usaid systems for health project final report...ring resiliency in northern ghana (a usaid project)...
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USAID Systems for Health Project
FINAL REPORT July 1, 2014–December 31, 2019
USAID Systems for Health Project
FINAL REPORT July 1, 2014–December 31, 2019
The authors’ views expressed in this report do not necessarily reflect the view of USAID or the United Stated Government (USG).
Front cover photos: Photos highlighting key elements of USAID Systems for Health work.
March 2020
This report was prepared by the USAID Systems for Health project, which is funded by the American People and jointly sponsored
by the United States Agency for International Development (USAID) and the Government of Ghana (GoG). The project is managed by
University Research Co., LLC (URC) under the terms of Agreement No. AID-641-A-14-00002. URC’s sub-grantees for the
Systems for Health project include PATH, Plan International, and Results for Development Institute.
CONTENTS
Acronyms ............................................................................ vi
List of Tables and Figures ..................................................viii
Executive Summary ..............................................................1
Introduction ......................................................................... 5
Implementation Strategies ............................................... 5
Cross-cutting Activities .......................................................8
Key Activities and Outputs ...............................................9
Key Results ......................................................................12
Quality Improvement / Leadership and Management ........17
Key Activities and Outputs ............................................. 18
An Overview of Key QI Results Found
Throughout This Report ..................................................19
Lessons Learned............................................................. 24
Health Financing ................................................................ 25
Key Activities and Outputs ............................................. 25
Key Results ..................................................................... 26
The Way Forward: Continuation and
Eventual Scale-up ............................................................31
Technical Achievements .................................................... 32
Maternal, Newborn, and Child Health ................................ 32
Key Activities and Outputs ............................................. 33
Evidence-based Interventions ........................................ 35
Key Results ..................................................................... 37
Nutrition ............................................................................42
Key Activities and Outputs ............................................. 42
Key Results .....................................................................44
Family Planning and Reproductive Health ..........................46
Key Activities and Outputs ............................................. 47
Key Results .....................................................................48
Malaria ............................................................................... 53
Key Activities and Outputs .............................................54
Key Results ..................................................................... 55
Infection Prevention and Control ......................................60
Key Activities and Outputs .............................................60
Key Results .....................................................................62
Keys to Success .............................................................. 63
Community-based Health Planning and Services Infrastructure ......................................................64
Key Activities and Outputs .............................................64
Key Results .....................................................................65
Community Mobilization for Community-based Health Planning and Services ............................................ 70
Key Activities and Outputs ..............................................71
Key Results ..................................................................... 74
Partner Coordination ......................................................... 78
Community Mobilization for CHPS (Including BCC) ......... 78
Family Planning and Reproductive Health ...................... 79
Health Financing ............................................................ 79
Infection Prevention and Control .................................... 79
Infrastructure and Medical Supplies ............................... 79
Malaria ........................................................................... 79
Maternal, Newborn, and Child Health ............................. 79
Nutrition ........................................................................80
Quality Improvement .....................................................80
Lessons Learned and Recommendations ........................... 81
Annex 1 ..............................................................................84
Performance Monitoring Plan Table ...................................84
Annex 2 .............................................................................98
Akatsi South Success Story: Increasing the Use
of Primary Care Services through Quality
Improvement and District Collaboration ............................98
CHPS Design Success Story: Incorporating Gender and
Privacy Concerns in the Design of CHPS Compounds ....... 100
Cord Sepsis Success Story: Reducing Cord Sepsis
in Neonates at Chereponi Government Hospital .............. 102
Ebola Success Story: Religious Leaders in
Ghana Unite Against the Ebola Virus ................................ 104
MAZA Success Story: Saving Lives Through
Improved Transportation in Rural Ghana ......................... 105
Emergency Obstetric Success Story: Improving
Care in Targeted Hospitals to Reduce Institutional
Maternal Mortality, Northern Region ............................... 108
QI Success Story: A Performance-based Leadership-led
Quality Improvement Initiative Improves Access
to Skilled Delivery in the Western Region .......................... 110
iv
ALMA African Leaders Malaria AllianceANC Antenatal CareASSIST Applying Science to Strengthen and Improve
Systems (a USAID project)
BCC Behavior Change Communication
C4H Communicate for HealthCHMC Community Health Management CommitteeCHN Community Health NurseCHO Community Health OfficerCHPS Community-based Health Planning and ServicesCHRB Child Health Record BooksCHV Community Health VolunteerCHW Community Health Worker CR Central RegionCWC Child Welfare Clinic
DHD District Health DirectorateDHIMS2 District Health Information Management System 2DHMT District Health Management Team
E4H Evaluate for Health (a USAID project)ENA Essential Nutrition ActionsENC Essential Newborn CareETAT Emergency Triage, Assessment, and Treatment
FAA Fixed Amount AwardFHD Family Health Division (part of the GHS)FP Family Planning
GAR Greater Accra RegionGHS Ghana Health Service (a part of the MOH)GHSC-PSM Global Health Supply Chain Program – Procurement
and Supply Management (a USAID project)GoG Government of Ghana
HFG Health Finance and Governance (a USAID project)
ICC-CS Interagency Coordinating Committee on Contraceptive Security
ICD Institutional Care Division (a part of the GHS)IHI Institute for Healthcare ImprovementIMNCI Integrated Management of Newborn and Childhood
IllnessesIPC Infection Prevention and ControlIPTp Intermittent Preventive Treatment in PregnancyIPTp3 The third dose of IPTpIUD Intrauterine Device
JICA Japan International Cooperation Agency
KOICA Korean International Cooperation Agency
LARC Long-acting Reversible ContraceptiveLB Live BirthsLLIN Long-lasting Insecticidal NetLM Leadership and ManagementLSS Life Saving Skills
MCHIP Maternal and Child Health Integrated ProgramMCSP Maternal and Child Survival ProgramMDSR Maternal Death Surveillance and Response
MHRB Maternal Health Record BookMMR Maternal Mortality RatioMNCH Maternal, Newborn, and Child HealthMOH Ministry of HealthMOU Memorandum of Understanding
NHIA National Health Insurance AuthorityNHIS National Health Insurance SchemeNHQS Ghana National Healthcare Quality Strategy (2017-2021)NMCP National Malaria Control Program (part of the GHS)NR Northern Region
PPME Policy, Planning, Monitoring, and Evaluation Division (a division of the GHS)
PPP Preferred Primary Care Provider (Network)PSM Procurement and Supply Management (a USAID project)PTFU Post-training Follow-upPWD Person with Disability
QI Quality Improvement
RDT Rapid Diagnostic TestRH Reproductive HealthRHD Regional Health DirectorateRHMT Regional Health Management TeamRING Resiliency in Northern Ghana (a USAID project)RMNCAH Reproductive, Maternal, Newborn, Child, and
Adolescent HealthRRIRV Request Receipts Issued and Report VouchersRRT Regional Resource Team
SAM Severe Acute MalnutritionSBCC Social and Behavior Change CommunicationSDG Sustainable Development GoalSMART Specific, Measurable, Achievable, Relevant, and
Time-relatedSP Sulfadoxine/PyrimethamineSPRING Strengthening Partnerships, Results, and Innovations
in Nutrition Globally (a USAID project)
T3 Test, Treat, TrackTOT Training of TrainersTTI Time Temperature IndicatorTWG Technical Working Group
UGSPH University of Ghana School of Public HealthUNICEF United Nations Children’s Fund (originally known as
the United Nations International Children’s Emergency Fund)
URC University Research Company, LLCUS United StatesUSAID United States Agency for International DevelopmentUSG United States Government
VR Volta Region
WASH Water, Sanitation, and HygieneWHO World Health OrganizationWR Western Region
ACRONYMS
v
TABLES AND FIGURES
TablesTable 1. On-site Support Visits—Key Activities and Outputs.......................................................................................................................... 8
Table 2. Health Information Systems—Key Activities and Outputs ............................................................................................................... 9
Table 3. Supply Chain—Key Activities and Outputs ......................................................................................................................................10
Table 4. Referrals—Key Activities and Outputs .............................................................................................................................................11
Table 5. Quality Improvement/Leadership and Management—Key Activities and Outputs .........................................................................18
Table 6. Final Leadership-led QI Outcomes ..................................................................................................................................................23
Table 7. Health Financing—Key Activities and Outputs ............................................................................................................................... 25
Table 8. Maternal, Neonatal, and Child Health—Key Activities and Outputs ................................................................................................33
Table 9. Progress on Improvement Aims for Maternal Death Interventions at Three District Hospitals in Three Regions ........................... 41
Table 10. Nutrition—Key Activities and Outputs ......................................................................................................................................... 43
Table 11. Family Planning and Reproductive Health—Key Activities and Outputs .........................................................................................47
Table 12. Examples of Change Ideas to Improve FP ..................................................................................................................................... 48
Table 13. Malaria—Key Activities and Outputs ............................................................................................................................................ 54
Table 14. Malaria-related Aims of Shared Learning ..................................................................................................................................... 56
Table 15. Infection Prevention and Control—Key Activities and Outputs .................................................................................................... 60
Table 16. Community-based Health Planning and Services—Key Activities and Outputs ............................................................................ 64
Table 17. Action Steps from the CHPS National Implementation Guidelines ................................................................................................ 70
Table 18. Community Mobilization—Key Activities and Outputs .................................................................................................................. 71
Table 19. Akatsi South Success Story—Problems Concerning National Health Insurance Utilization and Related Interventions ................ 99
Table 20. Shared Learning Improvement Aims and Activities ....................................................................................................................109
Table 21. Indicators of Change Resulting from the Western Region’s QI Project Concerning Skilled Delivery ............................................. 111
FiguresFigure 1. A map of Ghana with the shaded (green) areas representing the five regions in which Systems for Health operated ......................5
Figure 2. A map of the number of on-site support visits............................................................................................................................... 12
Figure 3. An example of the Greater Accra Region’s data dashboards, which help to assess each district’s performance using priority service delivery indicators ...................................................................................................................................... 14
Figure 4. A map and photo of districts’ shared learning activities ................................................................................................................ 21
Figure 5. A map of Ghana showing the results of financial risk assessments conducted during coaching visits to districts ....................... 26
Figure 6. The increases in the percentage of districts with adequate capacity to manage USG funds .........................................................27
Figure 7. Reductions in the percentage of rejected claims .......................................................................................................................... 28
Figure 8. A map of the shared learning topics covered to enhance MNCH services in the Greater Accra, Northern, Volta and Western Regions ....................................................................................................................................................................35
Figure 9. An 11.9% increase in skilled delivery coverage in eight of the Western Region’s districts ..............................................................37
vi
Figure 10. The proportion of births attended by a skilled health worker vs. a traditional birth attendant, comparing baseline to endline data in three subdistricts ........................................................................................................... 38
Figure 11. Institutional MMR: Shared learning districts in Greater Accra, Northern, and Volta.................................................................... 39
Figure 12. Stillbirth rates in shared learning districts in Greater Accra, Western, and Volta, October 2014–September 2019 .................... 39
Figure 13. The reduction in the neonatal mortality rate in six shared learning districts in the Volta Region ............................................... 39
Figure 14. Dramatic improvements in the SAM cure rates in Greater Accra’s shared learning districts ....................................................... 44
Figure 15. A 149% increase in CWC registration at 26 newly constructed CHPS zones ............................................................................... 44
Figure 16. A 79% increase in CWC attendance in 483 target CHPS zones ................................................................................................... 44
Figure 17. Reductions in underweight under-5 children in the Wassa East District, Western Region, after two rounds of improvement projects ................................................................................................................................. 45
Figure 18. A map of Ghana showing the 24 districts in four regions using shared learning to improve FP coverage ................................... 48
Figure 19. A 41% increase in FP new acceptors since the October 2016–September 2017 period ............................................................... 48
Figure 20. A steady increase in IUD new acceptors since September 2015 ................................................................................................. 49
Figure 21. An overall increase in IUD and implant new acceptors, with a slight decrease from October 2018–September 2019 ................ 49
Figure 22. The increase in CHPS facilities offering at least four modern methods of FP, Year 1 to Year 5 ................................................... 49
Figure 23. A map of Ghana showing malaria-related topics at shared learning sessions ..............................................................................55
Figure 24. The percentage increase in the number of women receiving three doses of SP (i.e., IPTp3 coverage) ........................................ 56
Figure 25. IPTp3 coverage in six shared learning districts in Volta vs. overall regional performance .......................................................... 58
Figure 26. The increase in the number of suspected malaria cases tested, Year 1 to Year 5 ........................................................................ 58
Figure 27. Decreases in the under-5 case fatality rates at Northern and Western shared learning facilities ............................................... 59
Figure 28. The inpatient under-5 malaria case fatality rate, all project-supported regions ......................................................................... 59
Figure 29. Percentage of Providers Meeting Competency Standards When Performing IPC Tasks ............................................................ 62
Figure 30. The increases in key primary care services, from Year 2 to Year 5, in 26 CHPS zones with new facilities ................................... 65
Figure 31. A 300% increase in ANC registrants (left chart) and an astronomical increase in the number of deliveries from Year 2 to Year 5 (right chart) ............................................................................................................................................... 66
Figure 32. A map of Ghana showing the 483 CHPS zones that were the focus of community mobilization efforts ..................................... 70
Figure 33. The progress on action plan implementation per region .............................................................................................................74
Figure 34. The percentage of CHPS facilities that have reached the threshold to be considered fully functional.........................................76
Figure 35. Key services provided in the 483 project-supported CHPS zones, a comparison of Year 2 to Year 5 ...........................................77
Figure 36. The number of people per quarter in Akatsi South who accessed outpatient departments for health care ............................... 99
Figure 37. The initial 2015 CHPS compound design and the revised design ............................................................................................... 101
Figure 38. A graph illustrating the decline in the number of newborns with cord sepsis at the Chereponi Government Hospital from January 2015 to December 2017 ......................................................................................................................... 103
Figure 39. The proportion of births attended by a skilled health worker vs. a traditional birth attendant, comparing baseline to endline data in the three sub-districts where MAZA operated ..............................................................106
Figure 40. The maternal deaths and MMR (per 100,000 LB) for 10 hospitals in the Northern Region, FY16–FY19 ..................................109
Figure 41. The combined stillbirth rate, per 1,000 births, from January 2017 to May 2019 in two districts of the Western Region: Wassa Amenfi West and Sefwi Wiawso ................................................................................................112
1
After five and a half years of successful
implementation, the United States Agency for
International Development (USAID) Systems of
Health project achieved measurable improvements in service
delivery and health outcomes. Through strategic, targeted
investments in the health system, the project positively
impacted maternal and perinatal mortality rates, family
planning (FP) uptake, malaria case fatality rates, and overall
utilization of primary care services. To ensure sustainability
beyond the life of the project, Systems for Health worked
side-by-side with Ghana’s health leaders in data-driven
planning and quality improvement (QI) and health leaders
rose to the challenge in many ways and fully engaged in all
aspects of implementation.
First, leaders and their staff demonstrated a keen ability
to manage their own projects and funds, both crucial for
the long-term growth of the health system. The Regional
Health Directorates (RHDs) in all five project-supported
regions directly implemented leadership-led improvement
projects through Fixed Amount Awards. This work was the
culmination of previous investments over the life of the
project to improve the readiness of the Ghana Health Service
(GHS) to access donor funds, pursue QI approaches, use data,
and enhance clinical competency to accelerate reductions in
preventable maternal and child deaths. The RHDs achieved
impressive results in intervention districts and/or facilities,
with an 11% reduction in the stillbirth rates in Greater Accra
(11 hospitals), 43% in Western (two districts), and 23% in
Volta (six districts). The Northern Region also reduced their
maternal mortality ratio (MMR) by 23% and their under-5
malaria case fatality rate by 15% (10 hospitals).
District-level health leaders also demonstrated strong
project-management capabilities, just as their regional
counterparts did. Coupled with ongoing technical assistance
to 114 District Health Directorates, Systems for Health helped
build financial and administrative capacity; 86% of health
directorates now demonstrate the capacity to manage donor
funds (compared to a baseline of 18%). These skills support
Ghana on its journey to self-reliance and USAID in its plans
to increasingly transition activities to direct government-to-
government funding.
Second, Ghana’s health leaders rose to the challenge of
pursuing innovative and more efficient health financing
models so that a growing population can access quality,
primary health care services and so that the country can
achieve universal health coverage. Systems for Health
worked with the GHS and 42 facilities to pilot Preferred
Primary Care Provider (PPP) networks, each of which
links several community-level facilities with a sub-district-
level facility. These networks were able to provide a more
comprehensive package of primary care services and
demonstrated many promising practices and results.
Many networks achieved dramatic reductions in their
National Health Insurance Scheme rejection rates. Cases
at Community-based Health Planning and Services (CHPS)
facilities are better managed now than they were before
the project’s PPP networks were founded, often averting
referrals because of improved communication between levels
of care. Where referrals are needed, they happen early. As
a result, the quality of care has increased, especially in the
South Dayi District, where they had zero maternal deaths
in 2018 and 2019. With support from the GHS, the Ministry
of Health, and the National Health Insurance Authority, the
networks will continue to function beyond the life of the
project.
The project team made referral strengthening a vital
component of grants, community mobilization, leadership-
led QI projects, and more. For example, several sub-districts
of the Northern Region established a motorized-tricycle
transport system to increase rates of skilled births. An
independent survey showed an increase in skilled delivery
attendance from 49% at baseline to 96% at endline.
Facilities in Greater Accra used the social media platform
WhatsApp to build an early warning system, which improved
communication and pre-referral treatment of emergencies.
In the receiving facility that first instituted the WhatsApp
EXECUTIVE SUMMARY
2
system, 50% of the cases have initiated treatment at the
referring facility to stabilize the patients before transfer,
according to the system’s guidelines. Plus, the platform
is expanding to additional receiving facilities. One final
example: The project helped to improve health care and
referrals in 141 hard-to-reach island communities of Volta
by designing and building a 25-seat medical pontoon boat
and then transferring ownership to the GHS in December
2018. Using this life-saving vessel, the district has thus
far implemented mass immunizations and supportive
supervision visits.
Another area where health leaders rose to the challenge
of better utilizing QI and data is in facilitating knowledge
sharing. In the latter half of the project, Systems for Health
focused much of its efforts on empowering the GHS to
sustain ongoing shared learning activities in 75 districts
across the five regions. Shared learning promotes peer-
to-peer learning and joint problem solving among groups
of health facilities. This package of activities continued
to show reductions in mortality (as of September 2019)
and contributed to sustainable improvements in health
across all technical areas. Select districts in all five regions
implemented shared learning sessions concerning maternal,
neonatal, and/or child health. At the same time, Greater
Accra, Northern, and Volta (29 districts) collectively
achieved a 42.1% reduction in their MMR (since Year 2 of
the project of the project—i.e., October 2015–September
2016). Furthermore, Greater Accra, Volta, and Western (25
districts) reduced the stillbirth rate by 35.2% (since Year
2). Shared learning for malaria case management in the
Northern and Western Regions (14 hospitals) saw a 77.9%
decrease in inpatient under-5 malaria case fatality rates
(since Year 2). After just 15 months of implementation, 21
shared learning districts (in Central, Greater Accra, Volta, and
Western) achieved a 16.1% increase in Intermittent Preventive
Treatment in Pregnancy coverage. Finally, 24 shared learning
districts (in Central, Northern, Volta, and Western) reported a
41% increase in FP acceptors compared to Year 3.
While leaders can ensure the sustainability of high-quality
health services and care through better management
and knowledge sharing, improving access to high-quality
primary health care is a separate component that must
guarantee sustainability in different ways. Systems for Health
helped 483 CHPS zones move closer to full functionality by
mobilizing communities and engaging district- and sub-
district-level stakeholders, which is crucial for increasing
access to a basic package of primary health care services
for women and children. With project support, 85% of these
CHPS zones have achieved full functionality based on the
achievement of at least 13 out of 15 key implementation
steps. To help ensure the sustainability of mobilized
communities, the project supported the launch of the Ghana
Community Scorecard. This management tool empowers
communities to give feedback to health authorities and
better understand local health outcomes. Perhaps most
importantly, it sets the stage for an ongoing dialogue
between communities and CHPS zones to continuously
improve the quality of and access to primary health care.
Over the life of the project, CHPS zones progressively
provided more preventive and primary care services with
more than 500,000 additional key services provided in the
483 project-supported CHPS zones in Year 5 when compared
to Year 2.
Having a health facility is a key step in achieving full CHPS
functionality and increasing access to primary care. Systems
for Health constructed new CHPS compounds and renovated
an additional 50 health facilities in the Northern and Volta
Regions—providing many new compounds with access to
solar power and boreholes. All 26 newly constructed CHPS
compounds offer a full range of services and have shown
dramatic increases in service utilization. Deliveries increased
from eight in Year 2 to 734 in Year 5. During the same period,
the number of women accessing antenatal care dramatically
increased from 422 to 1,694. Utilization also increased for
most major primary health care services from Year 2 to Year
5. The number of outpatient-department cases increased by
376%, the testing of suspected malaria cases increased by
360%, and new FP acceptors increased by 46%.
All the successes listed above are a direct result of the
excellent collaboration and engagement achieved with the
GHS counterparts. They were the drivers of this work and
fully embraced the evolution of the project’s implementation
strategies to promote a culture of continuous improvement
within the GHS. Now that the project has ended, GHS leaders
and staff members are poised to continue working toward
sustainable improvements in equitable access to care and
health outcomes.
3
Overview of the DocumentHere is a quick guide to the chapters in the main body of the report:
The infographic on the next page showcases the key
achievements achieved over the five and half years of the
project.
The chapters of Implementation Strategies, Cross-Cutting
Activities (including Health Information Systems, Supply
Chain and Referrals), Quality Improvement and Leadership
Management, and Health Financing represent the
foundational elements of the project. These chapters provide
an overview of our implementation strategies and how they
were applied throughout the technical portfolio.
The Technical Achievements chapters (Maternal, Newborn
and Child Health; Nutrition, Family Planning Reproductive
Health, Nutrition and Infection Prevention and Control)
include the specifics of intervention packages and their
associated results.
The project’s approaches and results to improve access to
high-quality health care are discussed in the Community-
Based Health Planning and Services (CHPS) Infrastructure
and Community Mobilization for CHPS sections.
The Partner Coordination of the report highlights the
numerous organizations which the project collaborated to
achieve results and improved synergy of efforts.
The final chapter of the report discusses the key Lessons
Learned and Recommendations gleaned over the five and
half years of the project.
4
KEY ACCOMPLISHMENTS IN GHANA 2014-2019
59,00016,000+ COACHING VISITS WITH
GHS TO HEALTH FACILITIES
TRAINING CONTACTS
OVER
IMPLEMENTING QI PROJECTS
89
NEW CHPS CONSTRUCTED
26
HEALTH FACILITIES RENOVATED
50
CHPS FACILITIES OFFERING 4+ MODERN FAMILY PLANNING METHODS
47% 80%2015 2019
HEALTH DIRECTORATES HAVE ADEQUATE CAPACITY TO MANAGE US GOVERNMENT FUNDS
18% 86%2015 2019
INCREASE IN NEW ACCEPTORS OF LONG-ACTING REVERSIBLE
CONTRACEPTIVES (IUD AND IMPLANT)
91%
DECREASE IN
UNDER-5 MALARIA
CASE FATALITY
RATE IN 15
HOSPITALS IN
NORTHERN AND
WESTERN REGIONS
HEALTH WORKERS TRAINED IN INFECTION
PREVENTION AND CONTROL
20,500 273 292016 2019
DISTRICTS
DECREASE IN MATERNAL MORTALITY RATIO IN 29 SHARED LEARNING DISTRICTS
42%2015-2019
35%2015-2019
REDUCTION IN INSTITUTIONAL STILLBIRTH RATE IN 25 SHARED LEARNING DISTRICTS
78%
DEATHS DEATHS
5
The United States Agency for International
Development (USAID) Systems for Health project
worked with the Ghana Health Service (GHS) to
strengthen efforts to reduce preventable child and maternal
deaths, reduce unmet need for family planning (FP) services,
reduce childhood mortality and morbidity from malaria,
and improve the nutritional status of children under
five and pregnant women. Over five and a half years of
implementation, the project enhanced vital health-system
building blocks while maximizing service coverage. It
promoted Community-based Health Planning and Services
(CHPS), strategic behavior change communication (BCC),
and targeted demand generation. Systems for Health has
left a legacy of strengthened Ghanaian health systems
that are empowered to pursue independent and lasting
improvements far beyond its conclusion.
URC and its partners have shared and achieved a common
vision: In 2019, Ghana’s health system is sufficiently robust
for the government and its health workforce to sustain
equitable access to, demand for, and use of high-quality,
high-impact health services in partnership with the
communities they serve and with reduced external support.
Implementation Strategies In the first two years of the project, Systems for Health laid
the foundation for technical activities by updating technical
guidelines and training materials. Years 2 and 3 saw these
trainings roll out across all five project regions. In Year 3
and beyond, the project progressively narrowed its focus to
sustaining and complementing gains in provider competency
through GHS-led on-site coaching and mentoring.
Shared learning was expanded to 75 districts. Leadership
engagement was enhanced through the development and
implementation of leadership-led quality improvement (QI)
projects.
In its final year, the project emphasized implementation
strategies to further integrate a culture of continuous
improvement within the GHS and enhance the readiness to
access and directly manage United States Government (USG)
funds. Core elements of the project’s approach included the
following:
More Efficient and Effective Use of ResourcesOver the life of the project, Systems for Health gradually
shifted activities away from regional capitals and hotels to
the district, sub-district, and facility levels. This evolution
not only reduced costs but also enhanced activity coverage,
allowing increased participation from GHS managers
INTRODUCTION
Figure 1. A map of Ghana with the shaded (green) areas representing the five regions in which Systems for Health operated
6
and providers and making it easier for the GHS to sustain
implementation beyond the life of Systems for Health.
This approach yielded results in technical areas that were
previously lagging, such as maternal mortality, stillbirths,
and neonatal mortality.
Improved GHS Readiness for Direct FundingThe project’s health financing, leadership, and QI work
converged when Systems for Health gave Fixed Amount
Awards (FAAs) to each Regional Health Directorate (RHD)
to implement a regionally specific, leadership-led QI project
aimed at improving key maternal, newborn, and child health
(MNCH) indicators. These awards built upon the work
done in previous years to prepare the RHDs technically and
administratively to take on high-level health challenges
independently. The regions designed and implemented
their own projects, which achieved results and enabled
teams to adopt new strategies to reduce maternal and child
mortality. See details in Quality Improvement/Leadership
and Management chapter. This work, coupled with technical
assistance in the management of USG funds, prepared RHDs
and District Health Directorates (DHDs) for eventual direct
funding.
Enhanced Use of DataThe robust nature of the District Health Information
Management System 2 (DHIMS2) ensures access to a
tremendous amount of information on service delivery at all
levels of care. However, a high-level review of the data does
not always offer complete information on the effectiveness
of project-supported interventions. Systems for Health
promoted the use of disaggregated data, emphasizing
district and facility-level values to target interventions to
facilities and districts with the highest service delivery gaps
and improving the efficiency and effectiveness in achieving
desired health outcomes. This approach also built the skills
of GHS leaders and providers to systematically use data
to implement adaptive interventions while addressing
challenges and sustaining systems-level change.
Shared LearningShared learning promotes best practices and joint problem
solving as the primary means to accelerate peer-to-peer
learning within groups of health facilities. Multidisciplinary
teams work collaboratively on common objectives and
focus on improving service delivery and health outcomes.
Under the leadership of GHS Improvement Coaches (trained
with project support), teams monitored process indicators
and DHIMS2 data to carry out QI cycles: identifying gaps,
proposing solutions, and evaluating whether changes were
leading to improvements. Since most of these activities were
carried out within districts, the GHS worked to integrate
shared learning sessions into routine meetings and sustain
efforts without external funding.
On-site CoachingBuilding provider and facility capacity takes time and
consistency; Systems for Health supported the GHS to coach
former trainees, institutionalize the competencies learned
during trainings, and support process improvement at
facilities throughout the five regions. With the use of data
from previous visits and DHIMS2, on-site mentoring focused
on specific competencies and challenges in targeted facilities
Health workers review data
7
or geographic areas. Coaching visits also targeted facilities
and districts that were participating in shared learning to
support the implementation of change ideas and enhanced
results. The project embraced a focused approach, ensuring
frontline workers benefited from one-on-one time with
supervisors through supportive supervision, integrated
coaching, and post-training follow-up (PTFU) visits. Core
elements of the process included data-driven planning,
counseling, constructive feedback, and supportive problem
solving.
Community Engagement in Primary Health CareOne of the aims of the project was to improve equitable
access to, demand for, and use of high-quality, high-impact
health services, with a focus at the primary care level—the
level of CHPS zones. To this end, the project used the
CHPS National Implementation Guidelines to improve the
functionality of targeted CHPS zones across all regions.
Systems for Health continued to support community
engagement and technical assistance to strengthen CHPS
implementation systems. Looking toward sustainability,
Community members discuss the quality of care with health providers
the project supported the rollout of the Ghana Community
Scorecard to empower community members and health
providers to work collaboratively to improve the quality
of primary health care services. These activities resulted
in considerable gains in the number and range of services
provided in supported CHPS zones.
8
CROSS-CUTTING ACTIVITIES
During its five and a half-yearmission, the Systems for
Health project has been dedicated to improving integrated
service delivery and, ultimately, ensuring high-quality health
care. The project collaborated with the GHS to integrate
and strengthen health providers’ knowledge and technical
capabilities as well as facility preparedness. And the team
targeted the priorities defined by each region, district, and
health facility. This chapter shares these cross-cutting
activities—interventions that diverged from a one-size-fits-all
technical area, instead, spreading across multiple indicators
that will be seen throughout the report.
First, this chapter discusses on-site visits, which were
critical to improving provider competency and facility
readiness by delivering coaching and mentoring within
their own environments. Planning was a core component
of the visits, and Systems for Health and the GHS reviewed
data and reports with members of the region, district,
and/or facility to determine priority interventions and
geographic areas. Beyond on-site visits, this chapter
focuses on health information systems, supply chain, and
referral activities, as they cut across technical areas and
were integrated into coaching visits, QI, and other activities
wherever possible. For example, the team integrated data
and information-system education and monitoring into
the planning and implementation of all activities. Similarly,
referral management and supply chain management—
both critical elements for ensuring quality of care—were
incorporated into all follow-up visits and QI activities.
Key objectives of the cross-cutting activities included the
following:
u Build capacity of GHS staff through on-site coaching and
supportive supervision.
u Integrate technical and systems-strengthening activities,
incorporating the private health sector as appropriate.
u Improve the availability of quality, safe, and efficacious
health products at service delivery points and facilities in
the five Systems for Health regions.
u Strengthen readiness of sub-district-level facilities to
provide appropriate and timely referrals, including the
improvement of pre-referral preparation before clients
leave sub-district facilities.
u Accelerate progress in achieving results, particularly
concerning service delivery and health outcomes.
Activity Output
On-site support visits Over the life of the project, Systems for Health supported a wide range of on-site support visits totaling
over 16,000, including the following:
• Supportive supervision visits conducted by the GHS (and funded through FAAs) covered all districts
in the 5 regions.
• PTFU visits covered all districts in the 5 regions.
• 483 targeted CHPS zones received CHPS strengthening visits (including more frequent visits to
newly constructed or renovated facilities).
• Integrated coaching visits covered all districts in the 5 regions.
• 75 districts participating in shared learning activities received at least 2 follow-up visits to
strengthen the implementation of QI projects.
Table 1. On-site Support Visits—Key Activities and Outputs
9
Key Activities and OutputsOn-site Support VisitsIn collaboration with the GHS, Systems for Health used
gaps identified during previous site visits to focus on-
site support visits on specific competencies that were
continued challenges for certain facilities or geographic
areas. Coaching visits also targeted facilities and districts
that were participating in shared learning to support the
implementation of change ideas and enhance results. All
visits strongly emphasized the importance of reporting and
using high-quality data. Coaches also encouraged staff to
embrace creative solutions to improve service delivery.
These visits progressively formed the backbone of
implementation as the project supported the GHS to
sustainably transform service delivery. To maximize limited
resources and to encourage the GHS to plan for continued
on-site support visits after the end of the project, many visits
were combined (e.g., PTFU and shared learning visits within
the same district). Thus, it is difficult to quantify the exact
number of visits conducted by technical area.
Health Information Systems Sustainable programming depends on improving the use of
data for decision making. From the beginning of the project,
Systems for Health prioritized support to GHS to improve
competencies in data management and to institutionalize
data use in existing systems. Activities listed in the next table
have a direct link to the goal of improving data use, which
cuts across all technical areas.
Activity Output
Improved use of
disaggregated data
Over the life of the project, Systems for Health collaborated with the GHS in all 5 regions to improve the use of disaggregated service delivery data to track performance and provide feedback. In the Greater Accra Region (GAR), Volta Region (VR), and Northern Region (NR), this collaboration included the use of a dashboard for the quarterly, district-level review of priority service delivery indicators. See the dashboard in Figure 2, an example from GAR, which rated each district’s performance against a set of indicators.
311 health management staff from regional and district levels participated in data visualization workshops designed to help increase the use of DHIMS2 data to improve service delivery, increase quality, and support regular feedback to sub-district facilities. See additional details in the “Spotlight on Improved Capacity in Data Analysis and Visualization” callout box.
Update of the Standard Operating Procedure (SOP) for Health Information Management
The project provided financial and technical assistance to the GHS to update the SOP. This update was necessitated by gaps identified in the use of the document. Some existing indicators, as well as new indicators and datasets, were better defined. The revision also included updated procedures for features of DHIMS2.
DHIMS2 Technical
Boot Camp
Systems for Health supported health information technical working-group sessions with key staff from the national divisions of the GHS. Annual workshops aimed to improve the definition and use of data from DHIMS2. Sessions often included the review and revision of indicators to realign and reprogram related formulas in DHIMS2.
Working-group members also developed the reports Health Sector in Ghana: Facts and Figures for 2018 and 2019. These documents serve as information and planning tools for policy-makers and health service/program managers, as well as a handy reference on the health sector’s performance.
Table 2. Health Information Systems—Key Activities and Outputs
A district-level supervisor coaches on how to accurately complete data reporting forms and registers
10
Activity Output
Commodity
management training
for frontline service
providers
27 regional and district-level supply chain managers trained as trainers on the management of public
sector commodities.
675 Community Health Officers (CHOs), Community Health Nurses (CHNs), midwives, storekeepers, and
pharmacy technicians trained.
Strengthened
documentation and
commodity tracking
Convened a technical working group (TWG) of GHS staff from national-level programs and the regions
to review and update the GHS Request Receipts Issued and Report Vouchers (RRIRV) for commodity
management. Supported dissemination of the updated RRIRV.
150,000 Inventory Control Cards (30,000 per region) printed and distributed. The card is the primary
logistics management information system used to track commodity availability at all levels of the supply
chain system.
On-site coaching
on commodity
management
Coaching on commodity management was integrated into on-site support visits, particularly for shared
learning activities and targeted PTFU visits. Coaches assessed the availability of key commodities and
supported facilities/providers in managing the products well and ensuring availability.
Supply chain in QI
projects
Techniques to improve commodity availability were integrated into many of the shared learning projects
as well as the leadership-led QI projects. For example, VR focused on increasing the availability of
neonatal resuscitation equipment while NR worked to improve the availability of essential emergency
medicines at Emergency Triage, Assessment, and Treatment (ETAT) delivery points. See this chapter’s
Key Results section for details.
Table 3. Supply Chain—Key Activities and Outputs
Supply ChainAn effective supply chain requires skilled workers with
necessary tools, infrastructure, and technical support; timely
monitoring of supply status and reporting; and a functional
and efficient distribution system. In the first half of the
project, Systems for Health built the capacity of regional,
district, and frontline service providers in commodity
management and supported the GHS in updating and/or
distributing commodity management tools.
With the launch of the USAID-funded Procurement and
Supply Management (PSM) project in Ghana midway through
the project, Systems for Health coordinated and collaborated
closely with PSM staff to ensure each project’s respective
approaches were synergistic and not duplicative. Systems
for Health subsequently shifted its support to more fully
integrate supply chain management into on-site coaching
visits and shared learning activities across all technical areas.
Visits to facilities included reviewing logistics records (stock
cards, the laboratory management information system),
assessing the stock status of commodities, conducting
physical inventories, and assessing storage conditions.
District/facility teams received support in implementing
service delivery changes to reduce commodity stock-outs
at the facility level.
A well-organized hospital IPC commodity storage area
11
ReferralsReliable referral systems are needed between lower and
higher levels of the health system to ensure continuity
of care for more complex cases and to reduce the risk
of adverse outcomes. In Ghana, the development of
reliable referral systems has been hampered by poor
telecommunications networks; the limited availability of
ambulance services or other transport solutions, especially
in rural areas; and an inadequate appreciation of the
importance of continuity of care. Over the five years of the
project, referral strengthening was integrated into CHPS
implementation, community mobilization, shared learning
sessions, leadership-led QI projects, and on-site support
visits.
Activity Output
Shared learning Referral strengthening was integrated into shared learning sessions by including both referring and
receiving facilities in most shared learning groups (particularly within a district). Their participation
helped to address key challenges, such as pre-referral care, timeliness of referrals, and communication
between levels of care before, during, and after referrals.
Referrals
strengthening at
the CHPS level,
Community Health
Management
Committee (CHMC)
meetings, and CHO
coaching
483 target CHPS zones across the 5 regions received ongoing technical support to improve community
emergency transport systems.
In NR, CHOs and CHMC members in 22 districts participated in technical coaching visits to strengthen
referrals at the CHPS level. As a result, 60 functional community emergency transport systems are
currently operating and accessible to CHPS zones.
Referral strengthening included the identification of referral gaps, analysis, agreed-upon possible
solutions, and the development and implementation of action plans. The focus was on the first 2
delays—(1) the delay in decision making and (2) the delay in reaching the first point of care—as well as on
improving the feedback loop to the original facility/provider that referred the client.
Improved referrals
to underserved
communities in VR
A 25-seater pontoon boat was formally commissioned and transferred to the GHS. The boat is being
used to provide routine and emergency services to underserved island communities in VR. See details in
this chapter’s Key Results section.
Grants for referrals 4 innovation grants included referral strengthening activities in NR and GAR. These projects focused on
obstetric emergencies (Kybele), community emergency transport (MAZA and Navrongo Health Research
Centre), and FP and skilled delivery for people with disabilities (University of Ghana School of Public
Health [UGSPH]).
GHS Referral Policy
and Guidelines
NR: 152 providers from all 26 districts trained in the GHS Referral Policy and Guidelines. Participants
included the District Director of Health Services, midwives, public health, nurse managers, nurses,
physician assistants, CHNs/CHOs, and staff nurses.
Table 4. Referrals—Key Activities and Outputs
A motorized tricycle and trained driver for referrals
12
Key Results
Improved data quality and service delivery in 114 districtsOver the five and a half years of the project, over 2,800
facilities in 114 districts received at least one on-site support
visit, and priority facilities received multiple visits each year
(Figure 2) for a total of over 16,000 facility visits conducted
by the GHS.
Figure 2. A map of the number of on-site support visits
An Integrated coaching visit jointly addresses data and service delivery issues
Leadership in the Northern Region reviews performance using key indicators
13
SPOTLIGHT
Improved Capacity in Data Analysis and Visualization
Since its inception, the Systems for Health project emphasized the use of data for decision making. For example, the project
prioritized supervision visits based on areas of need that were identified by continuously reviewing service delivery data.
In the latter half of the project, this support increasingly focused on strengthening the capacity of service providers and
management personnel to analyze and visualize district-level service delivery indicators for management decision making
through district-based workshops and reviews of key indicators in the Northern, Volta, and Greater Accra Regions.
District Directors, Disease Control Officers, Public Health Nurses, and Health Information Officers received hands-on,
practical instruction in the following:
u Data extraction in DHIMS2
u Data cleaning techniques in Microsoft Excel
u The generation of pivot tables and slicers in Excel and pivot charts
u The use of pivot charts to build a dashboard
Districts used the dashboards to effectively monitor the performance of key service indicators at the sub-district and facility
levels. The dashboards have also been deployed to improve data analysis in Excel for effective feedback to lower levels.
In many regions, the GHS also used the scorecard concept to develop district-wide performance league tables (Figure 3).
These tables serve as a management tool for improved decision making, generating healthy competition among regions and
districts.
A screenshot of a sample dashboard.
14
Figure 3. An example of the Greater Accra Region’s data dashboards, which help to assess each district’s performance using priority service delivery indicators
Districts ANC CoverageSkill Delivery
Coverage% FP Acceptor
Rate % 1st PNC Data %SB Rate % MR 1 Coverage Penta 3 CoverageMalaria testing
rate (%) Position
Ledzokuku 3 3 3 3 3 3 3 3 1
Shai-Osudoku 3 3 3 3 2 3 3 3 2
Accra Metro 3 3 3 3 2 3 3 2 3
Ashaiman 3 3 1 3 3 3 3 3 3
Ga West 3 3 3 3 2 3 3 2 3
Ningo Prampram 3 2 2 3 3 3 3 3 3
Ga East 2 1 3 3 3 3 3 3 7
Ga North 3 1 3 3 3 3 2 3 7
La-Nkwantanang-Madina 3 3 3 1 2 3 3 3 7
Ayawaso West 3 2 1 3 3 3 3 2 10
Korle-Klottey 3 3 3 1 1 3 3 3 10
Krowor 1 1 3 3 3 3 3 3 10
Tema 3 3 1 3 1 3 3 2 13
Ayawaso North 3 3 3 3 3 1 1 1 14
Kpone-Katamanso 3 1 1 2 3 3 3 2 14
Adentan 2 1 1 2 3 3 3 2 16
Ga Central 1 1 1 3 3 3 2 3 16
Okai Koi North 1 1 1 3 2 3 3 3 16
Weija-Gbawe 3 3 1 2 3 2 1 2 16
Ada West 1 1 1 2 3 3 2 3 20
Ayawaso Central 1 1 1 3 3 2 3 2 20
La-Dade-Kotopon 1 2 1 3 2 3 3 1 20
Ablekuma West 1 1 2 3 3 1 1 3 23
Ada East 1 2 1 3 3 1 1 3 23
Ayawaso East 1 3 1 3 2 1 1 3 23
Ga South 1 1 1 2 3 3 1 3 23
Tema West 1 1 1 2 3 3 1 3 23
Ablekuma Central 1 1 1 3 3 1 1 3 28
Ablekuma North 1 1 1 3 2 1 1 2 29
Total Score 59 55 51 77 75 73 66 74
% Score 67.8% 63.2% 58.6% 88.5% 86.2% 83.9% 75.9% 85.1%
Region 2 1 3 3 2 3 3 3
Excellent 3 (>40) 3 (>35) 3 (>30) 3 (>70) 3 (<1) 3 (>45) 3 (>45) 3 (>90)
Good 2 (35-39.9) 2 (30-34.9) 2 (25-29.9) 2 (50-69) 2 (1.1-2.5) 2 (40-44.9) 2 (40-44.9) 2 (70-89.9)
Unsatisfactory 1 (<35) 1 (<35) 1 (<25) 1 (<50) 1 (>2.5) 1 (<40) 1 (<40) 1 (<70)
Improved availability of essential drugs and equipment in the Northern and Volta RegionsUnder the leadership-led QI FAA, which ran from June 2018 to
June 2019, the Northern RHD implemented a project to reduce
maternal mortality and under-5 malaria case fatality in 10
hospitals. One of the key strategies employed by the RHD was
working with hospital management through shared learning
and on-site support visits to ensure that essential drugs
for pediatric and obstetric emergencies were consistently
available in all 10 hospitals. At the end of the FAA, the
percentage of tracer essential emergency medicines available
at service delivery points in the facilities increased from 64.0%
(baseline in 2017) to 91.8% (as of May 2019). Emergency packs and drugs for obstetric emergencies at the maternity unit
15
In the Volta Region, teams in six hospitals worked to ensure
the availability of essential neonatal resuscitation equipment
at all newborn care areas within the facilities. As of May
2019, all newborn areas (100%) had all neonatal resuscitation
equipment, including penguin suction bulbs, ventilation bags,
and masks of all required sizes (from a baseline of 27.3% in
September 2018).
Medical boat on Lake VoltaIn the east of Ghana, just six degrees north of the equator,
lies Lake Volta, with a shoreline exceeding 3,000 miles
(4,800 km). Many remote and hard-to-reach communities
populate its shores and islands, only accessible via rough
roads or by boat. Many people travel by canoe, which makes
it difficult for health care workers to reach people with
critical services, such as vaccinations and antenatal care
(ANC). It also makes it challenging for community members
to reach higher-level health care facilities.
A blueprint for the futureTo facilitate access to health care for these hard-to-reach
communities, Systems for Health worked with the GHS to
design and build a 25-seat medical boat, which was delivered
to the GHS on December 18, 2018. Locally made, the pontoon
boat, christened the Akpini Queen, is equipped with two
washrooms, medical supplies, a radio transmitter and
receiver, and life jackets. This first-of-its-kind vessel in Ghana
will serve as a blueprint to manufacture future medical boats
in the country.
At the boat’s commissioning ceremony, Deputy Director of
Public Health Dr. Yaw Ofori Yeboah, speaking on behalf of the
Regional Director of Health Services, praised the outstanding
collaboration between the GHS and Systems for Health in
making the life-saving boat a reality. Dr. Yeboah emphasized
the exemplary consultative processes, stating, “All parties
Many people in lakeside communities must travel via motorized canoes to reach health care
have been actively engaged—from the design stage to the
training of the coxswain to discussions on the maintenance
of the vessel.”
This boat will significantly contribute to the promotion of health and well-being on the islands.
— Dr. Yaw Ofori Yeboah, Deputy Director of Public Health
Reducing mortality and promoting universal health care With the new boat, health care workers can deliver services
to 141 island communities in the Kpando, Krachi West, and
Biakoye Districts of the Volta Region. Since its commissioning
in December 2018, the districts have used the boat for
supportive supervision visits of island CHPS zones. They have
also used the pontoon for two rounds of mass immunizations
in June and September 2019 in two districts, as well as for
inspections of work on the islands by the Kpando District
Assembly.
16
The 25-passenger pontoon boat at the commissioning ceremony. Left: An external view of the pontoon docking. Right: An internal view of passengers outfitted with life jackets.
GRANTEE SPOTLIGHT
Kybele-Ghana Uses Technology to Strengthen Referrals for Obstetric Emergencies
Launched under an innovation grant from Systems for Health, Kybele-Ghana established early
warning systems for major obstetric complications, developed job aids to improve pre-referral
treatment of emergencies, and applied WhatsApp mobile technology to facilitate remote
communication for referrals. (Grant name: Using Innovative Technology to Strengthen the
National Referral System and Postnatal Care.)
The WhatsApp group connected referring and receiving health facilities in Greater Accra to
improve communication and clinical care for patients. Uptake on the WhatsApp platform was
strong, averaging over 100 cases per month. In 50% of cases, treatment was initiated on-site
prior to referral through guidelines established by the project to ensure patients are stable
prior to transfer.
The merry-go-round is a situation whereby patients are transported to multiple hospitals
throughout the city before finding one that can provide care. This delay can be life-threatening
in emergency situations. The Kybele WhatsApp platform prevented the merry-go-round
in 75 cases in six months (March–August 2017). As of December 2019, the platform is still
operational and has expanded to include additional facilities in Greater Accra.
In addition to facilitating referrals, the platform provides useful feedback on patient outcomes, announces system failures (such as
oxygen outages), and allows providers to discuss near-misses as learning opportunities. There is minimal cost in maintaining the
platform, making it an easily sustainable and scalable way to improve maternal and neonatal survival.
An example of WhatsApp communication between facilities
17
QUALITY IMPROVEMENT/ LEADERSHIP AND MANAGEMENT
QI, including supportive supervision, is a longstanding
component of health sector interventions in Ghana. Over
the five years of the project, Systems for Health supported
numerous initiatives to promote harmonized QI approaches.
The work included supporting the GHS and partners to develop
a national health care quality strategy as well as supporting
the drafting, pretesting, and implementation of national
supportive supervision guidelines and training materials
for health workers. Systems for Health collaborated with
each region to build QI capacity among regional and district
leaders and managers by training GHS staff as Improvement
Coaches, emphasizing the importance of being champions
and facilitators of QI interventions in their respective areas.
The project also supported a wide range of data-driven
regional and district-specific QI interventions. In addition, the
project incorporated basic QI content into many of its project-
supported technical trainings of frontline health workers and
provided opportunities for promoting best practices and joint
problem solving through shared learning sessions.
From Year 3 of the project onward, Systems for Health linked
and jointly implemented QI with leadership and management
(LM) strengthening. These two activities were integrated
because service delivery gaps often cannot be completely
closed without empowering LM to address the issues. Over
the years, project support in QI/LM focused on helping GHS
leaders strengthen their skills in collaborative planning,
continuous use of data, coaching and mentoring, and follow-
up actions. Additionally, in the last year of the project, the
QI/LM activities focused on consolidating improvements in
service delivery and institutionalizing QI by strengthening
district-based learning sessions and coaching visits, rolling
out supportive supervision guidelines, and developing
implementation guidelines for the Ghana National Healthcare
Quality Strategy (2017-2021), otherwise known as the NHQS.
Key objectives of the QI/LM activities included the following:
u Build the capacity of managers and providers (public and
private) to continuously improve care, emphasizing the
use of data to monitor progress.
u Support GHS-trained Improvement Coaches to provide
on-site technical support to facility QI teams in order to
continuously improve care, emphasizing the use of data
to monitor progress.
u Support the GHS to promote best practices and joint
problem solving through shared learning sessions.
u Collaborate with the GHS and implementing partners
to support the institutionalization of finalized national
supervision guidelines and tools for integrated supportive
supervision and support the operationalization of the
NHQS.
A QI team uses data to conduct root cause analysis of gaps in service delivery
18
Activity Output
Improvement
Coaches and QI
projects
452 Improvement Coaches from 114 districts across the 5 regions trained in QI methods and tools to lead
and facilitate improvement work in their respective districts.
323 Improvement Coaches across districts in the 5 regions held at least 2 workshops per year to share
their experiences in leading and implementing QI projects and to harvest ideas for ongoing improvements
that are sustainable beyond the project. Coaches’ meetings and PTFU visits were integrated into shared
learning and other project-supported field visits.
Leadership-led
improvement
projects
All 5 regions implemented leadership-led QI projects, which ended in June 2019. Key results and lessons
learned from these efforts are available in the section of this chapter titled “An Overview of Key QI Results”.
Shared learning 75 districts across all 5 regions participated in district-based shared learning sessions. Sub-district and
facility teams shared improvements in service provision and coverage in the areas of early obstetric
referrals, FP and reproductive health (RH), malaria, ETAT, and MNCH. Teams discussed lessons learned and
plans for post-project sustainability. Details are available in the respective chapters of this report.
National
supportive
supervision
guidelines
Systems for Health provided technical and financial assistance to draft, pretest, and finalize national
supervision guidelines, training materials, and an integrated supportive supervision checklist. The project
supported the launch of the materials with the following outputs:
u 3,000 copies of the finalized national supportive supervision guidelines were printed and disseminated
to supervisors at all levels.
u 230 copies of the supportive supervision trainers’ guide were printed and disseminated to national and
regional training facilitators.
u 1,263 regional and district supervisors across all 5 regions trained on the supervision guidelines and
materials (via FAAs to each RHD).
Supportive
supervision visits
Over the 5 years of the project, all 5 RHDs conducted 4 rounds of supportive supervision visits to all
facilities funded through FAAs. Overall performance totaled 39,329 supervision contacts with health
workers via 9,314 health facility visits across the 5 regions.
National
quality strategy
implementation
Systems for Health played a leadership role on the steering committee of the Ministry of Health (MOH) to
organize and facilitate the inaugural National Healthcare Quality Forum in Ghana. The event rallied key
stakeholders to advocate for a harmonized national quality strategy for health care. Subsequently, Systems
for Health collaborated with other partners and supported the MOH in developing the NHQS, which was
launched in December 2016.
After the launch, Systems for Health supported the GHS through the Institutional Care Division (ICD) to
disseminate the strategy and put in place the necessary governance structures for its implementation.
This work included providing technical and financial assistance to develop operational guidelines for
the implementation of the NHQS at all levels of the GHS. As a result, 1,000 copies of the finalized NHQS
implementation guidelines were printed for distribution to health workers. Additional details are available in
the relevant callout box featured in the section of this chapter titled “An Overview of Key QI Results”.
Integrated work
planning and
review
5 RHDs received financial and technical support for the development of integrated regional work plans to
reduce duplication, cover gaps, and promote a synergy of efforts.
10 annual and midyear review meetings were held in NR, VR, Western Region (WR), Central Region (CR),
and GAR, with financial and technical support from the project.
Table 5. Quality Improvement/Leadership and Management—Key Activities and Outputs
Key Activities and Outputs
19
SPOTLIGHT
District-based Shared Learning: Improved Coverage and Sustainability at Reduced Costs
In the latter half of the project, shared learning sessions served as the backbone of the project’s technical implementation
strategies with the GHS. Following the Plan, Do, Study, Act cycle, shared learning brought together multidisciplinary teams
from different health facilities who worked to improve common service delivery or health outcomes. During an initial
workshop, the teams met face-to-face to set goals, exchange ideas, and solve problems jointly. Meeting every three to four
months, they learned how to apply QI methods, develop interventions (or “change ideas”), test change ideas locally, reflect
on the results, and compare lessons learned. Between sessions, while the teams at each facility were implementing changes
and gathering data, they also received support from trained Improvement Coaches to help them review progress and deal
with barriers.
As shared learning scaled up in Year 4, the project transitioned most of its work from cross-district (inter-district) to district-
based (intra-district) shared learning sessions, involving the staff of the health facilities and management teams within a
given district (as shown in the diagram). This approach enables more staff across levels of care to participate, improves
referral processes, and promotes sub-district teamwork at more sustainable costs. For example, in the Western Region,
the cost of FP shared learning dropped from $225 per participant in Year 3 to $63 in Year 4. At the same time, the Year 4
activities reached far more staff members and facilities,
scaling up from 6 sub-districts to 23. The lower costs
and improved engagement among a broad range of
managers and providers increased the likelihood the GHS
will continue to facilitate shared learning beyond the life
of the Systems for Health project. More details are in the
Technical Achievements chapters.
To promote sustainability, teams held most shared learning sessions within districts (or facilities) using conference room space, thus reducing costs and enabling more staff to participate
20
An Overview of Key QI Results71% of Improvement Coaches actively leading and facilitating improvement projects
Over the life of the project, Systems for Health collaborated
with the GHS to identify and train 452 regional GHS
managers as Improvement Coaches. Coaches serve as
champions and facilitators of improvement activities in their
respective districts. As of September 2019, 71% of these
coaches were still actively engaged in QI projects.
In the last three years of the project, Systems for Health
intensified its efforts to build GHS capacity to autonomously
design and implement service delivery improvement projects.
GHS Improvement Coaches led this effort by supporting sub-
district and facility teams to scale up QI interventions to new
areas as well as sustaining improvements in service provision
and coverage in technical areas already being addressed.
They put in place measures to institutionalize successful
changes in routine facility-level service delivery systems.
These coaches were supported by the project to visit
facilities to coach and mentor teams in developing strategies
to sustain and scale up their improvement work. Key
strategies across the regions to enhance the sustainability of
Improvement Coaches’ activities included the following:
u Actively engage trained Improvement Coaches as
supervisors during the rollout of the national supervision
guidelines. This initiative helped to address funding-
related delays in supportive site visits to facilities.
u Identify successful Improvement Coach projects for
district-wide scale-up using local resources to maximize
the benefits of high-impact changes.
u Identify platforms, such as performance review meetings
(quarterly, half-yearly, and annually), for Improvement
Coaches to share progress. These check-ins helped to
secure leadership buy-in for improvement work and
promoted the sharing of best practices across multiple
sites (facilities, sub-districts, and districts).
u High-functioning Improvement Coaches were identified
and included in the Regional Resource Teams (RRTs) as
QI facilitators to champion and support facility teams
A QI team shares results with an Improvement Coach
as they integrated QI into malaria, MNCH, RH/FP, and
nutrition interventions. The coaches helped to minimize
missed opportunities.
The GHS has pledged to support Improvement Coaches after
the project ends, agreeing to help continue the activities
described above.
75 districts actively implementing shared learningShared learning started in a small number of districts in Year
2 and eventually scaled up to 75 districts. The GHS used
these sessions to share best practices and joint problem
solving among groups of health facility teams (Figure 4) to
reduce service delivery gaps in MNCH, FP/RH, nutrition,
and malaria. Additionally, in the final year of the project, the
sessions focused on lessons learned over the implementation
period and on plans to sustain improved performance in
service delivery beyond the life of the project. Specific
sustainability activities included the following:
u QI training materials and other relevant resources were
shared with GHS regional and district training units to
ensure continuous capacity building in QI methods and
principles for both old and new staff.
u Facility managers were tasked with providing regular
orientation on their facilities’ QI interventions to all newly
posted employees. They also ensured action plans were
implemented and regularly updated to promote ongoing
on-the-job coaching and mentoring by line managers and
facility QI team leads.
21
u QI targets were to be included as key performance
indicators in the performance appraisals of district and
facility managers to ensure oversight and accountability
of QI projects in their districts and facilities.
u In some regions (GAR, VR, WR), the GHS incorporated
indicators on quality management and QI processes
into the facility peer review tool to monitor the
institutionalization of QI into facility-level processes.
u Many district-based shared learning activities
piggybacked on performance review meetings and other
existing fora. QI coaching visits were integrated into
supportive supervision visits.
u Ultimately, lessons learned, best practices, and
successful ideas harvested from these sessions
were used to develop action plans to consolidate
achievements in project-supported technical areas.
Figure 4. A map of districts’ shared learning activities
SPOTLIGHT
Improvement Coaches
Improvement Coaches continue to lead shared learning and QI work. They are GHS staff who serve as champions and
facilitators of improvement activities in their respective districts. To date, 452 GHS managers across the five regions have
been trained. Specific roles of Improvement Coaches include the following:
u Work closely with the regional QI focal person and Systems for Health staff to assist with implementation, monitoring,
and evaluation of the region’s QI work.
u Co-facilitate learning sessions at the district level.
u Visit each district and sub-district health facility on a monthly or quarterly basis to provide QI technical support.
u Report to the regional QI focal person on a monthly or quarterly basis and summarize the support provided.
Overall, trained coaches in 89 districts implemented improvement projects in the different technical areas supported by
Systems for Health.Ultimately, the implementation of the guidelines will enhance the sustainability of QI initiatives, including
the mainstreaming of quality management systems into routine GHS service delivery systems.
22
SPOTLIGHT
The National Healthcare Quality Strategy: Developing Guidelines to Institutionalize Quality Management
In 2016, the MOH developed and launched the NHQS, aiming to harmonize quality planning, quality assurance, and QI
approaches to achieve better health outcomes. Since that time, Systems for Health has been a key contributor to the process
of developing, launching, and disseminating the strategy to health workers.
In Year 5, the project supported the GHS in developing implementation guidelines to ensure the smooth rollout of the NHQS
at all levels of the GHS. The guidelines outline the roles and responsibilities of the various levels of the GHS and seek to
incorporate quality governance structures into existing GHS structures. They also define a framework for delivering the
strategic objectives of the NHQS and identify accountability and sustainability mechanisms for managing health care quality
and patient safety. The project supported a series of TWG meetings to draft, review, validate, and finalize the guidelines.
Additionally, the project printed 1,000 copies of the guidelines for dissemination and use by health workers.
Ultimately, the implementation of the guidelines will enhance the sustainability of QI initiatives, including the mainstreaming
of quality management systems into routine GHS service delivery systems.
Supportive supervision guidelines improving training for thousandsSupportive supervision is widely accepted within the health
sector as an effective approach to providing on-the-job
training to health workers and addressing gaps in service
delivery. In the first four years of the project, Systems for
Health supported the GHS to convene the Supervision TWG,
comprised of GHS staff and other implementing partners,
to begin drafting, pretesting, and finalizing the national
supportive supervision guidelines and training materials for
use by health workers. Through a series of TWG meetings
and stakeholder engagement and validation meetings
supported by the project, the guidelines were finalized and
launched in October 2017.
The guidelines provide supervisors at all system levels
with a harmonized approach for effectively planning and
implementing supportive supervision. Furthermore, the
guidelines outline steps on how to technically integrate
supportive supervision and appropriate follow-up with
supervisees. In Year 4 of the project, Systems for Health
provided further support to the GHS to develop an integrated
supervision checklist to be used alongside the national
supervision guidelines. In the project’s final year, 3,000
copies of the finalized guidelines and 230 copies of the
trainers’ guide were printed by Systems and disseminated to
supervisors and training facilitators at the national, regional,
and district levels of the GHS. A total of 1,263 regional and
district supervisors were trained on the new guidelines
across the five project-supported regions.
This training and support by Systems [for Health] is
very timely. Supportive supervision is not new to us,
but for a long time, we haven’t been able to conduct
any visits because of resource constraints. Also, in the
past, we did not give much attention to the use of data
to effectively plan and implement supervision visits.
However, with the training, we will be able to compose
our teams appropriately and provide the needed
coaching to improve staff performance.
~ Training participant in the Northern Region
23
Supportive supervision visits supporting thousands of health workersAlongside the development of national supervision
guidelines, Systems for Health provided FAAs to all five
regions to conduct, in total, four rounds of integrated
supportive supervision visits over the project’s life span.
Overall, 9,314 facility visits and 39,329 supervision contacts
with health workers were achieved across the five regions.
All visits were data-driven and covered technical content in
malaria case management and/or malaria in pregnancy, as
well as at least one other technical area (MNCH, FP/RH, or
nutrition), which was chosen by each district after review of
their DHIMS2 data. Each visit, therefore, focused on three to
four priority gaps in service delivery in each health facility,
and supervisors and facility staff jointly developed action
plans to address each issue with the understanding that each
action plan item should be fully implemented prior to the
next supportive supervision visit.
Leadership-led QI activities dramatically reducing maternal and child mortalityFrom June 2018 to May 2019, all five RHDs directly
implemented leadership-led improvement projects through
FAAs. These projects represented the culmination of
previous investments over the life of Systems for Health.
They improved GHS readiness to access USG funds, pursue
Region FAA IndicatorBaseline
(2017)End-of-project Value
(June 2018 – May 2019)
Volta (6 districts)
Neonatal mortality per 1,000 live births (LB)
Stillbirth rate per 1,000 births
9.65
16.1
4.4
12.4
Western (4 districts for skilled delivery and 2 for stillbirth)
Skilled delivery coverage
Stillbirth rate per 1,000 births
33.3%
23.4
49.1%
13.3
Greater Accra (11 hospitals)
Stillbirth rate per 1,000 births 22.9 20.4
Northern (10 hospitals)
MMR per 100,000 LB
Under-5 malaria case fatality
159
0.23
122.7
0.195
Central (6 districts)
Neonatal mortality per 1,000 LB 10.2 14.6
Table 6. Final leadership-led QI outcomes
More detailed results are available in the Cross-cutting Activities, MNCH, and Malaria chapters.
A supervisor coaches staff members during a facility visit
QI approaches, use data, and enhance clinical competency
to accelerate reductions in preventable maternal and child
deaths.
To design projects, each RHD leadership team identified the
districts and facilities that were the highest contributors
to the region’s maternal and child mortality, assessed the
root causes of mortality, and designed interventions to
address them. Interventions included coaching visits from
clinical and QI specialists to address gaps in service delivery,
shared learning workshops among facilities and their
referral networks to solve problems jointly, and community
engagement to improve health-seeking behavior. RHDs
received payments for implementing planned activities and
24
meeting process and outcome indicator targets in select
districts within each region. Throughout implementation,
Systems for Health monitored activities to ensure
compliance with grant requirements and to validate
reported data. Key results achieved include the following:
u After one year, all five regions improved process
indicators, including the implementation of perinatal
death audits and the correct use of a partograph.
u Four out of the five regions reduced mortality from the
2017 baseline, including lower stillbirth rates in Greater
Accra (11%), Volta (23%), and Western (43%). Volta
also reduced the neonatal mortality rate by 54%, and
Northern reduced the institutional maternal mortality
ratio (MMR) by 23%. See Table 6.
Leadership teams from the Volta and Northern RHDs discuss progress on indicators
Lessons LearnedEvery region showed an impressive commitment to
achieving results. However, more efforts are needed
to scale up interventions and sustain the gains made
without external sources of funding. The success of the
interventions described in this chapter hinged upon the
GHS leadership’s engagement throughout planning and
implementation. It was especially important for GHS
leaders to be involved in district-based activities and to
publicly recognize high-performing facilities. Furthermore,
empowering RHDs to autonomously design and implement
their programs enhanced their abilities to continuously use
data for adaptive learning, as well as the abilities of the
district and facility teams. Finally, the use of performance-
based grants motivated teams to achieve results and have a
higher level of accountability for the quality of their work.
25
HEALTH FINANCING
Expanding access to care for the underserved has been
and continues to be a high priority for the GoG. For close
to two decades, the MOH has worked to expand access to
primary health care offered in CHPS zones. Over the life of
the project, Systems for Health supported the expansion
of CHPS while improving other health system components
that are vital for accessible, high-quality care.
Systems for Health’s support in health financing focused on
sustainably expanding access to primary health care by:
Activity Output
Support in financial
and grants
management
345 regional and district directors, accountants, and internal auditors trained in financial management,
with an emphasis on USAID rules and regulations.
5 rounds of follow-up visits completed, serving 114 districts across the 5 regions for ongoing coaching
and the assessment of financial management practices, including cash management, governance,
organizational management, administrative processes, and program and donor experience.
FAAs 6 rounds of FAAs awarded to each RHD for the implementation of region-specific priority activities,
including trainings in infection prevention and control (IPC) and 3 rounds of supportive supervision.
Each region also successfully completed FAAs for the implementation of regional-leadership-led QI
projects that were awarded in Year 4. The projects aimed to address maternal, perinatal, and child
mortality.
Table 7. Health Financing—Key Activities and Outputs
u Piloting the Preferred Primary Care Provider (PPP)
Network with the goal of supporting the GoG to develop
a long-term primary health care model and financing
system that can sustain the delivery of equitable,
efficient, affordable, and high-quality primary health
care services.
u Building health systems financing and management
capacity at regional and district levels through FAAs to
improve capacity to source and manage funds for health
services.
Objectives:
u Strengthen the readiness of health directorates to
directly access diversified sources of funding.
u Implement appropriate performance-based incentives
to link funding to high-quality service delivery through
LM and QI approaches.
u Ensure financial resources for health are channeled to
the right people and places to support universal health
coverage and maximize the equitable access to quality
services through provider networking.
Key Activities and Outputs
A renovated maternity block, Tsanakpe Health Centre, South Dayi
continued
26
Activity Output
PPP Network Pilot u Designed and launched the PPP Network Pilot in 2 districts in the Volta Region in September 2017.
u 2 rounds of trainings in network operations and management were delivered for over 70 managers
and staff. 47 district managers, network leaders, and facility heads were trained in financial
management, focusing on the management of joint bank accounts.
u Basic equipment for health facilities was refurbished and distributed to enable them to function well
in network arrangements.
u All 10 networks received quarterly on-site support visits.
u A national stakeholder meeting was held in Year 5 to discuss the transition and scale-up of the
PPP Network arrangement. Stakeholders recommended that networks should be scaled up while
exploring the possibility of expansion to include the private sector and district hospitals in a second
phase.
u The PPP Network was expanded into 2 new districts (Adaklu and Ho West) in Year 5, forming 11 new
networks. 76 district and sub-district management team members and facility heads from the 2 new
districts received orientation in network management and operations.
u 3 policy briefs were finalized to highlight lessons learned and recommendations for government
policy decisions.
Table 7. Health Financing—Key Activities and Outputs continued
Key ResultsImproved readiness to manage donor fundsTraining and annual coaching visits to 114 districts showed
improvements in DHD financial management practices:
u During the project period, 79 more DHDs districts
attained low-risk status (scored >75% on the financial
risk assessment; see Figure 5) from a baseline of 17
districts in 2015.
u 86% of health directorates have systems in place
for sound financial and cash management as well
as governance and administrative processes. These
directorates were rated as having adequate capacity to
manage donor funds, from a baseline of 18% in 2015 and
exceeding the 2019 target of 60%. See Figure 6.
u Districts showed improvement in governance
(executive records maintenance and the filing of
meeting minutes), financial management (financial
manuals, budgets and work plans, assets, procurement,
vehicle, inventory management, and audits), and cash
management (ledgers and cash book maintenance, bank
reconciliations, and adherence to policy and procedures).
Figure 5. A map of Ghana showing the results of financial risk assessments conducted during coaching visits to districts
27
Figure 6. The increases in the percentage of districts with adequate capacity to manage USG funds.
12%
92%
10%
71%
19%
85%
43%
90%
9%
91%
18%
86%
OVERALLWESTERNGREATER ACCRANORTHERNCENTRALVOLTA
FY15 FY19
In FY15, all but Greater Accra had less than 20% capacity to manage the USG funds awarded to them. (Greater Accra had 43%.)
In FY19, all but Central had increased to 85% or more capacity. (Central had 71%.)
GRANTEE SPOTLIGHT
Strengthened Capacity in Performance-Based Grants Management
From 2015 to 2019, Systems for Health provided technical assistance in data-driven program design, proposal writing, budgeting,
grants management, and reporting to Regional Health Management Teams (RHMTs), completing six rounds of FAAs. Over time, the
FAAs moved from the simple implementation of a single activity to more complex results-based awards.
Over the life of the project, Systems for Health made the following observations about the FAAs awarded:
u Higher quality technical and cost proposals were submitted over time.
u Higher quality deliverables, in terms of completeness and content, were achieved.
u RHMTs submitted more timely deliverables.
u Leadership played a key role in the RHMTs’ abilities to successfully manage the awards.
2015
A single prescribed activity
covering all districts in the
region (e.g., supportive
supervision visits). No
proposals requested,
and payments based on
outputs (e.g., number of
visits made).
2016-2017
RHMTs responded to a request for
applications with technical proposals
and detailed activity budgets. Systems
for Health worked with RHMTs to
prioritize activities based on workplans
and to develop and revise proposals
based on feedback from a review panel.
Payments based on outputs.
2018-2019
Technical proposals required with
root cause analyses and the use of
district-disaggregated data to identify
challenges and design targeted
activities for rapid results. Payments
based on results (progress on process
indicators and achievement of
outcome indicator targets).
28
Preferred Primary Care Provider networks pilotedA PPP network is a “group of organizations that provide, or
arrange for the provision of, equitable and integrated health
services to a defined population. They are held accountable
for their clinical and financial outcomes and, in general,
for the health of the population they serve” (Pan-American
Health Organization, 2012).
PPP networks perform three functions:
1. Service delivery: The networks provide population-
based primary health care. They connect community-
based provider teams to higher-level facilities and/
or administrators. Network members are responsible
for health promotion, disease prevention, diagnosis,
treatment, disease management, rehabilitation, and
palliative care.
2. Organization and management: PPP networks deliver
integrated management of clinical, administrative, and
logistical support systems. Networks emphasize the use
of shared data and resource teams to provide technical
guidance and support decision making.
3. Financing and payment: PPP networks use financial
incentives for integrated prevention, health promotion,
and curative primary care.
Figure 7. Reductions in the percentage of rejected claims
17%
5%
5
19%
3%
4
19%
5%
3
14%
6%
2
18%
4%
1
Jul-Dec 2017 Jul-Dec 2018
NHIS claims often take over 12 months to be processed. The figures in this chart are the most recently available. In 2017, the lowest claim rejection rate among the networks was 14%, and the highest was 19%. In the second half of 2018, the rates had successfully declined to a low of 2% and a high of 7%.
Key achievement of the PPP Network Pilot: Reduced NHIS claim rejection ratesFacilities within a network plan address common problems
together as a team. During the pilot, four networks
comprising 11 credentialed facilities tackled a common
challenge early on: having the National Health Insurance
Authority (NHIA) reject many of their claims. The networks
reduced rejection rates from an average of 17% to 5% (Figure
7) through joint claim reviews and coaching. High-performing
facilities within the networks coached other facilities that
needed help.
A Community Health Officer (CHO) coaches the staff of other facilities within the network on how to fill out NHIS claims form
29
SPOTLIGHT
Preferred Primary Care Provider Networks
PPP networks connect a group of CHPS zones (rural clinics) to one health center (higher facility) to receive technical and
operational support, including access to a higher cadre of providers, laboratory services, mentoring, and supervision.
Facilities within a network support each other to implement activities, such as clinical outreach, community mobilization,
data validation, and report reviews. Networks link with district hospitals for improved referrals.
In September 2017, Systems for Health, in partnership with the MOH, GHS, and NHIA, launched a PPP Network Pilot in two
districts in the Volta Region with 42 facilities operating in 10 networks. The pilot was initiated in response to large human
resource and logistical gaps (especially at the CHPS level) identified through a facility mapping assessment conducted by the
NHIA in 2014. The pilot aimed to test network models that make CHPS thrive.
After 18 months of implementation, observations showed the following:
u Networks comprised of a health center with satellite primary health care facilities worked together and shared resources
as an effective unit, with members sharing knowledge, expertise, and logistical resources.
u Networks strengthened referral systems. They established processes and documentation for referrals that led to better-
informed providers and patients on referral cases.
u Once the initial investments were made to launch the networks, the networks were largely able to function
autonomously with limited technical assistance and resources.
u Joint planning meetings
u Resource sharing
u Referral arrangements and practices
u Coaching and Mentoring (through supportive supervision and ad-hoc calls)
u Clinical outreach
u Community mobilization
u Claims reviews and submission
u Financial management of account(s)
Network Model and Operations
Note: The health center in the middle of the network might, instead, be a stronger CHPS.
30
Key achievement of the PPP Network Pilot: Improved referral documentationNetwork facilities, in collaboration with the DHDs
and district hospital, established processes and
documentation for referrals. They created a WhatsApp
platform, appointed referral focal persons to ensure
feedback, and coordinated follow-up for referred clients
at home. Improvements in the referral system have led to
early referrals and, ultimately, reduced maternal deaths,
especially in the South Dayi District, where they had zero
maternal deaths in 2018 and 2019.
Because of the network pilot, feedback is consciously given to clients and followed to see the outcome. Facilities consciously follow up on their clients, and sometimes they call back to the hospital to show appreciation. This has built relationships among the health care providers.
We don’t see delayed referrals anymore because now, if you delay a referral, you will be called to answer why the delay.
— Community Health Nurse, Sogakope Hospital, South Tongu
A Physician Assistant/Network Leader supports a CHO when following up with a referred client at home
A midwife calls for help to attend to a sick child A CHO receives support from a colleague during a child welfare clinic session
31
SPOTLIGHT
In Their Own Words: How the Networks Have Changed Service Delivery
I did not know much about managing curative cases, but now, I manage cases I would have referred in the past.
The network has helped to improve our relationship with other facilities, so it is easy to call anyone for help.
Work is not so stressful anymore. With networking, I get support from a colleague when I am doing child welfare
clinics or any activity; we are able to attend to the women quickly, and they don’t have to wait long.
— CHN, Kpalime Tongor Network
I feel empowered in the network because, when I encounter a problem, I can manage it. I just have to call the
Physician Assistant or my colleague midwife in the network—or even receive instruction on the WhatsApp
platform—on what to do before referring a client.
The network has helped us improve relationships with other staff. In the past, I would not feel comfortable calling
my colleague for fear she will think low of me. But now we support each other, and this is helping us to provide
quality care for our clients.
— Midwife, Dzake Network
The Way Forward: Continuation and Eventual Scale-up The PPP Network Pilot design was aligned to the existing
sub-district health structure and sought to empower
sub-district heads (i.e., the health centers in-charge) so
that they would play their assigned supervisory roles more
effectively. In the beginning and still today, networks
exercise autonomy to identify how they want to operate and
what works best for them in ensuring their populations have
access to and receive quality health services. Thus, once the
initial investments were made to launch the networks, the
networks could largely function on their own with limited
technical assistance and resources.
At the national stakeholder meeting (July 2019) and at a
final round of monitoring visits in September 2019, network
stakeholders recommended rolling out a transition phase
for further learning on such issues as operating networking
accounts and engaging the community in the networking
model, including extending networking to other districts in
the Volta Region.
With available technical and financial resources to launch
new networks, the second phase of the proposed pilot
(extending to other regions) will explore:
u the inclusion of private facilities,
u the inclusion of district hospitals, and
u network credentialing, instead of the NHIA credentialing
individual facilities.
32
TECHNICAL ACHIEVEMENTS
Over the life of the project, Systems for Health supported the
GHS to institutionalize evidence-based interventions, such
as Essential Newborn Care (ENC), Integrated Management
of Newborn and Childhood Illnesses (IMNCI), Life Saving
Skills (LSS), ETAT, and chlorhexidine for cord care. These
interventions emphasized knowledge and skills development
and were integrated with leadership and QI methods through
on-site coaching and shared learning.
As part of efforts to not only sustain but also improve gains
in the MNCH portfolio, the project supported the GHS to
focus on leadership-led QI projects through FAA, shared
learning sessions for QI in clinical care, on-site support
visits to reinforce competencies, and CHPS strengthening to
improve access to and the utilization of high-quality MNCH
services. CHPS strengthening activities supported increased
access to and improved provision of MNCH services,
including ANC, postnatal care, child growth monitoring, and
immunization. CHPS providers also conducted community
education to promote the utilization of these services.
Objectives:
u Support the scale-up of evidence-based interventions
to reduce preventable maternal and child morbidity and
mortality.
u Sustain the capacity of the GHS to use data to analyze
healthcare delivery challenges and target prioritized
solutions through on-site visits, shared learning sessions,
and MNCH leadership-led QI projects.
u Support the GHS to improve health prevention,
promotion, and curative care for mothers, newborns, and
children through sustained improvements in community-
level integrated health care delivery and referral
practices.
MATERNAL, NEONATAL, AND CHILD HEALTH
A child receives a vaccine in the Western Region
33
Activity Output
Updated clinical
guidelines and
training materials
Provided technical support to the GHS to update technical guidelines and/or training materials for LSS /
Emergency Obstetric and Newborn Care, ENC, ETAT, and IMNCI.
Provider trainings 7,589 providers were trained in different MNCH-related evidence-based interventions, including the
following:
u 4,098 providers in ETAT (pediatric and/or obstetric)
u 174 providers in how to implement pregnancy schools
u 363 providers in the complete LSS package or in specific components, such as pregnancy-induced
hypertension (560), use of partograph (612), and managing referrals for women in labor (152)
u 788 in the complete ENC package or in specific components, such as Kangaroo Mother Care (20)
u 254 in conducting maternal and perinatal death audits
u 568 in IMNCI
Improved use of
MNCH data
1,441 providers were trained in different elements to improve MNCH data and its use for decision making:
u 1,208 in the use of Child Health Record Books (CHRBs; focused on the topics of growth monitoring and
promotion, immunization, health information, and childhood nutrition)
u 201 in the use of newly developed reporting forms for the Expanded Programme of Immunization
u 233 on the use of the Reproductive, Maternal, Neonatal, Adolescent, and Child Health (RMNCAH)
Scorecard, which is a web-based information and accountability framework used to strengthen and
harmonize reporting processes linked to ending preventable child and maternal deaths
200,000 copies each of the CHRB and Maternal Health Record Book (MHRB) were printed and
distributed, as well as 100,000 copies of the combined Maternal and Child Health Record Book.
Provision of neonatal
resuscitation
equipment
148 health facilities with trained service providers in 4 regions received sets of neonatal resuscitation
equipment. The sets included a neonatal resuscitation bag and mask, a penguin suction device, and a
practice mannequin. These supplies are essential to ensuring a facility’s readiness to provide neonatal
resuscitation at the sub-district level.
On-site coaching During targeted PTFU visits, coaches observed trainees’ skills and identified gaps in the quality of care
and service delivery. Subsequently, they provided targeted coaching to support trainees and facilities to
make improvements. This coaching often involved providers that had not been trained by the project but
needed guidance to sharpen their skills.
On-site coaching in
chlorhexidine use for
cord care
4,155 providers from 87 districts were coached: GAR—905 providers in 16 districts, CR—640 providers
in 14 districts, WR—263 providers in 9 districts, NR—1,286 providers in 23 districts, and VR—1,061
providers in 25 districts.
Table 8. Maternal, Neonatal, and Child Health—Key Activities and Outputs
continued
Key Activities and Outputs
34
Activity Output
Shared learning Health facilities in all 5 regions used shared learning to develop and test ideas to improve MNCH-related
health outcomes. Their change ideas were selected by each region or district using DHIMS2 data analysis
that identified areas needing extra support.
u CR: 6 districts implemented a package of interventions to reduce neonatal mortality.
u GAR: 13 hospitals and their referring networks focused on improving the management of pregnancy-
induced hypertension, ENC, and triage systems. (Note: 11 of the 13 hospitals worked to reduce
stillbirths under the leadership-led QI FAA.) 9 districts worked to improve ANC early registration. 9
districts worked to promote early care-seeking behaviors and the appropriate treatment for childhood
illnesses.
u NR: 10 hospitals continued to work to improve ETAT processes to reduce institutional delays in
treating obstetric and pediatric emergencies (funded under the leadership-led QI FAA). 6 referring
districts implemented changes to improve early obstetric referrals.
u VR: Through a combination of shared learning and clinical specialist outreach visits, 6 districts jointly
worked to reduce perinatal and maternal mortality (under the leadership-led QI FAA).
u WR: 4 districts implemented changes to improve skilled delivery, stillbirth rates, and the
administration of the third dose of intermittent preventive treatment in pregnancy (IPTp3). Under the
leadership-led QI FAA, 4 additional districts implemented changes to improve skilled delivery, and 2
districts worked to reduce stillbirth rates.
Leadership-led QI
activities
With FAAs from Systems for Health, the RHDs implemented activities in select districts, including clinical
coaching, shared learning, QI projects, and community engagement. Key outcomes achieved are as
follows:
u 11% reduction in the stillbirth rate in GAR, 43% in WR, and 23% in VR
u 54% reduction in neonatal mortality rate in VR
u 23% reduction in the MMR in NR
u 15% reduction in the under-5 malaria case fatality rate in NR
u 32% increase in the skilled delivery rate in WR
While the project and its partners achieved many successes, there was a 43% increase in the neonatal
mortality rate in CR, partially attributable to deaths at the Cape Coast Teaching Hospital. For details,
please see the QI/LM chapter and the Health Financing Chapter.
CHPS strengthening As part of technical support to 483 targeted CHPS zones, CHPS providers were coached on priority
MNCH services, including ANC (including malaria in pregnancy), postnatal care, child health, and
nutrition. See the results in the Community Mobilization for CHPS chapter.
QI on the Maternal
Death Surveillance
and Response (MDSR)
system
3 maternal death audit teams in 3 regions piloted a QI initiative to improve the MDSR system. Maternal
death audit teams were introduced to QI tools and tested change ideas to address contributory factors
leading to maternal deaths and the avoidance of early care-seeking behavior. Change ideas also
supported health facilities in engaging communities and generating demand.
Oxytocin with
Time Temperature
Indicators (TTIs)
A study was completed in 2 regions, and results were disseminated. For details, see the callout box in this
chapter’s Key Results section, titled “Keeping Oxytocin Cold.” Subsequently and in collaboration with key
government stakeholders, Systems for Health developed and disseminated a policy brief to identify the
benefits and key issues to consider in adding TTIs to injectable oxytocin to monitor heat exposure. The
project sponsored a stakeholders’ meeting in September to determine the next steps for its rollout.
Table 8. Maternal, Neonatal, and Child Health—Key Activities and Outputs continued
35
SPOTLIGHT
A Facility-based Approach to Essential Newborn Care in Greater Accra: A High Volume of Trainees and Lower Costs
Improving service delivery in newborn health is a top priority for Greater Accra due to the region’s high number of stillbirths.
And ENC training helps to make the necessary improvements by teaching providers to better manage three main conditions
related to newborn deaths: asphyxia, prematurity, and sepsis. Greater Accra found a way to deliver this critical training
program to more providers at a lower per-participant cost.
Even though Systems for Health had already trained 106 providers within the first two years of the project, the Greater
Accra team recognized a need to reach critical mass. So, they deployed a facility-by-facility training regime, as opposed
to traditional residential training. Targeting districts/sub-metros with a high rate of infant mortality/stillbirths, the team
trained twice as many service providers in half the time. In Year 3 alone, the team trained 208 providers in 10 different
training sessions. Plus, the cost per participant decreased by 30% using the facility-by-facility on-site training model.
Evidence-based InterventionsOver its first three and a half years, Systems for Health laid the
foundation for improving MNCH services by training more than
7,500 providers in evidence-based interventions. Recognizing
that training alone would not improve service delivery, the
project’s focus shifted away from trainings and toward on-site
support visits.
The project collaborated with the GHS to give frontline health
workers one-on-one time with supervisors to strengthen
provider competency and facility readiness. During PTFU
or other site support visits, supervisors coached providers
in areas of need. The contributions of these visits to
improvements in service delivery and health outcomes are
often hard to quantify. However, they have contributed to the
results in the subsequent section. What follows here are key
evidence-based interventions implemented by the GHS:
LSS teaches providers to prevent and manage complications
during pregnancy, delivery, and the postpartum period.
On-site coaching offered observations and feedback on skills
noted as challenges during the training, previous visits, and
the review of the data. For example, at these follow-ups,
providers learned how to use and complete a partograph,
diagnose and manage pre-eclampsia/eclampsia, and manage
postpartum hemorrhage.
A midwife conducts a home visit to provide postnatal care
A provider implements cord care on a newborn
36
ENC training equips service providers with the skills needed
to prevent and manage the three major causes of neonatal
mortality: infection, complications from prematurity, and
birth asphyxia. The package included three interventions:
Helping Babies Breathe, Essential Care for Every Baby, and
Infection Prevention and Control for Newborns. After training,
providers received on-site follow-up visits to reinforce
knowledge and skills, especially related to resuscitation.
IMNCI targets first-level providers to manage infant and
childhood illnesses, such as malaria, pneumonia, and
diarrhea. The training program also incorporates nutrition
and supply chain management into the curriculum to ensure
that life-saving commodities are available (e.g., antibiotics,
zinc, antimalarials, and oral rehydration solution). During
follow-up visits, trainers observed skills and reviewed
available commodities
The MDSR system is a comprehensive strategy that focuses
on the identification, notification, and auditing of maternal
deaths to understand contributory factors and ensure
accountability by acting on audit recommendations to prevent
similar deaths. Three district maternal death audit teams from
three regions were selected to pilot the intervention.
Chlorhexidine coaching provided on-site support for
frontline service providers on how to facilitate the uptake of
chlorhexidine. The GHS-led and project-supported coaching
Figure 8. A map of the shared learning topics covered to enhance MNCH services in the Greater Accra, Northern, Volta, and Western Regions
Keeping Oxytocin Cold
Oxytocin is a first-line drug used to prevent and treat postpartum hemorrhage, or
excessive bleeding after childbirth. It becomes less potent over time when exposed to high
temperatures. In an effort to make it easier for health providers to use the drug effectively,
Systems for Health, GHS, and PATH conducted operations research on the feasibility of
adding TTIs to oxytocin packaging in Ghana’s cold chain system. TTIs are heat-sensitive
labels that change color when exposed to high temperatures, thus indicating when the
oxytocin is heat-damaged. (See the image at right.)
Researchers conducted a study in 10 facilities in Greater Accra and Volta. They determined it
is indeed feasible to use TTI on oxytocin packages in the existing GHS cold chain distribution
system. Midwives in the study reported increased confidence when using oxytocin with
a TTI. To reduce the cost, the study suggested placing the TTI on packs of 10 ampoules of oxytocin. After the completion
of the study, the project sponsored advocacy meetings to implement a roadmap for adding TTIs to injectable oxytocin to
monitor heat exposure. This advocacy included the development and dissemination of a policy brief.
Sample TTI label
especially focused on midwives and CHNs. The MOH approved
using 7.1% chlorhexidine digluconate for newborn cord care to
prevent infections, which partly result from harmful care.
37
Examples of a pregnancy school and other shared learning activities established to improve skilled delivery rates. Left: A woman asks a question during pregnancy school. Right: Nurses prepare presentations at a shared learning session in the Western Region.
Key ResultsImprovements in skilled delivery, maternal mortality ratio and stillbirth and neonatal mortality ratesThe results presented below are from the shared learning
activities implemented in the five regions (Figure 8).
Skilled deliveryThe Western Region’s efforts to improve skilled delivery
rates began in Year 4 and covered eight districts. Four
of the districts were funded under the leadership-led QI
FAA, and the remaining four districts implemented an
integrated set of changes to improve skilled delivery,
stillbirth rates, and intermittent preventive treatment in
pregnancy (IPTp) coverage. To improve skilled delivery, the
districts established pregnancy schools in both facilities and
communities, collaborated with Traditional Birth Attendants
to refer labor cases, improved outreach to provide ANC and
track defaulters, and increased home deliveries by midwives.
These activities paid off with an 11.9% increase in skilled
delivery in the eight districts in one year, from 42% in Year 4
to 47% in Year 5 (Figure 9).
Collaborating to increase skilled deliveryUnder separate innovation grants, two organizations
collaborated to tackle the issue of low skilled delivery rates
in several sub-districts in Bunkpurugu-Yunyoo District in the
Northern Region. MAZA focused on developing community
emergency transportation networks using motorized
tricycles. Navrongo Health Research Centre promoted the
importance of skilled delivery and the use of the motorized
trikes through town hall meetings, home visits, and
pregnancy schools. It also trained providers in customer care
to improve women’s delivery experiences.
Figure 9. An 11.9% increase in skilled delivery coverage in eight of the Western Region’s districts.
50
40
30
20
10
0
36
42
Oct 2014–Sep 2015N=30,769
Oct 2015–Sep 2016
N=34,068
Oct 2016– Sep 2017N=35,338
Oct 2017–Sep 2018N=36,428
Oct 2018–Sep 2019N=37,401
3639 47
N=Expected Deliveries
38
Together, they transported 473 emergency cases between
April 2017 and April 2018, primarily women in labor and sick
newborns. An independent survey showed an increase in
skilled delivery attendance from 49% at baseline to 96% at
endline (Figure 10).
Maternal mortality ratioIn late 2016, the Northern Region identified 10 hospitals
that accounted for the majority of the region’s maternal
deaths. These facilities were grouped into two clusters,
called the referring and receiving clusters. The referring
cluster participated in shared learning to improve clinical
management while the receiving cluster improved the
management of emergencies and their complications. In
2018, this work was transitioned to the leadership-led QI FAA
and implemented directly by the Northern RHD.
In 2017, Systems for Health and the Volta RHD targeted
six districts to address district-specific causes of maternal
and neonatal mortality. With project support, a team of
regional clinical specialists and QI coaches provided targeted
training to multidisciplinary teams of district hospitals and
their networks of referring primary health care facilities.
The teams deployed QI strategies and tools to identify gaps
in service delivery. They also developed change ideas to
address their respective challenges. Similar to the Northern
Region, this work was implemented directly by the Volta
RHD under leadership-led QI funding. In June 2018, Systems
for Health fully transitioned the work to the Volta RHD to be
implemented directly as part of their leadership-led QI FAA.
Greater Accra launched their shared learning work in
November 2017, focusing efforts on a critical cause
of maternal deaths in the region: pregnancy-induced
hypertension. The participants conducted two rounds
of shared learning sessions in receiving hospitals—also
involving their referring primary health care facilities—
to improve the management of pregnancy-induced
hypertension, practice of ENC, and establishment of ETAT
processes. This work was complemented by leadership-
led QI funding to reduce stillbirths, with many common
interventions that simultaneously led to reductions in the
MMR and stillbirths.
Across the three regions—Northern, Volta, and Greater
Accra—institutional MMR was successfully lowered. It was
211.4 in the October 2015–September 2016 period and
decreased to 122.5 in the October 2018–September 2019
period, which is a 42.1% reduction (Figure 11).
Figure 10. The proportion of births attended by a skilled health worker vs. a traditional birth attendant, comparing baseline to endline data in three subdistricts
Baseline (N=228) Endline (N=73)*
* TBA = traditional birth attendant. For baseline/endline, independent evaluation by University for Development Studies. Baseline was 24 months (Mar 2015–Feb 2017); endline 12 months (Apr 2017–Mar 2018). Baseline also reflects data from three entire sub-districts while endline focuses on women in communities that received motorized tricycles (i.e., intervention communities).
Health Worker TBA*
49%
96%
37%
2.7%
A MAZA driver takes a call. Photo courtesy of MAZA
39
Figure 11. Institutional MMR in 29 shared learning districts in Greater Accra, Northern, and Volta regions
250
200
150
100
50
0
182.2
140.0
Oct 2014–Sep 2015N=90,831
Oct 2015–Sep 2016
N=89,400
Oct 2016– Sep 2017N=91,105
Oct 2017–Sep 2018N=99,317
Oct 2018– Sep 2019
N=102,049
211.4197.1
122.5
N=Total Live Births
Figure 12. Stillbirth rates in 25 shared learning districts in Greater Accra, Western, and Volta regions
23.025
20
15
10
5
0
20.6
17.4
Oct 2014–Sep 2015N=72,055
Oct 2015–Sep 2016
N=84,463
Oct 2016– Sep 2017
N=84,646
Oct 2017–Sep 2018N=91,253
Oct 2018– Sep 2019
N=92,995
23.0
14.9
N=Total Births
Stillbirth ratehe interrelated nature of the interventions referenced
previously simultaneously address the key causes of
stillbirth. Compared to Year 2, stillbirth rates in shared
learning districts in Greater Accra, Western, and Volta
decreased by 35.2%, from 23.0 to 14.9 stillbirths per 1,000
births (Figure 12), by the end of the project.
Continued reductions in the neonatal mortality rate in VoltaAfter an increase in Year 3, shared learning districts in Volta
significantly reduced their neonatal mortality rate. From
Year 3 to Year 5, the rate decreased by 42.3% (Figure 13).
This outcome is due to the interventions mentioned earlier
in this chapter as well as the establishment, maintenance,
and equipping of newborn health corners in many facilities,
and intensified coaching from clinical specialists on neonatal
resuscitation.
Best technical practicesWith project support, the GHS implemented several best
practices to reduce preventable morbidity and mortality,
particularly for women and children. The project-supported
regions are working to continue and potentially scale up
implementation without external support. Here are a few
examples:
u The introduction of QI approaches into clinical specialist
coaching visits significantly helped to reduce the
stillbirth and neonatal mortality rates in the Volta Region
(Figure 12 and Figure 13). Coaching visits are not entirely
new in the GHS. But when clinical specialist coaching
visits were introduced to QI approaches, it made the
difference.
u The Volta RHD plans to sustain the integration of QI into
specialist coaching visits by requesting that the visiting
hospitals use their internally generated funds to pay for
the costs of clinical specialists to visit their facilities. The
region also intends to institutionalize these specialist
coaching visits and schedule quarterly visits.
u Many core interventions have now become part of
routine work in health facilities. For instance, the Greater
Accra and Western Regions continue to implement
pregnancy schools. Also continuing are the routine
Figure 13. The reduction in the neonatal mortality rate in six shared learning districts in the Volta Region.
10.0
8.0
6.0
4.0
2.0
0
8.47
6.52
Oct 2014–Sep 2015N=14,114
Oct 2015–Sep 2016N=13,515
Oct 2016– Sep 2017N=14,165
Oct 2017–Sep 2018N=15,501
Oct 2018– Sep 2019N=15,336
5.92
3.33
4.89
N=Total Live Births
40
monitoring of partograph use and fetal and uterine
contract monitoring using an electronic fetal monitor.
Furthermore, triage corners established during the
project are being maintained, especially in the Greater
Accra and Northern Regions.
Making maternal death audit recommendations “SMART”erIn 2016, the Family Health Division (FHD) of the GHS
conducted a situational analysis of maternal death audits,
finding audit recommendations to sometimes be unspecific
and unimplemented. So, in 2018, FHD collaborated with
Systems for Health to pilot a QI initiative focused on the
MDSR system. Three district hospitals participated, as well
as maternal death audit teams from three regions.
Improvement teams planned, implemented, and evaluated
change ideas, aiming to improve measurability and timeliness
as well as the linkages between recommendations and
avoidable factors of maternal death. Across the intervention
sites, the teams tested BCC demand generation (described in
the next section) and the following change ideas:
u Targeted health education on early care-seeking when in
labor, especially focusing on ANC visits and prayer camps
u Coaching to improve partograph use and monitoring
adherence
u Steps to revitalize the triage system in the labor ward
u Coaching on SMART recommendations and assessor
feedback (SMART stands for specific, measurable,
achievable, relevant, and time-related)
u Action plans for all maternal deaths audited
u Status tracking for audit recommendations
BCC Demand GenerationRecognizing that changes at the facility level alone would
not avert the late arrival of obstetric emergencies to their
facilities, each hospital implemented outreach activities to
address key external contributors to maternal mortality,
which were identified during root-cause analysis. Examples
included the following:
u The facilities engaged the community on talk radio,
where they discussed pregnancy danger signs and the
need for early care-seeking. They also discussed the fear
of caesarean section and value of blood donation.
u Improvement teams provided orientation to prayer
camp leaders and Traditional Birth Attendants on the
danger signs during pregnancy and delivery, as well as
the need for early referral for definitive care. Afterward,
Catholic Hospital in Battor reported an increase in
referrals from prayer camps for ANC and deliveries.
Follow-up visits to other camps found that at least one
had stopped conducting deliveries altogether.
u The teams sensitized community members near
Swedru Municipal Hospital about how blood donations
prevent maternal deaths, including dispelling the myth
that donated blood was used for spiritual rituals. The
outreach increased family donations of replacement
blood and reduced the dependence on external sources
of blood.
The Maternal Death Audit Team at Catholic Hospital Battor meets
Providers participate in a talk radio show to discuss and answer questions about how pregnant women and their communities can ensure they receive proper care
41
ResultsAfter six months of implementation, all three hospitals
showed promising progress in achieving the aims they
defined for the interventions (Table 9), particularly in the
FAA Indicator
Baseline (Using audits from previous 2 years)
Endline(Jan–June 2019)
To improve the linkages between recommendations and avoidable factors of maternal death
56.5% 95.2%
To improve the measurability and timeliness in framing recommendations
6.6% 94.3%
To improve the implementation of recommendations within the defined timeframe
4.9% 71.4%
Table 9. Progress on improvement aims for maternal death interventions at three district hospitals in three regions.
documentation of SMART recommendations. The results
demonstrate the potential for these interventions to
avert future maternal deaths and to be scaled up to other
hospitals.
42
TECHNICAL ACHIEVEMENTS
NUTRITION
Systems for Health’s nutrition portfolio was dedicated to
improving the health and nutritional status of children
under five years of age and of pregnant and lactating
women. The project supported the GHS to implement
and sustain nutrition interventions focused on the use of
high-impact integrated service packages through provider
capacity development, mentoring, and coaching.
Systems for Health supported the GHS to improve service
providers’ competencies to conduct nutrition assessments
and provide appropriate counseling across the life cycle
continuum, using the Essential Nutrition Actions (ENA)
approach. The GHS was further supported to improve
service providers’ knowledge and skills in lactation
management, anemia prevention, and the diagnosis,
treatment, and management of malnutrition. The project
also strengthened the integration of nutrition services into
other program areas. Nutrition messages were integrated
into strategic BCC activities, especially at the district and
sub-district levels. Integrated coaching visits addressed
nutrition-related data collection and reporting issues in
DHIMS2. The project also used QI, integrated supportive
supervision, mentoring, coaching, and joint PTFU visits to
further consolidate the integration of nutrition services into
routine health service delivery. Integrated coaching visits
addressed nutrition-related data collection and reporting
issues in DHIMS2.
A provider checks a child for anemia
Objectives:
u Strengthen the capacity of service providers to
integrate nutrition interventions into other services and
appropriate nutrition assessment and counseling at all
client encounters.
u Strengthen the capacity of service providers to
adequately manage childhood malnutrition and improve
survival rates among malnourished children.
u Improve the nutritional status of pregnant women and
children under five.
43
SPOTLIGHT
Integrating Nutrition with MNCH Activities
To maximize opportunities to integrate nutrition into
routine service provision, Systems for Health included
nutrition assessment, counseling, and support in many
of its MNCH activities. Content on assessment and
counseling skills, breastfeeding, complementary feeding,
feeding during illness, and other relevant topics were
integrated into ENC and IMNCI training and follow-up.
A provider counsels mothers on nutrition while they wait for other services
Activity Output
ENA guidelines In collaboration with Strengthening Partnerships, Results, and Innovations in Nutrition Globally
(SPRING) and Resiliency in Northern Ghana (RING), supported the GHS to update the ENA guidelines.
Provider trainings u 808 trained in ENA.
u 661 trained in lactation management.
u 339 trained in community-based management of acute malnutrition.
u 196 trained in the diagnosis, prevention, and management of anemia.
u Content on nutrition integrated in MNCH trainings.
On-site coaching Former trainees, as well as target facilities across all 5 regions, received on-site support visits to
improve provider competency and facility readiness to provide nutrition services as well as to address
specific challenges with the provision of quality nutrition services. The integrated nature of the
interventions reduced missed opportunities to provide nutrition services. With nutrition being an
integrated topic, it is estimated that the vast majority of the 16,000 on-site support visits covered some
element of nutrition.
Shared learning 9 districts in the child health shared learning group in GAR worked to improve acute malnutrition case
detection and cure rates.
CHPS 483 target CHPS zones received nutrition-related technical support. Nutrition assessment, counseling,
and management is key to CHPS strengthening and home visits by CHOs.
Demand generation 12,348 people in 3 districts in WR were reached through demand-generation activities conducted
by CHOs/CHNs. The activities promoted continuous breastfeeding and the timely introduction of
complementary foods to infants’ diets. The demand generation activities included food demonstrations,
durbars, and discussions in churches/mosques, all of which were aimed at raising awareness about
appropriate feeding practices and building demand for nutrition services.
Table 10. Nutrition, Key Activities and Outputs
Key Activities and Outputs
44
KEY RESULTSA 75% improvement in SAM cure ratesIn Greater Accra, shared learning activities in nine
districts aimed to improve the severe acute malnutrition
(SAM) case detection and cure rates. Home visits were
intensified to detect cases and educate mothers. At Child
Welfare Clinics (CWCs), all children under five years old
who were underweight were assessed for SAM. Also,
community members were educated, and CHNs were
coached to improve case detection. After just over a year of
implementation, cure rates increased by 75% (Figure 14).
Provision of nutrition services at CHPS Newly constructed CHPS zones for expanded access to Child Welfare Clinics
CHPS compounds are a primary entry point for addressing
nutrition-related issues for under-5 children. At CWCs,
nurses track children’s growth over time and provide
counseling to strengthen feeding practices. The clinics
also identify children in need of more targeted counseling
and support. Nutrition assessment and counseling
services were routinely provided by CHOs in all 26 newly
constructed CHPS zones during CWCs, as well as at home
visits and through community radio. In these CHPS zones,
there was a 149% increase in CWC registration, from 11,624
in Year 2 (baseline) to 28,999 in Year 5 (Figure 15).
Similarly, the number of annual CWC visits dramatically
increased from 562,965 in Year 2 (baseline) to 1,009,637 in
Year 5 in the 483 target CHPS zones (Figure 16).
Figure 14. Dramatic improvements in the SAM cure rates in Greater Accra’s shared learning districts
50%
25%
0%
Oct 2017–Sept 2018 (N=419)
24.3%
42.5%
Oct 2018–Sept 2019 (N=398)
Figure 15. A 149% increase in CWC registration at 26 newly constructed CHPS zones
30
20
10
0
Oct 2017– Sep 2018
Oct 2018– Sep 2019
Oct 2016– Sep 2017
Oct 2015– Sep 2016
18,154
26,642
11,624
28,999thousands
Figure 16. A 79% increase in CWC attendance in 483 target CHPS zones
Oct 2015–Sept 2016
562, 965
1,009,637
Oct 2018–Sept 2019
45
SPOTLIGHT
Sustained QI Results: Spotlight on the Wassa East District in the Western Region
Weight for age (and particularly underweight for age) is one of the key measures used to assess a child’s nutritional status.
In Ghana, weight for age is routinely measured at all CWCs to track child growth and identify children that need additional
counseling and support. From 2014 to March 2016, the average underweight rate for under-5 children in the Wassa East District
was above 12%. To address this issue, the DHD, with the support of Systems for Health, initiated an improvement project to
reduce the percentage of underweight children from the baseline median of about 12% in April 2016 to 7.5% by December 2016.
From 2016 to 2019, the initial project and follow-up exceeded expectations.
As part of the improvement project, the district QI team implemented change ideas, including on-the-job coaching on weighing,
plotting on a growth chart, replacing faulty weighing scales, and hosting community food demonstrations. The team also
intensified community-level education on infant and young child nutrition and gave frontline service providers a refresher
training on new growth charts. The interventions led to positive impacts, reducing underweight children from an average
of 12% to 3% a year by the end of 2016 (Figure 17). Motivated by this result, the district strived to achieve even better results
by routinizing the sub-districts’ monthly data validation, giving CWCs on-the-job coaching on weighing/plotting, promptly
replacing faulty weighing scales, and assigning underweight children to CHNs for necessary support. These interventions
resulted in a significant reduction of underweight under-5 children in the district, from a baseline median of 12% in March 2016
to a median of 1% as of August 2019. This reduction equals nearly 92% since initiating the improvement project.
Figure 17. Reductions in underweight under-5 children in the Wassa East District, Western Region, after two rounds of improvement projects
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A
20192018201720162015
Post-proj. median #2 = 1%Post-proj. median #1 = 3%
Baseline median = 12%
QI intervention started
% of Underweight Median
25%
20%
15%
10%
5%
0%
1. 30 facilities: coaching visits2. 30 facilities: weighing scales replaced3. 20 communities: food demos4. 90 communities: food sensitization
1. Monthly data validation2. Coaching visits3. Prompt replacement of scales
1. 8 facilities: coaching visits2. 7 facilities: weighing scales replaced3. 6 communities: food demos4. 25 communities: food sensitization
46
TECHNICAL ACHIEVEMENTS
FAMILY PLANNING AND REPRODUCTIVE HEALTH
Systems for Health supported the GHS to increase access to
FP by building provider capacity to offer long-acting reversible
contraceptives (LARCs) at lower-level facilities, including CHPS
clinics. Furthermore, the project addressed systemic service
delivery challenges that affected access to and utilization
of services through QI approaches and shared learning.
The project also created user demand through community
meetings and health promotion activities.
In the second half of the project, FP/RH support largely
focused on the 1,000+ midwives and nurses in 105 districts
trained in FP counseling and LARC through on-site coaching
visits targeted to areas where the data showed the greatest
need. Shared learning began in Year 3 in six sub-districts in the
Western Region and expanded to 24 districts in four regions.
A mother receives postpartum FP servicesA woman receives FP services from CHN
Key objectives of the portfolio:
u Strengthen the capacity of service providers in the
five project-supported regions to provide quality FP/
RH services, including for adolescents, through on-site
coaching and mentoring.
u Institutionalize QI approaches that foster linkages
between FP and MNCH services and generate demand
at the sub-district and community levels for FP use
through ANC and postnatal care, CWCs, and integrated
FP and nutrition interventions.
u Increase the percentage of facilities in the five regions
that offer at least four modern methods of FP, with a
focus on increasing the facilities per district that offer
long-acting and permanent methods.
u Increase the uptake of modern FP methods.
47
Activity Output
Provider trainings 1,321 providers trained or received refresher training in LARC. LARC trainings covered voluntarism,
method mix, contraceptive basics, side effects, and practice sessions both for counseling and for the
insertion/removal of implants and intrauterine devices (IUDs).
642 providers trained in FP counseling and Contraceptive Technology Updates. The training program
equipped providers with up-to-date knowledge on contraceptives and skills to provide client-centered
care and services.
363 midwives trained in 5 regions on postpartum and post-abortion FP through LSS trainings. Sessions
focused on the importance of healthy timing and spacing of pregnancy (HTSP), contraceptives and
their timing of initiation, and effective counseling to enable clients to make informed choices about the
method to use.
RRTs 76 regional resource persons completed FP master training and received training equipment and
materials. This 2-week course equipped select providers to provide training and PTFU/supervision.
Participants who successfully complete the course act as advocates and resources in their regions for
up-to-date information on FP.
Preceptor site
support
22 preceptor sites strengthened across the 5 regions through the provision of preceptor trainings
as well as equipment and supplies to serve as clinical training sites for pre-service and in-service
training.
Adolescent and
youth-friendly
services
99 adolescent- and youth-friendly service providers/coordinators in 2 target areas received training. The
training encouraged the provision of services in a welcoming environment, where adolescents and youths
could access non-stigmatizing, private, and confidential services.
27 adolescent health clubs in target areas were formed/supported. These clubs incorporated community
involvement in adolescent- and youth-responsive health services.
On-site coaching Over the life of the project, trained providers and facility teams were coached to reinforce skills in
implant and IUD insertion and removal, FP counseling, and data and commodity management.
Shared learning Teams from 331 facilities in 24 districts from WR, CR, VR, and NR developed and implemented change
ideas to increase FP coverage. The project supported follow-up visits to reinforce knowledge and skills
in QI approaches.
CHPS strengthening Ongoing coaching for CHOs and support for CHMCs furthered FP service provision and demand
generation at the community level.
26 facility teams from newly constructed CHPS compounds were coached to improve the provision of
FP counseling and services. Providers from 9 newly constructed CHPS compounds in 6 districts in VR
completed internships in implant insertion and removal services.
Demand generation Generating demand for the utilization of FP services was a key change idea in all FP QI shared learning
interventions, as well as CHPS strengthening activities. Examples include health education talks and
durbars conducted by CHOs/CHNs to create awareness and demand for FP services.
In Year 2, targeted efforts were implemented in 17 districts with low FP coverage. Activities targeted
social and economic groupings in the communities with messages on various FP methods and services.
Speakers emphasized a client’s free choice in deciding on the type of FP device and service. FP
misconceptions were a major discussion topic.
Table 11. Family Planning and Reproductive Health—Key Activities and Outputs
Key Activities and Outputs
48
Key Results
A 41% increase in FP acceptors in shared learning districtsSystems for Health supported 24 districts across four regions
(NR, WR, VR, and CR) to use shared learning to improve FP
coverage. In each district, improvement projects were designed
within sub-districts to enhance the delivery and utilization of FP
services through change ideas (Table 12).
Shared learning started in the Western Region in March 2016
and launched more broadly from May to June 2018, rolling out
in 24 districts in the four regions (Figure 18). Annual new FP
acceptors rose steadily between October 2016 (59,796) and
September 2019 (84,289), achieving a 41% increase across the
24 intervention districts by Year 5 (Figure 19).
Change Ideas Activities
Increase male
involvement
• Including men in home visits and clinic-
based counseling
• Targeting messages to men during
durbars and events
Improve post-
partum FP
uptake
• Sending reproductive and child health
staff to the maternity ward to counsel
women on FP before discharge
• Coaching to improve postnatal FP
counseling
Community
mobilization
• Following up with clients via home
visits
• Providing community education with
subsidized FP services (supported
by the Maternal and Child Health
Integrated Program [MCHIP])
Table 12. Examples of change ideas to improve FP
Figure 18. A map of Ghana showing the 24 districts in four regions using shared learning to improve FP coverage
A couple receives counseling from a midwife
Figure 19. A 41% increase in FP new acceptors since the October 2016–September 2017 period.
90
80
70
60
50
40
30
20
10
0Oct 2016–Sep 2017
Oct 2017–Sep 2018
Oct 2015–Sep 2016
59,796
75,956
54,662
84,289
Oct 2018–Sep 2019
thousands
49
6000
5000
4000
3000
2000
1000
0
Figure 20. A steady increase in IUD new acceptors since September 2015.
Oct 2016– Sep 2017
Oct 2018– Sep 2019
Oct 2015– Sep 2016
Oct 2014– Sep 2015
3,9264,257
2,771
5,248
Oct 2017– Sep 2018
4,747
A supervisor coaches a CHO as they practice implant insertion
Increased uptake of LARCsFrom 2015 onward, Systems for Health supported the
implementation of an integrated set of interventions to
improve access to FP services, including provider training,
on-site support, QI, and demand generation. New users of
IUDs increased by nearly 90%, from 2,771 in the October
2014–September 2015 period to 5,248 in the October 2018–
September 2019 period (Figure 20).
The number of annual new users of LARC (implants and
IUDs) rose by more than 106% between September 2015
and September 2018 (Figure 21). A decrease in new users
between September 2018 and 2019 may be attributable
to an inadequate supply of commodities, data capture
irregularities, or a combination of factors. Nevertheless, the
results still reflect a 90.6% increase in new acceptors over
the life of the project.
Figure 21. An overall increase in IUD and implant new acceptors, with a slight decrease from October 2018–September 2019.
90
80
70
60
50
40
30
20
10
0Oct 2016– Sep 2017
Oct 2017– Sep 2018
Oct 2015– Sep 2016
61,754 71,422
41,607
Oct 2014– Sep 2015
79,289
thousands
Oct 2018– Sep 2019
85,610
Figure 22. The increase in CHPS facilities offering at least four modern methods of FP, Year 1 to Year 5.
100%
80%
60%
40%
20%
0%
59.1668.42
47.37
79.79
Oct 2016– Sep 2017
Oct 2017– Sep 2018
Oct 2015– Sep 2016
Oct 2014– Sep 2015
Oct 2018– Sep 2019
75.37
Increased access to FP at CHPSTo improve universal access to care, Systems for Health
trained CHNs, CHOs, and midwives to provide LARCs, helping
more CHPS facilities to achieve the goal of offering at least
four modern FP methods (Figure 22). Providing a minimum
of four methods at CHPS zones ensures that clients travel
shorter distances to access FP services and can choose a
method that works best for them. Systems for Health also
supported CHPS zones through on-site provider support,
CHPS strengthening activities, community mobilization, and
QI to assure the availability of services at lower levels of care.
50
SPOTLIGHT
Learning by Doing:Family Planning Preceptorships Enhance Decentralized Provider Training
The five project-supported regions established Regional Resource Teams (RRTs) to support the decentralization and
standardization of FP trainings. After the RRTs were set up, it became apparent that trainers needed standard sites for clinical
practice during LARC training. But preceptor sites were either nonexistent or poorly staffed and equipped. Thus, the regions
were unable to support decentralized and cost-effective training for FP service providers.
In 2016, all RRTs across the five regions developed criteria to enhance the preceptor sites. Among them were the following:
availability of active and trainable FP providers, high client load, adequate space for procedure rooms, management support,
and accommodations near the facility for trainees to lodge. Using these criteria, 22 sites were selected across the five regions
with the aims of ensuring geographic diversity and expanded access to district-level trainings. At each site, providers from
FP and maternity units were trained as preceptors. Systems for Health supplied all sites with training equipment for practical
sessions.
Three years later, one of the preceptor sites that stands out for its stellar performance is Nkwanta South Municipal Hospital
in the Volta Region. The site is well managed by the Preceptor In-Charge, with strong support from the hospital management.
There is a dedicated demonstration room where trainees practice on models to achieve an appropriate level of skill before
working on clients. The hospital management also provides short-term lodging facilities to interns at the site.
The site recently trained 16 CHOs from nine newly constructed CHPS compounds in the hard-to-reach districts of the Volta
Region. Interns improved their competencies in FP counseling and method provision. Students on pre-service clinical rotations,
including trainee midwives and general nurses, also continued to receive practical training, coaching, and mentorship at the
preceptor site.
Left: Nurses on rotation at the Nkwanta South Hospital FP preceptor site Right: A CHN on an internship at the Nkwanta FP preceptor site
51
Increased modern contraceptive use among people with disabilities
UGSPH (funded by the grant titled Increasing Use of Modern
Contraceptives and Skilled Delivery Services among Persons
with Disability in the Northern Region of Ghana) addressed
challenges faced by women in the Northern Region who are
of reproductive age and who have disabilities. Specifically,
the university used capacity building and social support
systems to address challenges in accessing and receiving FP
and maternity care.
Persons with disabilities (PWDs) are underserved by health
care services. UGSPH used a three-pronged approach to
increase FP and MNCH service uptake among PWDs in three
districts in the Northern Region from November 2016–
December 2017. The three tactics were to (1) build provider
capacity to provide respectful and competent care for PWDs,
(2) create a social support system to help PWDs access and
use FP and MNCH services, and (3) reduce provider stigma
and prejudice against PWDs who are sexually active and wish
to access contraceptives or MNCH services.
Through 71 trained health care providers and 59 “Safer Birth
Buddy” volunteers, the project reached 1,165 PWDs (348
females, 817 males). They also made referrals to health care
providers as needed.
For 89.7% of the PWDs reached, it was the first time anyone
had targeted them with specific information on FP and
MNCH services. At baseline, 13.2% of women reported
they had used a form of contraception before. During the
year of implementation, 112 (32%) of the women visited a
health facility in the three project districts for FP services,
more than doubling the proportion who had accessed
contraception. Many of these women were either specifically
referred by a volunteer or sought out services after one-on-
one outreach.
One important outcome was a reduction in stigma toward
PWDs among 130 participating providers and volunteers.
Prior to training, 67% felt that PWDs do not need FP services,
and 75.4% said that PWDs should be advised not to practice
FP even if they wanted to. After training, only 6% said that
PWDs did not need FP services, and 17.7% said that PWDs
should not be advised to practice FP.
A woman receives FP counseling at an accessible health center in Savelugu
52
Using CHPS to improve family planning uptakeColumbia University (grant name: CHPS+FP) used
community-based participatory research to enhance FP
access through the GHS CHPS model.
Columbia University’s CHPS+FP project used community
engagement strategies to increase FP uptake in the
Gushiegu District, Northern Region. Community-based
participatory research revealed that gender-based biases
often impede the use of contraceptive services. Such
obstacles could be overcome by regularly dialoguing with
male leaders, engaging male volunteers, and creating
community forums to openly address concerns.
Beginning in late 2017, the project held three rounds of
durbars in each community to raise awareness of FP,
answer questions, and eliminate misconceptions. The
durbars were moderated by a male and a female and
involved key community representatives, encouraging
female participation in the discussions.
Analysis of participant interviews indicated that the
durbars led to changes in FP perceptions and practices.
Respondents felt that parental or spousal conflict around FP
had decreased, as had the need for secrecy when seeking FP
services. These changes in perceptions were supported by
data from the three intervention CHPS zones, which showed
an 81% increase in new FP acceptors from FY17 (402 new
acceptors) to FY18 (727 new acceptors).
Community members discuss perceptions of FP
53
TECHNICAL ACHIEVEMENTS
MALARIA
Systems for Health’s malaria programming focused on
prevention (malaria in pregnancy) and treatment (case
management) to support the GHS National Malaria Control
Program (NMCP) goal of reducing malaria morbidity and
mortality by 75% by the year 2020 (using 2012 as the
baseline). In the first three years of the project, Systems for
Health trained more than 12,000 providers in malaria case
management (treatment and diagnostics) and malaria in
pregnancy. In the latter half of the project, the team supported
GHS supervisors and clinical specialists in conducting follow-
up visits, observing the practical application of skills, and
providing coaching to address gaps or facility-level challenges.
Integrated coaching visits offered additional opportunities for
on-site support on malaria topics.
A midwife counsels pregnant women on the prevention of malaria during pregnancy
Beginning in Year 3, malaria-focused shared learning sessions
brought together facilities with high malaria case burdens to
discuss challenges and best practices. The sessions used QI
methods to review data and identify the root cause of gaps in
malaria services. Subsequently, facility teams designed and
implemented interventions to improve severe malaria case
management. In Year 4, this work expanded to include districts
with low coverage of IPTp.
The availability of commodities, such as rapid diagnostic
tests (RDTs) and antimalarial medicines, is critical to effective
prevention and treatment of malaria. Therefore, supply chain
management was integrated into all coaching visits and shared
learning sessions.
54
Activities Output
Provider trainings 12,240 providers were trained in malaria case management, malaria in pregnancy, and the use of
malaria RDTs. In order to reduce costs and ensure maximum staff participation, most trainings were
held at hospitals and health centers.
777 providers received on-site training in the use of RDTs. This on-site training prepared nurses in
high-volume outpatient units to offer malaria testing in waiting rooms, thus decreasing wait times and
ensuring faster treatment.
CHO internships 524 providers from CHPS zones completed internships at high malaria-burden facilities, focusing on
fever case management and differential diagnosis.
CHO internships placed CHPS staff at high malaria-burden facilities to improve skills in fever case
management and differential diagnosis. Interns treated clients under coaching from experienced
providers on history-taking, physical examination, and malaria testing with RDT.
On-site coaching Over the life of the project, GHS clinical specialists and coaches received on-site support visits to
improve malaria service delivery. Visits focused on malaria testing, treatment, identification of danger
signs for referral, malaria in pregnancy, and malaria logistics and data management, particularly at the
sub-district level and below.
Shared learning All 5 regions—at the district, sub-district, and facility levels—used shared learning and QI projects to
increase IPTp3 coverage and reduce malaria deaths in children under the age of 5:
u CR: 16 sub-districts in 3 districts implemented shared learning to improve IPTp3 coverage, skilled
delivery, and first-trimester ANC registration.
u VR: 18 sub-districts in 5 districts implemented shared learning to increase IPTp3 coverage.
u WR: 4 district hospitals worked to improve severe malaria case management for children under 5; 27
sub-districts in 4 districts implemented shared learning to increase coverage of IPTp3.
u GAR: 9 districts implemented shared learning to increase IPTp3 coverage, skilled delivery, and first-
trimester ANC.
u NR: 15 hospitals implemented interventions to reduce the under-5 malaria case fatality rate (10 of
these hospitals were covered under the leadership-led QI FAA).
Between shared learning sessions, Improvement Coaches visited facilities to support the
implementation of facility-level changes.
Table 13. Malaria—Key Activities and Outputs
Key Activities and Outputs
Objectives:u Improve the uptake of IPTp for ANC registrants for up to
five doses through CHO-led BCC activities and improved
monitoring.
u Maintain the capacity of service providers at all levels
in the diagnosis and treatment of suspected malaria
cases and adherence to negative test results through
integrated coaching and supportive supervision at all
facilities.
u Institutionalize the management of severe malaria
according to clinical protocols through focused QI
activities in targeted facilities.
55
Malaria Talking Points
The following are three key malaria prevention and treatment strategies: (1) IPTp
through five doses of sulfadoxine/pyrimethamine (SP); (2) Test, Treat, and Track (T3),
which is a case management approach that involves confirming malaria through testing
before treating; and (3) the distribution of long-lasting insecticidal nets (LLINs), which
are nets to use over the beds of pregnant women and young children.
To support frontline health workers in implementing these strategies, Systems for
Health and NMCP developed and conducted on-site trainings of 5,888 providers
working at the health center and CHPS levels. Training sessions focused on talking
points related to IPTp, T3, and LLINs. (See image to the right.) These talking points
serve as tools for educating clients as well as reference materials to improve providers’
counseling skills. Malaria in pregnancy talking points distributed
to facilities throughout the five regions
Key Results
QI principles used in shared learning to increase IPTp coverage Malaria shared learning sessions are designed to improve
the prevention (IPTp) and treatment of malaria in targeted
low-performing facilities or districts. Specific malaria-related
aims are described in Table 14, and the geographic coverage
of the topics is shown in Figure 23.
Shared learning, aimed at increasing IPTp3 coverage,
launched in June 2018 in 21 districts. The results have been
encouraging, with a 16.1% increase in the percentage of
women receiving three doses of SP from October 2018 to
September 2019 when compared to the same period in the
previous year (Figure 24). This increase is higher than the
overall increase in IPTp coverage for the five regions, which
went from 45.4% to 45.9% (a 1.1% increase).
See the following spotlight for a specific example of how the
Volta Region applied QI methods to increase IPTp uptake.
Figure 23. A map of Ghana showing malaria-related topics at shared learning sessions
56
Improvement Aims Examples of Integrated Activities
Increase IPTp3+ coverage
• Weekly outreach to pregnant women
• Home visits to trace and dose defaulters
• On-the-job training on commodity management
• Client-centered counseling
Improve severe malaria case management for under-5s
• Audits of all under-5 deaths
• Refresher trainings on case management protocols
Decrease the average time for the initiation of malaria treatment for under-5s
• RDT use at emergency wards
• Staff training on triage
• Triage corners at outpatient departments (OPDs)
• Nurses empowered to initiate treatment while waiting for a doctor or senior clinician
Table 14. Malaria-related aims of shared learning. Figure 24. The percentage increase in the number of women receiving three doses of SP (i.e., IPTp3 coverage) in 21 shared learning districts in Central, Greater Accra, Volta, and Western Regions
60%
50%
40%
30%
20%
10%
0%
34.037.729.9
51.2
Oct 2016– Sep 2017
(N=75325)
Oct 2017– Sep 2018
(N=77398)
Oct 2015– Sep 2016
(N=74303)
Oct 2014– Sep 2015
(N=72815)
Oct 2018– Sep 2019
(N=78562)
44.1
N=ANC REGISTRANTS
A pregnant woman gets tested for malaria
57
SPOTLIGHT
IPTp Shared Learning: Improving IPTp3 Coverage through District-based Shared Learning Sessions in Five Districts in the Volta Region
Low uptake of IPTp during pregnancy can put both the
mother and unborn child at risk of malaria infection. Malaria
in pregnancy is a significant public health problem that can
cause maternal and fetal anemia, placenta parasitemia,
miscarriage, stillbirth, and low-birth-weight babies with
minimal chances of survival. As part of ANC services, WHO
recommends the administration of SP for malarial IPTp
in all geographic areas of moderate to high transmission.
Pregnant women are advised to take at least three doses of
SP, each a month apart, starting after 16 weeks of gestation
until delivery.
Five districts in the Volta Region had consistently recorded
low uptake of IPTp3 and remained at the bottom of
the region’s district league table. In 2017, the districts
collectively recorded coverage of 22%, compared to a
regional target of 50%. Systems for Health responded with
the application of QI methods and tools. Sub-district QI
teams came together in a shared learning setting to review
their local data. They agreed to increase IPTp3 coverage from 28.0% in 2017 to over 50.0% by June 2019. Teams were guided to
conduct problem analysis to identify root causes of the low IPTp uptake. They developed and implemented changes to address
priority root causes:
u Deliver on-the-job training on SP stock management to address shortages at the service delivery points.
u Track defaulters and reach out to them through home visits.
u Send midwives on monthly ANC visits to facilities without midwives (e.g., see the photo above).
u Conduct community BCC activities, such as meetings with mother-to-mother support groups and pregnancy schools, to
dispel misconceptions about SP.
These changes have impacted positively on the performance of the intervention districts, resulting in an increase in IPTp3
coverage from 28.0% in 2017 to 53.6% in 2019 (as of August), narrowing the performance gap between the intervention
districts and the region’s overall performance (Figure 25).
A midwife conducts a home visit to counsel a pregnant woman on the use of SP to prevent malaria in pregnancy
58
Figure 25. IPTp3 coverage in six shared learning districts in Volta vs. overall regional performance. January 2017–September 2019
Increased testing of suspected malaria cases
The T3 malaria initiative encourages 100% testing of
suspected malaria cases to confirm diagnoses. In the five
project regions, the proportion of suspected malaria cases
being tested increased from 89.4% in Year 4 to 91.4% in
Year 5, exceeding NMCP’s target of 90% for 2019 (Figure 26).
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
76.0
67.1
81.8
89.4
Oct 2016– Sep 2017
(N=4844283)
Oct 2017– Sep 2018
(N=5152502)
Oct 2015– Sep 2016
(N=4729382)
Oct 2014– Sep 2015
(N=4417845)
Oct 2018– Sep 2019
(N=5021247)
N=SUSPECTED MALARIA CASES
91.4
Figure 26. The increase in the number of suspected malaria cases tested, Year 1 to Year 5.
80%
70%
60%
50%
40%
30%
20%
10%
0%
Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Qtr1 Qtr1 Qtr1Qtr2 Qtr2 Qtr2Qtr3 Qtr3 Qtr3Qtr4 Qtr4
2017 2018 2019PERIOD
All 5 District Volta
Shared Learning Session (SL) 1
SL 2 SL 3
A child’s temperature is taken during a CHO PTFU visit on fever case management
59
1.20
1.00
0.80
0.60
0.40
0.20
0.00
0.77
1.05
0.390.32
Oct 2016– Sep 2017(N=27620)
Oct 2017– Sep 2018(N=18932)
Oct 2015– Sep 2016(N=35436)
Oct 2014– Sep 2015(N=34230)
Oct 2018– Sep 2019(N=16807)
N=TOTAL UNDER 5 MALARIA ADMISSIONS
0.17
Figure 27. Decreases in the under-5 case fatality rates, shared learning facilities in the Northern and Western Regions.
Figure 28. The inpatient under-5 malaria case fatality rate, all project-supported regions.
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0.52
0.66
0.27
0.21
Oct 2016– Sep 2017(N=82742)
Oct 2017– Sep 2018(N=73819)
Oct 2015– Sep 2016(N=97193)
Oct 2014– Sep 2015
(N=102822)
Oct 2018– Sep 2019(N=79863)
0.11
N=TOTAL MALARIA ADMISSIONS
A Community Health Officer tests a child for malaria
Dramatic reductions in inpatient malaria fatalitiesThe 11 hospitals in the Northern Region, where malaria
shared learning began in 2017, have seen drastic drops in
under-5 malaria case fatality rates. The same is true for four
hospitals in the Western Region, where shared learning
started in 2017 too. As shown in Figure 27, the rates dropped
from 0.77% (October 2015–September 2016) to 0.17%
(October 2018–September 2019) in four years. The number
of under-5 malaria deaths also decreased, from 273 to 29.
Under the leadership of NMCP, the collaborative work of
the GHS, Systems for Health, and other partners resulted in
dramatic reductions in under-5 malaria deaths across the
five regions. Significantly, the under-5 malaria case fatality
rate declined by 50%—that is, from 0.21% in the period from
October 2017 to September 2018 to 0.11% the following year
(Figure 28). This rate is well below the 2019 national target
of 0.43%.
60
INFECTION PREVENTION AND CONTROL
In 2014, five countries in West Africa suffered from an
unprecedented outbreak of Ebola virus disease. The World
Health Organization’s (WHO) Director-General declared the
outbreak a Public Health Emergency of International Concern
in August of that year and urged countries to reinforce
preparedness to be able to detect, investigate, and manage
possible Ebola cases.
Due to its geographic proximity to countries with outbreaks,
Ghana is among WHO’s 14 high-priority countries needing
to improve preparedness measures. The GoG established
measures to prevent the spread of the disease, including
creating a National Technical Coordination Committee;
developing a national preparedness/response plan;
and accelerating implementation of initiatives aimed at
strengthening the country’s capacity to prevent, detect, and
rapidly respond to Ebola and other infectious disease threats.
From November 2015–December 2017, USAID provided
funding to USAID Systems for Health and the Maternal and
Child Survival Program (MCSP) to jointly support Ebola
prevention work in Ghana, focusing on IPC. The two projects
worked with the GHS, through ICD, to launch initiatives to
enhance and reinforce IPC practices throughout the country.
The largest initiative was conducting whole-site IPC trainings
in targeted regional and district health facilities in each of
Ghana’s ten regions with each project covering five regions.
Activity Output
Update of national IPC policy, guidelines, and training materials
Supported MOH/GHS to update its Policy and Guidelines for Infection Prevention Control in Healthcare Facilities by incorporating current international standards on IPC as well as enhanced information on Ebola prevention and control measures.
Supported the IPC TWG to update the national IPC training package, including the creation of a facilitator’s guide.
Training of master trainers
24 master trainers and 205 regional trainers were trained.
Facility-level training of health care workers and support staff at regional and district hospitals
20,543 hospital staff from 106 facilities were trained in IPC. Each regional team of trainers was provided with 3 sets of IPC training kits comprised of medical equipment and supplies.
Major IPC competency areas covered by the training included hand hygiene, personal protective equipment, injection safety and handling of sharps, processing of used medical devices/equipment, environmental cleaning, and waste management.
Development and distribution of job aids
5 IPC job aids were developed and printed. Job aids were then disseminated to focal persons during workshops held in each region. All 106 facilities trained in IPC have received sufficient copies of the job aids so that they may be utilized in units throughout each hospital. A total of 30,800 copies have been distributed.
Support to the GHS in carrying out on-the-job coaching for trainees
106 hospitals received PTFU and on-the-job coaching visits. Coaches observed key skills such as handwashing and instrument cleaning. They provided feedback and coaching where there were skills gaps and supported facilities to develop or implement IPC action plans for continued improvement.
Table 15. Infection Prevention and Control—Key Activities and Outputs
Key Activities and Outputs
61
SPOTLIGHT
Capacity-Building Strategies
In 2014, as part of its health systems strengthening mandate,
Systems for Health began supporting the GHS to update its Policy and
Guidelines for Infection Prevention Control in Healthcare Facilities by
incorporating current international standards as well as enhanced
information on Ebola prevention and control measures. The MOH
approved the updated guidelines in 2015. Subsequently, Systems for
Health received additional funding to actively support the GHS and a
national IPC TWG. Activities focused on building health workers’ IPC
capacity in regional and district hospitals in the five regions where
Systems for Health works (MCSP covered Ghana’s remaining five
regions).
TrainingSystems for Health worked with the TWG to revise the national IPC
training package, including the creation of a facilitator’s guide. The
comprehensive, skills-based, on-site training package involved all
staff in every facility trained and was designed using adult learning
principles.
The project supported the GHS to implement a cascade approach
to train a critical mass of health workers, training master trainers
who in turn trained regional trainers, who then rolled out on-site,
skills-based IPC training at facilities throughout the five regions. The
trainings included both clinical staff and support staff, covering topics
appropriate to their roles in the facility per the agenda on the right.
Systems for Health provided funding to the GHS through FAAs
to carry out the on-site trainings for health workers. The project
supported the GHS with technical assistance, as well as training on
finance and grants management to support the administration of the
grants and build capacity for direct donor funding.
Job AidsTo support the institutionalization of IPC practices in each facility,
the project worked with the GHS to develop and distribute five job
aids. They covered the key topics of handwashing, alcohol hand rub,
chlorine solution, instrument wrapping, and waste segregation.
The job aids were pretested for clarity, ease of use, and durability. A
total of 30,800 copies were distributed, so that each facility would
have sufficient copies to place in strategic locations, such as above
handwashing stations.
TOT participants learn to decontaminate medical equipment
Examples of IPC job aids
Three-Day Agenda for Clinicians
• Intro to IPC*
• Standard precautions*
• Hand hygiene*
• PPE*
• Instrument processing
• Injection safety and the handling of sharps
• Environmental cleaning*
• Waste management*
• Action planning
• Designating IPC focal persons, committees, and/or teams to oversee implementation
* denotes topics covered in 1-day training for support staff
62
Key Results
Increases in provider competencyObservations at PTFUs showed high provider competency
in handwashing and environmental cleaning. Where skills
were lacking, the follow-up visits offered an opportunity to
provide feedback and coaching and to formulate action plans
for continued improvement at both the provider and facility
levels (Figure 29).
Hand hygiene: At follow-ups, staff showed high competence
in handwashing, completing, on average, 85% of the 16 key
steps correctly. Respondents noted that prior to the training,
handwashing stations were insufficient. After the trainings,
most facilities had necessary handwashing supplies (basin,
running water, soap, and single-use towels).
Supervisors coach on IPC practices in a neonatal intensive care unit during a PTFU visit
Personal protective equipment: Clinical and non-clinical
health workers emphasized that, before the training, they
did not know the importance of wearing gloves for all
procedures. After training, 77% of observed used sterile
gloves at the appropriate time, and 61% used exam gloves at
the appropriate time.
Decontamination of instruments: After training, staff
were able to correctly prepare chlorine solution (85%), use
the appropriate concentration (86%), and discard when
contaminated or after 24 hours (86%). On average, observed
staff completed 74% of decontamination steps correctly.
Waste management: Before IPC training, respondents noted
that waste segregation was insufficient and that they were
told all waste was the same. After training, 75% of visited
facilities had at least one color-coded waste bin available,
and 61% were segregating waste at the source, while 41%
segregated waste at the final disposal site.
Injection safety: Observed providers (n=1,282) adhered to the
major injection safety steps—using a new syringe for each
patient (85%), practicing aseptic techniques (70%), and safe
disposal of the syringe (85%). Nevertheless, there is still room
for improvement.
Figure 29. Percentage of Providers Meeting Competency Standards When Performing IPC Tasks
Cleaning patient areas (n=546)
Decontamination of instruments (n=1,582)
Wearing and removal of surgical mask (n=1,462)
Wearing of sterile gloves (n=1,396)
Hand washing (n=1,500)
87%
74%
85%
68%
75%
63
Environmental cleaning: Prior to training, staff noted that it
was a challenge for orderlies to wear appropriate personal
protective equipment. At PTFUs, 55% of observed orderlies
wore appropriate clothing when cleaning patient areas and
cleaning up blood/body fluid spills. Since many facilities hire
casual laborers who have a high rate of turnover, facilities
will need to have systems in place for ongoing training to
mitigate this challenge.
Increased ownership among facility leaders In addition to improved provider skills, there was increased
support and commitment from facility leadership for IPC
practices. Per the national guidelines, almost all facilities
have appointed an IPC focal person, and 65% of 546
wards visited had an active IPC committee. To ensure the
availability of IPC supplies, some facilities have begun
producing their own liquid soap, alcohol hand rub, and
chlorine. Others have added new handwashing stations,
installed isolation units, or built new incinerators or pits for
proper waste disposal.
Leaders have also implemented IPC trainings using their
own internally generated funds in facilities such as Ga
South Municipal Hospital, Taifa Polyclinic, and Saltpond
Hospital. In many facilities, new staff are trained in IPC and
Water, Sanitation, and Hygiene (WASH) practices, which
respondents felt would lead to sustaining IPC practices as a
norm.
The GHS has also committed to sustaining investments
made in IPC through the integration of IPC content into
supportive supervision visits and pre-service education,
expansion of training to frontline health workers, and
incorporation of IPC indicators into regional peer review
processes.
Keys to SuccessOver two years after USAID Ebola funding ended, many
facilities have sustained changes in their IPC practices
implemented after trainings. Listed below are a few
of the factors that the project considers keys to the
institutionalization and ownership of IPC in the GHS.
u The GHS led all IPC training and coaching activities, with
the project providing support.
u The cascade training strategy ensured that many IPC
experts and champions are now spread across Ghana to
support ongoing training and continued implementation
of IPC policies and recommendations.
u On-site training is cheaper and easier to implement; this
also supports sustainability.
u Strong management support backed by committed IPC
focal persons facilitated significant improvements at the
facility level.
u Competency-based training fostered learning and
retention of concrete skills among health care workers,
hospital management, and trainers.
u A whole-team approach to learning, coupled with the on-
site, practical nature of the training, supported the rapid
and cross-facility implementation of the IPC standards.
A supervisor demonstrates appropriate handwashing.
64
CHPS INFRASTRUCTURE
Systems for Health supported the GHS in implementing
the new national CHPS policy in two underserved regions
(Northern and Volta) by constructing and renovating
CHPS compounds. To ensure full stakeholder engagement,
the project collaborated closely with the GHS, district
assemblies, and communities throughout the process, from
planning to post-construction. After the completion of all
infrastructure in December 2018, the team collaborated
with the GHS on service delivery coaching visits to newly
constructed sites and completed the mechanization of all
boreholes to ensure a safe and consistent water supply.
Objectivesu Complete construction of 26 new CHPS compounds
and 50 renovation projects in collaboration with local
stakeholders, ensuring that all new and renovated
compounds adhere to national and international WASH
guidelines and national agency policies.
u Provide basic essential supplies for newly constructed
CHPS compounds.
u Expand the access to and utilization of services in CHPS
zones with new facilities.
Activities Output
New CHPS construction 26 new CHPS compounds constructed, equipped with basic medical equipment, and supplied and handed over to the GHS.
All newly constructed facilities received coaching visits to identify and address challenges in priority service delivery.
Community mobilization for new CHPS sites
New-construction communities were engaged to discuss their roles and responsibilities and to support the preparation and finalization of land documents.
Solar power and water at newly constructed CHPS
Drilled and mechanized boreholes at 20 facilities and installed solar panels at 15 newly constructed facilities without access to electricity and/or running water.
Facility Renovations 50 site renovations completed (NR: 25, VR: 25). Selected facilities received basic equipment, such as examination and/or delivery beds, stools, lockable refrigerators, and boilers.
In the Volta Region, renovations included 8 sites that were part of the PPP Network Pilot (details in the Health Financing chapter of this report).
In the Northern Region, Systems for Health renovated 11 sites, where the UN Foundation provided solar electricity, increasing the impact.
Table 16. Community-based Health Planning and Services, Key Activities and Outputs
Key Activities and Outputs
The US Ambassador to Ghana, Ghana’s Minister of Health, and the GHS Director-General, with other regional and local dignitaries, commissioned the Warivi CHPS compound in the Northern Region in January 2018
65
Key Results
Expanded access to primary care servicesThe overarching aim of the CHPS program is to increase
access to health services. Constructing and renovating CHPS
facilities supported this goal by making services available in
communities where none existed or by enhancing the variety
and volume of services available. In many locations with
newly constructed CHPS compounds, the CHPS zones were
already offering services via outreach and/or in buildings
that were not structurally viable. Thus, the community
mobilization work (mentioned above) played a pivotal role in
preparing stakeholders to better understand their roles in
CHPS implementation and contributed to increases in service
utilization (beginning in Year 3).
As more facilities were completed, service provision rates
continued to climb. Indeed, utilization increased for most
major primary health care services from Year 2 (October
2015–September 2016) to Year 5 (October 2018–September
2019). The number of outpatient-department cases increased
by 376%, the testing of suspected malaria cases increased
by 360%, and new FP acceptors increased by 46% (Figure
30). The number of CWC registrants increased by 149%, and
children immunized with Penta 3 increased by 51%. Penta 3
refers to the third dose of a pentavalent (5-in-1) vaccine that
protects against multiple common diseases and serves as a
proxy measure for completing the recommended vaccination
A new CHPS compound (including staff accommodations) constructed by Systems for Health
series. The percentage of suspected malaria cases tested
initially decreased but rebounded from Year 4 to Year 5, from
75% to 85%, which can be partially attributed to project-
supported coaching visits and advocacy with the RHDs so
that new facilities received adequate numbers of RDTs.
To support these facilities in starting strong and offering a
full range of high-quality services, the project also worked
with the GHS in Year 5 to conduct coaching visits for all 26
of the new CHPS compounds. Teams were able to address
many of the challenges confronting facilities, including NHIS
credentialing as well as gaps in provider competency. For
example, in Volta, several CHOs at new CHPS compounds
interned at preceptor sites to gain skills in implant insertion
and removal. (See the FP and RH chapter for details.)
SPOTLIGHT
Preparing Communities for New CHPS Clinics
Community mobilization played an important role in the construction
of new CHPS facilities. Systems for Health engaged communities
about their roles and responsibilities and helped them to achieve CHPS
functionality steps. Communities donated land and prepared land
documents prior to construction. For finished sites, CHMCs worked
with district assemblies to clean and beautify each compound and
provide security for the facility prior to the handover to the GHS. The
communities also donated comfort items for the CHO and midwife,
and the DHMTs procured items such as vaccine fridges and fire
extinguishers.Monthly site meeting with the GHS, community, construction company, and Systems for Health
66
Figure 31. A 300% increase in ANC registrants and an astronomical increase in the number of deliveries from Year 2 to Year 5.
1800
1600
1400
1200
1000
800
600
400
200
0
461422
1,140
1694
Oct 2017– Sep 2018
Oct 2018– Sep 2019
Oct 2016– Sep 2017
Oct 2015– Sep 2016
Total ANC Registrants in 26 New CHPS Zones with New Facilities
800
700
600
500
400
300
200
100
0
408
263
734
Oct 2017– Sep 2018
Oct 2018– Sep 2019
Oct 2016– Sep 2017
Oct 2015– Sep 2016
Deliveries in 26 CHPS Zones with New Facilities
The new CHPS compounds include staff accommodations
on clinic grounds, making it possible for the GHS to place
more midwives at the compounds and make them available
day and night. Also, a delivery room and recovery ward
were added in new CHPS buildings. Likely due to these
improvements, deliveries increased from eight in the October
2015–September 2016 period to 734 in the October 2018–
September 2019 period (Figure 31). In addition, the number
of women accessing ANC dramatically increased, from 422 in
Year 2 to 1,694 in Year 5 (a 300% increase).
A mechanized borehole at the Shelinvoya CHPS that is running on solar power (also provided by Systems for Health)
Figure 30. The increases in key primary care services, from Year 2 to Year 5, in 26 CHPS zones with new facilities
Oct 2015–Sep 2016 Oct 2016–Sep 2017 Oct 2017–Sep 2018 Oct 2018–Sep 2019
Total OPD Attendance Suspected Malaria Cases Tested
Family Planning Acceptors
Number of Children Immunized by Age 1 Penta 3
Total CWC Registrants(0-55 Months)
4,0
42
4,62
1
12,8
22 19,2
37
3,0
00
13,7
94
3,35
1 8,66
0
2,32
6
3,38
6
2,49
8
2,0
92
1,8
92
2,85
0
2,0
41
2,6
85
11,6
24
28,9
99
18,15
4
26,6
42
67
An incinerator at a newly constructed CHPS compound
Greater access to electricity, running water and improved waste managementSystems for Health completed the installation of solar power
systems at 15 new CHPS compounds in the Northern and
Volta Regions. Solar power provides reliable electricity at
these rural, off-grid clinics, ensuring they can keep vaccines
and critical medicines like oxytocin cold and can provide key
services, such as delivering babies at night.
The project also provided boreholes at 20 new CHPS
compounds that do not have access to running water (eight
Solar panels being installed at the Warivi CHPS compound, Northern Region
of the boreholes were drilled by Global Communities on
behalf of Systems for Health). Systems for Health completed
the mechanization of boreholes at 20 new CHPS compounds
that did not have access to running water. All the facilities
now have running water.
In the Northern Region, medical waste management remains
a problem in many health facilities. Apart from the hospitals,
many lower-level facilities do not have standard waste
management practices and often use waste pits, which are
not properly covered or fenced. Waste pits put community
members, especially children, at risk for encountering
contaminated medical waste (including sharp objects),
exposing them to harm. After observing these issues and
engaging with District Health Management Teams (DHMTs)
in districts with new CHPS compounds, stakeholders decided
that facilities without incinerators would be able to utilize the
incinerators at nearby compounds constructed by Systems
for Health. This practice has been adopted in six districts
with new CHPS compounds. DHMTs and other stakeholders
are also considering how to maximize the use of the 13
existing incinerators during mass immunization exercises;
nearby districts without incinerators might use the 13 that
are available. As a result, waste management in many parts
of the region is expected to improve.
Renovations for health facilitiesSystems for Health completed 50 health facility renovations
in the Volta and Northern Regions. The renovations focused
on service delivery, safety, and staff health. Each facility was
renovated based on specific needs and community priorities,
but typical improvements included replacing mosquito
screens; repairing roof leaks; fumigating for bats; replacing
doors, locks, and window bars; leveling floors and repairing
cracks; and applying a fresh coat of paint. Sun shelters
were installed in some facilities to provide a shady place
for patients to rest while waiting for services and for health
workers to conduct health education classes.
Feedback indicates that the renovations have given both
providers and clients improved confidence in the services
provided at their newly renovated facilities.
The photos on the next page show one renovated CHPS in
the Northern Region.
68
“I now feel very comfortable in my renovated consulting room. I have
enough ventilation as well as air from a ceiling fan, there is privacy,
the lighting system has improved and become more reliable and
safer. Because the place is now ‘shining’ (looking attractive), even
though we are closer to Ho (the regional capital) where there are
bigger health facilities, we receive more clients who feel comfortable
receiving healthcare in our health center.
~ A Physician’s Assistant at a renovated health facility
Renovations at the Sanguli CHPS in the Saboba District. Upper left and right: The exterior before and after renovations, respectively. Lower left and right: The interior before and after renovations.
Before (left) and after (right) a sun shelter is installed at the Tigenga CHPS in the Chereponi District
69
SPOTLIGHT
It Takes a Village: Equipping CHPS Compounds on Lake Volta
All the materials for Systems for Health’s two new clinics situated on remote parts of Lake Volta were delivered by boat. The
whole community pitched in, rain or shine, to move medical supplies, equipment, and furniture, from the lakeshore to the
facilities. The two CHPS compounds were turned over to the GHS in August 2018 and are now providing preventive, primary
care and skilled delivery services to a catchment area of nearly 8,000 people.
Communities around Lake Volta are often only accessible by boat. Community members offload and carry furniture and equipment from the lakeshore to the new CHPS facilities.
70
COMMUNITY MOBILIZATION FOR CHPS
Systems for Health supported the GHS to implement its
CHPS policy and implementation guidelines aimed at
reducing health inequalities and improving the delivery
of high-quality primary health care services. The project
also helped to remove geographical barriers and increase
community participation in health decision making.
Systems for Health collaborated with communities and
district- and sub-district-level stakeholders to support
483 target CHPS zones across the five regions (see
Figure 32). The zones advanced along 15 key steps to
achieve full functionality, as outlined in the CHPS National
Implementation Guidelines (Table 17).
Figure 32. A map of Ghana showing the 483 districts that were the focus of community mobilization efforts
Table 17. Action steps and milestones from the CHPS National Implementation Guidelines
Step Key Task Milestone
1 PlanDetailed plan created2 Consult and raise awareness of
CHPS
3 Dialogue with community leadership
Community entry conducted
4 Organize community information durbar
5 Select and train staff as CHOs
6 Select, approve, and orient CHMC
7 Compile community profile
8 Construct/operationalize compound (in Northern and Volta only)
CHPS Compound operationalised
9 Provide CHPS logistics (in Northern and Volta only)
Essential equipment supplied
10 Organize durbar to launch activities of the CHPS zone
CHO posted
11 Select community health volunteers (CHVs)
CHVs deployed
12 Approve CHV selection
13 Train CHVs
14 Procure logistics, equipment, and volunteer supplies
15 Launch the CHPS
15 Steps and Milestones for CHPS Implementation
* Bold text denotes steps that were the focus of Systems for
Health support.
71
In the project’s latter years, Systems for Health pivoted its
support toward enhanced community empowerment to
improve the quality of and access to CHPS services. Thus,
the project supported the GHS in introducing the Ghana
Community Scorecard in its five regions. The scorecard is
a management tool used to assess the quality of health
services and track nine key indicators. (See details in the
Key Results section). It also enables communities to give
feedback to health authorities and better understand
health outcomes at the local level.
Activity Output
Revisions and updates
to CHPS materials to
align with CHPS policy
and implementation
guidelines
Supported the GHS Policy, Planning, Monitoring, and Evaluation Division (PPME) to revise the
community mobilization and participation training manual and the CHMC flip chart.
CHPS strengthening for
Regional and District
Resource Teams
Trained 368 regional and district trainers and supervisors in CHPS Implementation.
Provider and
stakeholder trainings
424 CHNs, enrolled nurses, and midwives were trained to be CHOs. Training covered the 14 CHPS
modules to equip service providers in clinical practice, public health community mobilization, and
data management.
281 CHOs underwent 5-day CHO CHPS internships to build practical skills on the “Must Do” modules,
as prescribed in the CHPS implementation guidelines, before their deployment to CHPS zones.
Skills pertained to community mobilization, community decision making, home visits, and outreach
services.
1,015 CHMC members were trained on their roles and responsibilities in CHPS implementation.
CHPS shared learning 236 CHPS zones in 47 districts participated in peer-to-peer learning sessions, integrating QI into CHPS
activities (GAR: 107, VR: 54, NR: 75). Change ideas were developed to address performance gaps in
administering ANC, Penta 3, and IPTp3+, as well as to improve CHPS functionality. Example change
ideas included conducting active home visits to trace IPTp defaulters, monthly antenatal education at
prayer camps, and monthly weekend durbars.
Table 18. Community Mobilization — Key Activities and Outputs
Key Activities and Outputs
Objectives:u Provide technical assistance to regions and districts to
periodically analyze the level of CHPS functionality in
each zone, identify gaps, and plan activities to bridge the
gaps, including gender equity at each step.
u Support the GHS to build the capacity of supervisors (sub-
district officers), CHMCs, CHOs, nurses, and midwives
(especially those working in the CHPS zones with new
CHPS compounds and renovations).
u Give technical support to regions, districts, and
communities to strengthen community participation in
health service delivery. Ensure that individuals, especially
women and girls, are empowered to seek and access
quality health care.
continued
72
Activity Output
Stakeholder
engagement to achieve
the 15 steps of CHPS
functionality
483 target CHPS zones received ongoing coaching visits, which included follow-up to previously
trained CHOs and CHMCs as well as coaching on health services, community mobilization/
engagement, community decision making, home visits, and outreach services. More intensified
support was provided to CHPS zones with newly constructed compounds.
115 CHPS zones conducted BCC activities, including community durbars (NR: 30, VR: 62, WR: 23).
Themes included resource mobilization to support the CHPS zones, establishment of functional
Community Emergency Transport Systems, and communal labor to maintain the CHPS compound.
Updated Community Health Action Plans included activities to generate demand for CHPS services
(FP, MNCH, nutrition, and malaria).
Community Scorecard 134 DHMT members in 69 districts, 821 CHOs, and 3,457 CHMCs participated in orientation on the
Ghana Community Scorecard.
2 rounds of scorecard assessments were conducted by CHMCs. With assistance from the CHOs,
CHMCs developed a total of 956 action items to improve the quality of health services. Teams entered
assessment data and action plans into DHIMS2 and the scorecard platform. See the Key Results
section for additional information.
75 CHPS zones in the 5 regions received follow-up visits from the GHS PPME with the support of
Systems for Health. Information gleaned from these visits will inform and strengthen the scale-up of
the scorecard throughout the country.
Table 18. Community Mobilization — Key Activities and Outputs, continued
73
SPOTLIGHT
The Ghana Community Scorecard
The scorecard is a management tool that assesses the quality of health services. It includes a dashboard that reports
routine health indicators as well as patient perceptions of the quality of care, all of which are gathered quarterly through a
participatory process involving the community and providers. It empowers communities to actively take part in monitoring
community health services, to give feedback to health authorities, and to better understand local health outcomes.
At quarterly CHO meetings with CHMCs, each facility is
assessed using nine process indicators, and stakeholders
prioritize and discuss ones needing improvement and make
action plans to mitigate concerns. The results are entered
into DHIMS2, and the action plans entered into the district-
level Community Scorecard platform for further analysis. A
scorecard (example at right) illustrates performance.
Scorecard indicators:
u Caring, respectful, and compassionate care
u Wait time for health care services
u Availability of medicines, diagnostic services, and medical
supplies
u Availability, accessibility, and quality of services and
infrastructure
u Leadership and management of the facility
u Cleanliness and safety of the facility
u Performance during home visits by a CHO/CHN
u Performance during home visits by a Community Health
Worker (CHW) / Community Health Volunteer (CHV)
u Assessment of NHIA services
National GHS personnel reported that scorecards have enhanced data-driven decision making, illustrated community
perceptions about service delivery, and given leaders pragmatic actions for their QI initiatives. CHMCs and frontline health
staff use the scorecards to find local solutions to challenges and to make regional and district decisions.
A sample of the Ghana Community Scorecard
74
Figure 33 shows the percentage of regions’
actions developed and implemented during
the year. For many CHPS zones, scorecard
orientation occurred midyear. Thus, the
chart shows remarkable progress after
only a few months of implementation. For
example, Northern completed 62% of the
action items, and the remaining 38% are in
progress. Similarly, Volta completed 63% of
its actions, with 36% in progress.
“The scorecard assessment process has opened up
communication between the community and the
CHPS compound; the communities now feel there
is an avenue to channel their observations and
experiences to health staff, thus improving feedback
for quality health services.”
~ Acting CHPS Coordinator, Bodi District
“The scorecard has helped to improve the work we
do here. It teaches us how we can be accountable
to ourselves. The action plan helps us to know our
weaknesses and our strengths. So, from time to
time, when we meet with the elders and community
members, we all discuss what progress we have
made and change our strategy if we have to.”
~ CHMC Secretary, Asomdwee CHPS, AAK District
Key Results
Top left: CHMC and community members share perceptions on the quality of care during a CHPS zone’s scorecard assessment. Above right: A CHMC chairman discusses the results of an assessment with CHOs as the secretary prepares a template for action plan development.
Figure 33. The progress on action plan implementation per region, as of September 2019.
100%
80%
60%
40%
20%
0%Central (N=196)
G. Accra (N=98)
Northern (N=133)
Western (N=366)
Volta (N=163)
No Progress 9% 4% 0% 5% 1%
Some Progress 56% 54% 38% 52% 36%
Action Achieved 36% 42% 62% 43% 63%
36% 42%62%
43%
63%
Improved community participation in CHPS implementation
75
Strong support from CHMCs in resource mobilizationA CHMC serves as the liaison between the CHPS compound
(health workers) and community. One of its core mandates
is to mobilize resources to maintain and support health
activities in the zone. Following trainings in Years 2 and 3,
CHMCs mobilized resources across the five regions, including
construction services, furniture, security personnel, medical
supplies, wheelchairs, and vaccine refrigerators, among
others.
The CHMC presents benches, a mower, and a generator to the Bassengale CHPS compound
A CWC shed constructed jointly by the Nyibenya CHMC, community organizations, and health workers
The Salifa CHPS CHMC petitioned World Vision to donate this borehole in the Ahondzo community
A motorbike is donated to a CHO to enable regular outreach visits
Women empowered to participate in their communities’ health care decision makingSystems for Health worked to increase gender equity in
health care decision making through women’s participation
on CHMCs. Of 1,015 CHMC members trained, 32% were
women. By increasing representation on the CHMCs, women
are better positioned to advocate for gender-specific needs,
such as reproductive and maternal health services, and to
voice gender-specific concerns around service provision,
community engagement, and quality of care.
76
Figure 34. The percentage of CHPS facilities that have reached the threshold to be considered fully functional. October 2016–September 2019
CHOs give Vitamin A during a school outreach session
Full functionality at CHPS zones.The full functionality of a CHPS zone is based on the
achievement of 15 key implementation steps. As of
September 2019, 85% of 483 zones had achieved at
least 13 steps, the threshold for full functionality, from
a baseline of 13% in October 2016 (Figure 34).
Central (N=118)
G. Accra (N=107)
Northern (N=75)
Volta (N=113)
Western (N=70)
Grand Total (N=483)
100%
80%
60%
40%
20%
0%1%
97%
0%
87%
71%79%
3%
78%
9%
81%
13%
85%
Baseline Endline
“I am happy doing what I do for my community. The
health facility is for us, and we have to ensure it has
all it needs to serve us well. We are the ones who
benefit from it, so we have to help the health workers
for them to also provide the quality care we want.”
~ Madam Comfort, a queen mother and CHMC member at
the Duga CHPS Zone
77
Improved CHPS service delivery, including 500,000+ more servicesThe goal of the CHPS strategy is to bring health care to the
doorsteps of Ghanaians, and it is working. Over the life of the
project, CHPS zones progressively provided more preventive
and primary care services. Compared to the baseline period
(October 2015–2016), skilled deliveries at CHPS increased
by 192% by the end of the project, and postnatal care visits
within 48 hours of birth increased by 117%, CWC attendance
by 79%, ANC registrants by 54%, FP new acceptors by 44%,
tests for suspected malaria cases by 31%, and number of
children immunized by age 1 by 14%. These figures amount
to more than 500,000 additional key services provided
in the 483 project-supported CHPS zones in Year 5 when
compared to Year 2 (Figure 35).
Figure 35. Key services provided in the 483 project-supported CHPS zones, a comparison of Year 2 to Year 5
Oct 2015–Sep 2016 Oct 2018–Sep 2019
Maternal and Child Health Services Other Key Services
Child welfare clinic attendance
Suspected malaria cases
tested
1,0
09,
637
562,
965
313,
858
239,
911
ANC Registrants
Total Deliveries
Postnatal care visits within
48 hours of birth
# Children immunized
by age 1 (PENTA 3)
27,7
18
17,6
54
10,4
06
3,56
4
10,7
99
4,98
4
55,9
41
48,
920
78
PARTNER COORDINATION
The GHS was the primary partner
for Systems for Health. The project
worked closely with the GHS at the
national, regional, district, sub-
district, and facility levels to design,
plan, and implement effective
activities to support improvements in
the GHS and priority health indicators,
as defined by USAID.
At the national level, Systems for
Health worked closely with FHD in the
GHS, PPME, and ICD. The project also
worked closely with the NMCP under
the Disease Control Unit of the GHS
Public Health Division. The strategy
throughout the project was to work with existing structures
to strengthen and improve the overall health system. Critical
among this strategy was the way the project worked with
the GHS to use data to prioritize activities, especially to
help ensure that many activities could be sustained without
external support.
Throughout the project, Systems for Health also collaborated
with a wide range of partners on technical areas that span the
project portfolio as well as several overarching activities:
u Hosted and coordinated the quarterly Chiefs of Party
Meeting, which involved USAID health implementing
partners, and organized other activities among
implementing partners, as requested by USAID.
u Actively participated in quarterly meetings and trainings by
groups such as the Monitoring and Evaluation Community
of Practice of USAID’s Evaluate for Health (E4H) project.
u Supported the planning and organization of the joint review
and planning meetings between USAID, the GHS, and the
United Nations Children’s Fund (UNICEF). The purpose
of these meetings was to share and learn from past
experiences implementing programs, with the overarching
aim of improving coordination and ensuring programmatic
efficiencies.
Community Mobilization for CHPS (including BCC)Systems for Health collaborated with the GHS and numerous
other partners at all levels of the system to plan and
implement integrated CHPS strengthening activities, such as
the following:
GHS/PPME: Liaised regularly with the PPME Division to
discuss the progress of CHPS activities and coordinate the
rollout of the Ghana Community Scorecard, including the
following:
u Supported the GHS Accra-based staff to conduct
monitoring and coaching visits to CHPS zones on the
Ghana Community Scorecard implementation in all the
five regions.
u Held quarterly meetings to discuss progress made, data
entry into the DHIMS2 and scorecard platforms, and
lessons learned during implementation.
Systems collaborated closely with GHS/PPME and MCSP to
develop the CHPS implementation guidelines, CHPS costing
study, National CHPS Forum, and CHPS webpage.
Representatives of the GHS, UNICEF, USAID, and partners at a joint planning meeting
79
African Leaders Malaria Alliance (ALMA) and WHO:
Collaborated with ALMA and WHO to plan and execute
the successful rollout of the Ghana Community Scorecard
process in the country.
Communicate for Health (C4H): Collaborated with C4H
to distribute posters and other BCC materials to CHPS
zones for educating communities and CHOs on priority
health issues. In addition, the projects maintained regular
communication to coordinate activities and messages.
GHS/Health Promotion Division: Participated in the
division’s quarterly partner coordination meetings.
Family Planning and Reproductive HealthSystems for Health collaborated with various implementing
partners, including the Global Health Supply Chain
program–Procurement and Supply Management project
(GHSC-PSM), Health Keepers Network, and C4H. Also,
team members served on the Interagency Coordinating
Committee on Contraceptive Security (ICC-CS).
Health FinancingThe project worked closely with the World Bank, the Health
Finance and Governance (HFG) project, and the NHIA on
the performance-based finance and preferred-primary-care
provider (PPP) TWG meetings, as well as on the rollout of
the PPP pilot in the Volta Region.
Infection Prevention and ControlIn collaboration with MCSP, Systems for Health supported
the GHS (through the ICD) to update the national Policy and
Guidelines for Infection Prevention Control in Healthcare
Facilities, as well as to develop a comprehensive training
package. In addition, the project supported the IPC training
of trainers (TOT) as well as cascaded IPC training to facility-
level staff. Additional information is available in the IPC
chapter.
Infrastructure and Medical SuppliesSystems for Health and the UN Foundation collaborated
closely under the memorandum of understanding (MOU)
signed in September 2017 to renovate 11 facilities in the
Northern Region. The UN Foundation installed state-of-
the-art solar electric systems through a project funded
by the United Kingdom’s Department for International
Development, while Systems made physical upgrades to the
buildings.
Systems for Health received a donation of 10 midwife
delivery kits from Direct Relief. The kits were distributed to
seven health centers and three CHPS zones participating in
the PPP Network Pilot in the Volta Region.
Additionally, Systems and Global Communities collaborated
and drilled eight boreholes for CHPS compounds in areas
of the Northern and Volta Regions, where the projects
overlap. The boreholes have been mechanized with pumps
and connected to the CHPS compounds. Also, Power Africa
provided expert advice to prepare the request for proposals
and evaluate and score bids for solar installations at new
CHPS compounds.
MalariaIn the first three years of the project, Systems for Health
collaborated closely with the MalariaCare Project to ensure
coordinated and harmonized malaria-intervention support
in the five regions of Ghana. Activities included malaria case
management, malaria in pregnancy, and World Malaria Day.
Also, throughout the project, Systems actively participated
in the NMCP-led TWG meetings to review and update the
national malaria case management and malaria in pregnancy
guidelines. The project also regularly took part in the malaria
monitoring and evaluation working group meetings.
Maternal, Newborn, and Child HealthThe project provided technical and financial support for
the planning and organization of the First and Second
Maternal Child Health and Nutrition Conferences. The second
80
conference, which was held in the final year of the project,
had the theme “Enhancing Integrated RMNCAH & Nutrition
Interventions to Accelerate the Achievement of the SDGs.”
The conference sought to build on the agenda from the
maiden edition by bringing to the fore emerging policy issues
and facilitating discussions on solutions to overcome existing
challenges. The GHS highlighted project-supported activities
in several oral and poster presentations.
Systems for Health also participated in meetings of the
Subcommittee on Newborn Care, where stakeholders
(including the Ubora Institute, UNICEF, WHO, and the
Pediatric Society of Ghana) shared implementation ideas and
proposed sustainable approaches for enhancing newborn
care and service delivery. The project provided technical
support for the development of the new 2019–2023 strategy
and action plan for newborn health in Ghana. In addition,
Systems for Health collaborated with the aforementioned
partners in a series of planning meetings and provided
financial and/or technical support for the organization of
the annual newborn stakeholder conferences. The project-
supported regions highlighted the immense support received
from the project in implementing their newborn action plans
each year.
NutritionSystems for Health participated in quarterly meetings with
the GHS as well as the USAID-funded RING and SPRING
projects to give updates, share lessons, and harmonize
nutrition support to the Northern Region. The meetings were
coordinated by the USAID field office in Tamale.
Systems participated in the USAID-UNICEF Nutrition
Working Group Meetings. Among other things, the meetings
created an opportunity for stakeholders to share lessons
learned, successes, and challenges in the implementation of
their activities. Through these technical meetings, a nutrition
supportive supervision and monitoring tool was developed
and finalized.
Quality ImprovementThe project supported GHS-led TWG meetings (with
participation from several partners) to develop the Guidelines
for Supportive Supervision in the Health Sector, as well as
comprehensive training materials and tools. The project
partnered with the GHS, WHO, Christian Health Association
of Ghana, Japan International Cooperation Agency (JICA),
and Jhpiego to roll out the national supervision guidelines as
part of the trainings and supported the rollout of trainings in
the five project-supported regions. Additional information is
available in the QI/LM chapter.
Under the WHO-led Network for Improving Quality of Care
for Maternal and Newborn Health, the project partnered with
WHO, UNICEF, Institute for Healthcare Improvement (IHI),
the Ubora Institute, JICA, and the USAID Applying Science to
Strengthen and Improve Systems (ASSIST) project to provide
technical and financial support to network activities in
Ghana. Key activities included the following:
u Participated in TWG meetings to adapt the global
maternal and newborn health quality of care standards
for use in Ghana, particularly by health workers in
network facilities. The TWG also developed operational
guidelines and training materials for network districts and
facility QI teams. Also, partner organizations, including
Systems for Health, provided key updates on their QI
initiatives during these TWG meetings.
u Supported the GHS and the ASSIST project to successfully
scale up network activities to three additional regions (the
Northern, Volta, and Eastern Regions).
The project also provided technical and financial support
to the GHS-led TWG to develop operational guidelines for
implementing the NHQS at all levels within the GHS. The
TWG included representatives from the GHS, WHO, and the
Ubora Institute. Additional support for the NHQS is detailed
in the QI/LM chapter.
Finally, the project actively participated in planning
meetings for the 2019 Patient Safety and Healthcare Quality
Conference that brought together major stakeholders
operating in the quality space to celebrate, discuss lessons
learned, and chart the way forward for the country’s health
care quality management. Other participants included the
GHS, WHO, UNICEF, IHI, ActionAID, Ubora Institute, and
private sector health practitioners.
81
SPOTLIGHT
Partner Coordination: Korean International Cooperation Agency
In the Volta Region, Systems for Health supported
the implementation of an MOU between USAID and
the Korean International Cooperation Agency (KOICA)
to end preventable maternal and childhood deaths.
Specifically, the project worked closely with the GHS
and KOICA to support comprehensive health systems
strengthening activities in Keta Municipality, Ketu
North, and Ketu South Districts in the Volta Region.
This work included improving the accessibility, quality,
and use of FP/RH, MNCH, nutrition, malaria prevention/
treatment, and other priority health services
through capacity building, technical assistance, and
infrastructure improvements focused on CHPS.
In total, more than 1,800 training contacts were
made; some individuals may have been trained in more
than one technical area. Many trainees also received
PTFU visits and other on-site coaching and mentoring
opportunities to further support skills development and
implementation. The KOICA collaboration supported
infrastructure improvements such as the ones shown in
the newly constructed facilities featured in the photos:
Photos of the Lotakor facility. Top: The original, one-room Lotakor CHPS building. Middle: The new compound upon
completion in August 2017, including a seven-room clinic and apartments for two staff. Bottom: Dignitaries from the ribbon-
cutting ceremony at the Lotakor CHPS compound
82
LESSONS LEARNED AND RECOMMENDATIONS
Over the life of the project, Systems for Health was a vital
partner in Ghana’s health system, working with the GoG and
other partners to ensure equitable access to, demand for,
and use of high-quality, high-impact health services. At the
same time, the project yielded meaningful lessons—many
of which were progressively incorporated into project
implementation, as described throughout this report. The
lessons and recommendations in this chapter are intended
to complement the implementation strategies described
in the Introduction. It is the hope of the Systems for Health
team that these lessons and recommendations can be used
as goals and objectives for future GoG and USAID projects,
fostering good health for all Ghanaians and for communities
around the world.
Prioritize data-driven planning and implementation.
The systematic and continuous use of data by GHS
counterparts proved to be the most critical element to
achieving and exceeding the project’s desired results. Using
QI interventions, Systems for Health infused data-driven
thinking into all project-supported activities. It provided
managers and providers with the tools necessary to
continuously address gaps and improve service delivery.
Use contextualized and targeted approaches to deliver
improved results. Although there are common challenges
across Ghana’s regions and districts, the severity and root
cause of these challenges often vary. To more effectively
develop and implement contextualized solutions, the project
gradually supported the GHS as it decentralized technical
approaches and addressed region- and district-specific
priorities. Instead of trying to do everything everywhere,
the project promoted the use of disaggregated data and
emphasized district- and facility-level values to target
interventions where they were needed most. This approach
yielded better results and more cost-effective interventions.
It was about not just listening to what communities needed
but truly hearing them and giving them ownership of their
health outcomes—all the while focusing on shared, time-
tested QI and data management strategies to effectively
measure success.
Engage MOH/GHS leadership early and often. At the start of
the project, Systems for Health consulted with government
stakeholders at all levels of Ghana’s health system. More
extensive and frequent consultations were needed in the
early stages to better manage stakeholder relationships and
expectations and achieve buy-in for project strategies. By
working together, the GHS, Systems for Health, and other
partners established clear roles for national-level leadership
and regional applications to avoid redundancies and diffuse
ideas. By the middle years of the project, staff and project
partners became more adept at managing relationships,
which put the GHS in the driver’s seat.
Employ a capacity-building continuum dedicated to on-
site support. Systems for Health supported more than
59,000 training contacts, approximately 70% of which were
delivered on-site. Where feasible, the project largely adopted
a whole-site training approach with the GHS. It allowed
providers to benefit from team-based training, a culture of
shared learning and joint problem solving, and integrated
service delivery. This approach was also more cost-efficient
because travel and administrative costs were slashed. A
larger number of clinical as well as support staff were trained
at a lower cost. Consequently, a bigger cadre of health
workers now understands their roles and responsibilities
and is empowered to not only excel at their jobs but also to
champion high-quality health services.
On-site training proved to be more sustainable during
the project period and is well positioned to continue now
that Systems for Health has concluded. Facility, district,
and regional leaders arranged the trainings together for a
common purpose and to share lessons learned. They came
to view the trainings’ best practices and team collaborations
83
as necessary components of the health system’s success. So,
the health system is better able to withstand staff attrition
and facilitates improved follow-up by regional, district, and
facility supervisors and coaches.
Systems for Health placed a progressively larger emphasis
on the capacity-building continuum, realizing that ongoing
post-training coaching was necessary to institutionalize
improvements in provider competency and facility readiness.
The shared learning that the project and its partners
employed will be key to the success of similar efforts in the
future.
Infuse systems strengthening elements throughout the
portfolio. To effectively improve health and service delivery
outcomes, technical capacity building must simultaneously
strengthen systems. As an example, consider project-
supported malaria training. After the training sessions,
staff demonstrated a good understanding of the malaria
testing protocols and a willingness to test suspected cases
before treatment. However, the staff were confronted with
stock-outs of necessary supplies—such as RDT kits—or
inadequate logistics management at the facility level. The
health workers’ gains in knowledge and good intentions
were often negated because they lacked the tools to do
their jobs well. To address this gap, Systems for Health
added content to malaria case management trainings,
starting with QI approaches to build problem-solving skills,
then incorporating supply chain management skills. These
concepts were also integrated into all on-site support visits.
Any future trainings should follow a similar strategy—do not
just teach providers what they need to know but also give
them the tools to do it well.
Merge and leverage QI, leadership building, and health
financing activities to promote adaptive learning. The
leadership-led QI FAAs demonstrated an effective approach
that can easily be replicated. The FAAs enabled GHS regional
leadership teams to use data to design and autonomously
implement their own programs. Since a significant proportion
of the payment reimbursements were tied to achieving
results, teams felt empowered to continuously adjust their
implementation strategies. In other words, the FAAs taught
the grantees adaptive learning, an essential skill that can
be broadly applied across the health system to produce
sustainable results.
Follow CHPS for universal health coverage. Ghana has made
important strides to improve access to primary health care,
most notably by expanding CHPS zones and community
engagement with newly constructed and renovated CHPS
facilities. To strengthen primary health care, the CHPS
policy and implementation guidelines provide a clear
roadmap for improving both service delivery and stakeholder
engagement. Future programs should support the GHS and
its district, sub-district, and community stakeholders to
implement CHPS as defined in the guidelines. If this support
is coupled with the use of the Ghana Community Scorecard,
it will produce a practical approach to addressing both
supply and demand issues in the health system. CHPS offers
sustainable solutions to achieve UHC.
84
ANNEX 1
PERFORMANCE MONITORING PLAN (PMP) TABLE
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
Activity Result 1: Building Blocks of the Health System
IR 1.1 Management and Leadership
1.1.1 Number of stakeholder meetings conducted to develop regional and district-specific workplans and budgets
Region, district
Quarterly All 0 5 9 12 5 5 36
Central 0 1 2 1 1 1 6
G.Accra 0 1 2 2 1 1 7
Northern 0 1 2 5 1 1 10
Volta 0 1 1 2 1 1 6
Western 0 1 2 2 1 1 7
1.1.2 Number of management teams that have been trained in leadership development
Region, Sex of
participants
Annual All 0 7 72 25 0 0 104
Central 0 0 14 0 0 0 14
G.Accra 0 0 9 11 0 0 20
Northern 0 0 21 5 0 0 26
Volta 0 7 15 0 0 0 22
Western 0 0 13 9 0 0 22
1.1.3 Percent of district teams that achieve their LDP project results within the specified timeframe.
Region, district, type
of facility
Annual All N/A N/A 86% (6/7)
68% (13/19)
73.5% (36/49)
84% (32/38)
77% (87/113)
1.1.41 Number of USG-supported health facilities that receive at least one GHS-led integrated coaching visit in the year
Region, district, type
of facility
Annual All
N/A
653 952 1,100 874 508 4,087
Central 159 207 137 142 32 677
G.Accra 59 89 249 130 32 559
Northern 119 160 164 182 86 711
Volta 179 245 325 226 187 1,162
Western 137 251 225 194 145 952
IR 1.2 Health Information Systems
1.2.1 Percent of USG-supported primary health care facilities that submitted routine reports on time.
Region, district
Quarterly All 73% 86.8% (114738/ 132228)
83.7% (133350/ 159333)**
89.8% (135285/ 150588)
95.6% (171,833/ 179,679)
97.4% (44914/46091)
97.4% (44914/46091)
Central 73.8% 88.8% (22793/ 25668)
85.8% (22808/ 26595)**
89.9% (21208/ 23592)
93.8% (27,425/ 29,253)
94.7% (7254/7662)
94.7% (7254/7662)
G.Accra 80% 89.4% (19184/ 21468)
79.8% (22873/
28680)**
88.8% (21805/ 24552)
92.7% (32,370/ 34,917)
95.2% (8543/8971)
95.2% (8543/8971)
Northern 67.3% 82.4% (19403/ 23556)
84% (25939/ 30867)**
86.8% (28175/ 32472)
94.0% (33,773/ 35,943)
92.3% (8862/9596)
92.3% (8862/9596)
Volta 73.5% 89.2% (28344/ 31764)
82.6% (27967/
33852)**
88.2% (28121/ 31884)
97.2% (35,177/ 36,195)
97.8% (9228/9433)
97.8% (9228/9433)
Western 70% 84% (25014/ 29772)
85.8% (33763/ 39339)**
94.5% (35976/ 38088)
99.4% (43,093/ 43,371)
97.9% (11029/11259)
97.9% (11029/11259)
continued
85
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
1.2.2 % of regions and districts reporting timely and complete data for DHIMS-2 for key monthly reports
Region, district
Quarterly All 12.1% 36% (41/114)
33.3% (38/114)**
68.4% (78/114)
86.8% (99/114)
92.2% (107/116)
92.2% (107/116)
Central 0.0% 30% (6/20)
10% (2/20)**
80% (16/20)
80% (16/20)
77.3% (17/22)
77.3% (17/22)
G.Accra 9.5% 47.6% (10/21)
14.3% (3/21)**
42.9% (9/21)
71.4% (15/21)
95.2% (20/21)
95.2% (20/21)
Northern 11.5% 19.2% (5/26)
61.5% (16/26)**
61.5% (16/26)
84.6% (22/26)
92.3% (24/26)
92.3% (24/26)
Volta 28.0% 56% (14/25)
20% (5/25)**
76% (19/25)
92% (23/25)
96% (24/25)
96% (24/25)
Western 11.4% 27.3% (6/22)
54.5% (12/22)**
81.8% (18/22)
100% (22/22)
100% (22/22)
100% (22/22)
IR 1.3 Health Workforce
1.3.1 % of CHPS zones with at least one CHO for at least 6 consecutive months of the year
Region, district
Annual ALL 29.6% (292/987)
29.6% (292/987)
17% (261/1537)
38.7% (496/1283)
38.1% (551/1447)
36% (682/1892)
36% (682/1892)
Central 42.2% (79/187)
42.2% (79/187)
26.4% (56/212)
45.6% (82/180)
42.6% (100/235)
43% (101/235)
43% (101/235)
G.Accra 50.3% (95/189) 50.3% (95/189)
38.2% (99/259)
50.4% (127/252)
68.4% (117/171)
52.4% (142/271)
52.4% (142/271)
Northern 1.7% (2/121)
1.7% (2/121)
0.5% (2/368)
33.7% (55/163)
22.9% (111/484)
22.9% (111/484)
22.9% (111/484)
Volta 13% (30/231)
13% (30/231)
11% (30/273)
23.1% (63/273)
39.5% (62/157)
33.3% (167/502)
33.3% (167/502)
Western 33.2% (86/259) 33.2% (86/259)
17.4% (74/425)
41% (170/415)
40.3% (161/400)
40.3% (161/400)
40.3% (161/400)
1.3.2 Number of persons trained with USG funds
Region, type of training,
sex
Quarterly All 0 2,015 22,177 13,520 1,371 0 39,083
Female 0 1,167 14,336 9,636 968 0 26,107
Male 0 848 7,841 3,884 403 0 12,976
Central 0 292 3,614 2,119 235 0 6,260
G.Accra 0 546 4,326 4,460 360 0 9,692
Northern 0 295 6,592 2,835 0 0 9,722
Volta 0 295 4,206 2,205 116 0 6,822
Western 0 587 3,163 1,877 660 0 6,287
National level
0 0 276 24 0 0 300
Maternal, Neonatal, and Child Health; Nutrition
1.3.3 Number of birth attendants trained with USG funds to use chlorhexidine for cord care
Region, sex Quarterly All 0 0 606 523 24 0 1,153
Female 0 0 540 497 24 0 1,061
Male 0 0 66 26 0 0 92
Central 0 0 129 152 0 0 281
G.Accra 0 0 218 236 0 0 454
Northern 0 0 41 115 0 0 156
Volta 0 0 157 0 0 0 157
Western 0 0 61 20 24 0 105
1.3.4 Number of health workers trained in child health and nutrition through USG funds
Region, sex Quarterly All 0 284 2,993 998 25 0 4,300
Female 0 211 2,305 817 24 0 3,357
Male 0 73 688 181 1 0 943
Central 0 47 357 359 25 0 788
G.Accra 0 94 1,049 302 0 0 1,445
Northern 0 30 548 196 0 0 774
Volta 0 72 648 20 0 0 740
Western 0 41 391 121 0 0 553
continued
86
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
Malaria
1.3.5 Number of health workers trained in case management with artemisinin-based combination therapy (ACTs) with USG funds
Region, Sex Quarterly All 0 688 11,104 6,610 739 0 19,141
Female 0 368 6,729 4,588 550 0 12,235
Male 0 320 4,375 2,022 189 0 6,906
Central 0 83 2,374 1,357 146 0 3,960
G.Accra 0 183 1,503 1,550 0 0 3,236
Northern 0 83 3,847 1,938 0 0 5,868
Volta 0 0 1,957 1,080 0 0 3,037
Western 0 339 1,423 685 593 0 3,040
1.3.6 Number of health workers trained in malaria laboratory diagnostics (rapid diagnostic tests or microscopy) with USG funds
Region, Sex Quarterly All 0 688 11,104 7,386 739 0 19,917
Female 0 368 6,729 5,173 550 0 12,820
Male 0 320 4,375 2,213 189 0 7,097
Central 0 83 2,374 1,357 146 0 3,960
G.Accra 0 183 1,503 1,955 0 0 3,641
Northern 0 83 3,847 1,938 0 0 5,868
Volta 0 0 1,957 1,235 0 0 3,192
Western 0 339 1,423 901 593 0 3,256
1.3.7 Number of health workers trained in intermittent preventive treatment in pregnancy (IPTp) with USG funds
Region, Sex Quarterly All 0 688 11,104 6,610 739 0 19,141
Female 0 368 6,729 4,588 550 0 12,235
Male 0 320 4,375 2,022 189 0 6,906
Central 0 83 2,374 1,357 146 0 3,960
G.Accra 0 183 1,503 1,550 0 0 3,236
Northern 0 83 3,847 1,938 0 0 5,868
Volta 0 0 1,957 1,080 0 0 3,037
Western 0 339 1,423 685 593 0 3,040
IR 1.4 Infrastructure and Supply Chain
Supply Chain
1.4.12 % of facilities that maintain up-to-date inventory control cards (as assessed on the day of facility visit)
Region Baseline, Midline
and Endline
All 3.8% (14/370)
N/A N/A
17.3% (66/382)
N/A
28.5% (99/347)
28.5% (99/347)
Central 10.7% (8/75)
29.8% (25/84)
40.2% (33/82)
40.2% (33/82)
G.Accra 2.1% (1/48)
14.9% (7/47)
58.3% (14/24)
58.3% (14/24)
Northern 0% (0/65)
18.5% (12/65)
22.0% (13/59)
22.0% (13/59)
Volta 3.8% (4/104)
13% (14/108)
17.9% (19/106)
17.9% (19/106)
Western 1.3% (1/78)
10.3% (8/78)
26.3% (20/76)
26.3% (20/76)
CHPS Infrastructure Development
1.4.2 Number of USG-supported new CHPS compounds constructed in accordance with the CHPS policy and implementation guidelines
Region, district
Annual All 0 0 0 8 17 1 26
Central 0 0 0 0 0 0 0
G.Accra 0 0 0 0 0 0 0
Northern 0 0 0 4 8 1 13
Volta 0 0 0 4 9 0 13
Western 0 0 0 0 0 0 0
1.4.3 Number of USG-supported CHPS zones, health facilities, and clinics rehabilitated and/or equipped in accordance with the CHPS policy
Region, district
Annual All 0 0 0 0 19 31 50
Central 0 0 0 0 0 0 0
G.Accra 0 0 0 0 0 0 0
Northern 0 0 0 0 11 14 25
Volta 0 0 0 0 8 17 25
Western 0 0 0 0 0 0 0
continued
87
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
IR 1.5 Health Financing
1.5.1 Number of districts piloting performance-based financing
Region, district
Annual All
N/A
0 2 2 2 2 2
Central 0 0 0 0 0 0
G.Accra 0 0 0 0 0 0
Northern 0 1 1 1 1 1
Volta 0 1 1 1 1 1
Western 0 0 0 0 0 0
1.5.2 Number of RHMTs and DHMTs that receive a performance based grant (PBG) and report on results
Region, district
Annual All
N/A
1 5 9 5 5 25
Central 0 1 2 1 1 5
G.Accra 1 1 1 1 1 5
Northern 0 1 2 1 1 5
Volta 0 1 2 1 1 5
Western 0 1 2 1 1 5
1.5.3 Number of instances of results of PBG process being publicly shared within the health sector
Region, district
Semi-Annual
All
N/A
0 5 15 15 10 45
Central 0 1 3 3 2 9
G.Accra 0 1 3 3 2 9
Northern 0 1 3 3 2 9
Volta 0 1 3 3 2 9
Western 0 1 3 3 2 9
1.5.43 Percent of RHMTs and DHMTs that have adequate capacity to manage funds per USAID standards
Region, district
Annual All 17.9% (17/95)
N/A
31% (32/103)
53% (57/108)
81% (96/119)
86% 86% (102/118)
Central 5.3% (1/19)
20% (4/20)
45% (9/20)
76% (16/21)
71% 71% (15/21)
G.Accra 25% (5/20)
33% (2/6)
50% (9/18)
82% (18/22)
90% 90% (19/21)
Northern 20% (5/25)
35% (9/26)
48% (12/25)
85% (23/27)
85% 85% (23/27)
Volta 12% (3/25)
28 (7/25)
65% (15/23)
73% (19/26)
92% 92% (24/26)
Western 18.2% (4/22)
27% (6/22)
44% (8/18)
87% (20/23)
91% 91% (21/23)
Regional Health Direc-torates
100% (5/5)
100% (4/4)
100% (4/4)
100% (5/5)
100% (5/5)
100% (5/5)
IR 1.6 Community Mobilization for CHPS
1.6.1 Number of CHPS zones with active community health management committees (Note: previous indicator was “number of CHPS zones with active community QI teams”)
Region, district
Annual All
N/A N/A
273 6313 7789 7923 7923
Central 39 1080 1083 1382 1382
G.Accra 21 654 1204 1413 1413
Northern 41 1015 1906 1851 1851
Volta 72 1250 1316 1390 1390
Western 100 2314 2280 1887 1887
continued
88
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
Activity Result 2: Improved Accessibility and Availability of Quality Health Services
I.R. 2.1 Quality Improvement (including supportive supervision)
2.1.1 Percent of districts that have active QA/QI teams. (Note: previous indicator was % of clinical facilities that have active QA/QI programs (evidenced by active QI teams and QA plans and documentation of implementation and progress)
Region, district, type
of facility
Annual All
N/A N/A
66% (72/109)
71.6% (78/109)
78.1% (89/114)
75.4% (86/114)
75.4% (86/114)
Central 70% (14/20)
45% (9/20)
71.4% (15/20)
66.7% (14/21)
66.7% (14/21)
G.Accra 56% (9/16)
100% (16/16)
85% (17/21)
85% (17/20)
85% (17/20)
Northern 81% (21/26)
73.1% (19/26)
76.9% (20/26)
76.9% (20/26)
76.9% (20/26)
Volta 60% (15/25)
64% (16/25)
76% (19/25)
80% (20/25)
80% (20/25)
Western 59% (13/22)
81.8% (18/22)
81.8% (18/22)
81.8% (18/22)
81.8% (18/22)
2.1.2 Percent of USG-assisted SDPs providing FP counseling and/ or services
Region, district
Quarterly All 70.0% 66.7% (1716/2571)
70.6% (2004/2838)
77.1% (2418/3137)
77.5% (2682/3460)
76.7% (2878/3752)
76.7% (2878/3752)
Central 77.70% 79.6% (339/427)
82.7% (359/434)
89% (398/447)
84.3% (439/521)
84.2% (460/546)
84.2% (460/546)
G.Accra 36.20% 36.4% (252/691)
50.3% (297/590)
52.5% (330/628)
57.5% (462/804)
58.6% (540/922)
58.6% (540/922)
Northern 77.10% 75.9% (290/382)
66.7% (335/502)
73.9% (450/609)
78% (488/626)
76.8% (521/678)
76.8% (521/678)
Volta 86.60% 86.3% (447/518)
82.4% (487/591)
91.8% (570/621)
89% (593/666)
89.2% (628/704)
89.2% (628/704)
Western 71.90% 70.2% (388/553)
73% (526/721)
80.5% (670/832)
83% (700/843)
80.8% (729/902)
80.8% (729/902)
2.1.3 % of USG-assisted SDPs, including CHPS, that offered at least four modern methods of FP during the reporting period
Region, district, type
of facility
Quarterly All 55.36% 52.4% (1346/2571)
56.3% (1598/2838)
60.7% (1903/3137)
64.6% (2138/3309)
58.6% (2197/3752)
58.6% (2197/3752)
Central 66.40% 66.7% (284/426)
71.7% (311/434)
74.7% (334/447)
73.3% (367/501)
71.6% (391/546)
71.6% (391/546)
G.Accra 28.30% 30.3% (210/692)
40.5% (239/590)
46.2% (290/628)
47.4% (343/724)
40.8% (376/922)
40.8% (376/922)
Northern 52.30% 44.8% (171/382)
45.2% (227/502)
46.6% (284/609)
54.1% (329/608)
50.4% (342/678)
50.4% (342/678)
Volta 72.20% 72.2% (374/518)
70.1% (414/591)
82.3% (511/621)
81.9% (537/656)
78% (549/704)
78% (549/704)
Western 57.60% 55.5% (307/553)
56.4% (407/721)
58.2% (484/832)
68.5% (562/820)
59.8% (539/902)
59.8% (539/902)
2.1.4 % of USG-supported SDPs that offer long-acting and permanent methods (LAPM)
Region, district, type
of facility
Quarterly All 58.30% 39.6% (1019/2571)
53.6% (1522/2838)
62.4% (1958/3137)
68.7% (2273/3309)
64.6% (2423/3752)
64.6% (2423/3752)
Central 79.3% 63.4% (270/426)
71.4% (310/434)
80.8% (361/447)
81% (406/501)
79.1% (432/546)
79.1% (432/546)
G.Accra 28.8% 22% (152/692)
34.7% (205/590)
42.8% (269/628)
47.2% (342/724)
40.9% (377/922)
40.9% (377/922)
Northern 55.1% 32.7% (125/382)
47.4% (238/502)
52.2% (318/609)
64% (389/608)
62.8% (426/678)
62.8% (426/678)
Volta 73.3% 42.3% (219/518)
65% (384/591)
80% (497/621)
84% (551/656)
82.4% (580/704)
82.4% (580/704)
Western 55.0% 45.8% (253/553)
53.4% (385/721)
61.7% (513/832)
71.3% (585/820)
67.4% (608/902)
67.4% (608/902)
continued
89
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
2.1.54 Number of USG-supported facilities that provide appropriate life-saving maternity care.
Level of care Baseline and
Endline
All 96 N/A N/A N/A N/A 150 150
Hospitals 83 N/A N/A N/A N/A 117 117
Health Centers
13 N/A N/A N/A N/A 33 33
2.1.6 % of women delivering in a health facility who are checked for anemia
Region, district
Quarterly All 58.0% 60.6% (198906/ 328155)
59.7% (201288/ 337155)
58.2% (202078/ 347436)
58.2% (219203/ 376676)
56.8% (218205/ 384299)
56.8% (218205/ 384299)
Central 63.3% 58.9% (34672/58833)
71.2% (42679/59975)
67% (41281/61587)
60.7% (39783/65564)
59.9% (39859/66585)
59.9% (39859/66585)
G.Accra 56.3% 66.2% (72435/ 109363)
66.4% (72744/ 109540)
64% (67961/ 106155)
68.6% (76565/ 111571)
72.6% (79810/ 109881)
72.6% (79810/ 109881)
Northern 60.5% 57% (33699/59121)
53.6% (34183/63752)
54.2% (39307/72524)
49.9% (41285/82732)
42.7% (37084/86924)
42.7% (37084/86924)
Volta 54.2% 54.6% (22639/41449)
51% (21501/42172)
48.8% (21916/44903)
50% (24488/48941)
49.8% (24406/48961)
49.8% (24406/48961)
Western 55.70% 59.7% (35461/59389)
48.9% (30181/61716)
50.8% (31613/62267)
54.6% (37082/67868)
51.5% (37046/71948)
51.5% (37046/71948)
Hospital 96.5% (28/29)
N/A N/A N/A N/A
78.3% (18/23)
78.3% (18/23)
Health Center
67.3% (35/52)
59.5% (25/42)
59.5% (25/42)
CHPS 55.5% (5/9)
68.0% (34/50)
68.0% (34/50)
2.1.8 % of health facilities that provide counseling in exclusive breastfeeding for 6 months
Region, district
Semi-Annual
All 44% 87.6% (1095/1249)
89.5% (1302/1454)
94% (1202/1279)
98.7% (1594/1615)
98.8% (1761/1782)
98.8% (1761/1782)
Central 47.4% 93.2% (208/223)
86.2% (219/254)
95.9% (212/221)
98.2% (272/277)
96.7% (294/304)
96.7% (294/304)
G.Accra 36.5% 89.6% (251/280)
91.1% (287/315)
87.2% (218/250)
98.3% (298/303)
100% (328/328)
100% (328/328)
Northern 60.0% 94.7% (217/240)
92% (263/286)
103.6% (259/250)
99.4% (334/336)
99.5% (377/379)
99.5% (377/379)
Volta 30.0% 71.2% (163/229)
83.7% (220/263)
89.5% (221/247)
98.3% (294/299)
98.8% (321/325)
98.8% (321/325)
Western 48.10% 92.4% (256/277)
93.2% (313/336)
93.9% (292/311)
99% (396/400)
98.9% (441/446)
98.9% (441/446)
2.1.95 Number of supported health facilities using emergency triage assessment and treatment (ETAT) as per national guidelines
Region Annual All 9
N/A
47 50 50 50 50
Central 2 2 3 3 3 3
G.Accra 3 14 15 15 15 15
Northern 1 10 10 10 10 10
Volta 2 12 12 12 12 12
Western 1 8 9 9 9 9
National level
0 1 1 1 1 1
2.1.106 % of USG-supported SDPs, including CHPS, offering integrated management of neonatal and childhood illness.
Region, district, type
of facility
Baseline and
Endline
All 14.2% (21/148)
N/A N/A N/A N/A
34.5% (51/148)
34.5% (51/148)
Central 12.5% (3/24)
48.0% (12/25)
48.0% (12/25)
G.Accra 13.0% (3/23)
31.8% (7/22)
31.8% (7/22)
Northern 13.% (5/37)
27.0% (10/37)
27.0% (10/37)
Volta 15.8% (6/38)
28.9% (11/38)
28.9% (11/38)
Western 15.4% (4/26)
42.3% (11/26)
42.3% (11/26)
continued
90
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
2.1.11 % of supported health facilities that test children <5 for malaria and provide treatment with ACTs
Region, district, type
of facility
Quarterly All 70.2% (1806/2571)
69.1% (1961/2838)
70.9% (2225/3137)
70.7% (2338/3309)
66.5% (2495/3752)
66.5% (2495/3752)
Central 72.8% 84% (358/426)
88.2% (383/434)
93.7% (419/447)
87.6% (439/501)
87% (475/546)
87% (475/546)
G.Accra 39.6% 39.6% (274/692)
49% (289/590)
52.2% (328/628)
46.7% (338/724)
42% (387/922)
42% (387/922)
Northern 69.1% 80.1% (306/382)
66.9% (336/502)
66.3% (404/609)
74.2% (451/608)
68% (461/678)
68% (461/678)
Volta 67.6% 77.2% (400/518)
70.7% (418/591)
73.1% (454/621)
73.6% (483/656)
71.2% (501/704)
71.2% (501/704)
Western 75% 84.6% (468/553)
74.2% (535/721)
74.5% (620/832)
76.5% (627/820)
74.4% (671/902)
74.4% (671/902)
2.1.12 % of mothers (or caregivers) counseled in appropriate feeding practices in alignment with the ENA
Region, district
Baseline and
Endline
All 66.7% (419/628)
N/A N/A N/A N/A
86.3% (563/652)
86.3% (563/652)
Central 71.7% (76/106)
75.0% (81/108)
75.0% (81/108)
G.Accra 60.4% (67/111)
77.8% (70/90)
77.8% (70/90)
Northern 66.9% (97/145)
85.1% (149/175)
85.1% (149/175)
Volta 71.6% (126/176)
93.6% (162/173)
93.6% (162/173)
Western 58.9% (53/90)
95.3% (101/106)
95.3% (101/106)
2.1.137 Number of health facilities with established capacity to manage acute under-nutrition.
Region, district, type
of facility
Quarterly All 262 395 616 1,885 703 471 471
Central 53 (14%) 75 170 343 176 145 145
G.Accra 67 (11%) 59 74 205 105 82 82
Northern 97 (28%) 222 316 1,146 332 188 188
Volta 29 (6%) 24 24 120 50 29 29
Western 16 (3%) 15 32 71 40 27 27
2.1.14 Number of women who received breastfeeding education through USG-supported programs
Region, district
Quarterly All 295,993 302,805 319,167 328,257 345,924 375,236 1,671,389
Central 60,533 56,574 57,125 56,634 57,642 63,447 291,422
G.Accra 94,652 101,138 103,579 96,440 98,737 105,509 505,403
Northern 53,242 56,594 62,591 69,534 77,139 87,245 353,103
Volta 32,536 32,221 36,033 41,862 47,459 48,655 206,230
Western 55,030 56,278 59,839 63,787 64,947 70,380 315,231
2.1.15 % of facilities that confirm outpatient and inpatient cases of malaria by using RDT and/or microscopy
Region, district, type
of facility
Annual All 70.2% (1806/2571)
69.8% (1981/2838)
71% (2228/3137)
71.4% (2361/3309)
67.4% (2527/3752)
67.4% (2527/3752)
Central 82.8% 84% (358/426)
88.9% (386/434)
92.8% (415/447)
88.4% (443/501)
87.7% (479/546)
87.7% (479/546)
G.Accra 42.4% 39.6% (274/692)
50.2% (296/590)
52.5% (330/628)
47.5% (344/724)
43.4% (400/922)
43.4% (400/922)
Northern 80.9% 80.1% (308/382)
67.3% (338/502)
65.8% (401/609)
74.3% (452/608)
67.6% (458/678)
67.6% (458/678)
Volta 78.4% 77.2% (400/518)
70.9% (419/591)
73.3% (455/621)
74.1% (486/656)
71.6% (504/704)
71.6% (504/704)
Western 80% 84.6% (468/553)
75.2% (542/721)
75.4% (627/832)
77.8% (638/820)
76.1% (686/902)
76.1% (686/902)
continued
91
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
Supportive Supervision
2.1.168 % of supported health facilities and CHPS zones that receive two supervision visits in the year using supportive supervision protocols
Region, district, type
of facility
Annual All
N/A
0 83.8% (1806/2155)
55.3% (1220/2207)
75.4% (838/1112)
66.3% (1912/2882)
66.3% (1912/2882)
Central 0 92.7% (357/385)
57.9% (237/409)
81.3% (100/123)
64.3% (285/443)
64.3% (285/443)
G.Accra 0 78% (401/514)
59.9% (276/461)
84.6% (275/325)
34.2% (240/702)
34.2% (240/702)
Northern 0 87.7% (307/350)
40.3% (174/432)
65.3% (156/239)
49.2% (271/551)
49.2% (271/551)
Volta 0 84.9% (327/385)
58.6% (215/367)
79.4% (216/272)
53.1% (266/501)
53.1% (266/501)
Western 0 79.5% (414/521)
59.1% (318/538)
59.5% (91/153)
49.2% (337/685)
49.2% (337/685)
IR 2.2: Public Private Partnerships
No specific indicators
I.R. 2.3 Referrals
2.3.1 Number/percentage of sub district facilities with active referral systems (defined as facilities that have referred any clients in the past two months). (Note: Previous indicator was number of CHPS zones with active community-facility referral system).
Region, district
Baseline, Midline
and Endline
All 53.8% 53.8%
N/A
57.5%
N/A
63.4% (241/380)
63.4% (241/380)
Central 71.2% 71.2% 81.1% 72.6% (61/84)
72.6% (61/84)
G.Accra 22.9% 22.9% 37.0% 39.1% (18/46)
39.1% (18/46)
Northern 50.8% 50.8% 56.9% 86.2% (56/65)
86.2% (56/65)
Volta 46.2% 46.2% 51.0% 54.6% (59/108)
54.6% (59/108)
Western 70.5% 70.5% 56.4% 61% (47/77)
61% (47/77)
Activity Result 3: Demand for Quality Health Services
Behavior Change Communication & Gender Integration
No specific indicators
Use of High Impact Quality Services
Family Planning
USE 1 Number of counseling visits for FP/RH as a result of USG assistance
Region, district
Quarterly All 1,349,161 1,340,178 1,482,306 1,739,999 2,018,604 1,892,667 8,473,754
Central 282,598 265,228 261,895 281,101 268,146 254,246 1,330,616
G.Accra 402,902 424,327 565,800 708,812 907,583 883,710 3,490,232
Northern 146,461 136,976 135,175 154,401 182,698 175,257 784,507
Volta 255,466 243,092 217,110 261,477 265,117 218,450 1,205,246
Western 261,734 270,555 302,326 334,208 395,060 361,005 1,663,154
USE 2 Number of counseling visits for postpartum FP as a result of USG assistance
Region, district
Quarterly All 75,783 81,846 103,411 98,711 112,464 124,816 521,248
Central 15,737 19,744 20,862 19,051 23,045 26,999 109,701
G.Accra 28,048 30,206 36,987 34,212 33,372 33,410 168,187
Northern 8,823 8,158 13,955 13,021 12,739 14,998 62,871
Volta 11,011 11,236 15,600 16,407 18,555 16,407 78,205
Western 12,164 12,502 16,007 16,020 24,753 33,002 102,284
USE 3 Modern method contraceptive prevalence rate among married women of reproductive age (MWRA)
Region Baseline and
Endline
All
N/A N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 27.5%
G.Accra 19.4%
Northern 10.8%
Volta 29.5%
Western 23.3% (DHS 2014)
continued
92
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
USE 4 Number of new family planning acceptors
Region, district
Quarterly All 334,244 349,783 408,306 443,480 588,674 574,304 2,364,547
Central 60,587 59,385 64,171 65,068 70,708 75,878 335,210
G.Accra 127,084 143,009 178,867 190,589 293,373 280,918 1,086,756
Northern 40,882 39,451 47,426 56,971 78,060 84,465 306,373
Volta 60,170 63,156 61,667 69,852 72,932 53,138 320,745
Western 45,521 44,782 56,175 61,000 73,601 79,905 315,463
Maternal, Neonatal, and Child Health
USE 5 % of deliveries with a skilled birth attendant in USG-assisted programs
Region, district
Quarterly All 55.5% (331943/ 597968)
54.5% (327308/ 600595)
54.6% (337180/ 617266)
55.7% (347449/ 624150)
59.4% (376676/ 634104)
59.7% (384299/ 643314)
59.7% (384299/ 643314)
Central 57.3% (59264/ 103420)
57.5% (58599/ 101833)
57.1% (59975/ 104989)
61.4% (61600/ 100307)
64.9% (65564/ 100966)
65.2% (66585/ 102173)
65.2% (66585/ 102173)
G.Accra 59.5% (107751/ 181236)
59% (109463/ 185444)
57.3% (109540/ 191193)
56.2% (106155/ 188876)
58.1% (111571/ 192170)
56.5% (109881/ 194382)
56.5% (109881/ 194382)
Northern 54.4% (60496/ 111193)
51.5% (58488/ 113613)
54.6% (63777/ 116907)
61.9% (72524/ 117118)
69.5% (82732/ 119088)
71.9% (86924/ 120816)
71.9% (86924/ 120816)
Volta 46% (42997/ 93526)
43.3% (41271/ 95271)
43.2% (42172/ 97651)
45.1% (44903/ 99658)
48.2% (48941/ 101516)
47.4% (48961/ 103331)
47.4% (48961/ 103331)
Western 56.6% (61435/ 108593)
57% (59487/ 104433)
57.9% (61716/ 106525)
52.7% (62267/ 118192)
56.4% (67868/ 120364)
58.7% (71948/ 122611)
58.7% (71948/ 122611)
USE 6 Number of women giving birth who received uterotonics in the third stage of labor in USG-supported programs
Region, district
Quarterly All 294,708 307,565 316,897 347,449 376,676 384,299 1,732,886
Central 54,954 55,396 56,560 61600 65,564 66,585 305,705
G.Accra 95,860 102,938 102,186 106155 111,571 109,881 532,731
Northern 51,799 55,610 59,705 72524 82,732 86,924 357,495
Volta 37,858 38,504 39,796 44903 48,941 48,961 221,105
Western 54,237 55,117 58,650 62267 67,868 71,948 315,850
USE 7 % of mothers who receive postpartum care within two days of childbirth in USG-supported programs
Region, district
Quarterly All 37% 43.1% (258,682/ 600595)
54.6% (337180/ 617266)
46.7% (291733/ 624150)
51.8% (328275/ 634104)
53.1% (344115/ 647758)
53.1% (344115/ 647758)
Central 32.1% 42.9% (43710/ 101832)
57.1% (59975/ 104989)
53.3% (53426/ 100307)
56.3% (56853/ 100966)
57.9% (59138/ 102173)
57.9% (59138/ 102173)
G.Accra 37.3% 41.7% (77270/ 185444)
57.3% (109540/ 191193)
41.4% (78152/188876)
46.1% (88528/192170)
48.4% (95168/ 196609)
48.4% (95168/ 196609)
Northern 54.8% 51.9% (58953/113614)
54.6% (63777/116907)
58.2% (68139/117118)
63.8% (75957/119088)
63.1% (77198/ 122365)
63.1% (77198/ 122365)
Volta 39.7% 42.9% (40866/95272)
43.2% (42172/97651)
42.4% (42278/99658)
46.5% (47253/101516)
45.5% (47092/103591)
45.5% (47092/103591)
Western 36.80% 38.9% (40638/ 104433)
57.9% (61716/106525)
42.1% (49738/118192)
49.6% (59684/ 120364)
53.3% (65529/ 123030)
53.3% (65529/ 123030)
USE 8 % of women receiving at least four ANC visits during pregnancy
Region Baseline, Midline,
and Endline
All
N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 91.1% 89.7%
G.Accra 91.4% 93.0%
Northern 73.0% 87.2%
Volta 77.3% 83.5%
Western 92.1% (DHS 2014)
87.9% (GMHS 2017)
continued
93
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
USE 9 % of pregnant women who received at least two doses of IPTp
Region Baseline, Midline
and Endline
All N/A
N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 68.9% N/A 84.5%
G.Accra 59.3% N/A 78.7%
Northern 60.7% N/A 61.0%
Volta 65.1% N/A 75.1%
Western 67.3% (DHS 2014)
N/A 77.3% (GMHS 2016)
USE 10 % of pregnant women reporting 90+ days of intake of iron folate during pregnancy
Region Baseline and
Endline
All N/A
N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 57.6% N/A
G.Accra 71.3% N/A
Northern 52.8% N/A
Volta 38.9% N/A
Western 56.1% (DHS 2014)
N/A
USE 11 Percent of facilities conducting deliveries providing kangaroo mother care (Note: previous indicator was % of eligible low birthweight babies receiving kangaroo mother care)
Region, district, type
of facility
Baseline and
Endline
All 14.4% (13/90)
14.4% (13/90)
N/A N/A N/A
22.6% (26/115)
22.6% (26/115)
Central 14.3% (2/14)
14.3% (2/14)
9.5% (2/21)
9.5% (2/21)
G.Accra 0 (0/14)
0 (0/14)
29.4% (5/17)
29.4% (5/17)
Northern 20.7% (6/29)
20.7% (6/29)
27.6% (8/29)
27.6% (8/29)
Volta 27.8% (5/18)
27.8% (5/18)
19.4% (6/21)
19.4% (6/21)
Western 0 (0/15)
0 (0/15)
29.4% (5/17)
29.4% (5/17)
All 14.4% (13/90)
14.4% (13/90)
22.6% (26/115)
22.6% (26/115)
Hospital 20.7% (6/29)
20.7% (6/29)
36.8% (7/19)
36.8% (7/19)
Health Center
11.5% (6/52)
11.5% (6/52)
25.0% (8/32)
25.0% (8/32)
CHPS 11.1% (1/9)
11.1% (1/9)
22.0% (11/50)
22.0% (11/50)
USE 12 Percent of facilities providing ANC providing antenatal steroids according to national guidelines or protocols (Note: previous indicator was % of pregnant women with premature labor or risk of premature delivery who receive antenatal steroids according to national guidelines or protocol)
Region, district, type
of facility
Annual All 14.3% (23/124)
N/A N/A N/A N/A
24.8% (34/137)
24.8% (34/137)
Central 15.0% (3/20)
20.8% (5/24)
20.8% (5/24)
G.Accra 43.8% (7/16)
50.0% (10/20)
50.0% (10/20)
Northern 10.8% (4/37)
18.9% (7/37)
18.9% (7/37)
Volta 18.5% (5/27)
12.9% (4/31)
12.9% (4/31)
Western 16.7% (4/24)
32.0% (8/25)
32.0% (8/25)
All 14.3% (23/124)
N/A N/A N/A N/A
24.8% (34/137)
24.8% (34/137)
Hospital 72.4% (21/29)
89.7% (26/29)
89.7% (26/29)
Health Center
3.6% (2/55)
11.1% (6/54)
11.1% (6/54)
CHPS 0 (0/40)
3.7% (2/54)
3.7% (2/54)
continued
94
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
USE 13 Number of newborns receiving essential newborn care through USG-supported programs
Region, district, sex
Quarterly All 325,415 340,980 322,703 312,108 337,419 344,714 1,657,924
Central 56,502 60,745 59,502 60,783 60,085 61,447 302,562
G.Accra 86,899 96,342 98,560 83,725 89,210 83,716 451,553
Northern 63,035 80,834 69,146 70,407 80,689 86,118 387,194
Volta 59,154 43,661 37,425 40,214 44,385 44,976 210,661
Western 59,825 59,398 58,070 56,979 63,050 68,457 305,954
USE 14 % of newborns delivered in health facilities who were put to the breast within one hour of birth
Region, district, sex
Quarterly All 95.1% (341086/ 358791)
95% (322703/ 339608)
89.8% (312108/ 347436)
89.6% (337425/ 376684)
89.7% (344714/ 384299)
89.7% (344714/ 384299)
Central 95.3% 98.7% (60745/61524)
99.8% (59502/59608)
98.7% (60783/61587)
91.6% (60085/65564)
92.3% (61447/66585)
92.3% (61447/66585)
G.Accra 80.6% 82.5% (96342/116808)
88.7% (98560/111059)
78.9% (83725/106155)
80% (89210/111571)
76.2% (83716/109881)
76.2% (83716/109881)
Northern 104.2% 129.7% (80834/62320)
109.3% (69146/63271)
97.1% (70407/72524)
97.5% (80695/82740)
99.1% (86118/86924)
99.1% (86118/86924)
Volta 137.6% 96.9% (43661/45040)
84.9% (37425/44098)
89.6% (40214/44903)
90.7% (44385/48941)
91.9% (44976/48961)
91.9% (44976/48961)
Western 97.4%. 99.5% (59398/59708)
94.3% (58070/61572)
91.5% (56979/62267)
92.9% (63050/67868)
95.1% (68457/71948)
95.1% (68457/71948)
USE 15 Percentage of children born in the last 24 months who were put to the breast within one hour of birth
Region, district, sex
Baseline and
Endline
All
N/A N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 60.9%
G.Accra 52.8%
Northern 64.7%
Volta 44.1%
Western 62.0% (DHS 2014)
USE 16 Number of babies who received postnatal care within two days of childbirth in USG-supported programs
Region, district, sex
Quarterly All 239,104 258,682 277,319 291,723 328,275 343,577 1,499,576
Central 33,846 43710 51,668 53,416 56,853 59,089 264,736
G.Accra 67,529 77313 78,302 78,152 88,528 94,956 417,251
Northern 62,646 58946 60,228 68,139 75,957 76,916 340,186
Volta 37,175 38064 39,320 42,278 47,253 47,091 214,006
Western 37,908 40649 47,801 49,738 59,684 65,525 263,397
USE 17 Number of newborn infants receiving antibiotic treatment for infection through USG-supported programs
Region, district, sex
Quarterly All 4,333 10,396 10,174 12,159 9,784 11,596 54,109
Central 510 1,925 1,991 2,051 1,861 1,316 9,144
G.Accra 1,295 2,288 1,769 1,974 1,959 1,662 9,652
Northern 642 1,608 1,554 1,636 1,312 1,425 7,535
Volta 787 1,754 1,926 1,540 1,545 1,484 8,249
Western 1,099 2,821 2,934 4,958 3,107 5,709 19,529
USE 18 % of children that are fully immunized by 12 months of age
Region, sex Baseline and
Endline
All
N/A N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 51.1%
G.Accra 76.4%
Northern 41.0%
Volta 62.7%
Western 52.9% (DHS 2014)
continued
95
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
USE 19 Number of children less than 12 months of age who received DPT3 from USG-supported programs
Region, district, sex
Quarterly All 502,810 529,389 559,704 601,983 627,220 630,697 2,948,993
Central 81,989 88,160 91,692 91,431 91,350 97,649 460,282
G.Accra 128,480 148,615 162,907 177,869 189,467 187,538 866,396
Northern 123,232 122,106 123,875 143,636 150,992 148,159 688,768
Volta 74,061 78,571 81,737 87,227 88,461 84,479 420,475
Western 95,048 91,937 99,493 101,820 106,950 112,872 513,072
USE 20
Number of cases of child diarrhea treated in USG-supported programs
Region, district, sex
Quarterly All 361,733 363,805 359,964 349,256 337,093 301,944 1,712,062
Central 52,056 50,054 51,738 44,086 44,742 40,602 231,222
G.Accra 40,949 40,520 41,009 32,157 34,951 32,348 180,985
Northern 114,741 121,885 112,555 122,163 113,698 103,190 573,491
Volta 75,884 73,583 72,006 63,838 57,475 54,772 321,674
Western 78,103 77,763 82,656 87,012 86,227 71,032 404,690
USE 21 Number of children under five years of age with suspected pneumonia receiving antibiotics by trained facility or community health workers in USG-assisted programs
Region, district, sex
Quarterly All 41,633 35,646 41,260 46,807 60,007 77,621 261,341
Central 5,195 5,409 5,887 6,746 7,562 7,446 33,050
G.Accra 7,935 6,825 7,147 7,015 10,771 12,083 43,841
Northern 16,319 12,035 15,083 17,766 16,288 21,684 82,856
Volta 6,974 5,948 6,631 7,885 17,000 25,278 62,742
Western 5,210 5,429 6,512 7,395 8,386 11,130 38,852
Malaria
USE 22 % of households with at least one insecticide-treated net (ITN)
Region Baseline, Midline
and Endline
All
N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 69.7% N/A 84.3%
G.Accra 52.8% N/A 61.7%
Northern 71.3% N/A 83.8%
Volta 76.3% N/A 77.8%
Western 67.4% (DHS 2014)
N/A 69.1% (GMIS 2016)
USE 23
% of children <5 who slept under an ITN the previous night
Region Baseline, Midline
and Endline
All
N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 51.2% N/A 61.9%
G.Accra 25.9% N/A 32.6%
Northern 43.2% N/A 61.2%
Volta 66.3% N/A 54.8%
Western 48.0% (DHS 2014)
N/A 45.5% (GMIS 2016)
USE 24 % of pregnant women who slept under an ITN the previous night
Region Baseline, Midline
and Endline
All
N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 44.7% 58.2%
G.Accra 17.8% 36.6%
Northern 49.6% 58.8%
Volta 68.6% 56.3%
Western 41.9% (DHS 2014)
— (GMIS 2016)
USE 25
% of children <5 who receive ACT treatment within 24 hours of the onset of fever
Region Baseline and
Endline
All
N/A N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 32.7%
G.Accra 19.8%
Northern 9.7%
Volta 29.1%
Western 59.9% (DHS 2014)
continued
96
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
Nutrition
USE 26
Number of children under five reached by USG-supported nutrition programs
Region, district, sex
Annually All 971,704 1,090,082 882,220 1,193,505 1,174,896 1,098,401 5,439,104
Central 160,129 174,203 134,362 153,973 187,216 203,675 853,429
G.Accra 244,868 256,622 220,184 226,120 276,671 232,009 1,211,606
Northern 186,864 200,289 178,244 299,809 267,021 257,288 1,202,651
Volta 171,727 226,853 139,507 263,607 224,450 198,850 1,053,267
Western 208,116 232,115 209,923 249,996 219,538 206,579 1,118,151
USE 27 Number of children under five who received Vitamin A from USG-supported programs
Region, district, sex
Annually All 704,230 782,447 881,064 1,193,505 1,148,109 1,024,518 5,029,643
Central 113,926 152,183 133,137 153,973 134,341 148,076 721,710
G.Accra 140,906 179,431 179,174 226,120 246,673 226,515 1,057,913
Northern 194,692 191,363 198,511 299,809 248,607 226,470 1,164,760
Volta 130,710 142,495 204,848 263,607 267,824 198,432 1,077,206
Western 123,996 116,975 165,394 249,996 250,664 225,025 1,008,054
USE 28
Prevalence of children 6-23 months receiving a minimum acceptable diet (appropriate complementary feeding)
Region, sex Baseline and
Endline
All
N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 21.9% N/A
G.Accra 22.7% N/A
Northern 14.1% N/A
Volta 10.5% N/A
Western 12.7% (DHS 2014)
N/A
USE 29
% of children 0-5 months who are exclusively breastfed
Region, sex Baseline and
Endline
All
N/A N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 39.5%
G.Accra 21.1%
Northern 63.6%
Volta 49.1%
Western 46.8% (MICS 2011)
Health Outcomes
OUT 1 Couple-years of protection in USG-supported programs
Region, District
Annual All 137,118 880,315 1,211,190 1,477,197 1,684,042 1,486,574 6,739,318
Central 137,118 126,547 200,322 232,919 236,455 255,878 1,052,122
G.Accra 367,168 483,336 610,039 635,302 715,168 665,391 3,109,236
Northern 32,048 34,843 56,963 68,970 87,548 110,191 358,514
Volta 142,299 141,974 176,345 269,791 317,952 173,446 1,079,508
Western 92,241 93,614 167,521 270,215 326,919 281,668 1,139,938
OUT 2 Prevalence of anemia among women of reproductive age
Region Baseline and
Endline
All
N/A N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 46.7%
G.Accra 42.4%
Northern 47.5 %
Volta 48.7%
Western 42.6% (DHS 2014)
continued
97
Performance Indicator
Disag-gregation
Frequency of
Reporting Region Baseline FY 2015
Achieved FY 2016
Achieved FY 2017
AchievedFY 2018
AchievedFY 2019
Achieved EOP Result
OUT 3 % of children <2 registered in well-child clinics with global malnutrition (weight-for-age less than 2SD below the standard mean)
Region, district, sex
Quarterly All 46.2% (481379/ 1042762)
6.9% (390222/ 5674716)
4.8% (309446/ 6404019)
3.2% (218630/ 6805096)
2.4% (168329/ 7049649)
2.4% (168329/ 7049649)
Central 22.8% 15.2% (39455/ 258818)
5.2% (43886/ 838265)
4.8% (45501/ 945572)
3.8% (37049/ 976333)
2.8% (30490/ 1074887)
2.8% (30490/ 1074887)
G.Accra 51.5% 59.4% (82251/ 138392)
5.5% (87274/
1597737)
3.8% (70060/ 1848541)
2.9% (55760/ 1952051)
2.6% (49822/ 1905511)
2.6% (49822/ 1905511)
Northern 67.3% 47% (148926/ 316550)
7.8% (98419/
1268493)
5.6% (81877/
1456922)
3.5% (54596/ 1576415)
2.3% (35930/ 1577216)
2.3% (35930/ 1577216)
Volta 26.0% 41.3% (94967/ 229890)
6.4% (56462/ 878774)
5% (48933/ 983793)
3.6% (38359/
1060268)
2.4% (28024/ 1172009)
2.4% (28024/ 1172009)
Western 65.3% 116.8% (115780/99112)
9.5% (104181/ 1091447)
5.4% (63075/ 1169191)
2.7% (32866/ 1240029)
1.8% (24063/ 1320026)
1.8% (24063/ 1320026)
OUT 4 Prevalence of anemia among children 6-59 months
Region, sex Baseline and
endline
All
N/A N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 70.2%
G.Accra 59.6%
Northern 82.1%
Volta 69.9%
Western 64.6% (DHS 2014)
OUT 5 Prevalence of children under five years of age below minus two standard deviations from median height for age of reference population (stunting)
Region, sex Baseline and
endline
All
N/A N/A N/A N/ADHS 2019 results not available
DHS 2019 results not available
Central 18.4%
G.Accra 5.6%
Northern 26.5%
Volta 14.2%
Western 14.0% (DHS 2014)
Notes:
Required indicator reported to USAID/Washington.
N/A – Not applicable. Indicator not reported on a quarterly basis. Reported on semi-annual or annual basis.
N/A – Not applicable. Indicator not reported on yearly basis. (Baseline, Midline, or Endline)1 Indicator 1.1.4: Reported numbers include both first integrated coaching visits and follow-up visits. As of Q1 FY18, all target facilities received at least one visit. The unique number of facilities visited was 2,466.2 Indicator 1.4.1: The baseline, midline and endline figures are based on an independent analysis undertaken by the project. 3 Indicator 1.5.4: The total for each region includes the regional health directorate.4 Indicator 2.1.5 Baseline and endline assessments included 148 facilities. Baseline and end-of-project results are extrapolated values. 5 Indicator 2.1.9: Counts all facilities trained on ETAT.6 Indicator 2.1.10: Baseline results changed based on updated analysis conducted in 2019.7 Indicator 2.1.13: Counts all facilities with Severe Acute Malnutrition (SAM) admissions in the reporting period. Results lower in FY19 due to shortages in RUTF at lower-levels of care. Thus, many cases are being referred to hospitals for treatment.8 Indicator 2.1.16: Denominator based on data provided by GHS on facilities eligible for supportive supervision. Beginning in FY18, the project counted any coaching-oriented visit (conducted by GHS) against this indicator. This includes integrated coaching and post-training follow-up visits. Target reduced in FY18 (due to funding limitations) and FY19 due to consolidated focus in select districts implementing shared learning activities.
98
ANNEX 2: SUCCESS STORY
INCREASING THE USE OF PRIMARY CARE SERVICES THROUGH QUALITY IMPROVEMENT AND
DISTRICT COLLABORATION
An OPD client in Akatsi South receives counseling on infant feeding practices
IntroductionThe Systems for Health project supports the GHS to reduce
maternal and neonatal deaths through a broad range of
interventions across the life-cycle and service-delivery
continuums. Systems-strengthening activities, including
leadership and QI, are integrated to support systems-level
changes. One key leadership activity is building managers’
capacity to support facility teams by making data-driven
decisions and using QI processes to enact reforms and improve
service outcomes. This success story focuses on the Akatsi
South district, where managers developed a change package to
increase patient utilization of OPDs.
ContextThe Akatsi South District, in the Volta Region, has one
hospital, five health centers, and four CHPS zones spread
across five sub-districts. The DHMT is responsible for the
delivery of primary health care to more than 116,000 people.
In September 2016, the district managers in Akatsi South
noted decreasing attendance at OPDs, particularly at the
health centers and CHPS zones, and identified the decline
as a cause for concern. The managers worried about the
consequences of fewer people seeking primary care services.
Delays in seeking care can lead to more severe diseases
or complications, especially among children and pregnant
women, in turn leading to greater mortality.
Having recently completed a Systems for Health/GHS training
in QI, district-level managers decided to take a QI approach to
address the issue. They used their data to perform a problem
analysis and designed a change package to increase OPD
attendance and internally-generated funds. The package
centered around a partnership with the NHIA to increase
enrollment in and reimbursements from health insurance. As
the changes began to show results, many interventions were
continued or scaled up, while new interventions were added
to support continued improvements (Table 19).
ResultsThe activities carried out by the Akatsi South DHMT and the
district NHIA as part of the original improvement project
resulted in a 123% increase in annual OPD attendance from
FY16 to FY17 (Figure 36). In 2018, OPD attendance increased
another 86% thanks to the district’s continued commitment
to improving and evolving the package of interventions.
99
Problem Identified Interventions
Many patients lacked
insurance
• Delivered community education on the benefits of health insurance (2016–2018)
• Held NHIS enrollment clinics
• Made referrals to NHIS enrollment centers from CHPS and outreach services (2016–2018)
Lack of basic equipment
and personnel
required to meet NHIS
certification standards
and patient needs
• Assessed facilities to determine what equipment and staff were needed to meet NHIS standards
(2016)
• Procured delivery beds and equipment for 2 health centers (2017)
• Posted 5 new midwives (2016–2018)
• Posted 2 PAs to health centers (2018)
Low reimbursement
rates for NHIS claims
• Trained providers to complete NHIS forms properly to reduce claim rejections and revenue losses
(2017)
Lack of essential
medicines
• Pooled drug purchasing across facilities to fill gaps
Table 19. Akatsi South success story, problems concerning national health insurance utilization and related interventions
ConclusionsThe commitment of leadership is critical to achieving
sustainable changes in health outcomes. In Akatsi South,
the managers applied basic QI concepts to address gaps in
key health-system building blocks, such as health financing,
health workforce, and service delivery. These synergistic
efforts, implemented jointly by the GHS and NHIA, greatly
expanded access to high-quality primary health care in the
district. The District Health Director’s leadership and ongoing
support for these improvement activities have paid off in the
continued growth and quality of services.
Figure 36. The number of people per quarter in Akatsi South who access OPDs for health care
Package of changes implemented from Sep 2016 to June 2018
1. Six durbars, organized by the DHMT and NHIA, on how health insurance reduces out-of-pocket payments (Nov 2016)
2. Trainings for prescribers, by district NHIA, on how to complete NHIS claim forms to reduce revenue losses (Mar 2017)
3. Provision of safe delivery equipment to Avenorpedo Health Center (Mar 2017)
4. New midwives posted to health centers/CHPS (6 total, Sep 2016, Oct 2017, Mar 2018)
5. Physicians assistants posted to 2 health centers (Jun 2018)
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
1, 4
1,360
Jul–Sep 2018
Apr–Jun 2018
Jan–Mar 2018
Oct–Dec 2017
Jul–Sep 2017
Apr–Jun 2017
Jan–Mar 2017
Oct–Dec 2016
Jul–Sep 2016
Apr–Jun 2016
Jan–Mar 2016
Oct–Dec 2015
1,430 1,054 1,036
1,797
2,838 2,7773,485
4,026 4,241
5,439
6,663
2, 3
44
5
OPD Attendance
100
ANNEX 2: SUCCESS STORY
INCORPORATING GENDER AND PRIVACY CONCERNS IN THE DESIGN OF CHPS COMPOUNDS
BackgroundProviding primary health care in underserved areas of
Ghana continues to be a major challenge due to the lack
of resources. CHPS is a national strategy adopted by the
MOH and GHS to deliver essential community-based health
services. One of the essential steps to CHPS functionality is
the construction of a CHPS compound, which is an approved
structure consisting of a service delivery point and residential
accommodation complex. To expand the delivery of health
care, Systems for Health helped the MOH/GHS to build
new CHPS compounds in deprived districts of the Northern
and Volta Regions. Community mobilization activities
complemented construction.
The new CHPS facilities are intended to eliminate
geographical barriers to health care, particularly in rural
areas. The facilities are also meant to transform the delivery
of rural health care, changing the focus from clinic-based
care to active community and home-based outreach services.
The new facilities and mobilization activities are in line
with the CHPS National Implementation Guidelines and the
overarching CHPS policy defined by the MOH.
Community Engagement in CHPS DesignIn 2015, the standard CHPS building plans were redesigned
by the MOH. As part of the new CHPS policy, space was
added to the compound for health workers to provide
childbirth and FP services, along with primary care,
immunization, and other preventive care. On behalf of
the MOH, Systems for Health engaged community-level
stakeholders, providing feedback that helped guide the CHPS
compound redesign process. The goal was to ensure that the
new facilities met community needs.
A map of Ghana with CHPS facilities marked on the map in the Northern and Volta regions
Common themes emerged during meetings with regional,
district, and local leaders, and with community members
in both the Northern and Volta Regions. Stakeholders
frequently noted the need for privacy when accessing
services such as FP. One married woman said that her
marriage was put at risk because her sister-in-law saw her in
the FP queue, which was located right next to an outpatient
queue. Some Ghanaians perceive the use of FP as a sign of
promiscuity, and privacy is an important factor in increasing
uptake rates and allowing women to choose how to space
and time their pregnancies.
Other stakeholders desired gender-segregated washrooms,
additional exits for safety, and accommodations with more
privacy during and after childbirth. Figure 37 shows how the
MOH responded to stakeholder input.
101
ResultsThe MOH and Systems for Health teams discussed the
stakeholders’ concerns regarding gender-segregated areas
and privacy. The MOH officials responded by changing the
final design of the CHPS compounds. Notable design changes
included the following:
u Two sets of public, gender-segregated washrooms—one
with outside entrances and the other within the facility
(the red circle in Figure 37)
u A dedicated room for family planning services (the orange
circle in the same figure) and an additional entrance at the
rear of the facility, added to address the privacy concerns
of family-planning clients as well as for safety reasons (the
purple circle)
u A screen wall to offer privacy at exterior washrooms (the
blue circle)
u A washroom connected to the delivery room, which is
private from the rest of the facility (the green circle)
Furthermore, a second building with two residences, one for
a midwife and another for a community health officer, was
added. The second building (not shown in the figure) ensures
that women have access to skilled delivery 24 hours a day and
that providers can reside in the community.
Lessons LearnedRelatively simple changes in building design can influence
whether patients seek out and continue to use services. The
active engagement of community stakeholders in the design
process is critical. By addressing the privacy and gender
concerns of the community, the MOH developed a facility that
meets user needs and effectively improves access to care in
rural communities.
Over the life of the project, 26 new CHPS compounds were
completed in the Northern and Volta Regions, with support
from Systems for Health. Throughout the construction
process, Systems’ engineers and contractors continued to
make changes to both design and materials—in line with
community feedback and MOH concurrence—to ensure
the most sustainable, efficient, and user-friendly clinical
experience for both providers and patients.
Figure 37. The initial 2015 CHPS compound design and the revised design
The initial redesign (top) did not include changes suggested by stakeholders. The revised design (bottom), based on stakeholder input, included changes that are circled and explained in the Results section.
102
ANNEX 2: SUCCESS STORY
REDUCING CORD SEPSIS IN NEONATES AT CHEREPONI GOVERNMENT HOSPITAL
ContextInfections, including cord sepsis, account for 31% of all
neonatal deaths in Ghana, making it one of the top three
causes of mortality for neonates (Ghana Newborn Strategy
and Action Plan 2014–2018). Chereponi Government
Hospital, in the Northern Region, observed a high rate of
cord sepsis, with an incidence of 9.7% and 8.2% of all live
births in the district for 2015 and 2016, respectively.
In 2016, Systems for Health trained district-level staff
as QI coaches to initiate and lead QI projects in health
facilities across the country. The training built staff capacity
to address service-delivery gaps with QI methods and,
ultimately, improve health outcomes. The QI coaches decided
to focus on reducing the rate of cord sepsis in the district by
50%—from 8.2% to 4.1%—by December 2017.
Analysis of the ProblemDuring a series of antenatal and postnatal clinical sessions in
2016, the QI coaches worked with mothers and caregivers to
analyze the causes of umbilical cord sepsis using a fishbone
diagram. Causes identified included
u The application of inappropriate cord care remedies (e.g.,
toothpaste, cow dung, condiments, talc powder, herbal
concoctions, or palm oil),
u Non-sterile delivery in health and community facilities,
u Poor personal hygiene (e.g., infrequent handwashing
during care and the use of dirty clothing at home),
u Pressure from community members to use local remedies
when a cord was taking too long to drop off, and
u The late detection of cord sepsis cases, resulting in
complications.
InterventionBased on the existing high rate of cord sepsis and the
outcome of the analysis, the team did not wait for the year-
end report and instead started the following interventions in
August 2016:
u They deployed social and behavior change
communication (SBCC) around cord care for mothers and
caregivers at antenatal and postnatal clinic sessions and
during postnatal home visits. Messages and activities
included handwashing, personal and environmental
hygiene at home, unapproved substances that should
not be applied to the cord, and danger signs that should
be reported immediately to the hospital (e.g., a red or
swollen stump, discharge, or bleeding). Mothers were
given an emergency phone number to contact the
neonatal care unit in case of danger.
u The team trained staff on IPC practices, such as proper
handwashing and instrument sterilization.
A child resting in their mother’s arms
103
OutcomeThe team of district QI coaches used the percent of total
live births with umbilical cord sepsis to track results of the
interventions tested. SBCC interventions and the integration
of cord care began in August 2016, while hospital staff
members were trained in IPC in January 2017.
Figure 38 shows that the occurrence of umbilical cord sepsis
at the hospital declined remarkably, dropping from 8.2%
in 2016 to 1.6% in 2017—an 80% reduction. The absolute
number of cord sepsis cases went down from 68 in 2016 to
15 in 2017. The gains were larger than expected even though
the number of total births increased in the hospital during
that time, from 834 in 2016 to 914 in 2017.
Lessons LearnedThe district QI team learned that a few well-chosen
interventions, integrated into existing programs, could
have a significant impact on neonatal cord sepsis. Essential
elements for success included
u The cooperation of the health staff,
u The willingness of management to supply sterile
equipment at facilities and methylated spirits to mothers,
and
u Listening to clients to understand the underlying causes
of ill health.
To sustain the gains achieved thus far, the QI coaches will
continue SBCC and the other interventions at Chereponi
Government Hospital. All new staff in the hospital’s neonatal
unit will receive orientation on the interventions. Also, the QI
coaches will extend the interventions to the health centers
and CHPS clinics that make referrals to the hospital.
Figure 38. A graph illustrating the decline in the number of newborns with cord sepsis at the Chereponi Government Hospital from January 2015 to December 2017
14%
12%
10%
8%
6%
4%
2%
0%Jul–Sep
2017Apr–Jun
2017Jan–Mar
2017Oct–Dec
2016Jul–Sep
2016Apr–Jun
2016Jan–Mar
2016Oct–Dec
2015Jul–Sep
2015Apr–Jun
2015Jan–Mar
2015Oct–Dec
2017
1 & 2
3
9.8%
7.7%
9.4%
11.9% 11.3%
9.5%
6.3%
5.5%
2.6% 1.5%2.5%
0.4%
Interventions:
1. Education on cord care for mothers/caregivers
2. Integration of neonatal cord care with postnatal home visits
3. Staff trained in infection prevention and control
N values:
2015: 587 live births
2016: 834 live births
2017: 914 live births
104
ANNEX 2: SUCCESS STORY
RELIGIOUS LEADERS IN GHANA UNITE AGAINST THE EBOLA VIRUS
Unified in their declaration, religious leaders from across
Ghana convened in November 2014 to respond to the Ebola
virus outbreak in West Africa. The congregation of religious
heads and representatives from faith-based organizations
crafted a religious edict on Ebola that was immediately
circulated throughout churches, mosques, and religious
gatherings in Ghana.
This event, convened by Systems for Health, was held in
partnership with the MOH and GHS. It brought together the
Christian Council of Ghana and the Federation of Muslim
Councils of Ghana for discussions regarding the origins of
Ebola, how it is transmitted, and proper health measures to
quickly identify and reduce its potential spread. Although
there were no reported cases of Ebola in the country, it was
still a significant public health concern as other West African
countries had recorded over 13,000 cases between March
and November 2014.
Health and religious leaders gather to develop and discuss the Ebola Edict
“You can help raise awareness and promote safe behaviors
and practices in our societies … churches, mosques, shrines,
and others. You can bring out the facts and truth about the
disease—promote solidarity, social cohesion, compassion, and
humanity. You can help mobilize resources, promote access
to services for Ebola, and, as well, help create supportive
environments.” This was the impassioned advice from
Dr. Badu Sarkodie, GHS Director of Public Health, to the
assembled religious leaders.
Through services, meetings, and gatherings, religious leaders
issued the Ebola Edict nationwide. It was heard by 2.4 million
Christians and nearly 800,000 Muslims throughout Ghana.
Additionally, religious institutions pledged their resources
to increase information and education about hygiene and
healthy behaviors and, with a unified voice, to build Ghana’s
greatest defense against the disease: a knowledgeable
population.
105
ANNEX 2: SUCCESS STORY
SAVING LIVES THROUGH IMPROVED TRANSPORTATION IN RURAL GHANA
ContextIn remote areas of Ghana, an emergency trip to the hospital
is challenging because of long distances, impassable roads,
limited road networks, few motorized vehicles, unreliable
transportation, and a lack of money to pay for a ride. These
obstacles can delay the decision to seek care or prevent people
from reaching care in time, resulting in deaths that could have
been avoided.
Delays are especially dangerous for mothers and newborns.
According to the 2016 GHS annual report, pregnant women
in the Northern Region were more likely to die than their
counterparts in other areas of Ghana. The regional institutional
maternal mortality ratio in 2016 was more than 200 per
100,000 births.
In 2017, the Systems for Health project awarded a grant to
MAZA to assess the feasibility and scalability of an innovative
transportation model designed to reduce delays in seeking
and reaching care, thereby decreasing maternal and neonatal
deaths.
MAZAMAZA is a social enterprise whose mission is to provide
reliable and affordable transportation for urgent health
needs in rural Ghana. The organization seeks to improve
livelihoods through job creation and increased access to
markets.
MAZA’s model involves a network of motorized tricycles
operating in remote areas, designed to meet emergency
transportation needs safely and reliably while creating
income-generating opportunities for local drivers. The
tricycles are adapted for passenger use, and drivers
A MAZA driver takes a call Photo credit: MAZA
lease-to-own at a subsidized rate with the condition that they
must be on call for urgent health transport twice a week.
MAZA runs a toll-free hotline for passengers and provides
transportation free of charge for women in labor and sick
newborns.
InterventionMAZA first launched in 2015 in the Northern Region’s
Chereponi district. With support from a Systems for
Health’s grant, they expanded to three sub-districts in the
Bunkpurugu-Yunyoo district in April 2017. As they designed
and implemented their plan, they worked closely with the
GHS, especially at the district level, as well as with other key
stakeholders. MAZA’s program includes the following:
u 12 drivers selected by their communities, trained, and
provided with motorized tricycles
u Agreements from the drivers to be on call for emergencies
two days a week; the rest of the time, the motorized
tricycles can be used to earn income
106
Figure 39. The proportion of births attended by a skilled health worker vs. a TBA, comparing baseline to endline data in the three sub-districts where MAZA operates
* TBA = traditional birth attendant. For baseline/endline, independent evaluation by University for Development Studies. Baseline was 24 months (Mar 2015–Feb 2017); endline 12 months (Apr 2017–Mar 2018). Baseline also reflects data from three entire sub-districts while endline focuses on women in communities that received motorized tricycles (i.e., intervention communities).
Baseline (N=228)
Endline (N=73)*
Health Worker Traditional Birth Attendant*
96%
49%
2.7%
37%
“These days even the TBAs [traditional birth
attendants] themselves do not deliver us in the
community . . . If your time is up, she will follow you
to the hospital. So you see, now everybody goes to
the hospital when there is a health problem.”
~ New mother, Jimbale community
“The change is that, in the past if someone is sick,
you will have to go far before you can get means
to come and pick [up] the person, but these days,
because some motorized tricycles are around, it has
reduced our suffering.”
~ Male trader, Yunyoo community
u Community meetings and education for pregnant women
and their spouses on the importance of seeking care,
identifying danger signs, and accessing MAZA vehicles
u Meetings with opinion leaders and key stakeholders,
including health staff, the district assembly, and the
Ghana Ambulance Service, to foster strong partnerships
ResultsIn a 12-month period, MAZA transported 335 people in
300 rides, an average of 5.5 per week. Out of all the cases,
73% were women in labor or with complications related
to pregnancy/birth; another 19% were sick infants. Most
trips were to a health center, although on occasion the
drivers were asked by midwives to transport critical cases
to the district hospital when the district ambulance was
nonfunctional.
Client satisfactionPassenger surveys showed 90% satisfaction with the
drivers and vehicles. Nearly all respondents, 98%, said they
were likely to use the MAZA vehicles again for emergency
transportation.
Increased knowledge and health-seeking behaviorThe community members surveyed by MAZA demonstrated
an improved understanding of the need to seek emergency
care at health facilities, as a result of MAZA’s education
efforts.
107
Increase in skilled attendance at deliveryMAZA engaged the University for Development Studies to
conduct an independent evaluation of their intervention.
The baseline survey conducted in January 2017 found that
the skilled delivery rate in the three intervention sub-
districts was 49%, which is below the regional rate of 57.5%
in 2016. By the endline survey in March 2018, deliveries
conducted by a skilled health worker in the sub-districts
doubled from 49% to 96%, and the rate of births with a TBA
dropped to less than 3%. The percentage of babies delivered
at home decreased from 42% to 6% (Figure 39).
With more women delivering in health facilities, the
evaluation also showed improvements in the percentage of
women and babies receiving key services during labor (e.g.,
assessment of vital signs of mother increased from 48% to
96%) and after birth (e.g., breastfeeding within one hour of
delivery increased from 17% to 80%).
ChallengesMAZA uses an iterative process, adapting its model
to address challenges as they are encountered, when
possible. For example, overheating engines frequently
put the tricycles out of service. MAZA worked with the
manufacturer to procure new engines at a discount and to
improve the retail availability of spare parts in the district.
They also conducted training on maintenance for drivers.
High default rates on the loans to drivers threaten the
sustainability of the MAZA model. Drivers often use their
income for other purposes, rather than to pay back their
loans. As a result, MAZA had to confiscate vehicles from the
three worst defaulters and reassign them to other drivers.
Weekly loan repayment rates have been improving slowly.
Infrastructure challenges, such as bad roads and limited
cell networks (which make it difficult to use the MAZA toll-
free hotline), are more difficult to address and continue to
present obstacles to increasing access to health care.
Keys to SuccessMAZA credits a few factors as critical to its success:
u Continuous engagement with community leaders
u Health education for pregnant women and spouses
u Support from the District Health Management Team
(DHMT) and other stakeholders
u Eliminating the fee at the point of service delivery
Moving forward, MAZA will incorporate lessons learned to
increase the reach and sustainability of the intervention.
Based on customer feedback, they are working to procure
more vehicles to help ensure that one is always available.
They are also exploring how best to support drivers to
decrease default rates. The DHMT in Bunkpurugu-Yunyoo
plans to start a community emergency transport service
later this year, and MAZA will partner with the team to
increase efficiency and scale.
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ANNEX 2: SUCCESS STORY
IMPROVING EMERGENCY OBSTETRIC CARE IN TARGETED HOSPITALS TO REDUCE INSTITUTIONAL
MATERNAL MORTALITY, NORTHERN REGION
ContextIn 2016, the Northern Region’s institutional MMR was 207
per 100,000 LB, with 10 hospitals contributing 60% of
maternal deaths. With the support of Systems for Health, the
GHS designed and implemented a package of interventions to
reduce institutional maternal mortality in the 10 hospitals.
ObjectiveTo reduce overall MMR in the Northern Region from 207 per
100,000 LB in 2016 to 120 per 100,000 LB in 2018.
InterventionsTo address the high levels of maternal mortality in the 10
hospitals, the region grouped facilities into two clusters:
referring facilities and receiving facilities. The referring
cluster participated in shared learning to improve clinical
management while the receiving cluster (comprised of
the 10 hospitals) improved the management of obstetric
emergencies.
Across both clusters, an analysis of the root causes showed
gaps in timely referrals and the management of obstetric
cases. For example, the clusters lacked emergency/tracer
drugs, blood for transfusions, functional triage systems,
and basic skills to respond to emergency cases, many of
which could be addressed effectively with small, relatively
inexpensive changes to the current systems.
Multidisciplinary teams from the facilities used QI methods and
tools to improve the timely management of obstetric cases,
with the overarching aim to reduce institutional maternal
Facility staff meet in their triage corner
mortality. Key activities implemented included those found
in Table 20.
These interventions built upon previous investments in
training and PTFU visits in the areas of LSS and ETAT for staff
who are directly involved in the clinical management of women
during pregnancy, delivery, and the postpartum period.
Beginning in 2017, facility QI teams met monthly and the
clusters met quarterly to share results of their improvement
projects and revise their strategies based on their data,
feedback, and experiences from colleagues at other hospitals.
ResultsAs of May 2019, 90% of emergency cases received care within
15 minutes of arrival, and 92% of tracer medicines were
available at the 10 hospitals (a 44% increase from the baseline
figure of 64%). The overall institutional MMR for the Northern
Region reduced from 172.3 per 100,000 LB in FY16 to 100.7
109
per 100,000 LB in FY19, a 41.56% reduction. During the
same period, institutional MMR in the 10 hospitals reduced
from 180.5 per 100,000 LB to 100 per 100,000 LB, a 44.6%
reduction (Figure 40). There was also a 32.56% reduction
in the absolute number of annual maternal deaths in the 10
hospitals, from 43 in FY16 to 29 in FY19.
ConclusionThe region was able to begin addressing the high MMR
through integrated systems strengthening approaches
focused on capacity building, service redesign, continuous
on-the-job training, and supervision, as well as the provision
of essential health commodities and medicines. These
approaches, combined with referral strengthening at the
peripheral facilities, resulted in impressive reductions in the
institutional MMR.
Furthermore, the application of QI approaches enabled
health facilities to further reduce MMR by designing locally
appropriate and low-cost strategies to address facility-
specific causes of maternal deaths. The interventions
Improvement Aim Key Activities Implemented
Support the GHS
in carrying out on-
the-job coaching for
trainees
• Supported triage teams and the creation of dedicated space for patient triage (Figure 71).
• Coached on partograph use.
• Tracked emergency medical supplies daily to reduce stock-outs, particularly for postpartum
hemorrhage and eclampsia.
• Organized blood donation campaigns.
• Assigned hospital referral focal persons to coordinate and communicate with referring facilities.
• Intensified on-site coaching by clinical specialists to improve provider compliance with guidelines.
Table 20.Shared learning improvement aims and activities
A supervisor closely observes during an ETAT quarterly supportive supervision visit at the emergency unit of Bimbilla Hospital.
Figure 40. The maternal deaths and MMR (per 100,000 LB) for 10 hospitals in the Northern Region, FY16-FY19.
included both clinical staff within each facility as well as other
staff responsible for other aspects of services, including the
management of health records, commodities, and referrals.
Through the creation of a platform for shared learning,
hospitals were able to learn from the strategies employed
by other facilities, which led to even more substantive
improvements in their performance and service data.
50
40
30
20
10
0
Mat
erna
l Dea
ths
200
150
100
50
0
Mat
erna
l Mor
talit
y R
atio
n pe
r 10
0,0
00
Liv
e B
irth
s
180.5 181.2
131.1
100.0
Oct 2015 to Sep 2016 Oct 2016 to Sep 2017 Oct 2017 to Sep 2018 Oct 2018 to Sep 2019
Number of Maternal Deaths
Maternal Mortality Ratio (per 100,000)
43 4637
29
110
ANNEX 2: SUCCESS STORY
A PERFORMANCE-BASED LEADERSHIP-LED QUALITY IMPROVEMENT INITIATIVE IMPROVES ACCESS TO
SKILLED DELIVERY IN THE WESTERN REGION
BackgroundThough ANC coverage was high (90.5%), the Western Region
consistently recorded low skilled delivery and high stillbirth
rates. In 2017, the region’s skilled delivery coverage was 57.5%,
and its stillbirth rate was 16 per 1,000 births. To address these
gaps, the Western RHD sought support from Systems for Health
to implement a leadership-led QI project through an FAA.
Objectivesu 12 drivers selected by their communities, trained, and
provided with motorized tricycles
u Agreements from the drivers to be on call for emergencies
two days a week; the rest of the time, the motorized
tricycles can be used to earn income
Problem Assessment and PrioritizationUsing QI tools (fishbone and pareto analyses), the regional
team reviewed 2017 data to identify the source and root
causes of the deficits in delivery outcomes. The review
revealed four districts contributing disproportionately
to low skilled delivery coverage (33.3%) and two districts
contributing to the high stillbirth rate (23 per 1,000 births).
The review also identified the primary causes of the deficits,
which were gaps in community engagement, provider
competency in resuscitation, and consistent implementation
of perinatal death audits and related recommendations. The
RHD engaged district leaders in designing interventions to
address these gaps.
InterventionThe RHD set the stage for high-quality implementation by
taking full ownership of the activity and ensuring that the
appropriate stakeholders were involved in its design. Key
staff (including the Regional Director) participated in the
initial orientation meetings in each district to ensure that all
managers and facilities knew what was expected of them
to achieve results. Furthermore, the RHD worked with each
district to provide incentive awards to midwives that posted
their deliveries and/or cases needing management on a
regional WhatsApp platform (above). This platform, staffed
by doctors, enabled midwives to access clinical advice. In
addition, it served as a portal for referring and receiving
facilities to track and better manage referrals.
Other key activities to address low skilled delivery
included community durbars/sensitization meetings and
the institution of pregnancy schools in all facilities in the
The Regional Director of Health Services publicly recognizes the efforts of a high-performing midwife
111
prioritized districts. The region’s leaders also introduced
pregnancy diaries, which midwives used to trace ANC
defaulters and to follow-up with pregnant women until
delivery. Also, teams used shared learning sessions,
maternal health review meetings, regular clinical drills, data
validation meetings, and continuous on-site coaching to
reduce stillbirth rates in the two districts.
ResultsAfter 12 months of implementation, the region recorded
impressive changes in its process indicators, as detailed in
Table 21.
Table 21. Indicators of change resulting from the Western Region’s QI project concerning skilled delivery.
These improvements in processes ultimately led to a 35%
increase in skilled delivery coverage, from 33.3% in 2017 to
45% (June 2018–May 2019) in the intervention districts.
In addition, the interventions contributed to an impressive
reduction in stillbirth rates in the two intervention districts.
Per Figure 41, rates reduced by 40%, from 23.35 deaths
per 1,000 births in 2017 to 14 deaths per 1,000 births (June
2018–May 2019).
ConclusionThe leadership provided by the RHD proved to be a critical
factor in the success of these interventions. Leaders’
involvement began with the evidence-based design of
the interventions, and it continued through district-based
activities as well as public recognition of the efforts of high-
performing facilities and providers. This hands-on approach
empowered and inspired managers and providers in the
districts to fully commit to changing the ways that services
are delivered.
Furthermore, the commitment of providers to engage
community members through durbars and pregnancy
schools enabled them to develop tailored solutions that
addressed barriers to seeking and/or accessing care. This
type of client-centered approach can be replicated and
scaled up to further improve maternal and child health
outcomes.
Indicator (process data) BaselineEndline
(as of May 2019)
Pregnancy school enrollment 11.4% 58%
Adherence to correct partograph use 47.6% 83%
Emergency caesarean response time 147 mins 49 mins
Proper resuscitation of a neonate by the midwife (score over 80%) during the assessment
20% 81%
Stillbirths audited 12.7% 100%
Stillbirth audit recommendations implemented 37.8% 95%
A midwife answers questions from pregnancy school participants
112
Figure 41. The combined stillbirth rate, per 1,000 births, from January 2017 to May 2019 in two districts of the Western Region: Wassa Amenfi West and Sefwi Wiawso.
30
25
20
15
10
5
0
23.61
Jul–Sep 2018
Apr–Jun 2018
Jan–Mar 2018
Oct–Dec 2017
Jul–Sep 2017
Apr–Jun 2017
Jan–Mar 2017
Apr–May 2019
Jan–Mar 2019
Oct–Dec 2018
22.55 23.16 24.10
28.16
25.33
16.92
14.96
7.32
Interventions started
12.32
Stillbirth Rate
Intervention Package:
Pregnancy schools Community durbars
Maternal health review meetings Regular clinical drills
Data validation meeting On-the-job coaching
USAID Systems for Health
www.urc-chs.com