth Milliennium Goal (40 per
1000 live births). Box 2 shows the major
causes of under-five deaths in Ghana in
14
Almost
2003 as reported by WHO
one-third of all under-five deaths occur
in the neonatal period. Among these
deaths,
infections
account
for
11
approximately one-third (32%) with the remainder attributed to preterm births (26%), asphyxia (23%),
congenital (6%) tetanus (4%) and other causes (9%). Child undernutrition is also a problem in
Ghana. In 2006, estimates using the new WHO growth standards indicated that 28 percent of
children under five years of age were either moderately or severely stunted, 6 percent were wasted,
20
and 13 percent were underweight. Appendix A includes the full profile of maternal, newborn and
20
child health from the Countdown to 2015 2008 report.
3.3
Selection of the ACSD “high-impact” districts in Ghana
UNICEF and the Government of Ghana
Figure 3: Map of eight health districts, as
(GoG) selected the six districts in the
of 2005, Upper East region, Ghana
Bawku Mun.
Upper East region (UER) for “highimpact” implementation of ACSD. UER
Kassena/Nankana
Bongo
is one of the poorest regions in Ghana
and had high levels of under-five
Bawku
Bolgatanga M.
mortality, contributing to its choice for
West
GaruTempane
implementation of the ACSD approach.
Talensi-Nabdam
UNICEF had been supporting activities
in the Bawku West and Builsa districts
Builsa
in the UER since 1995; the ACSD
“high-impact” districts (HIDs) included
these two districts as well as the
remaining four districts in the UER.
Redistricting occurred in 2005 and the
UER is now comprised eight districts
(Figure 3). Key informants reported
that other factors considered in the
choice of the UER included: 1) political
stability; 2) a strong regional health team; and 3) a passable road network, ensuring high accessibility
to the entire region.
3.4
Socio-economic and demographic factors
Figure 4 shows the incidence of poverty in the HIDs and the geographic comparison area as
21
measured in the 2000 Housing and Population Census and the Ghana Living Standards Survey 4.
The poorest districts are located in the northern areas of the country, with the six HIDs, noted in the
call-out box, among the poorest in the country. Table 2 presents socio-demographic variables as
measured in household surveys in 1998-9, 2003 and 2006-7 in the HIDs and comparison area.
Based on our re-analyses of the DHS 1998-9, DHS 2003 and MICS 2006-7, households in the HIDs
remained significantly poorer relative to the comparison area throughout the evaluation period
(p<0.001), based on measures of household assets. The proportion of women with primary and
higher education was significantly greater in the comparison area than the HIDs across all time points
(p<0.001). In 1999 and 2003, almost two-thirds of women in the HIDs reported no schooling,
decreasing to 58 percent of women without schooling in 2006-7. Similarly, female literacy was two
times greater in the comparison area as compared to the HIDs in 1999 and 2003. The difference in
literacy between the HIDs and comparison area narrowed in 2006-7, but was still statistically
significant (p<0.001). The majority of households in the HIDs are of the Mole-Dagbani, Gruma and
Grussi ethnic groups, while the comparison has much larger proportion of Akan, Ewe and Ga
households (p<0.001). The apparent decline in the Gruma households in the 2003 DHS is thought to
be due to different classifications of responses between surveys or the sampling error.
3.5
Environmental characteristics
The HIDs fall into Ghana’s savannah zone, with the forest and coastal zones in the central and
southern areas of the country. The HIDs experience much less rainfall than the central and southern
22
areas of Ghana, with particular drought hazards between January and March in the HIDs.
Accordingly, malaria transmission is seasonal in the HIDs, with highest transmission between June
23
and October. Models predict that the length of annual malaria transmission is longer in the southern
24
areas of the country, becoming more seasonal in the northern zones, although other models predict
12
IIP-JHU | Retrospective evaluation of ACSD in Ghana
similar transmission intensities and prevalence of parasitemia among children less than five years of
25
Before and during ACSD
age in the northern, central and southern areas of the country.
26-28
Evidence suggests that
implementation, resistance of malaria parasites to chloroquine grew.
levels of chloroquine resistance differed by geographic region, with the highest chloroquine resistance
29
in the south and the lowest resistance levels in the north of the country.
The HIDs are significantly more rural than the comparison area (p<0.001), which excludes the major
metropolitan areas of urban Greater Accra and Ashanti regions (table 2). The apparent decrease in
rural residences between 1999 and 2003 is likely due to previously rural localities reclassified as
21
“urban” (population greater than 5,000) after the 2000 census. The proportion of households with
access to an improved water source was greater in the HIDs than the comparison in 1998-9 and
2006-7 (<0.001). In both areas, access to improved water sources significantly increased, with
greater increases over time in the comparison area. Less than five percent of households in the HIDs
reported access to improved sanitation facilities in 2003 and 2006-7. Access to improved sanitation
was significantly greater in the comparison area (p<0.001), but still less than 15 percent in 2003 and
2006-7.
Our investigations did not reveal any natural disasters in the HIDs over the primary evaluation period.
However, severe flooding took place in the northern regions of Upper East, Northern and Upper West
in August to November 2007, prompting the government to declare a state of disaster. Data collection
for the Supplemental MICS 2007 endline survey was on going at this time; we discuss the implications
of the flooding on intervention coverage (section 5) under methodological challenges.
Figure 4: Incidence of poverty in Ghana districts as measured by the 2000 Housing and
Population Census and 1999 Ghana Living Standards Survey
21
Source: Coulombe, 2005
IIP-JHU | Retrospective evaluation of ACSD in Ghana
13
Table 2: Selected characteristics of the “high-impact” districts and comparison area, as measured in the DHS 1998-9 and 2003, and MICS 2006-7, Ghana.
1998/99 DHS
2003 DHS
HIGH IMPACT GEOGRAPHIC
DISTRICTS COMPARISONS¥
INDICATORS
n*
%
n*
%
HIGH IMPACT GEOGRAPHIC
DISTRICTS COMPARISONS¥
p
n*
%
n*
%
<0.001
279
<0.001
310
72%
12%
16%
3870
31%
22%
46%
<0.001
309
14%
3853
37%
2007 S. MICS
2006 MICS
HIGH IMPACT
DISTRICTS
GEOGRAPHIC
COMPARISONS¥
p
n*
%
n*
%
<0.001
3324
<0.001
3288
58%
21%
21%
4167
30%
22%
48%
<0.001
3257
27%
4141
41%
p
Wealth quintiles
Poorest
Poorer 271
Poor
Less poor
Least poor
43%
37%
3%
4%
14%
Education among women
None 288
Primary school
Secondary school+
74%
10%
16%
3588
30%
20%
50%
20%
3588
53%
4615
17%
22%
16%
25%
20%
57%
15%
5%
14%
8%
4497
13%
20%
21%
24%
22%
287
Literacy among women
Ethnicity
Akan(Asante, Akwapim,
Fante and Other Akan)
Ewe
Gruma
288
Mole Dagbani
Grussi
Ga/Adangbe, Guan, Hausa,
Mande
Other
1%
0.9%
29%
43%
21%
271
89%
4615
79%
<0.001
279
80%
4497
70%
Improved water source 271
70%
4613
53%
<0.001
277
66%
4490
Rural residence
3588
58%
18%
5%
5%
2%
<0.001
310
0.3%
0.2%
1%
41%
17%
3868
52%
15%
3%
15%
1%
<0.001
3288
33%
28%
19%
10%
10%
0.6%
0.2%
28%
45%
12%
4344
4167
7%
8%
19%
31%
35%
47%
15%
2%
12%
1%
2%
8%
2%
10%
8%
11%
3%
5%
38%
4%
7%
12%
<0.001
<0.001
<0.001
<0.001
0.11
3324
78%
4344
71%
<0.001
61%
0.43
3316
83%
4297
72%
<0.001
12%
<0.001
3316
4%
4339
13%
Hygiene§
Improved sanitation
n/a
n/a
279
4%
4492
¥Excluding urban Great Accra and Ashanti region and High Impact districts
*Weighted
§ MDG definitions
14
IIP-JHU | Retrospective evaluation of ACSD in Ghana
3.6
Baseline health conditions
Section 3.2 presents a profile of child health in Ghana as a whole, including the cause of death profile.
Cause of death information is not available disaggregated by HIDs and comparison area. However, a
vitamin A trial conducted in the Kassena-Nankana district (one of the six HIDs) in 1989 to 1991 found
that children aged six to 59 months died from diarrhea (26%), malaria (23%), measles (19%),
30
The proportionate causes of child mortality found in the study
pneumonia (13%), malnutrition (8%).
were slightly different than 2008 estimates for Ghana, likely due to decreases in measles deaths since
31
and more HIV/AIDS deaths nationally and in later years. However, these findings suggest
1991
that the primary causes of death in the HIDs are similar to Ghana as a whole. We present and
consider baseline levels of undernutrition and under-five mortality in sections six (nutrition) and seven
(mortality).
3.7
Health service characteristics
Availability of health services.
The health services of Ghana have been decentralized, with regions and districts having more
autonomy than in the past. Since Alma-Ata in 1978, there has been a focus on development of
primary health care at the sub-district level, mostly through the training of health providers and
32
installation of health facilities. Table 3 presents the approximate coverage of all health facilities in
the HIDs and comparison area in 2002 and 2007. According to the Ghana Health Service (GHS)
33
annual reports, the HIDs had approximately one health facility per 15,500 population in 2002, with
coverage increasing to approximately one facility per 10,000 population in 2007. In the comparison
area, coverage was estimated at one facility per 12,000 population in 2002, and increased to one
facility per 10,000 population in 2007. These differences and increases are difficult to interpret, as
available measures included all public and private health facilities, maternity centers, as well as
nutritional rehabilitation centers.
Community-based Health Planning and Services (CHPS)
compounds, discussed below, were not included in these estimates.
The Community-based Health Planning and Services (CHPS), is an expansion of the primary health
care concept, through community engagement and placement of community health officers (CHOs) to
make primary health services more accessible. It began in the Kassena-Nankana district (one of the
34-36
and has since been expanded to other communities in the
HIDs) as a research project in 1994,
HIDs. In the HIDs, the GHS in UER reported seven functioning compounds in 2002 and 82
functioning compounds in 2006. The catchment area for community health officer or CHPS
37
compound is to be comprised of approximately 3000 individuals. The MOH planned to deploy 1570
community health officers (community health nurses) to various communities nation-wide by 2006;
however, implementation is far behind schedule and only 258 CHPS compounds were reported to be
functioning in the comparison area in 2006. Coverage of CHPS compounds in 2007 in the HIDs was
much greater (approx 11,220 population per CHPS facility) than in the comparison area (58,000
population per CHPS compound).
Table 3: Coverage of health facilities and CHPS compounds in 2002 and 2006, Ghana.
2002
Population**
Hospitals
Total health facilities***
CHPS compounds
HIDs (UER)
920,089
6
59
7
GHANA,
EXCLUDING
ACCRA & HIDs*
15,077,264
80
1244
32
2007
Total health facilities***
CHPS compounds
92
82
1425
258
YEAR
INDICATOR
*estimates exclude Greater Accra, but not urban Ashanti region
**estimates from 2000 Housing and Population census
***Includes hospitals, clinics, health centers and maternity homes, as well as private facilities; 2002
estimates taken from the GHS 2002 annual report; 2007 estimates from the GHS annual report and
33
website
IIP-JHU | Retrospective evaluation of ACSD in Ghana
15
Changes in health policies.
A number changes in national policies influencing child health took place between 2000 and 2007. In
2002, Hib vaccination was introduced into national policy and included in routine EPI vaccination
schedules. Due to growing chloroquine resistance, national policy changed to recommend ACTs as
the first-line antimalarial drug in April 2004. ACTs became available in health facilities & CHPS
compounds in late 2005; the community-based distribution of ACTs was not authorized until late
2007.
The GoG introduced the National Health Insurance Scheme (NHIS) in 1998, but inadequate and slow
reimbursement limited its effectiveness. The GoG passed a law concerning the NHIS in 2003 to
support districts to set up mutual health insurance schemes and to initiate activities to recruit and
register clients. The NHIS automatically covered children less than 18 years of age if parents have
paid at least the minimum contribution. No estimates of NHIS coverage were available at the writing
of this report, although the 2007 Supplemental MICS survey will provide estimates of coverage for the
Northern, Upper East, Upper West and Central regions.
3.8
Other projects that may impact child health
Child health partners and activities in the HIDs (UER).
As Belch states in his background document on Upper East region: “If signboards are held to
38
constitute development, then Northern Ghana has no further need of it. ” A multitude of international
and local development partners and NGOs implemented child survival, health and other development
activities in the HIDs both before and during ACSD implementation. Table 4 provides a summary of
the activities and approximate coverage of selected health projects in the HIDs from 1998 to 2007;
appendix M provides further details. We documented major child health and nutrition activities in the
HIDs during this period, given available data; this list should not be considered comprehensive of all
child health activities in the HIDs.
Many activities supported by partners in the HIDs focused efforts on child nutrition. The LINKAGES
project, funded by USAID and carried out by Academy for Education Development (AED), provided
support from 2000 to 2003 for activities to improve infant feeding practices in the northern regions,
including the HIDs. This project trained a variety of actors and provided technical support to NGOs,
the GHS, and UNICEF to implement packages to promote appropriate infant feeding, including early
initiation of breastfeeding, exclusive breastfeeding and complementary feeding.
There are
approximately 30 supplementary feeding centers in the HIDs (Upper East region) which provide
supplementary feeding for children and mothers through support from the World Food Program and
impart educational messages about child nutrition and survival. Fifteen nutritional rehabilitation
centers have also been established with support from churches, Catholic Relief Services (CRS) and
World Vision International.
With support from the American Red Cross, the Ghana Red Cross Society (GRCS) established over
60 mothers’ clubs in the Bawku East, Bawku West and Bolgatanga districts to promote child health
and infant feeding, and provide home based management of fever and diarrhea in 1999. The
mother’s clubs and health and nutrition promotion activities expanded over time, covering 200
communities in 2002, partially in collaboration with the LINKAGES project described above. Between
1999 and 2000, GRCS served an estimated 16,500 children under-five annually in the HIDs through
these activities. Starting in 2003, GRCS collaborated with the UNICEF ACSD project to train and
equip over 1800 community-based agents (CBAs) to carry out health promotion and community
management of common illnesses. Section 4, “ACSD as implemented in Ghana” describes these
activities in further detail.
16
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Table 4: Summary of selected child health and nutrition projects and activities outside of routine
services in the HIDs from 1998-2007, Ghana
PROGAM
CRS
Diocesan
Health and
development
programmes, in
coordination
with CRS
Ghana Red
Cross, UER
(with support
from EU,
AMCROSS &
UNICEF)
LINKAGES
Project (USAID
supported, AED
as implementers)
TYPE OF ACIVITY
Trainings & community
meetings f or improved nutrition;
on-going support to f eeding
centers
1 hospital & 7 health centers;
w ith outreach points
GEOGRAPHIC
COVERAGE
BEST ESTIMATE OF
COVERAGE OR
INTENSITY
TIMING
Bongo district
over 200 trained
2000-2002
n/a
Avg. 235 deliveries
annually in 1998-2002;
Six communities in
Avg. 1014 deliveries
Bongo, Builsa &
annually in 2004-2006
Avg. of 7422 ANC visit
KassenaANC
annually 1999-2006
Nankana
Avg. 21,045 children
Child w elf are clinics
served annually in 20012005
C-IMCI training
20 staf f trained
47 communities
~16,500 children served
(99) to 200
annually through mothers
communities (01) clubs; training of mothers in
in Baw ku West,
mothers' clubs in CS
Baw ku East,
interventions & inf ant
HBM of malaria & diarrhea; ARI
Bolgatanga
f eeding
recognition & ref erral; inf ant
Training and support
f eeding; immunization promotion
(bicycles & ,medicines) of
1820 w omen through
900 communities
ACSD project
in UER
Training and support of
9750 w omen
CHWs/volunteers
Workshops w ith ~100
Message & materials
participants f rom radio
development to promote BF,
stations, GHS, CRS, GRCS,
EBF, complementary f eeding
UNICEF
Training of partners &
over 150 participants
providers in nutritional BCC
(health staf f , NGOs, radio)
Training of trainers f or motherUER (& UWR &
Training of over 50 trainers
to-mother support groups f or
NR)
nutrition BCC
Reproductive health / skilled
deliveries
Over 400 Mother-to-mother
support groups f ormed &
supported by CRS, GRCS,
GHS, UNICEF, ACDEP
Formation of mother-to-mother
support groups f or improved
inf ant f eeding & nutrition
Radio broadcasts
Navrongo
Health
Research
Center
World Vision
International
Bongo Area
Development
Program
Child and maternal health
research
entire KasenaNankana district
Nutrition rehabilitation ceters
4 communities in
Bongo district
Logistic/equipment support to
district
Bongo district
Supplemental f eeding to school
children
Training on
nutrition/breastf eeding
Bongo district
Bongo district
IIP-JHU | Retrospective evaluation of ACSD in Ghana
500 in UER, UWR & NR
Early trials on
ef f ectiveness of ITNs,
vitamin A; CHPS delivery
strategy; malaria treatment
and prevention via
antimalarials
4 centers constructed
Scales, vaccination, vitamin
A, dew orming; See
Appendix L f or details on
inputs
Approx. 2000 children
served annually
Approx. 500 mothers
trained annually
1998 to
present
2005
1999-2002
2003-2005
2006
2000
2000-2003
2001-2003
2001-2003
2000-2003
1993-present
constructed in
1996-9
1998 - 2007
1999-2003
1999-2007
17
The Diocesan Health Services was active in the HIDs of Bongo, Builsa and Kassena-Nankana, with
one hospital and seven health centers with outreach points. Through these services, approximately
7000 ANC visits took place annually and a skilled provider attended 1000 deliveries annually.
Between 2001 and 2005, these services served approximately 21,000 children annually through child
welfare clinics providing preventative services, such as vaccinations, and curative care. Also located
in Kassena-Nankana district, the Navrongo Research Center conducted effectiveness trials on
30
35
supplementation of children with vitamin A, use of insecticide treated bednets for children and
39
34-36
over the last decade. The
pregnant women and the CHPS strategy for primary health care
Navrongo Center has continued to implement and conduct research around these and other
40
interventions in the entirety of the Kassena-Nankana district.
Other NGOs, among them Rural Help Integrated, Action Aid, and World Vision International, also
conducted water and sanitation, reproductive and sexual health and community development projects
throughout the period of 1999 to 2007. Additionally, CIDA, the World Bank and the GoG supported
water and sanitation projects in over 1000 communities in the HIDs.
Child health partners and activities in the rest of Ghana.
We provide here a brief overview of the external investments in health activities taking place in the
rest of Ghana (our comparison area) both before and after ACSD, appendix M provides detailed
descriptions of these activities.
Donor support for health and HIV/AIDS in Ghana totaled
approximately US$150 million annually between 2003 and 2007, the majority in grants rather than
through credit.
USAID supported promotion and marketing of ITNs, initiatives to improve the quality of care, and
community-based health & planning services (CHPS), as well and family planning and HIV/AIDS
activities in the comparison area before and during ACSD implementation. These activities focused in
30 target districts in the southern and central regions of Western, Central, Volta, Greater Accra,
Eastern, Ashanti & Brong-Ahafo and were carried out by partners including: Ghana sustainable
change project; Population council; JHPIEGO; Quality Health Partners; Engender Health; Abt
Associates; AED; CRS, Futures Group, DELIVER; Opportunities for Industrialization Centers
International; and Netmark. USAID supported technical assistance and partner programming with
annual budgets of approximately US$9-12 million. Approximately 50 percent of these funds
supported child survival and 50 percent supported HIV/AIDS activities through 2002; in 2003 to
present, approximately 30 percent of funds were targeted to child survival projects and 70 percent for
HIV/AIDS.
Japan International Cooperation Agency (JICA) provided support to EPI programs, GHS static and
outreach services, and HIV/AIDS logistic support in the south of the country and nationally. The
Global Fund to Fight Aids, Malaria and Tuberculosis (Global Fund) awarded the national MOH almost
US$9 million for malaria control in 2003; another US$38 million grant to control malaria followed in
2005. Additionally, the Global Fund has granted approximately US$51 million for HIV/AIDS
programming and US$24 million for tuberculosis programming to date, starting in 2003. The Global
Alliance for Vaccines and Immunizations (GAVI) supported national vaccination initiatives with
approximately US$5 million annually.
The World Bank provided support of approximately US$35 million through 1998-2002 through the
Sector-Wide Approach (SWAp) pooled health funding mechanism and provided over US$100 million
for health programming in 2003 to 2007. The Danish International Development Agency (DANIDA)
provided approximately US$10 million annually through the SWAp for health systems strengthening
between 2003 and 2007. During this same period, the British government’s Department for
International Development (DFID) provided over US$20 million annually for health at the national
level. The World Health Organization (WHO) also contributed to national pooled funding, as well as
supporting health system strengthening and child health clinics (preventative and curative) in eight
districts in the south and central Ghana.
The Government of the Netherlands (GoN) provided approximately US$10 million annually in 2003 to
2005 for health nationally. In 2006 and 2007, the GoN increased their support to more than US$28
million annually. Part of this investment was in support of the GHS child health strategy, High Impact
Rapid Delivery (HIRD), which is based closely on the ACSD approach. In addition to the GoN,
18
IIP-JHU | Retrospective evaluation of ACSD in Ghana
DANIDA supported the roll out of HIRD in the Northern, Upper West, Upper East and Central regions,
with US$0.80 to US$1.4 million for HIRD provided to each of the four regions in 2006. In 2006, DFID
donated US$11 million to UNICEF for the purchase and national distribution of almost two million
long-lasting ITNs to children under-two through a national campaign at the end of 2006.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
19
20
IIP-JHU | Retrospective evaluation of ACSD in Ghana
4.
ACSD as implemented in Ghana
This section provides an overview of the ACSD activities in the HIDs. We consider adaptation of the
generic ACSD package, funding, results-based planning and the timeline of activities; the inputs and
activities for each ACSD component are then briefly described. Appendix C includes further textual
description of the intervention implementation and detailed timelines of ACSD activities.
4.1 Introduction and adaptation of the generic ACSD intervention package
UNICEF introduced the ACSD approach to the Government of Ghana (GoG) in late 2001, followed by
planning meetings with regional officials in the Upper East and Northern regions. According to key
informants, UNICEF presented the generic ACSD framework to regional and district officials,
assessed current levels of intervention coverage, set coverage targets and planned how to achieve
the ACSD targets. As described above, various development partners—including UNICEF, the
Ghana Red Cross Society, and Navrongo Health Research Center—in collaboration with the Ghana
Health Services (GHS) had been supporting child survival activities in selected districts and
communities of the UER for over a decade. Interventions such as immunization, vitamin A
distribution, iron and folic acid supplementation for pregnant women, and the promotion of exclusive
breastfeeding, complementary feeding, and iodized salt were well established before ACSD was
introduced, albeit at less than ideal coverage levels. Before ACSD, some districts had started to
implement the promotion and distribution of insecticide treated nets (ITNs), as well as community
case management of diarrhea and malaria.
ACSD drew on the experiences of these programs to package the ACSD strategy of interventions for
region-wide scale-up. Additionally, the ACSD strategy supported the development training materials
and scale up of C-IMCI volunteers and introduced IPTp, PMTCT, deworming and post-natal
supplementation with vitamin A. The ACSD strategy was implemented at the regional, district and
sub-district levels in partnership with the Ghana Health Service (GHS) and other development
partners.
4.2 Funding
UNICEF-Ghana received support of US$3.8 million through Canadian CIDA for implementation of
ACSD, equivalent to approximately US$25 per child under-five years of age in the HIDs, as well as
ii
US0.7 million in resources from other donors from 2002 to 2004. The last transfer of CIDA funds was
in 2003, and by the end of 2004, expenditure was 97 percent of the initial funds. At the end of the
CIDA funds, the government continued in EPI+ and ANC+ through routine services. There was a lag
in external support for activities for over one year, until the Government of the Netherlands and
DANIDA provided significant funding for the northern regions to continue ACSD activities.
4.3 Results-based planning
ACSD implementers chose the package of interventions to be implemented in the four “high-impact”
countries based on evidence and cost-effectiveness. The ACSD strategy set specific targets for each
package and UNICEF monitored results actively at the regional, district, sub-district and community
10
Key informants noted that GHS implementers
level, in coordination with GHS implementers.
presented a report bi-annually to UNICEF to justify funds used for activities. We did not find evidence
that ACSD in Ghana included performance contracts or other innovations linking results to specific
incentives.
ii
Assuming that all funds were spent in the HIDs. We were not able to disaggregate funding by implementation
area, i.e. to identify support in the HIDs versus expansion areas. A review of ACSD conducted in 2004 estimated
10
a US$1.9 million price-tag for ACSD implementation outside of routine GHS expenditures from 2001-2003, with
an approximate expenditure of US$12.35 per child under-five over this period. UNICEF’s final report to CIDA
estimated a per capita annual cost US$0.34 through all funding sources and per capita annual costs of US$0.29
through CIDA funding for children in the HIDs and expansion regions.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
21
4.4 Time line of ACSD activities in the “high-impact” districts
UNICEF introduced the ACSD strategy to the GoG in late 2001 and logistical support for EPI+ started
in 2002, while ITN distribution and treatment programs kicked-off in early 2003. Figure 5 presents
summary timeline for the start of selected interventions within the ACSD approach, as well as for
household surveys. The C-IMCI program was scaled-up in all districts in late 2003 and ANC+ by
early 2004. Table 5 and Appendix C provide additional information about the timing of specific
activities.
Figure 5: Time line of the accelerated implementation of selected ACSD interventions and surveys
conducted to evaluate intervention coverage, 2001 - 2007, Ghana
Figure Key:
•
Grey bars represent implementation before ACSD, colored bars implementation supported by ACSD
•
Spotted area represents ITN stock-outs
•
Bars represent districts in the following order: Builsa, Bawku East, Kasena-Nankana, Bolgatanga, Bawju
West, Bongo
22
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Table 5: Start times for accelerated implementation of selected ACSD interventions in the ACSD
“high-impact” districts of Ghana.
INTERVENTION PACKAGE
APPROXIMATE START TIME IN HIDS (UPPER EAST REGION)
EPI+
Routine EPI on-going prior to ACSD; scale-up of EPI+ logistical
support began in early 2002
ITNs
On-going before ACSD in Kassena-Nankana and Builsa districts;
Started region-wide in second half of 2003
2004: first Tetanus Toxoid - Supplementary Immunization Activity
(SIA) campaigns; ACSD funded IPTp begins; postnatal vitamin A
ANC+
2004: de-worming for pregnant women
F-IMCI
2004/2005: training of facility staff
st
1 quarter 2003: Planning and budget meetings
nd
C-IMCI
th
2 -4 quarter 2003: Training of trainers and CBA training
sessions begin
2004: Sensitization workshops and full scale delivery
ITN stock-outs
2004 – 2005: Intermittent stock-out of retreatment chemicals (KO
tablets)
Late 2005 – 2006: Stock-out of ITN nets
Child Health Promotion Week
(CHPW)
May 2004
4.5 Description of ACSD activities in the “high-impact” districts
EPI+.
The EPI+ strategy in Ghana included: 1) routine immunization and periodic measles catch-up; 2)
twice yearly vitamin A supplementation of children six to 59 months of age; and 3) twice yearly deworming of children with anti-helminthic drugs. Distribution, promotion and retreatment of ITNs for
children under-five was promoted as part of the IMCI+ package in Ghana; however, we present this
intervention as part of EPI+ for consistency with overall ACSD documents.
Vaccination, vitamin A and de-worming
Delivery of routine vaccination occurs at health centers and through outreach activities, as well as
through National Immunization Days (NIDs), which occurred every quarter during the ACSD period.
The ACSD strategy in the HIDs started with EPI+ in early 2002 with US$0.5million in USAID support.
ACSD focused on developing and supporting strategies to improve defaulter tracing using communitybased surveillance systems. CBA volunteers used a register to trace children due for vaccinations.
Mop-up campaigns occurred after National Immunization Days (NIDs) to vaccinate “zero dose”
children identified by polio vaccinators. Vitamin A supplementation of children six to 59 months of age
started nationally in 1996. In 2004, NIDs incorporated de-worming, vitamin A supplementation and
tetanus toxoid (TT) supplemental immunization activities (SIA) as part of the ACSD program.
Many development partners contributed to vaccination activities and it is difficult to identify ACSDspecific contributions. UNICEF provided vehicles, motorcycles, bicycles and fuel for outreach and
supervision activities linked to routine vaccination activities. In addition, UNICEF provided logistical
IIP-JHU | Retrospective evaluation of ACSD in Ghana
23
assistance to the health sector when required. For instance, UNICEF purchased polio vaccines to
assist GHS in achieving the polio eradication goals.
Table 6 summarizes available information, extracted from administrative and summary reports, about
ACSD inputs intended to reinforce EPI+ activities. To provide rough guidance on the potential
coverage of these activities, we present several of the indicators as ratios per 1,000 children underone year of age or under-five years of age. Appendix C presents further description of EPI+ activities
and timing, as well as quantitative monitoring data.
Table 6: Description of inputs related to the accelerated implementation of the EPI+ intervention
package in the HIDs, Ghana.
DESCRIPTION OF ACTIVITY
TIMING
Provision of bicycles, motorcycles
and vehicles for outreach
activities
2002 – 2004
Training of health agents in EPI
provision, monitoring and
surveillance
2002-2007
COVERAGE
ESTIMATE
Estimated as 814 bicycles, 18
*
motorcycles and 1 truck for the district
553 refrigerator units distributed to
health facilities to support cold chain
2002 – 2004
1522 CBAsurveillance
volunteers trained
2004
54,803 vitamin A
supplements
2005
Quantitative data not available
Vitamin A supplementation
integrated in NIDs and CHPW
2004
Integration of child de-worming
into NID activities
2005
EPI+ annual totals
INTENSITY OF
ACTIVITY
2003 - 2006
170,736
antihelminthic
doses***
177,553
antihelminthic
doses***
40 per 1000
children 0-11
months of age**
356 supplements
per 1000 children
under-five**
1110 doses per
1000 children
under-five**
1154 doses per
1000 children
under-five**
Monitoring data available in Appendix C;
Table C2
*Unknown for which ACSD program transportation was purchased; cumulative total uncertain; see Table C5
in Appendices for further information
**Estimated population from 2004 projections: 153,799 under five children, 36,223 pregnant women &
38,450 children 0-11m
***Delivered through two campaigns in March and September
Insecticide-treated nets (ITNs).
ACSD-supported distribution of ITNs began in the second half of 2003, the exact start of
implementation varying by district. ITNs were distributed to the district offices, then to the volunteers
and then to the communities. The ACSD strategy employed multiple approaches for bednet delivery
and treatment:

Sale of bed nets to target groups at health centers;

Sale of bednets by commissioned volunteer sales agents accompany nurses on health
outreach sessions;

Distribution and treatment by community-based agents (CBAs) trained in C-IMCI activities;

Campaigns for distribution and retreatment.
All volunteers, CBAs and nurses involved in the ITN program received training on bed net distribution
and treatment.
ITNs were sold at a reduced price to families with children under five and pregnant women through a
chit (voucher) system. Initial insecticide treatment was provided with the net and included in the price.
24
IIP-JHU | Retrospective evaluation of ACSD in Ghana
However, as demand for ITNs increased, the subsidized nets were sold using the 20/80 rule. Target
groups could purchase 80 percent of the ITNs for 5000 cedis (~US$0.50) and non-target groups could
purchase the remaining 20 percent for 23,000 cedis (~US$2.30). Volunteers were responsible for
advising customers at the time of purchase to retreat the net every six months, through the health
centre or a volunteer. Retreatment cost 2000 cedis (~US$0.20) per net and the ITN volunteer agents
received 1000 cedis (~US$0.10) per net sold or retreated. In May 2004, nets were retreated free of
charge during national child health week. Reports indicated that although each ITN purchased came
with an initial insecticide treatment kits, supply and stock-outs of insecticide for retreatment of existing
nets was an on-going issue.
A large number of ITNs were distributed through 2005 (table 7), although key informants reported,
and monitoring data reflect, stock-outs of ITNs starting in late 2005. The GHS in the HIDs reported
procuring ITNs through the Global Fund in 2006. In late 2006, two million long-lasting ITNs were
distributed countrywide to children under-two during the national immunization and vitamin A
campaign, with support from DFIF (~$US11 million) and UNICEF. The HIDs distributed almost
90,000 long-lasting ITNs during this campaign in late 2006.
Table 7 summarizes available information, extracted from administrative and summary reports, about
ACSD inputs intended to reinforce ITN activities. Once again, to consider the potential coverage of
these activities, we present several of the indicators as ratios per 1,000 children under-five years,
even though it is recognized that the ITNs may have been used by non-targeted members of the
population. As a result, the coverage estimates below are likely overestimated. Appendix C presents
further description of ITN activities and details on exact timing.
Table 7: Description of inputs related to the distribution, promotion and treatment of ITNs in the ACSD
“high-impact” districts of Ghana.
DESCRIPTION OF
ACTIVITY
TIMING
INTENSITY OF
ACTIVITY
109,579 ITNs distributed for
children under-five
712 ITNs per 1000
children under-five*
36,223 ITNs distributed to
pregnant women
1000 ITNs per 1000
estimated pregnant
women*
132,270 ITNs distributed for
children under-five
860 ITNs per 1000
children under-five*
40,576 ITNs distributed to
pregnant women
1120 ITNs per 1000
estimated pregnant
women*
93,832 long-lasting ITNs
distributed**
610 ITNs per 1000
children under-five*
2002 –2004
Distribution of ITN
2005
2006
June 2003 –
June 2004
Re-treatment
campaigns
2005
mid 2006
Cumulative total of
Mosquito nets provided
by UNICEF
Reported
2006
COVERAGE
ESTIMATE
Approx. 82 nets retreated
per 1000 nets estimated
in the community
103 nets retreated per
25,034 nets retreated
1000 nets estimated in
the community
28 nets retreated per
6,829 nets retreated
1000 nets estimated in
the community
287,850 ITNs distributed from 2002 to mid-2006 (not
inclusive of national campaign LLITNs in late 2006)
Approximately 14,000 nets
retreated
NB: Global Fund provided 80,000 ITNs in the HIDs, included
in numbers above
*Estimated population from 2004 projections: 153,799 under five children, 36,223 pregnant women
**includes long-lasting ITNs distributed through DFID-supported national campaign in late 2006
IIP-JHU | Retrospective evaluation of ACSD in Ghana
25
IMCI+.
The IMCI+ strategy in Ghana included: 1) integrated management of childhood malaria, diarrhea, and
pneumonia at facility and community/household levels; 2) promotion of infant feeding practices,
including exclusive breastfeeding and complementary feeding; and 3) promotion of improved hygiene
and consumption of iodized salt. The IMCI+ strategy in Ghana also included distribution and
promotion of ITNs, which are discussed above.
Community IMCI
The UER has a strong history of community-based health volunteers and before ACSD, Ghana Red
Cross, Catholic Relief Services, and others supported community volunteers and community
integrated management of childhood illness (C-IMCI) on a small scale. ACSD built on and
harmonized these experiences, implementing C-IMCI at a greater scale than before. Through a
memorandum of understanding (MOU) UNICEF, Kwame Nkrumeh University of Science and
Technology (KNUST), Ghana Red Cross and Ghana Health Services (GHS) collaboratively
developed and supported a CBA training program, with almost 2000 community based agents (CBA)
trained starting in the second half of 2003 to deliver services and educational messages in 600
communities. The volunteer CBAs received training to carry out following activities:

Promotion of appropriate infant feeding practices;

Provision of health education to mothers, including recognition and referral of childhood
pneumonia;

Treatment of fever with pre-packed chloroquine, management of diarrhea with ORS;

Promotion of immunization and iodized salt;

Mobilization of communities for participation in de-worming, NIDs and other programs.
The CBA volunteers were equipped with bicycles, educational materials and health kits containing
chloroquine doses for children and infants, ORS sachets and handwashing materials, although key
informants and document review revealed that not all CBAs received bicycles, educational materials
or health kits. CBAs earn a small percentage of medicine sales, for example a CBA earns 100 cedis
(US$~0.01) for every ORS sachet sold.
Monitoring reports documented that CBAs focused on illness management and health education
activities were sporadic or absent in many cases. CBAs treated more than 80,000 children with fever
and more than 60,000 children with diarrhea between 2003 and 2006; CBAs referred less than 1000
children with pneumonia annually. In 2004, due to growing levels of antimalarial resistance, Ghana
national policy changed the first-line antimalarial to artemisinin combination therapies (ACTs). CBAs
retained chloroquine in their kits until the end of 2006, and received authorization and training to use
ACTs only at the end of 2007. Appendix C presents detailed information about childhood illnesses
treated and health education activities conducted at the community level as reported through routine
monitoring systems.
The KNUST team and the regional UNICEF office carried out monitoring and supervision of CBA
activities, at times integrated into routine supervision by the Regional Health Management Team
(RHMT). Key informants noted that integrated supervision was problematic at times: for example,
sub-district supervisors are reluctant to carry out CBA supervision without additional funds for fuel.
They also noted stronger supervision and monitoring of CBAs in CHPS zones where these activities
were incorporated in the responsibilities of the community health officers (CHOs).
In 2006, supervision teams found that out of 1366 CBAs visited, almost one-half had no bicycles,
more than half (~60%) had no health kits and one-third did not have reporting forms. We did not find
comprehensive information about retention of CBAs initially trained through ACSD; however, key
informants in Bongo district noted that 60 percent of CBAs remained active in 2006.
Facility-based IMCI
Facility-based IMCI started after C-IMCI in the HIDs. In 2005, ACSD supported the standard IMCI
training of 48 clinicians and three regional staff. The training-of-trainers at the regional level included
sessions pertained to CBA supervision. In 2006, the IMCI monitoring team evaluated IMCI-trained
prescribers and found high non-compliance with the IMCI objectives regarding assessment, diagnosis
and supervision. Standard IMCI training for facility-based providers is on-going in the HIDs.
26
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Infant feeding practices.
In addition to infant feeding promotion included in IMCI activities, UNICEF supported facilities to
implement the Baby Friendly Health Initiative (BFHI) to promote appropriate infant feeding practices.
In partnership with the Ghana Red Cross Society, ACSD also supported promotion of appropriate
infant feeding practices by developing guidelines on exclusive breastfeeding, training mother-tomother support groups and providing training materials. ACSD explicitly did not focus on nutritional
rehabilitation.
Table 8 summarizes available information about ACSD inputs intended to reinforce IMCI activities.
Again, to estimate rough coverage, we present selected inputs and activities as ratios per 1,000
children under-five years of age or ratios of CBAs supplied. Appendix C provides more description of
IMCI+ activities and timing.
Table 8: Description of inputs related to the implementation of the IMCI+ intervention package in
the ACSD “high-impact” districts of Ghana.
DESCRIPTION OF
ACTIVITY
TIMING
INTENSITY OF
ACTIVITY
COVERAGE
ESTIMATE
Facility-based agent
(prescriber) training
2004 - 2006
72 prescribers & 10
clinicians trained in
HIDs
1 IMCI-trained provider
per 1000 children underfive
CBA training in C-IMCI
2003 - 2006
1982 CBAs trained
in 600 communities
13 trained CBAs per 1000
children under-five*
Provision of 1400
health/medicine kits
706 kits per 1000 trained
CBAs
C-IMCI CBA supplies
Supervision
Monitoring
2003-2006
(cumulative
total)
Provision of 2022
reporting booklets
Provision of
746,100 doses of
chloroquine
Provision of
645,900 ORS
sachets
1020 booklets per 1000
trained CBAs
4851 doses chloroquine
per 1000 children underfive*
4200 ORS sachets per
1000 children under-five*
2004 - 2006
Supervision ongoing by regional teams, facilitybased health staff and KNUST**
2004 - 2006
Monitoring of the number of cases with diarrhea,
fever and ARI seen and referred**
*Estimated population from 2004 projections: 153,799 under five children, 36,223 pregnant
women & 38,450 children 0-11m
**See further details in Appendix C, Table C2
ANC+.
ANC+ in Ghana was implemented with the aim of preventing maternal and neonatal tetanus and low
birth weight due to malaria and severe anemia in pregnancy. The ANC+ strategy in Ghana included:
1) distribution and promotion of ITNs for pregnant women; 2) IPT for malaria with sulphadoxine
pyremethamine; 3) tetanus toxoid immunization during pregnancy; 3) supplementation with iron and
folic acid during pregnancy and vitamin A in the post-natal period; and 4) voluntary counseling and
testing (VCT) for HIV/AIDs and prevention of mother to child transmission (PMTCT). The ANC+
10
strategy did not focus explicitly on delivery and neonatal care.
The GHS provided ANC and delivery services, including supplementation with iron and folic acid and
TT immunization, before ACSD. ACSD and other partners supplied support for the distribution and
IIP-JHU | Retrospective evaluation of ACSD in Ghana
27
promotion of ITNs for pregnant women; these activities are discussed above under the EPI+
component. ANC+ included support for TT immunization, with many women immunized during NIDs.
The first round of TT supplementary immunization activities (SIA) took place in early 2004, with an
estimated 46 percent coverage of the targeted population. Subsequent rounds of TT SIA achieved
higher rates of coverage (table 9).
IPTp was coupled with routine ANC services at facilities and promoted through radio spots. Bongo
and Bawku East districts received Global Fund support for IPTp activities starting May 2004. In mid2004, ACSD extended IPTp to the remaining four HIDs, with a training of trainers and district level
training. Approximately 25,000 doses of SP were administered annually, although monitoring data
show high drop out rates after first and second dose. Deworming for pregnant women and postnatal
vitamin A supplementation began in mid-2004 through facilities. In 2005, TBAs and CBAs received
training to distribute vitamin A in the postpartum period.
Table 9 summarizes available information, extracted from administrative and summary reports, about
ACSD inputs intended to reinforce ANC+ activities. Appendix C presents further description and
exact timing of ANC+ activities.
Table 9: Description of inputs related to the implementation of the ANC+ intervention package in
the ACSD “high-impact” districts of Ghana.
DESCRIPTION OF
ACTIVITY
TT SIA
IPT training
TIMING
INTENSITY OF ACTIVITY
2004
143,954 / 230,700 women
targeted
2005
No data
2006
National EPI+ report for UER: TT2 – 78%**
2004
May: Training of trainers
June: District level training
May –Dec 2004
IPT dosing
24,046 doses of SP
July – Dec 2004
2005
2006
35,257 doses of SP
23,260 doses of SP
2004 - 2005
2006
Postnatal Vitamin A
supplementation
COVERAGE
ESTIMATE
5,973 vitamin A supplements
2,217 vitamin A supplements
10,351 vitamin A
supplements
62%**
IPT1:50%*
IPT2:31%*
IPT3:16%*
IPT1:30%*
IPT2:21%*
IPT3:13%*
IPT1:30%*
IPT2:22%*
IPT3:15%*
16%**
6%**
29%**
* as reported in ACSD monitoring reports,
**coverage estimated based on target population from 2004 projections: 36,223 pregnant women
28
IIP-JHU | Retrospective evaluation of ACSD in Ghana
5. Coverage and family practices
This section of the report presents the results for priority coverage and family practices indicators and
their interpretation. Section 2 describes the methodology used for the analysis, and appendix D
defines the priority coverage indicators. We present the results in graphical form for selected priority
coverage indicators within each intervention package. Two graphs are presented for each package.
The first shows time trends in indicator levels in the HIDs. Arrows in these graphs indicate the ACSD
coverage targets as adapted for Ghana. We present data from the ACSD-CDC survey conducted in
2003 in shades of grey and without confidence limits because, as explained in the methods section,
these estimates are of lesser quality and should be interpreted with caution.
The second graph for each intervention component presents indicator levels in 1998-9 (baseline) and
2006-7 (endline), with an intermediate point in 2003 for the HIDs and comparison area. The number
at the bottom of each bar in the graph is the percent coverage of the indicator and the black lines in
these graphs represent the 95 percent confidence limits. We carried out differences-in-differences
statistical tests for these comparisons and the results are presented in the text. Appendices G and H
present the full results for HIDs and comparison groups.
Tables in appendix I present coverage results from the 2007 Supplemental MICS survey in the HIDs
by district, urban versus rural residence, socio-economic status and age of the child. Here we present
only statistically significant results on differences in coverage by sub-populations. For certain
indicators and sub-populations, the results should be interpreted with caution due to the small sample
sizes for some cells. Chapter 8 includes further results in the context of equity.
5.1 Results
EPI+.
Vaccinations and vitamin A supplementation.
Figure 6 shows the time trends in measles and DPT vaccinations and one dose vitamin A
supplementation in the previous six months in the HIDs in Ghana, based on the two DHS, two MICS
with an additional point estimate drawn from the ACSD survey carried out in mid-2003. Coverage
levels for these three indicators increased significantly between 1998-9 and 2006-7 (p<0.001). The
results suggest that gains in vaccination were gradual over the evaluation period, while gains in
vitamin A supplementation mostly occurred between 1998-9 and 2003. All indicators were at or
above their ACSD program targets of 80 percent coverage, indicated in the graph with an arrow.
Appendix tables I2 and I3 provide further information on coverage levels for vaccinations and vitamin
A supplementation by sub-groups of the population in the HIDs in 2007. No significant differentials in
sub-groups of the population were observed for vaccination. Vitamin A supplementation in the
previous six months varied significantly (p<0.001) by district, with children in Kasena-Nankana having
the highest coverage (96%) and children in Bongo the lowest coverage with vitamin A
supplementation (74%). Coverage with vitamin A was marginally higher in urban areas compared to
rural areas (p=0.07) and children aged six to 11 months were less likely to receive vitamin A than
older children (p<0.001).
IIP-JHU | Retrospective evaluation of ACSD in Ghana
29
Figure 6: Coverage levels for measles and DPT3 immunization and receipt of one vitamin A
supplement in the preceding six months in the HIDs as measured in DHS (1998-9 and 2003),
the ACSD survey (2003), and MICS (2006 and 2007), Ghana.
100
ACSD vaccination &
vitamin A objective
93 95
Coverage (%)….
80
60
84 86
82 80
73
91 90
76
68
68 66
§ §
§
65
60
40
20
§
§ §
0
Measles
immunization
DPT3 immunization
Vitamin A
supplementation
(one dose)
DHS 1998-9
ACSD 2003
DHS 2003
MICS 2006
Sup MICS 2007
§ Estimate based on less than 100 children
* Vitamin A coverage data only available for children 6-32 months in 2003 ACSD survey
Note: Measles and DPT3 indicators are calculated based on MICS protocol, where the distribution of
children reporting vaccination before 12m in vaccination card is applied to all other children reported as
vaccinated.
Figure 7 shows coverage levels for vaccinations and vitamin A supplementation in the HIDs and the
comparison area in 1999 and 2006-7, with a midpoint in 2003. Measles vaccine coverage increased
significantly between 1998-9 and 2006-7 in both the HIDs and comparison area; the increase in the
HIDs was not significantly different from gains in the comparison area. DPT3 coverage also
increased in both areas, with greater increases in the HIDs (p<0.001). Vitamin A supplementation
with one dose in the previous six months increased by 25 and 74 percentage points (pp) in the HIDs
and comparison area, respectively. Increases in vitamin A coverage over time in both the HIDs and
comparison areas were statistically significant (p <0.001). Baseline levels of vitamin A coverage were
significantly less in the comparison area, and the increase in coverage in the comparison area was
significantly greater relative to the increase in the HIDs (p<0.001).
30
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Figure 7: Coverage levels for measles and DPT3 immunization and receipt of one vitamin A
supplement in the preceding six months in HIDs and the comparison area as measured in DHS in
1998-9 and 2003, and MICS 2006-7, Ghana.
§
§
§
§
§ Estimate based on less than 100 children
Note: Figures inside bar represent percentage coverage
Insecticide-treated bednets (ITNs).
Figure 8 shows the time trends in the use of ITNs in the HIDs in Ghana, based on the two DHS, two MICS
with an additional point estimate drawn from the ACSD survey carried out in mid-2003. The 1998-9 DHS
did not collect information pertaining to bednet use; thus, no comparable indicators for ITN use among
children were available at baseline. However, if ITN use among children is assumed to be close to zero in
1998-9, there were significant increases between 1998-9 and 2007. In 2007, ITN use among children (58
pp) exceeded the ACSD target of 50 percent coverage. The MICS 2006 and supplemental MICS 2007
did not collect information about ITN use among pregnant women, precluding the examination of this
indicator in our analyses.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
31
Figure 8: Coverage levels for insecticide-treated nets in the HIDs as measured in DHS (1998-9
and 2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.
Coverage (%) ….
100
80
60
50
ACSD target (ITN child)
58
40
43
20
0
27
23
~0 0
ITNs (child)
DHS 1998-9
ACSD 2003
DHS 2003
MICS 2006
Sup MICS 2007
Appendix table I4 provides further information on coverage levels for ITNs in 2006-7 in the HIDs by
district, urban/rural residence, child’s sex and age, and wealth quintile. ITN use among children was
significantly higher in Builsa, Bongo and Talensi-Nabdam districts relative to the other districts (p<0.001).
Higher proportions of children aged zero to 35 months slept under ITNs as compared to children aged 36
to 59 months (p<0.001)
Figure 9 shows coverage levels of ITN use in the HIDs and the comparison area in 1999 and 2006-7, with
a midpoint in 2003. The proportion of children sleeping under an ITN increased by approximately 58 pp
in the HIDs and 24 pp in the comparison area, if coverage in 1998-9 is assumed to have been close to
zero in both areas (both trends p<0.001). The rates of increase over time, between 1999-9 and 2006-7
and between 2003 and 2006-7, were significantly greater in the HIDs relative to the comparison area
(p< 0.001).
32
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Figure 9: Coverage levels for insecticide-treated nets in HIDs and the comparison area as measured
in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.
High-impact districts (UER)
Comparison area
Absolute change in percentage points between
1998-9 and 2006-7
~+24
~+58
Coverage (%)
100
80
60
40
20
0
§ ~0
~0
§ 23
1998-9
3
2003
58
24
2006-7
ITN
Note: Figures inside bars represent percentage coverage
IMCI+.
The IMCI+ package includes case management and nutrition assessment and counseling, and the
provision of locally adapted messages to improve family practices related to child survival. In this section,
we focus on results related to the case management of childhood illness and child feeding practices.
Case management.
Figure 10 shows time trends in the HIDs in the administration of any antimalarial for the management of
childhood fever (presumed to be malaria in this highly endemic country), appropriate care-seeking for
suspected pneumonia and oral rehydration therapy and continued feeding for diarrhea.
The
measurement of these indicators is based on reports by mothers of children who reported these illness
symptoms in the two weeks prior to the survey. Additional data are available in appendix tables I5, I6 and
I7. About three-fourths of mothers of febrile children reported giving their child an antimalarial at baseline,
and this decreased significantly in 2007, with only about half receiving an antimalarial. However, in 2007
mothers reported that only nine percent of febrile children received artesunate-amodiaquine, the first line
antimalarial in Ghana since 2004 (appendix table I6). Approximately one-half of children with probable
pneumonia were taken to a health facility in both 1998-9 and 2007, with no significant change during this
period. The proportion of children with diarrhea receiving oral rehydration therapy or increased liquids to
prevent dehydration, along with continued feeding, decreased over time, from 39 percent in 1998-9 to 28
percent in 2007. Case-management indicators stagnated or declined over time; none of the ACSD case
management coverage targets (indicated with arrows) were met by 2007.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
33
Figure 10: Coverage levels for case management indicators in the HIDs as measured in DHS
(1998-9 and 2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.
ACSD target (antimalarial & pneumonia)
80
78
71
60
67
66
61
53
40
50
54
35
20
§
ACSD taregt (oral
rehydration & con't
feeding)
§ §
§
§
Sample size too small..
Proportion of ill children managed for illness (%)...
100
50
39 37
§
32 30
28
§ §
0
0
Antimalarial treatment
DHS 1998-9
ACSD 2003
Careseeking for
pneumonia
DHS 2003
Oral rehydration and
continued feeding
MICS 2006
Sup MICS 2007
§ Estimate based on less than 100 children
Appendix I presents further details and analyses stratified by sub-population (where sample-sizes permit)
for the management of fever and diarrhea, as well as careseeking for pneumonia, in 2007 in the HIDs.
Treatment of febrile children with an antimalarial varied significantly by district (p<0.001); only 42 percent
of febrile children living Garu-Tempane district received an antimalarial, while in Bolgatanga municipality
85 percent of febrile children received an antimalarial. Antimalarial coverage among urban children was
higher than among their rural counterparts (p<0.01). Fifty-eight percent of boys received an antimalarial,
while coverage among girl children was 48 percent (p=0.02). Girls were marginally more likely to be
adequately managed for diarrhea than boys were (p=0.05). Sample sizes were too small to perform all
stratified analyses for indicators related to careseeking for suspected pneumonia and diarrhea
management.
Figure 11 presents coverage levels for the case management of childhood illness in the HIDs and the
comparison area in 1999 and 2006-7, with a midpoint in 2003. Levels of treatment with any antimalarial
for fever decreased significantly in the HIDs, while stagnating in the comparison area. The difference in
the changes between 1998-9 and 2006-7 in the HIDs relative to the comparison area was statistically
significant (p<0.001). However, if the indicator is defined as “treatment of fever with an effective and
nationally recommended antimalarial” there was a precipitous drop in coverage in both the HIDs and the
national comparison area, because chloroquine was no longer recommended at the end of the period, but
use remained frequent (appendix table I6). Care seeking for pneumonia remained relatively stable in the
HIDs, while increasing 14 pp in the comparison area and the difference-in-differences was significant
(p=0.04). Correct home management practices for diarrhea decreased in the HIDs, while increasing
34
IIP-JHU | Retrospective evaluation of ACSD in Ghana
seven pp in the comparison area; the difference between the trends in the HIDs and comparison area
was statistically significant (p<0.01).
Figure 11: Coverage levels for case management indicators in HIDs and the comparison area as
measured in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.
Absolute change in percentage points btw. 1998-9 to 2006-7
Proportion of ill children managed for illness
(%)
+1
100
High-impact districts (UER)
Comparison area
+14
-25
+7
-11
-4
80
60
40
20
0
§
§
78 60 71 67 53 61
1998-9 2003
2006-7
§
§
54 22 66 40 50 36
1998-9
Antimalarial treatment
2003
2006-7
Careseeking for
pneumonia
§
§
39 23 32 38 28 30
1998-9 2003
2006-7
Oral rehydration and
continued feeding
§ Estimate based on less than 100 children
Note: Figures inside bars represent percentage coverage
Figure 12 presents the use of antibiotics for suspected pneumonia among children aged 0-59 months in
the HIDs and the comparison area in 1999 and 2006-7. Coverage with antibiotic treatment was low at
baseline in the HIDs (2%), and increased to just over 50 percent in 2006-7. Use of antibiotics for
suspected pneumonia also increased in the comparison area, although only by 15 pp. These results are
inconsistent with the trends in careseeking for pneumonia presented in the previous graphs, which
showed stagnation in the HIDs. Secondary analyses (appendix table I7) found that 12 percent of children
with suspected pneumonia in the HIDs were taken for care at a private drug vendor in 2007, while no
mother reported this behavior in the comparison area. Similarly, approximately 25 percent of mothers in
the HIDs reported obtaining the antibiotic for their child’s pneumonia outside of an appropriate health
facility, with 21 percent of antibiotics obtained at a drug shop and 4 percent obtained from drug peddlers.
Antibiotic distribution at the community level is not authorized in Ghana through community-based
distributors or drug peddlers.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
35
Figure 12: Coverage levels for use of antibiotics for suspected childhood pneumonia in HIDs and the
comparison area as measured in DHS in 1998-9 and MICS 2006-7, Ghana.
High-impact districts (UER)
Comparison area
% of children with suspected pneumonia receiving
antibiotics..
Absolute change in percentage points between
1998-9 and 2006-7
+15
100
+49
80
60
40
2
20
§
2
0
§
20
1998-9
§
51
35
2006-7
Antibiotic treatment for pneumonia
§ Estimate based on less than 100 children
Note: Figures inside bars represent percentage coverage
Feeding, including breastfeeding.
IMCI+ in the context of ACSD also included promotion of appropriate infant and young child feeding
practices (Box 1). Figure 13 shows the prevalence of selected feeding behaviors as reported by mothers
of children less than one year of age at the time of the survey. Breastfeeding behaviors tend to be
relatively stable over time, so apparent fluctuations should be interpreted with caution as they may reflect
differences in how the questions were posed, the answers recorded or statistical error due to small
sample sizes. The proportion of mothers reporting initiation of breastfeeding within one hour of birth
increased significantly between 1998-9 and 2007 (p<0.001), with a large, unexplained fluctuation in the
2003 DHS. The prevalence of exclusive breastfeeding of infants less than six months steadily increased
over time, from 28 percent of mothers reporting this practice in 1998-9 to 55 percent of mothers reporting
this practice in the 2007 survey (p<0.01). This exceeded the ACSD objective of 50 percent coverage by
five pp. Complementary feeding among children six to nine months of age remained stable between
2003, 2006 and 2007, with approximately half of children in this age group reported to have received
complementary feeding and continued breastfeeding throughout the period. Sample sizes in the 1999-8
and 2003 DHS were too small to provide valid estimates of complementary feeding from these surveys.
Prevalence of appropriate complementary feeding practices fell well short of the ACSD target of 90
percent. Mothers reported continued breastfeeding 84 percent of children aged 20-23 months in 2007 in
the HIDs (appendix table G3); sufficient sample sizes were not available for baseline estimation of this
indicator.
36
IIP-JHU | Retrospective evaluation of ACSD in Ghana
100
ACSD target
(complementary feeding)
90
80
85
52
40
20
45
50
42
39
56 55
43
28
11
0
0
Initiation of breastfeeding Exclusive breastfeeding (<
within one hour of birth
6 months)
DHS 1998-9
ACSD 2003
DHS 2003
50
Sample size too small..
ACSD target (exclusive
breastfeeding)
60
Sample size too small..
Prevalence of behavior as reported by mothers (%)...
Figure 13: Prevalence of infant feeding behaviors as reported by mothers in the HIDs as measured in
DHS (1998-9 and 2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.
53 53
0
Breastfeeding plus
complementary food
(6-9 months)
MICS 2006
Sup MICS 2007
§ Estimate based on less than 100 children
Appendix table I8 shows the breakdown of breastfeeding practices by selected sub-groups of the
population, where sample sizes permit. The proportion of rural mothers initiating breastfeeding within one
hour of birth (54%) was marginally greater than that among their urban counterparts (42%); (p=0.05).
The proportion of infants exclusively breastfed varied significantly by district, with over 70 percent
exclusive breastfeeding in Kasena-Nankana, Bongo and Bolgatanga municipality districts and only 37
percent in Bawku municipality (p=0.02). Exclusive breastfeeding was more common among women
residing in urban areas (p<0.01) and in wealthier households (p=0.01) than among women in rural and
poorer households.
Figure 14 shows the prevalence of infant feeding behaviors in the HIDs and the comparison area in 1999
and 2006-7, with a midpoint in 2003. Initiation of breastfeeding within one hour of birth significantly
increased by 41 pp in the HIDs and increased only eight pp in the comparison area; the difference in the
rates of change was significant (p<0.001). Exclusive breastfeeding up to six months of age increased by
more than 20 pp in both the HIDs and the comparison area; the difference-in-differences was not
significant. Complementary feeding of children six to nine months of age declined by 10 pp in the
comparison area. Sufficient sample sizes were not available in the HIDs in 1998-9 or 2003, precluding a
comparison in trends.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
37
Figure 14: Prevalence of infant feeding behaviors as reported by mothers in HIDs and the
comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.
High-impact districts (UER)
Comparison area
Absolute change in percentage points between 1998-9 and 2006-7
+22
+41
-10
+27
100
80
40
20
0
§
11
§
23
1998-9
85
41 52
2003
31
2006-7
Initiation of breastfeeding within
one hour of birth
*
*
§
§
28 29
43
49 55
51
2003
2006-7
1998-9
Exclusive breastfeeding
(< 6 months)
0
67
Sample size too small ..
60
Sample size too small..
Prevelance of behavior as reported by mother (%)...
+8
64 53
57
1998-9
2003
2006-7
Breastfeeding plus
complementary food
(6-9 months)
§ Estimate based on less than 100 children
*Estimation based on unweighted data, no 95% confidence intervals presented
Note: Figures inside bars represent percentage coverage
ANC+.
The ANC+ package as implemented in Ghana included interventions in both the antenatal and perinatal
periods. In this section, we address coverage levels for antenatal interventions and interventions
designed to improve maternal and neonatal health during delivery and the post-natal period.
Antenatal care.
Figure 15 shows the time trends in coverage of antenatal care in the HIDs. Further details are presented
in appendices G, H and I. The proportion of women reporting four or more ANC attendances increased
steadily by 17 pp over the evaluation period (p<0.001). The ACSD target of 80 percent coverage of four
or more ANC visits was achieved. Intermittent presumptive treatment (IPTp) with two doses of SP for
malaria during pregnancy was not measured in 1998-9, and coverage was only four percent in 2003,
IPTp coverage increased dramatically between 2003 and 2006, with further increases between 2006 and
2007 (p<0.001). Approximately two-thirds of women reported IPTp, falling just short of the ACSD
objective of 75 percent ITPp coverage. Tetanus toxoid (TT2) vaccination, consisting of two doses during
pregnancy, remained stable, with approximately one-third of women not reporting two vaccinations during
their previous pregnancy. However, in 2007 in the HIDs, 78 percent of women reported full neonatal
protection from tetanus toxiod in their previous pregnancy, close to the ACSD target of 80 percent
coverage. Comparable information about neonatal protection from tetanus toxoid was not collected in
earlier surveys, precluding comparisons of this indicator over time.
38
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Figure 15: Coverage levels of antenatal indicators in the HIDs as measured in DHS (1998-9 and
2003), the ACSD survey (2003), and MICS (2006 and 2007), Ghana.
100
ACSD target
(ANC 4+)
ACSD target (NN
protection)
80
86
81
80
ACSD target
(IPT)
75
60
64
67
64
63
61 63
56
47
40
20
0
§
§ §
Antenatal care
(4+ visits)
DHS 1998-9
ACSD 2003
0
No data..
33
No data..
Coverage (%)...
74
§
4 §
§
IPTp with SP
DHS 2003
§ §
2 TT doses
MICS 2006
Sup MICS 2007
§ Estimate based on less than 100 women
Appendix I9 provides further information on coverage levels of antenatal care in the HIDs as measured in
the 2007 Supplemental MICS. The proportion of women reporting four or more antenatal care visits
varied somewhat by district (p=0.07), with highest levels in Kasena-Nankana district (94%) and the lowest
in Garu-Tempane district (73%). Coverage of ANC interventions was inequitable in 2007 in the HIDs.
Significantly more women in the wealthiest households reported four or more ANC visits (93%) as
compared to those in the poorest households (75%); (p=0.02). Similar inequities were observed for two
doses of tetanus toxiod during the previous pregnancy (p=0.06) and full neonatal protection (p=0.04).
Figure 16 shows reported antenatal care in the HIDs and the comparison area in 1999 and 2006-7, with a
midpoint in 2003. The proportion of women reporting of four or more ANC attendances and IPTp with two
doses of SP increased significantly in both the HIDs and comparison area (p<0.001). Receipt of two
doses of tetanus toxoid vaccination during the previous pregnancy did not increase in the HIDs, while
increasing 14 pp in the comparison area. Absolute pp increases were significantly greater in the HIDs for
IPTp with SP than in the comparison area (p<0.001). The differences in changes over time between the
HIDs and the comparison area for four ANC attendances and TT2 were not statistically significant.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
39
Figure 16: Coverage levels of antenatal indicators in HIDs and the comparison area as measured in
DHS in 1998-9 and 2003, and MICS 2006-7, Ghana.
§
§
§
§
§ Estimate based on less than 100 women
Note: Figures inside bars represent percentage coverage
Skilled attendant at delivery and postnatal care.
Figure 17 shows trends in deliveries assisted by a skilled attendant and postnatal supplementation with
vitamin A as reported by women giving birth within the 12 months before the survey. Assisted deliveries
by trained workers included those attended by a doctor, nurse, midwife or auxiliary midwife. Additional
data concerning these indicators are available in appendices G, H and I. Assistance at delivery by a
skilled provider increased from 17 percent in 1998-9 to 40 percent in 2007 (p<0.001). However, more
than half of women giving birth do not benefit from a skilled attendant at delivery and coverage levels fell
far short of the initial ACSD target of 80 percent. Supplementation with vitamin A within 40 days after
birth was high at baseline (72%) and declined over the period from 1998-9 to 2007 (p=0.01).
Appendix table I10 presents the breakdown of skilled delivery and postnatal vitamin A supplementation in
the HIDs by socio-demographic characteristics as measured in the 1007 Supplemental MICS. More than
double the proportion of urban dwellers reported a skilled attendant at delivery (71%) than their rural
counterparts (31%); (p<0.001). Coverage levels of skilled delivery were similar among women reporting
no formal education or primary school; however, women with secondary or higher education were more
likely to deliver with a skilled attendant (p<0.01). Women in the highest wealth quintile were more than
three times as likely to have a delivery assisted by a skilled provider (77%) than women in the poorest
households (23%); (p<0.001).
40
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Figure 17:
Coverage levels of skilled attendant at delivery and postnatal vitamin A
supplementation in the HIDs as measured in DHS (1998-9 and 2003), the ACSD survey (2003),
and MICS (2006 and 2007), Ghana.
100
80
Coverage (%)...
72
60
4
§
47
40
52
51
57
40
27
20
17
18
§
§
§
§
§
0
Skilled attendant at delivery
DHS 1998-9
ACSD 2003
DHS 2003
Postnatal vitamin A
MICS 2006
Sup MICS 2007
§ Estimate based on less than 100 women
Figure 18 shows coverage levels of skilled deliveries and postnatal supplementation with vitamin A as
reported by women giving birth within the 12 months before the survey in the HIDs and the comparison
area in 1999 and 2006-7, with a midpoint in 2003. Deliveries assisted by a skilled health provider
increased by 23 pp in the HIDs and by 4 pp in the comparison area; the difference between the HIDs and
comparison area in the rates of change was significant (p=0.01). Levels of postnatal supplementation with
vitamin A decreased by 15 pp in the HIDs, while increasing by 25 pp in the comparison area (p<0.001).
IIP-JHU | Retrospective evaluation of ACSD in Ghana
41
Figure 18: Coverage levels of skilled attendant at delivery and postnatal vitamin A supplementation
in HIDs and the comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7,
Ghana.
High-impact districts (UER)
Comparison area
Absolute change in percentage points between 1998-9 and 2006-7
+4
Coverage (%)...
100
+25
-15
+23
80
60
40
20
§
0
17
38
1998-9
§
18
2003
§
§
35
40
42
72
23
1998-9
2006-7
Skilled attendant at delivery
58
36
2003
57
48
2006-7
Postnatal vitamin A
§ Estimate based on less than 100 women
Note: Figures inside bars represent percentage coverage
5.3
Summary and interpretation of results
Table 10 summarizes the main results of the adequacy analyses of time trends in coverage in the HIDs.
In table 10, we present indicators showing significant improvement between 1998-9 and 2007 in the HIDs
in bold italics. Indicators showing positive trends over time in the HIDs included vaccinations, vitamin A,
ITNs, antibiotics for suspected pneumonia, timely initiation of breastfeeding, exclusive breastfeeding,
antenatal care, IPTp and skilled assistance at delivery. Indicators that were observed to stagnate or
decline included case management of common childhood illnesses, tetanus toxoid vaccination and
postnatal vitamin A. In the last column of table 10, we present the stated ACSD targets in Ghana in
relation to the coverage levels measured in 2007. Many of the stated objectives were fully met or
exceeded; however, management of diarrhea, complementary feeding and skilled delivery were 30 pp or
more short of the stated ACSD targets for coverage.
42
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Table 10: Summary of ACSD coverage results in HIDs as measured in DHS 1998-9 and 2003 and
Supplemental MICS 2007, Ghana, as compared to initial ACSD objectives.
MIDLINE
ENDLINE
CHANGE
ABSOLUTE
BASELINE LEVEL IN LEVEL IN
1999 to
DIFFERENCE
LEVEL IN
2003
2007
2007
ACSD
BETWEEN
COVERAGE
1999 DHS
DHS
MICS
TARGET
ENDLINE &
INDICATOR
(%)
(%)
(%)
P value
(%)
OBJECTIVE
Measles
<0.001
60
68
80
80
0
vaccine
DPT3
68
76
95
<0.001
80
+15
Vitamin A to
child
65
86
90
<0.001
80
+10
ITN for child
~0
23
58
<0.001*
50
+8
78
71
53
<0.001
50
+3
54
66
50
>0.10
50
0
2
-
51
<0.001
50
+1
39
32
28
0.05
80
-52
11
85
52
<0.001
n/a
n/a
28
43
55
<0.01
50
+5
-
-
53
-
90
-37
64
64
81
<0.001
80*
+1
~0
4
67
<0.001*
75
-8
63
33
63
>0.10
n/a
n/a
n/a
n/a
78
n/a
80
-2
17
18
40
<0.001
80
-40
72
58
57
0.01
n/a
n/a
Any antimalarial
for fever
Careseeking for
pneumonia
Antibiotics for
pneumonia
Oral rehydration
for diarrhea
Breastfeeding
initiation
Exclusive
breastfeeding
Complementary
feeding
Antenatal care
(4+ visits)
IPTp with 2+
SP
TT2 in
pregnancy
Full neonatal
TT protection
Skilled
delivery
Postnatal
vitamin A
*Changes calculated assuming 0% coverage at baseline
NOTE: Indicators in bold italics represent significant positive changes over time
Table 11 summarizes the main results of the plausibility analysis, comparing time trends in coverage for
HIDs and the comparison area. Estimates that showed a positive trend over time in HID that were
significantly greater than the comparison area at p<0.05 are shown in bold italics. Vaccination, vitamin A
supplementation for children aged 6-59 months, ITN utilization among children, antibiotics for pneumonia,
exclusive breastfeeding, four or more antenatal care visits, and IPTp all improved by 10 pp or more in
both HIDs and comparison area; ITNs, antibiotics for pneumonia, and IPTp increasing significantly more
in the HIDs. Breastfeeding initiation and delivery assisted by a skilled worker improved by more than 10
pp in the HIDs, while increasing less than 10 pp in the comparison area. Two doses of tetanus toxoid
during pregnancy, careseeking for suspected pneumonia and postpartum vitamin A stagnated (=/- 9pp) in
the HIDs, while increased by more than 10 pp in the comparison area. Appropriate management of
childhood fever and diarrhea decreased in the HIDs, while stagnating in the comparison area (difference
in difference test were statistically significant). These results suggest that ACSD as implemented in the
IIP-JHU | Retrospective evaluation of ACSD in Ghana
43
HIDs in Ghana had a positive effect on levels of coverage for some of the interventions targeted for
accelerated implementation.
Table 11: Summary of ACSD coverage results in HIDs and the comparison area as measured in as
measured in DHS 1998-9 and 2003, MICS 2006 and Supplemental MICS 2007, Ghana.
COVERAGE
INDICATOR
Measles vaccine
DPT3
Vitamin A to child
ITN for child**
Any antimalarial
for fever
Careseeking for
pneumonia
Antibiotics for
pneumonia
Oral rehydration
for diarrhea
Breastfeeding
initiation
Exclusive
breastfeeding
Antenatal care
(4+ visits)
IPTp with SP**
Tetanus toxoid in
pregnancy
Skilled delivery
Postnatal vitamin
A
AREA
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
HIDs
Comparison
ABSOLUTE CHANGE
(% POINTS)
BASELINE
VALUE IN
1999-9
(%)
MIDLINE
VALUE IN
2003
(%)
1998-9 to
2006-7
2003 to
2006-7
60
60
68
65
65
22
~0
~0
78
60
54
22
2
20
39
23
11
23
28
29
64
55
~0
~0
63
46
17
38
72
23
68
67
76
76
86
79
23
3
71
67
66
40
n/a
n/a
32
38
85
41
43
49
64
58
4
1
33
47
18
35
58
36
+20
+18
+27
+14
+25
+74
+58
+24
-25
+1
-4
+14
+49
+15
-11
+7
+41
+8
+27
+22
+17
+11
~+67
~+31
0
+14
+23
+4
-15
+25
+12
+11
+19
+3
+4
+17
+35
+21
-14
-6
-16
-4
n/a
n/a
-4
-8
-33
-10
+12
+2
+17
+8
+63
+30
+30
+13
+22
+7
-1
+12
DIFFERENCE
IN
DIFFERENCES
TEST (p LEVEL)
1998-9
2003
to
to
2006/7 2006-7
>0.10*
>0.10*
0.001
<0.001
<0.001
0.01
<0.001
<0.001
<0.001
>0.10
0.04
>0.10
<0.01
n/a
<0.01
>0.10
<0.001
0.001
>0.10
>0.10
>0.10
>0.10
<0.001
<0.001
0.12
0.04
0.01
0.02
<0.001
0.05
*P value based on children 12-13 months of age ever receiving measles or DPT3 vaccination
**Difference in end-line estimates only assuming 0% coverage at baseline in HIDs and comparison area.
NOTE: Indicators in bold italics represent positive changes over time in HID that were significantly
greater than the comparison area at p < 0.05
Coverage results: contributions and challenges of ACSD implementation.
Preliminary results were reviewed and discussed with a technical team from Ghana that included those
directly involved in ACSD implementation and/or the collection and analysis of the data used in the
evaluation. We have incorporated the interpretation of results based on discussions with the Ghana
technical team and review coverage in the context of ACSD implementation by each ACSD component,
as well as overall ACSD contributions and challenges associated with changes in coverage.
44
IIP-JHU | Retrospective evaluation of ACSD in Ghana
EPI+.
ACSD in Ghana had set targets to achieve 80 percent coverage for vaccination and vitamin A coverage
and reached these goals; routine monitoring system data in the HIDs mirrored these trends. ACSD
started with the EPI+ strategy, which focused primarily on preventative services delivered through
campaigns and outreach. Key informants noted that ACSD’s key contributions in achieving the EPI+
targets included the supply of commodities and clear targets at the district level. Vaccination and vitamin
A supplementation coverage increased in both HIDs and comparison area, although DPT3 increased
more rapidly in the HIDs. The GHS and other development partners supported these activities in the
comparison area, discussed in section 3 and below in contextual factors.
The promotion, distribution and re-treatment of ITNs were large components of the ACSD strategy in
Ghana and elsewhere. Our results show large increases in coverage with ITNs between 1999 and 20067 in the HIDs, with fewer gains in coverage in the comparison area. ACSD supplied large quantities of
ITNs early, with other donors such as the Global Fund also providing support for ITN interventions. Key
informants reported widespread stock-outs in ITNs, starting in late 2005 and persisting until late 2006,
although other partners, such as the Global Fund provided ITNs at this time. UNICEF, with substantial
funding from DFID, supported a national campaign to distribute two million long-lasting ITNs in late 2006,
with approximately 90,000 LLITNs distributed in the HIDs.
IMCI+.
ACSD efforts included expanding coverage and strengthening existing community-based systems,
primarily by training, equipping and supporting CBAs to treat childhood illness in the community in the
HIDs. However, we found that case management practices for fever and diarrhea declined or stagnated
in the HIDs. Administrative data from communities showed similar trends. Likewise, careseeking for
pneumonia to an appropriate health provider did not increase, although antibiotic treatment for
pneumonia increased. Secondary analyses revealed that this increase was at least partially driven by
antibiotics from shops and drug peddlers. The government and partners scaled up C-IMCI before training
facility-based staff in IMCI, which may have lessened the synergistic effect of the full IMCI package.
Key informants and program documents noted important challenges to implementing the case
management of fever. The GoG changed the first-line antimalarial policy to ACTs in 2004 due to high
levels of resistance to chloroquine in Ghana. Although our indicator for treatment of fever appears to
have declined marginally in the HIDs, this does not necessarily represent effective management of fever
with the recommended first-line antimalarial. Only nine percent of caretakers reported that febrile children
received an ACT in 2007 in the HIDs, and fewer than five percent did so in comparison area. Although
health facilities and CHPS centers stocked ACTs in 2005, national policy did not allow ACTs at the
community level (through CBAs) until 2007. CBAs retained chloroquine in their health kits until it was
retired from the communities at the end of 2006. Roll out of ACTs in the community began just after
collection of our endline data.
At the end of 2004, CIDA funding was mostly depleted and this affected the constant supply of
commodities, especially drugs for managing sick children. Many CBAs, who had previously focused on
treating children with fever did not have antimalarials (chloroquine) and reportedly saw fewer sick children
for fever, as well as diarrhea, and ARI referrals. Sporadic stock-outs of antimalarial drugs were also
noted at facilities. Program implementers reported that gaps in supplies and the end of incentives for
health workers (both facility-based and community-based) linked to the end of CIDA hampered the
continuation of some ACSD activities.
Key informants reported that the C-IMCI activities through CBAs were a great strength of ACSD, but
challenging to sustain. Sufficient supervision and monitoring of the CBA system were reported as ongoing issues. Incentives for CBAs were primarily limited to job aids and bicycles given at the beginning of
implementation, and program implementers postulated that lack of on-going incentives and packages to
increase CBA motivation limited the impact of C-IMCI activities, including community case management
of child illnesses.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
45
Infant and young child feeding practices improved somewhat in the HIDs over the course of the study
period. Program implementers noted that there were strong nutritional interventions through other donors
and NGOs in the HIDs in the early part of the decade, while ACSD focused more strongly on the EPI+,
ANC+ and case management of illness components. Nutritional interventions did not receive much
emphasis, and some key informants reported a lack of coordination between ACSD activities and regional
nutrition activities.
ANC+.
Most ANC+ interventions increased over the period of evaluation. IPTp was introduced in 2004 in the
HIDs and nationally, although coverage increased significantly more in the HIDs. This strategy was
strongly supported by ACSD and the Global Fund in the HIDs. The proportion of women reporting a
skilled attendant at delivery increased in the HIDs, but failed to reach the ACSD of 80 percent coverage.
Key informants and documents cited explicitly that delivery care was not a focus of the ACSD approach in
Ghana. Reported coverage with postnatal supplementation with vitamin A stagnated in the HIDs, while
increasing in the comparison area. Measured levels of coverage were exceptionally high at baseline in
the HIDs and we were not able to ascertain if this was due to statistical fluctuations or intervention
coverage through previous projects.
Overall contributions and challenges of ACSD implementation.
Early in the program, ACSD reinforced and strongly supported outreach activities for vaccination, ITNs
and ANC services. ACSD built partnerships and built on what exists; this strategy was often cited as the
“value-added” aspect of ACSD. Across the mix of child survival interventions, ACSD was also noted as
contributing to capacity building and technical support for program implementers and partners. Key
informants recognized that enhanced monitoring was important part of ACSD, but also noted that
monitoring was weak and became weaker after initial CIDA funds for ACSD were depleted.
Support for ACSD through Canadian CIDA ceased in 2005, with important gaps in sustained external
funding as discussed above. Gaps and delays in funding were cross-cutting, affecting: 1) the constant
supply of commodities such as antimalarials and ITNs; 2) continued supervision and motivation of CBAs;
3) insufficient resources for recurring costs such as motorbikes, fuel and incentives for health providers;
and 4) delays in the development of health promotion materials for CBAs and radio spots. Despite these
constraints, other partners, including the GHS continued to support the ACSD activities, with large
infusions of support provided by the government of the Netherlands and DANIDA in 2006.
Contextual factors.
11
The contextual factors considered in the evaluation were based on those proposed as relevant for child
11
survival programs. Section 3 and appendices A and M provides a more comprehensive description of
contextual factors. Given that the adequacy findings on coverage suggest that ACSD had positive effect
on some indicators but not on others, the analysis of contextual factors here examines two questions to
better interpret the results:
1. Were there any major disruptions in the HIDs or nationally that could explain why ACSD did not
lead to a more marked effect on coverage levels?
2. Were there other activities outside of ACSD in the HIDs or nationally that could have led to
increases in coverage in the HIDs?
Major disruptions.
To our knowledge, there were no natural disasters or other emergencies in the HIDs from 1998 to present
that would have influenced the effect of ACSD on intervention coverage. Flooding occurred during data
collection for the Supplemental MICS 2007, used for endline estimates. In order to assess the impact of
the flooding on the population, as well as on the MICS survey, we developed an additional questionnaire
module to assess household damage and migration due to the flooding. Twenty-eight percent of the
households in the HIDs reported affects of the flood and 24 percent reported damage to the household
structure. This emergency would not affect our coverage measures of interventions delivered well before
the survey data collection, such as vaccination, vitamin A supplementation, ANC visits, delivery care, etc.
46
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Disruptions due to the flooding may have negatively affected indicators related to management of
childhood illness, which rely on a two-week recall period or use of ITNs, which pertain to the night before
the survey. We performed secondary analyses to assess if household disruptions due to flooding may
have affected these indicators. There were no significant differences in management of diarrhea or
pneumonia or use of ITNs between households affected by the flood and those not affected. A
significantly higher proportion of febrile children in flood-affected households received an antimalarial for
fever (61%) than children in non-affected households (50%); (p=0.02). Key informants reported that the
increase in malaria treatment in the flood areas was likely associated with an emergency procurement of
ACTs funded through the European Commission’s Humanitarian Aid Office–the remaining non-flooded
areas did not receive this additional funding. Coverage of case management interventions was also
similar in the 2006 MICS, and it is unlikely that the flooding biased our coverage estimates.
Other activities in HIDs and comparison area.
As part of the evaluation, we documented other health and development project activities in the HIDs and
comparison area between 1999 and 2006-7; section 3 and appendix M provide further details. A number
of multilateral, bilateral, and non-governmental agencies, as well as Navrongo Health Research Center,
implemented similar and complementary interventions targeting child health and nutrition before and
during ACSD implementation. It is difficult to quantify the contributions and population coverage of these
programs, but activities widely implemented and supported outside of ACSD included: 1) supplementation
with vitamin A for children; 2) ITNs; 3) promotion and support of appropriate infant feeding practices; and
4) community case management for common childhood illnesses. Between 1998 and 2007, coverage of
CHPS compounds, also focusing on preventative and primary health care, expanded more rapidly in the
HIDs than in comparison area. We were not able to find measures of intervention coverage associated
with the CHPS strategy, although the literature suggests that the implementation of this strategy in the
Kassena-Nankana district led to greater declines in child mortality than routine services or routine
34,36,42
services with community volunteers only.
Thus, changes in intervention coverage in the HIDs cannot be attributed to ACSD alone and must be
viewed in light of prior and concurrent activities of other partners in the health sector. Additionally, the
GoN and DANIDA provided substantial financial support in 2006 and 2007 to the HIDs and other northern
regions for the HIRD strategy, the national GHS continuation of the ACSD strategy. Many other
development programs in the HIDs focused on education and literacy, agriculture, poverty reduction
through micro-credit, and water and sanitation. We would not expect these projects to have a large shortterm influence on coverage of maternal and child health interventions, because they do not directly
address the interventions.
As described in section 3 and appendix M, over the period of 1998 to 2007, Ghana benefited from
massive investments in health at the national level. In the comparison area, USAID, WHO, and others
supported child survival activities similar to those promoted by ACSD.
Summarizing the presentation on contextual factors:
•
No major humanitarian or natural crises were found that affected the coverage results;
•
A multitude of maternal and child health activities were implemented by development partners
in the HIDs, some in close collaboration with ACSD;
•
The expansion of CHPS compounds may have differentially improved access for preventative
and curative care in the HIDs;
•
Development partners supported activities similar to those included in the ACSD package in
the comparison area.
Methodological Challenges.
Here we present a very brief overview of methodological challenges encountered in the retrospective
evaluation of ACSD in Ghana, noting how they may have affected the evaluation results related to
coverage. Complementing this section, appendix K provides a more thorough review of methodological
challenges, appendix F provides descriptions of surveys included in the evaluation, and appendix D and
IIP-JHU | Retrospective evaluation of ACSD in Ghana
47
E provide indicator definitions and a list of the questionnaire items supporting the measurement of the
priority indicators in each survey.
Many of the challenges encountered reflect the retrospective nature of the evaluation. The evaluation
2
team was forced to rely existing data and information, even if imperfect. . The 1998-9 and 2003 DHS had
limited sample sizes for calculation of baseline coverage indicators in the HIDs, especially those
indicators measured among small subgroups of the sample such as exclusive breastfeeding or
careseeking for pneumonia. These small sample sizes affect the precision of point estimates and the
statistical power to detect small differences over time.
Collection of data occurred approximately one year apart for the Supplemental MICS 2007 (used for
endline coverage estimates in the HIDs) and MICS 2006 (used for endline coverage estimates in the
comparison area). We compared estimates of coverage between 2006 and 2007 in the HIDs to assess if
the one-year time lag could have influenced our results. Most coverage indicators remained relatively
stable in the HIDs between 2006 and 2007, and were not statistically significant. ITNs for children and
IPTp were significantly greater in 2007 as compared to 2006 in the HIDs; coverage with any antimalarial
for fever was significantly less in 2007. For these three indicators, we reran statistical tests using the
2006 MICS as our endline estimate to identify any possible bias introduced by using the 2007 MICS
survey only in the HIDs. Statistical inferences were the same for trends over time and differences in
changes over time in the HIDs and comparison area.
The DHS and MICS use slightly different methodologies to collect data. DHS ask only biological mothers
of young children about intervention coverage, while MICS questions caretakers of children, even if not
biologically related, about intervention coverage. Appendices D and E note differences in the DHS and
MICS questions used for indicator calculations; appendices F and K review the differences between the
surveys. These differences were minimal and we would not expect them to affect the findings.
The data available in the 1998-9 DHS did not allow for calculation of all priority indicators for the
evaluation, which are identical to those used for monitoring progress toward the Millennium Development
7,8
In the 1998-9 DHS, several essential questions were not included: use of bednets by
Goals (MDG).
children or pregnant women, timing of antimalarial administration for febrile children, SP taken as part of
IPT for pregnant women, or full neonatal tetanus toxoid protection. For the evaluation of time trends
between 1998-9 and 2006-7, we used indicator definitions that could be calculated from the 1998-9 data
to ensure comparability with indicator estimates in 2006-7 (see appendices D and E). These proxy
indicator definitions were less stringent than the priority indicator in all cases; coverage estimates from
2006-7 using the more stringent, MDG priority coverage indicators are presented in appendices G, H and
I.
Taken together, these methodological issues are not likely to influence the endline comparisons between
the HIDs and national comparison area. Differences in the conduct of the survey, the DHS and MICS
questionnaires and interviewers’ style of asking questions may have introduced some bias into the
comparison of coverage levels between 1998-9, 2003 and 2006-7. However, these methodological
challenges are not likely to change the main evaluation findings or conclusions in any substantial way.
48
IIP-JHU | Retrospective evaluation of ACSD in Ghana
6. Nutrition
In this section, we describe the differences in nutritional status of young children between the HIDs
(comprised of the UER) and comparison area; the latter includes the rest of the country with the exception
of the HIDs and urban Greater Accra and Ashanti regions (Accra and Kumasi).
Anthropometric data from the HIDs are available for the 1998-9 and 2003 DHS, and for the main MICS in
2006 and the supplementary MICS in 2007. The same surveys – except for the 2007 supplementary
MICS – also provide data for the national comparison area. We used data from the 2006 MICS for the
comparison area and from the 2007 supplemental MICS for the HIDs for the endline results. Section 2
explains the rationale in more detail.
Three indicators of undernutrition prevalence were calculated from these surveys: prevalence of stunting
(low length for age for children below 24 months; low height for children 24-59 months of age), wasting
(low weight for length/height), and underweight (low weight for age). We used the minus two z-score
12
cutoff based on the 2006 WHO Growth Standards, to identify children with moderate or severe
undernutrition; for severe undernutrition we used the minus three z-scores cutoff. Mean z scores of the
three indices were also calculated. Appendix J presents a schematic of the inclusion and exclusion
criteria for children included in the analysis.
We present results for all children less than five years of age. For stunting, results are also presented for
43
children aged 24-59 months, the age group with the highest prevalence of this condition . Likewise,
wasting results are described for children aged less than 24 months. Table 12 presents the numbers of
children included in the analyses.
Presentation of the results follows the approach used in the section on coverage indicators. First, the
adequacy findings are presented (time trends in the HIDs), followed by the plausibility results (comparison
between HIDs and the rest of the country). Appendix J presents full nutrition results for sub-groups in
both areas.
6.1
Results
Figure 19 shows that stunting decreased over time in the HIDs. Wasting and underweight remained
relatively unchanged over time, with a peak observed in the 2003 DHS, possibly due to seasonality of
surveys.
Table 12 and Figure 20 show results for the HIDs as well as the comparison area, in the 1998-9, 2003
and 2006-7 surveys.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
49
Figure 19: Time trends in stunting (children 24-59 months), wasting (children 0-23 months) and
underweight (children 0-59 months) in the ACSD “high-impact” districts as measured in DHS and
MICS in 1998-9, 2003 and 2006-7, Ghana.
Prevalence of moderate and severe (%)...
100
80
60
56
40
42
37 35
27
20
0
§ §
§ §
Stunting (24-59m)
DHS 1998-9
18
14
§
25
§
23 21
14
Wasting (0-23m)
DHS 2003
30
Underweight (0-59m)
MICS 2006
Sup MICS 2007
§ Estimate based on less than 100 children
Stunting.
From 1998-9 to 2006-7, there was a reduction of 21 percentage points (pp) for children 24-59 months in
the HIDs (p<0.001), compared to a four pp decline in the comparison area. The decline in overall stunting
(moderate or severe) in the HIDs was mostly due to the reduction in the prevalence of severe stunting,
which fell from 26 to 10 percent. The reduction in the comparison area was from 17 to 13 percent. Mean
height/length for age also improved more markedly in the HIDs than in the comparison area. Similar
patterns were also observed when all under-five children were analyzed. Despite the small baseline
sample size in the HIDs, the difference in difference tests showed that the decline in the HIDs was
significantly greater than in the comparison area (p<0.001).
Of the 21 pp reduction in stunting among children 24-59 months observed between 1998-9 and 2007 in
the HIDs, the largest drop - of 14 pp - seems to have occurred between 1998-9 and 2003, before ACSD
was fully implemented (p<0.01). The seven pp reduction between 2003 and 2007 was not significant
(p>0.10). Nevertheless, the confidence intervals for these estimates are wide due to the small sample
sizes.
50
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Table 12: Summary of anthropometry results in ACSD “high-impact” districts and comparison area as measured in DHS 1999, 2003 and MICS
2006-7, Ghana.
1998 DHS
HIGH IMPACT
DISTRICTS
NUTRITIONAL INDICATOR
n
% / 95% CI
mean / (SD)
2003 DHS
GEOGRAPHIC
COMPARISON¥
n
CI /
%/
mean (SD)
HIGH IMPACT
DISTRICTS
n
% / 95% CI
mean / (SD)
GEOGRAPHIC
COMPARISON¥
n
% / 95% CI
mean / (SD)
2007 Sup. MICS
2006 MICS
HIGH IMPACT
DISTRICTS
GEOGRAPHIC
COMPARISON¥
n
% / 95% CI
mean / (SD)
n
% / 95% CI
mean / (SD)
High impact
Comparison:
districts: Change in
Change in
baseline to 2007 baseline to 2007
1999 to
2007
2003 to 1999 to 2003 to
2007
2007
2007
p
p
p
p
Stunting (height for age)
24-59 months
% stunted (< -2 SD)
56 50-63
41 38-45
97
1138
90
% severely stunted (< -3 SD)
26 20-32
17 15-19
mean Z score (sd)
-2.1 (1.4)
-1.8 (1.3)
0-59 months
% stunted (< -2 SD)
44 38-49
32 30-35
168
2068
143
% severely stunted (< -3 SD)
19 13-24
13 12-15
mean (sd)
-1.6 (1.6)
-1.4 (1.5)
Wasting (weight for height)
0-23 months
% wasted (< -2 SD) 71 14 7-21 952 17 15-20 48
% severely wasted (< -3 SD)
0-10
3-6
5
4
mean (sd)
-0.9 (1.3)
-0.8 (1.3)
0-59 months
% wasted (< -2 SD)
4-12
8
11 9-12
171
2186
137
% severely wasted(< -3 SD)
1-5
2-3
3
2
mean (sd)
-0.6 (1.1)
-0.5 (1.2)
Underweight (weight for age)
0-59 months
% underweight (< -2 SD)
173
% severely underweight (< -3 SD)
mean (sd)
25
21-30
7
5-9
-1.3
(1.2)
2121
22
20-24
6
5-8
-1.1 (1.2)
145
42 28-56
47 44-50
35
1316
1336
18 11-25
18 16-21
10
-1.8 (1.2)
-1.9 (1.3)
-1.6
32-38
37
1385
9-12
13
(1.2)
-1.6
33-40
11-15
(1.2)
<0.001
<0.001
<0.001
>0.10
<0.01
0.08
0.04 <0.001
0.01 <0.01
<0.01 <0.001
36 29-44
39 37-41
29 27-31
31
2277
2192
2429
8-11
14 9-20
15 14-17
9
11
-1.4 (1.5)
-1.6 (1.5)
-1.3 (1.3)
-1.3
29-33
9-13
(1.4)
<0.001
<0.001
<0.001
0.03
0.03
>0.10
>0.10 <0.001
0.05 <0.001
>0.10 <0.001
27 18-36
955
10 3-18
-1.1 (1.4)
9
2
-0.5
7-11
1-4
(1.2)
>0.10
<0.001 <0.001
>0.10
>0.10
0.02
0.04
0.04 >0.10
<0.001 >0.10
6
2
-0.2
5-7
0-2
(1.1)
>0.10
>0.10
>0.10
0.04
>0.10
>0.10
<0.001 0.02
0.03 >0.10
<0.001 >0.10
15
13-17
0.03
<0.01
<0.001 <0.001
4
3-5
0.10
<0.01
0.01
>0.10
-0.9
(1.1)
0.02
<0.01
<0.001
0.03
13 11-15
865
2-5
4
-0.5 (1.4)
13 7-18
8
2264
1-7
4
2
-0.7 (1.2)
-0.2
30
21-38
9
6-13
-1.4
(1.2)
2317
14 11-17
1075
3-6
4
-0.7 (1.3)
6-9
8
2226
1-2
2
(1.2)
-0.5
7-10
1-3
(1.1)
20
18-22
21
19-23
5
4-6
5
4-6
-1.0
(1.2)
-1.1
(1.1)
2230
¥Comparison area comprised of Ghana national level, minus urban Greater Accra and Ashanti regions
IIP-JHU | Retrospective evaluation of ACSD in Ghana
51
2603
2504
0.01
Figure 20: Prevalence of stunting, wasting and underweight, and absolute change in percentage
points in the HIDs and comparison area as measured in DHS in 1998-9 and 2003, and MICS 2006-7,
Ghana.
Absolute change in percentage points between 1998-9 to 2006-7
-4
Prevalence of moderate and severe (%)...
100
High-impact districts (UER)
Comparison area
-8
-21
0
-7
-4
80
60
40
§
20
§
0
§
56 41 42 47 35 37
§
14 17 27 13 14 9
25 22 30 20 21 15
1998-9 2003 2006-7
Stunting (24-59m)
1998-9 2003 2006-7
Wasting (0-23m)
1998-9 2003 2006-7
Underweight (0-59m)
§ Estimate based on less than 100 children
Wasting.
Time trends in wasting should be interpreted with caution because of small sample sizes in the HIDs that
are reflected in the wide confidence intervals. For children under 24 months, the prevalence of wasting
declined between 1998-9 and 2006-7 by eight pp in the national comparison, but there was no decline in
the HIDs. This difference was statistically significant (p=0.03) in favor of the comparison area.
There was a marked peak in prevalence in 2003 in the HIDs, but this estimate is based on only 48
children. Trends in severe wasting and in mean weight-for-length showed similar patterns. No significant
differences were observed between the time trends in intervention and comparison area for the period
2003 to 2006-7.
Underweight.
The analyses of underweight included all under-five children. Using the 1998-9 baseline, there was a
decline of four pp in the HIDs and seven pp in the comparison area. As for wasting, underweight
prevalence showed a peak in 2003 in the HIDs, but not in the comparison area. After this peak,
prevalence declined by nine pp in the HIDs and by five pp in the comparison area. Trends in severe
underweight and in mean weight-for-age showed similar patterns. The difference-in-differences tests
were not significant for the 1998-9/2006-7 period or for the 2003/2006-7 period.
5.3 Summary and interpretation of results
Summary.
Stunting.
According to national surveys, the prevalence of stunting in under-five children in the comparison area
16,44
The decline between
increased between 1998-9 and 2003 and declined between 2003 and 2006
2003 and 2006 is probably related to overall socioeconomic progress and improvements in health care
and coverage of preventive interventions as described in section 3. Stunting is primarily influenced by
dietary quality and quantity, as well as by the incidence and severity of infections. Coverage of
interventions for preventing infections, such as ITNs and vitamin A, increased substantially in the HIDs
and comparison area. There are insufficient data to assess time trends in complementary feeding, so
that these cannot be related to changes in stunting prevalence.
Our results suggest that there was a substantial decline in stunting prevalence in HIDs between 1998-9
and 2003, compared to absence of a decline in the comparison area during the same period. After 2003,
the reductions in stunting prevalence were maintained and improved upon, although the rates of decline
appear to have been similar in HIDs and comparison area.
Wasting.
From 1998-9 to 2006, the prevalence of wasting among children less than five years of age has steadily
16,44
Our results show an
declined in Ghana as a whole, from 10 percent in 1998-9 to 5.4 percent in 2006.
apparent increase in the prevalence of wasting in the HIDs, but not in the comparison area, between
1998-9 and 2003, followed by a reduction of the same magnitude. Looking at the whole period, from
1998-9 to 2006-7, there was a reduction by almost half in the prevalence of wasting in the comparison
area that was significantly different from the lack of progress observed in the HIDs.
Underweight.
For Ghana as a whole, the prevalence of underweight has shown similar trends as wasting, declining
16,44
We observed these declining trends in both HIDs
from 25 percent in 1998-9 to 18 percent in 2006.
and the comparison area, with no significant differences between the two.
Cross-cutting implementation and contextual factors.
Here we review factors that may affect the comparisons described above.
Socio-economic status.
Poverty is associated with stunting (see section 8 on equity for further discussion) and as discussed in
section 3, the HIDs were significantly poorer than comparison area. Thus, our stunting results could be
affected by this imbalance of poverty. We used direct standardization to estimate the stunting prevalence
in HIDs in 2007, had these areas presented a similar wealth distribution to that in the comparison area.
The standardized prevalence in 2007 in the HIDs became 31 percent, compared to the crude prevalence
of 35 percent in HIDs and of 37 percent in the comparison area. The small number of children available
in the earlier surveys in the HIDs does not allow breakdown by socioeconomic position, but because the
HIDs are historically poorer than the rest of the country, the time trends are unlikely to be affected.
Presence of other nutritional interventions or programs in the HIDs.
Understanding of the role of nutritional interventions requires a discussion of the timing of growth
faltering. The active process of stunting, or growth faltering, occurs up to the age of 24 months, and
thereafter prevalence remains constant up to five years of age. The most sensitive indicator, therefore, is
the prevalence of stunting among children age 24-59 months, who are already fully “stunted.” However,
for ACSD to have an impact on stunting, children should be exposed to it during their first two years of life
when active faltering, or stunting, is occurring. For this reason, there is a lag between the time of the
intervention and the time when an impact on height-for-age can be measured. Most of the reduction in
stunting in the HIDs appears to have happened between 1998-9 and 2003 (figure 19), which means that
whatever caused this reduction must have happened at least a couple of years before the 2003 survey.
Implementation of ACSD started in 2002, thus ACSD activities cannot explain this reduction. Interviews
IIP-JHU | Retrospective evaluation of ACSD in Ghana
53
with key informants and review of documentation showed that strong nutritional interventions (presented
in section 3), such as the establishment and support of feeding and nutritional rehabilitation centers and
45
the LINKAGES project which focused exclusively on infant feeding practices, were present in the HIDs
before the launch of ACSD. These activities are a possible explanation for the marked reduction in
stunting prior to 2003.
Natural occurrences.
We investigated reasons for the apparent increase in wasting prevalence in HIDs between 1998-9 and
2003. Unlike stunting, changes in wasting can occur soon after a change in causal factors, because it
usually reflects acute weight loss. A potential cause of sharp increases in wasting is food shortage, but
our interviews with key informants and reviews of the documentation did not indicate that this was the
case. It is possible that the apparent increase in wasting is due to statistical fluctuation given the small
sample size of fewer than 50 children in the HIDs in 2003.
Summing up, after consideration of other factors, there was still no evidence of a differential impact of
ACSD on any of the three nutritional indicators studied. As will be discussed below (section 9 on
conclusions), this is consistent with the finding on coverage of interventions with a potential impact on
nutrition.
54
IIP-JHU | Retrospective evaluation of ACSD in Ghana
7. Mortality
This section reports on changes in child mortality in the HIDs and mortality trends in the comparison area.
The methods used to estimate mortality for the results presented in this section differ from those used for
coverage and nutrition analyses. The methods also differ by HIDs and comparison area due to data
availability. Below we provide a brief review of the analyses used for mortality estimation for the HIDs
and comparison area separately.
Mortality estimation in the HIDs.
We used the full birth history data collected in the 2007 Supplemental MICS to estimate child mortality in
the HIDs both before (baseline) and after ACSD became operational (endline). There are two reasons
why we elected to use the 2007 survey as the basis for estimating mortality throughout the evaluation
period. First, the use of a full birth history allows the calculation of period estimates of mortality from the
previous year to 10 or more years in the past because a child’s birth and/or death is very significant to the
mother and generally can be recalled reliably. Second, using a single survey to estimate mortality for the
two periods – baseline and endline – builds on the correlation between periods arising from use of the
same sample of households. This usually reduces the sampling error of the difference in mortality
between the two periods, enabling smaller differences to be measured more precisely. Third, this method
reduces the impact of non-sampling errors since there is generally more consistency of non-sampling
errors within a survey than between surveys.
Whether one or more surveys are used to estimate mortality, larger sample sizes are associated with
more precise estimates of mortality. Thus, we want to maximize the sample size by selecting longer time
periods for mortality estimation. These periods need to be consistent with ACSD implementation and the
baseline period should not extend far into the past, as this would result in a higher mortality estimate
before initiation of ACSD in contexts where mortality levels are declining over time. We calculated
mortality for two periods of the same length, 3½ calendar years each, before and after ACSD
implementation in the HIDs. As shown in Figure 21, based on the documentation of ACSD
implementation, we defined the baseline period as July 1998 to December 2001, and the full
implementation period as January 2004 to July 2007, with a phase-in period in between baseline and full
implementation.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
55
Figure 21: ACSD implementation time periods in Ghana for the retrospective mortality
analysis using full-birth history data, based on documentation of ACSD implementation.
YEAR (from full birth history)
Time periods used in mortality analysis
1998
1999
A. BASELINE:
2000
before
implementation ACSD
Jul 1998-Dec 2001
2001
2002
B. PHASE-IN: start of
2003
ACSD interventions
Jan 2002-Dec 2003
Compare U5MR
2004
2005
C. ENDLINE- Full
implementation ACSD
Jan 2004-Jul 2007
2006
2007
A. BASELINE: No ACSD implementation: start of period chosen for symmetry with period C
B. PHASE-IN: Start reinforcement of EPI & cold chain; donation of vehicles, motos & refrigerators; ITNs
Vitamin A; reinforcement of ANC activities
C. ENDLINE = EPI + ITNs; Vitamin A; ANC; CHW training & deployment; Facility IMCI
The under-five mortality rate (U5MR) is our priority indicator for measuring changes in mortality in the
46
HIDs, because the primary goal of the ACSD project was to reduce it by 25 percent by the end of 2006.
One benefit of using U5MR relative to other measures of child mortality (see Box 3) is that it provides the
largest sample size and is less sensitive to errors in reporting age than infant or neonatal mortality.
Although we present findings for specific age groups within 0 to 59 months, we have considered U5MR
as the primary indicator of mortality impact.
Mortality estimation in the comparison
area.
In Ghana, there is no single recent
household survey with a full birth history to
generate comparable direct child mortality
estimates for the comparison area (defined
as the rest of Ghana minus the HIDs, and
urban Greater Accra and Ashanti regions).
The most recent national survey in Ghana
with a full birth history is the 2003 DHS.
The 2006 Ghana MICS used the Brasstype questions on children even born and
children surviving. These questions only
provide indirect estimates of child mortality,
which cover a period of up to 15 years
before the survey.
Box 3:
Measures of child mortality
(expressed as deaths per 1,000 live births)
Neonatal mortality
(NN)
The probability of dying between birth
and the first month of life
Post-neonatal
mortality
The probability of dying between the
exact age of one month and the exact
age of one year
Infant mortality (IMR)
The probability of dying between birth
and exact age one year
Child mortality (CMR)
The probability of dying between
exact ages one and five years
Under-five mortality
(U5MR)
The probability of dying between birth
and exact age five years
Thus, we use the available data from both
the 2003 DHS and 2006 MICS to estimate and project trends in the under-five mortality rate for the
56
IIP-JHU | Retrospective evaluation of ACSD in Ghana
comparison area. We focus on U5MR since this is most robust indicator of child mortality, as described
above. Yearly direct mortality estimates were calculated from the DHS 2003 and then averaged over a
two-year period. The indirect estimates of under-five mortality (from DHS 2003 and MICS 2006) had their
most recent two points excluded. The most recent point is always excluded by demographers as being
too inaccurate, and the second most recent is recognized as often being biased, usually to higher levels
of mortality. We then fit a trend line to all the available data points to estimate increases or declines in
mortality in the comparison area, described further in section 7.1.
7.1
Results
Figure 22 presents the annual direct mortality estimates of U5MR in the HIDs from 1997 to 2007, as well
as the estimated mortality trend in the comparison area. Mortality over the last 10 years is declining in
the HIDs (95% confidence intervals shown in dashed, red lines). The U5MR in the comparison area is
estimated to have stagnated over the last 10 years, although trends from 2004 forward are projected from
available data (shown in blue dashed bar) and should be interpreted with great caution.
Figure 22: Annual estimates of under-five mortality rates in the HIDs as measured in the 2007
Supplemental MICS and estimated levels of mortality in the comparison area, 1997-2007, Ghana.
180
U5MR (deaths per 1000 births)
160
140
120
100
80
60
40
20
0
1997
High-impact
High-impact - 95% confidence bounds
National comparison - estimated
National comparison - projected
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Year
Note: Projected mortality in comparison area shown in dashed blue bar
HIDs.
Table 13 presents several age-specific mortality rates in the periods before ACSD implementation and
after full implementation, as well as the absolute reduction over time expressed as deaths per thousand
births. We present the 95 percent confidence limits for these estimates, as well as the p-value for
comparisons of estimate between baseline and endline.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
57
Table 13: Mortality rates by time period and changes between baseline and endline periods in the HIDs,
Ghana.
HIGH IMPACT ZONES
Under-five mortality (5q0)
A. JUL 1998 DEC 2001
106.7
95% CI
(87.9 - 125.6)
95% CI
(28.5 - 48.4)
Age-specific indicators
Neonatal mortality (NN)
38.4
Postneonatal mortality (PNN)
20.4
C. JAN 2004 JUL 2007
ACSD Phase-in period
MORTALITY MEASURES
Priority Indicator
DIFFERENCE IN BASELINE
AND ENDLINE (A minus C)
Absolute
difference
p value
86.2
20.6
(72.2 -100.1)
(-4.3 to 45.5)
26.3
12.1
(17.8 - 34.8)
(-1.3 to 25.5)
26.9
-6.4
(18.2 - 35.6)
(-17.8 to 5.0)
95% CI
(13.9 - 27.0)
58.9
53.2
5.7
95% CI
(47.5 - 70.2)
(41.4 - 64.9)
(-12.0 to 23.4)
50.9
34.9
16
95% CI
(37.3 - 64.4)
(26.7 - 43.0)
(-0.2 to 32.2)
Infant mortality (1q0)
Child mortality (4q1)
0.1
0.07
>0.10
>0.10
0.05
The U5MR decreased over time in the HIDs, from 106.7 in the period of July 1999 to December 2001 to
86.2 in the period of January 2004 to July 2007, representing a decline in UM5R of approximately 20
percent. This decline in U5MR just failed to reach statistical significance (p=0.10). Neonatal and child
mortality showed the fastest relative declines (32% and 31%, respectively, with p levels of 0.07 and 0.05),
while infant mortality decreased by 9.7 percent (p>0.10). Postneonatal mortality was observed to
increase, although this change was not statistically significant (p>0.10).
Comparison area.
As described above, no comparable data was available for the comparison area. Figure 23 presents the
trend line as estimated from available direct and indirect mortality estimates. The U5MR remained
approximately constant between 1994 and 2003 at 115 deaths per 1000 live births. We can project this
estimate forward to 2006 to cover the ACSD period; however, the uncertainty of this projection increases
as it gets further from 2003. Nevertheless, these estimates based on available data suggest that U5MR
has been constant in the comparison area for much of the period of the ACSD, but with considerable
uncertainty in the period since 2004.
58
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Figure 23: Estimated and projected under-five mortality rate in the comparison area as measured
using indirect and direct mortality estimates from DHS 2003, and indirect estimates from MICS 2006,
Ghana.
160
U5MR (deaths per 1000 births)
140
120
100
80
60
Excluding women aged 20-24 yrs data in trend line
40
20
0
1990
7.2
1992
DHS 2003 direct
DHS 2003 indirect
MICS 2006 indirect
Linear trend
1994
1996
1998
Year
2000
2002
2004
2006
Summary and interpretation of results
Based on these findings, the U5MR in the HIDs implementing ACSD in Ghana declined by 20 percent in
the period from 1998 to 2007—from 107 to 86 per 1,000 live births (p=0.10). Based on available data, the
U5MR was estimated to stagnate at approximately 115 per 1000 live births through 2003 in the
comparison area where ACSD was not implemented.
Cross-cutting implementation and contextual factors.
We considered the implementation and contextual factors that might have offset the impact of ACSD, with
special attention to factors that would have influenced the HIDs and comparison area differentially.
As presented in section 3, we observed that the HIDs were significantly poorer than the comparison area.
Available data suggested higher rates of mortality in the less poor comparison area and mortality in the
HIDs did not show a strong social gradient (see next section), thus it is difficult to assess how socioeconomic status might affect our estimates of mortality.
As discussed in section 3 and previous results sections, many child health and nutrition activities took
place outside of routine services in the HIDs before and during ACSD. These activities, in addition to
other development activities, such as improvements in water and sanitation, most likely contributed
significantly to the observed declines in mortality. Evidence reported in the literature suggests that the
CHPS strategy as implemented in the Kassena-Nankana district (one of the HIDs) led to declines in child
34,36,42
Coverage of CHPS in the HIDs greatly expanded over the evaluation period, although
mortality.
with lower population coverage than in the original experiment conducted by the Navrongo Health
Research Center taking place in Kassena-Nankana district.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
59
Thus, as noted above, the observed declines in mortality in the HIDs must be interpreted as a result of
broad efforts to improve child survival and health in these areas. Despite large-scale health programming
in the southern and central regions of the country and substantial investments in health at the national
level, available data suggest that mortality in the comparison area stagnated.
Methodological Challenges.
There are important methodological issues that may have affected the results of this retrospective
estimation of the effect of ACSD on under-five mortality. Appendix K provides a complement to this
section with a more detailed discussion of these issues.
Mortality data in comparison area.
Our primary methodological limitation is the lack of comparable data in the comparison area. We were
not able to estimate mortality, using direct estimates from the full birth history, for the same time periods
in the comparison area as in the HIDs. We estimated mortality trends in the comparison area using all
available data (direct estimates from the DHS 2003 and indirect estimates from the MICS 2006 and DHS
2003) to assess trends. Although this provides an estimate of mortality trends, it is a composite, based
on different surveys and different methodological assumptions in the calculation of mortality. Additionally,
these surveys only provide data that refer to mortality experiences up to 2004; the overall trend was
projected to 2007, but with the large uncertainty associated with any projection. The incomparability of
the data and methodologies between the two areas also precludes statistical comparisons of changes in
mortality between the two areas. More appropriate comparison data would consist of direct estimation of
mortality through full-birth histories collected in the neighboring districts in the Northern and Upper West
regions during the Supplemental MICS 2007—the same survey and methodology used for estimation in
the HIDs. In spite of numerous attempts, we were unable to obtain such data in a timely fashion.
Definition of the “before” and “after” periods of ACSD
A second methodological challenge was the definition of the “before” and “after” periods of ACSD
implementation. Documentation of implementation is difficult in a retrospective evaluation, and is based
by necessity on records maintained for other purposes and the subjective recall of project implementers.
The two periods defined for the purpose of this evaluation were discussed and agreed to with in-country
teams composed of ACSD implementers and national counterparts, and we believe that they accurately
distinguish between periods before ACSD was implemented and periods during which ACSD was “fully
implemented” in the views of those responsible.
In summary, despite these methodological challenges, there is sufficient evidence to conclude that that
there was a reduction in child mortality in the HIDs from before to after ACSD was implemented, that just
failed to reach statistical significance. The 20 percent reduction in U5MR between the two periods comes
close to the reduction goal for the ACSD project of 25 percent by the end of 2006. At the same time,
available data suggest that U5MR has stagnated in the comparison area, at least through 2004. In our
conclusions, we discuss how these findings relate to the results on coverage and nutrition.
60
IIP-JHU | Retrospective evaluation of ACSD in Ghana
8. Equity of coverage, nutrition and mortality
In addition to evaluating the impact of ACSD implementation on indicators of coverage, undernutrition and
mortality, it is also important to assess whether or not the strategy helped reduce inequities in health.
In this chapter, we describe within-population inequalities according to socioeconomic position, place of
residence and sex, separately for the HIDs and for the comparison area. Socioeconomic position was
categorized according to wealth quintiles, obtained from an index based on ownership of household
assets and building characteristics (described in Appendix D). The definition of urban or rural residence
was based on survey classification, derived from the 2000 Ghana Housing and population census.
The sample size available in 1998-9 and 2003 DHS for the calculation of baseline indicators in the HIDs
was small. Because equity analyses require breakdown of these already small samples into two to five
subgroups, it was not advisable to carry these out for the coverage and nutrition data. Given the oversampling of the HIDs at endline in the Supplemental MICS in 2007, it was possible to carry out equity
analyses for the post-implementation period. Our analyses, therefore, will be restricted to documenting
how inequalities differ between the two areas after ACSD implementation. We also attempted to
investigate ethnic group inequalities, but except for the Mole-Dagbani ethnicity, no other group accounted
for more than 10 percent of the sample in both the HIDs and comparison area, and thus it was not
possible to compare ethnic inequalities across areas.
Families in the HIDs were markedly poorer than those in the national comparison area (see figure 4 and
table 2 in section 3). For example, only nine percent of the under-five children belonged to the wealthiest
quintile based on the national sample). The small sample size in the upper quintiles in the HIDs should
be borne in mind when interpreting the results.
Appendix I presents the breakdown of all coverage indicators according to sex and wealth quintiles within
the HIDs zones in 2007. Due to the imbalance in the number of children in each wealth quintile in the
HIDs when the combined samples were used, the analyses in appendix I relied on a different asset index,
based exclusively on the HID sample in order to produce quintiles with approximately equal number of
children. The results in Appendix I, therefore, may differ from those presented in this chapter.
In this section, we present results for both the HID and comparison area, but restrict the results to six
coverage indicators representing the different components of ACSD. These include EPI+ (measles
vaccine, ITNs for children and vitamin A to children), IMCI+ (diarrhea management / ORT) and ANC+
(three or more antenatal visits, skilled attendant at delivery). We also carried out equity analyses for the
two main indicators of impact: stunting among children aged 24-59 months and under-five mortality rate.
Socioeconomic inequalities.
These results are summarized in figures 24a-h and in table 14. The table presents two summary
measures of inequality. The slope index shows the absolute difference between top and bottom of the
wealth scale, based on a regression approach the uses data from all quintiles rather than just the two
extreme groups. For example for skilled delivery in the HIDs, the index of 65.6 indicates that this is the
difference in percentage points (pp) in the coverage between the richest and poorest children. Table 14
also presents the concentration index that summarizes the overall amount of inequity in the population.
Concentration indices take values between minus one and one. A value of zero indicates that the
outcome is equitably distributed across all wealth groups. A negative value indicates disproportionate
concentration of the health variable among the poor, for example in the case of disease or malnutrition,
where the poor are more likely to be affected. A positive value indicates that the poor are getting less
than would be expected had the distribution been equitable, as often occurs for preventive and curative
iii
interventions.
iii
More information available at: (http://siteresources.worldbank.org/INTPAH/Resources/Publications/QuantitativeTechniques/ health_eq_tn07.pdf)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
61
Figure 24a-h: Socioeconomic inequalities, showing breakdown by wealth quintiles of selected
indicators in “high-impact” zones and comparison area, Ghana, 2006-7.
62
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Table 14: Summary indices of socioeconomic inequalities for selected indicators in HIDs and
comparison area, Ghana, 2006-7.
SLOPE INDEX OF
INEQUALITY
CONCENTRATION INDEX
Comparison
Comparison
INDICATOR
HIDs
Area
HIDs
Area
Measles coverage
-0.6
2.8
-0.001
0.004
Vitamin A (children)
1.0
1.1
0.005
0.008
ITNs (children)
-0.5
-0.3
0.000
-0.058
Diarrhea Management*
13.6
13.7
0.077
0.089
ANC (3 visits)
13.5
22.4
0.031
0.049
Skilled delivery
65.6
60.2
0.254
0.230
Stunting
-5.1
-11.1
-0.070
-0.129
Underfive mortality
-18.8
N/A
-0.037
N/A
* ORS, recommended home fluids, or increased fluids with continued feeding
There were virtually no inequities for indicators such as measles vaccination, vitamin A and ITNs, which
were promoted using campaign and community outreach approaches. In contrast, poor children
presented lower coverage levels than their better-off peers for diarrhea management, antenatal and
delivery care. The largest gaps refer to skilled attendance at delivery. There was only one significant
difference between HIDs and the comparison area in terms of equity in coverage – in the latter, ITN
coverage was slightly higher among the poor than among the rich, whereas in the HIDs there was no
inequality (p=0.02).
To better understand the equity gap in diarrhea management, we carried out additional analyses of
children who received ORS packets from a provider. Inequities were even sharper, with seven percent
coverage in the poorest quintile and 42 percent in the better-off. This is in agreement with the finding that
interventions requiring contact with a provider – ANC, skilled delivery, etc – tend to be more inequitable
than those delivered through community channels.
In terms of stunting and mortality (Figures 24g-h) the slopes are in the opposite direction than for most
coverage indicators, that is, levels are higher among the poor than the rich. The summary indices (table
14) take a negative sign under these conditions. The degree of inequality in stunting was lower in the
HIDs than in the comparison area, but this was not statistically significant.
For mortality, data on equity are available only for the HIDs, because of the limitations of the data
collected in the comparison area (see section 7). For this reason, the quintiles used for the mortality
analyses are based on the asset distribution in the HIDs only rather than the joint distribution of assets in
HIDs and comparison area. Use of the joint distribution, with very small numbers of HIDs children in the
better-off quintiles, would not allow precise estimation of mortality rates for these groups. Our results
show that children in the poorest quintile had mortality levels that were substantially greater than those in
all other quintiles (Figure 24-h). This pattern is uncommon at high mortality levels such as that observed
in the HIDs; when mortality is high, such as observed in Ghana, the better-off quintile usually stands out
from the other quintiles with markedly lower mortality levels.
Summing up, the analyses of socioeconomic inequalities show remarkably small gaps between rich and
poor for interventions delivered through campaigns and outreach, but there are substantial inequities for
those that depend on health services. Appropriate management of diarrhea, which is mostly indicative of
family practices, also showed inequities. Inequalities in stunting prevalence are lower in the HIDs, but it is
difficult to attribute this finding to ACSD given the lack of differential effect on inequities in coverage
indicators.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
63
Gender inequalities.
Table 15 presents data on possible inequities in terms of gender. There is no evidence of a preferential
treatment for boys, either in the HIDs or in the comparison area. Gender inequalities were not analyzed
for antenatal or delivery care, when the sex of the baby was yet to be known (assuming a low frequency
of pregnancy ultrasound). For the impact indicators (table 15), stunting prevalence was similar in both
sexes, but mortality was higher for boys than for girls, as is the case in most places in the world, although
this difference was not statistically significant.
Table 15: Selected coverage, nutrition and mortality indicators for boys and girls in the HIDs and
comparison area, Ghana, 2006-7.
COVERAGE or
NUTRITIONAL
INDICATOR
2006 MICS and 2007 SUPPLEMENTAL MICS
MALE
AREA
TOTAL
%
n
FEMALE
%
n
p
Any measles
Innoculation (1223m)
HIDs
98%
98%
187
99%
208
>0.10
Comparison
96%
95%
274
98%
276
0.07
ITN use for
under five
children
HIDs
58%
57%
1119
58%
1137
>0.10
Comparison
24%
24%
1364
23%
1304
>0.10
Vitamin A
supplementation
of children (659m)
HIDs
90%
90%
991
90%
984
>0.10
Comparison
96%
96%
1217
96%
1151
>0.10
HIDs
28%
23%
183
34%
174
0.05
Comparison
30%
33%
231
27%
173
>0.10
Moderate &
severe stunting
(24-59m)
HIDs*
35%
37%
671
32%
665
0.08
Comparison
37%
37%
730
35%
654
>0.10
MORTALITY
AREA
U5MR
U5MR
Births
U5MR
Births
p
Under-five
mortality
HIDs
86.2
93.8
834
77.6
858
>0.10
ORT for diarrhea
Urban-rural inequalities.
Urban residents accounted for 11 percent of the HID sample and 21 percent of the comparison area.
Urban women showed higher coverage of skilled attendance at birth and urban children had lower
prevalence of stunting in both the HIDs and comparison area (table 16). In contrast, rural children in the
comparison area were significantly more likely to sleep under an ITN. There were no significant
urban/rural differentials for under-five mortality rates, nor for coverage with the remaining interventions
(measles vaccine, vitamin A, diarrhea managment and ANC). There is no evidence that ACSD
implementation affected urban/rural differentials.
In summary, the analyses of inequalities by socioeconomic position, gender and urban/rural residence did
not provide evidence that ACSD implementation contributed to improving equity in Ghana.
64
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Table 16: Selected coverage, nutrition and mortality indicators for urban and rural areas in the HIDs
and comparison area, Ghana, 2006-7.
COVERAGE or
NUTRITIONAL
INDICATOR
AREA
Any measles
HIDs
Innoculation (1223m)
Comparison*
ITN use for
HIDs
under five
children
Comparison*
Vitamin A
supplementation HIDs
of children (6Comparison*
59m)
ORT for
diarrhea
Skilled birth
attendant:
doctor or
nurse/midwife
3+ visits ANC
care
Moderate &
severe stunting
(24-59m)
2006 MICS and 2007 SUPPLEMENTAL MICS
URBAN
RURAL
TOTAL
%
%
n
n
p
98%
99%
87
98%
309
>0.10
96%
97%
110
96%
439
>0.10
58%
53%
418
59%
1838
>0.10
24%
17%
586
25%
2083
0.01
90%
93%
368
89%
1607
0.07
96%
97%
511
96%
1857
HIDs
28%
32%
58
27%
299
>0.10
Comparison
30%
36%
86
29%
319
>0.10
HIDs*
40%
71%
94
33%
392
<0.001
Comparison*
42%
61%
114
37%
419
HIDs
89%
94%
94
88%
385
>0.10
Comparison*
80%
88%
113
77%
419
0.09
HIDs*
35%
27%
228
36%
1108
0.03
Comparison*
36%
23%
333
41%
1052
<0.001
U5MR
U5MR
Births
U5MR
Births
p
86.2
83.6
329
86.4
1363
>0.10
MORTALITY
AREA
Under-five
mortality
HIDs
IIP-JHU | Retrospective evaluation of ACSD in Ghana
>0.10
<0.001
65
66
IIP-JHU | Retrospective evaluation of ACSD in Ghana
9. Conclusions
In this section, we summarize the findings of the evaluation, addressing two separate questions:
a. Was ACSD implementation associated with improvements in coverage, nutrition and mortality
over time?
b. If so, was progress in the ACSD districts faster than observed for the rest of the country?
As described in section 2 (methods), there was no true baseline survey in the HIDs and comparison area
that met the quality criteria for coverage and nutritional data. Implementation of ACSD started in mid
2002, and therefore the 1998-9 DHS was too early for a baseline, and the 2003 DHS survey a bit too late.
It is important to keep this issue in mind when interpreting the evaluation results.
Figure 25 summarizes these trends in the HIDs and comparison area during the period from 1998-9 to
2006-7. The horizontal axis shows the change in coverage in the HIDs and the vertical axis the
corresponding changes in the comparison area. All dots are on the right side of the y-axis, that is, the
indicators showed an increase in the comparison area (although not all of these increases were
statistically significant). Most dots are also above the x-axis, meaning that the indicators increased in the
HIDs. A few interventions, mainly related to case management, showed some degree of decline in the
HIDs.
Figure 25: Summary of absolute changes between 1998-9 and 2006-7 in coverage and family
practices in “high-impact” districts and comparison area, Ghana.
Absolute percentage change in coverage
Comparison area
-40
-20
0
20
40
60
80
IPTp
Antibiotics for
pneumonia
60
ITN (child)
BF within 1 hr
40
HIDs
Absolute percentage change in coverage
80
Skilled delivery
20
DPT3
EBF
Vitamin A
(child)
Measles
ANC4+
TT2
0
Careseeking pneumonia
ORT &
feeding
-20
Vitamin A
(postnatal)
AM for fever
-40
Key:
ANC+ interventions
EPI+ interventions
Infant feeding
Case management
When the indicator increased (or decreased) to a similar extent in both areas, the points are close to the
diagonal. Indicators that are above the diagonal showed better performance in HIDs than in comparison
IIP-JHU | Retrospective evaluation of ACSD in Ghana
67
area. The reverse is true for those below the diagonal. A larger number of indicators improved faster in
the HIDs than in the comparison area than the reverse, but key indicators of case-management tended to
increase faster in the latter areas, except for antibiotics for pneumonia. A caveat of the results shown in
Figure 25 is that they do not reflect baseline levels. For example, vitamin A to the child shows a larger
increase in the comparison area than in the HIDS, but it started out from baseline levels of 65 percent in
the HIDs and 22 percent in the comparison area, so that the scope for improvement was much greater in
the latter.
Relative to the two questions posed at the beginning of the chapter, the answers for coverage indicators
are:
(a) Most coverage indicators improved over time in the HIDs and reached the target coverage levels
set by ACSD, although declines were observed for case management indicators.
(b) Comparison with the rest of the country showed mixed results, although more indicators showed
faster increase in the HIDs than in the comparison area.
Turning to nutritional status, the answers to the two basic questions are:
(c) The HIDs showed a reduction between 1998-9 and 2007 in underweight and stunting prevalence,
but not in wasting.
(d) Over the period from 1998-9 to 2006-7, stunting declined significantly faster in HIDs than in the
comparison area. Because of the time lag between the implementation of ACSD-promoted
nutritional interventions and the detection of an impact on stunting, it is unlikely that ACSD can
account for much of the observed reduction in this indicator. Wasting, on the other hand,
declined significantly in the comparison area while remaining stable in the HIDs.
Reducing under-five mortality by 25 percent by 2006 was the primary goal of the ACSD strategy. Our
analyses showed that:
(c) There was a reduction of 20 percent in under-five mortality in the HIDs, close to the ACSD goal of
25 percent. This trend was ascertained through the full birth history technique, and the reduction
was close to reaching statistical significance (p=0.10).
(d) Data on under-five mortality trends in the comparison area were available from a different source
than those for the intervention area, with an endpoint in 2004. Other analyses suggest that
mortality levels remained stable at around 115 deaths per thousand live births, in contrast to the
20 percent reduction by 2007 in the HIDs. The different endpoints and analytical techniques used
in the two time series preclude a more accurate comparison.
Because of the small sample sizes in the HIDs at baseline, analyses of inequalities in coverage and
nutrition indicators were limited to comparisons at the end of the study period. Our conclusions are:
(a) Only small socioeconomic inequalities were observed for interventions delivered through
campaign approaches such as vaccination, vitamin A and ITNs. Diarrhea management, four or
more ANC visits, stunting and mortality showed intermediate magnitudes of inequalities, whereas
large rich-poor gaps were observed for skilled delivery care. Inequalities between boys and girls
were virtually non-existent. Urban-rural inequalities were small, except for skilled attendance at
delivery and for stunting.
(b) When HIDs were compared to the rest of the country, there was no evidence of differences in
patterns of health inequalities for intervention and coverage indicators.
The retrospective nature of the evaluation imposed a number of important constraints that may have
affected our findings. These include the fact that no true baseline data were available, as discussed
above. Secondly, the available “near-baseline” samples were very small in the HIDs, precluding the
precise measurement of coverage and nutrition indicators. Third, the methods and timelines for mortality
assessment were different in the two areas being compared. Finally, HIDs were markedly poorer than the
rest of the country, so that comparability is affected; a more appropriate comparison area would consist of
neighboring districts in the Northern and Upper West regions, but in spite of numerous attempts we were
68
IIP-JHU | Retrospective evaluation of ACSD in Ghana
unable to obtain such data in a timely fashion.
The joint interpretation of findings on coverage, nutrition and mortality in the HIDs is limited by the
different time spans for the coverage and nutrition indicators (1998-9 to 2006-7) and for mortality
estimation (1998-2001 to 2004-2007). The main causes of under-five deaths in Ghana in 2003 were
malaria (33%), neonatal causes (29%), pneumonia (15%) and diarrhea (12%). The highest coverage
levels in the endline surveys in the HIDs were achieved for vaccinations, vitamin A supplementation to
children, antenatal interventions (including IPTp and TT) and ITNs. Exclusive breastfeeding also showed
large increases. One would expect these interventions to have a greater impact on deaths due to
malaria, neonatal causes and diarrhea. None of these preventive interventions, except for HiB vaccine
and exclusive breastfeeding, would be expected to affect pneumonia deaths. Reported careseeking for
pneumonia stagnated while antibiotics for pneumonia significantly increased. Further analyses showed
that over one-fourth of the reported antibiotics came from drug shops and itinerant vendors, making it
difficult to interpret the impact of this practice. Key informants reported that mothers might have chosen
to go to drug vendors when community-based workers encouraged mothers to seek care for cases of
childhood pneumonia. Case-management interventions against malaria and diarrhea showed low and
declining coverage levels in the HIDs. Taken together interventions showing large gains in coverage had
only limited impact on the main causes of death, and hence are compatible with a moderate decline in
mortality levels, similar to the 20 percent reduction observed in the HIDs.
When contrasting trends in the ACSD and comparison area, it is important to consider that a large
number of international, bilateral and Ghanaian agencies have been operating in both areas, before as
well as during the study period. The sections on background characteristics and implementation
(sections 3 and 4) show that many of the interventions promoted by ACSD had been actively
implemented by other agencies, some well before ACSD was formally launched in 2002, and others in
collaboration with ACSD. These included, but were not limited to; the Navrongo Health Research Center
(vitamin A, ITNs and CHPS strategy), Ghana Red Cross Society (mother-to-mother support groups and
community activities), World Food Program feeding programs, the LINKAGES project (infant feeding
interventions), World Vision and CRS (nutritional rehabilitation centers and education), CHPS centers
(access to primary health care), etc. The coverage of the CHPS strategy, posting community nurses to
improve preventative and curative primary health care, expanded greatly in the HIDs over the ACSD
implementation period. ACSD worked with many of these partners to achieve further increases in
coverage.
Building upon what exists is a key ACSD strategy, and although this makes strong programmatic sense, it
renders it difficult if not impossible to attribute specific coverage gains to ACSD per se. Thus, the results
must be interpreted in light of combined efforts to improve child survival in the region. The Ghana
implementation team noted on various occasions several key ACSD contributions, including: 1) the
program’s ability to concentrate on a package of effective interventions; 2) additional resources for
commodities, equipment and human resources; 3) clearly stated targets; 4) establishment of productive
partnerships and synergies across institutions; and 5) achievement of strong commitment from the GoG,
GHS and other donors. The Ghana team also noted key lessons learned from the ACSD experience and
recommendations for future child health programming, shown in box 4.
At the same time, other development partners, including UNICEF, provided massive investments in the
rest of Ghana, again making it difficult to ascertain the additional impact of ACSD by comparing the HIDs
with other geographical regions.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
69
Box 4:
The way forward: Lessons learned in ACSD Ghana according to national
counterparts
1. The ACSD strategy did not focus strongly on interventions to improve child undernutrition
 New ACSD-like programs need a “nutrition-plus” component to ensure that efforts and resources
are devoted specifically to nutritional interventions.
2. Community-based activities, including training and supporting CHWs, were an integral, but challenging
component of ACSD
 More attention needs to be given to the motivation of community-based agents and their
supervisors at the sub-district level
 Support for adequate supervision, monitoring and incentives and an uninterrupted supply of
commodities will be essential to sustain adequate levels of motivation and quality
3. Gains for behaviors related to management of childhood illness, skilled assistance at delivery, and
nutritional practices were less than expected
 Changing behaviors is complicated and time consuming. More efforts and resources should be
devoted to behavior-change strategies, especially face-to-face counseling and mother’s support
groups
4. Supervision and monitoring system are often weak and untimely, particularly at the sub-district and
community levels. Problems, such as stock-outs of ORS and antimalarials, were picked up by the
current system, but only after persisting for long periods.
 Importance needs to be given to supervision and M & E systems, developing systems that function
in real time.
5. Increased supply of commodities was a contribution of ACSD; however, stock-outs of essential
commodities associated with weak supply management, gaps in funding and changes to national
policies hindered potential gains in intervention coverage.
 Ensuring an adequate and continuous supply of essential commodities will strengthen future
program efforts;
 Commodity security should be included in program planning and monitoring; alternative approaches
should be explored to strengthen commodity security.
6. ACSD was integrated into the planning processes at the regional level; it now needs to be better
integrated into the national and district-level planning processes
7. Government ownership of the program was an on-going issue; the program is still often viewed as an
externally driven project outside of the routine health services.
8. External evaluation results can be used to improve new ACSD-like programs
 ACSD successes should provide an impetus for scale-up of similar packages and new interventions;
 Introduction of interventions should be done incrementally with early review;
 Evaluation results should convey a sense of urgency of all that remains to be done, especially for
nutrition and case management of childhood illness
The findings reported above should not detract from the fact that remarkably high and equitable levels of
coverage with key child survival interventions were achieved in the HIDs, and that ACSD coverage goals
were met for a majority of these indicators, in a region of extreme poverty when compared to the rest of
the country. Stunting prevalence declined markedly over time, although much of the improvement seems
to have occurred prior to ACSD implementation, likely associated with strong nutrition programs present
in the HIDs for a number of years. Under-five mortality also showed a 20 percent reduction, which just
failed to reach statistical significance. The fact that gains in intervention coverage were greater in the
HIDs than in the comparison area lends plausibility to the hypothesis that some part of the mortality
reduction found in the HIDs may be attributed to activities linked to ACSD.
70
IIP-JHU | Retrospective evaluation of ACSD in Ghana
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Trop Med Int Health. 6 (9): 667-76 (2001).
40.
Binka, F.N., Hodgson, A., Adjuik, M. & Smith, T. Mortality in a seven-and-a-half-year follow-up of
a trial of insecticide-treated mosquito nets in Ghana. Trans R Soc Trop Med Hyg. 96 (6): 597-9
(2002).
41.
UNICEF. Stratégies accélérées de survie et du développement du jeune enfant (SASDE) au Mali:
Un recherche opérationnelle mise en œuvre dans le cadre du PRODESS dans six cercle de
démonstration. Bamako, Mali, 2005.
42.
Pence, B.W., Nyarko, P., Phillips, J.F. & Debpuur, C. The effect of community nurses and health
volunteers on child mortality: the Navrongo Community Health and Family Planning Project.
Scand J Public Health. 35 (6): 599-608 (2007).
43.
Shrimpton, R., Victora, C.G., Onis, M., Lima, R.C., Blossner, M. & Clugston, G. World wide timing
of growth faltering: implications for nutritional interventions. Pediatrics. 107 (5): E75 (2001).
44.
GSS, NMIMR & ORC_Macro. Ghana Demographic and Health Survey 2003. Calverton,
Maryland, Ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical Research
(NMIMR), and ORC Macro, 2004.
45.
AED. LINKAGES Project Ghana: Final Report (1997-2004). Washington, DC, Academy for
Educational Development 2004.
46.
UNICEF. Accelerating early child survival and development in high under-five mortality areas in
the context of health reform and poverty reduction: a results-based approach. UNICEF proposal
to Canadian CIDA. New York, 2002.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
73
ACCELERATING CHILD SURVIVAL AND DEVELOPMENT (ACSD)
Final Report
The Retrospective Evaluation of ACSD:
Ghana
APPENDICES
Submitted to UNICEF Headquarters on 7 October 2008
Institute for International Programs
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD
A. Description of Ghana and “high-impact” districts
B. Methodology for documentation of implementation activities and contextual factors
C. Documentation of implementation
D. Definition of key indicators
E. Survey Questions
F. Methodologies of surveys in Ghana 1998-2007
G. Tables presenting priority coverage indicators over time for ACSD high-impact districts
H. Tables presenting comparisons of priority coverage indicators over time in ACSD high-impact districts
and the comparison area
I.
Tables presenting 2007 MICS results for key coverage indicators in the ACSD high-impact districts by
socio-demographic characteristics of the population
J. Additional tables for nutrition
K. Methodological challenges
L. References for the appendices
M. Mapping of partners’ activities in “High-impact” districts (Upper East region) and nationally
APPENDIX A
Description of Ghana and “high-impact” districts
Geography
Ghana, located in West Africa, maintains three international boarders and a coast off the Gulf of Guinea.
Togo is situated to the East, Cote d’Ivoire to the West, and Burkina Faso to the North and Northwest.
Formerly known as the Gold Coast, Ghana achieved independence from Great Britain in 1957. Ghana’s
23,383,000(2) people are distributed over 238,500 km, with their capital in Accra. Divided into 10 political
regions, 17% of the population resides in the three northern regions (Upper West, Upper East, and
Northern Regions), which along with Brong Ahafo region comprise Ghana’s Savannah ecologic zone.(3)
Greater Accra and part of Central Region encompass the Coastal zone, while Ashanti, Volta, Western
and Eastern Regions are predominantly in the Forest zone.(4)
Fig A1: Ecological map of Ghana
Fig A2:
regions
Map of Ghana showing the
Population
Of Ghana’s 23,383,000 people, 38% are younger than 15 years old.(2) In 2000, 47% of households were
in urban areas, but given the higher average number of people per household in rural areas, an estimate
41% of the population is urban.(5) However, some regions, like the Upper East Region, host as much as
87% of the population in rural areas.(3) The overall male-female ratio is 100.2:100, but distribution is
unequal with more women living in rural areas than men. The estimated growth rate is currently 1.9% with
a total fertility rate of 3.8 births per woman.(5)
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Diversity typifies Ghana’s population with more than 50 languages and dialects spoken throughout the
country. According to the 2000 Census, Akans comprise 45.3% of the population, Mole-Dagbon 15.2%,
Ewe 11.7%, Ga-Dangme 7.3%, and less than 5% each of Guan, Gurma, Mande-Busanga and others. In
terms of religion, approximately 69% are Christian, 15-30% Muslim, and the other faiths include traditional
African religions and Judaism.
Economy
Well endowed with natural resources, Ghana’s per capita output is twice that of neighboring West African
countries. In 2005 and 2006, the Gross Domestic Product grew at a rate of 6%. The domestic economy is
based on subsistence agriculture, while gold, timber and cocoa earn most foreign exchange. Even though
60% of the labor force is involved in agriculture, it only contributes 34% of the GDP. The services
industry, employing 25% of the labor force, supplies 41% of the GDP.(6, 7)
Despite prosperity relative to its neighbors, Ghana maintains a 5.7 billion (US$) debt, 26% of the Gross
National Income. In 2001, the unemployment rate rested at 20% with no recent updates. According to a
2003 Poverty Profile, roughly 40% of Ghanaians live below the poverty line (900,000 cedis), and 27% are
in extreme poverty (less than 700,000 cedis). However, rural areas suffer the brunt of poverty with an
average of 55% below the poverty line.(8) The northern savannah regions are most affected with 70-88%
of households in poverty.(3)
Table A1: Percentage of Population below Poverty Lines(8)
National Average
Poverty (>900,000 c)
Absolute poverty
(>700,000)
Rural Average
Urban Average
39.5%
54.6%
23%
26.6%
40.7%
14.2%
Education
Fifty-eight percent of Ghanaians 15 years or older are literate. Literacy among youth (15-24 years) is
higher, but the gender disparity continues with rates of 76% for males and 66% for females. The primary
school net enrololment ratio, the number of school-aged children enrolled divided by the number of
school-aged children in the population, is 69-70% for boys and girls. The gross enrollment ratio, which
includes children outside the age-appropriate limits, is 93-94%, suggesting that children older than official
primary school-aged enroll as well.(9) Similar to the poverty trends, the 3 northern regions have the
lowest adult literacy rate at 24%.(3)
Health
Primary health program expansion since 1978 has reduced childhood mortality rates. Additional subdistrict health facilities and trained personnel, along with the Expanded Programme on Immunization
(EPI) initiated in 1976, have contributed to health gains that now provide Ghanaians with an average life
expectancy of 59 years.(9) Additionally, health reforms in early 1990s focused on an achieved reduction
in early childhood mortality. However, progress plateaued by 2003. Table 3 provides a 1998-2003
comparison of various health indicators.
Of particular concern, the infant mortality rate (IMR) rose from 57 deaths of infants less than 12 months
per 1,000 live births in 1998 to 63 deaths per 1,000 as measured in the 2003 DHS. The Upper West and
Northern Regions were estimated to have the highest infant and child mortality rates in the 10 years
previous to the 2003 DHS. Rising vaccination coverage and health care seeking behavior prompted the
Ghanaian Ministry of Health to investigate explanations for the mortality stagnation. The Upper East
Region was identified as an anomaly to the trend, and their child survival interventions are currently being
explored.
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UPPER EAST REGION
Given the disparities observed among health, education and economic indicators, the Upper East Region
(UER) has become one of the focal points for collaborative programs and intervention projects.
Geography
Located in the north-eastern corner of Ghana, UER shares international borders with Burkina Faso and
Togo, along with internal borders with Upper West Region and Northern Region. Cross-border movement
is common and gives way to difficulties in disease surveillance and control. UER is divided into 8 districts,
each autonomous regarding planning, budgeting and implementation of projects. Bolgatana is the
Region’s capital. Overall, there are 911 communities both dispersed and sometimes overlapping. Of the
Region’s 1017 km of road, 69% is considered motorable. Unlike the Ghana’s southern regions, UER has
2 seasons instead of 4, with particular drought hazards between January and March.
Fig A3: District Map of UER
Population
According to the 2000 census, 4.8% of Ghanaians live in UER, which represents only 3.7% of the
country’s landmass. Despite a higher than average population density, 87% of the population is rural.
The 2006 estimated population was almost 983,000, up from 920,000 in 2000. The growth rate is 1.1%,
below the national average. 56.3% of males and 49% of females are 0-19 years old. The proportions
reflect an excess of adult females compared to national averages. Out-migration of men is the
predominant explanation. (10) Ethnically, 74.5% are Mole-Dagbon, 8.5% Grusi, 6.2% Mande-Busanga,
and 3.2% Gurma. The Region’s main languages are Gurune, Kusal, Kasem, Buili and Bisa. 46% of the
population practices traditional religions, 28% Christianity, and 23% Islam.
Economy
UER is has the highest percent of the population living below the poverty among Ghana’s 10 Regions.
88% earn less than 900,000 cedis annually. According to the Ghana Living Standards Survey, poverty
worsened between 1992 and 1999 in UER. Over 80% of the economically active population engages in
agriculture, predominantly grains and cattle. Only one industry, a cotton ginnery, is active.
Education
UER also has the highest level of illiteracy in the country. Seventy-eight percent of adults 15 years or
older are not literate in either English or a Ghanaian language. The disparity between male and female
literacy is most exaggerated in UER as well. The Region supports 449 primary schools, 177 junior
secondary schools, and 23 senior secondary schools, but 71.8% over the population 6 years and older
have never attended school. More males than females have attended school, 35.3% versus 23.6%
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
respectively of the 6 years and older population; however the proportion varies by district. 34% of children
7-14 years work full-time, over half of which are boys. (7)
Table A2: Educational Attainment for Those Who Ever Attended School
Education Level
Attained
Percent of >6 years old population who have
attended school and attained given educational
level
Primary
Middle/JSS
Secondary/SSS
Vocational/Technical
Post-secondary
48.1%
20.8%
12.5%
4.2%
4.5%
Health
UER’s health situation presents an interesting mix of improvements and declines. In 1998, DHS
information indicated that UER had the highest early childhood mortality rates in Ghana, as shown in
Table 3. However, by the 2003 DHS, UER reduced both infant and under-5 mortality rates were
estimated to have dramatically decreased, despite the lack of progress in neighboring regions. However,
many other health indicators remained above national averages, such as the percent of malnourished
children. UER mothers actually received less antenatal care (ANC) in 2003, while the percentage of
professionally assisted births rose. However, the majority of UER deliveries were still unattended
professionally, at slightly over half the national average. In comparison with Upper West Region and
Northern Region, which have basically similar populations in terms of culture, socio-economic conditions,
health determinants and human resource difficulties, the Upper East Region far exceeded mortality rate
expectations.
Fig A4: Average annual
rainfall in Ghana
Sentinel site data indicated that 44%
of UER’s mortality burden was attributed to
deaths of children younger than 5 years old. The
primary under-5 mortality contributors were:
malaria, anaemia, diarrhoea, malnutrition, acute
respiratory infections, measles and neonatal
complications. Child survival interventions, such
as the Integrated Management of Childhood
Illnesses, may be related to UER’s deviant
results. Several organizations have supported
projects in the Region; such as the Dioscesan
Health Service (1998-2006), Ghana Red Cross
Society (1999-2006), World Vision International
(1996-2007), Community Water and Sanitation
Agency
(1973-2005),
US
Agency
for
International
Development
(1998-2007),
Japanese International Cooperation Agency
(2003-2007), World Health Organization (20032007), Opportunities Industrialization Centres
International
(2003-2006),
and
Danish
International Development Agency (20032007).(10)
Source: FAO Gateway to Land and Water Resources, Ghana(1)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A5
APPENDIX B
Methodology for implementation of ACSD activities and contextual
factors
Various techniques were employed to collect information retrospectively about the implementation of
ACSD activities and contextual factors in the “high-impact” zones. Much information was gathered
from colleagues at the UNICEF-Ghana field office, who have been collaborating on the retrospective
evaluation throughout the process. Field visits, key informant interviews and working meetings to
review of the preliminary coverage results all provided information pertaining to details of ACSD
implementation and contextual factors. Details of these discussions are provided in table B1. During
these encounters, the JHU evaluation team requested any documents providing more details on
ACSD and other partner’s activities.
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
A7
UNICEF, GSS and Harvard
School of Public Health
Review of data
processing
Jan 2008
16 – 17
Nov,
2006
Ghana MOH
GHS – Public Health Div.
Ghana Statistical Service
Meeting
Meeting
Meeting
Key informant interviews / discussions
UNICEF, GSS, Macro and
MICS interviewer teams
Aug &
Sept 2007
UNCEF, MOH, Danida/DFID,
district and regional
representatives
PARTICIPANTS
Training and
supervision of survey
teams
Nov 2006
DESCRIPTION
To collect
information about
Ghana’s experience
with ACSD, and
available data on the
process, outcomes
and potential impact
of ACSD in Ghana.
Field Visits
DATE
upon request
Gareth Jones,
Kate Gilroy
Gareth Jones,
Kate Gilroy
Discussion of MICS 2006 – implementation, processing and
progress; other available data sources
Gareth Jones ,
Kate Gilroy
Gareth Jones
and Elizabeth
Hazel
Kate Gilroy and
Elizabeth Hazel
Jennifer Bryce,
Robert Black,
Gareth Jones
and Kate Gilroy
PARTICIPANTS
TEAM
Discussion of ACSD
Discussion of ACSD and mortality rates in Ghana & UER
Provided logistical assistance during data processing; performed
a comprehensive review of data quality; provided feedback to
UNICEF and GSS. Full documentation available upon request
Provided technical assistance during interviewer team training
for the 2007 supplemental MICS survey. Provided on-site
supervision of interviewer team and feedback to UNICEF and
GSS. Full documentation available upon request
Areas of focus: (i) impressions of ACSD-Ghana ii) challenges for
the evaluation; and (iii) communications from those
implementing the program. The objective of the visit was to
begin the learning process and identify promising avenues for
further documentation and analysis Full documentation available
TOPICS COVERED
EVALUATION
Table B1. Description of field visits, key informant interviews, and work sessions carried out to document ACSD implementation activities and
contextual factors
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
20-24
Nov.
2006
16 – 17
Nov,
2006
DATE
Description of research projects past and present carried out at
Navrongo; description of DSS; discussion of mapping exercise of
UER
Discussion of ACSD in Bawku West district; including nutritional
centers and ITNS
GHS – Bongo district,
Kodoro CHPS facility
Navrongo health research
center
GHS – Bawku West district
offices
Site visit to health
centre
Site visit to CHPS
center
Site visit to
Navrongo
Mtg with district
Description of CHPS centre and work of CHO in community;
review of CHPS registers and records; review of CHPS centre
supplies
Description of CHOs and CBAs roles in outreach and health
promotion; description of promotion of child birth at health
facility; review of kit boxes
GHS – Bongo district,
Zorkor facility
Mtg
Discussion of ACSD in Bongo district; Follow up with C Samata
Azaba, G Alcolba, & A Anyinato for documents concerning
implementation of ACSD and annual reports
Discussion of implementation of ACSD, IMCI; discussion of
national policies re: CCM, IMCI, etc
Presentation of the evaluation overview; general discussion of
ACSD
Poverty maps of Ghana & other West Africa countries
TOPICS COVERED
GHS – Bongo District
Offices
Meeting / interview
UNICEF
Meeting / informal
discussion
GHS – Reproductive & child
health unit
Ghana Statistical Service
PARTICIPANTS
Informal discussion
DESCRIPTION
Jennifer Bryce,
Gareth Jones,
Kate Gilroy
Jennifer Bryce,
Robert Black,
Gareth Jones,
Kate Gilroy
Jennifer Bryce,
Robert Black,
Gareth Jones,
Kate Gilroy
Jennifer Bryce,
Robert Black,
Gareth Jones,
Kate Gilroy
Jennifer Bryce,
Robert Black,
Gareth Jones,
Kate Gilroy
Jennifer Bryce,
Robert Black,
Gareth Jones,
Kate Gilroy
Jennifer Bryce,
Robert Black,
Gareth Jones,
Kate Gilroy
Kate Gilroy
PARTICIPANTS
TEAM
EVALUATION
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A9
20-24
Nov.
2006
DATE
UNICEF
UNICEF
UNICEF
UNICEF
Debriefing of site
visit
Informal discussion
Debriefing of site
visit
Informal discussion
Jennifer Bryce,
Gareth Jones,
Kate Gilroy
Jennifer Bryce,
Kate Gilroy
Informal presentation of preliminary findings/perceptions from
site visit; Discussion of successes & challenges
Identification of documents with UNICEF inputs & timeline for
ACSD
Gareth Jones
UNICEF
Discussion
Discussion of MICS 2006 survey and possibility of further
sampling in UER, UWR & Northern Region (also on 24-11-2006)
Jennifer Bryce,
Gareth Jones,
Kate Gilroy
Discussion of ACSD implementation and progression; challenges,
etc
Jennifer Bryce,
Gareth Jones,
Kate Gilroy
Gareth Jones
Discussion of mapping activity and availability of
protocol/questionnaire/data
Navrongo health research
center
Follow-up mtg
Informal presentation of preliminary findings/perceptions from
site visit; Discussion of successes & challenges
Jennifer Bryce,
Kate Gilroy
Discussions of available data & annual reports and collection of
data/reports; discussions of communications strategies and
collection of materials; discussions of training & monitoring of
CBAs; collection of pertinent documents
GHS – Upper East Regional
office
F-U mtgs; collection
of keydocs
PARTICIPANTS
TEAM
EVALUATION
Jennifer Bryce,
Gareth Jones,
Kate Gilroy
GHS – Bawku West –
Sapelliga health center
Site visit to health
center
TOPICS COVERED
Description of CHOs and CBAs roles in outreach and health
promotion; Description of antenatal services; review of health
center register; review of CBAs monitoring notebooks
PARTICIPANTS
DESCRIPTION
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
UNICEF
UNICEF
IN-DEPTH
KNUST
Informal discussion
Mtg
Informal discussion
PARTICIPANTS
Informal discussion
DESCRIPTION
Kate
Discussion of training and monitoring of CBAs; collection of
pertinent KNUST documentation
July 2008
Presentation of
preliminary results
GHS, MOH, KNUST<
UNICEF, GSS
Full review of coverage, nutrition and mortality preliminary
results
TBD
Gareth
Discussion of mapping exercise project for UER
Gareth, Kate
Collection and discussion of further data sources available;
identification of mico-data files
PARTICIPANTS
TEAM
EVALUATION
Kate Gilroy
TOPICS COVERED
General timeline of implementation; collection of further
documentation and data sources
Work sessions to review and interpret preliminary results
20-24
Nov.
2006
DATE
APPENDIX C
Documentation of ACSD implementation activities
UNICEF-ACSD, consolidating the efforts of previous programs, presented a package of cost effective
intervention and a strategy of service delivery for scale-up region-wide(11). UNICEF acted as the
facilitator with partner support and the Ghana Health Service (GHS) implemented the interventions at the
regional, district and sub-district levels(11). The UER has a strong history of community-based health
volunteers. UNICEF-ACSD utilized this resource for intervention delivery: developing a community
health curriculum and recruiting and training Community Based Agents (CBAs)(11). De-worming, PMTCT
and IPTp programs were introduced as part of ACSD(11).
The ACSD implementation activities are described in more detail here, expanding on the information
provided in the main body of the report. Timelines of implementation activities for each ACSD component
are presented in tabular format with brief explanatory text. In order to estimate the magnitude of
implementation, the population projection for adults, children and infants in 2004 was used to standardize
and provide a coverage estimate.
Delivery of ITNs
In late 2002, distribution of ACSD ITNs began in the Upper East region (table C1). The start of
implementation was variable by district, some districts adopted ITN delivery before the overall ACSD
program(11). Bed nets were distributed to the district offices, then to the volunteers and then to the
communities(11). Multiple strategies of community delivery were used:
1. ITN sale of nets to target groups at health centers
2. Volunteer sales agents accompany nurses on health outreach session
to sale nets while the nurses work
3. Community based agents (CBA) trained in management of childhood
illnesses began distributing and retreating ITNs(11).
4. Retreatment and distribution campaigns
All volunteers, CBAs and nurses involved in the ITN program have been trained on ITN distribution and
retreatment (11).
Treated bed nets were sold at a reduced price to families with children under five and pregnant women
through a chit (voucher) system(11). However as demand for nets increased, the subsidized nets were
sold using the 20/80 rule(11). Eighty percent of the nets are sold to the target groups for 5000 cedis and
the remaining 20% are sold to anyone for 23,000 cedis(11). At the time of purchase, the customers are
advised by the volunteers to retreat every six months, through the health centre or a volunteer(11).
Retreatment cost is 2000 cedis per net and the ITN volunteer agents receive a 1000 cedis per net sold or
retreated(11).
From November 2002 to September 2004, volunteers in UER sold 156,510 out of 236,500 (66%) ITN
nets received (Table C1). In the UER, a reported 36,223 ITN nets were distributed for an estimated
38,450 (94%) pregnant women and 109,579 ITN nets distributed for an estimated 144,187 (76%) under
five children (Table C1). Distribution occurred at ANC, PNC, CWS and delivery service points (12). At the
end of 2004, 100% coverage is reported for children under five and pregnant women(13).
The first household retreatment campaign occurred in May of 2003 (11) and the second retreatment
campaign was planned for April of 2004(12). The retreatment campaign in 2004 was delayed until June,
leading to concerns that the campaign occurred too late in the rainy season(12). Retreatment was also
integrated into Child Health Week in May of 2004(11, 12). The campaigns that occurred during 2003 and
the 2004 Child Health week were free of charge(11). After Child Health week in 2004, the nets were
retreated for 2000 cedis(11). During this second retreatment exercise, there was poor turnout as cost
was a barrier for many people(14). Also there were limited chemicals for retreatment(11). The
cumulative outputs from these campaigns are listed in Table C1. By mid-2004, depending on the source
12,000 – 13,000 nets were retreated out of an estimated 169,965 nets in the community, approximately
10 percent (table C1).
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A11
ITN distribution and retreatment activities continued into 2005. By December 2005, most of the districts
had stock-outs of ITN nets, except for Bongo and Bawku Municipal districts funded through the Global
Fund and Roll back Malaria(15). Therefore only modest gains in cumulative ITN distribution for pregnant
women and under five children are reported since 2004 (table C1). Ghana submitted a proposal to
UNICEF for addition bed nets in 2005 (15). In order to estimate the number of bed nets required, Ghana
completed a bed net inventory that was integrated into the filariasis treatment campaigns(15).
Retreatment of bed nets in 2005 was planned for the spring but then delayed until Child Health Promotion
Week(15). There are also several accounts of first and second quarter funds delayed until later in the
year(16, 17) although ITN distribution was reportedly ongoing (15). At the end of the year approximately
25,000 were retreated out of an estimated 244,000 nets in the community (Table C1). Retreatment levels
are still relatively low (25%) however the Upper East region received approximately 40,000 KO tablets to
help with retreatment activities(17).
The proposal for UNICEF was for one billion, one millions cedis for additional nets(18). At the first quarter
of 2006, the region had 40,000 KO tablets but no nets to distribute(18). Instead the region procured nets
from the Global Fund to distribute while awaiting the UNICEF nets(18). The Global Fund nets were
significantly more expensive at 20,000 cedis compared to the UNICEF nets which were sold for 5,000
cedis(19). Retreatment campaigns began during Child Health Promotion Week and continued for several
months in order to address the issue of low retreatment levels (18). At this point, CBA-IMCI volunteers
are the primary mechanism for retreatment campaigns(19). The mid-2006 totals for bed net distribution
and retreatment are quite low compared to earlier years (Table C1). However as Ghana moves towards
exclusive use of long-lasting ITN nets, the retreatment campaigns will become less important(11).
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A13
2004
2003
2002
Year
Annual Total/
Unspecified
Oct-Dec
Jul-Sept
Apr-Jun
Jul-Sept
Oct-Dec
Annual Total/
Unspecified
Jan-Mar
Apr-Jun
Annual Total/
Unspecified
Jan-Mar
Oct-Dec
Jan-Mar
Apr-Jun
Jul-Sept
Months
Regional
Area
Annual ITN Distribution(13)
Regional
Cumulative ITN Distribution
from 2002 to Sept. 2004 (12) Regional
(Dec. 2004) (20)
June: second retreatment of
ITN (12)
May: Health Week(11, 12)
May-July: first retreatment of
ITN(11, 20)
Nov: began distribution of
ITNs(11, 20)
Activity
38,450 / 36,2231 pregnant women targeted
144,187 / 153,7991 under-five children targeted
36,223 / 36,2231 pregnant women targeted
109,579 / 153,7991 under-five children targeted
12,012 re-treated out of estimated 169,965
nets in the community(12)
13,766 re-treated (14)
13,353 retreated (20)
ITN retreatment integrated into Child Health
Week activities(12)
Intensity
Table C1: Overview of ITN distribution and retreatment in the Upper East region, 2002-2006
▪ Received: 236,500 ITN; Total sales:
156,510 ITN
▪ Cumulative nets retreated since June
2003
▪ Different totals reported by source
Cumulative ITN distribution listed under
second retreatment, May-June 2004
Kick-off date
Notes
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
Area
Regional
Mid year report: bed net
distribution and
retreatment(13, 18)
Jul-Sept
Annual Total/
Unspecified
Oct-Dec
Regional
Regional
Mid year report: ITN
retreatment(13)
ITN sales agent trained(21)
Cumulative ITN Distribution
from 2002 to Dec. 2005 (13, Regional
15)
May: Child Health Week (16) Regional
Activity
Apr-Jun
Jan-Mar
Annual Total/
Unspecified
Jul-Sept
Oct-Dec
Apr-Jun
Jan-Mar
Months
▪ Different totals reported by source
Notes
5,489 / 153,7991 under-five children targeted
2,541 / 36,2231 pregnant women targeted
6,829 retreated out of an estimated 244,000
nets in the community
40,000 KO tablets have been delivered in 2005
684 per 190,022 pregnant women and
children under five
1
40,576 / 36,2231 pregnant women targeted
▪ Used 2005 estimated for number of
nets in community
184,069 ITN
132,270 / 153,7991 under-five children targeted ▪ Received: 236,500 ITN; Total sales:
25,812 retreated in early May before the rainy
season (17)
25034 retreated out of an estimated 244,000
nets in the community(16)
Intensity
1 – Estimated population from 2004 projections(22) : 153,799 under five children, 36,223 pregnant women & 38,450 children 0-11m ; 807,447 adults and children >5y
2006
2005
Year
EPI+
The strengthening of the preexisting EPI+ program involved many partners and it is difficult to decipher
the exact UNICEF contribution(23).
UNICEF-ACSD mostly focused on developing strategies to improve defaulter tracing (11). Using
community based surveillance systems, the CBA volunteers used a register to trace children due for
vaccinations(11). Mop-up campaigns occurred after National Immunization Days (NID) to vaccinate “zero
dose” children identified by polio vaccinators during the NID(11). UNICEF also worked through GHS,
District Assemblies and the BESFA and BUCO rural banks to allocate funds for the purchase of iodized
salt to women in microcredit groups in the Builsa and Bawku East districts(12).
In 2003, monitoring data shows 45% BCG, 38% measles and 35% Penta3 coverage for an estimated
23,207 children under five targeted (Table C2). Concerns during implementation of EPI+ in 2003 include:
poor quality of district-level EPI data, continuing high levels of wastage and defaulting, incomplete or late
EPI form submissions and irregular submission of Cold Chain inventory reports(23).
Vitamin A campaigns were initiated during the 2004 Child Health Promotion Week(24). Monitoring data
from 2004 shows an estimated 44% of children 6-11m and 27% of children 12-59m received vitamin
A(25). In 2004, two campaigns for de-worming children under five and pregnant women occurred during
the NID in March and September, resulting in very high coverage for the target populations (12). Four
rounds of NID occurred in the Upper East region in February, March, October and November (26). The
monitoring data from the first quarter of 2004 shows large gains compared with 2003: 36% BCG, 30%
Measles and 31% for Penta3 (Table C2). The NID campaigns are successful; polio coverage is above
100% and no wild-type polio has been detected since September 2003(14). However the issue is still
adherence to immunization schedule: initial contact with EPI+ is high, but continuation is poor, effecting
the quality of vaccination (14). Intermittent shortages of measles vaccine were reported in BW district(12,
26)
In addition to campaigns, the Upper East regional office also provided cold chain equipment, logistical
assistance and monthly or quarterly feedback at the district level (23). UNICEF contributed to these
efforts along with other partners. The issues identified at the end of the year by the UNICEF for the EPI+
programs are late release of funds, inadequate incentives for volunteers, inadequate information of
immunization schedule and inadequate monitoring and supervision(14).
In 2005, the NID continued, four rounds in February, April, November and December(27). UNICEF
procured 26.2 millions doses of OPV to assist the GHS in polio eradication efforts(17). The EPI+ program
received adequate quantities of routine vaccines: MOH and GAVI purchased all vaccine using UNICEF
procurement services(17). All districts in the Upper East region have a community-based registration
system in place: 992+ CBS volunteers have been trained in all 8 districts and deployed with community
registers(17). Four districts in the UER have functional defaulter tracing and outreach services(17). The
CBS volunteers received defaulter tracing refresher training and conducted a market immunization and
defaulter tracing exercise, results on Table C2 (16) (27).
In addition to the defaulter tracing training and exercises, Bawku West district reported strong EPI+
activity for 2005: routine monthly static and outreach immunizations, quarterly mop-up immunizations and
training of Health Staff on increasing immunization coverage at sub-district levels (27). A GHS National
EPI report shows high coverage for the UER at the end of 2005 (Table C2). Continuing measles
shortages is reported for the BW district(19). No Vitamin A coverage data for this year although continued
distribution. De-worming campaigns for children under five continued with very high coverage rates,
almost 100% (Table C2).
In 2006, an EPI survey completed in four districts, shows defaulter tracing and mop-up campaigns need
to be strengthened(18). Defaulter tracing exercises are to be done monthly, but some districts are not in
compliance(19). A GHS National EPI report shows high coverage for the UER at the end of 2006 (Table
C2). There was no quarterly mop-up of iodization campaign although market supplementation occurred
(Table C2).
IIP-JHU | Retrospective evaluation of ACSD in Ghana
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
2004
2003
2002
Year
Jan: ACSD EPI+ activities
begin (11)
Activity
Antigen
Cold chain expansion
Increase demand for EPI services
Intensity
Oct-Dec
Jul-Sept
1
Oct: second round of de- NID:
Regional (district 170,736 / 153,799 de-wormed
worming (12, 14)
Antihelminth level available)
Measles: 33,927/ 38,4501 targeted
National
Immunization
National
Penta3: 33,395/ 38,4501 targeted
Days (NID)(14)
1
BCG: 41,528/ 38,450 targeted
Regional (district
54,803 / 153,7991 targeted
level available)
Apr-Jun
Vitamin A
May: Child Health
Promotion Week(25)
Jan-Mar
BCG: 10462 / 38,4501 targeted
Regional (district
1
level available) Measles: 8735 / 38,450 targeted
1
DPT: 8177 / 38,450 targeted
Area
March: First round of de- NID:
Regional (district 177,533 / 153,7991 de-wormed
worming(12, 14)
Antihelminth level available)
BCG: 8357 / 38,4501 targeted
BCG,
Regional (district
EPI+ first quarter
1
Measles,
level available) Measles: 7037 / 38,450 targeted
totals(20)
DPT3
DPT: 711 / 38,4501 targeted
BCG,
Annual Total Cumulative immunization
Measles,
/Unspecified for 2003(20)
DPT3
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Annual Total/
Unspecified
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Months
Table C2: Timeline of implementation of EPI+ activities in the Upper East region, 2002 - 2006
▪ First quarter EPI+ results for 2004
much higher than 2003 annual results
▪ USAID 0.5 million USD grant (28)
Notes
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A17
Iodized salt(13)
Iodized salt
National
National
UER: BCG: 111%
Penta3: 93%
Measles: 96%
GHS EPI report
Supplemented 100 bags of salt in ▪ No mop-up campaign held during
Bolga market
this quarter
Yellow fever: 1509 /38,4501 targeted
UER: BCG: 111%
Penta3: 96%
GHS EPI report
Measles: 90%
Yellow fever
▪ Market immunization and defaulter
tracing
Measles: 1503 / 38,4501 targeted
Regional (district Penta3: 1074 / 38,4501 targeted
level available)
OPV3: 1052 / 38,4501 targeted
Measles
OPV3
Penta3
Annual regional summary of EPI
Annual Total activities(24)
/Unspecified
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Annual regional summary of EPI
activities(24)
EPI+ annual totals(15)
BCG
Regional (district
1
177,553 / 153,799 targeted
level available)
BCG: 1140 / 38,4501 targeted
▪ Since Oct 2004
Antihelminth
Notes
Annual total de-worming
for under fives(15)
Intensity
Oct-Dec
Area
Only found in district report
Antigen
Child Health Week(27)
Activity
Jan-Mar
Apr-Jun
Jul-Sept
Months
1 – Estimated population from 2004 projections(22) : 153,799 under five children, 36,223 pregnant women & 38,450 children 0-11m ; 807,447 adults and children >5y
2006
2005
Year
IMCI
Before ACSD, IMCI interventions were implemented on a smaller scale by partners such as Ghana Red
Cross and Catholic Relief Services (11). ACSD pulled together the experiences of these pilot programs
and presented a common framework for scale-up region-wide(11). Community IMCI was implemented in
2003 however the majority of community based agents (CBA) did not begin service until 2004(11). The
C-IMCI model utilizes trained CBAs on a voluntary basis to provide the following services: appropriate
infant feeding practices(12), health education to mothers, fever treatment with pre-packed chloroquine,
diarrheal treatment with ORS, recognition and referral of ARI, promote immunization and iodized salt and
mobilize the community for participation in de-worming, NIDs and other programs(11). UNICEF
collaborated with KNUST, Ghana Red Cross and Ghana Health Services to develop a CBA training
program. CBA volunteers were equipped with bicycles, educational materials and health kits containing
Kinaquine junior and infant (chloroquine), ORS sachets and hand washing material(11). In order to
continue motivation and commitment, the CBA volunteers earn a percentage of sales(11). For instance,
a CBA earns 100 cedis on every ORS sachet sold(11). Based on past experience in the regions with
volunteers, female volunteers are preferred over men(11).
Monitoring and supervision was carried out by the KNUST team and the regional office(12). However the
most of the time it is integrated into routine supervision with Regional Health Management Team (RHMT)
members(12). However there are issues with integration, sub-district supervisors are reluctant to carry
out CBA supervision without additional funds for fuel, for instance(29).
In the first half of 2003, IMCI scale-up activities and CBA volunteer recruitment took place (Table C3).
CBA volunteers were trained at the district and regional level and also at KNUST Community Health
Department of the School of Medical Science (11). The first CBA training session occurred from MayJune 2003, in which 1039 or 1118 (depending on the source) volunteers were trained (Table C3).
Training of Trainers (TOT) sessions are reported in July 2003 at the sub-district level (Table C3).
Additional volunteer training sessions occurred in July and November and December of 2003 in all
districts although there is no record on the number of volunteer trained (20). The number of children seen
and referred for illness for 2003 is reported in Table C3.
In March of 2004, an additional 744 CBAs were trained bring the total to 1780 or 1892, depending on the
source (Table C3). The first two quarters of 2004 show poor supervision of CBAs at the district and subdistrict level (12). In June 2004, KNUST conducted CBA supervisory visits, covering one-third of the subdistricts in the region in one month (30). KNUST visited the CBAs and the households that had accessed
services from the CBAs. Some of the results were promising: there was an itinerary and plans for
continued supervisory visits, CBAs are undertaking follow-up visits for illness treatment and CIMCI
implementation has strong community support(30). However supervision is weak, CBA coverage is
inadequate and distribution of inputs is incomplete and behind schedule(30). For childhood illnesses, the
KNUST team found that mothers are accessing CBAs too late (more than 24 hours after onset of
symptoms) and many adults are consuming the drugs meant for children(30). Also it was found that
CBAs focused more on drug treatment than the health education messages(30). Finally KNUST noted
that many areas in the region will be inaccessible to CBAs during the rainy season.
KNUST participated in CBA training in October of 2004, training approximately 100 CBAs in the Bolga
and BE districts(31, 32).
Also in October, UNICEF held a TOT session for 30 extension field staff from GHS, Department of
Community Development and Environmental Health of Sanitation Unit (33). The TOT session focused on
ACSD activities so that the leaders could return their communities and train representatives to
disseminate the information(33). Later in November, the 30 participants in this TOT exercise trained a
total of 300 representatives on the ACSD objectives. The purpose of these workshops was to strengthen
the capacity of community members on ACSD activities and promote the use CBAs (33) In November,
UNICEF conducted an ACSD sensitization workshop for 36 political authorities including council
chairpersons, opinion leaders, assembly-persons, market queens and political representatives(33).
Another component of CIMCI is training of clinicians. UNICEF reported 5 clinicians were trained in the
CIMCI module although it is difficult finding trainers in the UER(14).
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
In October, KNUST undertook another CBA supervisory visit this time focusing on CBAs to discuss the
implementation process; this was the fourth such supervision exercise since May of 2004 (32). KNUST
found that many of the CBAs had not received refresher training since their initial training, 11 months ago
and weak supervision continues to be an issue. However many of the supervisors had been introduced
to various M&E tools. The quality of training differed by district, Bolga had the most well organized
training and Bawku the poorest(32). Also at the district level, there is a lack of the computer literacy for
proper data processing, analysis and interpretation. KNUST found CBAs continuing to emphasis drug
treatment over health education and had difficultly filling out paperwork.
The number of children seen and referred for illness for 2004 is reported in Table C3. In 2004, health
education sessions were only taking place in three districts: Bawku West, Bolga and Bongo. The number
of adults and adolescent children receiving health education from CBAs is shown on Table C3.
As of 2004, five district hospitals have been designated as Baby Friendly as part of the Baby Friendly
Health Initiative Facilities (BFHI). UNICEF- ACSD supports BFHI by developing guidelines on exclusive
breastfeeding, training Mother to Mother Support Groups (MtMSG) and providing training materials. A
district report from Bawku West offers more details on BFHI training: meeting with midwives and sub
district leaders on BFHI, 20 health staff trained on lactation management and complementary feeding and
100 TBAs trained on exclusive breast-feeding(26).
In 2005, UNICEF continued clinical staff training exercises, 48 prescribers and 3 regional staff were
trained in the UER, 20 RHMT and NGO partners sensitized to CIMCI, 20 district level TOT sessions and
sub-district TOT and CBA training(16, 17). At there end of the year, UNICEF reports a total of 1780 CBAs
providing CIMCI servicing 922 communities(17). Other reports state 1810 CBAs trained(16) and 1892
total trained(29).
Throughout 2005, KNUST and the regional staff supervised the CBAs. Sub-district supervision was
found to continue to weak and there is an inadequate supply of logistics such as kits, training materials
and bicycles(15). There was also an issue with expired Kinaquine(16). There are been some CBA dropout: either the CBAs left, found other jobs or the women got married(16). Replacement of CBA staff
affecting CBA supervision and new staff claim they are not trained in CIMCI(19). The number of children
seen and referred for illness for 2005 is reported in Table C3. In 2005, health education sessions were
only taking place in three districts: Bawku West, Bolga and Bongo. The number of adults and adolescent
children receiving health education from CBAs is shown on Table C3.
BFHI activities continued; UNICEF focused on exclusive breastfeeding training and 16 health facilities
were assessed and 15 qualified as Baby Friendly(16).
In mid 2006, TOT sessions are continued with 10 clinicians and 3 regional focal persons participating(13).
In October, 24 prescribers were trained(34). The monitoring team evaluated trained prescribers and
found high non-compliance with the ACSD objectives (13) Monitoring and supervision of CBAs are
ongoing but not to expectation(13). In 2006, a total of 1982 CBAs are reported (19). The regional team
conducted supervision visits to 1366 of the 1982 CBAs in the region. The team found poor supervision at
the district and sub-district level for instance many supervisors were not inquiring about ACSD activities
during their supervisory visits. In some districts the supervisors did not know where their volunteers were
or even how many CBAs were in their jurisdiction. The CBAs complained of missing or irregularly paid
commissions and lack of mobility due to broken bicycles(19). The regional team also found poor
integration of ACSD activities into routine services(19).
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A19
Annual Total /
Unspecified
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Months
Results of community
health volunteers:
treatment and referrals
(13)
Community volunteer
training(12, 14)
July: TOT for sub-districts
begin(20)
July: volunteer
training(20)
Nov/Dec: volunteer
training (20)
Regional
Regional
Regional
Regional
Community entry and
volunteer recruitment
(20) (11)
May-June: volunteer
training (29)
Regional
Area
Planning meeting(20)
Activity
1118 trained per 153,799
Under-five children
Intensity
1
1
ARI: 549 cases per 153,7991
Under-five children ;all referred
Diarrhoea: 21,444 cases per
153,7991
Under-five children ; 268 referred
Malaria: 50,760 cases per 153,7991
Under-five children ; 970 referred
UNICEF
1039 trained per 153,799
Annual review Under-five children
IMCI
Monitoring
report
Source
Notes
▪ Different number reported than elsewhere
▪ No data on number of volunteers trained
▪ No data on number of volunteers trained
▪ Different number reported than elsewhere
▪ Reported program kick-off date
▪ “Action plan & budget IMCI scale up meeting
with KNUST Home Management of Malaria: Feb
2003”
Table C3: Timeline of implementation of IMCI+ activities in the Upper East region, 2002 - 2006
Year
2003
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Year
2004
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A21
Annual Total/
Unspecified
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Months
KNUST report
Source
Intensity
Regional
Regional
Training
36 leaders participated
briefing report
KNUST report
Regional,
Training
held in
30 extension field staff
briefing report
Tamale
Bolga, BE KNUST report ~100 CBAs in various sub-districts
Regional
Area
Regional
(district
available)
Results of community
Bawku
health volunteers: health West,
Results of community
health volunteers:
treatment and referrals
(12)
Malaria: 14,003 cases per 153,7991
Under-five children
Diarrhoea: 21,444 cases per
1
153,799
Under-five children
ARI: 549 cases per 153,7991
Under-five children
Diarrhoea/sanitation: 8895 per
807,4471 population over 5y
Regional,
25-26th Nov: Community
held in
Training
representative
300 participants
briefing report
various
workshops(33)
locations
1036 (2003) + 744 (2004) = 1780
CBA volunteer training
1
Regional
cumulative trained per 153,799
(14) (13) (25) (29)
Under-five children
IMCI Clinical Training
5 clinicians trained per 153,7991
Regional
(14)
Under-five children
June: KNUST CBA
supervisory visits(30)
July: received Kinaquine
prepacks(20)
25 -31st Oct: KNUST
CBA training(31, 32)
26-29th Oct: TOT for
general ACSD
activities(33)
Oct: : KNUST CBA
supervisory visits(32)
2nd Nov: Sensitization
exercise for political
authorities(33)
Quarterly supervision
report(12)
Activity
▪ Number of adults and adolescent children
received health education from community health
▪ Slightly different (smaller) numbers in annual
report(25) and in a 2006 brief resume(13)
▪ Cumulative CBAs reported trained
▪ 1118 also reported trained in 2003
▪ Community representatives were trained on
ACSD objectives by 30 TOT members trained in
Aug 2004
▪ From GHS, Dept. of Community Development
& Environmental Health of Sanitation Unit
▪ Poor supervision from district to sub-district
level for the first two quarters
Notes
Year
2005
A22
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Months
Area
Source
Results of community
health volunteers:
treatment and referrals
(15)
Oct: Training for
prescribers (14, 16, 17)
Regional
Regional
Database for community Regional
Volunteer
based volunteers and
(district
database
midwives (35)
available)
Baby Friendly Health
Regional
Initiative (BFHI) facilities
Activity
Notes
ARI: 944 cases per 153,7991
Under-five children ; 944 referred
Diarrhoea: 11,839 cases per
153,7991
Under-five children ; 968 referred
Malaria: 20,189 cases per 153,7991
Under-five children ; 1,556 referred
1
48 prescribers trained per 153,799
Under-five children; 3 regional staff
trained
Infant feeding: 4665 per 807,4471
population over 5y
Immunization: 6688 per 807,4471
population over 5y
Malaria: 8158 per 807,4471
population over 5y
ARI: 1643 per 807,4471 population
over 5y
5 health institutions qualify for BFHI; 3
district hospitals and 18 health
centres to follow.
TBA: 495 per 36,2231 pregnant
women
CBA-agents: 1892 per 153,7991
Under-five children
▪ Number of different health volunteers, more to
CBA-surveillance: 1522 per 153,7991
be trained.
Under-five children
▪ Lists different number of CBAs = 1892
1
ITN volunteers: 684 per 153,799
Under-five children
Midwives: 173 per 36,2231 pregnant
women
Intensity
Year
Area
Oct-Dec
1
Supervision report(19)
24 prescribers trained per 153,799
Under-five children
ARI: 166 cases per 153,7991
Under-five children ; all referred
Diarrhoea: 9.897 cases per 153,7991
Under-five children ; 172 referred
Malaria: 10,377 cases per 153,7991
Under-five children ; 513 referred
1
10 clinicians per 153,799
Under-five children; 3 regional focal
persons
ARI: 7,068 per 807,4471 population
over 5y
Malaria: 21,319 per 807,447
population over 5y
Meeting report
Regional
& IMCI
1366 met by supervision team out
(by district
supervisory
1982 CBAs trained
available)
report
Jul-Sept
▪ 642/1366 with no bicycles
▪ 816/1366 had no kits
▪ 460/1366 had no reporting formats
▪ Nov 21st training date, in addition to 48 trained
in Oct 2005 (34)
▪ No education reported in other districts
Immunization: 23,447 per 807,4471
population over 5y
1
▪ Strongest level of health education in Bawku
West
Notes
Infant feeding: 24,140 per 807,4471
population over 5y
Diarrhoea/sanitation: 24,401 per
807,4471 population over 5y
Intensity
Not
specified
Mid year report: results of
community health
Regional
volunteers: treatment and
referrals(13)
Source
Mid year report: IMCI+
(13)
Midyear report: IMCI
case management TOT
training(13)
Not
specified
Bawku
Results of community
West,
health volunteers: health
Bolga,
education(15)
Bongo
Activity
Apr-Jun
Jan-Mar
Months
1 – Estimated population from 2004 projections(22) : 153,799 under five children, 36,223 pregnant women & 38,450 children 0-11m; 807,447 adults and children >5
2006
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A23
ANC+
ANC services, known as the IPT package, were offered through the Antenatal clinics to pregnant women.
The IPT package includes Vitamin A supplements, Iron and folic acid supplements, antihelminths and IPT
of malaria with sulphadoxine pyremethamine. Two districts were supported by the Global Fund starting
May 2004: Bongo and Bawku East(11). In June 2004, ACSD extended IPT to the remaining four
districts(11).
Tetanus Toxoid immunization of pregnant women is also included, but as part of the EPI+ program and
many of the immunizations were done during NIDs(23). UNICEF supported TT immunization along with
other partners(23).
In May 2004, a National TOT for IPT activities took place in all six UER districts(20) . District level IPT
training occurred in June 2004(11). Also this year sensitization activities took place in ANC clinics by
services provider(20). TT immunization was scaled up to all districts, the first round of TT supplementary
immunization activities (SIA) took place in early 2004 with 46% coverage of the target population (Table
C4). The second round of TT SIA occurred later in the year with an estimated 62% coverage(23). The
third round of TT SIA only covered two districts with 73-95% estimated coverage (Table C4). Distribution
of postnatal vitamin A and SP to pregnant women began mid-2004, with service through ANC delivery
centres(12). Annual postnatal vitamin, SP and de-worming coverage for 2004 can be seen in Table C4.
UNICEF-ACSD completed a market immunization and defaulter tracing exercise for EPI+ antigens, TT
was included in the exercise (Table C4). Bawku West district reported
iron deficiency and anaemia control training for midwives and other health workers (Table C4).
In 2005, de-worming activities were scaled up in Bawku West. Annual de-worming rates for the region
are reported in Table C4. BW reported three rounds of TT SIA in 2005 and even though we found no
other evidence of TT SIA in other UER districts, it is assumed that it was ongoing because TT coverage is
estimated at 76% for the UER in 2005(24). Data in postpartum vitamin A distribution is variable during
2005, but up to 2217 women were dosed (Table C4). SP distribution continued with no reported side
effects (Table C4) although there are high drop-out rates after first and second dose(15). Use of SP by
pregnant women was promoted through radio health education discussions(16). TBAs and CBAs were
trained on distribution of postpartum Vit A (16)
The 2006 annual monitoring data for vitamin A, SP, de-worming and TT are reported in Table C4.
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
A25
2004
2003
2002
Year
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Annual Total/
Unspecified
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Annual Total/
Unspecified
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Months
Regional
Area
July: Postnatal
vitamin A
supplementation
begins(12) (25)
De-worming of
pregnant women
began(12)
Post natal Vitamin A Regional
supplementation
(district
(12)
available)
7 – 12 June: District
IPT training(20)
May: ACSD funded
BW, Bol,
IPT begins with TOT
Buil, KN
training (11, 20) (25)
TT SIA round 1(23)
PMTCT sensitization
activities (20)
Activity
1st dose: 5,973 / 36,2231 pregnant women targeted
2nd dose: 7,320 / 36,2231 pregnant women targeted
105,879 / 230,700 targeted women
Intensity
Table C4: Timeline of implementation of ANC+ activities in the Upper East region, 2002 – 2006
▪ July-Dec 2004
MW, CHN doing ANC, CHO
??
▪ No data on number of TOT
participants
▪ No data on scale of
sensitization activities
Notes
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
2005
Year
Bol: 54,307 / 57,372 targeted women
Buil: 13,816 / 18,899 targeted women
Bolga and
Builsa only
TT SIA round 2 (23)
TT SIA round 3 (23)
Annual Total/
Unspecified
Oct-Dec
Annual total for IPT
since May 2004(15,
16)
Annual total
postpartum Vitamin
A(15)
Apr-Jun
Regional,
district
available
1
No deworming in Bawku
West(12) (26)
▪ May – Dec 2004
Notes
st
1
1 : 10700 / 36,223 pregnant women targeted
nd
1
2 : 7717 / 36,223 pregnant women targeted
3rd: 4843/ 36,2231 pregnant women targeted
1649 reported in 2006 Brief
Resume (13)
2217 received PP Vit A but
number of dose not
specified. (16)
BW: 20th -24th June 2005
Regional: No dates or
numbers specified (14)
Twenty nine midwives and CHNs trained out of 5190 Training on iron deficiency
pregnant women targeted
and anaemia control in
pregnancy.
312 /6708 pregnant women targeted
7320 / 36,2231 pregnant women targeted
Bawku,
Bawku West 1st dose: 645/ 36,2231 pregnant women targeted
nd
1
(other
2 dose: 645/ 36,223 pregnant women targeted
districts are
nil)
BW
Three rounds of TT
SIA coverage
Jul-Sept
BW
Jan: deworming of
pregnant women
began in BW(27)
Regional
Deworming of
(district
pregnant women(12)
available)
Results of market
Bolga,
immunization, TT for
Builsa
pregnant women
Iron Deficiency
Anaemia control
BW
Training (26)
143,954 / 230,700 targeted women
Regional
IPT for pregnant
women (12)
Intensity
IPT1: 18,197 / 36,2231 pregnant women targeted
IPT2: 11,115 / 36,2231 pregnant women targeted
1
IPT3: 5,945 / 36,223 pregnant women targeted
Area
Regional
(district
available)
Activity
Jan-Mar
Annual Total/
Unspecified
Months
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A27
Annual Total/
Unspecified
Oct-Dec
Jul-Sept
Apr-Jun
Jan-Mar
Months
Area
Regional
Annual regional
summary of EPI
activities(24)
GHS EPI
report
Mid year report:
Postpartum vitamin A Regional
totals (13)
Mid year report:
deworming of
Regional
pregnant women
totals (13)
Mid year report: IPT
totals (13)
Annual total
Regional,
Deworming for
district
pregnant women(15) available
Activity
UER: TT2 – 78% (24)
1
5,051 / 36,223 pregnant women targeted
6,019 / 36,2231 pregnant women targeted
1
IPT1: 10,698 / 36,223 pregnant women targeted
1
IPT2: 7,793 / 36,223 pregnant women targeted
1
IPT3: 5,555 / 36,223 pregnant women targeted
6711 / 36,2231 pregnant women targeted
Intensity
Notes
5,937 reported in 2006 Brief
resume report (13)
1 – Estimated population from 2004 projections(22) : 153,799 under five children, 36,223 pregnant women & 38,450 children 0-11m; 807,447 adults and children >5y
2006
Year
Table C5: Summary of inputs of supplies and logistics for the ACSD program, UER
Date
Supplies
Number
Year 1
Motor bikes (20)
12
Year 1
June 2003
Pickup truck (20)
Kinaquin
prepacks
(20)
Kit boxes(20)
Bicycles (20)
Bicycles (20)
Bicycles (16)
FIMCI
training
manuals: (16)
Introduction
Assess and class sick
child
Identify treatment
Assessment chart
Counsel to mother
Bicycles (19)
Kit boxes (19)
Motor bikes (19)
1
January 2004
January 2004
May 2004
No date given
Reporting
booklets
(19)
Breast
feeding
posters (19)
Kinaquine junior (19)
Kinaquine infant (19)
ORS (19)
Facility
training
manuals (19)
Mosquito nets from
UNICEF (19)
Mosquito nets from
revolving fund (19)
KO tablets (19)
Scales mother/child
(19)
A28
300
216
300
800
60
60
60
60
60
Notes
42
motor
planned/requested
bikes
Reported in 2005
Reported in 2005. Missing the
“Treat
the
child”
and
“Management of sick infant 1
wk to 2 m” manuals
814
1,400
6
Reported in 2006
Reported in 2006
Reported in 2006
2,022
Reported in 2006
1,440
Reported in 2006
645,900
100,200
645,900
420
Reported in 2006
Reported in 2006
Reported in 2006
Reported in 2006
287,850
40,000
Reported in 2006
Global Fund provided 80,000
nets
Reported in 2006
287,850
20
Reported in 2006
Reported in 2006
IIP-JHU | Retrospective evaluation of ACSD in Ghana
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A29
Hib3
immunization
coverage §
Coverage of
vitamin A in last 6
months §
3
4
Eligible children receiving
vitamin A in previous 6m
according to mother's report
or immunization card
Eligible children received
measles inoculation before 12
months of age; according to
immunization card, mother's
report or receipt of
vaccination during national
3
campaign
Eligible children received
DPT3 before 12 months of
age; according to
immunization card or mother's
3
report
Eligible children received Hib3
before 12 months of age;
according to immunization
card
NUMERATOR
²
All children 6-59m, still
alive, include MB
All children 12-23m,
still alive, include MB
All children 12-23m,
still alive, include MB
All children 12-23m,
still alive, include MB
DOMINATOR ¹
EXCLUDE CASES: Missing mother's
report and no entry on vaccination card
EXCLUDE CASES: Unknown/missing
mother's report and no card data
IMPUTE TIMING 2: Missing/invalid
date on card: impute timing with
distribution of known vaccination dates
IMPUTE TIMING 1: Missing card or
vaccination on card: use mother's
report & impute timing with distribution
of known vaccination dates
PROTOCOL FOR
MISSING/UNKNOWN DATA
¹ MB=Multiple birth: include all multiple birth children
² CDC 2003 - due to data quality issues, all children with valid data for indicator variables were included
3
To estimate the children without a card to have rec'd vaccine before 12m of age, the proportion of vaccinations given in the first year is assumed to be the same as the proportion
of children with an immunization card who rec'd the vaccine before 12m of age (MICS manual)
§ International Consensus Coverage Indicator
Child
Child
Child
Percentage of children aged
12-23 months who received
3 doses of DPT vaccine
before first birthday.
DPT3
immunization
coverage §
2
Percentage of children aged
12-23 months received full
(3x doses) HIB vaccination
before first birthday.
Percentage of children 6 59m who received at least
one high dose vitamin A
supplement within the last 6
months
Child
DATAFILE
Percentage of children aged
12-23 months who received
measles vaccine before first
birthday
INDICATORS
Measles
immunization
coverage §
EPI+
ACSD
TARGET
1
NO.
Table D1: Definition of priority indicators and protocols for missing data
Definition of priority coverage and family practice indicators for the evaluation of ACSD
APPENDIX D
A30
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Child
Child
Child
Child
Percentage of children
aged 0-59 months with
fever receiving any
antimalarial drugs
Percentage of children
aged 0-59 months with
suspected pneumonia
taken to an appropriate
health care facility.
Percentage of children
aged 0-59 months with
suspected pneumonia
receiving antibiotics
Case management
malariaprogrammatic
(programmatic)
Care seeking
pneumonia §
Antibiotic treatment
of pneumonia
6
7
8
DATAFILE
5
INDICATORS
Percentage of children
aged 0-59 months with
fever receiving appropriate
antimalarial drugs
IMCI+
ACSD TARGET
Case management
malaria (effective)
NO.
Eligible children given
antibiotics
Eligible children were seen at
appropriate health care facility:
excluding pharmacy and other
drug vendors
Eligible children received any
antimalarial medication during
illness in previous two weeks
Eligible children received
appropriate antimalarial
medication according to
national policy in previous two
weeks
NUMERATOR
Children (0-59) with:
DHS: cough AND
labored breathing
MICS: cough, labored
breathing and chest
congestion
in previous two weeks,
include MB, exclude
deceased
Children (0-59) with:
DHS: cough AND
labored breathing
MICS: cough, labored
breathing and chest
congestion
in previous two weeks,
include MB, exclude
deceased
EXCLUDE CASES: Reported treatment
of child but missing for specific
medications used
EXCLUDE CASES: Reported treatment
of child but missing for specific location
of treatment
EXCLUDE CASES: Reported treatment
of child but missing for specific
medications used
Children (0-59) with
reported fever in
previous two weeks,
include MB, exclude
deceased
PROTOCOL FOR
MISSING/UNKNOWN DATA
EXCLUDE CASES: Reported treatment
of child but missing for specific
medications used
²
Children (0-59) with
reported fever in
previous two weeks,
include MB, exclude
deceased
DOMINATOR ¹
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A31
Continued feeding
Increased fluids (IF)
ORT/RHF
ORS
ORS/RHF/increased
fluids for children
with diarrhoea +
continued feeding §
IMCI+
ACSD TARGET
Rec'd somewhat less,
about the same or more
(MICS)
Rec'd more (MICS)
recommended home fluids
ORS packets
Percentage of children
aged 0-59 months with
diarrhoea receiving ORS
OR RHF OR increased
fluids AND continued
feeding
INDICATORS
Child
DATAFILE
Eligible children received
ORS, RHF or increased fluids
AND continued feeding
NUMERATOR
² CDC 2003 - due to data quality issues, all children with valid data for indicator variables were included
¹ MB=Multiple birth: include all multiple birth children
§ International Consensus Coverage Indicator
9
NO.
²
Children (0-59) with
reported diarrhoea in
previous two weeks,
include MB, exclude
deceased
DOMINATOR ¹
EXCLUDE CASES 2: Reported
treatment of child but positive/missing
for ORS, RHF or IF and missing for
continued feeding
EXCLUDE CASES 1: Reported
treatment of child but missing for ORS,
RHF and IF and positive/missing for
continued feeding
PROTOCOL FOR
MISSING/UNKNOWN DATA
A32
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Percentage of infants
aged 6-9 months who
are breastfed and
receive complementary
food (solid or semisolid
foods)
Percentage of children
aged 20-23 months who
are currently
breastfeeding
Breastfeeding
and
complementary
feeding (6-9
months) §
Continued
breastfeeding
(20-23 months)
§
Consumption of
iodized salt
Consumption of
iodized salt
12
13
14
15
Eligible HH has salt with
>=15ppm iodine
Eligible children still
breastfeeding
Eligible children still
breastfeeding and received
solid/semisolid foods in the
previous 24hr
Eligible children still
breastfeeding and did not
receive any liquids or foods in
previous 24h
Women initiated breastfeeding
within the first hour after
delivery
NUMERATOR
² CDC 2003 - due to data quality issues, all children with valid data for indicator variables were included
¹ MB=Multiple birth: include all multiple birth children
HH
HH
Child
Child
Child
Women
DATAFILE
§ International Consensus Coverage Indicator
Percentage of
households consuming
iodized salt: exclude HH
with no salt
Percentage of
households consuming
iodized salt: include HH
with no salt
Percentage of infants
aged 0-5 months who
are exclusively breastfed
11
10
Exclusive
breastfeeding
through 6
months (0-5m) §
INDICATORS
Percentage of newborns
put to the breast within
one hour of birth; most
recent live birth previous
12m
IMCI+
ACSD
TARGET
Timely initiation
of breastfeeding
§
NO.
²
All HH with completed
surveys
All HH with completed
surveys and salt
available for testing
DHS: most recently
born (include only one
MB) still alive & living
with mom.
MICS: Child (20-23)
with completed
questionnaire
DHS: most recently
born (include only one
MB) still alive & living
with mom.
MICS: Child (6-9) with
completed
questionnaire.
Children (20-23m):
DHS: most recently
born (include only one
MB) still alive & living
with mom.
MICS: Child (0-5) with
completed
questionnaire
Children (6-9m):
Children (0-5m):
Women with a birth in
previous 12m
DOMINATOR ¹
EXCLUDE CASES: Missing salt test
EXCLUDE CASES: Missing salt test and HH
with no salt
EXCLUDE CASES: Missing for still
breastfeeding
EXCLUDE CASES 2: Positive/missing for all
feeding variables AND missing for still
breastfeeding
EXCLUDE CASES 1: Missing for all feeding
variables AND positive/missing for still
breastfeeding
EXCLUDE CASES 2: Negative/ missing for all
feeding variables AND missing for still
breastfeeding
EXCLUDE CASES 1: Missing for all feeding
variables AND positive/missing for still
breastfeeding
EXCLUDE CASES: Reported ever
breastfeeding, but missing timing of initiation
PROTOCOL FOR
MISSING/UNKNOWN DATA
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A33
Eligible pregnant woman slept
under an ITN mosquito net last
night
Eligible child slept under an
ITN mosquito net last night
Eligible pregnant woman slept
under a mosquito net last night
NUMERATOR
² CDC 2003 - due to data quality issues, all children with valid data for indicator variables were included
¹ MB=Multiple birth: include all multiple birth children
§ International Consensus Coverage Indicator
18
Woman
Effective use of
bednets by
children < 5yr §
17
Percentage of pregnant
women sleeping under an
insecticide treated mosquito
net last night (Use trt'd <=12
months due to heaping at
12m)
Woman
Percentage of children aged
0-59 months sleeping under
an insecticide treated
mosquito net (Use trt'd <=12
months due to heaping at
12m)
Effective use of
bednets by
pregnant women
Woman
DATAFILE
Percentage of pregnant
women sleeping under any
mosquito net last night
INDICATORS
Use of bednets by
pregnant women
ITNs
ACSD TARGET
16
NO.
²
All eligible pregnant
women
All children under five,
still living
All eligible pregnant
women
DOMINATOR ¹
EXCLUDE CASES 3: Positive/missing
for a, b & c AND unknown/missing for
slept under a bed net last night
EXCLUDE CASES 2: Unknown/missing
for a,b & c and
positive/missing/unknown for slept under
a net last night
EXCLUDE CASES 1: Missing ITN data
(a) Net obtained <=12m prior AND
missing if treated when obtained
(b)Treated net obtained AND missing
months ago obtained (c) Treated the
net after obtaining but missing months
ago treated
EXCLUDE CASES: Unknown/missing
for slept under a bed net last night
PROTOCOL FOR
MISSING/UNKNOWN DATA
A34
IIP-JHU | Retrospective evaluation of ACSD in Ghana
DATAFILE
NUMERATOR
Women
Women
Women
Percentage of pregnant
women receiving 3 months of
iron supplementation.
Percentage of births
attended by skilled health
worker: doctor, nurse/midwife
or auxiliary midwife
Pregnant women
take 3 months iron
supplements
Skilled attendant
at delivery §
23
24
21
Full TT coverage
Women
Percentage of newborns
protected against tetanus:
Mother rec'd at least 2 doses
of TT during pregnancy
TT2 coverage
during pregnancy
§
20
22
Women
Percentage of pregnant
women receiving intermittent
preventative treatment for
malaria during pregnancy
Intermittent
malaria
treatments in
pregnancy
Percentage of newborns
protected against tetanus:
Mother rec’d immunity
through injections previous to
pregnancy
Women
19
²
Eligible women delivered with
a trained health care worker.
Eligible women received iron
supplementation daily for at
least 90 days
EXCLUDE CASES: Unknown/missing data
for birth attendant
EXCLUDE CASES: Unknown/missing if
received iron or received iron but for unknown
time period
EXCLUDE CASES: Unknown/missing if
received TT or received TT but unknown
dosage or date of most recent injection
Eligible women received any
of the following:
▪ 2+ does during pregnancy
▪ 1 dose during pregnancy +
any doses before pregnancy
▪ 2+ doses prior, the most
recent 3 years before
pregnancy
▪ 3+ doses prior, the most
recent 5 years before
pregnancy
▪ 4+ doses prior, the most
recent 10 years before
pregnancy
▪ 5+ lifetime doses
EXCLUDE CASES: Received medicine
during pregnancy for malaria but unknown.
missing type of medicine
EXCLUDE CASES: Unknown/missing for
number prenatal visits AND positive/missing
for skilled HCW
PROTOCOL FOR
MISSING/UNKNOWN DATA
EXCLUDE CASES: Unknown/missing if
received TT or received TT but unknown
dosage
All eligible women with
a pregnancy resulting
in a live birth in the
previous 12m
DOMINATOR ¹
Eligible women received at
least two doses of tetanus
toxoid during the pregnancy
Eligible women received at
least two doses of SP during
the pregnancy
Eligible women received 4+
prenatal care visits with a
trained health care worker
Most recent live birth within previous 12m
INDICATORS
Percentage of pregnant
women who report at least 4
prenatal visits to a skilled
health worker: doctor,
nurse/midwife or auxiliary
midwife
ANC+
ACSD TARGET
4+ prenatal visits,
trained health
care worker
NO.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A35
DATAFILE
NUMERATOR
Women
Women
Percentage of women
receiving vitamin A
supplementation within 2
months of birth
Postnatal visit
within 3 days of
delivery, trained
health worker
Postnatal
supplementation
with Vitamin A §
² CDC 2003 - due to data quality issues, all children with valid data for indicator variables were included
¹ MB=Multiple birth: include all multiple birth children
Eligible women received
vitamin A supplementation
within 2 months of delivery
(a) Eligible women delivered at
an institutional facility (nondomestic)
(b) Eligible women who
delivered domestically
received at least one postnatal
checkup within 3 days of
delivery with a trained health
care worker
Most recent live birth within previous 12m
INDICATORS
Percentage of newborns
receiving a postnatal visit by
a trained worker (doctor,
nurse/midwife or auxiliary
midwife) within 3 days of
delivery.
ANC+
ACSD TARGET
§ International Consensus Coverage Indicator
26
25
NO.
²
All eligible women with
a pregnancy resulting
in a live birth in the
previous 12m
DOMINATOR ¹
EXCLUDE CASES: Unknown/missing if
received vitamin A
EXCLUDE CASES 2: Non-institutional
delivery and positive/missing skilled HCW
and positive/missing received postnatal care
EXCLUDE CASES 1: Unknown/missing place
of delivery and no data for postnatal care
PROTOCOL FOR
MISSING/UNKNOWN DATA
A36
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Household
Household
Stunting (low height for
age) among children 2459 months of age*
Wasting (weight for
height) among children 023 months of age*
Underweight (weight for
age) for children 0-59
months of age*
Under-five mortality rate
1
2
3
4
Birth
history
extracted
from
women’s
file
Household
DATAFILE
INDICATORS
NO.
NUMERATOR
The probability of dying
between birth and exact
age five years
Moderate and Severe:
Children with <-2 z scores
for weight for height based
on the 2006 WHO growth
curves(36)
Severe: Children with <-3 z
scores for weight for
height based on the 2006
WHO growth curves(36)
Moderate and Severe:
Children with <-2 z scores
for weight for age based on
the 2006 WHO growth
curves(36)
Severe: Children with <-3 z
scores for weight for age
based on the 2006 WHO
growth curves(36)
Moderate and Severe:
Children with <-2 z scores
for height for age based on
the 2006 WHO growth
curves(36)
Severe: Children with <-3 z
scores for height for age
based on the 2006 WHO
growth curves(36)
Table D2: Definition of priority impact indicators
N/A
Cases with improbable values for
weight-for-age are excluded from
analysis; improbable defined as
+/- 4 standard deviations of Z
score relative to the overall
median Z score value from the
crude datafile
Children aged 0-59 months who:
1. Have a reported (nonmissing) birth month & year
2. Have a valid (non-missing)
anthropometric measure
3. Slept in the house the night
before the survey
Expressed as 1000 live births
Cases with improbable values for
weight-for-height are excluded
from analysis; improbable
defined as +/- 4 standard
deviations of Z score relative to
the overall median Z score value
from the crude datafile
Cases with improbable values for
height-for-age are excluded from
analysis; improbable defined as
+/- 4 standard deviations of Z
score relative to the overall
median Z score value from the
crude datafile
PROTOCOL FOR EXCLUSION
OF CASES§
Children aged 0-23 months who:
1. Have a valid (non-missing)
anthropometric measure
2. Slept in the house the night
before the survey
Children aged 24-59 months
who:
1. Have a reported (nonmissing) birth month & year
2. Have a valid (non-missing)
anthropometric measure
3. Slept in the house the night
before the survey
DOMINATOR§
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A37
MDG water and sanitation definitions
(http://www.unicef.org/wes/mdgreport/definit
ion.php)
Improved
Sanitation
Facilities
Wealth quintiles
MDG water and sanitation definitions
(http://www.unicef.org/wes/mdgreport/definit
ion.php)
DHS standard calculation of wealth quintiles
(http://www.childinfo.org/mics/mics3/docs/D
HS%20Wealth%20Index%20(DHS%20Com
parative%20Reports).pdf)
Improved Water
Source
SOURCE OF DEFINITION
CONTEXTUAL
VARIABLE
DESCRIPTION OF DEFINITION
Improved sanitation facilities include:
1) Connection to a public sewer,
2) Connection to a septic system,
3) Pour-flush latrine,
4) Simple pit latrine,
5) Ventilated improved pit latrine.
.
Unimproved sanitation facilities include:
1) Public or shared latrine,
2) Open pit latrine,
3) Bucket latrine.
Unimproved drinking water sources include: 1) Unprotected well, 2)
Unprotected spring, 3) Rivers or ponds, 4) vendor provided water, 5) Bottled
water, 6) Tanker truck water
For the calculation of wealth quintiles for the ACSD evaluation, the urban areas
of Ashanti and Great Accra region are removed and the indices calculated for
households in the HIDs and comparison area only.
All household assets and utilities are dichotomized into indicator variables.
Principle components analysis is performed using all the indicator variables to
standardize the weights of the variables using the first principle factor. Each
household is then assigned a weighted index value, based on its reported assets
and utilities. Households are then divided into quintiles based on their index
value.
Table D3: Definition of contextual variables used in the ACSD evaluation
APPENDIX E
Survey questions used in the calculation of coverage indicators
NO.
ACSD TARGET
DHS Questionnaire
1998/99
DHS Questionnaire
2003
ACSD Questionnaire
2003
MICS Questionnaire
2006 & 2007/08
EPI+
Measles immunization
coverage
Have vaccination card
Have vaccination card
(q458); Measles innoc. on
(q443); Measles innoc. on
card (q460); Rec'd other
card (q444); Rec'd other
vaccines (q462); Mom
vaccines (q446); Mom report
report of measles innoc
of measles innoc (q447G)
(q463G)
2
DPT3 immunization
coverage
Have vaccination card
(q443); DPT3 on card
(q444); Rec'd other
vaccines (q446); Mom report
of DPT(q447E); number of
doses(q447F)
Have vaccination card
(q458); DPT3 on card
(q460); Rec'd other
vaccines (q462); Mom
report of DPT(q463E);
number of doses(q463F)
Have vaccination card
(q404); DPT3 on card
(q405); Rec'd other
vaccines (q407); Mom
report of DPT(q412);
number of doses(q413)
Have vaccination card (IM1); DPT3
on card (IM5C); Rec'd other
vaccines (IM10); Mom report of
DPT(IM15); number of
doses(IM16)
3
Hib3 immunization
coverage
N/A
N/A
N/A
Have vaccination card (IM1); Hib3
innoc. on card (IM5C)
4
Coverage of vitamin A in
last 6 months
1
Have vaccination card
(q458); Mother's report
(q448)
Have vaccination card
Have vaccination card (IM1);
(q404); Measles innoc. on
Measles innoc. on card (IM6);
card (q405); Rec'd other Rec'd other vaccines (IM10); Mom
vaccines (q407); Mom
report of measles innoc (IM17);
report of measles innoc
rec'd vaccine during campaign
(q414)
(IM19)
Have vaccination card
Have vaccination card
Have vaccination card (IM1); VitA
(q458); VitA on card (q460); (q404); VitA on card (q405); on card (IM8a/b); Mother's report
Mother's report (q457)
Mother's report (q403)
(VA1,VA2)
IMCI+
Had fever(q466); gave
Had fever(q449); gave meds
meds (q473); what meds
(q449A); what meds (q449B)
(q474)
Had fever(q515); gave
meds (q517); what meds
(q518); prescribed meds
(q523); what meds
prescribed(q524)
Had fever(ML1); gave meds
(ML3/ML5); what meds (ML4/ML7)
Had fever(q515); gave
meds (q517); what meds
(q518); prescribed meds
(q523); what meds
prescribed(q524)
Had fever(ML1); gave meds
(ML3/ML5); what meds (ML4/ML7)
5
Case management
malaria (effective)
6
Case management
malaria-programmatic
(programmatic)
N/A
Had fever(q466); gave
meds (q473); what meds
(q474)
7
Care seeking pneumonia
Suspected pneum. (q450 &
q451); consulted for
treatment (q452); where
consulted (q453)
Suspected pneum. (q467 &
q468); consulted for
treatment (q470); where
consulted (q471)
Suspected pneum. (q511 &
Suspected pneum. (CA5, CA6,
q512); consulted for
CA7); consulted for treatment
treatment (q513); where
(CA8); where consulted (CA9)
consulted (q514)
8
Antibiotic treatment of
pneumonia
Suspected pneum. (q450 &
q451); consulted for
treatment (q451A); where
consulted (q451B)
N/A
Suspected pneum. (q511 &
Suspected pneum. (CA5, CA6,
q512); consulted for
CA7); consulted for treatment
treatment (q513); where
(CA8); where consulted (CA9)
consulted (q514)
ORS/RHF/increased
fluids for children with
diarrhoea + continued
feeding
Had diarrhea (q454)
Had diarrhea (q475)
Had diarrhea (q501)
9
ORS ORS (q461)
ORS (q478a)
ORS (q506a)
ORS (CA2a)
ORT/RHF RHF (q461)
RHF (q478b)
RHF (q506b)
RHF (CA2b)
Increased fluids (q476)
Increased fluids (q504)
Increased fluids (CA3)
Continued feeding (q477)
Continued feeding (q505)
Continued feeding (CA4)
Increased fluids (IF) Increased fluids (q457)
Continued feeding Continued feeding (q458)
A38
Had diarrhea (CA1)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
ACSD TARGET
10
11
Timely initiation of
breastfeeding
DHS Questionnaire
1998/99
DHS Questionnaire
2003
Ever breastfed (q440);
Ever breastfed (q427);
Timing of BF initiation
Timing of BF initiation (q425)
(q441)
ACSD Questionnaire
2003
Ever breastfed (q323); Timing of
BF initiation (q3243)
MICS Questionnaire
2006 & 2007/08
Ever breastfed (MN12); Timing of
BF initiation (MN13)
Exclusive breastfeeding Still breasfeeding (q447);
liquids & foods in last 24h
through 6 months (0(q434)
5m)
Still breasfeeding (q445);
liquids in last 24h (q492a- Still breasfeeding (q326);
e); food in last 24h (q493a- liquids/food in last 24h (q331b-g)
j)
Still breasfeeding (BF2);
liquids/foods(BF3)
12
Breastfeeding and
Still breasfeeding (q447);
complementary feeding liquids & foods in last 24h
(6-9 months)
(q434)
Still breasfeeding (q445); Still breasfeeding (q326); food in
food in last 24h (q493a-j) last 24h (q331g)
Still breasfeeding (BF2);
liquids/foods(BF3)
13
Continued
breastfeeding (20-23
months)
14
Consumption of iodized
salt
15
Consumption of iodized
salt
Still breasfeeding (q447)
Still breasfeeding (q445)
Still breasfeeding (q326)
Still breasfeeding (BF2)
Salt tested for iodization (SL1)
Iodized salt (q35)
Iodized salt (q35)
Iodized salt (q29)
N/A
Child slept under net last
night (H32D); How long ago
was net obtained (H31);
Was a treated net obtained
(H31b); Was the net ever
treated(H32A); How long
ago treated (H32B)
Child slept under net last night
(q465C); How long ago was net
obtained (q465E); Was a treated
net obtained (q465F); Was the net
ever treated(q465G); How long
ago treated (q465H)
Child slept under net last night
(ML10); How long ago was net
obtained (ML11); Brand of net
(ML12); Was a treated net
obtained (ML13); Was the net ever
treated(ML14); How long ago
treated (ML14)
N/A
Currently pregnant (q226);
How long ago was net
obtained (H31); Was a
treated net obtained
(H31b); Was the net ever
treated(H32A); How long
ago treated (H32B)
N/A
N/A
ITNs
17
18
Effective use of
bednets by children <
5yr
Effective use of
bednets by pregnant
women
ANC+
19
4+ prenatal visits,
skilled HCW
Prenatal care and who did
Prenatal care (q407);
you consult (q407); Number
Number of visits (q409)
of visits (q409)
20
Intermittent malaria
treatments in
pregnancy
N/A
21
TT2 coverage during
pregnancy
Rec'd TT (q410); number of Rec'd TT (q415); number of Rec'd TT (q308); number of doses Rec'd TT (TT2); number of doses
doses (q411)
doses (q416)
(q309)
(TT3)
22
Pregnant women take 3
months iron
N/A
supplements
Rec'd iron (q417); Number Rec'd iron (q313); Number of days
N/A
of days took iron (q418)
took iron (q314)
23
Skilled attendant at
delivery
Assisted with birth (q426)
24
Postnatal visit within 3 Days after delivery rec'd
days of delivery, skilled care (q417B); who
HCW
performed care (q417C)
25
Postnatal
supplementation with
Vitamin A
Assisted with birth (q414)
Rec'd vitamin A (q417G)
Prenatal care (q303);who did you
consult (q304); Number of visits
(q306)
Took meds for malaria
Took meds for malaria (q223);
(q421); Which meds (q422) Which meds (q224)
Location of delivery (q427);
Rec'd postnatal care if noninstitutional delivery (q429)
Prenatal care and who did you
consult (MN2); Number of visits
(MN2bb)
Took meds for malaria (MN6A);
Which meds (MN6B)
Assisted with birth (q320)
Assisted with birth (MN7)
N/A
N/A
Rec'd vitamin A (q322)
Rec'd vitamin A (MN1)
Days after delivery rec'd
care (q430); who performed
care (q431)
Rec'd vitamin A (q433)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A39
APPENDIX F
Methodology and implementation of household surveys in Ghana 1998 to 2008
The methodologies and implementation of households surveys re-analyzed for the ACSD retrospective
evaluation are presented in table F1. Less documentation of the methods and implementation was
available for the ACSD 2003 survey. This survey is presented in the body of the report, but should be
interpreted with caution due to questions about the data quality and the exact methodologies utilized. A
full report describing data quality issues in the ACSD 2003 survey is available on request from the JHU
evaluation team.
A40
IIP-JHU | Retrospective evaluation of ACSD in Ghana
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A41
General
Survey
documentation available
Datafile
available for
reanalysis
Implementing
Agency (& TA)
Geographic
Coverage
Survey Component
Sampling methods /
size; Sampling frame/
selection/weights;
Revised
questionnaire;
Training manual;
Interviewer manual;
Supervisor manual;
Datafile for analysis;
Report of data
analyses
English
questionnaires;
Datafile for analysis
Yes
Sampling methods /
size; Sampling frame/
selection/weights;
Revised
questionnaire;
Training manual;
Interviewer manual;
Supervisor manual;
Datafile for analysis;
Report of data
analyses
Yes
Ghana Statistical
Services & DHS,
Macro International
Navrongo Health
Research Centre, TA
(CDC – Atlanta &
UNICEF)
Ghana Statistical
Services & DHS,
Macro International
Yes
National
DHS 2003
National
ACSD 2003
Upper East
Region
DHS 1998-99
Ghana
Sampling methods
/ size; Sampling
frame/
selection/weights;
Revised
questionnaire;
Training manual;
Interviewer
manual;
Supervisor
manual; Datafile
for analysis;
Report of data
analyses
Sampling methods / size;
Sampling frame/
selection/weights;
Revised questionnaire
Training manual;
Interviewer manual;
Supervisory field report;
Datafile for analysis
Yes
Ghana Statistical
Services and
Ministry of Health
with UNICEF; TA
(PEPFAR, Macro
& Ghana AIDS
Commission)
Yes
Ghana Statistical
Services and UNICEF;
TA (Macro and JHSPH)
National
MICS
supplementary
2007
Upper East Region
(also data available in
Northern and Upper
West regions)
MICS 2006
Table F1: Methodology and implementation of household surveys in Ghana 1998 to 2008 presented in the ACSD evaluation report
A42
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Sampling &
enumeration
Unknown
Unknown
Complete listing in
EAs with <500 HHs;
partial listing in larger
EAs. August –
October 1998
Done by Macro from
household listing
before survey field
work
Mapping/
listing
Household
selection
Unknown
83
2 stage sampling
design; Unknown
stratification
ACSD 2003
20 in the UE, UW and
Northern regions; 15
in all other regions
400
2 stage sampling
stratified by region &
urban/rural; clusters
chosen from 1984
census; oversampling
in UE, UW & Northern
regions
DHS 1998-99
Number of
households
per cluster
Number of
clusters
Stratification
& sampling of
clusters
Survey Component
2 stage sampling,
clusters selection
stratified by region
and urban/rural;
clusters chosen
from Ghana Living
Standards Survey
5; oversampling in
UE, UW &
Northern regions
Complete listing in
May – July 2005;
some re-listed
early 2006
Done by GSS
from household
listing before
survey field work
Done by Macro from
household listing
before survey field
work point)
25 in rural UE,
UW & Northern;
20 in all other HHs
Done by GSS from
household listing
throughout period of
survey field work
Listing of selected HH
only; technical team
recommended standard,
full listing
20
HID: 173
2 stage sampling
stratified by district &
urban/rural
MICS 2006
300
MICS
supplementary
2007
Complete HH listing;
May – June 2003
20 in the UE, UW &
Brong Ahafo; 16 in
Northern and 15 in all
other regions
412
2 stage sampling,
clusters selection
stratified by region
and urban/rural;
clusters chosen from
2000 census;
oversampling in UE,
UW, Northern &
Brong Ahafo regions
DHS 2003
Ghana
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A43
Questionnaires
Household,
women's
Sociodemographic
Info; Reproduction;
Contraception;
Pregnancies, ANC,
& breastfeeding;
Immunzation; Child
illness and care;
Hygiene, marital
status, work of
women
Unknown
Household, women's
[Men's]
Sociodemographic
Info; Reproduction;
Contraception;
Pregnancies, ANC, &
breastfeeding;
Immunization and
Health; Marriage;
Fertility Preferences;
Husband/Partner’s
Background and
Women’s Work; AIDS;
Height and Weight
Pretest of all
questionnaires in Sept
1998; the 5 local
languages were
pretested.
Questionnaires used
Modules
included in
women's/child
questionnaire
Pre-test / pilot
English
ACSD 2003
Akan, Ga, English,
Ewe, Hausa, and
Dagbani
DHS 1998-99
Language of
questionnaire
Survey Component
Household, women's and
Under-five [Men's]
Sociodemographic Info ;
child mortality; Tetanus
Toxoid; Maternal and
Newborn Health;
Marriage and Union;
Security of Tenure;
Contraception; Domestic
Violence; HIV/AIDS;
National Health
Insurance; Birth
Registration and Early
Learning; Child
Education; Vitamin A;
Breastfeeding; Care of
Illness; Malaria;
Immunization;
Anthropometry
Full birth history was
added to women’s quest.
& Flooding module was
added to HH quest.
Household,
women's and
Under-five [Men's]
SES Info ; child
mortality; Maternal
and Newborn
Health; Marriage
and Union;
Security of
Tenure;
Contraception;
Domestic
Violence; Female
Genital Mutilation;
Sexual Behaviour;
HIV Knowledge;
Birth Registration
and Early
Learning; Child
Development;
Vitamin A;
Breastfeeding;
Care of Illness;
Malaria;
Immunization;
Anthropometry
Pretested in
Greater Accra
region in 2 urban
and 2 rural EAs in
June 2006
Household, women's
[Men's]
Sociodemographic
Info; Reproduction;
Contraception;
Pregnancies, ANC, &
breastfeeding;
Immunization and
Health; Marriage and
sexual activity;
Fertility Preferences;
Husband’s
Background and
Women’s Work;
AIDS & STDs;
Pretest of all
questionnaires in
urban & rural areas
5-7 May 2003 in all 5
local languages;
Also pretested AIDS
module
Pretested in peri-urban
Kumasi
English
MICS 2006
MICS
supplementary
2007
English
Akan, Ga, English,
Ewe, Nzema, and
Dagbani
DHS 2003
Ghana
A44
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Field
organization
/ work
Training
Mid November 1998
Nov – Feb 1999
Period of field
work
14 teams
1 supervisor
(13/14 were male)
1 field editor
(male or female)
3 interviewers
(male or female)
1 driver (male)
Standard DHS
training.
Survey startup
Number of
teams
Survey team
composition
Practice
survey admin
in field
Training
content
3 week period, OctNov 1998.
Logistics &
timing
Standard DHS
training.
Two day training on
anthropometric
measurement.
Standard DHS guides
DHS 1998-99
Manuals
Survey Component
July – Sept 2003
July 2003
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
ACSD 2003
Interviewing
techniques,
discussion of the
questionnaires,
and mock
interviews among
trainees
3 days conducting
interviews in 16
urban & rural EAs
Standard DHS
training including
anthro. measures.
Nurses trained in
blood collection for
anemia and AIDS
Late July – late
October, 2003
Late July 2003
15 teams
1 supervisor; 1 editor;
1 nurse; 4
interviewers; 1 driver
3 month period
August 2006
9 teams
1 supervisor; 1
field editor; 4
interviewers; 1
driver
80 interviewers
and 10 data entry
operators: 17–31t
July, 2006
102 interviewers, 23
nurses & 12 data
entry operators;
6-27 July 2003
Standard DHS
training.
Standard MICS
guides
MICS 2006
Standard DHS
guides
DHS 2003
Ghana
Sept – Dec 2007
Follow-up with a few
additional clusters in FebMarch 2008
September, 2008
4 teams in HIDs
1 supervisor; 1 field
editor; 4 interviewers; 1
driver
2 days conducted in periurban Kumasi
Interviewing techniques,
discussion of the
questionnaires, and mock
interviews among
trainees
Two weeks in Aug-Sept
2007; TA by Macro &
JHSPH
Interviewer manual
MICS
supplementary
2007
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A45
Data
processing
Supervision
Similar to MICS 2006, TA
(Trevor Croft & Gareth
Jones)
Data
edited/cleaned for
internal
consistency by
GSS using CSPro
Files transferred to
SPSS & Stata for
analysis
Completed mid-March
1999 by GSS
Done according to
DHS standard
Finalization of
data
Imputation of
birth dates
Done according to
DHS standard
Completed midDecember 2003 by
GSS
Unknown
Data editing
Missing birth month
imputed to “6”
Data edited/cleaned
for internal
consistency by GSS
using CSPro
Data edited/cleaned
for internal
consistency by GSS
Done according to
standard MICS
Trevor Croft, consultant
Upper East region
completed early June
2008
Similar to MICS 2006
Data processing
concurrent with
fieldwork;
feedback sent to
field teams
Data processing
concurrent with
fieldwork; feedback
sent to field teams
Completed
November 2006
by GSS
Similar to MICS 2006
Unknown
Data entry
procedures
Data processing
concurrent with
fieldwork; 10 data
entry operators
with 2 data entry
supervisors & 4
secondary editors;
double entry and
consistency
checking
Data processing
concurrent with
fieldwork; 12 data
entry operators;
double entry and
consistency checking
Similar to MICS 2006
Start-up supervision done
by GSS, Macro, & IIPJHU team for 1 week
Yes
MICS
supplementary
2007
Field editors
Office editors at
GSS
Unknown
Unknown
The data were then
entered and
edited using
microcomputers and
the Integrated System
for Survey Analysis
(ISSA) programme
developed
for DHS surveys.
Unknown
10 regional
statisticians acted as
coordinators and
GSS coordinated and
supervised fieldwork
Field editors
Office editors at GSS
Unknown
MICS 2006
Unknown
DHS 2003
Quality
control loop
Unknown
Field editors
Office editors at GSS
Editing of
questionnaires
Unknown
Unknown
ACSD 2003
Unknown
Unknown
DHS 1998-99
Technical
team
supervision
Observation
of interviews
Survey Component
Ghana
A46
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Sources:
Survey Component
DHS 1998 report(37)
DHS 1998-99
Files transferred
from UNICEF;
discussion with
Howard Goldberg
ACSD 2003
DHS 2003 report(38)
DHS 2003
Ghana
Ghana MICS 2006
report; available
from UNICEfF
MICS 2006
Field visits; key
informants
MICS
supplementary
2007
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A47
N/A
2
0
1
No Data
No Data
65
68
60
%
59 71
58 78
50 70
n
1
5³
78
N/A
64
59
%
31
230
185
39
39
n
[32]
23
86
1
0
0
0
0.4
N/A
76
68
%
n/a
16 30
75 97
65 87
59 77
miss( 95%
%)
CI
2003 DHS
84
3
N/A
66
73
%
166
26
4
1394 27 4
656
323
276
n
0
6
7
7
17
miss(
%)
2003 ACSD-CDC
144
131
30
30
30
n
1
2
2
1.4
0
No Data
43
91
66
93
82
%
34 52
87 94
53 79
88 98
78 85
miss( 95%
%)
CI
MICS 2006
2256
1975
397
396
n
0.7
0.9
miss(
%)
0.5
2
No Data
58
90
same as DPT
95
80
%
54 61
.88 92
93 97
79 82
95%
CI
MICS 2007 Suppl.
*All vaccination indicators calculated based on MICS protocols (where distribution of children reported vaccination before 12m in card s applied to all children reported as vaccinated).
(1) IHNS data not available; indicators from IHNS 2002 survey report
(2) ITN = Insecticide treated net defined as treated within 12 months before the survey or long-lasting net.
(3) Only available for children 6-32 months of age
(4) Includes bednets treated in previous 6 months only (previous 12 m not available in data)
Percentage of pregnant
women sleeping under an
insecticide treated
mosquito net (ITN)
Percentage of children
aged 0-59 months sleeping
under an insecticide
treated mosquito net (ITN)
ITNs2
Percentage of children 6 59 who received at least
one high dose vitamin A
supplement within the last
6 months
155
38
Percentage of children
aged 12-23 months who
received 3 doses of DPT
vaccine
Percentage of children
aged 12-23 months who
are immunized against Hib
38
n
Percentage of children
aged 12-23 months who
are immunized against
measles
Indicators*
EPI+
miss( 95%
%)
CI
1998/1999 DHS
2002
1
IHNS
Table G1. EPI+ and ITN coverage indicators over time in the “high impact” districts, Ghana (weighted)
Tables presenting priority indicators over time for ACSD “high impact” districts
APPENDIX G
A48
IIP-JHU | Retrospective evaluation of ACSD in Ghana
39
2
32
35
54
32
2
0
2
28 49
0-5
36 72
68 89
39
%
24
53
chloroquine
n
2002
1
IHNS
43
29
44
44
n
0
0
0
32
59
61
%
0.3
0.3
35
1
58 76
3.6 0 - 0.8
3.6
31
20
20
30
n/a
n/a
n/a
4
1
n/a
4
20 40
n/a
n/a
357
136
145
554
554
n
4
4
28
51
50
48 58
0.9
6
0
24 33
41 60
41 58
1.6 6 - 12
1.6
Miss( 95%
%)
CI
ACT
9
53
%
2007 MICS suppl
(2) ANY ANTIMALARIAL MEDICATION
37
0
0.3
67
%
ACT (since 2004)
38
38
n
Miss( 95%
%)
CI
2006 MICS
(4) MICS DEFINITION OF PNEUMONIA DIFFERENT FROM DHS (SEE APP.D)
431
No data
206
chloroquine
367
367
n
Miss(
%)
(1) IHNS DATA NOT AVAILABLE; INDICATORS FROM IHNS 2002 SURVEY REPORT
18 46
n/a
47 84
54 87
95%
CI
2003 ACSDCDC
(3) INCLUDED TREATMENT WITH APPROPRIATE ANTIMALARIAL ACCORDING TO NATIONAL POLICY
0
No data
[66]
chloroquine
66
71
%
Miss(
%)
2003 DHS
[UNWEIGHTED: BASED ON CASES 25-49] [N/A: RESULTS NOT SHOWN; BASED ON >24 CASES]
Percentage of children
aged 0-59 months with
diarrhoea receiving ORS,
RHF or increased fluids
and continued feeding
Percentage of children
aged 0-59 months with
suspected pneumonia
taken to an appropriate
health provider
Percentage of children
aged 0-59 months with
suspected pneumonia
treated with antibiotics
chloroquine
0
Ghana antimalarial policy
78
%
No data
60
n
Miss( 95%
%)
CI
1998/1999 DHS
Percentage of children
aged 0-59 months with
fever receiving appropriate
3
antimalarial drugs
Percentage of children
aged 0-59 months with
fever receiving antimalarial
2
drugs
IMCI case
management
indicators
Table G2. Illness case management indicators over time in the “high impact” districts, Ghana (weighted)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A49
39
39
19
13
Percentage of
newborns put to the
breast within one
hour of birth
Percentage of
infants aged 0-5
months who are
exclusively breastfed
Percentage of
infants aged 6-9
months who are
breastfed and
receive
complementary food
Percentage of
children aged 20-23
months who are
currently
breastfeeding
n/a
n/a
[28]
11
%
n/a
n/a
3
0
n/a
n/a
n/a
3-19
n
33
%
2002
IHNS¹
21
18
28
45
n
n/a
n/a
[43]
85
%
n/a
n/a
0
0
miss(
%)
2003 DHS
n/a
n/a
n/a
73 97
95%
CI
93
94
168
328
n
82
50
39
45
%
8
5
3
2
miss(
%)
2003 ACSDCDC
25
30
32
28
n
[92]
[53]
[56]
42
%
0
0
0
0
miss(
%)
2006 MICS²
n/a
n/a
n/a
2955
95%
CI
(2) MICS 2006: NO FULL BIRTH HISTORY; UNABLE TO CALCULATE BREASTFEEDING INDICATORS AS DHS (SEE APP.D)
[UNWEIGHTED: BASED ON CASES 25-49] [N/A: RESULTS NOT SHOWN; BASED ON >24 CASES] (1) IHNS DATA NOT AVAILABLE; INDICATORS FROM IHNS 2002
n
Indicators
miss(
95% CI
%)
1998/1999 DHS
Table G3. Feeding behaviour indicators over time in the “high impact” districts, Ghana (weighted)
125
159
258
484
n
84
53
55
52
%
0
0
0
0.8
miss(
%)
77 92
42 63
46 64
47 56
95%
CI
2007 MICS suppl²
A50
IIP-JHU | Retrospective evaluation of ACSD in Ghana
1
45
19
72
39
39
0
0
61-83
10-27
7-27
47
1
17
46-79
39
0
18
20
45
45
0
0
0
2
47-70
5-34
10-30
332
332
281
51
No data
27
10
74
322
4065
56
320
1947
5
74
82
%
No data
318
326
326
n
0-10
0-10
50 78
5898
95%
CI
<1
<1
16
4
4
5
2
2
miss(
%)
2003 ACSDCDC
28
28
28
28
23
23
28
28
n
52
No data
47
1
0
0
1
16
16
0
0
4162
3361
4874
64 86
481
485
482
484
479
480
4068
37 57
478
478
1
1
2
2
2
2
1
57
1
No data
40
51-62
35-46
57-68
73 82
61-72
78-86
77 85
86-92
miss(
95% CI
%)
No data
78
63
67
82
81
89
%
2007 MICS suppl
n
77 95
8598
miss( 95%
%)
CI
No data
75
61
47
54
86
91
%
2006 MICS
(3) SKILLED HEALTH WORKER DEFINED AS DOCTOR, NURSE/MIDWIFE OR AUXILLIARY MIDWIFE
(2) WOMEN WITH INSTITUTIONAL DELIVERIES ASSUMED TO HAVE APPROPRIATE POSTNATAL CARE
58
52
45
0
0
0
0
0
miss(
%)
No data
33
44
45
4
4
45
45
64
45
78
%
52 75
n
45
81
63
No data
%
2003 DHS
66-82
n
2002
IHNS¹
No data on # of days
39
64
39
1
miss(
95% CI
%)
No data
74
%
39
n
1998/1999 DHS
(1) IHNS DATA NOT AVAILABLE; INDICATORS FROM IHNS 2002 SURVEY REPORT
Percentage of pregnant women
receiving intermittent preventative
treatment for malaria during pregnancy
in previous year (2+ doses)
Percentage of newborns protected
against tetanus (2+ doses TT during
pregnancy)
Percentage of newborns fully protected
against tetanus
Percentage of pregnant women
receiving 3 months of iron
supplementation.
Percentage of births attended by skilled
health worker ³
Percentage of newborns receiving a
postnatal visit by a skilled health worker
within 3 days of delivery ² ³
Percentage of women receiving vitamin
A supplementation within 2 months of
birth
Percentage of pregnant women who
report at least 3 prenatal visits to a
skilled health worker³
Percentage of pregnant women who
report at least 4 prenatal visits to a
skilled health worker³
Percentage of pregnant women
receiving intermittent preventative
treatment for malaria during pregnancy
in previous year (any SP)
Indicators
Ghana (weighted)
Table G4: Antenatal and postnatal care over time among women with a live birth in the previous 12 month for “high impact” districts,
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A51
2099
515
511
n
1
1
3
No Data
22
17 - 26
60 - 70
55 - 64
Miss
95% CI
(%)
No Data
65
60
%
Comparison area ¥
76
68
%
230
185
23
86
No Data
39
39
n
HID
328
2765
2271
537
536
n
0.3
0.5
Miss
(%)
2
3
79
0.1
0.4
2
No Data
76
67
%
0.5 - 4
2-4
77 - 81
73 - 80
64 - 71
95% CI
Comparison area ¥
2003 DHS
(1) ITN = INSECTICIDE TREATED NET DEFINED AS TREATED WITHIN 12 MONTHS BEFORE THE SURVEY OR LONG-LASTING NET.
95
80
%
58
90
No Data
2256
1975
same as DPT
397
396
n
2668
2368
555
545
549
n
95 - 97
44 - 56
0.9 21 - 26
1
0
1.8 78 - 81
1.1 76 - 79
Miss(
95% CI
%)
No Data
24
96
50
79
78
%
Comparison area ¥
2006 MICS
2006 MICS/ 2007 MICS suppl.
U
E
HID 2007
R
MICS suppl
2
¥ COMPARISON AREA IS GHANA – NATIONAL LEVEL, EXCLUDING THE HIDS AND URBAN AREAS OF THE GREATER ACCRA AND ASHANTI REGIONS
Percentage of pregnant women
No Data
No Data
31 [32]
sleeping under an insecticide
treated mosquito net (ITN)
[UNWEIGHTED: BASED ON CASES 25-49] [N/A: RESULTS NOT SHOWN; BASED ON >24 CASES]
Percentage of children aged 0-59
months sleeping under an
insecticide treated mosquito net
(ITN)
65
No Data
Percentage of children 6 - 59 who
received at least one high dose
155
vitamin A supplement within the last
6 months
ITN ¹
68
60
%
No Data
38
Percentage of children aged 12-23
months who received 3 doses of
DPT vaccine
Percentage of children aged 12-23
months who are immunized against
Hib
38
n
Percentage of children aged 12-23
months who are immunized against
measles
EPI+ *
Indicators
HID
1998/1999 DHS
Table H1. EPI+ and ITN coverage indicators over time in “high impact” districts and comparison areas, Ghana (weighted)
Tables presenting comparisons of priority indicators over time in ACSD “high impact” districts and the
comparison area
APPENDIX H
A52
IIP-JHU | Retrospective evaluation of ACSD in Ghana
78
%
39
2
32
35
54
32
chloroquine
No Data
60
n
430
318
336
637
n
0
23
20
22
1
5
0
chloroquine
18 - 28
15 - 25
17 - 26
55 - 64
Miss(
95% CI
%)
No Data
60
%
Comparison area ¥
66
71
%
[66]
43
32
No Data
29
chloroquine
44
44
n
HID
396
276
518
518
n
6
6
38
0.7
33 - 43
1.1 33 - 47
No Data
40
60 - 68
62 - 72
Miss(
95% CI
%)
chloroquine
64
67
%
Comparison area ¥
2003 DHS
357
136
145
28
51 ³
(2) INCLUDED TREATMENT WITH APPROPRIATE ANTIMALARIAL ACCORDING TO NATIONAL POLICY
(3) MICS DEFINITION OF PNEUMONIA DIFFERENT FROM DHS (SEE APP.D)
(1) ANY ANTIMALARIAL MEDICATION
9
53
%
50 ³
ACT
554
554
n
405
146
158
600
602
n
30
35 ³
36 ³
3
61
%
1.2
7
0
ACT
2.8
2.5
Miss(
%)
25 - 35
27 - 43
28 - 44
1-5
55 - 68
95% CI
Comparison area ¥
2006 MICS
2006 MICS/ 2007 MICS suppl.
HID
2007 MICS
suppl
¥ COMPARISON AREA IS GHANA – NATIONAL LEVEL, EXCLUDING THE UER AND URBAN AREAS OF GREATER ACCRA AND ASHANTI REGIONS
Percentage of children aged 0-59
months with diarrhoea receiving
ORS, RHF or increased fluids
and continued feeding
Percentage of children aged 0-59
months with suspected
pneumonia taken to an
appropriate health provider
Percentage of children aged 0-59
months with suspected
pneumonia treated with
antibiotics
Ghana antimalarial policy
Percentage of children aged 0-59
months with fever receiving
antimalarial drugs (program)¹
Children 0-59m with fever in
previous 2 weeks, rec'd
appropriate antimalarial
treatment (effective)²
IMCI case management
indicators
HID
1998/1999 DHS
Table H2. Case management indicators over time in “high impact” districts and comparison areas, Ghana (weighted)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A53
n/a
13
270
16
No data
n/a
[28]
11
%
19
39
39
n
5606
165
190
235
509
n
0
1
0
28
2
27 30
21
54 68
259
273
18
28
60 74
23 36
45
19 27
0.1
n
4123
4441
131
188
240
566
n
23
21
71
64
49
41
%
37 - 45
95%
CI
62 - 80
9
20 - 25
1.4 19 - 23
1
0.3 55 - 72
0.6 42 - 56
0
Miss(
%)
Comparison area ¥
2003 DHS
3222
3314
125
159
258
484
n
(1) MICS 2006: NO FULL BIRTH HISTORY; UNABLE TO CALCULATE BREASTFEEDING INDICATORS AS DHS (SEE APP.D)
12
12
84
53
55
52
%
HID 2007
MICS suppl
4027
4311
183
180
297
527
n
29
27
60
57
51
31
%
7
0.8
0
0.7
0.2
1.1
26 - 33
24 - 31
51 - 68
49 - 65
44 - 58
26 - 35
Miss(
95% CI
%)
Comparison area ¥
2006 MICS
2006 MICS/ 2007 MICS suppl. ¹
¥ COMPARISON AREA IS GHANA – NATIONAL LEVEL, EXCLUDING THE UER AND THE MAJOR METROPOLITAN AREAS OF ACCRA AND KUMASI
6
6
n/a
n/a
[43]
85
%
HID
Miss( 95%
%)
CI
No data
61
67
29
23
%
Comparison area ¥
[UNWEIGHTED: BASED ON CASES 25-49] [N/A: RESULTS NOT SHOWN; BASED ON >24 CASES]
Percentage of households
consuming iodized salt
(>=15ppm)
(exclude HH with no salt)
Percentage of households
consuming iodized salt
(>=15ppm)
Percentage of infants aged 6-9
months who are breastfed and
receive complementary food
Percentage of children aged 2023 months who are currently
breastfeeding
Percentage of infants aged 0-5
months who are exclusively
breastfed
Percentage of newborns put to
the breast within one hour of birth
IMCI feeding behavior
indicators
HID
1998/1999 DHS
, Table H3. Feeding behaviour indicators over time in “high impact” districts and comparison areas, Ghana (weighted)
A54
IIP-JHU | Retrospective evaluation of ACSD in Ghana
63
509
508
508
0.7
23
38
38
0
0.1
0.2
No data
No data
46
33
4
4
64
78
%
45
45
45
33 42
19 27
44
58
20
18
52
No data
45
45
33 43
41 51
45
50 59
45
45
61 70
n
HID
566
664
566
506
562
542
542
552
552
0.6
4
4
2
2
36
35
35
33
0
0.4
0
11
No data
47
1
1
58
76
32 - 40
31 - 40
30 - 40
29 - 38
43 - 51
0-1
0-2
54 - 63
72 - 80
Comparison area ¥
Miss(
n
%
%) 95% CI
2003 DHS
78
63
67
82
81
89
%
40
481
531
533
529
531
500
500
532
532
(1)Women with institutional deliveries assumed to have appropriate postnatal care (2) Skilled health worker defined as Doctor, nurse/midwife or auxilliary midwife
57
No data
485
No data
482
484
479
480
478
478
n
1
0
48
36 - 48
70 - 79
0.5 43 - 53
No data
42
26 37
37 - 48
0.5 55 - 65
6
6
0.3 61 - 71
0.3 76 - 84
No data
75
60
31
43
66
80
Comparison area ¥
2006 MICS
Miss(
n
%
%) 95% CI
2006 MICS/ 2007 MICS suppl.
HID 2007
MICS suppl
¥ COMPARISON AREA IS GHANA – NATIONAL LEVEL, EXCLUDING THE UER AND THE MAJOR METROPOLITAN AREAS OF ACCRA AND KUMASI
72
19
39
39
17
39
Percentage of births attended by skilled
health worker ²
Percentage of newborns receiving a
postnatal visit by a skilled health worker
within 3 days of delivery¹ ²
Percentage of women receiving vitamin A
supplementation within 2 months of birth
No data
No data
39
505
1
No data
55
1
No data
505
66
No data
64
39
505
Comparison area ¥
Miss( 95%
n
%
%)
CI
No data
74
%
39
n
Percentage of pregnant women receiving 3
months of iron supplementation.
Percentage of newborns fully protected
against tetanus
Percentage of newborns protected against
tetanus (2+ doses TT during pregnancy)
Percentage of pregnant women who report
at least 3 prenatal visits to a skilled health
worker ²
Percentage of pregnant women who report
at least 4 prenatal visits to a skilled health
worker ²
Percentage of pregnant women receiving
intermittent preventative treatment for
malaria during pregnancy in previous year
(any SP)
Percentage of pregnant women receiving
intermittent preventative treatment for
malaria during pregnancy in previous year
(2+ SP)
ANC, assisted delivery and
postnatal care indicators
HID
1998/1999 DHS
Table H4: Antenatal delivery and postnatal care indicators over time in “high impact” districts and comparison areas, Ghana (weighted)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A55
21%
10%
12%
22%
78%
Bawku Municipality
Talensi-Nabdam
Garu-Tempane
Residence
Urban
Rural
Total
10%
Bawku West
8
Residence
412
3324
2580
58%
21%
21%
None
Primary
Secondary +
Total
7%
0.1%
Yes
Not sure
Education
3288
674
702
1911
3
229
914
28
<24
Currently pregnant
488
2517
771
437
294
798
317
15
77%
23%
13%
9%
24%
10%
406
171
<12
Months since last birth
Rural
Urban
7
344
744
6
5
319
712
395
12%
12%
Bolgatanga Municipality
184
4
5%
3
6%
Bongo
51%
Total
49%
Female
81%
19%
17%
9%
26%
10%
9%
5%
12%
13%
Percent
Sex
Male
Rural
Urban
8
Residence
7
6
5
4
3
2
1
487
15%
2
378
11%
1
567
17%
Kasena-Nankana
390
12%
Builsa
Total Women
Districts
Percent
2268
1146
1122
1848
420
377
206
591
226
199
103
272
295
Total Children
Table I1c: Under five Children with
complete interviews
Districts
Total Households
Table I1b: Eligible women with complete
interviews
Districts
Percent
Table I1a: Households interviewed
Table I1: Description of households, eligible women and children under five supplemental MICS 2007-8 in the “high impact” districts,
Ghana
Tables presenting 2007-8 results for key indicators in the HIDs by socio-demographic characteristics of the
population
Appendix I
A56
IIP-JHU | Retrospective evaluation of ACSD in Ghana
85%
80%
77%
84%
88%
Bolgatanga Municipality
Bawku West
Bawku Municipality
Talensi-Nabdam
84%
84%
Male
84%
Rural
Female
83%
Urban
98%
84%
n/a
82%
78%
89%
87%
73%
80%
80%
84%
83%
77%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
80%
78%
86%
86%
71%
79%
79%
82%
81%
77%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
396
85
79
85
72
75
208
187
309
87
n/a
n/a
n/a
n/a
n/a
n/a
n/a
96%
99%
98%
99%
92%
92%
95%
97%
95%
99%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Rec'd
vaccine
(%)
99%
100%
98%
100%
100%
97%
99%
98%
99%
99%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
95
99
95
99
92
89
94
95
94
98
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
397
85
79
84
72
77
209
188
310
87
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Innoculated against DPT
ACSD
vaccine
Number of
before 12m indicator children 12(%)
23m¹
(%) ²
¹ Children 12-23 months of age, still alive with non-missing data for indicator calculation: weighted
² ACSD indicator: multiply the percent of children that received vaccination before first birthday, according to immunization card, by the total
percentage of children vaccinated, according to card or mother’s report.
Total
99%
83%
Least Poor
99%
97%
86%
82%
97%
99%
99%
98%
98%
99%
n/a
n/a
n/a
n/a
n/a
n/a
4
2
n/a
n/a
3
85%
83%
Poorest
Wealth index quintiles
Sex
Residence
87%
Bongo
Garu-Tempane
88%
87%
Builsa
Kasena-Nankana
Districts
% with
EPI card Seen
Innoculated against measles
ACSD
Number of
Rec'd
vaccine
vaccine before 12m indicator children 1223m¹
(%)
(%)
(%) ²
Children 12-23 months of age vaccinated against mealses and DPT
Table I2: Vaccination by socio-demographic characteristics in “high-impact” districts, Ghana 2007-8
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A57
89%
83%
Talensi-Nabdam
Garu-Tempane
92%
91%
94%
90%
88%
91%
88%
93%
24-35
36-47
48-59
Wealth index quintiles
Poorest
2
3
4
Least Poor
1975
377
417
417
389
375
439
460
460
395
221
984
991
1607
368
332
176
515
87
¹ Children 6-59 months of age, still alive with non-missing data for
indicator calculation: weighted
90%
90%
Total
72%
90%
6-11
90%
Male
Female
12-23
Age in months
Sex
89%
93%
93%
96%
Bawku West
Bawku Municipality
Rural
91%
Bolgatanga Municipality
Urban
198
74%
Bongo
Residence
175
96%
232
88%
Builsa
260
Number of children
6-59 months of
age¹
Kasena-Nankana
Districts
Vitamin A
supplementation (%)
Children 6-59 months of age receiving one dose
vitamin A supplementation in the previous 6 months
Table I3: Vitamin A supplementation (one-dose) in previous 6 months by socio-demographic characteristics in “high-impact” districts,
Ghana 2007-8
A58
IIP-JHU | Retrospective evaluation of ACSD in Ghana
67%
54%
51%
61%
61%
61%
62%
61%
24-35
36-47
48-59
Wealth index quintiles
Poorest
2
3
4
Least poor
76%
61%
61%
61%
61%
60%
60%
50%
53%
66%
69%
64%
61%
60%
62%
55%
54%
76%
47%
58%
71%
76%
58%
58%
59%
57%
58%
58%
56%
48%
49%
63%
67%
62%
58%
57%
59%
53%
53%
72%
45%
56%
65%
76%
54%
72%
2256
428
469
473
452
434
405
507
463
399
483
1137
1119
1838
418
376
205
589
225
196
102
268
294
Number of
children 0-59
months of
age²
² Total children under five who slept in HH last night, with non-missing data for indicator calculation:
weighted
¹ ITN=Mosquito net treated with insecticide in the previous 12 months, or a long-lasting net
61%
70%
Total
65%
0-11
61%
61%
Male
62%
Rural
Female
55%
Urban
12-23
Age in months
Sex
Residence
55%
Garu-Tempane
58%
Bawku West
47%
71%
Bolgatanga Municipality
77%
76%
Bongo
Talensi-Nabdam
59%
Bawku Municipality
78%
Builsa
Kasena-Nankana
Districts
Percentage of children who:
Slept under an
Slept under an everSlept under
ITN* last night
treated mosquito net
mosquito net last
(%)
last night (%)
night (%)
Children aged 0-59 months sleeping under a mosquito net, a treated net or an
ITN¹ the night preceding the survey
Table I4: Utilization of bednets by children aged 0-59 months by socio-demographic characteristics in “high-impact” districts, Ghana
2007-8
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A59
General
Survey
documentation available
Datafile
available for
reanalysis
Implementing
Agency (& TA)
Geographic
Coverage
Survey Component
Sampling methods /
size; Sampling frame/
selection/weights;
Revised
questionnaire;
Training manual;
Interviewer manual;
Supervisor manual;
Datafile for analysis;
Report of data
analyses
English
questionnaires;
Datafile for analysis
Yes
Sampling methods /
size; Sampling frame/
selection/weights;
Revised
questionnaire;
Training manual;
Interviewer manual;
Supervisor manual;
Datafile for analysis;
Report of data
analyses
Yes
Ghana Statistical
Services & DHS,
Macro International
Navrongo Health
Research Centre, TA
(CDC – Atlanta &
UNICEF)
Ghana Statistical
Services & DHS,
Macro International
Yes
National
DHS 2003
National
ACSD 2003
Upper East
Region
DHS 1998-99
Ghana
Sampling methods
/ size; Sampling
frame/
selection/weights;
Revised
questionnaire;
Training manual;
Interviewer
manual;
Supervisor
manual; Datafile
for analysis;
Report of data
analyses
Sampling methods / size;
Sampling frame/
selection/weights;
Revised questionnaire
Training manual;
Interviewer manual;
Supervisory field report;
Datafile for analysis
Yes
Ghana Statistical
Services and
Ministry of Health
with UNICEF; TA
(PEPFAR, Macro
& Ghana AIDS
Commission)
Yes
Ghana Statistical
Services and UNICEF;
TA (Macro and JHSPH)
National
MICS
supplementary
2007
Upper East Region
(also data available in
Northern and Upper
West regions)
MICS 2006
Table F1: Methodology and implementation of household surveys in Ghana 1998 to 2008 presented in the ACSD evaluation report
A60
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Sampling &
enumeration
Unknown
Unknown
Complete listing in
EAs with <500 HHs;
partial listing in larger
EAs. August –
October 1998
Done by Macro from
household listing
before survey field
work
Mapping/
listing
Household
selection
Unknown
83
2 stage sampling
design; Unknown
stratification
ACSD 2003
20 in the UE, UW and
Northern regions; 15
in all other regions
400
2 stage sampling
stratified by region &
urban/rural; clusters
chosen from 1984
census; oversampling
in UE, UW & Northern
regions
DHS 1998-99
Number of
households
per cluster
Number of
clusters
Stratification
& sampling of
clusters
Survey Component
2 stage sampling,
clusters selection
stratified by region
and urban/rural;
clusters chosen
from Ghana Living
Standards Survey
5; oversampling in
UE, UW &
Northern regions
Complete listing in
May – July 2005;
some re-listed
early 2006
Done by GSS
from household
listing before
survey field work
Done by Macro from
household listing
before survey field
work point)
25 in rural UE,
UW & Northern;
20 in all other HHs
Done by GSS from
household listing
throughout period of
survey field work
Listing of selected HH
only; technical team
recommended standard,
full listing
20
HID: 173
2 stage sampling
stratified by district &
urban/rural
MICS 2006
300
MICS
supplementary
2007
Complete HH listing;
May – June 2003
20 in the UE, UW &
Brong Ahafo; 16 in
Northern and 15 in all
other regions
412
2 stage sampling,
clusters selection
stratified by region
and urban/rural;
clusters chosen from
2000 census;
oversampling in UE,
UW, Northern &
Brong Ahafo regions
DHS 2003
Ghana
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A61
Questionnaires
English
Household,
women's
Sociodemographic
Info; Reproduction;
Contraception;
Pregnancies, ANC,
& breastfeeding;
Immunzation; Child
illness and care;
Hygiene, marital
status, work of
women
Unknown
Household, women's
[Men's]
Sociodemographic
Info; Reproduction;
Contraception;
Pregnancies, ANC, &
breastfeeding;
Immunization and
Health; Marriage;
Fertility Preferences;
Husband/Partner’s
Background and
Women’s Work; AIDS;
Height and Weight
Pretest of all
questionnaires in Sept
1998; the 5 local
languages were
pretested.
Questionnaires used
Modules
included in
women's/child
questionnaire
Pre-test / pilot
ACSD 2003
Akan, Ga, English,
Ewe, Hausa, and
Dagbani
DHS 1998-99
Language of
questionnaire
Survey Component
Household, women's and
Under-five [Men's]
Sociodemographic Info ;
child mortality; Tetanus
Toxoid; Maternal and
Newborn Health;
Marriage and Union;
Security of Tenure;
Contraception; Domestic
Violence; HIV/AIDS;
National Health
Insurance; Birth
Registration and Early
Learning; Child
Education; Vitamin A;
Breastfeeding; Care of
Illness; Malaria;
Immunization;
Anthropometry
Full birth history was
added to women’s quest.
& Flooding module was
added to HH quest.
Household,
women's and
Under-five [Men's]
SES Info ; child
mortality; Maternal
and Newborn
Health; Marriage
and Union;
Security of
Tenure;
Contraception;
Domestic
Violence; Female
Genital Mutilation;
Sexual Behaviour;
HIV Knowledge;
Birth Registration
and Early
Learning; Child
Development;
Vitamin A;
Breastfeeding;
Care of Illness;
Malaria;
Immunization;
Anthropometry
Pretested in
Greater Accra
region in 2 urban
and 2 rural EAs in
June 2006
Household, women's
[Men's]
Sociodemographic
Info; Reproduction;
Contraception;
Pregnancies, ANC, &
breastfeeding;
Immunization and
Health; Marriage and
sexual activity;
Fertility Preferences;
Husband’s
Background and
Women’s Work;
AIDS & STDs;
Pretest of all
questionnaires in
urban & rural areas
5-7 May 2003 in all 5
local languages;
Also pretested AIDS
module
Pretested in peri-urban
Kumasi
English
MICS 2006
MICS
supplementary
2007
English
Akan, Ga, English,
Ewe, Nzema, and
Dagbani
DHS 2003
Ghana
A62
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Field
organization
/ work
Training
Mid November 1998
Nov – Feb 1999
Period of field
work
14 teams
1 supervisor
(13/14 were male)
1 field editor
(male or female)
3 interviewers
(male or female)
1 driver (male)
Standard DHS
training.
Survey startup
Number of
teams
Survey team
composition
Practice
survey admin
in field
Training
content
July – Sept 2003
July 2003
Unknown
Unknown
Unknown
Unknown
Unknown
3 week period, OctNov 1998.
Logistics &
timing
Standard DHS
training.
Two day training on
anthropometric
measurement.
Unknown
ACSD 2003
Standard DHS guides
DHS 1998-99
Manuals
Survey Component
Interviewing
techniques,
discussion of the
questionnaires,
and mock
interviews among
trainees
3 days conducting
interviews in 16
urban & rural EAs
Standard DHS
training including
anthro. measures.
Nurses trained in
blood collection for
anemia and AIDS
August 2006
3 month period
Late July – late
October, 2003
9 teams
Late July 2003
15 teams
1 supervisor; 1 editor;
1 nurse; 4
interviewers; 1 driver
1 supervisor; 1
field editor; 4
interviewers; 1
driver
80 interviewers
and 10 data entry
operators: 17–31t
July, 2006
102 interviewers, 23
nurses & 12 data
entry operators;
6-27 July 2003
Standard DHS
training.
Standard MICS
guides
MICS 2006
Standard DHS
guides
DHS 2003
Ghana
Sept – Dec 2007
Follow-up with a few
additional clusters in FebMarch 2008
September, 2008
4 teams in HIDs
1 supervisor; 1 field
editor; 4 interviewers; 1
driver
2 days conducted in periurban Kumasi
Interviewing techniques,
discussion of the
questionnaires, and mock
interviews among
trainees
Two weeks in Aug-Sept
2007; TA by Macro &
JHSPH
Interviewer manual
MICS
supplementary
2007
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A63
Data
processing
Supervision
Similar to MICS 2006, TA
(Trevor Croft & Gareth
Jones)
Data
edited/cleaned for
internal
consistency by
GSS using CSPro
Completed midDecember 2003 by
GSS
Unknown
Files transferred to
SPSS & Stata for
analysis
Missing birth month
imputed to “6”
Completed mid-March
1999 by GSS
Done according to
DHS standard
Data editing
Finalization of
data
Imputation of
birth dates
Done according to
DHS standard
Data edited/cleaned
for internal
consistency by GSS
using CSPro
Data edited/cleaned
for internal
consistency by GSS
Done according to
standard MICS
Trevor Croft, consultant
Upper East region
completed early June
2008
Similar to MICS 2006
Data processing
concurrent with
fieldwork;
feedback sent to
field teams
Data processing
concurrent with
fieldwork; feedback
sent to field teams
Completed
November 2006
by GSS
Similar to MICS 2006
Data processing
concurrent with
fieldwork; 12 data
entry operators;
double entry and
consistency checking
Unknown
Data entry
procedures
Data processing
concurrent with
fieldwork; 10 data
entry operators
with 2 data entry
supervisors & 4
secondary editors;
double entry and
consistency
checking
Unknown
Unknown
The data were then
entered and
edited using
microcomputers and
the Integrated System
for Survey Analysis
(ISSA) programme
developed
for DHS surveys.
Similar to MICS 2006
Field editors
Office editors at
GSS
Field editors
Office editors at GSS
Start-up supervision done
by GSS, Macro, & IIPJHU team for 1 week
Unknown
10 regional
statisticians acted as
coordinators and
GSS coordinated and
supervised fieldwork
Yes
Unknown
MICS 2006
MICS
supplementary
2007
Unknown
DHS 2003
Quality
control loop
Unknown
Field editors
Office editors at GSS
Editing of
questionnaires
Unknown
Unknown
ACSD 2003
Unknown
Unknown
DHS 1998-99
Technical
team
supervision
Observation
of interviews
Survey Component
Ghana
A64
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Sources:
Survey Component
DHS 1998 report(37)
DHS 1998-99
Files transferred
from UNICEF;
discussion with
Howard Goldberg
ACSD 2003
DHS 2003 report(38)
DHS 2003
Ghana
Ghana MICS 2006
report; available
from UNICEfF
MICS 2006
Field visits; key
informants
MICS
supplementary
2007
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A65
N/A
2
0
1
No Data
No Data
65
68
60
%
59 71
58 78
50 70
n
1
5³
78
N/A
64
59
%
31
230
185
39
39
n
[32]
23
86
1
0
0
0
0.4
N/A
76
68
%
n/a
16 30
75 97
65 87
59 77
miss( 95%
%)
CI
2003 DHS
84
3
N/A
66
73
%
166
26
4
1394 27 4
656
323
276
n
0
6
7
7
17
miss(
%)
2003 ACSD-CDC
144
131
30
30
30
n
1
2
2
1.4
0
No Data
43
91
66
93
82
%
34 52
87 94
53 79
88 98
78 85
miss( 95%
%)
CI
MICS 2006
2256
1975
397
396
n
0.7
0.9
miss(
%)
0.5
2
No Data
58
90
same as DPT
95
80
%
54 61
.88 92
93 97
79 82
95%
CI
MICS 2007 Suppl.
*All vaccination indicators calculated based on MICS protocols (where distribution of children reported vaccination before 12m in card s applied to all children reported as vaccinated).
(1) IHNS data not available; indicators from IHNS 2002 survey report
(2) ITN = Insecticide treated net defined as treated within 12 months before the survey or long-lasting net.
(3) Only available for children 6-32 months of age
(4) Includes bednets treated in previous 6 months only (previous 12 m not available in data)
Percentage of pregnant
women sleeping under an
insecticide treated
mosquito net (ITN)
Percentage of children
aged 0-59 months sleeping
under an insecticide
treated mosquito net (ITN)
ITNs2
Percentage of children 6 59 who received at least
one high dose vitamin A
supplement within the last
6 months
155
38
Percentage of children
aged 12-23 months who
received 3 doses of DPT
vaccine
Percentage of children
aged 12-23 months who
are immunized against Hib
38
n
Percentage of children
aged 12-23 months who
are immunized against
measles
Indicators*
EPI+
miss( 95%
%)
CI
1998/1999 DHS
2002
1
IHNS
Table G1. EPI+ and ITN coverage indicators over time in the “high impact” districts, Ghana (weighted)
Tables presenting priority indicators over time for ACSD “high impact” districts
APPENDIX G
A66
IIP-JHU | Retrospective evaluation of ACSD in Ghana
39
2
32
35
54
32
2
0
2
28 49
0-5
36 72
68 89
39
%
24
53
chloroquine
n
2002
1
IHNS
43
29
44
44
n
0
0
0
32
59
61
%
0.3
0.3
35
1
58 76
3.6 0 - 0.8
3.6
31
20
20
30
n/a
n/a
n/a
4
1
n/a
4
20 40
n/a
n/a
357
136
145
554
554
n
4
4
28
51
50
48 58
0.9
6
0
24 33
41 60
41 58
1.6 6 - 12
1.6
Miss( 95%
%)
CI
ACT
9
53
%
2007 MICS suppl
(2) ANY ANTIMALARIAL MEDICATION
37
0
0.3
67
%
ACT (since 2004)
38
38
n
Miss( 95%
%)
CI
2006 MICS
(4) MICS DEFINITION OF PNEUMONIA DIFFERENT FROM DHS (SEE APP.D)
431
No data
206
chloroquine
367
367
n
Miss(
%)
(1) IHNS DATA NOT AVAILABLE; INDICATORS FROM IHNS 2002 SURVEY REPORT
18 46
n/a
47 84
54 87
95%
CI
2003 ACSDCDC
(3) INCLUDED TREATMENT WITH APPROPRIATE ANTIMALARIAL ACCORDING TO NATIONAL POLICY
0
No data
[66]
chloroquine
66
71
%
Miss(
%)
2003 DHS
[UNWEIGHTED: BASED ON CASES 25-49] [N/A: RESULTS NOT SHOWN; BASED ON >24 CASES]
Percentage of children
aged 0-59 months with
diarrhoea receiving ORS,
RHF or increased fluids
and continued feeding
Percentage of children
aged 0-59 months with
suspected pneumonia
taken to an appropriate
health provider
Percentage of children
aged 0-59 months with
suspected pneumonia
treated with antibiotics
chloroquine
0
Ghana antimalarial policy
78
%
No data
60
n
Miss( 95%
%)
CI
1998/1999 DHS
Percentage of children
aged 0-59 months with
fever receiving appropriate
3
antimalarial drugs
Percentage of children
aged 0-59 months with
fever receiving antimalarial
2
drugs
IMCI case
management
indicators
Table G2. Illness case management indicators over time in the “high impact” districts, Ghana (weighted)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A67
39
39
19
13
Percentage of
newborns put to the
breast within one
hour of birth
Percentage of
infants aged 0-5
months who are
exclusively breastfed
Percentage of
infants aged 6-9
months who are
breastfed and
receive
complementary food
Percentage of
children aged 20-23
months who are
currently
breastfeeding
n/a
n/a
[28]
11
%
n/a
n/a
3
0
n/a
n/a
n/a
3-19
n
33
%
2002
IHNS¹
21
18
28
45
n
n/a
n/a
[43]
85
%
n/a
n/a
0
0
miss(
%)
2003 DHS
n/a
n/a
n/a
73 97
95%
CI
93
94
168
328
n
82
50
39
45
%
8
5
3
2
miss(
%)
2003 ACSDCDC
25
30
32
28
n
[92]
[53]
[56]
42
%
0
0
0
0
miss(
%)
2006 MICS²
n/a
n/a
n/a
2955
95%
CI
(2) MICS 2006: NO FULL BIRTH HISTORY; UNABLE TO CALCULATE BREASTFEEDING INDICATORS AS DHS (SEE APP.D)
[UNWEIGHTED: BASED ON CASES 25-49] [N/A: RESULTS NOT SHOWN; BASED ON >24 CASES] (1) IHNS DATA NOT AVAILABLE; INDICATORS FROM IHNS 2002
n
Indicators
miss(
95% CI
%)
1998/1999 DHS
Table G3. Feeding behaviour indicators over time in the “high impact” districts, Ghana (weighted)
125
159
258
484
n
84
53
55
52
%
0
0
0
0.8
miss(
%)
77 92
42 63
46 64
47 56
95%
CI
2007 MICS suppl²
A68
IIP-JHU | Retrospective evaluation of ACSD in Ghana
1
45
19
72
39
39
0
0
61-83
10-27
7-27
47
1
17
46-79
39
0
18
20
45
45
0
0
0
2
47-70
5-34
10-30
332
332
281
51
No data
27
10
74
322
4065
56
320
1947
5
74
82
%
No data
318
326
326
n
0-10
0-10
50 78
5898
95%
CI
<1
<1
16
4
4
5
2
2
miss(
%)
2003 ACSDCDC
28
28
28
28
23
23
28
28
n
52
No data
47
1
0
0
1
16
16
0
0
4162
3361
4874
64 86
481
485
482
484
479
480
4068
37 57
478
478
1
1
2
2
2
2
1
57
1
No data
40
51-62
35-46
57-68
73 82
61-72
78-86
77 85
86-92
miss(
95% CI
%)
No data
78
63
67
82
81
89
%
2007 MICS suppl
n
77 95
8598
miss( 95%
%)
CI
No data
75
61
47
54
86
91
%
2006 MICS
(3) SKILLED HEALTH WORKER DEFINED AS DOCTOR, NURSE/MIDWIFE OR AUXILLIARY MIDWIFE
(2) WOMEN WITH INSTITUTIONAL DELIVERIES ASSUMED TO HAVE APPROPRIATE POSTNATAL CARE
58
52
45
0
0
0
0
0
miss(
%)
No data
33
44
45
4
4
45
45
64
45
78
%
52 75
n
45
81
63
No data
%
2003 DHS
66-82
n
2002
IHNS¹
No data on # of days
39
64
39
1
miss(
95% CI
%)
No data
74
%
39
n
1998/1999 DHS
(1) IHNS DATA NOT AVAILABLE; INDICATORS FROM IHNS 2002 SURVEY REPORT
Percentage of pregnant women
receiving intermittent preventative
treatment for malaria during pregnancy
in previous year (2+ doses)
Percentage of newborns protected
against tetanus (2+ doses TT during
pregnancy)
Percentage of newborns fully protected
against tetanus
Percentage of pregnant women
receiving 3 months of iron
supplementation.
Percentage of births attended by skilled
health worker ³
Percentage of newborns receiving a
postnatal visit by a skilled health worker
within 3 days of delivery ² ³
Percentage of women receiving vitamin
A supplementation within 2 months of
birth
Percentage of pregnant women who
report at least 3 prenatal visits to a
skilled health worker³
Percentage of pregnant women who
report at least 4 prenatal visits to a
skilled health worker³
Percentage of pregnant women
receiving intermittent preventative
treatment for malaria during pregnancy
in previous year (any SP)
Indicators
Ghana (weighted)
Table G4: Antenatal and postnatal care over time among women with a live birth in the previous 12 month for “high impact” districts,
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A69
2099
515
511
n
1
1
3
No Data
22
17 - 26
60 - 70
55 - 64
Miss
95% CI
(%)
No Data
65
60
%
Comparison area ¥
76
68
%
230
185
23
86
No Data
39
39
n
HID
328
2765
2271
537
536
n
0.3
0.5
Miss
(%)
2
3
79
0.1
0.4
2
No Data
76
67
%
0.5 - 4
2-4
77 - 81
73 - 80
64 - 71
95% CI
Comparison area ¥
2003 DHS
(1) ITN = INSECTICIDE TREATED NET DEFINED AS TREATED WITHIN 12 MONTHS BEFORE THE SURVEY OR LONG-LASTING NET.
95
80
%
58
90
No Data
2256
1975
same as DPT
397
396
n
2668
2368
555
545
549
n
95 - 97
44 - 56
0.9 21 - 26
1
0
1.8 78 - 81
1.1 76 - 79
Miss(
95% CI
%)
No Data
24
96
50
79
78
%
Comparison area ¥
2006 MICS
2006 MICS/ 2007 MICS suppl.
U
E
HID 2007
R
MICS suppl
2
¥ COMPARISON AREA IS GHANA – NATIONAL LEVEL, EXCLUDING THE HIDS AND URBAN AREAS OF THE GREATER ACCRA AND ASHANTI REGIONS
Percentage of pregnant women
No Data
No Data
31 [32]
sleeping under an insecticide
treated mosquito net (ITN)
[UNWEIGHTED: BASED ON CASES 25-49] [N/A: RESULTS NOT SHOWN; BASED ON >24 CASES]
Percentage of children aged 0-59
months sleeping under an
insecticide treated mosquito net
(ITN)
65
No Data
Percentage of children 6 - 59 who
received at least one high dose
155
vitamin A supplement within the last
6 months
ITN ¹
68
60
%
No Data
38
Percentage of children aged 12-23
months who received 3 doses of
DPT vaccine
Percentage of children aged 12-23
months who are immunized against
Hib
38
n
Percentage of children aged 12-23
months who are immunized against
measles
EPI+ *
Indicators
HID
1998/1999 DHS
Table H1. EPI+ and ITN coverage indicators over time in “high impact” districts and comparison areas, Ghana (weighted)
Tables presenting comparisons of priority indicators over time in ACSD “high impact” districts and the
comparison area
APPENDIX H
A70
IIP-JHU | Retrospective evaluation of ACSD in Ghana
78
%
39
2
32
35
54
32
chloroquine
No Data
60
n
430
318
336
637
n
0
23
20
22
1
5
0
chloroquine
18 - 28
15 - 25
17 - 26
55 - 64
Miss(
95% CI
%)
No Data
60
%
Comparison area ¥
66
71
%
[66]
43
32
No Data
29
chloroquine
44
44
n
HID
396
276
518
518
n
6
6
38
0.7
33 - 43
1.1 33 - 47
No Data
40
60 - 68
62 - 72
Miss(
95% CI
%)
chloroquine
64
67
%
Comparison area ¥
2003 DHS
357
136
145
28
51 ³
(2) INCLUDED TREATMENT WITH APPROPRIATE ANTIMALARIAL ACCORDING TO NATIONAL POLICY
(3) MICS DEFINITION OF PNEUMONIA DIFFERENT FROM DHS (SEE APP.D)
(1) ANY ANTIMALARIAL MEDICATION
9
53
%
50 ³
ACT
554
554
n
405
146
158
600
602
n
30
35 ³
36 ³
3
61
%
1.2
7
0
ACT
2.8
2.5
Miss(
%)
25 - 35
27 - 43
28 - 44
1-5
55 - 68
95% CI
Comparison area ¥
2006 MICS
2006 MICS/ 2007 MICS suppl.
HID
2007 MICS
suppl
¥ COMPARISON AREA IS GHANA – NATIONAL LEVEL, EXCLUDING THE UER AND URBAN AREAS OF GREATER ACCRA AND ASHANTI REGIONS
Percentage of children aged 0-59
months with diarrhoea receiving
ORS, RHF or increased fluids
and continued feeding
Percentage of children aged 0-59
months with suspected
pneumonia taken to an
appropriate health provider
Percentage of children aged 0-59
months with suspected
pneumonia treated with
antibiotics
Ghana antimalarial policy
Percentage of children aged 0-59
months with fever receiving
antimalarial drugs (program)¹
Children 0-59m with fever in
previous 2 weeks, rec'd
appropriate antimalarial
treatment (effective)²
IMCI case management
indicators
HID
1998/1999 DHS
Table H2. Case management indicators over time in “high impact” districts and comparison areas, Ghana (weighted)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A71
n/a
13
270
16
No data
n/a
[28]
11
%
19
39
39
n
5606
165
190
235
509
n
0
1
0
28
2
27 30
21
54 68
259
273
18
28
60 74
23 36
45
19 27
0.1
n
4123
4441
131
188
240
566
n
23
21
71
64
49
41
%
37 - 45
95%
CI
62 - 80
9
20 - 25
1.4 19 - 23
1
0.3 55 - 72
0.6 42 - 56
0
Miss(
%)
Comparison area ¥
2003 DHS
3222
3314
125
159
258
484
n
(1) MICS 2006: NO FULL BIRTH HISTORY; UNABLE TO CALCULATE BREASTFEEDING INDICATORS AS DHS (SEE APP.D)
12
12
84
53
55
52
%
HID 2007
MICS suppl
4027
4311
183
180
297
527
n
29
27
60
57
51
31
%
7
0.8
0
0.7
0.2
1.1
26 - 33
24 - 31
51 - 68
49 - 65
44 - 58
26 - 35
Miss(
95% CI
%)
Comparison area ¥
2006 MICS
2006 MICS/ 2007 MICS suppl. ¹
¥ COMPARISON AREA IS GHANA – NATIONAL LEVEL, EXCLUDING THE UER AND THE MAJOR METROPOLITAN AREAS OF ACCRA AND KUMASI
6
6
n/a
n/a
[43]
85
%
HID
Miss( 95%
%)
CI
No data
61
67
29
23
%
Comparison area ¥
[UNWEIGHTED: BASED ON CASES 25-49] [N/A: RESULTS NOT SHOWN; BASED ON >24 CASES]
Percentage of households
consuming iodized salt
(>=15ppm)
(exclude HH with no salt)
Percentage of households
consuming iodized salt
(>=15ppm)
Percentage of infants aged 6-9
months who are breastfed and
receive complementary food
Percentage of children aged 2023 months who are currently
breastfeeding
Percentage of infants aged 0-5
months who are exclusively
breastfed
Percentage of newborns put to
the breast within one hour of birth
IMCI feeding behavior
indicators
HID
1998/1999 DHS
, Table H3. Feeding behaviour indicators over time in “high impact” districts and comparison areas, Ghana (weighted)
A72
IIP-JHU | Retrospective evaluation of ACSD in Ghana
63
509
508
508
0.7
23
38
38
0
0.1
0.2
No data
No data
46
33
4
4
64
78
%
45
45
45
33 42
19 27
44
58
20
18
52
No data
45
45
33 43
41 51
45
50 59
45
45
61 70
n
HID
566
664
566
506
562
542
542
552
552
0.6
4
4
2
2
36
35
35
33
0
0.4
0
11
No data
47
1
1
58
76
32 - 40
31 - 40
30 - 40
29 - 38
43 - 51
0-1
0-2
54 - 63
72 - 80
Comparison area ¥
Miss(
n
%
%) 95% CI
2003 DHS
78
63
67
82
81
89
%
40
481
531
533
529
531
500
500
532
532
(1)Women with institutional deliveries assumed to have appropriate postnatal care (2) Skilled health worker defined as Doctor, nurse/midwife or auxilliary midwife
57
No data
485
No data
482
484
479
480
478
478
n
1
0
48
36 - 48
70 - 79
0.5 43 - 53
No data
42
26 37
37 - 48
0.5 55 - 65
6
6
0.3 61 - 71
0.3 76 - 84
No data
75
60
31
43
66
80
Comparison area ¥
2006 MICS
Miss(
n
%
%) 95% CI
2006 MICS/ 2007 MICS suppl.
HID 2007
MICS suppl
¥ COMPARISON AREA IS GHANA – NATIONAL LEVEL, EXCLUDING THE UER AND THE MAJOR METROPOLITAN AREAS OF ACCRA AND KUMASI
72
19
39
39
17
39
Percentage of births attended by skilled
health worker ²
Percentage of newborns receiving a
postnatal visit by a skilled health worker
within 3 days of delivery¹ ²
Percentage of women receiving vitamin A
supplementation within 2 months of birth
No data
No data
39
505
1
No data
55
1
No data
505
66
No data
64
39
505
Comparison area ¥
Miss( 95%
n
%
%)
CI
No data
74
%
39
n
Percentage of pregnant women receiving 3
months of iron supplementation.
Percentage of newborns fully protected
against tetanus
Percentage of newborns protected against
tetanus (2+ doses TT during pregnancy)
Percentage of pregnant women who report
at least 3 prenatal visits to a skilled health
worker ²
Percentage of pregnant women who report
at least 4 prenatal visits to a skilled health
worker ²
Percentage of pregnant women receiving
intermittent preventative treatment for
malaria during pregnancy in previous year
(any SP)
Percentage of pregnant women receiving
intermittent preventative treatment for
malaria during pregnancy in previous year
(2+ SP)
ANC, assisted delivery and
postnatal care indicators
HID
1998/1999 DHS
Table H4: Antenatal delivery and postnatal care indicators over time in “high impact” districts and comparison areas, Ghana (weighted)
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A73
21%
10%
12%
22%
78%
Bawku Municipality
Talensi-Nabdam
Garu-Tempane
Residence
Urban
Rural
Total
10%
Bawku West
8
Residence
412
3324
2580
58%
21%
21%
None
Primary
Secondary +
Total
7%
0.1%
Yes
Not sure
Education
3288
674
702
1911
3
229
914
28
<24
Currently pregnant
488
2517
771
437
294
798
317
15
77%
23%
13%
9%
24%
10%
406
171
<12
Months since last birth
Rural
Urban
7
344
744
6
5
319
712
395
12%
12%
Bolgatanga Municipality
184
4
5%
3
6%
Bongo
51%
Total
49%
Female
81%
19%
17%
9%
26%
10%
9%
5%
12%
13%
Percent
Sex
Male
Rural
Urban
8
Residence
7
6
5
4
3
2
1
487
15%
2
378
11%
1
567
17%
Kasena-Nankana
390
12%
Builsa
Total Women
Districts
Percent
2268
1146
1122
1848
420
377
206
591
226
199
103
272
295
Total Children
Table I1c: Under five Children with
complete interviews
Districts
Total Households
Table I1b: Eligible women with complete
interviews
Districts
Percent
Table I1a: Households interviewed
Table I1: Description of households, eligible women and children under five supplemental MICS 2007-8 in the “high impact” districts,
Ghana
Tables presenting 2007-8 results for key indicators in the HIDs by socio-demographic characteristics of the
population
Appendix I
A74
IIP-JHU | Retrospective evaluation of ACSD in Ghana
85%
80%
77%
84%
88%
Bolgatanga Municipality
Bawku West
Bawku Municipality
Talensi-Nabdam
84%
84%
Male
84%
Rural
Female
83%
Urban
98%
84%
n/a
82%
78%
89%
87%
73%
80%
80%
84%
83%
77%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
80%
78%
86%
86%
71%
79%
79%
82%
81%
77%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
396
85
79
85
72
75
208
187
309
87
n/a
n/a
n/a
n/a
n/a
n/a
n/a
96%
99%
98%
99%
92%
92%
95%
97%
95%
99%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Rec'd
vaccine
(%)
99%
100%
98%
100%
100%
97%
99%
98%
99%
99%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
95
99
95
99
92
89
94
95
94
98
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
397
85
79
84
72
77
209
188
310
87
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Innoculated against DPT
ACSD
vaccine
Number of
before 12m indicator children 12(%)
23m¹
(%) ²
¹ Children 12-23 months of age, still alive with non-missing data for indicator calculation: weighted
² ACSD indicator: multiply the percent of children that received vaccination before first birthday, according to immunization card, by the total
percentage of children vaccinated, according to card or mother’s report.
Total
99%
83%
Least Poor
99%
97%
86%
82%
97%
99%
99%
98%
98%
99%
n/a
n/a
n/a
n/a
n/a
n/a
4
2
n/a
n/a
3
85%
83%
Poorest
Wealth index quintiles
Sex
Residence
87%
Bongo
Garu-Tempane
88%
87%
Builsa
Kasena-Nankana
Districts
% with
EPI card Seen
Innoculated against measles
ACSD
Number of
Rec'd
vaccine
vaccine before 12m indicator children 1223m¹
(%)
(%)
(%) ²
Children 12-23 months of age vaccinated against mealses and DPT
Table I2: Vaccination by socio-demographic characteristics in “high-impact” districts, Ghana 2007-8
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A75
89%
83%
Talensi-Nabdam
Garu-Tempane
93%
Least Poor
90%
88%
4
1975
377
417
417
389
375
439
460
460
395
221
984
991
1607
368
332
176
515
87
¹ Children 6-59 months of age, still alive with non-missing data for
indicator calculation: weighted
Total
91%
3
94%
48-59
Wealth index quintiles
88%
91%
36-47
90%
92%
24-35
2
90%
Poorest
72%
90%
6-11
90%
Male
Female
12-23
Age in months
Sex
89%
93%
93%
96%
Bawku West
Bawku Municipality
Rural
91%
Bolgatanga Municipality
Urban
198
74%
Bongo
Residence
175
96%
232
88%
Builsa
260
Number of children
6-59 months of
age¹
Kasena-Nankana
Districts
Vitamin A
supplementation (%)
Children 6-59 months of age receiving one dose
vitamin A supplementation in the previous 6 months
Table I3: Vitamin A supplementation (one-dose) in previous 6 months by socio-demographic characteristics in “high-impact” districts,
Ghana 2007-8
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
67%
54%
51%
61%
61%
61%
62%
61%
24-35
36-47
48-59
Wealth index quintiles
Poorest
2
3
4
Least poor
76%
61%
61%
61%
61%
60%
60%
50%
53%
66%
69%
64%
61%
60%
62%
55%
54%
76%
47%
58%
71%
76%
58%
58%
59%
57%
58%
58%
56%
48%
49%
63%
67%
62%
58%
57%
59%
53%
53%
72%
45%
56%
65%
76%
54%
72%
2256
428
469
473
452
434
405
507
463
399
483
1137
1119
1838
418
376
205
589
225
196
102
268
294
Number of
children 0-59
months of
age²
² Total children under five who slept in HH last night, with non-missing data for indicator calculation:
weighted
¹ ITN=Mosquito net treated with insecticide in the previous 12 months, or a long-lasting net
61%
70%
Total
65%
0-11
61%
61%
Male
62%
Rural
Female
55%
Urban
12-23
Age in months
Sex
Residence
55%
Garu-Tempane
58%
Bawku West
47%
71%
Bolgatanga Municipality
77%
76%
Bongo
Talensi-Nabdam
59%
Bawku Municipality
78%
Builsa
Kasena-Nankana
Districts
Percentage of children who:
Slept under an
Slept under an everSlept under
ITN* last night
treated mosquito net
mosquito net last
(%)
last night (%)
night (%)
Children aged 0-59 months sleeping under a mosquito net, a treated net or an
ITN¹ the night preceding the survey
Table I4: Utilization of bednets by children aged 0-59 months by socio-demographic characteristics in “high-impact” districts, Ghana
2007-8
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A77
302
24%
25%
23%
3
4
Least Poor
2265
428
473
473
53%
53%
63%
57%
53%
47%
47%
48%
59%
55%
53%
55%
34%
51%
67%
42%
59%
47%
37%
85%
66%
74%
87
554
98
119
116
119
103
274
280
358
112
55
29
465
89
123
61
126
48
49
15
45
6%
7%
6%
7%
7%
5%
7%
6%
6%
7%
9%
5%
6%
6%
8%
10%
5%
4%
8%
6%
6%
7%
% with
suspected
pneumonia
2266
429
473
473
455
435
1145
1121
1381
399
183
302
1846
420
376
206
591
226
199
103
271
295
Number of
children 059m*
50%
71%
55%
45%
39%
41%
53%
46%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
% taken to
health
facility
51%
65%
60%
48%
50%
35%
54%
48%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
% treated
with
anitiobics
145
28
31
31
31
27
80
64
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Number of
children 059m with
pneumonia¹
Children 0-59 with suspected pneumonia in previous 2 weeks
16%
16%
14%
17%
16%
16%
15%
17%
15%
22%
22%
9%
16%
14%
17%
19%
14%
14%
16%
10%
12%
23%
% with
diarrhea
¹ Children under five with non-missing data for indicator calculation: weighted; n/a - small sample size >25 cases; [unweighted] - >50 cases in at least one cell
25%
27%
Total
435
24%
2
455
1145
25%
1120
1380
399
184
24%
29%
26%
12-23
24-59
419
1846
male
9%
31%
0-5
6-11
Rural
206
376
female
Wealth index quintiles
Poorest
Gender
Age in months
22%
26%
Urban
Garu-Tempane
Residence
30%
33%
Talensi-Nabdam
591
226
22%
22%
Bawku West
Bawku Municipality
102
198
16%
25%
Bongo
Bolgatanga Municipality
295
272
30%
17%
Builsa
Kasena-Nankana
Districts
% with
fever
Number of
Number of % given any children 0antichildren 059m with
59m*
malarial
fever¹
Children 0-59 with fever in previous 2 weeks
2268
429
474
473
457
435
1146
1122
1382
399
185
302
1848
420
377
206
591
226
199
103
272
295
Number of
children 059m*
41%
42%
39%
56%
29%
37%
39%
43%
[47%]
[41%]
[41%]
[14%]
42%
33%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
ORS
(%)
47%
43%
51%
62%
36%
40%
45%
48%
[54%]
[46%]
[41%]
[21%]
48%
37%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
ORS +
RHF (%)
74%
73%
74%
79%
77%
68%
74%
74%
[81%]
[74%]
[69%]
[50%]
75%
69%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
28%
32%
32%
30%
28%
19%
34%
23%
[32%]
[26%]
[28%]
[14%]
27%
32%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
357
67
66
79
74
71
174
183
195
93
39
29
299
58
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
ORS/ RHF/
Number of
ORS/ RHF/ increased fluids children 0increased with continued 59m with
fluids (%)
feeding (%)
diarrhoea¹
Children 0-59 with diarrhoea in previous 2 weeks
Table I5: Illness case management by socio-demographic characteristics in “high-impact” districts, Ghana 2007-8
Care management of fever, suspected pneumonia, and diarrhea for children 0-59 months with illness in the previous 2 weeks
A78
IIP-JHU | Retrospective evaluation of ACSD in Ghana
28%
2%
9%
15%
2%
1%
6%
1%
3%
3%
3%
9%
66%
9%
64%
0%
0%
53%
61%
71%
67%
Any AM
treatment
²Children under five with non-missing data for indicator calculation: weighted
¹ Appropriate antimalarial treatment defined as Mali policy for first line malaria treatment (CQ in 1998-9 & 2003; ACT in 2006 & 2007-8)
NOTE: Anti-malarial treatment columns are not mutually exclusive
High Impact districts
1%
1%
National comparison
MICS 2007/2008
66%
High Impact districts
MICS 2006
43%
64%
0%
0%
Data not available
High Impact districts
DHS 2003
National comparison
Data not available
Children with a fever in the last two weeks who were treated with:
ACT/
Appropriate
Chloroquine Amodiaquine
Quinine
CoArtem
AM¹
National comparison
DHS 1998/1999
SP/
Fansidar
554
602
44
518
No. of children with
fever in last two
weeks²
Table I6: Treatments given for fever in the 2 weeks preceding the survey in “high-impact” districts and comparison areas over time, Ghana
2007-8
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A79
6%
n/a
5%
34%
n/a
28%
National comparison
National comparison
12%
0%
28%
n/a
0%
n/a
0%
23%
0%
n/a
20%
n/a
Private sector drug
vendor
Village Health worker
¹Children under five with non-missing data for indicator calculation: weighted
High Impact districts
46%
Note: Mutally exclusive in order of table
MICS 2007/2008
High Impact districts
MICS 2006
3%
5%
n/a
High Impact districts
DHS 2003
16%
n/a
Private Health
center / facility
National comparison
DHS 1998/1999
Public health
center / facility
2%
1%
1%
n/a
4%
n/a
Other
Children with suspected pneumonia in the last two weeks who were taken to:
36%
44%
31%
n/a
55%
n/a
145
158
279
n/a
336
n/a
Number of
Not treated / children aged 0treated at home 59 months with
/ neighbors
pneumonia¹
Table I7: Locations where care was sought for suspected pneumonia in the 2 weeks preceding the survey in “high-impact” districts
and comparison areas over time, Ghana 2007-8
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
[53%]
[41%]
[55%]
Bawku Municipality
Talensi-Nabdam
Garu-Tempane
52%
47%
Least Poor
93
484
97
91
95
108
55%
[79%]
[62%]
[52%]
[45%]
[55%]
55%
54%
80%
33%
[54%]
[75%]
[53%]
[53%]
[37%]
[49%]
n/a
[72%]
[73%]
[58%]
Exclusively
breastfeed
258
42
52
46
62
58
144
115
120
138
216
44
36
32
38
37
24
32
30
31
Number of
children
0-5m²
n/a - small sample size >25 cases; [unweighted] - >50 cases in at least one cell
¹Women with a live birth in previous 12 months with non-missing data for indicator analysis: weighted
² Children with non-missing data for indicator analysis: weighted
Total
57%
60%
3
4
50%
44%
-
-
2
-
-
male
256
228
390
94
82
56
73
62
42
61
46
60
female
47%
56%
0-2
3-5
Poorest
Wealth index quintiles
Sex
Age in months
42%
[45%]
Bawku West
54%
[43%]
Bolgatanga Municipality
Rural
[66%]
Bongo
Urban
[50%]
Kasena-Nankana
Residence
[57%]
Builsa
Districts
Timely
Birth within
initiation of
previous
12m¹
breastfeeding
53%
[38%]
[67%]
[50%]
[62%]
[49%]
53%
159
29
27
34
34
33
79
80
-
52%
-
-
131
26
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Number of
children 69m²
-
[52%]
[58%]
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Complementary
feeding
84%
n/a
n/a
n/a
n/a
n/a
[85%]
[83%]
-
-
[87%]
[74%]
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Continued
breastfeeding
125
n/a
n/a
n/a
n/a
n/a
73
47
-
-
93
27
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Number of
children 2023m²
Timely initiation of breastfeeding, exclusive breastfeeding among children 0-5 months, complementary feeding among
Table I8: Prevalence of infant feeding behaviours as reported by mothers by socio-demographic characteristics in “high-impact”
districts, Ghana 2007-8
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A81
[69%[
[82%]
Talensi-Nabdam
Garu-Tempane
83%
76%
84%
Mother's education level
None
Primary School
Secondary school+
82%
79%
Least Poor
67%
71%
69%
69%
67%
56%
70%
63%
67%
70%
63%
66%
70%
[67%]
[59%]
[68%]
[58%]
[73%]
[53%]
[74%]
[69%]
2+
487
96
93
92
107
91
60
103
316
252
227
387
92
81
54
72
62
41
60
46
61
Birth
within
previous
12m¹
63%
66%
68%
70%
56%
53%
64%
61%
63%
61%
65%
62%
68%
[51%]
[59%]
[74%]
[68%]
[76%]
[67%]
[72%]
[34%]
TT2
78%
83%
80%
85%
70%
71%
84%
74%
77%
80%
75%
76%
83%
[68%]
[66%]
[90%]
[84%]
[91%]
[75%]
[89%]
[51%]
Full TT
Neonatal tetanus
protection
484
97
93
93
107
93
62
104
318
256
228
390
94
61
47
61
42
62
72
56
81
Birth within
previous
12m¹
n/a - small sample size >25 cases; [unweighted] - >50 cases in at least one cell
¹ Women with a live birth in previous 12 months with non-missing data for indicator analysis: weighted
Total
89%
86%
3
2
4
73%
81%
Poorest
Wealth index quintiles
79%
84%
0-5
6-11
Months since birth
84%
[85%]
Bawku Municipality
81%
[82%]
Bawku West
Rural
[93%]
Bolgatanga Municipality
Urban
[60%]
Bongo
Residence
[80%]
[89%]
Kasena-Nankana
1+
Builsa
Districts
IPT during
pregnancy
89%
96%
91%
92%
84%
84%
94%
92%
88%
87%
92%
88%
81%
93%
83%
80%
75%
75%
89%
83%
79%
79%
84%
80%
85%
[73%]
[83%]
94%
[75%]
[84%]
[83%]
[89%]
[94%]
[93%]
[83%]
[77%]
[87%]
[86%]
[94%]
[74%]
4+
[100%]
[84%]
3+
Prenatal visits with a
trained health care
worker
478
96
92
92
107
92
62
103
313
254
224
385
94
73
75
83
62
42
60
46
61
Birth
within
previous
12m¹
Antenatal care (including IPT, TT, Fe) among women who have given birth in the previous 12 months
Table I9: Antenatal care indicators among women giving birth within the previous 12 months by socio-demographic characteristics in
“high-impact” districts, Ghana 2007-8
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
[43%]
[34%]
[33%]
Bawku Municipality
Talensi-Nabdam
Garu-Tempane
38%
65%
Primary School
Secondary school+
29%
46%
77%
3
4
Least Poor
40%
27%
2
485
97
93
95
107
93
62
104
319
256
230
392
94
81
56
73
62
42
61
47
61
Birth within
previous
12m²
95
481
57%
92
94
108
93
60
104
318
255
226
389
92
82
56
72
60
41
61
47
60
Birth within
previous
12m²
60%
58%
62%
51%
52%
63%
60%
54%
56%
57%
54%
66%
[51%]
[63%]
[58%]
[60%]
[63%]
[43%]
[55%]
[55%]
Postnatal
supplementation
with Vitamin A
n/a - small sample size >25 cases; [unweighted] - >50 cases in at least one cell
²Women with a live birth in previous 12 months with non-missing data for indicator analysis:
weighted
¹Trained health care worker: doctor, nurse/midwife or auxilliary midwife
Total
23%
Poorest
Wealth index quintiles
36%
Mother's education level
None
46%
35%
0-5
6-11
Months since birth
33%
[37%]
Bawku West
71%
[55%]
Bolgatanga Municipality
Rural
[46%]
Bongo
Urban
[45%]
Residence
[36%]
Builsa
Kasena-Nankana
Districts
Skilled birth
attendant ¹
Delivery and postnatal care indicators among women who have given birth in
Table I10: Assisted delivery and post-natal care among women giving birth in the previous 12 months by socio-demographic
characteristics in “high-impact” districts, Ghana 2007-8
IIP-JHU | Retrospective evaluation of ACSD in Ghana
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4%
2%
4%
National comparison
High Impact districts
MICS 2006
National comparison
37%
36%
11%
29%
13%
17%
Nurse/midwife
0%
2%
4%
1%
3%
17%
Aux.
midwife
1%
0%
0%
0%
0%
0%
24%
37%
20%
40%
71%
47%
Traditional birth
attendant¹
² No assistance or assisted by friend/relative
³ Women with a birth in previous 12m with non-missing data for indicator calculation: weighted
Note: Chart mutually exclusive in order of doctor to no assistance
¹ Trainied or untrained TBA
High Impact districts
2%
1%
High Impact districts
DHS 2003
MICS 2007/2008
4%
National comparison
DHS 1998/1999
Doctor
Community
health
worker
Delivery assisted by:
35%
21%
63%
25%
12%
15%
No
assistance²
485
533
45
566
39
508
Birth within
previous 12m³
Table I11: Health providers assisting deliveries in “high-impact” districts and comparison areas over time, Ghana 2007-8
APPENDIX J
Additional tables for nutrition
Figure J1: Protocol for inclusion and exclusion of cases for nutrition analyses in “high-impact”
districts and national comparison as measured in 1998 DHS, Ghana
Excluded:
National
comparison
1998
Total Number of children
under five
n=2612
13%
n=199
Incomplete
result
Wt/Ht
4% outliers
5%
A84
Excluded:
High impact
districts
11%
Wt/Ht
3% outliers
Unknown DOB
0.6%
Ht/age
4% outliers
Ht/age
5% outliers
Wt/age
1% outliers
Wt/age
2% outliers
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Figure J2: Protocol for inclusion and exclusion of cases for nutrition analyses in “highimpact”districts and national comparison as measured in 2003 DHS, Ghana
Excluded:
National
comparison
2003
Total Number of children
under five
n=2834
3%
12%
4%
n=241
Did not sleep in
household last
night
4%
Non-biological
children
15%
Incomplete
result
25%
Wt/Ht
4% outliers
<0.1%
Excluded:
High impact
districts
Wt/Ht
7% outliers
Unknown DOB
0%
Ht/age
3% outliers
Ht/age
3% outliers
Wt/age
1% outliers
Wt/age
1% outliers
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Figure J3: Protocol for inclusion and exclusion of cases for nutrition analyses in “high-impact”
districts and national comparison as measured in 2006 & 2007 MICS, Ghana
Excluded:
National
comparison
2006/2007
Total Number of children
under five
n=2,268
n= 2,606
1%
Incomplete
result
Wt/Ht
2% outliers
5%
A86
Excluded:
High impact
districts
1%
Wt/Ht
1% outliers
Unknown DOB
0.5%
Ht/age
3% outliers
Ht/age
2% outliers
Wt/age
0.5% outliers
Wt/age
0.4% outliers
IIP-JHU | Retrospective evaluation of ACSD in Ghana
Table J4: Prevalence of stunting among children 0-59 months of age by sub-groups of the
population in the “high impact” districts and comparison in the 2006 and 2007 MICS, Ghana
2006/2007 MICS
High Impact Districts
% stunting (<
-2 SD)
% severely
stunting
(< -3 SD)
n
29%
9%
2192
Geographic comparison
% stunting
(< -2 SD)
% severely
stunting
(< 3 SD)
n
28%
34%
15%
23%
30%
38%
30%
36%
28%
9%
9%
3%
8%
11%
15%
9%
15%
9%
324
262
60
225
425
232
285
523
94
Region
Upper East
Western
Central
Greater Accra
Volta
Eastern
Ashanti
Brong Ahafo
Northern
Upper West
Residence
Urban
Rural
26%
30%
7%
10%
403
1789
19%
35%
6%
12%
550
1879
33%
26%
11%
8%
1089
1103
33%
29%
12%
10%
1255
1175
11%
31%
37%
35%
32%
6%
10%
10%
12%
9%
469
387
455
454
427
11%
37%
42%
37%
30%
3%
12%
16%
13%
10%
518
527
478
474
432
32%
28%
30%
31%
19%
11%
10%
9%
7%
7%
719
640
449
190
194
44%
37%
34%
34%
17%
19%
17%
13%
10%
5%
219
266
584
747
614
Sex
Male
Female
Age
0-11
12-23
24-35
36-47
48-59
Wealth index quintiles
Poorest
2
3
4
Least Poor
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Table J5: Prevalence of wasting among children 0-59 months of age by sub-groups of the
population in the “high impact” districts and comparison in the 2006 and 2007 MICS, Ghana
2006/2007 MICS
High Impact Districts
% severely
(< % wasting (< wasting
-2 SD)
3 SD)
n
Geographic comparison
% wasting
-2 SD)
% severely
(< (< wasting
3 SD)
n
Region
Upper East
8%
2%
2226
Western
Central
Greater Accra
Volta
Eastern
Ashanti
Brong Ahafo
Northern
Upper West
6%
4%
0%
6%
4%
4%
3%
9%
8%
1%
1%
0%
2%
1%
1%
1%
3%
2%
342
294
60
244
447
243
306
566
103
Residence
Urban
Rural
9%
8%
1%
2%
409
1817
5%
6%
1%
2%
579
2023
9%
8%
3%
2%
1103
1123
6%
5%
1%
2%
1335
1268
14%
14%
9%
1%
4%
4%
4%
2%
0%
0%
470
395
462
461
439
11%
7%
5%
2%
3%
3%
1%
2%
0%
1%
539
536
497
525
505
11%
8%
7%
5%
7%
3%
2%
3%
1%
0%
729
653
452
193
199
8%
9%
6%
5%
3%
3%
3%
1%
1%
1%
250
292
625
793
642
Sex
Male
Female
Age
0-11
12-23
24-35
36-47
48-59
Wealth index quintiles
Poorest
2
3
4
Least Poor
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Table J6: Prevalence of underweight among children 0-59 months of age by sub-groups of the
population in the “high impact” districts and comparison in the 2006 and 2007 MICS, Ghana
2006/2007 MICS
High Impact Districts
%
underweight
(< -2 SD)
% severely
underweight
(< -3 SD)
n
21%
5%
2230
Geographic comparison
area
% underweight
(< -2 SD)
% severely
underweight
(< -3 SD)
n
11%
13%
5%
14%
13%
19%
11%
1%
2%
0%
6%
4%
5%
3%
330
270
61
235
440
241
291
21%
16%
8%
4%
539
97
Region
Upper East
Western
Central
Greater Accra
Volta
Eastern
Ashanti
Brong Ahafo
Northern
Upper West
Residence
Urban
Rural
17%
21%
2%
5%
407
1823
10%
17%
2%
5%
564
1940
23%
19%
6%
4%
1102
1128
17%
13%
5%
4%
1292
1213
16%
24%
26%
18%
19%
4%
7%
7%
4%
3%
478
396
460
459
437
13%
18%
18%
13%
13%
4%
4%
6%
4%
3%
552
531
489
487
445
22%
23%
20%
15%
13%
6%
6%
4%
2%
2%
734
653
453
191
200
24%
20%
16%
15%
9%
10%
8%
4%
4%
1%
229
275
605
768
627
Sex
Male
Female
Age
0-11
12-23
24-35
36-47
48-59
Wealth index quintiles
Poorest
2
3
4
Least Poor
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APPENDIX K
Methodological challenges
This section discusses the methodological challenges of the evaluation design. Many of the weaknesses
are due to the retrospective nature of the evaluation, which necessitates relying on existing—even if
imperfect—data and information. The drawbacks of retrospective evaluations have been explained
elsewhere.(39) We first discuss general methodological considerations, and then describe challenges in
measuring levels of coverage for each ACSD implementation package. Complementing this section,
appendix F provides descriptions of surveys included in the evaluation and appendix E provides a side-by
side comparison of the questions utilized for indicator calculation for each survey.
Challenges in documentation.
Due to the retrospective nature of the evaluation, it was difficult to collect complete and standardized
information on ACSD implementation activities and other health activities in the HIDs. The collaborative
nature of ACSD makes it difficult to distinguish which activities were: 1) carried out as part of the ACSD
program, 2) carried out with only partial technical and/or financial support from the ACSD program, or 3)
carried out by ACSD partners, but independent of the ACSD program. This was especially difficult in
Ghana due to the large number of NGOs and governmental programs in the Upper East region. Primary
data sources pertaining to ACSD activities taking place in 2003 and earlier were less available than more
recent documents; where necessary, we relied on summative reports and presentations for this
information. Sometimes, although not often, information in one document conflicted with information
found in other sources. In these cases, we present the information found in the most primary source. The
evaluation team has collected and reviewed the available information pertaining to ACSD implementation
and contextual factors to ensure the most complete documentation and interpretation possible. However,
some uncertainty and gaps in information will be inevitable.
Challenges in utilization of existing surveys.
One challenge was to establish a baseline using preexisting data. The 1998 DHS occurred several years
before ACSD implementation began. It is difficult to know if any differences in the 1998 DHS compared
to the endline surveys are due to changes during the ACSD period or before. The 2003 DHS survey
occurred towards the beginning of ACSD implementation. Many packages were rolled out after the 2003
survey but several began before such as logistic EPI+ support and ITN campaigns. Knowing the
limitations, we focused on the 1998 DHS while also examining the 2003 DHS to get a full picture. The
2003 ACSD survey estimates were also considered but given less importance due to data quality issues.
We were unable to obtain accompanying documentation for the 2002 IHNS survey in the Upper East
region and could not perform the analysis with confidence.
The 1998 and 2003 DHS had limited sample sizes for calculation of baseline coverage indicators in the
HIDs, especially those indicators measured among small subgroups of the sample such as exclusive
breastfeeding or careseeking for pneumonia. These small sample sizes affect the precision of point
estimates and the statistical power to detect small differences over time.
The second major challenge was comparing the baseline DHS surveys to the endline MICS surveys. The
DHS and MICS use slightly different methodologies to collect data. DHS ask only biological mothers of
young children about intervention coverage, while MICS questions caretakers of children, even if not
biologically related, about intervention coverage. Also differences in the conduct of the survey, the DHS
and MICS questionnaires and interviewers’ style of asking questions may have introduced some bias into
the comparison of coverage levels between 1998-9, 2003 and 2006-7. Appendices D and E note
differences in the DHS and MICS questions used for indicator calculations; appendices F review the
differences between the surveys. The major differences were in breastfeeding indicators and definition of
pneumonia cases. For infant feeding, the DHS (2003) only collects data on a woman’s youngest children
whereas the MICS collects data on all under-five children. The DHS defines suspected pneumonia cases
as “cough” plus “difficulty breathing” whereas the MICS also includes “difficulty breathing due to problem
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with the chest”. However, these differences were minimal and we would not expect them to affect the
findings.
The 2006 MICS, used for endline coverage of the comparison area, occurred almost one year before the
2007 MICS in the Upper East region. We compared estimates of coverage between 2006 and 2007 in
the HIDs to assess if the one-year time lag could have influenced our results. Most coverage indicators
remained relatively stable in the HIDs between 2006 and 2007, and were not statistically significant. ITNs
for children and IPTp were significantly greater in 2007 as compared to 2006 in the HIDs; coverage with
any antimalarial for fever was significantly less in 2007. For these three indicators, we reran statistical
tests using the 2006 MICS as our endline estimate to identify any possible bias introduced by using the
2007 MICS survey only in the HIDs. Statistical inferences were the same for trends over time and
differences in changes over time in the HIDs and comparison area.
During the MICS 2007 supplemental survey, there was extensive flooding throughout the northern
regions of Ghana, including the HIDs. In order to assess the impact of the flood, we prepared an
additional module to the Household questionnaire. The module aimed to measure the severity of the
flood on the household focusing on damage and migration. Twenty-eight percent of the households in
the HIDs reported being affected by the flood and 24 percent reported damage. We selected several
coverage indicators that might be differentially affect by the flood: diarrhea, pneumonia and fever case
management and ITN use in underfive children. There is a significantly higher proportion of children
receiving an antimalarial for fever in the households affected by the flood. (50% vs. 61%; P=0.02). For
the remaining indicators tested, there is no significant difference between households affected by the
flood and those not affected.
Challenges in measuring vaccination and vitamin A coverage.
Baseline vaccination coverage estimates are based on very small numbers which may affect precision.
In the MICS 2007, there was some confusion about the timing of vitamin A campaigns and how it was
presented to the survey respondents. We discussed the issue with UNICEF-Ghana and the survey
teams; they recommended that a positive response to any campaign where vitamin A was distributed be
counted as the child receiving vitamin A in the previous six months.
Challenges in measuring ITN coverage.
The 1998 DHS did not collect data on ITN use. The 2003 DHS collected data on ITN use from the head
of household in the Household questionnaire. While the MICS 2006 and 2007 collected ITN use data
from the caretaker in the under-five questionnaire. Comparability could be an issue because the
caretaker might have more accurate information on childcare than the head of household. However we
expect the effect to be very small. The MICS 2006 and 2007 did not collect data on whether pregnant
women slept under an ITN last night.
Challenges in measuring case management and feeding practices.
The 1998 and 2003 DHS surveys contained inadequate sample size (less than 25 cases) in the HIDs to
determine coverage of complementary and continued feeding. We analyzed exclusive breastfeeding at
baseline but the sample size is very small, less than 50 cases. As previously mentioned the DHS and
MICS collect infant feeding data on slightly dissimilar populations: youngest children versus all children.
However, we do not believe this difference impacts the inference.
Again, the two baseline DHS surveys had a small sample size for the illness case management
indicators. The 1998 DHS only collected data on the type of fever treatment, not specific anti-malaria
drugs. Therefore, we also included the proxy indicator of “any anti-malarial treatment of fever” for all
surveys. Specific anti-malarial treatment was available in the other surveys. The 2003 DHS did not
collect data on antibiotic treatment of suspected pneumonia. As previously mentioned the MICS and DHS
questionnaires use different pneumonia definitions. The MICS defines suspected pneumonia as “cough”
plus “difficulty breathing” plus “problem in the chest” and if the child does not fit all criteria then the
subsequent pneumonia questions are skipped.
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Challenges in measuring antenatal, delivery and postnatal care.
The 1998 DHS collected limited data on antenatal and postnatal care compared to the other surveys.
There was no data available for IPTp, full tetanus protection and length of iron supplementation. The
2003 DHS did not collect data on full tetanus protection and both baseline surveys had small sample
sizes in the HIDs. The MICS 2006 and 2007 did not collect data on iron supplementation or postnatal
care.
Challenges in measuring nutrition.
Both baseline surveys had very low sample sizes for anthropomorphic measures in the HIDs. The 1998
DHS and the MICS surveys collected nutritional data in the womens and under-five questionnaires,
respectively. The 2003 DHS collected data in the household questionnaire. Following DHS protocol, we
excluded children whose biological mothers were not in the household listing and those who did not sleep
in the household last night for 2003. This insures that only the children from selected households are
measured. We could not follow this protocol for the 1998 DHS and the MICS surveys due to
questionnaire structure. However, inclusion of the excluded children in the 2003 DHS did not greatly
affect the nutritional estimates, changing them by less than a percentage point.
Challenges in measuring mortality and data quality assessment.
The aim of this section is to provide more detail on child mortality data in Ghana “high-impact” areas,
particularly as to the data quality and its likely impact on the estimates documented in the main report.
Figure 22 in the main part of the Ghana report shows mortality change by year for the “high-impact” (HID)
and national comparison area. While mortality appears to have declined in the HIDs from 1997 to 2006,
the comparison area is flat over the period 1997 to 2003 and projected as flat for the period since 2003.
With this large degree of uncertainty in mortality change in the national comparison area during ACSD
implementation, comparison between the two areas is problematic, and made more so by the large 95%
confidence limits around the HIDs yearly estimates.
Nevertheless, it is still necessary to assess mortality data quality for the HIDs. Is the nearly 20% U5MR
decline an actual decline or is it the result of non-sampling errors. A first step is to focus on the elements
included in table K1. This table is extensively used in DHS final reports to provide an assessment of data
quality (see for example the Ghana DHS 2003 report, page 284). The table naturally divides into three
parts.
The first part, on number of births, is used to identify any unexpected peaks or dips in the number of
living, dead or total births, and the right-most set of three columns in the table, headed Calendar year
ratio helps more easily identify these variations. If the number of births changed in the same direction by
the same amount each year, the value in these last three columns would be 100. The wider the
divergence from this smooth change in the number of births, the larger the divergence from 100. Table
K1 shows a wide variation around 100 – from 76 to 152.
Despite the detail provided by these data, a chart can provide a clearer picture. Figure K1 shows the
number of births by year from table A1 and highlights an issue that has become a common occurrence in
DHS – the shift of births from the 5-year period immediately before the survey data collection, to the
previous 5-year period.
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Table K1: Births by calendar year in Ghana "high impact" districts. Upper East region 2007
Number of births
Calendar
year
Living
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
2003-2007
1998-2002
1993-1997
1988-1992
<= 1991
All
Dead
423
397
443
451
405
357
477
423
430
426
2,120
2,113
1,765
1,346
1,060
8,403
Percentage with complete birth date¹
Total
10
29
32
35
59
43
52
50
57
50
165
252
285
270
345
1,317
Living
433
426
475
485
464
400
529
473
487
476
2,284
2,365
2,050
1,617
1,404
9,720
Dead
100
100
100
99.8
99.1
98.9
98.8
98.4
98.2
96.9
99.8
98.2
96.8
95.3
92
97.1
Sex ratio at birth²
Total
100
100
92.2
92.2
86.6
95
98.7
84.3
88.4
85.6
92
90.3
86.5
83.4
80.2
85.6
1
Both year and month of birth given
2
(Bm/Bf)x100, where Bm and Bf are the numbers of male and female births, respectively
3
[2Bx/(Bx-1+Bx+1)]x100, where Bx is the number of births in calendar year x
Living
100
100
99.5
99.3
97.5
98.5
98.8
96.9
97
95.7
99.2
97.4
95.4
93.3
89.1
95.5
Dead
89
109.3
95.7
93.2
115.1
116.4
125.6
96.2
116.6
122
99.6
115.1
93.4
113.2
109.5
105.2
Calendar year ratio³
Total
94.3
127
70.3
98.6
121
124
181.9
131
203
179.6
103.7
162.6
118
111.6
121.7
122.9
89.1
110.4
93.7
93.6
115.8
117.2
130.2
99.3
124.1
126.9
99.9
119.3
96.5
112.9
112.3
107.5
Living
104.6
106.2
100.4
81
122.2
93.3
101.2
103.6
-
Dead
Total
100.6
75.9
152.1
77.1
112.8
91.1
115.1
90.9
-
104.3
103.3
104.9
80.6
121.2
93.1
102.7
102.2
-
Figure K1: Births by calendar year in “high-impact” districts, Upper East region 2007
600
500
Births
400
300
Asked health questions for all children with birth in 2002 or later
200
Living
Dead
Total
100
0
1997
Jul 1998 - Dec 2001
1998
1999
2000
2001
Jan. 2004 - Jul. 2007
2002
2003
2004
2005
2006
2007
2008
Year
The primary cause of this shift of births has been ascribed to interviewers pushing births outside a period
where they have to ask many detailed questions about a child. For the MICS 2007 supplemental, this
period applied to any child born after 1 January 2002. The dip in births for 2002 is evident in figure A1, as
is the peak in 2001. The result of this can be a shift in mortality between the two 5-year periods used for
reporting U5MR by DHS. In general this appears to lead to a decrease in mortality for the 5-year period
immediately before data collection, and an increase in mortality for the preceding 5-year period – leading
to an estimated faster decline in mortality than is actually occurring.
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Unfortunately, while the endline period (January 2004 to July 2007) generates a smoothed average of the
mortality, the baseline period (July 1998 to December 2001) does not. The reason for this latter situation
is that the baseline period includes the peak of births in 2001, but not the dip in 2002.
However, the impact on child mortality of this unbalanced baseline period can be assessed by including
the annual estimates of U5MR. This is done in figure K2, where it can be seen that there is no significant
impact on the U5MR estimates by year. Furthermore, the baseline period provides a balanced average
across the small humps and dips of the annual U5MR.
The second part of table K1 contains the three sets of columns headed Percentage with complete birth
date. This shows that births with a complete birth date vary from 100% down to 84% over the ten-year
period from 1998 to 2007. Not having a complete birth date (month and year) increases the uncertainty
of the mortality estimates and hence one would like to have close to 100% of births with complete birth
dates. Respondents in Ghana and other countries in West Africa have difficulty in providing complete
birth dates, as can be see from a review of the comparable table in DHS reports in Benin and Senegal.
At the same, Ghana is not the worst of countries in West Africa in providing a complete birth date.
Figure K2: Births and U5MR by year in “high-impact” districts, Upper East region 2007
600
200
160
140
400
Births
120
300
100
80
200
60
Births
Living
Dead
Total
U5MR
40
100
U5MR (deaths per 1000 live births)
180
500
20
0
1997
Jan. 2004 - Jul. 2007
Jul 1998 - Dec 2001
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
0
2008
Year
However, month is the major missing part of the birth date. The implication is that mortality estimates for
multiple year periods should reduce the impact of missing month in the birth date.
The third part of table K1 is the three columns headed Sex ratio at birth. These are used to check, using
the last row of table, that the sex ratio of total births is around 105, as generally more males than females
are born. The sex ratio for those that have died should also be larger than the sex ratio for total births
since in general more males die than females. In addition, the table is used to assess variability by year.
In the latter case, there is a dip around 2005, to 70, and three noticeable peaks at 2001, 1999 and 1998
of 180 to 200. This suggests that the shift in births noted in figure K1 may also be associated with a
differential shift with respect to sex, and particularly in terms of deaths.
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However, table K2 shows that the periods used for calculating mortality (as delineated in figure A1) in
general provide an averaging of births and deaths data across the low and high sex-ratios. At the same
time the value of 171 for the ratio for those who have died in the baseline period is surprising high and
suggests that some female deaths may have been missed. Other than for this one exception, the periods
used in the ACSD evaluation in Ghana for estimating endline and baseline mortality, reduce the impact of
these sex-ratio variations.
Table K2: Sex ratios at birth by year in “high-impact” districts, Upper East region 2007
Sex ratio at birth*
Calendar year
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
All
Living
Dead
Total
89
109.3
95.7
93.2
115.1
116.4
125.6
96.2
116.6
122
105.2
94.3
127
70.3
98.6
121
124
181.9
131
203
179.6
122.9
89.1
110.4
93.7
93.6
115.8
117.2
130.2
99.3
124.1
126.9
107.5
Sex ratio, multi-years
L
96.3
D
95.1
T
96.2
113.9
171.2
118.8
* (Bm/Bf)x100, where Bm and Bf are the numbers of male and
female births, respectively
A conclusion from this section is that there are quality concerns with the mortality data from the highimpact areas, but that they are reduced by the selection of baseline and endline periods for calculation of
U5MR.
IIP-JHU | Retrospective evaluation of ACSD in Ghana
A95
APPENDIX L
References for Appendices
1.
FAO. Gateway to Land and Water Resources, Ghana obtained from:
http://www.fao.org/ag/agl/swlwpnr/reports/y_sf/z_gh/gh.htm#overview, accessed 10 August 2008.,
2004.
2.
U.S. Census Bureau. International Data Base - Country Summary: Ghana, 2008.
3.
Efem, I.J.-A., Caroline; Anemana, Sylvester; Addai, Edward; Awittor, Evelyn; Ankrah,
Victor. Report of the Review of the Accelerated Child Survival and Development Programme in the
Upper East Region of Ghana, Nov. 2004, 2004.
4.
Germer, J.S., Joachim. Climate at Valley View University. Stuttgart, Germany, University of
Hohenheim, 2008.
5.
Ghana Statistical Service (GSS) and Macro International Inc (MI). Ghana Demographic and
Health Survey 2003. Calverton, Maryland, GSS and MI, 2003.
6.
Aventis. K-O Tab Net Treatment Kit, ND.
7.
Republic of Ghana. Districts of Ghana, Republic of Ghana.
8.
Adjasi, C.D.K.O., K.A. Poverty Profile and Correlates of Poverty in Ghana. International Journal
of Social Economics. 34 (7): 22 (2007).
9.
United Nations Children's Fund. The State of the World's Children - Child Survival. New York,
UNICEF, 2008.
10.
Otupiri, E.O.-A., Rose. Health and Development Programs and Policy Mapping Exercise in
Upper East Region and the Rest of Ghana. Kumasi, School of Medical Sciences, Kwame Nkrumah
University of Science and Technology, 2007.
11.
UNICEF. Report of the Review of the Accelerated Child Survival and Development Programme in
the Upper East Region of Ghana, November 2004. Upper East Region, 2004.
12.
Abaseka, V. Annual Performance Review, 2004. Upper East Region, 2004.
13.
NA. A Brief Resume on ACSD Acitivies In Upper East Region. Upper East Region, 2006.
14.
UNICEF. In-House Annual Review (2004), 2004.
15.
NA. ASCD Annual Report: January-December 2005. Upper East Region, 2005.
16.
Abaseka, V. Annual Report of Activities of ACSD, January-December 2005. Upper East Region,
2005.
17.
UNICEF. In-House Annual Review (2005), 2005.
18.
Abaseka, V. Abaseka, V./2006. Upper East Region, 2006.
19.
NA. Report on Accelerated Child Survival and Development Meeting (ACSD) in Upper East
Region-3rd August 2006. Upper East Region, 2006.
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
20.
Abaseka, V. & Nsiire, A. Overview & Update on ACSD in UER. Upper East Region, 2004.
21.
Service, G.H. Annual Report 2005, Upper East Regional Health Administration 2006
22.
Service, G.H. Annual Report, 2004; Upper East Regional Health Administration (2005).
23.
Office, U.R.H. None (EPI Report). Upper East Region, 2004?
24.
GHS. Expanded Programme on Immunization, Ghana Health service EPI Annual Report - 2006
[Health Children Happy Nation!], 2007.
25.
NA. Achievements 2004. Upper East Region, 2004.
26.
Administration(?), D.H. Executive Summary (Annual Report). Upper East Region, 2004.
27.
Administration(?), D.H. None (Annual Report). Upper East Region, 2005.
28.
UNICEF. Final Progress/Financial Report; A Grant For Better Utilization of Immunization
Services; SC/2000/0329. Upper East Region, Northern Region, 2003.
29.
NA. A Report on Monitoring Visits of CIMI Agents, ND.
30.
NA. 2nd Report of KNUST Team on Implementation of Region-wide C-IMCI, UER. Upper East
Region, 2004.
31.
NA. Report on 2nd CBA Training in Half of Upper East Region. Upper East Region, 2004.
32.
NA. 5th Report of KNUST Team on Region-wide Impementation of C-IMCI, UER. Upper East
Region, 2004.
33.
NA. Report on Extension Staff Training Workshop Held at Bawku on 26-29 Oct. 2004, 2004.
34.
NA. IMCI Case Management Training, 2006.
35.
NA. Database For Community Based Volunteers and Midwives Upper East Region-2004, 2004.
36.
WHO. WHO Child Growth Standards: Methods and development: Length/height-for-age, weightfor-age, weight-for-length, weight-for-height and body mass index-for-age. Geneva, World Health
Organization, 2006.
37.
Ghana Statistical Service and Macro International, I. Ghana Demographic and Health Survey
(October 1999).
38.
Ghana Statistical Service, N.M.I.f.M.R.a.M.I., Inc. Ghana Demographic and Health Survey,
2003 September 2004.
39.
Bryce, J., Gilroy, K., Black, R.E., Jones, G. & Victora, C.G. A Retrospective Evaluation of the
Accelerated Child Survival and Development Project in West Africa; Inception Report. Baltimore, MD,
Johns Hopkins University Institute for International Programs, 2007
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APPENDIX M
Mapping of partners; activities in “High-impact” districts (Upper East
region) and nationally
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HEALTH AND DEVELOPMENT PROGRAMS AND
POLICY MAPPING EXERCISE IN UPPER EAST
REGION AND THE REST OF GHANA
School of Medical Sciences
Kwame Nkrumah University of Science and Technology
Kumasi, Ghana
December, 2007
IIP-JHU | Retrospective evaluation of ACSD in Ghana
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Health and development programs and policy mapping 1996­2007 This document is prepared by the School of Medical Sciences-Kwame Nkrumah
University of Science and Technology, Kumasi for the sole purpose of The Institute for
International Programs, based at Johns Hopkins University Bloomberg School of Public
Health, internal use. All information contained in this document may not be disclosed,
distributed or reproduced in whole or in part to any third party without the express
written permission of The Institute for International Programs.
Authors:
Dr. Easmon Otupiri and Ms Rose Odotei-Adjei
SMS-KNUST
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Health and development programs and policy mapping 1996­2007 CONTENTS
CONTENTS
3
ACKNOWLEDGEMENTS
5
LIST OF ACRONYMS AND ABBREVIATIONS
6
LIST OF TABLES AND FIGURES
10
EXECUTIVE SUMMARY
11
1. INTRODUCTION
1.1 Background Information
12
1.2 Country Profile
13
1.3 Objectives and Framework of Mapping Exercise
14
2. METHODOLOGY
2.1 Study Methods and Design
15
2.1.1 Desk Review
15
2.1.2 Key Informant Interviews
15
2.1.3 Field Work
15
2.1.4 Period of Mapping Exercise
15
2.1.5 Organization of Report
16
3. HEALTH AND DEVELOPMENT PROGRAMS UPPER EAST REGION
3.1 Profile of Upper East Region
17
3.2 Diocesan Health Services
19
3.3 Ghana Red Cross Society
22
3.4 World Vision International
23
3.5 Widows and Orphans Movement
26
3.6 Community Water and Sanitation Agency
26
4. HEALTH AND DEVELOPMENT PROGRAMS GHANA
4.1 Ghana Sustainable Change Project
28
4.2 Japanese International Cooperation Agency
30
4.3 United States Agency for International Development
31
4.4 Donor Support
34
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Health and development programs and policy mapping 1996­2007 4.5 World Health Organization
35
4.6 Opportunities Industrialization Centres
37
4.7 Department for International Development
38
4.8 Danish International Development Agency
38
4.9 Engender Health
40
5. CHANGES IN HEALTH POLICIES IN GHANA
5.1 Global and Regional Policies
41
5.2 National Policies
42
5.3 Health Sector Policies
43
5.4 Health Interventions and Programs
44
6. CONCLUSION
51
APPENDICES
List of Selected Reviewed Documents
52
Summary of Focus Group Discussions Results
54
Interview Schedule for Regional and National Level Agencies
55
Focus Group Discussion Guide for Groups in Upper East Region
56
Dummy Table for Mapping Exercise
58
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Health and development programs and policy mapping 1996­2007 ACKNOWLEDGEMENTS
SMS-KNUST would like to acknowledge the following individuals and organizations for their
support in the production of this report.
Non-Governmental Organizations and Communities – Upper East Region
Mr. Joseph Ayembilla
Diocesan Health Service, Bolgatanga
Mr. James Tobiga
Diocesan Health Service, Bolgatanga
Mr. Joseph Abarike Azumah
Ghana Red Cross Society
Ms. Benedicta Pielore
World Vision International
Ms. Betty Ayagiba
Widows and Orphans Ministry
Mr. Suleman Alhassan
Action Aid
Communities in Bongo district
Health Partners – Accra
Mr. Jacob Larbi
GSCP
Ms Comfort Yankson
GSCP
Mr. George Graves Woode
JICA
Ms. Julia A. Pwamang
USAID
Ms. Gregoria Dawson-Amoah
World Bank
Dr. Nana Ama Brantuo
WHO
Mr. Stanley Diamenu
WHO
Dr. Atubrah
OICI
Ms. Yvonne Agbesi
DFID
Ms. Helen Dzikunu
DANIDA
Mr. Marius DeJong
Netherlands Embassy
Ms Loretta Benton
EU
Ghana Health Service
Dr. K.O Antwi-Agyei
EPI
Dr. Isabella Sagoe-Moses
Child Health
Dr. Henrietta Odoi-Agyarko
Reproductive Health Unit
Ms. Esi Amoafo
Vitamin A programme
Ms Vida Abaseka
RHA – Upper East Region
Dr. Joseph Amankwah
Regional Director of Health – Upper East
Dr. K. Marfo
DDHS – Bongo District
Dr. Dodoo
DDHS – Bawku Municipality
Ms. Naa Kokor Allotey
NMCP
KNUST
Ms. Janet Asihene
Department of Community Health – SMS
Ms. Bibi Kaleem
Department of Community Health – SMS
Mr. Samuel Boateng
Department of Community Health – SMS
Dr. E.N.L. Browne
Department of Community Health – SMS
5
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Health and development programs and policy mapping 1996­2007 LIST OF ACRONYMS AND ABBREVIATIONS
ACSD
Accelerated Child Survival and Development
ACT
Atermisinin Combination Therapy
ADB
African Development Bank
ADP
Area Development Programme
AED
Academy for Educational Development
AIDS
Acquired Immune-deficiency Virus
AMCROSS
American Red Cross
ANC
Ante-natal Clinic
ARI
Acute Respiratory Infection
BCC
Behaviour Change Communication
BCG
Bacillus Chalmette Guerin
CBD
Community-based Distributor
CBGP
Community-based Growth Promotion
CD4
Cluster of Differentiation 4
CDD
Control of Diarrhoeal Diseases
CEDEP
Centre for the Development of People
CHPS
Community-based Health Planning and Services
CHPW
Child Health Promotion Week
CIDA
Canadian International Development Agency
C-IMCI
Community-Integrated Management of Childhood Illness
CND
Canadian Dollar
CRS
Catholic Relief Services
CSM
Cerebro-spinal Meningitis
CSO
Civil Society Organization
CWC
Child Welfare Clinic
CWSA
Community Water and Sanitation Agency
DANIDA
Danish International Development Agency
DDHS
District Director of Health Services
DFID
Department for International Development
DIS
Daily Immunization Services
DHMT
District Health Management Team
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Health and development programs and policy mapping 1996­2007 EMD
Epidemic Meningococcal Disease
EPI
Expanded Programme on Immunizations
EU
European Union
FBO
Faith-based Organization
GAIN
Global Alliance for Improved Nutrition
GAVI
Global Alliance for Vaccine and Immunization
GBP
Great Britain Pound
GDP
Gross Domestic Product
GFATM
Global Fund to fight AIDS, Tuberculosis and Malaria
GHS
Ghana Health Service
GPRS
Ghana Poverty Reduction Strategy
GRCS
Ghana Red Cross Society
GSCP
Ghana Sustainable Change Project
GSK
Glaxo SmithKline
GOG
Government of Ghana
HC
Health Centre
HIRD
High Impact Rapid Delivery
HIV
Human Immune-deficiency Virus
HRAP
Human Rights-based Approach to Planning
HSPS
Health Sector Programme Support
IEC
Information Education and Communication
ILO
International Labour Organization
IDSR
Integrated Disease Surveillance and Response
IMCI
Integrated Management of Childhood Illness
IMR
Infant Mortality Rate
IPTP
Intermittent Preventive Treatment in Pregnant Women
IPTI
Intermittent Preventive Treatment in Infants
ITN
Insecticide Treated Net
JHPIEGO
Johns Hopkins International Education Programme in Gyn & Obst
JICA
Japanese International Cooperation Agency
K-N
Kassena-Nankana
LSS
Life Saving Skills
MCH
Maternal and Child Health
MDG
Millennium Development Goal
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Health and development programs and policy mapping 1996­2007 MH
Maternal Health
MNH
Maternal and Neonatal Health
MoH
Ministry of Health
MSHAP
Multi-sector HIV/AIDS Project
MTHS
Medium Term Health Strategy
NEPAD
New Partnership for Africa’s Development
NGO
Non-Governmental Organization
NHIS
National Health Insurance Scheme
NID
National Immunization Day
NMCP
National Malaria Control Programme
OICI
Opportunities Industrialization Centres International
OPV
Oral Polio Vaccine
ORS
Oral Rehydration Salt
PLWHA
People Living with HIV/AIDS
PMTCT
Prevention of Mother-to-Child Transmission
POW
Programme of Work
RBM
Roll Back Malaria
RCH
Reproductive and Child Health
RH
Reproductive Health
RHA
Regional Health Administration
RHI
Rural Help Integrated
RED
Reaching Every District
SHARP
Strengthening HIV/AIDS Response
SMI
Safe Motherhood Initiative
SWAP
Sector-wide Approach
TBA
Traditional Birth Attendant
TT
Tetanus Toxoid
U5MR
Under-five mortality rate
UK
United Kingdom
UN
United Nations
UNAIDS
Joint United Nations Programme on HIV/AIDS
UNDP
United Nations Development Programme
UNFPA
United Nations Population Fund
UNICEF
United Nations Children’s Fund
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Health and development programs and policy mapping 1996­2007 US
United States
USAID
United States Agency for International Development
USD
United States Dollar
VCT
Voluntary Counselling and Testing
VIP
Ventilated Improved Pit
VLOM
Village Level Operated and Maintained
WATSAN
Water and Sanitation
WB
World Bank
WFP
World Food Programme
WHO
World Health Organization
WVI
World Vision International
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Health and development programs and policy mapping 1996­2007 LIST OF TABLES AND FIGURES
Table 2.1
Mapping exercise steps
Table 3.1
Trend in growth of health facilities and health centres in UER
Table 3.2
Diocesan health and development programmes (1998-06)
Table 3.3
GRCS health and development programmes (1999-06)
Table 3.4
World Vision International health and development programmes (1996-06)
Table 3.5
Community Water and Sanitation Agency Projects, UER (1973-2005)
Table 4.1
GSCP health and development programmes (1995-09)
Table 4.2
JICA health and development programmes (2003-07)
Table 4.3
USAID support for HIV/AIDS, child survival and nutrition (1998-07)
Table 4.4
USAID funded interventions in 30 target districts (2003-07)
Table 4.5
Donor support for health including HIV/AIDS (2003-07)
Table 4.6
Donor support for water and sanitation (2003-07)
Table 4.7
WHO health and development programmes (2003-07)
Table 4.8
OICI health and development programmes (2003-06)
Table 4.9
DANIDA health support (2003-07)
Table 4.10
DANIDA health funds for HIRD (2006)
Table 5.1
Immunization coverage in Ghana (1997-2006)
Table 5.2
Integrated Measles/Polo/Vitamin A/ITN Distribution Campaign 2006
Table 5.3
National Immunization Days 2005
Table 5.4
GAVI Immunization financing 2006-2010
Table 5.5
Major child nutrition-related projects in Ghana (1988-2010)
Table 5.6
Health policies and programmes in Ghana
Figure 3.1
Spot map of health institutions in Upper East Region, 2006
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Health and development programs and policy mapping 1996­2007 EXECUTIVE SUMMARY
This report presents the results of the Health and Development Programmes and Policy
Mapping Exercise in Upper East Region and the rest of Ghana which was conducted in JulyAugust 2007. The Report covers the period 1996-2007. Its aim was to provide data for an
external retrospective evaluation of the Accelerated Child Survival and Development (ACSD)
Programme in four countries of West Africa. The ASCD aims to reduce child mortality using cost
effective interventions, namely the Integrated Management of Childhood Illness (IMCI+),
Antenatal Care (ANC+) and Expanded Programme on Immunizations (EPI+) interventions.
The Mapping Exercise covered non-Governmental Organizations (NGOs) and Civil Society
Organizations (CSOs) involved in maternal and child health interventions in Upper East Region
and Health Development Partners and the Ghana Health Service at the national level. This
report presents data on the specific child health, reproductive health, maternal health, micro
credit and, water and sanitation interventions by the various agencies in the Upper East Region.
At the national level the Report provides data on policies and programmes by the Ghana Health
Service with nationwide coverage. It also includes a description of the activities and funding
provided by the health development partners to Ghana over the period 1996-2007. The main
data collection methods used were; interviews, focus group discussions and a review of
secondary data in the form of reports, newsletters and presentations.
In Upper East Region various agencies have implemented maternal and child health
interventions with varying degrees of coverage in terms of districts, communities and population.
Even though quite a number of such agencies were identified data were collected from the topfive performing agencies in terms of programme relevance and coverage. The Diocesan Health
Service provides static and outreach maternal and child health services through a hospital,
seven (7) health centres and many outreach points. The Ghana Red Cross Society which is
uniquely positioned as an auxiliary of the Ghana Health Service has implemented maternal and
child health interventions including a child survival project in three districts from 2000-2002. The
World Vision International focused its health and development programme in one district and
since 1996 has supported and or implemented maternal and child health interventions in
selected communities. The Community Water and Sanitation Agency has since 1994 provided
more than 2000 water points and nearly 600 latrines region-wide.
At the national level the Expanded Programme on Immunization, the Child Health Programme,
the Vitamin A Programme and the National Malaria Control Programme among others have
implemented various interventions designed to reduce the morbidity and mortality burden of
children under-five. Health development partners such as the United Nations Agencies, the
World Bank, and bi-lateral and multi-lateral agencies have all supported Ghana’s Health Sector
Programme. Some agencies provided support at the national level only while others supported
at the national level and provided support directly to some districts.
Ghana has been implementing almost the full range of cost-effective evidence-based maternal,
neonatal and child health interventions and this combined with an increasing expenditure on
health should have resulted in improved maternal and child health indicators for the country. If
there is evidence to demonstrate that the child health indicators for Upper East region are better
than the rest of the country and that the difference is significantly attributable to the ACSD
intervention then the health systems for delivery of the interventions evidenced to reduce the
morbidity and mortality burden in the rest of Ghana should be revised
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Health and development programs and policy mapping 1996­2007 1.0 INTRODUCTION
Even though Ghana has achieved commendable economic growth in recent years (GDP growth
rate at 6% in 2004 and 2005) the same cannot be said about the health gains in the country.
Health indicators that showed a steady improvement in the 1990s have stagnated and in some
instances have worsened in spite of the increased expenditure on health.
The 2006 Ghana Multiple Indicator Cluster Survey (preliminary report) reveals worsening of
infant rate (IMR) and stagnation of the hitherto worsening under-five mortality rate (U5MR) in
Ghana over the past eight years, even though these rates have been decreasing consistently
over the past two decades. The infant mortality rate has increased from 57/1000 live births (LB)
in 1998 to 64/1000 LB in 2003 to 71/1000 LB in 2006. Within the same period the under-five
mortality (U5MR) has increased from 108/1000 live births to 111/1000 LB. This presents a major
challenge to achieving the country’s targets for the 4th Millennium Development Goal (MDG 4).
1.1 Background
In 1998 the health status indicators for the Upper East Region were the worst in Ghana; the
infant and under-5 mortality rates in the Region were 82 and 155 deaths per 1,000 live births
respectively, while the corresponding national figures were 57 and 108 deaths per 1,000 live
births. The regional figures were marked by important district disparities. Malaria, diarrhoea and
acute respiratory infections (ARI) with malnutrition as an underlying cause are responsible for
most of the deaths. Since 1995, the United Nations Children’s Fund (UNICEF) in partnership
with the Ministry of Health/Ghana Health Service (MOH/GHS) has been working to reduce child
morbidity and mortality in Upper East Region in two target districts; Bawku East and Builsa. The
partnership provided child survival interventions such as immunization campaigns, promotion of
exclusive breastfeeding, vitamin A supplementation and, iron and folic acid supplementation at
antenatal clinics. The national traditional birth attendant (TBA) programme trained TBAs to
conduct safe delivery in the communities. Rural Help Integrated (RHI), a non-governmental
organization (NGO) based in the Region trained community-based distributors (CBDs), to
distribute family planning devices and also treat minor ailments in children and adults using
chloroquine for malaria, and oral rehydration salts (ORS) for diarrhoea, while referring serious
cases to health centres.
In spite of all these interventions the health status of children under-five remained poor and
access to health care was limited; the interventions were not reaching enough of those who
needed them most; the poor and vulnerable. Coverage of the key child survival interventions
remained critically low. There was need to introduce a more rationale-based integrated
approach that would use the tenets of human rights-based approach to programming (HRAP).
This would ensure active community involvement by using the triple ‘A’ construct (Assessment,
Analysis and Action) to get the interventions to reach the neediest.
West Africa is the region of the world with the highest maternal, neonatal and child mortality
rates. Large scale collaboration across 100 districts within 11 countries in West and Central
Africa began in 2002 with the aim of a phased approach to scaling up essential child health
interventions. Partnership was key – funded by the Canadian Government and initiated by
UNICEF, Accelerated Child Survival and Development (ACSD) involves the expertise and
partnership of multiple players, including governments and health ministries, the World Health
Organization (WHO), the World Bank, non-governmental organizations, NGOs and local
community leaders and members.
12
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Health and development programs and policy mapping 1996­2007 Through ACSD, effective interventions for children and pregnant women are bundled in an
integrated, cost-effective package including immunization of children and pregnant women,
micronutrient supplementation, breastfeeding promotion, supply of oral rehydration solution for
diarrhoea and insecticide-treated bed nets for protecting children and women from malaria. The
approach focuses on extending health coverage to underserved communities and using
community outreach efforts to deliver services and commodities closer to families. Outreach
services are also accompanied by programmes to educate families on home-based healthcare
practices for their children.
In 2000 UNICEF started implementing aspects of the Upper East Region ACSD project in
collaboration with the Ghana Government and with support from the Canadian International
Development Agency (CIDA), the MOH/GHS, the Ghana Red Cross (GRC) and the American
Red Cross (AMCROSS) in three districts (Bolgatanga, Bawku East and Bawku West). The main
objective was to use results-based planning techniques and evidence from other interventions
within Africa and in-country experience to increase coverage with three packages of high-impact
rapid delivery interventions known to reduce the morbidity and mortality burden in childrenunder-five and pregnant women. The focus was on EPI+ (vaccinations, Vitamin A
supplementation, ITN usage and deworming); ANC+ (IPTp, tetanus vaccination, Iron/folic acid
supplementation, ITNs usage and PMTCT) and IMCI+ (clinical and home management of
malaria, diarrhoea and ARI, community-based growth promotion and iodated salt usage). The
initial selected implementation was scaled-up to assume a region-wide dimension in 2002.
1.2 Country Profile
The Republic of Ghana located in West Africa is bordered on the north and north-west by
Burkina Faso, on the east by Togo, on the south by the Gulf of Guinea, and on the west by La
Côte d’Ivoire.
Formerly a British colony known as the Gold Coast, Ghana was the first majority-ruled nation in
sub-Saharan Africa to achieve independence, in 1957. The population of the country, according
to the 2000 Population census was 18,800,000. However current estimates in the year 2005,
put the population of Ghana at 21,946,000. The total area of Ghana is 238,500 km2 (92,090
miles2). The capital is Accra.
Ghana’s overall long-term vision for growth and development is detailed in the GHANA VISION
2020 document. The Medium Term Health Strategy (MTHS) Towards Vision 2020 articulates
the national health plan which has been made operational in three programmes of work (POW)
spanning five years each; POW I (1996-2001), POW II (2002-2006) and POW III (2007-2011).
The Ghana Poverty Reduction Strategy (GPRS I and II) provides broad policy directions to
guide the implementation of POW II and III in three key areas; bridging the equity gap, ensuing
sustainable financial arrangements for the poor and enhancing efficiency in the health system.
The policy thrust of each annual POW is informed by an assessment of the previous year’s
POW by joint independent Ministry of Health/Ghana Health Service/Health partner reviews with
external assistance. A number of sector-wide indicators have been developed to measure
performance. Total per capita health expenditure grew in 2005-6, by 40% in nominal and 26% in
real terms. Source of funding include public and donor sources, as well as user fees paid
through public facilities. Total health as a proportion of total government expenditure increased
from 12% in 2002 to 14% in 2005.
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Health and development programs and policy mapping 1996­2007 1.3 Objectives and Framework of the Mapping Exercise
1. To collect information about other health and development programs in districts in the
Upper East Region from 1999 to present, including the overall effort and geographical
coverage of these projects.
2. To collect information about other large-scale health and development initiatives in the
rest of Ghana from 1999 to present, including the overall effort and geographical
coverage of these projects.
3. To document changes in national and local health policies in Ghana from 1999 to
present that may have impacted child health and survival.
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Health and development programs and policy mapping 1996­2007 2.0
Methodology
2.1 Study Methods and Design
In general, the mapping exercise employed literature/secondary resources review, semistructured interviews, focus group discussions, observations and visual techniques such as
village mapping and transect walks. A sample interview guide for semi-structured interviews
with NGOs, programme managers of GHS and health development partners is included at the
end of this document.
2.1.1 Desk review
Information was gathered and analysed on child health, child health strategies and
programmes, IMCI, and the context in which reproductive and child health interventions are
implemented. The full list of documents reviewed is in the reference. The data gathered were
entered into a dummy table
2.1.2 Key informant interviews
Semi-structured interviews were conducted with programme managers, directors and
coordinators at headquarters, health partners and their collaborating agencies and the private
sector. The interviews were recorded either manually or with a digital voice recorder.
2.1.3 Field work
The Upper East region was visited. At the regional level key informant interviews were
undertaken with NGOs in reproductive and child health. At the community level, key informant
interviews involved community health officers, volunteers and community leaders, and focus
group discussions were done with men and women’s group separately with the view validating
the information gathered at the regional level. At the national level unstructed interviews were
held with health development partners, bi-lateral and multi-lateral donor agencies and program
managers of relevant units within the Ghana Health Service such as EPI, vitamin A, child health
and RBM.
All data collected were manually analyzed.
2.1.4 Period of mapping exercise
The major part of the mapping exercise took place from July 2 – August 13, 2007. Due to the
incomplete and sometimes outright paucity of information gathered a series of follow-ups are
on-going. Information gathering at the national level has been very challenging. Agencies,
health development partners and programme managers of the GHS were quite uncooperative in
many instances.
2.1.5 Organization of Report
The report starts with an introduction that captures the background to the report and gives an
account of the objectives for the mapping exercise. Chapter two states the methods used for
the data collection. Chapter three gives an account of the health and development programs in
Upper East Region dating 1996-2007. In Chapter four the health and development programs
undertaken by health development partners in Ghana are presented. Chapter five looks at the
health-related policies from the global angle to the national dimension. In Chapter six
conclusions are drawn based on the data collected.
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Health and development programs and policy mapping 1996­2007 Table 2.1: Mapping Exercise Steps
Area of Inquiry/Topic
1. Health and development projects in Upper
East region
•
•
a. Summarize interviews of personnel from the
Ghana Health Service, Diocesan Health Service,
Ghana Red Cross Society and World Vision
International.
b. Meet women’s groups and community-based
agents in communities region-wide
c. Undertake transect walks through selected
communities to observe evidence of interventions
(bore holes, clinics, services) by agencies.
•
•
Methodologies
July 2007, discuss tools with study
agencies
Study visit notes and reports
collected from agencies
Transcribe audio recordings of
interviews
Take digital pictures of some
respondents
Interviews
• Ghana Health Service
• Diocesan Health Service
• Ghana Red Cross Society
• World Vision International
• CWSA
• AfriKids
• Action Aid
• Rural Aid
• SYTO
• Action Child Mobilization
Focus Group Discussions
• Community-based volunteers and
mothers
Observation
• Evidence of interventions by NGOs
2. National Policies and Programmes
a. Meet and interview representatives of health
development partners
b. Meet and interview GHS programme
managers
3. Report Writing
Analysis
• Manual
• Send out letters to request
interviews with health development
partners and GHS programme
managers
• Late-July undertake interviews and
collect reports for study
• Transcribe interviews
• Initiate report writing
• Undertake follow-up to complete
gaps in information collected
• Early-August prepare initial draft
report
• Submit final draft report by end of
August 2007
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Health and development programs and policy mapping 1996­2007 3.0 Health and Development Programmes in Upper East Region (1996-2007)
3.1 Profile of Upper East Region
The Upper East Region is located in the north-eastern corner of the country between longitude 0°
and 1° West and latitudes 10° 30″N and 11°N. It has two international boundaries; namely
Burkina Faso to the north and the Republic of Togo to the East. Peoples of these three
countries share so much in common: language, socio-cultural and belief systems. There is
intense cross border movement of people, goods and services at these borders. The
challenges of disease surveillance and control in particular and health service delivery in
general arising out of this geo-physical and social cultural associations are enormous and often
overwhelming.
The Region lies within the meningitis belt of Africa. This belt is made up of 21 countries with a
population of 250 million in the age group 2- 29 years. This age group is the most vulnerable to
Epidemic Meningococcal Disease (EMD/CSM) epidemics. Focal outbreaks and sometimes
very widespread and devastating epidemics are commonplace events in the region each year.
The Region also lies within the savannah blinding onchocerciasis belt of West Africa. Before
the inception of Onchocerciasis Control Programme, blinding rates from onchocerciasis were as
high as 10% in some communities. Even though the disease is practically controlled, the flies
still pose serious nuisance to farming communities along the fertile river basins. In addition to
mass distribution of ivermectin to communities with residual infections, active epidemiological
surveillance is on-going for early detection of any recrudescence of the disease.
The other major characteristic features are:
• Surface area of the region is 8,842 sq.km (about 3.7% of the country), with:
• A short and scanty rainfall of about 800-900mm per annum followed by a long dry season
with dry harmattan winds and hot periods – 40o C.
• Population from 2000 census is 920,089 (this is about 4.8% of total population of country)
• Growth rate 1.1%
• Projected Population for 2006 is 982,510
• Density 110 people/sq.km, range 36 - 175 as compared to national average of 91
• Population is largely rural (87%).
• Settlement pattern is highly dispersed in 911 communities
• Five main languages are spoken in the region (Gurune, Kusal, Kasem, Buili and Bisa)
Road network
The Region has 1017 kilometres of feeder roads. Of this, 700 km representing 69% are
motorable and 317 km, representing 31% are certified as non-motorable. It has a total of 54.8
km of trunk roads. Of these 31.0 km is national road, 63.6 km is inter-regional and 173.3 km is
regional roads.
Safe water coverage
• In Bawku East - 55.62%
• Bawku West - 96.49%
• Bolgatanga - 39.25%
• Bongo - 59.40%
• Builsa - 74.02%
• Kassena-Nankana
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Health and development programs and policy mapping 1996­2007 Fig 3.1: Spot Map of Health Institutions, Upper East Region, 2006
&d
d
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&
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10
0
10
20 Kilom eters
Clinics
Distric t Hos pita ls
Health Ce nt res
Compl eted C HP S com po unds
Ñ Reg Ho spital
N ew dist sam .s hp
Baw ku Eas t
Baw ku W est
Bolga tanga
Bongo
Builsa
Garu-T em pane
Kass en a-N anka na
Ta lens i-N abdam
d
Ñ
Ñ
&
N
W
E
S
Source: Regional Annual Health Report, 2006
Table 3.1: Trend in Growth of Health Facilities and Health Centres in UER
Institution/Year
2002
2006
% Increase
Hospital
6
6
0.0
Health Centres
26
32
23.1
Clinics
46
47
2.2
Maternity Home Private)
2
2
0.0
CHPS
7
68
871.4
Training Institutions
4
5
25.0
Total
91
160
75.8
Source: Regional Annual Health Report, 2006
This mapping exercise identified six (6) leading CSOs/NGOs regionally but was able to capture
information from four (4). Of the two (2) from which information was not available, one (Rural
Help Integrated) which was very active in sexual and reproductive issues had folded up and the
other (Action Aid) had experienced such a high staff turnover that it was impossible to get their
records straight.
Rural Help Integrated was active in Bolgatanga, Bongo, and Builsa districts. It distributed
condoms, promoted family planning and provided home-based management of uncomplicated
cases of malaria and diarrhoea (in children and adults) with referral for severe cases through a
network of community-based distributors. The districts in which it operated recorded remarkable
increases in contraceptive acceptance and use. Rural Help Integrated handed its assets over to
18
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IIP-JHU | Retrospective evaluation of ACSD in Ghana
Health and development programs and policy mapping 1996­2007 the GHS and AfriKids (an NGO that supports street children). Action Aid has been involved in
reproductive health interventions region-wide. It has also provided hand dug wells in Bawku
West district and has funded interventions through other NGOs and agencies such the Widows
and Orphans Movement, the Ghana Red Cross Society and the Diocesan Health Service.
Action Aid funded the training and equipping of over 50 TBAs in various communities.
Information was collected from the Navrongo—Bolgatanga Diocesan Health Service of the
Roman Catholic Church, the Ghana Red Cross Society (Upper East Region), the Widows and
Orphans Movement and the World Vision International (Bongo Area Development Programme).
A quasi-governmental agency responsible for water and to some extent sanitation in small
towns and communities; Community Water and Sanitation Agency, was included in the mapping
exercise for Upper East region in view of the impact water and sanitation has on child survival.
3.2 Diocesan Health Service
The Navrongo-Bolgatanga Diocese of the Roman Catholic Church is one of the 18 archdioceses in Ghana. It covers 11 districts with a total population of 1.6 million spread over 885
communities in Upper East and Northern regions. The Diocesan Health Office provides static
and outreach services through one (1) hospital and seven (7) health centres and many outreach
points. The Health Office works in conjunction with the Catholic Relief Services.
Table 3.2: Diocesan Health and Development Programmes (1998-2006)
Year
1998
Intervention
RH (MNH)
1999
RH (MNH)
RH (MH)
CH
Activity
Skilled attendant
birth
Skilled attendant
birth
Indicator
at 110 deliveries
at 123 deliveries
ANC
CWC
4550 women
6998 children
District
Builsa, K-N,
Bongo
Bongo, Builsa
Bongo,
Builsa, K-N
Bongo,
Builsa, K-N
Community
Wiaga, Sirigu,
Biu
Kongo,
Wiaga
Kongo,
Wiaga,
Nakolo,
Zorko
Biu,
Kongo,
Nakolo
Wiaga, Zorko
2000
RH (HIV/AIDS)
RH (MNH)
Care and support for
PLWHA and orphans X
and
vulnerable
children
110 deliveries
Skilled attendant at
birth
RH (MH)
ANC
CH
5693
attendance
X
X
Bongo, Builsa
Nakolo, Zorko
Bongo, Builsa
Nakolo,
Zorko,
Kongo, Biu
Bongo,Builsa
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Health and development programs and policy mapping 1996­2007 CWC
2001
RH (HIV/AIDS)
2002
Skilled
birth
RH (MH)
ANC
attendant
at 541 deliveries
9697
attendances
2871
TT2 Immunization
Nakolo,
Zorko, Kongo
X
X
Bongo,
Builsa, K-N
Nakolo,
Sirigu,
Kongo,
Wiaga, Zorko,
Biu
Bongo,
Builsa, K-N
Bongo,
Builsa, K-N
Bongo,
Builsa, K-N
CH
CWC
15252
attendances
CH
EPI
BCG (2594), Bongo,
OPV
3 Builsa, K-N
(2765), DPT
3
(2719),
Measles
(3917)
RH/CH
Free
services
for
pregnant women and
children under-five
RH (MNH)
Skilled
birth
RH (MH)
ANC
CH
2003
2004
Health
education,
training of HIV/AIDS X
educators
RH (MNH)
RH (MNH)
8612
attendance
RH (HIV/AIDS)
CWC
attendant
at 292 deliveries
Nakolo,
Kongo,
Wiaga, Biu
Sirigu,
Kongo,
Wiaga, Zorko
Sirigu,
Kongo,
Wiaga, Zorko
Sirigu,
Kongo,
Wiaga, Zorko
Bongo,
Builsa,
K-N
Kongo,
Nakolo,
Sirigu, Wiaga,
Zorko
Bongo,
Builsa, K-N
Kongo,
Nakolo,
Sirigu, Wiaga,
Biu, Zorko
Bongo,
Builsa, K-N
Kongo,
Sirigu, Wiaga,
Zorko
9089
14059
NOT AVAILABLE
Support for orphans 500
and
vulnerable
children
Bongo,
Builsa,
Bawku East,
Bawku West,
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Health and development programs and policy mapping 1996­2007 Bolgatanga
857
RH (MNH)
Bongo,
Builsa, K-N
Skilled attendance at
birth
7304
RH (MH)
Bongo,
Builsa, K-N
ANC
19480
CH
Bongo,
Builsa, K-N
CWC
2005
RH (MNH)
Skilled attendance at 1053
birth
Bongo,
Builsa, K-N
RH (MH)
ANC
8204
Bongo,
Builsa, K-N
CH
Kongo,
Nakolo,
Sirigu, Wiaga,
Zorko
CWC
35390
Bongo,
Builsa, K-N
CH
C-IMCI training
20 staff
Bongo,
Builsa, K-N
WATSAN
Mechanized borehole
1
Bongo
RH(HIV/AIDS)
Support for PLWHA
and
orphans
and
vulnerable children
Kongo,
Nakolo,
Sirigu, Wiaga,
Zorko
Nakolo,
Sirihu, Wiaga,
Zorko
Biu, Kongo,
Nakolo,
Sirigu, Wiaga,
Zorko
Biu, Kongo,
Nakolo,
Sirigu, Wiaga,
Zorko
Biu, Kongo,
Nakolo,
Sirigu, Wiaga,
Zorko
Zorko
2006
RH (MNH)
WATSAN
HIV
awareness
creation
Skilled attendance at 1133
birth
Mechanized borehole
Bongo,
Builsa, K-N
1
Bongo
1/1
Bongo
Biu, Kongo,
Nakolo,
Sirigu, Wiaga,
Zorko
Nakolo
Health
systems Vehicle/ambulance
strengthening
Source: Field data, 2007
Zorko/Kongo
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Health and development programs and policy mapping 1996­2007 3.3 Ghana Red Cross Society, Upper East Region
The Ghana Red Cross Society (GRCS) seeks to serve humans and promote healthy living in
more deprived areas. The GRCS launched its first primary health care programme in 1974 at
Nsuopun (Western Region) when through women volunteers called mothers clubs it sought to
reduce morbidity and mortality in vulnerable children and mothers. Currently more than 500
mothers clubs are registered nationwide. In Upper East Region the GRCS is uniquely positioned
as an auxiliary of the Ghana Health Service. The American Red Cross (AMCROSS) supported
60 GRCS mothers clubs from 1999-2002 to implement a child survival project in three districts
(Bawku East, Bolgatanga and Bawku West that focused on;
Social mobilization for immunization
Nutrition and breastfeeding education
Acute respiratory infection recognition and prompt referral
Diarrhoea case management with ORS
Malaria prevention and home based care.
Table 3.3: Ghana Red Cross Society Health and Development programmes (1999-2006)
Intervention Activity
Indicator
District
Community
15000 children Bawku East,
47
CH
Child survival intervention;
Bawku West,
communities
health education
Bolgatanga
home-based management of
malaria
home-based management of
diarrhea
referrals for ARI
60
18097 children Bawku East,
Child survival intervention
2000 CH
Bawku West,
communities
(AMCROSS) through 60
Bolgatanga
mothers’ clubs (total
membership of 120 mothers)
Year
1999
WATSAN
Wells and Mozambican toilets
3 wells
3 Mozambican
toilets
Bawku East
and West,
Bolgatanga
CH
Child survival (EU) through 180
mothers’ clubs
Not available
145
communities
2001
MCH
Training in child survival
interventions
400 members
of mothers’
clubs
Bawku East
and West,
Bolgatanga
Bawku West
and East,
Bolgatanga
2002
2003
MCH
MCH
Child survival project ends
Basic care for women and
children project in rural
communities (EU)-training for
women
Bawku East
and West,
Bolgatanga,
Builsa, K-N,
Bongo
All (over
900)communit
ies within
Upper East
Region
2004
MCH
ACSD training
ACSD
1802 women
1802 women
200
communities
Bawku East
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Health and development programs and policy mapping 1996­2007 and West,
Bolgatanga,
Builsa, K-N,
Bongo
2005
2006
ACSD retraining
140 women
Bawku East
and West,
Bolgatanga,
Builsa, K-N,
Bongo
Health systems strengthening
Bicycles and
medicines
Bawku East
and West,
Bolgatanga,
Builsa, K-N,
Bongo
WATSAN
Well provision
1
Bolgatanga
MCH
ACSD
9750 mothers
Bawku East
and West,
Bolgatanga,
Builsa, K-N,
GaruTempane,
TalensiNabdam,
Bongo
MCH
Source: Field data, 2007
3.4 World Vision International – Bongo Area Development Programme
The World Vision International (WVI) developed the Area Development Programme (ADP) as a
strategy to implement a total development agenda for areas in greatest need. The Bongo ADP
began in 1996 with funding from World Vision Switzerland. The ADP has operated district wide
but with emphasis on three zones (sub-districts); Bongo-Soe, Beo-Adaboya and Bongo Central.
Year
199698
Table 3.4: World Vision International Health and Development Programs (1996-2007)
Intervention Activity
Indicator
District
Community
Bongo-Soe,
Bongo
3 centres
Construction of nutrition
CH
Bongo
rehabilitation centres
Central, Beo
Equipment supply for
supplementary feeding
600 pre-school
children
Logistics to DHMT for
CWC
10 weighing scales
10 hanging scales, 5
cradle scales 1438
children dewormed,
2850 children
Bongo
Adaboya
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Health and development programs and policy mapping 1996­2007 1999
CH
vaccinated
Bilhazia survey in
school children
Bongo
Construction of
rehabilitation centre
1
Bongo
Adaboya
Training on nutritional
management
150 lactating mothers
Bongo
Bongo Soe,
Adaboya
Bongo
Central
Training and logistic
support to DHMT
Equipment supply
Supplementary feeding ( a
lunch a day for school
children)
2000
CH
Supplementary feeding
(daily lunch for 10 nursery
and primary schools)
Training in child nutrition
2002
3 gas refrigerators, 8 Bongo
sphygmomanometers
80 mini bags of
beans, 131 mini bags
of rice, 370 mini-bags
of maize, 320L of
cooking oil to cover
5791 children
2000 children
Bongo
Bongo Soe,
Beo,
Adaboya
Bongo
1200 lactating
mothers and
pregnant women
26
Bongo
WATSAN
VIP toilet
Bongo
CH
Logistic support for 2
rounds of polio, BCG and
measles immunization
and vitamin A
supplementation
17822 children
Bongo
Training in child nutrition
1200 mothers
Bongo
Deworming
4420 children
Bongo
Supplementary feeding
(daily lunch FebruaryApril)
2000
Bongo
RH
HIV/AIDS education
998 youths
Bongo
MH
TBA skills training
10
Bongo
Gowire
Nayie,
Kunkwa
District-wide
District-wide
2003
Micro credit
CH
Basic health training
1614 women
Bongo
Support for women
Logistic support for 3 NIDs
450 women
76712 vaccinated
Bongo
Bongo
District-wide
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Health and development programs and policy mapping 1996­2007 MH
2004
Micro credit
CH
Daily lunch (April-July) in
10 schools
Training in maternal
nutrition
1325 children
Bongo
600 pregnant and
lactating mothers
Bongo
Financial support
Logistic support for NIDs
1800 women
64175 children
vaccinated against
polio
Deworming
17903
MCH
CH
WATSAN
2007
against polio in 3
rounds and vitamin A
given to 18952
HIV/AIDS educational
campaign
Best practices training
RH
2005
for polio immunization and
vitamin A supplementation
CH
RH
Bongo
District-wide
Bongo
District-wide
Bongo
20
communities
District-wide
160 volunteers
70 TBAs
Bongo
Training in child nutrition
640 mothers
Bongo
6 subdistricts
Logistic support for 3
rounds of NIDs
87,724 children
vaccinated
22905 dewormed
Bongo
District-wide
Malaria control
1449 ITNs to children
under-five
Bongo
District-wide
Water pump management
training
Training in child nutrition
122 people
Bongo
250 mothers
Bongo
Supplementary feeding
934 pre-schoolers in
8 nurseries
Bongo
Deworming
40000 children
Bongo
Training in safe delivery
55 TBAs
Bongo
6 zones
Training in maternal
health
1200 pregnant
women
Bongo
7 zones
100 women
Bongo
Micro-credit $ 1429 support for women
Bongo
Central,
Bongo Soe,
Beo,
Adaboya
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Health and development programs and policy mapping 1996­2007 Source: Field data, 2007
3.5 Widows and Orphans Movement – Upper East Region
The Movement started out as the Widows Ministries, then Widows and Orphans Ministries
before becoming a movement. The Movement promotes women’s and children’s rights through
advocacy and capacity building. The Movement provides training and financial support to
widows all over the Upper East Region. Currently 6865 widows are registered with the
Movement. The movement is present in other regions in Ghana
3.6 Community Water and Sanitation Agency
The Community Water and Sanitation Agency (CWSA) in Upper East region has been
facilitating the region-wide provision of water supply and sanitation to communities. CWSA was
established as a division of the Ghana Water and Sewerage Corporation in 1994. Water and
sanitation coverage for Region stands at 51.27% and 0.81% respectively.
Over the period 1994 to 2007 a total of 2 067 water point sources (boreholes and hand dug
wells) and eight (8) pipe-borne schemes have been provided by the CWSA with support from
various partners. A total of 75 institutional VIP latrines and 498 household VIP latrines were
provided throughout the Region during the same period.
Table 3.5: Community Water and Sanitation Projects, UER (1973-2005)
Intervention Activity
Indicator
District
Water
Boreholes fitted with hand
1 860
Region-wide
provision
pumps
(CIDA)
1979- Training
Education on maintenance and 1 000
1992
(CIDA)
management of water pumps
communities
1982- Training
Maintenance , repairs and
1 000
1988
(CIDA)
hygiene promotion
communities
Bolgatanga
50
1988- Training
Ownership and management
communities
1992
(UNDP)
of pumps
Year
19731981
19932000
Community
water
project
(CIDA)
20042005
WATSAN
(GOG)
20002004
Water
provision
(WB)
Installation of village level
operated and maintained
pumps
50
Bolgatanga
Hand pump mechanics
Animation of pump
communities
100
1 647
Bolgatanga
Region-wide
Borehole conversion to VLOM
1 602
Training of pump mechanics
Boreholes
3 204
68
Region-wide
VIP
Boreholes
4
500
Region-wide
Hand dug well with hand pump
4
Community
500
communities
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Health and development programs and policy mapping 1996­2007 Rehabilitation of water system
4
Bawku,
TalensiNabdam
K-N,
Builsa
Source: Field data, 2007
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Health and development programs and policy mapping 1996­2007 4.0 Health and Development Programmes in Ghana
4.1 Ghana Sustainable Change Project (GSCP)
The Ghana Sustainable Change Project (GSCP) is one of the leading NGOs which undertake
USAID funded projects. GSCP is active mainly in 30 districts spread across the seven (7)
southern regions in Ghana; Brong-Ahafo, Ashanti, Volta, Eastern, Western, Central and Greater
Accra.
Table 4.1: Ghana Sustainable Change Project Health and Development Programs (20052009)
Year
Intervention Activity
Indicator
Region
District
4 districts;
Western
2005- RCH
Family planning, HIV/AIDS
Ahanta West
(4 districts)
09
stigmatization and behaviour
Bibianichange communication and
Ahwiasomalaria control
Bekwai,
Juabeso,
Bia
13 districts;
Central
Abua-Asebu(13 districts)
Kwamankese,
Agona,
AjumakoEnyanEssiam,
AsikumaOdobenBrakwa,
KomendaEdinaEguafoAbirem,
Mfantsiman
Twifo-HemanLower
Denkyira,
Upper
Denkyira,
Assin North,
Assin South,
Awutu-EfutuSenya, Cape
Coast,
Gomoa,
Greater Accra (1) Dangbe West
Volta (5)
Kajebi,
Akatsi,
North Tongu,
28
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Health and development programs and policy mapping 1996­2007 South Tongu,
Nkwanta
Eastern (2)
Kwahu North,
Birim North
Ashanti (3)
Ahafo-Ano
South,
BosomtweAtwimaKwanwoma,
Amansie
West
Brong-Ahafo (2)
Asutifi,
Sene
2005
2006
Upper West,
Upper East,
Northern,
Greater Accra,
Eastern,
Brong-Ahafo
CH
Training in malaria
communication
100 health
staff
RH
Training in HIV/AIDS BCC
CH
Training in malaria
communication strategy
19 health
personnel
46 health
personnel
MCH
Training
750
personnel
from
NGOs,
CSOs
7 southern
regions
30 districts
RH
FP methods distribution
4 176 560
condoms
249 324
oral
contracept
ives
7 southern
regions
30 target
districts
Training in HIV/AIDS
communication
23 health
personnel
Training in HIV/AIDS stigma
reduction
268
members
of FBOs
and
Upper East,
Upper West,
Northern
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Health and development programs and policy mapping 1996­2007 NGOs
2007
RH
Training in social mobilization
Training on HIV/AIDS stigma
reduction
23
268
members
of FBOs
and
NGOs
Training in counselling skills
60 health
personnel
Source: Field data, 2007
4.2 Japanese International Cooperation Agency (JICA)
JICA is one of the leading health development partner agencies in Ghana.
Table 4.2 Japanese International Cooperation Agency Health and Development (2003-07)
Year
Intervention Activity
Indicator
Region
District
2003- RCH
Financial support to GHS
US $ 377 095.65
Eastern,
Birim North,
06
PPAG to run static and
Central
Amuano
outreach services –FP,
Praso
deliveries, child welfare
clinics
2004- CH
Funding for Parasite
Greater
Dangbe East
08
control project
Accra
Greater
1 district per
2004
RH
Equipment supply
2 CD4 counter
Accra,
region
machines,
Eastern
2 haemoglobin
analyzers +
reagents
2005- RH
HIV/AIDS control
Eastern,
6 districts,
09
Ashanti
4 districts
2005
CH
Financial support to GHS
US $ 170 000
National
National
for EPI
2006
2007
RH
Funding ITN retreatment
US $ 29 905
Upper West
Equipment supply
2 CD4 counter
machines, 2
haemoglobin
analyzers, 2
chemistry
analyzers +
reagents
Brong-Ahafo
US $ 49 000
US $ 170 000
National
National
EPI funding
CH
CH
Funding for EPI
Source: Field data, 2007
Sissala East,
Sissala West,
Lawra
Wenchi,
Dormaa
National
National
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Health and development programs and policy mapping 1996­2007 4.3 United States Agency for International Development (USAID)
USAID is currently committed to assist the Ministry of Health and the Ghana Health Service to
improve the health status of Ghanaians through the Strategic Objective Grant Agreement
Number Seven which covers the period 2003-2007. Over this period the USAID has provided
nearly US $ 20 000 000 annually in the form of technical assistance and other support to
Ghana.
USAID funded maternal and child health interventions through implementing partners in 30
target districts in the seven regions of southern Ghana (Brong-Ahafo, Eastern, Volta, Western
Central Ashanti and Greater Accra). The specific interventions include;
¾ family planning; training of providers, improving private sector marketing of
contraceptives and BCC at the community level
¾ newborn and neonatal care; immunizations
¾ hygiene improvement
¾ safe motherhood; strengthening health systems quality care interventions
¾ BCC interventions
¾ Scaling-up of proven cost effective clinical practices suitable for low-resource
settings
¾ Nutrition of mothers infants and young children
Year
1998
Table 4.3: USAID support for HIV/AIDS, Child Survival and Nutrition (1998-2007)
Intervention Activity
Indicator
Region
District
US $ 2995000
HIV/AIDS
RH
CH
Child survival
US $ 2412000
Nutrition
Micro nutrient
US $ 200000
RH
HIV/AIDS
US $ 3925000
CH
Child survival
US $ 3350000
Nutrition
RH
Micro nutrient
HIV/AIDS
US $ 500000
US $ 4025000
CH
Child survival
US $ 4350000
2001
Nutrition
RH
Micro nutrient
HIV/AIDS
US $ 1000000
US $ 4950000
2002
CH
RH
Child survival
HIV/AIDS
US $ 4010000
US $ 5500000
CH
Child survival
US $ 4300000
2003
RH
HIV/AIDS
US $ 8000000
2004
CH
RH
Child survival
HIV/AIDS
US $ 3600000
US $ 6300000
1999
2000
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Health and development programs and policy mapping 1996­2007 2005
CH
RH
Child survival
HIV/AIDS
US $ 3200000
US $ 9135000
2006
CH
RH
Child survival
HIV/AIDS
US $ 3200000
US $ 6255000
2007
CH
RH
Child survival
HIV/AIDS
US $ 2835000
US $ 6750000
CH
Child survival
Source: Field data, 2007
US $ 2986000
USAID’s target regions and districts are; Ashanti Region (Bosomtwe-Atwima-Kwanwoma,
Ahafo-Ano South and Amansie West districts), Brong-Ahafo Region (Sene and Asutifi districts),
Central Region (Abura-Asebu-Kwamankese, Agona, Ajumako-Enyan-Essiam, AsikumaOdoben-Brakwa, Assin North, Assin South, Awutu-Efutu-Senya, Cape Coast, Gomoa,
Komenda-Edina-Eguafo-Abirem, Mfantsiman, Twifi-Heman-Lower Denkyira and Upper Denkyira
districts), Eastern Region ( Kwahu North and Birim North districts), Greater Accra Region
(Dangbe West district), Volta Region (Kadjebi, Akatsi, North Tongu, South Tongu and Nkwanta
districts), Western Region (Juabeso, Ahanta West, Bibiani-Anhwiaso-Bekwai and Bia districts).
Table 4.4: USAID-funded Interventions in 30 target districts (2003-2007)
Project
Implementing partner
Sub-grantees
Region
District
30 target districts
Population Council
American College Seven
Communitytarget
of Nurse
based health
Midwives (ACNM) regions
planning and
services
Engender Health
Quality of care
Strengthening
HIV/AIDS
Response
(SHARP)
Quality Health
Partners/Engender
Health
Academy for
Educational
Development (AED)
Centre for the
Development of
People (CEDEP)
Abt Associates
30 target districts
JHPIEGO
Seven
target
regions
Initiatives Inc
Catholic Relief
Services (CRS)
Ashanti
(9 )
Adansi East,
Adansi West,
Adansi South,
Amansie East,
Amansie West,
Bosomtwe-AtwimaKwanwoma,
Kumasi
Obuasi
Offinso
Asuogyaman,
Fanteakwa,
Futures Group
Eastern
(9)
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Health and development programs and policy mapping 1996­2007 Kwaebibirim,
Kwahu South,
Yilo Krobo,
Manya Krobo,
Koforidua,
Akwapim South,
Suhum-KraboaCoaltar
Exp Momentum/
Group Africa
Manoff Group
CARE
Greater
Accra (3)
Accra,
Tema,
Ashiedu-Keteke
Western
(10)
Takoradi,
Sekondi,
Jomoro,
Amanfi East,
Amanfi West,
Nzema West,
Shama-Ahanta East,
Shama-Ahanta West,
Wassa West,
Mpohor-Wassa East
Volta (1)
Seven
target
regions
Ketu
30 target districts plus
29 SHARP districts
Ghana
Sustainable
Change Project
AED
Social
marketing of
ITNs
Netmark
Technical
assistance in
procurement
and logistics of
health
commodities
Demographic
and Health
Surveys
Hygiene and
sanitation
DELIVER
John Snow Inc
National
ORC Macro
Ghana Statistical
Service
National
All districts
Volta,
Ashanti,
Eastern,
Brong-Ahafo
60000
beneficiaries
in Upper
East, Upper
West and
Brong-Ahafo
Source: Field data, 2007
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Health and development programs and policy mapping 1996­2007 4.4 Donor support (bi- and multi-lateral) including The World Bank
The World Bank (WB) provides funding for health through the Sector-Wide Approach (SWAp)
which is a pooled funding mechanism that operates at the national level. Under the Health
Sector Support Project I the World Bank provided funding for health to the tune of US $ 35m
from 1998 to 2002. For the period 2005-2011 the Bank will support the national HIV/AIDS
programme with US $ 20m through the multi-sector HIV/AIDS Program (MSHAP). Specific child
health interventions by the Bank in the form of Community-based Growth Promotion can be
found in four (4) districts in as many regions; Komenda-Edina-Eguafo-Abirem district (Central
Region), Sewfi-Wiawso district (Western Region), Kadjebi district (Volta Region) and Bongo
district (Upper East Region). A total of 180 community-based growth promoters have been
trained in these districts.
Table 4.5: Donor-support for Health including HIV/AIDS (2003-2007)
2003
2004
2005
2006
Total (US $m)
104.31
174.10
180.18
165.12
Credit (US $m) 14.47
38.06
43.96
8.82
Grant (US $m)
89.84
136.03
136.21
156.30
World Bank
18.06
55.42
63.38
6.36
ADB
0
0
0
3.87
EU
1.04
0.64
5.77
0.15
Denmark
10.29
15.23
10.43
9.14
Japan
2.00
4.12
7.72
6.53
Netherlands
11.33
16.18
4.81
28.65
Nordic
Devp 0
0
1.04
0.11
Fund
Spain
0
15.00
0
0
UK
22.95
23.48
25.74
36.22
US
20.46
21.12
21.06
16.68
ILO
0
0.20
0.20
0.10
IOM
0
0
0.01
0.01
UNAIDS
0.57
0.41
0.28
0.26
UNFPA
3.50
3.50
3.50
4.50
UNICEF
4.14
7.57
8.18
18.30
UNDP
0.24
0.44
0.30
0.53
WFP
0.28
1.63
0.90
0.85
WHO
6.32
5.08
5.68
6.43
Global Fund
3.15
4.08
21.15
26.16
Source: Field data, 2007
Table 4.6: Donor support for Water and Sanitation (2003-2007)
2003
2004
2005
2006
Total (US $m)
53.07
44.81
59.21
75.15
Credit (US $m) 13.55
11.83
10.89
16.34
Grant (US $m)
39.52
32.99
48.33
58.81
World Bank
12.66
11.31
20.50
9.26
ADB
0
0
0.52
6.22
EU
1.05
0.75
8.90
0
Canada
1.31
1.30
1.73
2.95
2007
150.61
17.78
132.83
12.16
4.02
0
7.49
5.80
25.34
1.60
3.02
20.68
32.39
0
0
0.26
2.96
6.40
3.05
1.22
6.43
17.80
2007
84.62
29.63
54.99
25.64
8.47
16.00
1.58
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Health and development programs and policy mapping 1996­2007 Denmark
15.57
France
0.36
Netherlands
6.15
Nordic
Devp 0.80
Fund
Spain
10.00
UK
0.22
US
0.92
Source: Field data, 2007
14.01
1.68
8.24
0.08
11.60
2.16
7.86
0.40
11.94
6.60
20.73
1.53
12.61
0.01
0
6.13
0
0.84
1.47
0
0.73
1.34
0
10.90
1.65
3.02
3.66
1.30
4.5 World Health Organization
The World Health Organization (WHO) provides funding through the pooled funding mechanism
at the national level. Over the period 2003-2007 in addition to the funding at national level, the
WHO provided funding for some district-specific interventions; EPI, Outreach (child welfare
clinics) and Health System strengthening (review meetings, supervision and training) in selected
districts.
Table 4.7: WHO Health and Development Programmes (2003-2007)
Year
Intervention
Activity
Indicator
Region
Brong-Ahafo
EPI, Child Welfare Clinic
2003 CH
(1)
Training, Monitoring,
Health
Volta (4)
supervision, micro planning
system
strengthening
2004
CH
EPI, Child Welfare Clinic
CH
EPI, Child Welfare Clinic
Krachi,
North Tongu,
Kpando,
Jasikan
Ashanti (1)
Sekyere East
Western (1)
MpohorWassa West
Eastern (1)
Volta (4)
Kwahu North
Krachi,
North Tongu,
Jasikan,
Kpando
Brong-Ahafo
(1)
Nkoranza
Northern (2)
Bole,
Nanumba
Ashanti (2)
Amansie
East,
Sekyere East
Eastern (1)
Volta (4)
Kwahu North
Kpando,
Training, Monitoring,
Health
supervision, micro planning
system
strengthening
2005
District
Sene,
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Health and development programs and policy mapping 1996­2007 Krachi West
Jasikan,
Krachi East
Health
Training, Monitoring,
system
supervision, micro planning
strengthening
2006
CH
EPI, Child Welfare Clinic
Training, Monitoring,
Health
supervision, micro planning
system
strengthening
2007
CH
EPI, Child Welfare Clinic
Training, Monitoring,
Health
supervision, micro planning
system
strengthening
Ashanti (3)
Kwabre
Amansie
East,
Sekyere East
Northern (2)
Bole,
Sawla-TunaKalba
Brong-Ahafo
(2)
Northern (2)
Techiman,
Sunyani
Bole,
Sawla-TunaKalba
Volta (4)
AdakluAnyigbe
South Dayi,
Krachi East,
Tain
Ashanti (1)
AtwimaNwabiagya
South Dayi,
Jaskan,
Kpando
Volta (3)
Ashanti (2)
Ahafo-Ano
South
Eastern (1)
ManyaKrobo
Greater
Accra (3)
Source: Field data, 2007
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Health and development programs and policy mapping 1996­2007 4.6 Opportunities Industrialization Centres International (OICI)
OICI is one of the major implementing agencies for USAID-Ghana. OICI with support from
Counterpart International (US-based NGOs) undertook some reproductive and child health
programs from 2004 to 2006.
Table 4.8: OICI Health and Development (2003-2006)
Year
Intervention Activity
Indicator
Nutrition, training, BCC
2004
MCH
2005
2006
District
SaveluguNanton,
TolonKumbungu
Micro credit
Financial support to women in
agriculture
SaveluguNanton,
TolonKumbungu
CH
Community-based growth
promotion
MCH
Nutrition, training, BCC
SaveluguNanton,
TolonKumbungu
SaveluguNanton,
TolonKumbungu
Micro credit
Financial support to women in
agriculture
SaveluguNanton,
TolonKumbungu
CH
Community-based growth
promotion
MCH
Nutrition, training, BCC
SaveluguNanton,
TolonKumbungu
SaveluguNanton,
TolonKumbungu
Micro credit
Financial support to women in
agriculture
SaveluguNanton,
TolonKumbungu
CH
Community-based growth
promotion
SaveluguNanton,
TolonKumbungu
Community
Source: Field data, 2007
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Health and development programs and policy mapping 1996­2007 4.7 Department for International Development (DFID)
DFID of the United Kingdom has supported interventions of the GHS at the national level; DFID
provided UK £ 35 000 000 in the form of financial assistance and UK £ 5 000 000 through
technical assistance from 2002 to 2006. In 2006 DFID supported the purchase and distribution
of ITNs with UK £ 6 000 000. In 2007 DFID spent UK £ 2 500 000 to purchase and distribute
ITNs. Over 2007-2011 DFID plans to support the health sector with UK £ 50 000 000. DFID
funds health and development activities through the Netherlands embassy in Ghana.
4.8 Danish International Development Agency-Health Sector Support Office
The Danish Government has supported the health sector in Ghana through the Health Sector
Program Support run by the Danish International Development Agency (DANIDA). DANIDA
support has been packaged into 5-year phases which began in 1993. The data available covers
phase III (HSPS III) of DANIDA’s support to the health sector which spans the period 20032007.
The earmarked funding under the Danida Health Sector Programme Support has continued to
provide technical and financial assistance to areas of critical importance to the success of POW
II but which are difficult to implement or are at risk of being side-lined in a resource constrained
environment.
Right from the start of HSPS III, attempts were made to channel ear-marked funds through the
so-called “aid pool account”. Serious delays in the transfer of funds had negative impact on the
implementation of planned activities and subsequently most activities were funded directly from
the HSSO.
Year
2003
Table 4.9: DANIDA health support in 000 DKK (2003-2007)
Intervention
Activity
Indicator
3.52
Exemptions for the poor
Improving access
to health system
Risk sharing
arrangements
Strengthening
district health
system
Region
National
District
3.52
Management capacity
Quality of care
Enhancing partnerships
Incorporating key issues
on district agenda
Central level
initiatives
Regulation
0.23
Financial management
2004
Improving access
to health system
Policy development
Exemptions for the poor
5.17
National
Risk sharing
arrangements
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Health and development programs and policy mapping 1996­2007 Strengthening
district health
system
Management capacity
5.83
Quality of care
Enhancing partnerships
Incorporating key issues
on district agenda
Central level
initiatives
Regulation
2.31
Financial management
2005
Improving access
to health system
Policy development
Exemptions for the poor
5.17
National
Risk sharing
arrangements
Strengthening
district health
system
Management capacity
6.60
Quality of care
Enhancing partnerships
Incorporating key issues
on district agenda
Central level
initiatives
Regulation
2.31
Financial management
2006
Improving access
to health system
Policy development
Exemptions for the poor
1.76
National
Risk sharing
arrangements
Strengthening
district health
system
Management capacity
5.50
Quality of care
Enhancing partnerships
Incorporating key issues
on district agenda
Central level
initiatives
Regulation
1.76
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Health and development programs and policy mapping 1996­2007 Financial management
2007
Improving access
to health system
Policy development
Exemptions for the poor
1.762
National
Risk sharing
arrangements
Strengthening
district health
system
3.19
Management capacity
Quality of care
Enhancing partnerships
Incorporating key issues
on district agenda
Central level
initiatives
Regulation
1.76
Financial management
Policy development
Source: Field data, 2007
Year
2006
Table 4.10: DANIDA Health Funds for HIRD 2006
Intervention
Activity
Indicator
Funding for
Implementation of HIRD
US $1.360m
maternal and child interventions
health
US $ 1.275m
Region
Upper West
District
Region-wide
Northern
Region-wide
US $ 0.8075m Upper East
Region-wide
US $ 0.8075m Central
Region-wide
Source: Field data, 2007
4.9 Engender Health
Engender Health, an implementing partner of USAID, has a five-year project (June, 2004-May,
2008) on child health targeting 28 most deprived districts (USAID target districts) in seven
regions, excluding the three northern regions. The components of the programme are:
• Child survival focusing on the three components of IMCI but the community component
is integrated into CHPS;
• National level support especially in the development of standards and protocols for
quality improvement; and
• Regional level support, including capacity building, monitoring and supervision, provision
of equipment and minor renovation of buildings.
The project is demand-driven and intended to be aligned to the needs of beneficiaries.
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Health and development programs and policy mapping 1996­2007 5.0 CHANGES IN HEALTH POLICIES IN GHANA
This section includes data on global and regional policies (MDGs 4 and 5, NEPAD and Abuja
declaration) national policies (Ghana Vision 2020, Ghana Poverty Reduction Strategy, Medium
Term Health Strategy), heath sector policies (5-year programmes of work, child health policy,
reproductive health policy, drug policy, National Health Insurance, community-based health
planning and services), and interventions/programs (Roll Back Malaria, EPI, HIRD, SMI, IMCI,
HIV/AIDS and others.
5.1 Global and Regional Policies
5.1.1 Millennium Development Goals
In 2000, a millennium summit was held under the auspices of the United Nations (UN) at which
representatives from 189 countries committed themselves to sustaining development and
eliminating poverty. They set goals, targets and indicators to measure progress towards
achieving these goals by 2015. These goals became known as the Millennium Development
Goals (MDGs). Of the 48 indicators, 18 are directly related to health. The reference year is 1990
and Ghana is committed to achieving these goals.
To achieve the MDG 4 Ghana has to reduce U5MR from 111/1000 LB in 2003 to at least
40/1000 LB by 2015. More importantly, the rate of reduction should be at least the same as the
rate of fall between 1985 and 1990. Similarly the MMR has to be reduced from 214/100 000 LB
to 54/100 000 LB. At the current rate of reduction Ghana is unlikely to achieve MDGs 4 and 5.
5.1.2 International Conference on Population and Development (ICPD)
This conference was held in September 1994 in Cairo, Egypt. It led to the finalization of a
programme of action in the area of population and development for the following 20 years. The
20-year goals were spelt out in four related thematic areas; universal primary education before
2015, reduction of infant and child mortality below 35 per 1000 LB and 45 per 1000 LB
respectively by 2015, reduction of maternal mortality to levels where they no longer constitute a
public health problem and access to the complete range of sexual and reproductive health
services through the primary health care system by 2015.
5.1.3 Bamako Initiative
The Bamako Initiative was to commit nations to implement strategies designed to increase
essential drugs’ availability and other health care services for sub-Sahara Africa.
5.1.4 Abuja Declaration
In April 2000, an African Summit on Roll Back Malaria was held in Abuja, Nigeria. Forty-four of
the fifty malaria-affected countries in Africa were present. The nations committed themselves to
the principles and targets of the Harare Declaration of 1997 and to initiate appropriate and
sustainable action to strengthen health systems to ensure the achievement of certain targets
particularly related to malaria. Additionally they were to commit at least 15% of their GDP to
health. In 2005 and 2006 Ghana committed 14% of GDP to health.
5.1.4 New Partnership for Africa’s Development
African heads of states and presidents have pledged themselves to the duty of poverty
eradication on the continent. This pledge is captured in the New Partnership for Africa’s
Development (NEPAD). The leaders recognize the urgent need to place African countries on a
path of sustainable growth and development while participating actively in the world economic
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Health and development programs and policy mapping 1996­2007 and body politic. The goals outlined in NEPAD are the same as MDGs but add a goal to achieve
and sustain an average GDP growth rate of over 7% per anum for the next 15 years. Ghana is
signatory to NEPAD.
5.2 National Health Policies
5.2.1 Ghana Vision 2020
In 1995, Ghana launched a programme of economic and social development policies dubbed
“Ghana -Vision 2020”. This 25-year programme had as its long term goal to transform the
country’s economy from its present low-income status to that of a middle-income country by the
year 2020. In order to realize this vision, Vision 2020 looked at the 1990s level of social and
economic development as a benchmark against which future progress would be measured. In
addition, a medium term (1996-2000) objective to consolidate the foundations for accelerated
economic and social development in the long term was also launched. Vision 2020 had a health
component that sought to improve the health status of all Ghanaians through well articulated
strategies.
5.2.2 Medium Term Health Strategy
Based on the Vision 2020 document, the Ministry of Health (MoH) Ghana, published a Medium
Term Strategic document in September 1995, which detailed the development of the health
sector (health sector reform programme) in the medium term. To operationalize the Medium
Term Strategy Health Strategy (MTHS), MoH in consultation with the donor community, regional
and district level health management, identified the key medium term objectives set out in the
Strategy for their achievement. These formed the basis of the first in the series of Health Sector
5 Year Programme of Work (5YPOW I) which covered the period 1997-2001. Since then a POW
II has been implemented and currently Ghana is into the third in the series; POW III which will
span the period 2007-2011.
Each POW has set strategic objectives, targets to be achieved and sector-wide indicators to
measure progress. At the end of each year an assessment of the overall performance of the
health sector is undertaken and recommendations are put forward with the view to facilitate the
achievement of the strategic objectives.
5.2.3 Ghana Poverty Reduction Strategy I and II
The Ghana Poverty Reduction Strategy (GPRS I and II) is the Government of Ghana’s medium
term strategy for national development. The GPRS is the tool to ensure sustainable and
equitable growth, accelerated poverty reduction and protection of the vulnerable and
marginalized within a decentralized and democratic milieu.
For child health the GPRS places emphasis on the delivery of cost effective and high impact
interventions to reduce U5MR particularly in the four regions with the poorest indicators;
Central, Northern, Upper West and Upper East regions.
The POW represents the health sector’s response to the GPRS and aims to bridge the
inequalities in health in Ghana
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Health and development programs and policy mapping 1996­2007 5.2.4 Ghana Health Service
The establishment of the Ghana Health Service (GHS) as the operational wing of the MoH was
one of the major pillars acknowledged in the health sector reform process as described in the
Medium Term Health Strategy. The GHS was established under Act 525 of 1996 and it was
envisaged that its establishment and subsequent operationalization would contribute to the
delivery of a more equitable, accessible, efficient and responsive health system.
5.3 Health Sector Policies
5.3.1 Child Health Policy
In 1999 the MoH developed a comprehensive child health policy that targeted the management
of the six leading causes of mortality; malaria, pneumonia, measles, malnutrition, diarrhoea and
neonatal deaths. The Policy envisaged the reduction of U5MR from 66/1000 LB in 1997 to
50/1000 LB in 2001. The Policy identified five priority areas of action; improving neonatal health
care, prevention and control of growth and nutritional problems, prevention of and control of
infectious diseases and injuries, clinical care of the sick and injured child, and health related
interventions. The Policy was developed before the MDGs were set and is currently under
review to meet the challenges of the MDGs.
5.3.2 Reproductive Health Policy
This policy was first published in 1996. Its 2003 edition (2nd edition) has been reviewed but the
broad contents remain the same.
The components of reproductive health care services in Ghana are;
• Safe motherhood (antenatal, safe delivery, post-natal care including breast feeding and
infant health)
• Family planning
• Prevention and management of unsafe abortion and post-abortion care
• Prevention and management of reproductive tract infections including sexually
transmitted diseases and HIV/AIDS
• Prevention and management of infertility
• Prevention and management of cancers of female and male reproductive system
including the breast
• Responding to concerns about meno and andropause
• Discouragement of harmful traditional practices and gender-based violence that affect
the reproductive health of men and women
• Information and counselling on human sexuality, responsible sexual behaviour,
responsible parenthood, pre-conceptual care and sexual health
5.3.3 National Drug Policy
In 1992 Ghana operated a revolving drug fund (influenced by the Bamako Initiative) using
capital that had accumulated in health facilities through fees retention during the previous year.
A ‘cash and carry’ manual written in 1989 provided some guidelines on the operational aspect of
the Fund. Ghana revises its national drug policy, essential drug list and standard treatment
guidelines regularly to meet current demands. The latest revision was in 2004. Most of the
drugs for the management of common childhood illnesses are found in the List. The Policy does
permit the use of antibiotics by community-based agents to manage uncomplicated ARI in
children under-five.
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Health and development programs and policy mapping 1996­2007 An anti-malaria drug policy for Ghana was published with support from the Global Fund and
National Malaria Control Programme (NMCP) in 2004. This Policy introduced the use of ACT
and sulphadoxine-pyrimethamine for the management of uncomplicated malaria and IPTp
respectively.
5.3.4 The National Health Insurance Scheme
In the 60s a limited number of fees for specific hospital services were introduced. In 1985 GOG
introduced user fees for all medical services except specific communicable diseases. This was
complemented with a full cost recovery for drugs as a way of generating revenue to address
drug shortages.
Initially (1998) in order to reduce the financial barrier to accessing health services Ghana
operated an exemption policy for children under-five, pregnant women, the elderly and the poor.
Inadequate and very slow reimbursement limited its effectiveness.
In 2003, Act 650 was passed to govern the establishment of the National Health Insurance
Scheme (NHIS). Nearly 75 districts were supported to set up district-wide mutual health
insurance schemes and to initiate activities to recruit and register clients. It is envisaged that by
2009 every resident of Ghana should belong to a health insurance scheme. The NHIS is based
on equity, cross-subsidization, quality of care and community ownership. Children under-18 are
automatically covered if parents have paid at least the minimum contribution. Ghana has
experienced one of the fastest growing national insurance schemes worldwide in terms
coverage.
5.3.5 Community-based Health Planning and Services
Community-based Health Planning and Services (CHPS) is a strategy to provide cost-effective
and adequate quality basic primary health services to individuals and households at the
community level through engagement of the communities in the planning and delivery of
services. In began as a research project in the Kassena-Nankana district of Upper East region
which sought to address inequalities in the health system by mobilizing both community and
health services resources. In the medium term, MoH plans to deploy 1570 community health
officers (community health nurses) to various communities nation-wide by 2006. The idea was
that 80% of districts in Ghana would have completed CHPS implementation by 2006. Nationwide scale up began in 1998. The scale-up is far behind schedule.
5.4 Health Interventions and Programmes
5.4.1 Safe Motherhood Initiative
Safe motherhood-making pregnancy safer was adopted by Ghana in 1987. More than two
decades after launching SMI, maternal mortality is still a major public health problem in Ghana.
5.4.2 Traditional Birth Attendants
The concept of TBAs has been in Ghana for ages. In 1977, fifty-seven (57) TBAs were identified
and trained in a rural community near Accra. In 1989 USAID (five regions), UNICEF three
regions) and UNFPA (one region) sponsored a TBA training programme intended to
institutionalize national standardized training of TBAs in all regions of Ghana. TBA training has
been implemented under a number of different health projects for decades.
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Health and development programs and policy mapping 1996­2007 5.4.3 Roll Back Malaria
In Ghana malaria is the most common cause of morbidity and mortality in children under-five. In
1999 Ghana adopted the Roll Back Malaria (RBM) strategy to control malaria. The main pillars
of action were; use of insecticide treated nets (ITNs) and materials, intermittent preventive
treatment (IPTp) of malaria in pregnant women, effective management of cases and homebased management of fevers. In 2003, Ghana received support from the Global Fund to fight
AIDS, tuberculosis and malaria (GFATM) to energize her roll back malaria activities. Twenty
(20) districts were selected nationwide to pilot the Global Fund initiative. An important
component of the initiative was the training of community-based agents who promoted malaria
control at the household level through health education, sale and retreatment of ITNs and
referral facilitation. In some districts these agents were trained to monitor and report adverse
effects in pregnant women who had received IPTp using sulphadoxine pyremethamine at the
facility level. Currently Ghana uses ACT for the treatment of uncomplicated malaria.
Substantive ITN distribution began in 2003 gradually increasing from about 150 000 nets
annually to over half a million in 2005. Late in 2006 the first large scale of long-lasting
insecticide treated nets was undertaken with assistance from UNICEF and DFID; over 2.1
million nets were distributed free of charge as part of the integrated measles/polio/vitamin A/ITN
distribution campaign. The Global Fund now covers all districts in Ghana.
5.4.4 Expanded Programme on Immunization
The Expanded Programme on Immunization (EPI) was introduced in 1978. Since 1985 it is
operational in all districts and focused on immunization against tuberculosis, diphtheria,
neonatal tetanus, pertussis, acute poliomyelitis, measles and yellow fever. It took the form of
mass immunization till 1999 when the weaknesses of this approach were observed. A mix
strategies including; national immunization days (NID) daily immunization services (DIS), child
health promotion week, outreach, mop up, visit to island and lake communities (extremely hard
to reach), reaching every district (RED), monitoring for action, supportive supervision, support to
districts and addressing system-wide barriers were used to improve coverage. Immunization
against Haemophilus influenza type B (Hib) and hepatitis B (HepB) were introduced in 2002.
Table 5.1: Immunization coverage in Ghana 1997-2006 (%)
Antigen
1997 1998
1999
2000
2001
BCG
70
77
85
94
91
OPV3
X
X
X
82
80
Measles
57
67
71
84
82
Yellow fever
41
41
64
74
76
TT2+
X
X
X
73
61
DPT/Penta 3
56
68
73
84
76
Source: EPI Ghana, 2007
2002
97
79
85
71
68
79
2003
93
76
80
73
66
76
2004
92
76
78
76
62
76
2005
100
85
83
82
71
85
2006
100
84
85
84
69
84
In 2004 three rounds of maternal and neonatal tetanus campaigns were undertaken in 13
districts, in 2005 a similar campaign was organized in 27 districts and in 2006 another 27
districts benefitted from the campaign.
In 2005 a supplementary measles immunization activity (a catch-up campaign) was carried out
nationwide for children aged 9 months – 15 years. In 2006 a follow-up measles campaign was
carried out nationwide as part of an integrated measles/polio/vitamin A/ITN distribution
campaign for children 9 months – 15 years.
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Health and development programs and policy mapping 1996­2007 Table 5.2 Integrated Measles/Polio/Vitamin A/ITN Distribution Campaign 2006
Antigen/service provided
Coverage (%)
Measles
79
Polio
84.6
Vitamin A
84.3
ITN distribution
92.3
Source: EPI Ghana, 2007
National Immunization Days have been observed in Ghana for years. In 2005, four (4) rounds of
synchronized polio NIDs were organized nationwide in two phases. Vitamin A supplementation
was integrated in two (2) rounds of the polio NIDs while deworming was added to the campaign
in Northern and Upper East regions during the two phases.
Table 5.3: National Immunization Days 2005
PHASE I
Round
Antigen/service
Round 1
OPV
Mebendazole
Round 2
OPV
Vitamin A
PHASE II
Round
Antigen/service
Round 1
OPV
Vitamin A
Round 2
OPV
Mebendazole
Source: EPI Ghana, 2007
Coverage (%)
104.8
101.7
104.4
94.5
Coverage (%)
103.8
101.3
107.9
104.9
The Global Alliance for Vaccine Initiative (GAVI) has been supporting EPI in Ghana.
Table 5.4: GAVI Immunization Financing (2006-2010) US$
2006
2007
2008
Finance
4 466 413
6 893 500
11 506 211
Source: EPI Ghana, 2007
2009
11 803 898
2010
12 092 671
5.4.5 High Impact Rapid Delivery Interventions
The high-impact, rapid-delivery and sustainable approach is a strategy for scaling-up maternal
and child survival interventions in Ghana. The approach is based on the, MoH’s CHPS model,
the IMCI strategy, Safe Motherhood Initiative and the ACSD approach. These four approaches
have several common elements and complement one another. Some of the common elements
are a focus on primary level high-impact, cost-effective interventions that address major causes
of childhood deaths, use of community development approaches to extend service delivery
rapidly, broad partnerships, and extensive planning at the micro level. In line with
recommendations from the Ghana Health Summit (2004) an inter-sectoral approach will be
adopted for strengthening the capacity of communities by using sound communication
strategies and involving other ministries departments and agencies (such as Department of
Community Development, NGOs and CBOs) that have comparative advantage in this area.
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Health and development programs and policy mapping 1996­2007 5.4.6 Integrated Management of Childhood Illness
In 1998, Ghana adopted IMCI as a key strategy for reducing U5MR and developed a strategic
plan (2002-2006) with a goal to reduce morbidity and mortality due to major causes of diseases
in the under-five and ensure healthy growth and development of children. The objectives of the
policy are:
• 60% of first level health facilities have at least one staff trained in IMCI;
• 80% of prescribers correctly prescribe anti-malaria drugs for U5 children;
• 60% of health workers correctly assess children for danger signs;
• 80% of health workers correctly assess children for three main symptoms of cough,
diarrhoea and fever; and
• 50% of mothers/care givers of U5 children reporting to health facilities know the three
rules of home care: give extra fluids, continue feeding and when to return.
A national IMCI orientation meeting recommended that IMCI should provide technical and
advocacy support. IMCI was initially piloted in four districts (Ga, Atwima-Nwabiagya, ManyaKrobo and Tolon-Kumbungu) and planned to be scaled up to 30 districts by 2004, 60 districts by
2005 and 90 districts by 2006. IMCI is one of the priority interventions identified under the
second POW - 2002 – 2006.
Collaboration between IMCI and Roll Back Malaria (RBM) started at the African Regional level
in 1996, and has since expanded to operations at country level. In Ghana, there has been
collaboration between the two programmes in case management training, home-based care,
and Information, Education and Communication (IEC) among others. In November 2001, the
MoH/GHS took the RBM-IMCI partnership a step further by involving other programmes –
Expanded Programme on Immunisation and Integrated Disease Surveillance and Response
(IDSR). The MOH/GHS in collaboration with WHO developed a proposal to integrate service
provision, monitoring and evaluation of these interventions in 10 selected districts. These
districts have therefore been designated as the districts of focus for the programme
interventions in the IMCI, Malaria (RBM), EPI and IDSR.
At present 62 out of the 138 districts have at least one health staff trained in IMCI, which falls
short of the World Health Organisation’s requirement that 60% of all prescribers from 80% of
districts should be trained in order to make an impact.
5.4.7 Community-based Growth Promotion
Community-based growth promotion was piloted in three districts (Tolon-Kumbungu, Atwima
and Manya Krobo) in 2001. The World Bank, GSK, WVI and Plan Ghana have supported the
implementation of CBGP in 40 other districts. The initiative is to be scaled up in 65 districts as
part of the Nutrition and Malaria Control for Child Survival Project.
5.4.8 Community-based Surveillance
The community-based surveillance system was piloted in the Northern region in 1988 as an
expansion of the village volunteers surveillance system (of the 1970s) as part of the Guinea
worm eradication programme. The System has seen many modifications in different regions of
the country and some of the regional variations are observed in terms of actual coverage,
quality surveillance, supervision of volunteers and the use of data generated by the volunteers.
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Health and development programs and policy mapping 1996­2007 5.4.9 Nutrition and micronutrient deficiency
Priority actions undertaken to control under- and malnutrition are increased awareness on
nutrition to improve child feeding practices, promotion and management of the malnourished
child and prevention of micronutrient deficiencies such as iron, vitamin A and iodine deficiency.
A number of initiatives have been introduced:
• Infant and young child feeding strategy;
• Community based nutrition and food security project;
• Supplementary feeding programme;
• Iodine deficiency disorders control programme; and
• Vitamin A deficiency control programme.
Table 5.5: Major Child Nutrition-related Projects, Ghana (1988-2010)
Funding Source
Project Title
Amount
World Bank
Health Sector Support USD 35m
Project (1988-2002)
Ghana AIDS Response USD 25m
Project (2002-2005)
USD 1.8m
Community-based
Poverty
Reduction
Project – Nutrition and
Food
Security
Component
(1999
–
2003)
POW II (2003-2006)
USD 57.6m (credit)
USD 32.4m (grant)
MSHAP (2002-2010)
USD 20m
Community-based Rural USD 60m
Development
(20042008)
Multi-lateral
Micro-nutrient Deficiency UNICEF: 5.85m
(2006-2010)
Agencies
Control
High
Impact
Rapid GAIN: 1.80m
(2006-2008)
Delivery
Child Survival
Bi-lateral Agencies Community-driven
CND 12m
Initiatives
in
Food
Security (2005-2010)
District Capacity Building CND 5m
Project (2001-2005)
School
Feeding
and USD 8.426m
Nutrition Education
CBGP
GBP 0.221
RBM
Round 4: USD 38.8m
Round 2: USD 8.8m
Source: Field data, 2007
Implementer
GOG
GOG
GOG
GOG
GOG
GOG
UNICEF/WFP/WHO/
GAIN
CIDA
CIDA
WFP
USAID/GHS/GSK
GFATM
5.4.10 Integrated maternal and child health campaign
In 2007, the GHS launched the nationwide Integrated maternal and child health campaign. The
target population was pregnant women and children 1 year or below. The Campaign involved
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Health and development programs and policy mapping 1996­2007 TT and long-lasting insecticide-treated nets (LLINs) for pregnant women while children 1 year or
below received; OPV, dewormer (children 24-59 months), vitamin A (children 6-59 months), ITN
and birth registration. Lactating mothers (up to eight weeks post-partum) received vitamin A
supplementation if they had not already received it.
5.4.11 Child Health Promotion Week
The Child Health Promotion Week Celebration (CHPW) was instituted in 2004 by the Ghana
Health Service to create and sustain awareness of the many services available in the health
system to promote the healthy growth and prevention of common childhood conditions in
children under five years. It was also to sensitize the general public on the importance of Births
and Deaths Registration. In view of this, the Ghana Health Service dedicated the second week
of May every year for the celebration of CHPW. This celebration has contributed immensely in
creating awareness of the many services available as well as improving access to these
services. It contributed to improving routine EPI coverage.
Table 5.6: Health policies and programs in Ghana
Year
Health policy
Target
Implemented
in Ghana?
Global/Regional Health Policies
1987
Bamako Initiative
1994
International
Population-wide
Conference
on
Population
and Reproductive health
Yes
Yes
Development Cairo
2000
Abuja Declaration
Population-wide
Yes
2000
Millennium Development Goals 4 and 5
Maternal and child Yes
health
2001
New
Partnership
for
Africa’s
Development Population-wide
Yes
(NEPAD)
National Health Policies
1995
Ghana Vision 2020
Population-wide
1995
Medium Term Health Strategy
Population-wide
1996
GHS Act 525
Population-wide
2002-2005
GPRS I
Population-wide
2006-2009
GPRS II
Population-wide
Health-sector policies
1997-2001,
5-year programmes of work I, II, III
Population-wide
CHPS
Population-wide
2002-2006,
2007-2011
1998
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Health and development programs and policy mapping 1996­2007 1996
Reproductive health
Population-wide
1989
National Drug
Population-wide
2003
National Health Insurance Scheme
Population-wide
Health Interventions/programmes
1987
1999
Safe Motherhood Initiative
Maternal health
Traditional Birth Attendants
Maternal health
NMCP-Roll Back Malaria
Maternal and child
health
1978
Expanded Programme on Immunization
Child health
2004
High Impact Rapid Delivery
Maternal, neonatal
and child health
1998
IMCI
Child health
2000
CBGP
Child health
1970
Community-based surveillance
Population-wide
1998
Integrated disease surveillance and response
Child health
2000
PMTCT/VCT
Maternal
and
neonatal health
2007
Nutrition and micronutrient deficiency
Child health
Integrated maternal and child health campaign
Maternal and child
health
2004
Child health promotion week
Child health
Source: Field data, 2007
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Health and development programs and policy mapping 1996­2007 6.0 Conclusion
Ghana has been implementing almost the full range of cost-effective evidence-based maternal,
neonatal and child health interventions and this combined with an increasing expenditure on
health should have resulted in improved maternal and child health indicators for the country. If
there is evidence to demonstrate that the child health indicators for Upper East region are better
than the rest of the country and that the difference is significantly attributable to the ACSD
intervention then the health systems for delivery of the interventions evidenced to reduce the
morbidity and mortality burden in the rest of Ghana should be revised to include systems that
would increase coverage to 90-99%. It would prudent to increase coverage so that those who
need the interventions most (the poor and vulnerable) and who ultimately determine the rate of
improvement in maternal and child health indicators are adequately covered so that Ghana can
achieve MDGs 4 and 5.
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Health and development programs and policy mapping 1996­2007 Appendix 1: SELECTED REVIEWED DOCUMENTS
1. DANIDA (2006) Health Sector Programme Support Annual Report 2005
2. DANIDA (2007) Health Sector Programme Support Annual Report 2006
3. Ghana Health Service (2006) Expanded Programme on Immunization Annual Report
2005. Accra
4. Ghana Health Service (2007) Expanded Programme on Immunization Annual Report
2006. Accra.
5. Ghana Red Cross Society-Upper East Region (2001) Annual Report 2000
6. Ghana Red Cross Society-Upper East Region (2002) Report on Child Survival Project
2000-2001
7. Ghana Red Cross Society-Upper East Region (2003) Annual Report 2002
8. Ghana Red Cross Society-Upper East Region (2004) Annual Report 2003
9. Ghana Red Cross Society-Upper East Region (2006) Annual Report 2005
10. Ghana Red Cross Society-Upper East Region (2007) Annual Report 2006
11. GHS (2002) Annual Review 2001
12. GHS (2003) Programme of Work 2004
13. GHS (2003) Reproductive and Child Heal Unit Annual Re port 2002
14. GHS (2003) Review of Health Sector Programme of Work 2002
15. GHS (2004) Main Sector Review 2003
16. GHS (2004) Policies and Priorities for 2005
17. GHS (2004) Review of Health Sector Programme of Work 2003
18. GHS (2005) Community-based Surveillance in Ghana
19. GHS (2006) Annual Report 2005
20. GHS (2006) Expanded Programme on Immunization Annual Progress Report
21. GHS (2006) Facts and Figures 2005
22. GHS (2006) Programme of Work 2007
23. GHS (2007) Review of Health Sector Programme of Work 2006
24. GHS (2007) Upper East Region Annual Report 2006
25. GHS 5-year Programmes of Work (I II and III)
26. GOG Ghana Poverty Reduction Strategy I and II
27. GSS/MOH/ORC Macro (2003) Ghana Service Provision Assessment Survey 2002
28. GSS/NMIMR/ORC Macro (2004) Ghana Demographic and Health Survey 2003.
Calverton, Maryland
29. JICA (2007) Health Interventions in Ghana 1999-2006
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Health and development programs and policy mapping 1996­2007 30. MOH (1995) Medium Term Health Strategy
31. MOH (1999) Policy and Strategies for Improving the health of Children under-five in
Ghana
32. MOH (2000) IMCI Strategic Plan for Ghana 2002-2006
33. MOH (2000) Roll Back Malaria Strategic Plan for Ghana
34. MOH (2006) C-IMCI Annual Report 2005
35. MOH (2006) Directory of Policies, Standards and Guidelines
36. Navrongo-Bolgatanga Diocese (2001) Annual Report 2000
37. Navrongo-Bolgatanga Diocese (2002) Annual Report 2001
38. Navrongo-Bolgatanga Diocese (2003) Annual Report 2002
39. Navrongo-Bolgatanga Diocese (2004) Annual Report 2003
40. Navrongo-Bolgatanga Diocese (2005) Annual Report 2004
41. Navrongo-Bolgatanga Diocese (2006) Annual Report 2005
42. Navrongo-Bolgatanga Diocese (2007) Annual Report 2006
43. The Abuja Declaration (extract from the Africa Summit on RBM Abuja 2000
44. UNDP (2005) MDG Report Ghana 2004
45. UNICEF/USAID/MICS/GSS (2007) Multiple Indicator Cluster Survey Preliminary Report
46. WHO (2002) First Two Years of IMCI Implementation in Ghana
47. WHO (2004) IMCI documentation; progress, experiences and lessons learnt
48. WHO/UNICEF (2006) Review of National Immunization Coverage Ghana 1980-2005
49. World Bank (2003) Ghana Health Sector Programme Support Project II
50. World Vision International (1998) Bongo ADP Annual Report 1997
51. World Vision International (2000) Bongo ADP Annual Report 1999
52. World Vision International (2001) Bongo ADP Annual Report 2000
53. World Vision International (2001) Bongo ADP Mid-Term Evaluation Report
54. World Vision International (2002 Bongo ADP Annual Report 2001
55. World Vision International (2003) Bongo ADP Annual Report 2002
56. World Vision International (2004) Bongo ADP Annual Report 2003
57. World Vision International (2005) Bongo ADP Annual Report 2004
58. World Vision International (2006) Bongo ADP Annual Report 2005
59. World Vision International (2007) Bongo ADP Annual Report 2006
60. World Vision International (2007) Bongo ADP Profile 2006
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Health and development programs and policy mapping 1996­2007 Appendix 2: Summary results from Focus Group Discussions of mothers in five
communities in Bongo district
1. What proportion of children under-five do you think receive the following interventions or
experience the following?
a. Vitamin A capsules (80%)
b. Exclusive breast feeding (30%)
c. Iodized salt (2%)
d. Pneumonia treatment with antibiotics (60-70%)
e. Measles vaccination (80%)
f. Oral rehydration Salt for diarrhoea (60-70%)
g. Penta 3 vaccination (60%)
h. Skilled attendance at birth (70%)
i. Die before the first month of life (20%)
j. Die before the first year of life (30%)
k. Sleep under ITN (70%)
l. Are low birth weight babies (40%)
m. Have access to clean drinking water (20%)
2. What proportion of mothers do you think receive or know the following?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
At least 2 TT injections before delivery (60-70%)
Receive IPT (70%)
At least two danger signs of pregnancy (20%)
At least two danger signs of newborns (90%)
At least four danger signs for children under-five (90%)
Proportion of women accompanied by their husbands to ANC (20%)
Information on birth preparedness (100%)
Practice family planning (60-70)
Sleep under ITN (70%)
Deliver through caesarean section (50%)
Bathe their newborns within 24 hours of delivery (80%)
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Health and development programs and policy mapping 1996­2007 Appendix 3: INTERVIEW GUIDES
HEALTH PROGRAMMES AND POLICY MAPPING EXERCISE IN UPPER EAST REGION
AND THE REST OF GHANA
SEMI-STRUCTURED INTERVIEW GUIDE
RESPONDENT: NOGOs/CSOs/FBOs IN MATERNAL AND CHILD HEALTH IN UPPER EAST
REGION
1. What type of health related interventions are you into?
2. What specific types of your interventions relate to maternal and child health?
3. Please give a chronological account of these interventions since 1996?
4. In which districts have you been focusing?
5. What are your estimates of coverage for your interventions?
6. What is your relationship with the Ghana Health Service?
7. Who are your major donors?
8. Who are your main collaborators in the field?
9. What are the funding forecasts?
10. Have you in way been involved with the UNICEF funded ACSD in the region?
RESPONDENT: GHS PROGRAMME MANAGERS (EPI, Child Health, RBM)
1. What are GHS’ strategies and priorities in child health?
2. What is the place of ACSD in GHS’ child health policies?
3. What is the role of your programme in child health?
4. What coverage has your programme experienced?
5. What are the achievements and constraints of your programme?
6. Could you share with us copies of reports or documents covering your programme
activities since 1997?
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Health and development programs and policy mapping 1996­2007 Appendix 4: FOCUS GROUP DISCUSSION GUIDE FOR COMMUNITIES IN BONGO
DISTRICT, UER
1. What proportion of children under-five do you think receive the following interventions or
experience the following;
a. Vitamin A capsules
b. Exclusive breast feeding
c. Iodized salt
d. Pneumonia treatment with antibiotics
e. Measles vaccination
f.
Oral rehydration salt for diarrhoea
g. Penta 3 vaccination
h. Skilled attendance at birth
i.
Die before the first month of life
j.
Die before the first year of life
k. Sleep under ITN
l.
Are low birth weight babies
m. Have access to clean drinking water
2. What proportion of mothers receive or know the following;
a.
at least 2 tetanus injections before delivery
b. Receive IPT
c. Know at least two danger signs of pregnancy (mention two signs)
d. Know at least two danger signs of newborns (mention two signs)
e. Know four danger signs for children under-five (mention four)
f.
Proportion of mothers are accompanied by their husbands to ANC
g. Information on birth preparedness
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Health and development programs and policy mapping 1996­2007 h. Practice family planning
i.
Sleep under ITN
j.
Deliver through Caesarean section
k. Bathe their newborns within 24 hours of delivery
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Health and development programs and policy mapping 1996­2007 Year
Appendix 5: Dummy table to record health interventions and coverage at national level
Intervention
Activity
Indicator
Region
District
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Health and development programs and policy mapping 1996­2007 Year
Appendix 6: Dummy table to record interventions and coverage in Upper East Region
Intervention Activity
Indicator
District
Community
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