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

Global Health Action æ ORIGINAL ARTICLE Temporal trends in childhood mortality in Ghana: impacts and challenges of health policies and programs Gbenga A. Kayode1*, Diederick E. Grobbee1, Augustina Koduah2,3, Mary Amoakoh-Coleman1,4, Irene A. Agyepong4,5, Evelyn Ansah5, Han van Dijk3 and Kerstin Klipstein-Grobusch1,6 1 Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands; 2Ministry of Health, Accra, Ghana; 3Social Science Group, Wageningen University and Research Center, Wageningen, The Netherlands; 4School of Public Health, University of Ghana, Legon, Accra, Ghana; 5Ghana Health Service, Greater Accra Region, Accra, Ghana; 6Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Background: Following the adoption of the Millennium Development Goal 4 (MDG 4) in Ghana to reduce under-five mortality by two-thirds between 1990 and 2015, efforts were made towards its attainment. However, impacts and challenges of implemented intervention programs have not been examined to inform implementation of Sustainable Development Goal 3.2 (SDG 3.2) that seeks to end preventable deaths of newborns and children aged under-five. Thus, this study aimed to compare trends in neonatal, infant, and under-five mortality over two decades and to highlight the impacts and challenges of health policies and intervention programs implemented. Design: Ghana Demographic and Health Survey data (1988
2008) were analyzed using trend analysis. Poisson regression analysis was applied to quantify the incidence rate ratio of the trends. Implemented health policies and intervention programs to reduce childhood mortality in Ghana were reviewed to identify their impact and challenges. Results: Since 1988, the annual average rate of decline in neonatal, infant, and under-five mortality in Ghana was 0.6, 1.0, and 1.2%, respectively. From 1988 to 1989, neonatal, infant, and under-five mortality declined from 48 to 33 per 1,000, 72 to 58 per 1,000, and 108 to 83 per 1,000, respectively, whereas from 1989 to 2008, neonatal mortality increased by 2 per 1,000 while infant and under-five mortality further declined by 6 per 1,000 and 17 per 1,000, respectively. However, the observed declines were not statistically significant except for under-five mortality; thus, the proportion of infant and under-five mortality attributed to neonatal death has increased. Most intervention programs implemented to address childhood mortality seem not to have been implemented comprehensively. Conclusion: Progress towards attaining MDG 4 in Ghana was below the targeted rate, particularly for neonatal mortality as most health policies and programs targeted infant and under-five mortality. Implementing neonatalspecific interventions and improving existing programs will be essential to attain SDG 3.2 in Ghana and beyond. Keywords: neonatal; infant; under-five mortality; Ghana Responsible Editor: Stig Wall, Umea University, Sweden. *Correspondence to: Gbenga A. Kayode, Julius Center for Health Sciences and Primary Care, P.O. Box 85500, NL-3508 GA Utrecht, The Netherlands, Email: g.a.kayode@umcutrecht.nl Received: 12 April 2016; Revised: 16 June 2016; Accepted: 16 June 2016; Published: 23 August 2016 Introduction Early childhood mortality continues to remain a prominent global health issue even though Millennium Development Goal 4 (MDG 4) was universally adopted to reduce underfive mortality by two-thirds between 1990 and 2015 (1). Also, several ‘calls for action’ to reduce neonatal mortality have been made (2
5), and in response, both governmental and non-governmental bodies have committed considerable resources to this public health challenge. Similar to other low- and middle-income countries (LMICs), postadoption of MDG 4 in Ghana has witnessed formulation and implementation of maternal and child health policies and intervention programs towards actualizing MDG 4. For example, from 1988 to 1998, the Safe Motherhood Global Health Action 2016. # 2016 Gbenga A. Kayode et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license. 1 Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 (page number not for citation purpose) Gbenga A. Kayode et al. Program (SMP) (6), Life Saving Skills (LSS) program (7), and Integrated Management of Childhood Illness (IMCI) program (8) were initiated. The SMP aims to secure safe delivery for women and improve child health services while the LSS (7) seeks to sharpen the clinical skills of midwives. Similarly, the IMCI (8) targets to improve child survival through the provision of clinical guidelines for management of childhood illnesses, health system strengthening, and improving community health practices. In the subsequent decade, from 1998 to 2008, some additional intervention programs and policies implemented were the Community-Based Health Planning and Services (CHPS) (9), User Fees Exemption for Delivery (UFED) (10), Focused Antenatal Care (FANC) (11), and National Health Insurance Scheme (NHIS) (12). The CHPS program aims to bring healthcare closer to the people through primary health care service while the UFED (10) and NHIS programs seek to ease the financial burden of healthcare service and reduce inequality in healthcare uptake. The FANC pursues improvement in maternal and child survival through individualized antenatal care that entails a comprehensive assessment of pregnant women in terms of their socio-cultural beliefs, lifestyle, and medical characteristics to improve early detection and treatment of illness and pregnancy complications. In addition to these national programs and policies, various regions also implemented different intervention programs, for example, the Kybele program in the Greater Accra region (13, 14), Accelerated Child Survival and Development (ACSD) (15) sponsored by United Nation Children and Education Fund (UNICEF) in the Northern, Upper East, and Upper West regions, and Kangaroo Mother Care (KMC) (16) which commenced in six regions in 2007. Although the deadline for the attainment of MDG 4 has elapsed, 99% of childhood mortality still occurs in LMICs (5, 17), with Africa accounting for about 50% (18). Assessment of progress made so far is of utmost importance to inform policy makers and healthcare planners tasked to realize the newly adopted Sustainable Development Goal 3.2 (SDG 3.2) that seeks to end preventable deaths of newborns and under-five children by 2030. Thus, this study aimed to 1) compare the temporal trends in neonatal, infant, and under-five mortality in Ghana from 1988 to 2008; 2) describe the trends in the proportion of infant and under-five mortality attributed to neonatal deaths in Ghana over the same period; 3) compare national and regional trends in neonatal mortality over the same period; and 4) identify the impact and challenges of health policies and intervention programs implemented in Ghana during this time period. Methods Setting Ghana is located in sub-Saharan Africa, along the Gulf of Guinea with a total population of about 24.4 million (19). 2 (page number not for citation purpose) It has an annual growth rate of about 2.4% per year (20). Ghana has 10 administrative regions, namely Greater Accra, Western, Central, Volta, Eastern, Ashanti, Brong-Ahafo, Northern, Upper East, and Upper West. It has about 100 ethnic groups with different languages but the major ethnic groups are Akan, Ewe, Mole-Dagbane, Guan, and Ga-Adangbe (21). Design of data collection This longitudinal study compared the trends in neonatal mortality, infant and under-five mortality, and described the trends in the proportion of infant and under-five mortality attributed to neonatal deaths in Ghana, from 1988 to 2008, using Ghana Demographic and Health Survey (GDHS) datasets obtained in 1988, 1993, 1998, 2003, and 2008 (22). These datasets were collected by the ICF Macro in conjunction with the Ghana Statistical Service and the Ministry of Health/Ghana Health Service. All the GDHSs followed the same sampling technique; households were randomly sampled for interview by applying a stratified, two-stage cluster random sampling technique. All women and men in all the selected households, within the age range 15
49 and 15
59 years, respectively, were targeted for face-to-face interview using questionnaires. Prior to the interview, informed consent was obtained from every participant. The datasets are nationally representative with an individual response rate of 95
97% and a household response rate of 97
99%. The datasets were weighted to have a better representation of the study population. In GDHS, neonatal mortality was defined as the probability of dying within the first month of life, infant mortality was defined as the probability of dying before the age of 12 months, and under-five mortality was defined as the probability of dying before the age of 60 months. Detailed information on the sampling techniques and procedures for the data collection has been published elsewhere (22). In order to highlight the impact and challenges of health policies and intervention programs implemented in Ghana from 1988 to 2008, MEDLINE, EMBASE, Google Scholar, African Index Medicus, and Ghana Medical Journal were searched, and the articles that assessed the impact and challenges of these interventions implemented from 1988 to 2008 in Ghana were identified and reviewed. Statistical analysis Neonatal, infant, and under-five mortality rates estimated at national and regional level from each GDHS were used to perform trend analysis. Temporal trend patterns were depicted by plotting the number of neonatal deaths per 1,000 live births against the year when the data were captured; infant and under-five mortality underwent a similar analysis at national level. Also, temporal trend pattern of neonatal mortality at the national level was compared with that of regions. Likewise, the proportion of infant and under-five mortality attributed to neonatal mortality was examined by plotting the percentage of Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 Temporal trends in childhood mortality in Ghana infant and under-five mortality attributed to neonatal death against the year when the data were captured. In order to quantify the trends objectively, a Poisson regression analysis was applied to quantify the incidence rate ratios of the trends. Statistical significance was determined by two-tailed Wald test at significant level of alpha equal to 5%; all analyses were performed in Stata statistical software package version 11 (23). Ethical approval Anonymous publicly available data were utilized in this study. Thus, no ethical approval is required. Results Descriptive statistics Table 1 shows the total number of live births captured per each GDHS and the number of neonatal, infant, and under-five deaths. Over this period, five demographic and health surveys were conducted in Ghana for which a total of 16,474 live births (average 3,295 live births per GDHS) were captured. Total neonatal, infant, and under-five deaths captured over this period was 673 (average 135 deaths per GDHS), 1,013 (average 203 deaths per GDHS), and 1,378 (average 276 deaths per GDHS), respectively. The average rates of decline per year for neonatal, infant, and underfive mortality were 0.6, 1.0, and 2.1%, respectively. National trends in neonatal, infant, and under-five mortality Figure 1 shows the trends in neonatal, infant, and underfive mortality from the 1988 to the 2008 GDHS while Table 2 reports the results of Poisson regression analysis that quantified the changes in the trends observed in Fig. 1. From 1988 to 1998, neonatal mortality declined from 47.9 per 1,000 to 33.1 per 1,000 and by 2008 neonatal mortality increased to 35.4 per 1,000. Considering the results in Table 2, neonatal mortality has not witnessed any significant decline over this period. Infant mortality declined from 72.3 per 1,000 to 58.2 per 1,000 from 1988 to 1998 and by 2008 infant mortality dropped to 52.5 per 1,000. However, the results in Table 2 shows that the decline observed in infant mortality from 1988 to 2008 was not statistically significant. From 1988 to 1998, under-five mortality declined from 107.8 per 1,000 to 82.5 per 1,000 and by 2008 under-five mortality had further declined to 66.2 per 1,000. Over the same period, the results in Table 2 shows that under-five mortality was significantly lower in 1993 and 2008 when compared with 1988. In 1993 and 2008, the risk of under-five death was reduced by 38% (IRR 0.62; 95% CI: 0.46
0.84) and 39% (IRR 0.61; 95% CI: 0.45
0.83), respectively, when compared with that of 1988. Figure 2 depicts the trends in the proportion of infant and under-five mortality attributable to neonatal deaths. From 1988 to 1998, the percentage of infant mortality attributed to neonatal mortality declined from 66 to 57%; however, by 2008, it increased to 67%. Likewise, from 1988 to 1998, the proportion of under-five mortality attributable to neonatal deaths reduced from 44 to 40%; however, by 2008 it increased to 53%. Regional trends in neonatal mortality The regional trends of neonatal mortality are shown in Fig. 3. In 1988, neonatal mortality rates in the Central, Volta, and Ashanti regions were above the national rate (48 neonatal deaths per 1,000 live births); in 1998, Central, Eastern, Brong Ahafo, Upper East, and Upper West regions had a higher neonatal rate than the national average (33 neonatal deaths per 1,000 live births). By 2008 the Central, Upper West, and Northern regions exceeded the national neonatal mortality rate (35 neonatal deaths per 1,000 live births). The neonatal mortality in the Central region was persistently higher than the national average, whereas neonatal mortality in the Greater Accra region (GAR) stayed below the national average from 1988 to 2008. Impact of implemented health policies and intervention programs on MDG 4 in Ghana Following the adoption of the MGDs in Ghana, the Ghanaian government in collaboration with international donors implemented several intervention programs and health policies aimed at accelerating attainment of MDG Table 1. Neonatal, infant, and under-five deaths, 1988
2008 Ghana Demographic and Health Survey Total live births Neonatal deaths Infant deaths Under-five deaths Number (n) Number (rate) Number (rate) Number (rate) GDHS 1988 4,136 198 (47.9) 299 (72.3) 446 (107.8) GDHS 1993 2,204 94 (42.6) 130 (59.0) 148 (67.2) GDHS 1998 3,298 109 (33.1) 192 (58.2) 272 (82.5) GDHS 2003 3,844 166 (43.2) 235 (61.1) 314 (81.7) GDHS 2008 2,992 106 (35.4) 157 (52.5) 198 (66.2) GDHS Average rate of decline per year: neonatal mortality 0.6%, infant mortality 1.0%, and under-five mortality 2.1%. GDHS: Ghana Demographic and Health Survey. Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 3 (page number not for citation purpose) Gbenga A. Kayode et al. and implementation, erratic funding, insufficient community engagement, lack of proper monitoring, and inadequate manpower and equipment. Discussion Fig. 1. Trends in childhood mortality in Ghana from 1988 to 2008. 4 and MDG 5 in Ghana. We examined the impact and limitations of national health policies that were implemented post-adoption of MDG 4 until 2008. Findings of studies that have assessed the policies quantitatively and/ or qualitatively have been summarized in Table 3. At the national level, the LSS (7), SMP (6), and IMCI (8) programs were initiated between 1988 and 1998 and subsequently scaled up thereafter. Additional interventions such as the CHPS (9), User Fees Exemption for Delivery Care (UFEDC) (10), FANC (11), and the NHIS (12) were implemented from 1999 onward to complement the impact of the existing programs so as to accelerate attainment MDG 4 and MDG 5. Maternal and child policies reviewed (Table 3) showed that most of the policies were directed at maternal, infant, and under-five mortality rather than neonatal mortality. Results presented indicate that these policies seem to have a greater effect on maternal healthcare utilization and maternal and childhood mortality and morbidity during the initiation phase than the scale-up phase (24
26, 48). Factors consistently identified to have a negative impact on the effectiveness of the various interventions were: deviation from good standard practice in policy formulation This study compared the trends in neonatal, infant, and under-five mortality from 1988 to 2008 in Ghana. It also identified the impact and challenges of various health policies and programs implemented during this time period to attain MDG 4. Despite the global attention on childhood mortality, we noticed that from 1988 to 2008 in Ghana, the decline rates in neonatal, infant, and under-five mortality were far below the expectation of a 4% annual decline to attain MDG 4 globally (49) and less than the 7% annual reduction stipulated to achieve MDG 4 in sub-Saharan Africa (50). Similar to what Baiden et al. (51) and Welaga et al. (52) observed in the Kassena-Nankana district of Northern Ghana, the observed trends in childhood mortality cannot be directly attributed to the various overlapping policies and programs implemented. However, some important observations were noticed. Health policies and intervention programs implemented from 1988 to 1998 (SMP (6), LSS for midwives (7), and IMCI (8)) were observed to have a larger effect on childhood mortality than those implemented from 1998 to 2008 (UFEDC (10), Focus Antenatal Care (FANC) (11), NHIS (12), and CHPS (9)). Generally, the decline rates in neonatal, infant, and under-five mortality were far below expectations, and the implemented health policies and intervention programs appeared to have had more impact on under-five mortality than on neonatal and infant mortality. Due to the paltry decline in neonatal mortality, the proportion of infant and under-five mortality attributed to neonatal mortality has increased; this mimics global and SSA observations (49, 53). In addition, we identified in our review factors that were responsible for the slow decline observed in neonatal, infant, and under-five mortality. Studies that have evaluated health policies and intervention programs implemented in Ghana repeatedly showed that factors Table 2. Poisson regression analyses of the trend in neonatal, infant, and under-five mortality, 1988
2008 Ghana Demographic and Health Survey Year 1988 GDHS 1993 GDHS Neonatal death Infant death Under-five death IRR (95% CI) IRR (95% CI) IRR (95% CI) 1 (reference) 0.90 (0.60
1.35) 1 (reference) 0.82 (0.58
1.15) 1 (reference) 0.62 (0.46
0.84)** 1998 GDHS 0.69 (0.44
1.07) 0.81 (0.57
1.14) 0.76 (0.57
1.01) 2003 GDHS 0.90 (0.59
1.35) 0.85 (0.60
1.19) 0.76 (0.57
1.01) 2008 GDHS 0.73 (0.47
1.12) 0.72 (0.50
1.03) 0.61 (0.45
0.83)** CI: confidence interval; GDHS: Ghana Demographic and Health Survey; IRR: incidence risk ratio; **pB0.01. 4 (page number not for citation purpose) Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 Temporal trends in childhood mortality in Ghana At the regional level, we observed some degree of variation in neonatal mortality trends. This observation may partly be explained by differences in implementation of national health policies and programs in conjunction with the disparities in additional programs implemented in the regions; examples of such regional differences are the Kybele program in the Greater Accra region (13, 14), kangaroo mother care (55), UNICEF-sponsored ACSD (15) in Northern Ghana, High Impact Rapid Delivery (HIRD) (56), and Project Five Alive (57, 58). The variation may also be driven by differences in baseline rate of neonatal mortality across the regions. Fig. 2. Trends in proportion of infant and under-five mortality attributed to neonatal death. such as deviation from good standard practice in policy formulation and implementation (27, 28), erratic funding (29, 30), insufficient community engagement (9), inadequate monitoring (31, 32), and inadequate manpower and equipment (29, 33) are major challenges of health policies and programs that might have hindered a more pronounced decline in childhood mortality. Our observation was corroborated by a previous multi-country study that identified factors such as inadequate policy formulation and implementation, poor financing, shortage of health human resources, lack of re-training of staff, inadequate medical products and technologies as the major constraints to scale up intervention programs to improve survival in early life (54). Recommendation Considering the slow rate of decline in childhood mortality, particularly in neonatal mortality, implementation of cost-effective, neonatal-specific interventions, such as newborn resuscitation, exclusive breastfeeding, use of partograph, kangaroo mother care, use of micronutrients, tetanus toxoid immunization, will be needed to successfully address attainment of SDG 3.2 (2, 5, 59). In addition, implemented interventions to tackle childhood mortality should be reformed based on the recurrent defects identified in policy formulation and implementation to accelerate attainment of SDG 3.2 (9, 31, 34). Study limitations and strengths This is the first study in Ghana that utilized nationally representative data to examine trends in childhood mortality, allowing us to generalize our findings. GDHS data are generally regarded as high-quality data because Fig. 3. National and regional trends in neonatal mortality in Ghana. Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 5 (page number not for citation purpose) Gbenga A. Kayode et al. Table 3. Overview of National Health Policies implemented to address childhood mortality in Ghana from 1988 to 2008 Findings of studies assessing National Health policy Activities Time of the effectiveness of national health assessment policy programs Safe Motherhood (6) Ghana SMP entails primary health care, Program (SMP) antenatal care, essential obstetric care, were implementing other interventions clean/safe delivery, family planning and outside the objectives of the SMP, and the equity for women. (Launched in 1993 authors concluded that such action might and scaled up in 2000.) dilute the expected effect of the policy (35). After scale-up Okiwelu et al. showed that some donors Anderson et al. identified migration of care providers (medical doctors) out of Ghana as one of the main factors that hampered the SMP in Ghana (36). Maine et al. in his review on the SMP showed that the policy was not well-defined and most policy makers believed that most of the components of SMP were already implemented prior to the SMP (37). Community-Based Community health officer (CHO) provides Prior to scale-up Prior to policy implementation at the Health Planning and the following services: treatment of minor (experimental national level, Phillips et al. showed that the Services (9) (CHPS) illness, health education, family planning, phase) CHPS program decreased childhood skilled delivery, and antenatal and mortality and fertility rate (24). postnatal care. Community volunteers are trained to carry out community mobilization. (First piloted in 1999, adopted nationwide in 2005.) Prior to scale-up Prior to policy implementation at the national level, Debpuur et al. showed that the CHPS program increased women’s knowledge of contraception, willingness for birth spacing, and usage of contraception (38). Before the policy was adopted nationally, Pence et al. showed that the CHPS program decreased childhood mortality (39). Before the CHPS program was adopted, Binka et al. found that the program decreased childhood mortality and improved parental health-seeking behavior (40). Phillips et al. observed that CHPS improved contraceptive usage before the policy was adopted nationwide (41). Prior to the adoption of the policy, AwoonorWilliams et al. showed that CHPS increased usage of contraception, skilled antenatal delivery, and postnatal attendants (42). During scale up, During the scale-up phase, Awoonor-Williams et al. observed the following challenges: inadequate funding, less preparedness of community health officer, inadequate community engagement, shortage of manpower and equipment and inadequate monitoring (31). 6 (page number not for citation purpose) Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 Temporal trends in childhood mortality in Ghana Table 3 (Continued ) National Health policy Activities Time of Findings of studies assessing the effectiveness of national health assessment policy programs After the adoption Assessment of the CHPS initiative by of the policy Adongo et al. after its adoption showed that the program improved the acceptance of family planning (43). Following adoption of the CHPS, Adongo et al. observed that the implementation of the program in urban areas was difficult due to contextual differences between rural (where the CHPS was tested) and urban areas, suggesting further modification of the implementation strategies (44). Post-adoption of During post-adoption of CHPS, CHPS initiative Nyonator et al. identified the following: inadequate community engagement, lack of funds made health managers to perceive CHPS as an administrative burden (9). User Fees Exemption for Delivery Care (UFEDC) (10) Exemption for pregnant women from Prior to scale up Before the policy was adopted, Asante et al. paying delivery fees in order to increase skilled delivery. Public, private, and mission reported that the policy decreased catastrophic out-of-pocket payment (45). health care providers were receiving Before the policy was scaled up, Bosu et al. reimbursement for service rendered showed that the policy had no statistically (Initiated in 2003, scaled up in 2005) significant effect on maternal mortality (25). Before the scaling up of the policy, Penfold et al. observed that the policy increased skilled delivery and reduced inequality in the utilization of maternal healthcare service (46). McKinnon et al. observed that facility-based delivery increased while neonatal mortality decreased (47). After scale up Witter et al. reported that the stakeholders believed that the policy was a cost-effective initiative that can reduce inequality in the utilization of maternal healthcare service. Insufficient funding, inadequate management, irregular reimbursement, increased workload without any increase in staff strength subsequently hampered the quality of maternal healthcare (29). Witter et al. reported that the stakeholders believed that the policy was a good initiative to improve skilled delivery. The study showed improvement in early antenatal registrants but regions were not well consulted in terms of reimbursement. Consequently, reimbursement was erratic and insufficient (30). Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 7 (page number not for citation purpose) Gbenga A. Kayode et al. Table 3 (Continued ) National Health policy Activities Time of Findings of studies assessing the effectiveness of national health assessment policy programs The study conducted by Witter et al. showed that the policy was well accepted as an effective strategy to improve safe delivery; contents of the policy were clear but insufficient; erratic funding delayed inadequate reimbursement; increased workload without incentive or any corresponding increase in the number of care providers militate against the sustainability of the policy (34). Meessen et al. observed 1) Agenda setting: It was not clear whether the policy was adopted as a result of pressure from donors or taking the advantage of the offer of being a ‘‘low resource setting’’. 2) Policy formulation: Assessment of this policy based on good practices in policy formulation showed that the objectives of the policy were clear and the stakeholders welcomed the policy but its formulation was not free from donor’s influence. Important policy formulation good practices such as situation analysis, assessment of different policy options, and stakeholders’ involvement were not observed. 3) Implementation stage: suffered from erratic and insufficient funding (27). Focused Antenatal Care Individualized care for pregnant women (FANC) (11) to improve efficiency and safe delivery. During policy Increased antenatal registrants, increased implementation early antenatal registrants, improved It involves early detection of complication, patient
doctor interaction, reduced waiting pre-existing morbidity, birth preparedness, health education, and health promotion. time, improved quality of antenatal care, increased health facility delivery, reduced For a healthy woman, four antenatal stillbirth, and increased postnatal care visits at B16, 26, 32, and 36 weeks were utilization were observed by Deganus recommended. (Implemented in 2002) et al. following the implementation of FANC (26). Nyarko et al. reported that both patients and healthcare providers accepted the policy. It improved the quality of antenatal care. However, there was no difference between the intervention facilities and the control facilities in terms of birth preparedness, complication readiness, and postnatal care. In addition, some intervention facilities were unable to implement some of the components of FANC due to lack of equipment (33). 8 (page number not for citation purpose) Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 Temporal trends in childhood mortality in Ghana Table 3 (Continued ) National Health policy National Health Activities Time of Findings of studies assessing the effectiveness of national health assessment policy programs National health insurance for pregnant Following the Witter et al. showed that the policy makers Insurance Scheme women: six antenatal visits, delivery implementation did not learn from errors of free delivery (12) (NHIS) (incl. obstetrics complications), two of NHIS policy; NHIS policy formulation was top- postnatal visits within 6 weeks down, politically induced by donors, no post-delivery, neonatal care up to well-prepared policy guidelines, no proper age 3 months. (Implemented in 2008) consultation, poor communication of the policy, no proper costing, no additional funds were made available, no long-time financial plan, erratic and insufficient reimbursement. Sub-optimal implementation, lack of adequate monitoring and evaluation, increased workload with a negative impact on healthcare quality. Despite these limitations implementation of the NHIS increased Integrated Management Aims to improve case management at Following the access to healthcare (32). Baiden et al. observed that many of the of Childhood Illness primary level of care, management of implementation care providers were yet to receive training (8) (IMCI) childhood illnesses, and family and of IMCI on IMCI. The study showed a significant community childcare practices. It involves level of non-compliance with the IMCI antenatal, delivery, and postnatal services; guidelines; all the 11 items in the IMCI treatment and prevention of infectious checklist were observed in just 1% of the diseases (pneumonia, diarrhea, malaria, children. 95% of them received antimalarial measles, HIV/AIDS); improves nutrition (improves breastfeeding, reduces treatment but only 11% underwent laboratory investigation (28). malnutrition), vaccination, and psychosocial development. (Started in 1998, by 2000 all districts started IMCI.) Maine et al. provided assessment was a general assessment of the SMP. of the sampling technique and the excellent household and respondent response rates (22). We went beyond the traditional graphical description of the mortality trends by applying Poisson regression to quantify the risk of dying over time. However, we are aware that there may have been the possibility of underreporting and misclassification in childhood mortality as a result of recall bias (60). In addition, non-sampling error such as misunderstanding of the question on the part of the participant or the interviewer could have occurred. As the current study was based on published articles, some valuable information on the impact and challenges of the intervention programs implemented and reported in the grey literature may not have been fully captured in this study. Also, most articles that assessed the implemented intervention programs were not properly designed to evaluate the effectiveness of these intervention programs. Conclusion This study compared the trends in neonatal, infant, and under-five mortality over two decades in Ghana. The observed decline rates were generally slow, particularly for neonatal mortality. This could be attributed to the shortcomings identified for health policies and intervention programs formulation and implementation, particularly with regard to neonatal mortality. Implementation of a sustainable evidence-based neonatal-specific intervention and improving other existing interventions will be a prerequisite to actualize SDG 3.2 in Ghana and beyond. Summary What’s known: Interventions were implemented in Ghana to achieve MDG 4 but the impact and challenges have not been assessed to inform SDG 3.2. What’s new: Since 1988, the decline in childhood mortality in Ghana was below the expected rate and the proportion of Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 9 (page number not for citation purpose) Gbenga A. Kayode et al. infant and under-five mortality attributed to neonatal death has increased because implementation of most intervention programs was suboptimum and newborns less considered. Implications: Implement neonatal-specific interventions and improve existing programs. 9. Authors’ contributions GAK, DEG, HD, and KKG designed the study, whereas GAK carried out data collection, literature review, data analysis, and also drafted the first version of the manuscript. All authors reviewed and approved the final version of the manuscript. 10. Acknowledgements 12. We appreciate Measures DHS for permitting us to analyze Ghana DHS. We also grateful for the financial support from the Netherlands Organization for Scientific Research/WOTRO Science for Development (Grant Number: 07.45.102.00) toward the completion of this study. 13. 11. 14. Conflict of interest and funding The authors declare that they have no competing interests. 15. Paper context Since the adoption of Millennium Development Goal 4 in Ghana to reduce under-five mortality by two-thirds between 1990 and 2015, efforts were made towards attainment. However, impacts and challenges of implemented intervention programs have not been examined to inform implementation of SDG 3.2. This study examined what has been achieved in neonatal, infant and under-five mortality over two decades and highlighted the impacts and challenges of intervention programs implemented. This study provided important information that policy makers can utilize towards actualizing SDG 3.2. 17. 18. References 1. United Nations Millennium Declaration. Available from: http://www.unorg/millennium/declaration/ares552epdf [cited 14 Febrauary 2014]. 2. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005; 365: 977
88. 3. Knippenberg R, Lawn JE, Darmstadt GL, Begkoyian G, Fogstad H, Walelign N, et al. Systematic scaling up of neonatal care in countries. Lancet 2005; 365: 1087
98. 4. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? where? why? Lancet 2005; 365: 891
900. 5. Martines J, Paul VK, Bhutta ZA, Koblinsky M, Soucat A, Walker N, et al. Neonatal survival: a call for action. Lancet 2005; 365: 1189
97. 6. The safe motherhood action agenda: priorities for the next decade. Available from: http://files.givewell.org/files/DWDA 2009/ Interventions/Maternal Mortality/SafeMotherhoodActionAgenda. pdf [cited 23 April 2015]. 7. Overview of ACNM’s Life Saving Skills Program (LSS). Available from: http://www.midwife.org/Life-Saving-Skills-LSS [cited 14 September 2014]. 8. Integrated Management of Childhood Illness (IMCI). Available from: http://www.google.co.uk/url?sat&rctj&q&esrcs&frm 10 (page number not for citation purpose) 16. 19. 20. 21. 22. 23. 24. 25. 26. 1&sourceweb&cd1&ved0CCYQFjAA&urlhttp%3A%2F% 2Fwww.afro.who.int%2Findex.php%3Foption%3Dcom_docman %26task%3Ddoc_download%26gid%3D1594&eiCNQ4VbL5 EorgaO-dgMAF&usgAFQjCNGZapepAsyvI9tVeiqXLrWD kFJNfw [cited 23 April 2015]. Nyonator FK, Woonor-Williams JK, Phillips JF, Jones TC, Miller RA. The Ghana community-based health planning and services initiative for scaling up service delivery innovation. Health Policy Plan 2005; 20: 25
34. Ministry of Health (2004). Guidelines for implementing the exemption policy on maternal deliveries. Accra: Ministry of Health. Report No. MoH/Policy, Planning, Monitoring and Evaluation-59. 2015. Focused Antenatal Care. Available from: http://www.who.int/ pmnch/media/publications/aonsectionIII_2.pdf [cited 23 April 2015]. Ghana National Health Insurance Act (Act 650) 2003. Available from: http://www.social-protection.org/gess/ResourcePDF. do?resource.ressourcel [cited 6 July 2016]. Engmann C, Olufolabi A, Srofenyoh E, Owen M. Multidisciplinary team partnerships to improve maternal and neonatal outcomes: the Kybele experience. Int Anesthesiol Clin 2010; 48: 109
22. Srofenyoh E, Ivester T, Engmann C, Olufolabi A, Bookman L, Owen M. Advancing obstetric and neonatal care in a regional hospital in Ghana via continuous quality improvement. Int J Gynaecol Obstet 2012; 116: 17
21. Ghana Accelerated Child Survival and Developement Approach (ACSD). Available from: http://www.google.co.uk/url? sat&rctj&q&esrcs&frm1&sourceweb&cd1&ved 0CCYQFjAA&urlhttp%3A%2F%2Fwww.unicef.org%2Finno vations%2Ffiles%2Fghana.doc&eiGP04VePxDcf7arOfgdAH &usgAFQjCNFviowYjuuXq2IjhvMR__tExTTFbQ&bvm bv.91427555 [cited 23 April 2015]. Kangaroo Mother Care in Ghana. Available from: http://www. unicef.org/sowc09/docs/SOWC09-Panel-3.5-EN.pdf [cited 24 April 2015]. You D, Hug L, Ejdemyr S, Idele P, Hogan D, Mathers C, et al. Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet 2015; 386: 2275
86. MDG 2014 Report: assessing progress in Africa towards the Millennium Development Goals: United Nations. Available from: http://www.afdb.org/fileadmin/uploads/afdb/Documents/Publications/MDG_Report_2014_11_2014.pdf [cited 24 April 2015]. World Bank Data: Ghana. Available from: http://data.world bank.org/country/ghana [cited 21 January 2013]. World Bank Data: population growth. Available from: http:// search.worldbank.org/data?qtermghana population growth rate &languageEN [cited 9 January 2013]. Ghana: ethnic groups. Available from: http://www.ghanaweb. com/GhanaHomePage/tribes/ [cited 11 January 2013]. Measure Demographic and Health Survey. Available from: http://www.measuredhs.com [cited 4 June 2013]. StataSE 11. Available from: www.stata.com [cited 13 May 2013]. Phillips JF, Bawah AA, Binka FN. Accelerating reproductive and child health programme impact with community-based services: the Navrongo experiment in Ghana. Bull World Health Organ 2006; 84: 949
55. Bosu W, Bell JS, Rmar-Klemesu M, Tornui JA. Effect of delivery care user fee exemption policy on institutional maternal deaths in the central and volta regions of Ghana. Ghana Med J 2007; 41: 118
24. The maternal and neonatal health program’s ‘Champions for change: improving maternal and newborn survival’. Available from: http://pdf.usaid.gov/pdf_docs/PNADA618.pdf [cited 12 July 2014]. Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 Temporal trends in childhood mortality in Ghana 27. Meessen B, Hercot D, Noirhomme M, Ridde V, Tibouti A, Tashobya CK, et al. Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries. Health Policy Plan 2011; 26 Suppl 2: ii6
29. 28. Baiden F, Owusu-Agyei S, Bawah J, Bruce J, Tivura M, Delmini R, et al. An evaluation of the clinical assessments of under-five febrile children presenting to primary health facilities in rural Ghana. PLoS One 2011; 6: e28944. 29. Witter S, Adjei S, Rmar-Klemesu M, Graham W. Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana. Glob Health Action 2009; 2: 1881, doi: http://dx.doi.org/10.3402/gha.v2i0.1881 30. Witter S, Adjei S. Start-stop funding, its causes and consequences: a case study of the delivery exemptions policy in Ghana. Int J Health Plann Manage 2007; 22(2): 133
43. 31. Awoonor-Williams JK, Sory EK, Nyonator FK, Phillips JF, Wang E, Schmitt ML. Lessons learned from scaling up a community-based health program in the Upper East Region of Northern Ghana. Glob Health Sci Pract 2013; 1: 117
33. 32. Witter S, Garshong B, Ridde V. An exploratory study of the policy process and early implementation of the free NHIS coverage for pregnant women in Ghana. Int J Equity Health 2013; 12: 16. 33. Acceptability and feasibility of introducing the WHO focused antenatal care package in Ghana. Available from: http://www. popcouncil.org/uploads/pdfs/frontiers/FR_FinalReports/ghana_ who_anc.pdf [cited 14 Febrauary 2014]. 34. Witter S, Arhinful DK, Kusi A, Zakariah-Akoto S. The experience of Ghana in implementing a user fee exemption policy to provide free delivery care. Reprod Health Matters 2007; 15: 61
71. 35. Okiwelu T, Hussein J, Adjei S, Arhinful D, Rmar-Klemesu M. Safe motherhood in Ghana: still on the agenda? Health Policy 2007; 84: 359
67. 36. Anderson FW, Mutchnick I, Kwawukume EY, Danso KA, Klufio CA, Clinton Y, et al. Who will be there when women deliver? Assuring retention of obstetric providers. Obstet Gynecol 2007; 110: 1012
16. 37. Maine D, Rosenfield A. The safe motherhood initiative: why has it stalled? Am J Public Health 1999; 89: 480
2. 38. Debpuur C, Phillips JF, Jackson EF, Nazzar A, Ngom P, Binka FN. The impact of the Navrongo Project on contraceptive knowledge and use, reproductive preferences, and fertility. Stud Fam Plann 2002; 33: 141
64. 39. Pence BW, Nyarko P, Phillips JF, 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 2007; 35: 599
608. 40. Binka FN, Bawah AA, Phillips JF, Hodgson A, Adjuik M, MacLeod B. Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana. Trop Med Int Health 2007; 12: 578
83. 41. Phillips JF, Jackson EF, Bawah AA, MacLeod B, Adongo P, Baynes C, et al. The long-term fertility impact of the Navrongo project in northern Ghana. Stud Fam Plann 2012; 43: 175
90. 42. Awoonor-Williams JK, Feinglass ES, Tobey R, VaughanSmith MN, Nyonator FK, Jones TC. Bridging the gap between evidence-based innovation and national health-sector reform in Ghana. Stud Fam Plann 2004; 35: 161
77. 43. Adongo PB, Tapsoba P, Phillips JF, Tabong PT, Stone A, Kuffour E, et al. The role of community-based health planning and services strategy in involving males in the provision of family planning services: a qualitative study in Southern Ghana. Reprod Health 2013; 10: 36. 44. Adongo PB, Phillips JF, Aikins M, Arhin DA, Schmitt M, Nwameme AU, et al. Does the design and implementation of 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. Citation: Glob Health Action 2016, 9: 31907 - http://dx.doi.org/10.3402/gha.v9.31907 proven innovations for delivering basic primary health care services in rural communities fit the urban setting: the case of Ghana’s Community-based Health Planning and Services (CHPS). Health Res Policy Syst 2014; 12: 16. Asante F, Chikwama C, Daniels A, Rmar-Klemesu M. Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana. Ghana Med J 2007; 41: 110
17. Penfold S, Harrison E, Bell J, Fitzmaurice A. Evaluation of the delivery fee exemption policy in Ghana: population estimates of changes in delivery service utilization in two regions. Ghana Med J 2007; 41: 100
9. McKinnon B, Harper S, Kaufman JS, Bergevin Y. Removing user fees for facility-based delivery services: a difference-indifferences evaluation from ten sub-Saharan African countries. Health Policy Plan 2015; 30: 432
41. Dzakpasu S, Soremekun S, Manu A, Ten AG, Tawiah C, Hurt L, et al. Impact of free delivery care on health facility delivery and insurance coverage in Ghana’s Brong Ahafo Region. PLoS One 2012; 7: e49430. Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, LevinRector A, Dwyer L, et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970
2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet 2010; 375: 1988
2008. United Nation (2009). The Millennium Development Goals Report 2009. New York: United Nation. Baiden F, Hodgson A, Adjuik M, Adongo P, Ayaga B, Binka F. Trend and causes of neonatal mortality in the Kassena-Nankana district of northern Ghana, 1995
2002. Trop Med Int Health 2006; 11: 532
9. Welaga P, Moyer CA, Aborigo R, Adongo P, Williams J, Hodgson A, et al. Why are babies dying in the first month after birth? A 7-year study of neonatal mortality in northern Ghana. PLoS One 2013; 8: e58924. Oestergaard MZ, Inoue M, Yoshida S, Mahanani WR, Gore FM, Cousens S, et al. Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Med 2011; 8: e1001080. Dickson KE, Simen-Kapeu A, Kinney MV, Huicho L, Vesel L, Lackritz E, et al. Every newborn: health-systems bottlenecks and strategies to to accelerate scale-up in countries. Lancet 2014; 384: 438
54. Nguah S, Wobil P, Obeng R, Yakubu A, Kerber K, Lawn J, et al. Perception and practice of Kangaroo Mother Care after discharge from hospital in Kumasi, Ghana: a longitudinal study. BMC Pregnancy Childbirth 2011; 11: 99. Ghana Ministry of Health. High impact rapid delivery. Available from: http://www.moh-ghana.org/UploadFiles/Publications/HIRD120506090346.pdf [cited 11 July 2014]. Twum-Danso NAY, Akanlu GB, Osafo E, Sodzi-Tettey S, Boadu RO, Atinbire S, et al. A nationwide quality improvement project to accelerate Ghana’s progress toward Millennium Development Goal Four: design and implementation progress. Int J Qual Health Care 2012; 24: 601
11. Singh K, Speizer I, Handa S, Boadu RO, Atinbire S, Barker PM, et al. Impact evaluation of a quality improvement intervention on maternal and child health outcomes in Northern Ghana: early assessment of a national scale-up project. Int J Qual Health Care 2013; 25: 477
87. Mangiaterra V, Mattero M, Dunkelberg E. Why and how to invest in neonatal health. Semin Fetal Neonatal Med 2006; 11: 37
47. Assessment of the quality of data used for direct estimation of infant and under-five mortality in DHS-II surveys: demographic and health surveys. Available from: http://www.dhsprogram. com/pubs/pdf/OP3/OP3.pdf [cited 21 July 2014]. 11 (page number not for citation purpose)